Helping Children and Adolescents Cope with Violence and Disasters

Bethel, Alaska; Pearl, Mississippi; West Paducah, Kentucky; Jonesboro, Arkansas; Edinboro, Pennsylvania; Springfield, Oregon; Littleton, Colorado; Santee, California... school shootings in these communities have shocked the country. Many questions are being asked about how these tragedies could have been prevented, how those directly involved can be helped, and how we can avoid such events in the future.

Children who have witnessed violence in their families, schools, or communities are vulnerable to serious long-term problems. Most will recover in a short time, but the minority who develop post-traumatic stress disorder or other persistent problems need treatment.

School shootings are only a small fraction of the tragic episodes that affect children's lives. Each year many children and adolescents sustain injuries from violence, lose friends or family members, or are adversely affected by witnessing a violent or catastrophic event. Each situation is unique, but cause similar reactions in children. Helping young people avoid or overcome emotional problems in the wake of violence or disaster is one of the most important challenges a parent, teacher, or mental health professional can face.

Reactions to trauma may appear immediately after the traumatic event or days and even weeks later. Loss of trust in adults and fear of the event occurring again are responses seen in many children and adolescents who have been exposed to traumatic events. Other reactions vary according to age.

In children 5 years of age and younger typical reactions can include a fear of being separated from the parent, crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions and excessive clinging. Children might return to behaviors exhibited at earlier ages (called regressive behaviors), such as thumb-sucking, bedwetting, and fear of darkness. Children this age tend to be strongly affected by the parents' reactions to the traumatic event.

Children 6 to 11 years old may show extreme withdrawal, disruptive behavior, and/or inability to pay attention. Regressive behaviors, nightmares, sleep problems, irrational fears, irritability, refusal to attend school, outbursts of anger and fighting are also common in traumatized children of this age. The child may complain of stomach aches or other bodily symptoms that have no medical basis. Schoolwork often suffers. Depression, anxiety, feelings of guilt and emotional numbing or "flatness" are often present as well.

Adolescents 12 to 17 years old may exhibit responses similar to those of adults, including flashbacks, nightmares, emotional numbing, avoidance of any reminders of the traumatic event, depression, substance abuse, problems with peers, and anti-social behavior. Also common are withdrawal and isolation, physical complaints, suicidal thoughts, school avoidance, academic decline, sleep disturbances, and confusion. The adolescent may feel extreme guilt over his or her failure to prevent injury or loss of life, and may harbor revenge fantasies that interfere with recovery from the trauma.

• Find ways to protect children from further harm and exposure to traumatic stimuli. Protect children from onlookers and the media covering the story.
• Direct children away from the site of violence or destruction, away from severely injured survivors, and away from continuing danger.
• Identify children in acute distress and stay with them until initial stabilization occurs. Acute distress includes panic (marked by trembling, agitation, rambling speech, becoming mute, or erratic behavior) and intense grief (signs include loud crying, rage, or immobility).
• Use a supportive and compassionate verbal or non-verbal exchange (such as a hug, if appropriate) with the child to help him or her feel safe. Reassurances are important to children.

• Explain the episode of violence or disaster as well as you are able.
• Encourage children to express their feelings and listen without passing judgment. Help younger children learn to use words that express their feelings. However, do not force discussion of the traumatic event.
• Let them know that it is normal to feel upset after something bad happens.
• A gradual return to routine can be reassuring to the child. If your children are fearful, reassure them that you love them and will take care of them. Stay together as a family as much as possible.
• If behavior at bedtime is a problem, give the child extra time and reassurance. Let him or her sleep with a light on or in your room for a limited time if necessary.
• Reassure children and adolescents that the traumatic event was not their fault.
• Do not criticize regressive behavior or shame the child with words like "babyish."
• Allow children to cry or be sad. Don't expect them to be brave or tough.
• Encourage children and adolescents to feel in control. Let them make some decisions about meals, what to wear, etc.
• Take care of yourself so you can take care of the children.

