Traumatic Stress as a Public Health Issue

John A. Fairbank is codirector of the National Center for Child Traumatic Stress sponsored by the Substance Abuse and Mental Health Services Administra-tion. He is an associate professor of medical psychology in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center, past president of the International Society for Traumatic Stress Studies and a member of the Scientific Advisory Board for the Department of Veterans Affairs' National Center for PTSD. He is a co-author of a recent article in the Journal of the American Medical Association on the effects of Sept. 11, one of the first published studies on the subject.

Q. How do children's reactions to traumatic events differ from those of adults?

A. Traumatic stress can adversely affect children's and teens' school performance, mental and physical health, use of alcohol and drugs and delinquent behavior. As children get older, their traumatic stress reactions tend to look more like the kinds of reactions observed in adults. In adolescents there has been a reasonable amount of research on post-traumatic stress disorder and symptom patterns look quite comparable to what you see in adults. At earlier developmental stages, children may react to traumatic events with markedly fearful and regressive behavioral changes such as fear of separation from adults, more aggressive or withdrawn behaviors, more crying and re-enactment of aspects of the traumatic event in play. Children's reactions to trauma are difficult to predict, and you really have to take into account where the child is developmentally, which will have a big impact on the expression of reactions.

Q. What does the research literature say about the extent of children's exposure to trauma?

A. Findings from one study show that probably fewer than 20 percent of children with a history of exposure to traumatic events develop a psychiatric disorder by 16 years of age. One might interpret these findings in terms of children's resilience. (11) However, the finding that nearly 20 percent experience mental health problems underscores the impact of trauma on children.

If you look at the school-based surveys, in elementary and middle schools in inner-city Chicago, for example, 30 percent of children witnessed a stabbing and 26 percent saw a shooting. (12) Other studies have shown even higher rates. A recent Columbia University report on children in the New York City public school system indicates that nearly two-thirds of the children had been exposed to at least one traumatic event, including things like seeing the violent or accidental death of a close friend or family member, prior to the terrorist attacks on the World Trade Center. (2) The Columbia report estimates that 10 percent of children in New York City reported significant symptoms of PTSD six months after the attack on the World Trade Center. Consistent with these findings, we reported recently that parents in New York City said their children experienced more emotional distress and behavioral dysfunction post-9/11 than the parents of children in other regions of the country. (8)

Q. Are there specific considerations in treating children that are different from treatment approaches for adults?

A. Treatment of children should include the involvement of parents and other stakeholders in the child's life. Treatment of traumatic stress in adults is generally focused on individual treatment or group therapy with other individual adults who have experienced a similar type of trauma.

Q. How does early trauma affect the risk of repeat trauma or psychological problems later in life?

A. Various risk factors are associated with an increase in the likelihood of the development of post-traumatic stress disorder and with an increase in the incidence of exposure to further trauma. It's really clear that there are a number of vulnerability factors for initial and repeat exposure to trauma, such as poverty, having to change residence often and having family, particularly parents, with a history of mental illness. One of the things we know is that children victimized at an early age are at risk of continued victimization and that exposure to multiple traumas increases the risk for post-traumatic stress disorder and other types of traumatic reactions.

Q. In what way do their parents' reactions affect how children deal with traumatic events?

A. There is a body of work, including some of the research that is being done around 9/11, that suggests that risk for the development of post-traumatic reactions, including post-traumatic stress disorder, is determined by multiple factors, including parents' response to the event. A child's direct exposure to trauma certainly contributes, but the parent's reaction also has a role to play in that children often take cues from how their parents are responding to an event.

Q. What factors affect a child's risk of developing post-traumatic stress disorder after exposure to trauma?

A. Factors that tend to contribute to children's adaptation after a trauma include the safety of the post-traumatic environment, the family's material and other losses in the wake of the event, the child's exposure to subsequent traumatic events and the quality and amount of social support available to the child. Children's exposure to traumatic reminders may also play a role in adaptation. We are learning from events such as 9/11 and the Oklahoma City bombing that media exposure does seem to have some association with children's reactions.

Q.What is the role of the National Child Traumatic Stress Network?

A.The Network seeks to raise the standard of care and improve access to services for traumatized children and their families and communities nationwide. It includes programs for children who have experienced maltreatment, such as sexual abuse, physical abuse or neglect. Other programs include providing services to refugee children, children who have experienced war and other types of trauma associated with major humanitarian crises. We also have programs that are focused on disasters and terrorism.

