Children’s Responses to
Terror and Trauma
John Sargent, M.D.
Children’s Responses depend
upon several variables:
Child’s age and developmental status
Previous experiences of trauma
Family risk and resiliency factors
Children’s Responses depend
upon several variables (cont):
Preexisting attachment relationship
Nature of traumatic experience and
continuing threat
Nature of community and family support
Influence of Developmental Stage
on Child Responses
Preschool children
Primary problems are related to separation



Refuse to attend preschool
Sleeping with parent
Whining and clinging behavior with parent
Influence of Developmental Stage
on Child Responses (cont.)



Trouble sleeping and nightmares
Reactive aggressiveness
Repressive behaviors; bed wetting and fears
Influence of Developmental Stage
on Child Responses (cont.)
School Age Children



Attention and concentration problems
Anxiety with associated school avoidance,
fears and somatic symptoms
Sleep problems and nightmares
Influence of Developmental Stage
on Child Responses (cont.)


Angry outbursts
Depression and withdrawal
Influence of Developmental Stage
on Child Responses (cont.)
Adolescence



Hypervigilance and intrusive thoughts
Emotional numbing and nightmares
avoidance
Influence of Developmental Stage
on Child Responses (cont.)



Peer and family problems
Substance abuse
Overt depression
Influence of Developmental Stage
on Child Responses (cont.)
Other affective aspects of
trauma/terrorism




Humiliation, shame and self-blame
Alienation and demoralization
Chronic anger and irritability
Reexperiencing worsening other symptoms
Unique features of Terroristic
Events Effects on Children
Terroristic events have a profound
effect upon adults – including parents
and teachers
Adult depression may negatively
influence children
Adults may underestimate effects upon
children, especially for distant events
Parents’ emotional responses very
influential in the children’s reactions
Persistent threat worsens
children’s exposure and
reactions
Repeated media viewing also
worsens the effects upon
children
PTSD occurs in 30 – 50% of
children exposed to terrorist
violence
Physical proximity, degree of
actual family member
involvement and witnessing
violence significantly increase
risk of developing PTSD
10% of New York City public
school students developed PTSD
after September 11, 2001. World
Trade Center attacks.
Disruption, confusion, chaos,
uncertainty of events and
surrounding events often
worsens the situation
Rumors, excitement, disorder
among helpers can be present at
the scene or at hospital or care
settings
Parental availability and support
is highly protective for children
(including adolescents)
Helpful interventions:
Establishing order at the site
Ensuring coordinated, cooperative and
competent activity among helpers
Ensure parents are with children if
possible
Helpful interventions (cont.):
Provide accurate and complete
information as soon as available
Ensure appropriate medical care
Support parents and family care givers
especially if child is injured and receiving
hospital care
Psycho educational supports for
families and community networks
also are helpful and can lead to
rebuilding efforts for the
community
School based interventions for
children can be very helpful:
group discussions, resumption of
daily routine and structure,
gradual expectation of training
and competence
Dimensions of Assessment
Physical well being, differences, acute
symptoms and physiologic problems
Developmental capacities, variability,
deficiencies and areas of regression
Nature of trauma and its effects
Cognitive capacities including intellectual
capacity, specific areas of learning
disability and ability to utilize cognitive
capacity to understand trauma
• Psychiatric symptoms and
diagnostic considerations
including:
Acute Stress Reaction
PTSD
Depression
Substance Abuse
Eating Disorders
Complex PTSD
Conduct Disorder, etc.
Assessment of Context: family
relationships and interaction, community
connectedness, community institutions
and rituals
Areas of Risk and Resilience: family
risk, poverty, social discrepancies,
individual strengths, skills and
competencies, family and community
connection and support.
• Other important issues:
Cultural background
Ethnicity
Cultural stories of adversity and survival
Belief systems about trauma recovery
Peer relationships
Current functioning





academic
family
social
community
(especially in relation to expected development)
Stage I: Stabilization
Develop a collaborative team with
planned, coordinated responses to
traumatic events that are competent,
compassionate and caring
Parents will need to be invited to be
members of the team with defined and
important roles
Swiftly end traumatic events and define
all future responses as courageous
healing efforts (no matter how disruptive
or painful)
Treatment is based upon
building a relationship of
connection and trust,
recognizing the experience of
shock, anxiety and arousal in
the child and family
Ensuring physical and
psychological comfort produces
the possibility of focused
attention so that information
about plans, procedures and
treatment can be shared with
and gained by child and family
Predictability, clarity, integrity and
competence follow the explanations to
reinforce trust and collaboration
Be prepared to operate on limited,
incomplete and often disguised
information, focusing upon what is
known and what is required by the
situation
Do not expect that a one time
large scale debriefing or
counseling effort will produce
large scale recovery - in fact
“Critical Incident Debriefing”
often worsens individual
psychological responses
Stage II: Restoration
Identify key issues which require attention
to reestablish continuity of life for children
and their family:


Housing - Living situation - Care-taking
relationships
Centrality of Parental Figures (if possible)


Financial resources to ensure family
continuity
Building competence through encouragement
and active reinforcement of rehabilitation
activities


Recognizing grieving as an important activity
Identify appropriate anger and begin
discussions of accountability

Resume, whenever possible, developmentally
appropriate activities with parental
encouragement (which reinforces parenting
role)
At this point a comprehensive
assessment highlighting individual
risk and resilience factors,
attention to psychiatric symptoms,
and specifics of traumatic
experience and emotional
reactions is essential and points to
appropriate interventions
These interventions further
reinforce the relationship
between the family and the
healing system and further
support future collaboration
This leads to increasing clarity
about what has changed,
been lost and must be grieved
for as well as what new
competencies have emerged
and must be integrated
Build to a recognition of an
integrated appreciation of a
transformed child and family
Stage III: Recovery
This stage focuses directly upon attention
to significant psychiatric symptoms and
syndromes
This requires integrated therapeutic
responses


Exposure and response prevention directly
addresses PTSD symptoms (e.g. Foa’s
treatment for rape victims)
Family therapy leads to greater
organization, more parental effectiveness
and improved social support

Attachment focused psychodynamic
psychotherapy enhances mentalization,
reduces interpersonal objectification and
enhances empathy

Cognitive - behavioral therapy addresses
depressed mood, inappropriate attributions of
helplessness and shame and excessive focus
upon retribution and revenge


Psychopharmacology to improve mood,
increase threshold and decrease amplitude of
arousal
Behavioral support to decrease avoidance

Enhancing physiologic self-awareness to
assist in managing and modulating arousal
and psychologic self-awareness to
appropriately assess danger

Work toward the consolidation of a coherent
narrative of self, family, community
experiences of this trauma that becomes a
nuanced, textured memory that can be
recalled as a whole and reviewed without
reproduction of heightened arousal
An orientation toward
community and national (if
possible) growth through
advocacy, truth and
reconciliation experiences,
memorial and artistic expression
Key Issues
Competence and connection are
antidepressants
Information, predictability, intellectual
mastery and mentalization manage
anxiety, splitting and impulsivity
Recognition of what needs to be protected
now and of the value of new skills promote
consolidation of a transformed self
Therapist is vulnerable to burn out,
vicarious traumatization and personal
experience of vicitimhood
Therapists will need to identify the value
and meaning of their work while they
integrate their awareness of tragic
events and of change and growth that
reinforces hope