Psychological Reactions of Children Impacted by Trauma and Death
EDITOR’S NOTE: The first anniversary of September 11 has passed. Our nation is grateful that there were no further terrorist attacks that affected this day of reflection and mourning. Nonetheless, there are many who are still suffering and require help. Some of them are among our most vulnerable—our nation's children. In this three-part series, Philip J. Lazarus, our VIRTUS programs school violence consultant, discusses the psychological reactions of children impacted by trauma and death and tells us how help has been provided in the aftermath. In related articles, Dr. Lazarus outlines how the American Red Cross and the September 11th Fund are underwriting expenses and extending mental health treatment for families impacted by the terrorist attacks. For those directly impacted, he explains how to access benefits. And, in a third article he discusses what we have learned about the long-term effects of trauma and grief on children based on recently published research on the Oklahoma City bombing and other mass disasters.
(posted October 14, 2002)
Philip J. Lazarus, Ph.D., NCSP
Associate Professor and Director of the School Psychology Training Program,
Florida International University
Nicole is 12 years old and is in 7th grade at I.S. 89. She lives in Battery Park City, in Manhattan. Since September 11, 2001, she has had problems keeping bad thoughts from flooding her mind. She said, “At night I have thoughts that come into my head like Osama bin Laden will come into my room. I know that won’t happen, but I still have those thoughts. They started about a month ago. When I hear a loud noise I can’t sleep. I know it is not rational.” She then added, “When I hear a loud noise, I have to open my blinds and look out. Sometimes I think there’s an atom bomb” (Kleinfield, 2002).
In the first few weeks after the terrorist attacks, Calla, age 8, was filled with anger. At times she expressed her rage in ways that she would later regret. She sometimes hit and kicked her dog and cat. Calla said, “I’m so angry I don’t know what to do.” When she walked by a sign advertising World Trade Center pictures, she would kick it. She would carry her stuffed animals to the bathroom, announcing the Trade Center was falling and she had to get her stuffed friends to safety. Later she calmed down, but recently she regressed.
Calla is in the 2nd grade at Public School 89 near ground zero. Since the school reopened at the end of February only about half her relocated class returned to the building. She has become very aggressive—pushing and striking other children and calling them names and regressing to behavior she displayed in kindergarten (Kleinfield, 2002).
A year after the attack most children in New York City appeared to have bounced back. They resumed their normal lives of playing soccer games, rooting for their favorite sports teams, and doing their homework. Yet for others, especially for those directly impacted, the struggle has been immense. They are living childhood lives with adult troubles.
In order to estimate the dimension of the problem of children’s reactions to trauma and grief, a study was released by the Board of Education of New York City. It concluded that approximately 75,000 are suffering symptoms of post-traumatic stress disorder (PTSD) and 190,000 of the 712,000 children in grades 4 through 12 were candidates for mental health intervention with a professional therapist (Purnick, 2002).
Fortunately, many children will recover with the passage of time. However, for others, trauma can have a long life. Psychologist Claude Chemptop, who specializes in trauma and disaster, has been working with some of the downtown schools. He noted that without treatment, symptoms could persist for years. For example, studies show that children evidenced detrimental effects from a 1972 flood in West Virginia more than 20 years later. He said, “We know children don’t ask for help on their own and we know that parents and teachers are not particularly good at knowing which kids are hurting when they hurt silently” (Kleinfield, 2002).
For example, after Hurricane Iniki hit the Hawaiian island of Kauai in 1992, a study showed that teachers often missed the symptoms of the withdrawn children (Lazarus, Jimerson, & Brock, 2002). The teachers were able to refer students who acted out and disrupted the class, but often ignored those who suffered quietly.
In understanding the impact of the September 11 terrorist attacks, it is helpful to picture a stone being tossed into a body of water and sending out ripples (Goodman, Brown, Courtney, 2002). Children most likely to suffer are those nearest the epicenter, either because of physical proximity (they witnessed the attack or were physically hurt) or because someone close to them was injured or killed in the collapse.
Problems are more likely for children and adolescents who had prior losses or had previously suffered traumatic experiences—before September 11. Children are at higher risk if they have limited social support or when their parents have additional problems in the aftermath due to a change in residence, economic difficulties, loss of job, or physical injuries (Lazarus et al., 2002). More severe reactions are often seen in those with previously diagnosed emotional disorders (North et al., 1999).
Children far away from the attack who lost a friend, relative or family member are also at increased risk (Pfefferbaum et al., 1999). It is not unusual for any trauma to trigger the same feelings and reactions of previously experienced traumas. That is why we often see children who did not suffer a personal loss in the present go into crisis—because the current event evoked a severe reaction to a prior trauma or loss.
