Children’s Responses to Children’s Responses to Terror and TraumaTerror and Trauma

John Sargent, M.D.John Sargent, M.D.

Children’s Responses depend upon Children’s Responses depend upon several variables:several variables:

Child’s age and developmental statusChild’s age and developmental status

Previous experiences of traumaPrevious experiences of trauma

Family risk and resiliency factorsFamily risk and resiliency factors

Children’s Responses depend upon Children’s Responses depend upon several variables (cont):several variables (cont):

Preexisting attachment relationshipPreexisting attachment relationship

Nature of traumatic experience and Nature of traumatic experience and continuing threatcontinuing threat

Nature of community and family supportNature of community and family support

Influence of Developmental Stage Influence of Developmental Stage on Child Responseson Child Responses

Preschool childrenPreschool children

Primary problems are related to separationPrimary problems are related to separation Refuse to attend preschoolRefuse to attend preschool Sleeping with parentSleeping with parent Whining and clinging behavior with parentWhining and clinging behavior with parent

Influence of Developmental Stage Influence of Developmental Stage on Child Responses (cont.)on Child Responses (cont.)

Trouble sleeping and nightmaresTrouble sleeping and nightmares Reactive aggressivenessReactive aggressiveness Repressive behaviors; bed wetting and fearsRepressive behaviors; bed wetting and fears

Influence of Developmental Stage Influence of Developmental Stage on Child Responses (cont.)on Child Responses (cont.)

School Age ChildrenSchool Age Children Attention and concentration problemsAttention and concentration problems Anxiety with associated school avoidance, Anxiety with associated school avoidance,

fears and somatic symptomsfears and somatic symptoms Sleep problems and nightmaresSleep problems and nightmares

Influence of Developmental Stage Influence of Developmental Stage on Child Responses (cont.)on Child Responses (cont.)

Angry outburstsAngry outbursts Depression and withdrawalDepression and withdrawal

Influence of Developmental Stage Influence of Developmental Stage on Child Responses (cont.)on Child Responses (cont.)

AdolescenceAdolescence Hypervigilance and intrusive thoughtsHypervigilance and intrusive thoughts Emotional numbing and nightmaresEmotional numbing and nightmares avoidanceavoidance

Influence of Developmental Stage Influence of Developmental Stage on Child Responses (cont.)on Child Responses (cont.)

Peer and family problemsPeer and family problems Substance abuseSubstance abuse Overt depressionOvert depression

Influence of Developmental Stage Influence of Developmental Stage on Child Responses (cont.)on Child Responses (cont.)

Other affective aspects of Other affective aspects of trauma/terrorismtrauma/terrorism Humiliation, shame and self-blameHumiliation, shame and self-blame Alienation and demoralizationAlienation and demoralization Chronic anger and irritabilityChronic anger and irritability Reexperiencing worsening other symptomsReexperiencing worsening other symptoms

Unique features of Terroristic Unique features of Terroristic Events Effects on ChildrenEvents Effects on Children

Terroristic events have a profound Terroristic events have a profound effect upon adults – including parents effect upon adults – including parents and teachersand teachersAdult depression may negatively Adult depression may negatively influence childreninfluence childrenAdults may underestimate effects upon Adults may underestimate effects upon children, especially for distant eventschildren, especially for distant eventsParents’ emotional responses very Parents’ emotional responses very influential in the children’s reactionsinfluential in the children’s reactions

Persistent threat worsens Persistent threat worsens children’s exposure and children’s exposure and reactionsreactions

Repeated media viewing also Repeated media viewing also worsens the effects upon worsens the effects upon childrenchildren

PTSD occurs in 30 – 50% of PTSD occurs in 30 – 50% of children exposed to terrorist children exposed to terrorist

violenceviolence

Physical proximity, degree of Physical proximity, degree of actual family member actual family member

involvement and witnessing involvement and witnessing violence significantly increase violence significantly increase

risk of developing PTSDrisk of developing PTSD

10% of New York City public 10% of New York City public school students developed PTSD school students developed PTSD after September 11, 2001. World after September 11, 2001. World

Trade Center attacks.Trade Center attacks.