Q. What else can help children who have been exposed to trauma?

A. Even beyond the notion of developing effective interventions for children, we need to think about interventions at the community and society level, not only to treat children who have been exposed to traumatic events, but to prevent such exposure in the first place. Given high rates of children's exposure to trauma in this country, we need increased understanding that traumatic stress is a major public health issue. As a nation, we're not invested in viewing this as a serious public health issue that requires the kinds of interventions that we have adopted for the prevention of disease associated with other major public health problems, such as smoking.

Planning Can Soften Psychological Impact

The School Crisis Response Initiative of the National Center for Children Exposed to Violence began 10 years ago to help schools prepare for the psychological problems that arise from crisis situations, such as community violence. Members developed a working model and began implementing it. By last September, the Center had trained about 15,000 school professionals, says Yale professor David Schonfeld, M.D.

"We were trying to train schools so that they would become better prepared to deal with crisis events, whether they were natural disasters or man-made events and to empower them to bring together the resources in their own school and the broader community to respond constructively," says Schonfeld, creator and program coordinator of the School Crisis Response Initiative, a collaboration of the Yale Child Study Center and experts in mental health, law enforcement and education.

Schonfeld also wrote a recent commentary in the Journal of Developmental and Behavioral Pediatrics about children and post-traumatic stress disorder after Sept. 11, available here. (14)

The terrorist attacks brought new focus to the task of supporting children who were coping with traumatic events. Soon the New York City school administrators asked NCCEV to help them apply their model for crisis response preparedness.

"Many projects were and still are going on in New York City to try to deal with the events of Sept. 11, and the ongoing needs of the children and school staff," Schonfeld says. "But we are helping to develop a response system for the school system that would deal with future crisis events."

The group's protocol was meant to address a full range of crises - not just terrorist attacks or school shootings, but natural disasters as well as wartime losses. The model calls for adapting existing resources to deal with a crisis as it is happening. Schonfeld notes that it is sometimes possible to identify vulnerabilities and even prevent some crises before they happen.

Crisis plans should take into consideration the psychological aspects of an event while it is occurring. Failing to do so not only makes the recovery period more difficult, but undermines the effectiveness of guiding students during the event.

"There is a tendency in some of the crisis plans out there to think about physical security first and then think about the mental health as though it is only relevant in the aftermath," says Schonfeld. "As a crisis is occurring, you need to attend to the emotional, psychological and information needs of the people being affected or else you risk further traumatizing them."

It has become clear from talks with school administrators that implementing a plan can reduce the psychological impact of an event. Schonfeld recalls a conversation with an administrator who initially could not recall any crises during the past year. Despite deaths and serious illness in the school community, she said, she didn't think of them as crises, because they knew how to provide support and assistance to students and staff.

"That's the kind of resiliency we are looking to build into a system," Schonfeld says, "which then gets translated into resiliency within the individual children."

Interview:

Signs of Trauma Depend on Age

Robin H. Gurwitch is an associate professor in the Department of Pediatrics at the University of Oklahoma Health Sciences Center. She is a licensed clinical psychologist and marriage and family therapist. Dr. Gurwitch specializes in work with children, particularly those considered at-risk. Since the bombing in Oklahoma City in 1995, she has devoted much time to understanding the impact of trauma and disaster on children. She has served on state and national committees and task forces focusing on trauma/disaster, terrorism, and violence. Since the events of Sept. 11 and their aftermath, Dr. Gurwitch has been providing training and consultation services on the impact of terrorism on children to agencies, schools and organizations across the country.

Q. Television viewing plays an important role in PTSD in children. To what extent does this fall into a pattern of self-perpetuating symptoms among children exposed to trauma?

A. We are still really in the early stages of understanding the impact of media on children's reactions to trauma. Some of the early research, both following the Challenger disaster as well as Oklahoma City, does suggest that if children are spending a lot of their time watching coverage, their reactions to the traumatic events may be greater. (13)

Q. If children are watching TV to try to understand the event, is this creating more symptoms?

A. At this point we just can't answer that. The other question that we need to consider is: Are there variables that can affect the impact of media? For example, does it make a difference if the child watches this coverage alone or if she watches it with an adult, who she can talk to about what she is seeing? Does it make a difference for children to have the opportunity to process the images or material on the Internet or pictures in a magazine?