When a parent experiences symptoms of post-traumatic stress disorder, this can send shock waves through the family. We know that children’s reactions are impacted by the responses of significant adults in their lives (Pfohl, Jimerson, & Lazarus, 2002. Parents, grandparents, older siblings and other adults serve as role models (either effectively or ineffectively) for how to cope in the aftermath of a traumatic event. Therefore, to understand children’s reactions it is important to examine the impact of September 11, 2001, on adults.
In a study by William E. Schlenger and colleagues at the Research Triangle Institute in North Carolina, published in the Journal of the American Medical Association, they examined clinically significant distress and post-traumatic stress disorder in New York, Washington, D.C., and across the nation (Schlenger et al., 2002). In the first post-September 11 research article, they estimated that more than 10 million Americans knew a friend, family member or co-worker who died or was injured in the attack (Schlenger et al., 2002). They reported that there are about two million of those people in New York, 500,000 in the Washington, D.C., area and another seven million or more across the country.
The authors of the study estimate that more than 500,000 people may have developed post-traumatic stress disorder as a direct result of the terrorist attacks. About 11 percent of the respondents in New York City reported symptoms consistent with post-traumatic stress disorder. This is about three times the national average.
In the Washington, D.C., area the PTSD estimates were surprisingly similar to that of the entire country. The researchers surmise that the Pentagon is more isolated from the general population than the World Trade Center; that the Pentagon is a military rather than civilian target; and that the crash into the Pentagon was much less devastating than the crashes into the twin towers (in terms of visual images and the magnitude of injuries and death). A positive finding was that two months after the attack the overall distress levels of the nation at-large were within normal ranges (Schlenger et al., 2002). Therefore, it can be seen that the overwhelming majority of children who require emotional help are in New York City and the surrounding areas.
In order to help these impacted children, the faculty and staff of the New York University Child Study Center (NYU Center) have been working to address their needs. They have provided services to about 5,000 children who attended schools near ground zero and 500 bereaved children of firefighters, police and emergency rescue workers. Moreover, the systems (e.g., families, schools, and government agencies) that cared for and educated the children have also been traumatized. The NYU Center mental health recovery program has three necessary components: 1) outreach and education, 2) identification and evaluation, and 3) treatment and referral (Goodman et al., 2002).
Outreach and education is essential to help identify and treat children at risk. The goal of this component is to inform the public about what reactions to expect, the possible mental health consequences of trauma and bereavement, and ways to prevent future problems from occurring. The emphasis is on conveying to the public that treatment is available and there is no shame in seeking help. After the attack, the NYU Center prepared two manuals on coping with trauma and death. More than 50,000 copies were distributed and are now available online as free downloads at www.aboutourkids.org.
Identification and evaluation are necessary to pinpoint an accurate diagnosis and provide effective intervention. The NYU Center has developed a screening questionnaire because many children who need help were not referred for treatment because their symptoms of anxiety and depression were less apparent than symptoms of “acting out” behavior. Children identified by the screening are then more thoroughly evaluated.
Treatment is based on principles applicable to trauma and grief. Cognitive behavior therapy is most often effective for those who are suffering from the effects of September 11, 2001. Children are taught deep breathing and progressive muscle relaxation to relieve distress. They are helped to re-experience the trauma in a safe and controlled setting. The intention is to have children tell their story—either realistically or symbolically—while their anxiety is being monitored. They then learn to recognize their reactions and control intrusive thoughts, feelings and behavior. In addition, they are taught ways to cope with stress and prepare for the future.
As noted by the research, there are thousands of children like Nicole and Calla who require help. However, the number of children getting psychological assistance has been small compared with the need (American Red Cross, 2002; Goode, 2002). Fortunately, the Red Cross and the September 11th Fund will underwrite mental health treatment to make it available to more than 150,000 families directly affected by the terrorist attacks.
For more information please see the following related articles:
Emotional Help Extended to September 11 Victims—For those still suffering from the events of September 11, the amount and quality of support has a direct impact on the long-range effects of trauma. Family, faith, and friends are the primary support systems. Nonetheless, counseling can provide emotional relief in the aftermath of a tragedy. The American Red Cross and the September 11th Fund are working together to eliminate the financial barriers and provide mental health treatment for people impacted by the terrorist attacks.
Lessons from Oklahoma City and Other Disasters about the Long-range Psychological Effects of September 11 on Children and Families—After the Oklahoma City bombing, it took some survivors who had serious emotional difficulty two to three years to seek treatment. Often the hardest time comes when survivors least expect it. The next time someone hijacks a plane or a terrorist attack is shown on television, this can bring back the anxiety and sadness all over again. For example, during the week of September 11, 2001, more than six years after the April 19, 1995, Oklahoma City bombing, the hotline at the department of mental health for Oklahoma got 300 calls—triple its average volume. Based on these and similar facts, the question is often asked, “Where might children and families be emotionally years from now?”
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