Disruption, confusion, chaos, Disruption, confusion, chaos, uncertainty of events and uncertainty of events and surrounding events often surrounding events often

worsens the situationworsens the situation

Rumors, excitement, disorder Rumors, excitement, disorder among helpers can be present at among helpers can be present at

the scene or at hospital or care the scene or at hospital or care settingssettings

Parental availability and support Parental availability and support is highly protective for children is highly protective for children

(including adolescents)(including adolescents)

Helpful interventions:Helpful interventions:

Establishing order at the siteEstablishing order at the site

Ensuring coordinated, cooperative and Ensuring coordinated, cooperative and competent activity among helperscompetent activity among helpers

Ensure parents are with children if Ensure parents are with children if possiblepossible

Helpful interventions (cont.):Helpful interventions (cont.):

Provide accurate and complete Provide accurate and complete information as soon as availableinformation as soon as available

Ensure appropriate medical careEnsure appropriate medical care

Support parents and family care givers Support parents and family care givers especially if child is injured and receiving especially if child is injured and receiving hospital carehospital care

Psycho educational supports for Psycho educational supports for families and community networks families and community networks also are helpful and can lead to also are helpful and can lead to

rebuilding efforts for the rebuilding efforts for the communitycommunity

School based interventions for School based interventions for children can be very helpful: children can be very helpful:

group discussions, resumption of group discussions, resumption of daily routine and structure, daily routine and structure,

gradual expectation of training gradual expectation of training and competenceand competence

Dimensions of AssessmentDimensions of Assessment

Physical well being, differences, acute Physical well being, differences, acute symptoms and physiologic problemssymptoms and physiologic problems

Developmental capacities, variability, Developmental capacities, variability, deficiencies and areas of regressiondeficiencies and areas of regression

Nature of trauma and its effectsNature of trauma and its effects

Cognitive capacities including intellectual Cognitive capacities including intellectual capacity, specific areas of learning capacity, specific areas of learning disability and ability to utilize cognitive disability and ability to utilize cognitive capacity to understand traumacapacity to understand trauma

• Psychiatric symptoms andPsychiatric symptoms and diagnostic considerations diagnostic considerations including: including:

Acute Stress ReactionAcute Stress Reaction

PTSDPTSD

DepressionDepression

Substance AbuseSubstance Abuse

Eating DisordersEating Disorders

Complex PTSDComplex PTSD

Conduct Disorder, etc.Conduct Disorder, etc.

Assessment of Context: family relationships Assessment of Context: family relationships and interaction, community connectedness, and interaction, community connectedness, community institutions and ritualscommunity institutions and rituals

Areas of Risk and Resilience: family risk, Areas of Risk and Resilience: family risk, poverty, social discrepancies, individual poverty, social discrepancies, individual strengths, skills and competencies, family strengths, skills and competencies, family and community connection and support.and community connection and support.

• Other important issues:Other important issues:

Cultural backgroundCultural background

EthnicityEthnicity

Cultural stories of adversity and survivalCultural stories of adversity and survival

Belief systems about trauma recoveryBelief systems about trauma recovery

Peer relationshipsPeer relationships

Current functioningCurrent functioning academicacademic family family socialsocial communitycommunity (especially in relation to expected development)(especially in relation to expected development)

Stage I: Stage I: StabilizationStabilization

Develop a collaborative team with Develop a collaborative team with planned, coordinated responses to planned, coordinated responses to traumatic events that are competent, traumatic events that are competent, compassionate and caringcompassionate and caring

Parents will need to be invited to be Parents will need to be invited to be members of the team with defined and members of the team with defined and important rolesimportant roles

Swiftly end traumatic events and define Swiftly end traumatic events and define all future responses as courageous all future responses as courageous healing efforts (no matter how disruptive healing efforts (no matter how disruptive or painful)or painful)

Treatment is based upon Treatment is based upon building a relationship of building a relationship of connection and trust, connection and trust, recognizing the experience of recognizing the experience of shock, anxiety and arousal in shock, anxiety and arousal in the child and familythe child and family

Ensuring physical and Ensuring physical and psychological comfort produces psychological comfort produces the possibility of focused the possibility of focused attention so that information attention so that information about plans, procedures and about plans, procedures and treatment can be shared with treatment can be shared with and gained by child and familyand gained by child and family

Predictability, clarity, integrity and Predictability, clarity, integrity and competence follow the explanations to competence follow the explanations to reinforce trust and collaborationreinforce trust and collaboration

Be prepared to operate on limited, Be prepared to operate on limited, incomplete and often disguised incomplete and often disguised information, focusing upon what is known information, focusing upon what is known and what is required by the situationand what is required by the situation

Do not expect that a one time Do not expect that a one time large scale debriefing or large scale debriefing or counseling effort will produce counseling effort will produce large scale recovery - in fact large scale recovery - in fact “Critical Incident Debriefing” “Critical Incident Debriefing” often worsens individual often worsens individual psychological responsespsychological responses

Stage II: Stage II: RestorationRestoration

Identify key issues which require attention Identify key issues which require attention to reestablish continuity of life for children to reestablish continuity of life for children and their family:and their family: Housing - Living situation - Care-taking Housing - Living situation - Care-taking

relationshipsrelationships Centrality of Parental Figures (if possible)Centrality of Parental Figures (if possible)