• If possible, give yourself a bit of time to come to terms with the event before you attempt to reassure the children. This may not be possible in the case of a violent episode that occurs at school, but sometimes in a natural disaster there will be several days before schools reopen and teachers can take the time to prepare themselves emotionally.
• Don't rush back to ordinary school routines too soon. Give the children or adolescents time to talk over the traumatic event and express their feelings about it.
• Respect the preferences of children who do not want to participate in class discussions about the traumatic event. Do not force discussion or repeatedly bring up the catastrophic event; doing so may re-traumatize children.
• Hold in-school sessions with entire classes, with smaller groups of students, or with individual students. These sessions can be very useful in letting students know that their fears and concerns are normal reactions. Many counties and school districts have teams that will go into schools to hold such sessions after a disaster or episode of violence. Involve mental health professionals in these activities if possible.
• Offer art and play therapy for children in primary school.
• Be sensitive to cultural differences among children. In some cultures it is not acceptable to express negative emotions, and the child who is reluctant to make eye contact with a teacher may not be depressed, but may simply be exhibiting behavior appropriate to his or her culture.
• Encourage children to develop coping and problem-solving skills and age-appropriate methods for managing anxiety.
• Hold meetings for parents to discuss the traumatic event, their children's response to it, and how they and you can help. Involve mental health professionals in these meetings if possible.

• Re-experiencing the event through play or in trauma-specific nightmares or flashbacks, or distress over events that resemble or symbolize the trauma.
• Routine avoidance of reminders of the event or a general lack of responsiveness (e.g., diminished interests or a sense of having a foreshortened future).
• Increased sleep disturbances, irritability, poor concentration, startle reaction and regressive behavior.

People differ in their vulnerability to PTSD. Research has shown that PTSD clearly alters a number of fundamental brain mechanisms, and abnormalities have been detected in brain chemicals that affect coping behavior, learning, and memory among people with the disorder. Recent brain imaging studies have detected altered metabolism and blood flow as well as anatomical changes in people with PTSD.

Play therapy and art therapy also can help younger children to remember the traumatic event safely and express their feelings about it. Group therapy and exposure therapy also help people with PTSD. A reasonable period of time for treatment of PTSD is 6 to 12 weeks with occasional follow-up sessions, but treatment may be longer depending on a patient's particular circumstances. Support from family and friends can be an important part of recovery, and involving people in group discussion very soon after a catastrophic event may reduce some of the symptoms of PTSD.

Research is just beginning on the use of medications to treat PTSD in children and adolescents. There is preliminary evidence that psychotherapy focused on trauma and grief, in combination with selected medications, can be effective in alleviating PTSD symptoms and accompanying depression. A mental health professional with special expertise in the area of child and adolescent trauma is the best person to help a youngster with PTSD.

Parents' responses to a violent event or disaster strongly influence their children's ability to recover. This is particularly true for mothers of young children. If the mother is depressed or highly anxious, she may need to get emotional support or counseling in order to be able to help her child.

Community violence can have a profound effect on teachers as well as students. One study of Head Start teachers who lived through the 1992 Los Angeles riots showed that 7% had severe post-traumatic stress symptoms, and 29% had moderate symptoms. Children also were acutely affected by the violence and anxiety around them. They were more aggressive and noisy and less likely to be obedient or get along with each other.

PTSD is often accompanied by depression. In a group of teenage school students who survived a terrorist shooting in Brooklyn, New York, 4 of the 11 survivors interviewed had both PTSD and depression.

Exposure to violence in the home for an extended period of time or exposure to a one-time event like an attack by a dog can cause PTSD in a child. Some scientists believe that younger children are more likely to develop the disorder than older ones.

Inner-city children experience the greatest exposure to violence. A study of young adolescent boys from inner-city Chicago showed that 68% had seen someone beaten up and 22.5% had seen someone shot or killed. Youngsters who had been exposed to community violence were more likely to exhibit aggressive behavior or depression within the following year.

The National Institute of Mental Health supports research on the impact of violence and disaster on children and adolescents. One ongoing study will follow 6,000 Chicago children from 80 different neighborhoods over a period of several years. Researchers will examine the emotional, social and academic effects of exposure to violence. In some of the children, the researchers will look at the role of stress hormones in a child or adolescent's response to traumatic experiences.

Another study will deal specifically with the victims of school violence, attempting to determine what places children at risk for victimization at school and what factors protect them. It is particularly important to conduct research to discover which Individual, family, school and community interventions work best for children and adolescents exposed to violence or disaster, and to find out whether it is possible for a well-intended but ill-designed intervention to set the youngsters back by keeping the trauma alive in their minds.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.