Q. How does age affect a child's perception?

A. When looking at the media, it is important to take into account the child's age. For many 4-year-olds watching the events of 9/11, as the images of the buildings being hit was replayed, they did not really understanding that it was the same event being shown over and over again, whereas a 14-year-old understands this. But for the 4-year-old, they might expect that there were few buildings left standing in New York, for the number of times we saw the attacks replayed. Age is a critical factor in understanding.

Parents should guide this kind of viewing, either making sure that they talk to their children about what they are reading and seeing - or for very young children, limiting it or turning it off altogether. And as kids get older, limiting even then is important, so they are not constantly barraged by these images. Coming up with other ways to try to process what is happening, such as talking with adults, rather than just watching it over and over and over again, is helpful.

Q. What role can television have in helping children cope with and understand a traumatic event?

A. The research is really just beginning to answer these questions, but our thoughts are that television can be helpful in some ways. It does provide us with important and useful information. But in terms of constant re-exposure of the incidents, we have to be very careful about that and monitor it, if not significantly limit it, because the preliminary research suggests that children who spend all their time watching this kind of event are having more traumatic stress reactions. Again we need to look at whether there are factors that can reduce these reactions, but I think the first one is to reduce the amount of time children spend watching.

Q. If television can act, in effect, to extend exposure to a traumatic event, what about the effect of parents' distress on their children's experience?

A.Parental reactions to a trauma certainly are an incredibly important variable to consider in terms of how their children are going to do. This is particularly true in very young children who take their cues from their parents. But at any age, if mom and dad, or grandmother, or whoever is distressed or is having a hard time coping, a couple of things can happen. Children may also become increasingly distressed. Seeing caregivers distress, children might also not want to make it worse for parents and therefore might not share their own reactions and distress with their parents. They may feel that when they talk about it or when they see adults watching this and becoming so upset, they don't want to add to the distress.

It is important for us to appreciate that children's reactions can be mediated by how distressed their parents are. That doesn't mean that parents need to act like everything is fantastic in the light of a trauma or a loss, but rather just monitor how they're expressing their reactions, monitor their level of distress and consider their child's age. A 3-year-old is different from a 12-year-old in terms of how parents can handle their reactions in front of their children.

Q. Are children deceived by parents' attempts to put a positive face on things?

A. Children have wonderful radar. Parents can deceive themselves thinking their children aren't listening, and in the clinic, we often hear that working with couples who are going through a divorce or financial worries or other difficulty. They say, "We never talk about it in front of the children; they don't know." And yet, you can talk to the children and they can give you chapter and verse of what is going on.

Kids can pick up on things, whether it's stress over a traumatic event or worries about dad losing his job. Children pick up on the signs, both happy and sad.

Q. Does trauma affect very young children differently from adolescents and adults?

A. There are differences by age. Whereas we can often put adults in one category, we can't lump all children within one category. Preschoolers, elementary school, middle school and high school children are all different, in terms of their level of understanding.

Preschoolers are a group that we are not as knowledgeable about in terms of reactions to trauma. Most of the measures of PTSD and distress require that the child be able to read or respond to an interview. So it is going to be harder to figure out what is going on with a 2-, 3- or 4-year-old. The diagnostic criteria we have right now were developed for use with adults and, for the most part, we are still painting children's reactions with that adult brush. There have been some changes to the diagnostic guides to incorporate some reactions that children have, but we really still need to go back and redevelop our diagnostic criteria because we are still missing signs in many children.

Q. What behaviors should a parent look for as a sign of PTSD?

A. We may see in very young children an increase in temper tantrums, separation anxiety or regressive behaviors, such as children who are potty-trained and start having accidents again. Suddenly, they need more help dressing themselves again. When before they were proud of how they could zip up their coat, now they want their parents to do it. There also may be language regression, like returning to baby talk.

Q. These sound like pretty subtle signs.

A. Sometimes they are. We need to do a better job educating families, caregivers and teachers on signs and symptoms of stress reactions in children. With the numbers of children affected by recent world events, we really need to expand outreach to caregivers, educators and mental health and medical providers, because a lot of children show up in the physician's office or present clues to the school counselor or preschool teacher.

Q. How does the cognitive stage of very young children affect their experience when exposed to trauma?

A. Hearing that more than 2,000 people were killed, a 14-year-old understands that death is permanent, these people are not coming back to their families, whereas a 4-year-old's understanding of death isn't well developed yet and the concept of numbers that large is not there yet either. The experience is going to be more of a personal issue for the 4-year-old, while it is also more of a global issue for the 14-year-old.