Financial resources to ensure family Financial resources to ensure family continuitycontinuity

Building competence through encouragement Building competence through encouragement and active reinforcement of rehabilitation and active reinforcement of rehabilitation activitiesactivities

Recognizing grieving as an important activityRecognizing grieving as an important activity

Identify appropriate anger and begin Identify appropriate anger and begin discussions of accountabilitydiscussions of accountability

Resume, whenever possible, developmentally Resume, whenever possible, developmentally appropriate activities with parental appropriate activities with parental encouragement (which reinforces parenting encouragement (which reinforces parenting role)role)

At this point a comprehensive At this point a comprehensive assessment highlighting individual assessment highlighting individual risk and resilience factors, risk and resilience factors, attention to psychiatric symptoms, attention to psychiatric symptoms, and specifics of traumatic and specifics of traumatic experience and emotional experience and emotional reactions is essential and points to reactions is essential and points to appropriate interventionsappropriate interventions

These interventions further These interventions further reinforce the relationship reinforce the relationship between the family and the between the family and the healing system and further healing system and further support future collaborationsupport future collaboration

This leads to increasing clarity This leads to increasing clarity about what has changed, about what has changed, been lost and must be grieved been lost and must be grieved for as well as what new for as well as what new competencies have emerged competencies have emerged and must be integratedand must be integrated

Build to a recognition of an Build to a recognition of an integrated appreciation of a integrated appreciation of a transformed child and familytransformed child and family

Stage III: Stage III: RecoveryRecovery

This stage focuses directly upon attention This stage focuses directly upon attention to significant psychiatric symptoms and to significant psychiatric symptoms and syndromessyndromes

This requires integrated therapeutic This requires integrated therapeutic responsesresponses

Exposure and response prevention directly Exposure and response prevention directly addresses PTSD symptoms (e.g. Foa’s addresses PTSD symptoms (e.g. Foa’s treatment for rape victims)treatment for rape victims)

Family therapy leads to greater Family therapy leads to greater organization, more parental effectiveness organization, more parental effectiveness and improved social supportand improved social support

Attachment focused psychodynamic Attachment focused psychodynamic psychotherapy enhances mentalization, psychotherapy enhances mentalization, reduces interpersonal objectification and reduces interpersonal objectification and enhances empathyenhances empathy

Cognitive - behavioral therapy addresses Cognitive - behavioral therapy addresses depressed mood, inappropriate attributions of depressed mood, inappropriate attributions of helplessness and shame and excessive focus helplessness and shame and excessive focus upon retribution and revengeupon retribution and revenge

Psychopharmacology to improve mood, Psychopharmacology to improve mood, increase threshold and decrease amplitude of increase threshold and decrease amplitude of arousalarousal

Behavioral support to decrease avoidanceBehavioral support to decrease avoidance

Enhancing physiologic self-awareness to Enhancing physiologic self-awareness to assist in managing and modulating arousal assist in managing and modulating arousal and psychologic self-awareness to and psychologic self-awareness to appropriately assess dangerappropriately assess danger

Work toward the consolidation of a coherent Work toward the consolidation of a coherent narrative of self, family, community narrative of self, family, community experiences of this trauma that becomes a experiences of this trauma that becomes a nuanced, textured memory that can be nuanced, textured memory that can be recalled as a whole and reviewed without recalled as a whole and reviewed without reproduction of heightened arousal reproduction of heightened arousal

An orientation toward An orientation toward community and national (if community and national (if possible) growth through possible) growth through advocacy, truth and advocacy, truth and reconciliation experiences, reconciliation experiences, memorial and artistic expressionmemorial and artistic expression

Key IssuesKey Issues

Competence and connection are Competence and connection are antidepressantsantidepressants

Information, predictability, intellectual Information, predictability, intellectual mastery and mentalization manage mastery and mentalization manage anxiety, splitting and impulsivityanxiety, splitting and impulsivity

Recognition of what needs to be protected Recognition of what needs to be protected now and of the value of new skills promote now and of the value of new skills promote consolidation of a transformed selfconsolidation of a transformed self

Therapist is vulnerable to burn out, Therapist is vulnerable to burn out, vicarious traumatization and personal vicarious traumatization and personal experience of vicitimhoodexperience of vicitimhood

Therapists will need to identify the value Therapists will need to identify the value and meaning of their work while they and meaning of their work while they integrate their awareness of tragic integrate their awareness of tragic events and of change and growth that events and of change and growth that reinforces hopereinforces hope