Q. What can parents expect as anniversaries of traumatic events approach?

A. One of the things we can expect with anniversaries is a return or an increase in symptoms, because all of the triggers, all of the reminders are going to be there. This is true for adults and kids. Adults shouldn't be surprised if a child's schedule had returned to normal and then they go back to having problems with sleep, they become more irritable, their concentration is worse, their appetite is different. They're thinking about it more; their worries increase. That's pretty common around a significant reminder like an anniversary.

Over this past year, hopefully, we have talked with children and misconceptions and misunderstandings have been processed at a level they can understand, so that they do have better idea of what happened. This understanding will allow continued processing around the anniversary to be possible.

Q. Are there any positives that can be associated with the anniversary of a tragedy?

A. Anniversaries are an opportunity for us to commemorate what happened, but it is also really important that we use that time to think about where we have been, what we have accomplished in this past year. We shouldn't just remember and commemorate the tragedy and loss, but also look at how far we have come and where we're going next, so that there is some forward thinking. Kids need to be part of this so that they can own the event too.

Q. What role can parents play in lessening children's distress? A. One thing that we do know is that adults are not good estimators of children's distress. We routinely underestimate it. That may be for a variety of reasons, including a lack of education in recognizing the subtle signs in children or it may be because some of the signs are internal, or it may be a product of wishful thinking or a combination of all these factors. Also, the idea that if you talk or ask about it you are going to retraumatize them and make things worse is a false assumption. Just "letting it go" may make it worse.

Q. Can parents getting treatment for their own distress be something that benefits their children?

A. Any time parents develop strategies to help their own mental health, it can only improve the way they work with their children. The reverse holds true too. Any kind of intervention program for working with children is strengthened by having components that educate and include caregivers.

Tragedies Can Affect Children on a Personal Level

Children today are exposed to various forms of traumatic events and violence, spanning a continuum defined by how personalized the trauma is.

Natural disasters, such as tornados or earthquakes, have little potential for being personalized, so they lie on one end of this continuum. In contrast, victims of rape or torture usually face their assailants. In between are technological disasters, such as dam bursts or airplane crashes that usually occur as the result of human error on a grand scale.

"If somebody is trying to hurt you, then there are a lot of questions about fairness. Why did they choose you? What's wrong with them? What's wrong with you? And if it is someone you know, there is the whole issue of being betrayed by someone you may have trusted," says Bonnie L. Green, Ph.D., of Georgetown University.

The extreme example of this is the child who has been sexually abused by a parent, when a mother or father should be protecting the child from harm rather than inflicting it, says Green, a past president of the International Society for Traumatic Stress Studies.

The more personal the trauma is, evidence suggests, the more likely persistent psychological problems are to arise from it. Such traumas are also more likely to include elements of anger and hostility. (10)

"Once people have had an experience like sexual abuse in childhood, it may interfere so profoundly with their development that they are then more vulnerable to having other events happen to them," she says.

Green noted research of her own in which women who had been sexually abused as children almost universally experienced trauma later in life as well. In contrast, women who were physically abused had a rate of trauma later in life that was more toward the norm.

"Part of coming to terms with having been through a traumatic event includes accepting the fact that the world isn't the way we think it ought to be," she said. "Struggling to make sense of it, asking why did this happen, is always part of trying to deal with a trauma, but when it has been an intentional trauma, it just adds another layer."

That layer can raise trust issues that complicate the individual's relationships, not only with people in their lives, but with therapists trying to help them cope with the aftermath of their trauma, Green notes.

Victims of interpersonal violence are also more likely to come away from their experience with multiple psychological disorders, in addition to self-esteem and trust issues, meaning the traumas that children suffer can have a lifelong effect.

Signs and Symptoms of PTSD in Children

From the National Center for PTSD

Young children (1-6 years):

• Helplessness and passivity; lack of usual responsiveness


• Generalized fear


• Heightened arousal and confusion


• Cognitive confusion


• Difficulty talking about event; lack of verbalization


• Difficulty identifying feelings


• Nightmares, sleep disturbances


• Separation fears and clinging to caregivers


• Regressive symptoms (e.g., bed-wetting, loss of speech/motor skills)


• Inability to understand death as permanent


• Anxieties about death


• Grief related to abandonment by caregiver


• Somatic symptoms (e.g., stomach aches, headaches)


• Startle response to loud noises


• "Freezing" (sudden immobility)


• Fussiness, uncharacteristic crying, neediness
• Avoidance of or alarm response to specific trauma-related reminders involving sights/physical sensations

School-aged children (6-11 years):

• Feelings of responsibility and guilt


• Repetitious traumatic play


• Feeling disturbed by reminders of the event


• Nightmares, other sleep disturbances


• Concerns about safety, preoccupation with danger


• Aggressive behavior, angry outbursts


• Fear of feelings, trauma reactions


• Close attention to parents' anxieties


• School avoidance


• Worry/concern for others


• Behavior, mood, personality changes


• Somatic symptoms (complaints about bodily aches/pains)


• Obvious anxiety/fearfulness


• Withdrawal


• Specific trauma-related fears; general fearfulness


• Regression (behaving like a younger child)


• Separation anxiety


• Loss of interest in activities


• Confusion, inadequate understanding of traumatic events (more evident in play than in discussion)


• Unclear understanding of death, causes of "bad" events


• Giving magical explanations to fill in gaps in understanding


• Loss of ability to concentrate at school, with lower performance


• "Spacy" or distractible behavior

Pre-adolescents and adolescents (12-18 years):

• Self-consciousness


• Life-threatening re-enactment


• Rebellion at home or school


• Abrupt shift in relationships


• Depression, social withdrawal


• Decline in school performance


• Trauma-driven acting out, e.g. sexual activity, reckless risk-taking


• Effort to distance self from feelings of shame, guilt, humiliation


• Excessive activity/involvement with others, or retreat from others in order to manage inner turmoil


• Accident proneness


• Wish for revenge, action-oriented responses to trauma


• Increased self-focusing, withdrawal


• Sleep/eating disturbances, including nightmares

Online Resources

Health Behavior News Service's Facts of Life
* Grief: Coming to Terms With Loss Six Months After Sept. 11
March 2002

* PTSD: The Psychological Wounds of Terror
Oct. 2001

The National Center for Children Exposed to Violence

The ChildTrauma Academy

The International Society for Traumatic Stress Studies

The National Child Traumatic Stress Network

National Center for PTSD

The Sidran Institute

The Research

Bibliography

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2. Applied Research and Consulting, LLC, Columbia University Mailman School of Public Health & New York State Psychiatric Institute. (2002) Effects of the World Trade Center attacks on NYC public school students: initial report to the New York City Board of Education.

3. Fletcher, K.E., (1996). Childhood posttraumatic stress disorder. In E.J. Mash & R.A. Barkley (Eds.) Child Psychopathology (pp. 242-276). NY: The Guilford Press.

4. Perry, B.D., (1999) Effects of traumatic events on children: an introduction. Child Trauma Academy.

5. Green, B.L., Goodman, L.A., Krupnick, J.L., et al. (2000) Outcomes of single versus multiple trauma exposure in a screening sample. Journal of Traumatic Stress 13(2), 271-286.

6. Kilpatrick, D. & Saunders, B. (1997). Prevalence and consequences of child victimization. Research Preview. Washington, D.C.: National Institute of Justice, U.S. Department of Justice.

7. Carlson, B.E. (1984) Children's observations of interparental violence. Edwards, A.R. (ed.) Battered Women and Their Families. New York: Springer. pp147-167.

8. Schlenger, W.E., Caddell, J.M., Ebert, L., et al. (2002) Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11. Journal of the American Medical Association 288(5), 581-588.

9. Peter D. Hart Research Associates. Students' reactions to September 11 and the war on terrorism. (2001) Horatio Alger Association of Distinguished Americans Inc.

10. Green, B.L. (1998). Psychological responses to disasters: Conceptualization and identification of high-risk survivors. Psychiatry and Clinical Neurosciences, 52 (Suppl.), 567-573.

11. Farmer, E.M., Stangl, D.K., Burns, B.J., et al. (1999) Use, persistence, and intensity: patterns of care for children's mental health across one year. Community Mental Health Journal 35(1), 31-46.

12. Bell, C.C. & Jenkins, E.J. (1993) Community violence and children on Chicago's southside. Psychiatry 56(1), 46-54.

13. Pfefferbaum, B., Nixon, S.J., Tivis, R.D., et al. (2001) Television exposure in children after a terrorist incident. Psychiatry 64(3), 202-211.

14. Schonfeld, D. Almost one year later: looking back and looking ahead. (2002) Journal of Developmental and Behavioral Pediatrics (23)4.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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