Reaching Out to Children

The September 11 events triggered profound reactions in everyone. The world became a scary and overwhelming place for those injured, loved ones, survivors, and witnesses-including children of all ages. Whether a child lost a loved one or viewed the events on televison, child-serving institutions saw different types of reactions to the terrorist attacks and their aftermath (see previous articles). Many staff in these institutions had no experience in how to respond to the unique mental health needs of children following these events.

There are many parallels between the recent events and child maltreatment. In both cases, the events are perceived as an attack and children fear for their lives or those of the people they love. Children who have been abused know the confusion and shock that comes from being hurt with no apparent reason. They know quite well how it feels to live in an unsafe world. Children who have witnessed or experienced trauma struggle on a daily basis to feel safe. Some have had to work hard at knowing that they are safe, and that they no longer have to live in fear of another "attack."

Not much has been said about the impact of the September 11 events on children in the child welfare system who may be reacting strongly to these events, as the tragedy aggravates the effects of past traumas and fears.

Post-traumatic stress disorder

Frightening things happen to children all the time, whether they experience the death of a beloved grandparent, being hospitalized, or other stressors. In most cases, children are scared, sad, angry, or confused for a period of time. Soon, they are able to get their strength back and move on with a sense of confidence that they can cope when times get tough. It may happen that when something reminds them of the frightening incident, they become sad or scared again for a while.But the grief or fear does not interfere with their everyday life. But being "traumatized" is a different kind of being scared. When anyone, young or old, experiences a real or perceived threat to his or her life (or to the life of someone very close), certain physiological changes are automatically triggered: the heart rate quickens, stress hormones pour into the bloodstream. In the immediate aftermath of the trauma, almost everyone will have acute mental health needs that are demonstrated in symptoms such as extreme anxiety, nightmares, or fearfulness. Sometimes the part of the brain that triggered the initial alarm goes into overdrive and never calms down. Recurring intrusive recollections of the event cause an individual to remain in a perpetual state of fear and anxiety, on the lookout for signs of danger. Or, children may become emotionally numb-appearing as if they are fine-but their hearts are racing and their brains are shrieking "danger." This is what is called post-traumatic stress disorder (PTSD).

Children can demonstrate symptoms of PTSD after witnessing isolated, terrifying events, such as a devastating hurricane, tornado, or living with chronic domestic or community violence or physical abuse. These children may be in a constant state of fearfulness, reliving the experience over and over again in their play, their sleep, their drawings, their speech, or their relationships with others, as they try to make sense of the incomprehensible. Some show disorganized and agitated behavior; they may regress to earlier behaviors such as clinging, bedwetting, or thumb-sucking; they may become irritable and have difficulty sleeping or concentrating. Worse still, because some people do not believe that children can be affected-even by a single traumatic experience-their symptoms are frequently overlooked or dismissed and many children never receive treatment.

Some signs of post-traumatic stress are obvious. Infants cry and cling more than usual. Pre-schoolers regress to soiling their pants, sucking their thumbs, or stuttering. School-age children are unable to concentrate on work or complain of headaches, stomachaches, nausea, or nightmares. They may even convince themselves that the terrible ordeal they witnessed will happen again-and worse-that they were responsible for its occurrence in the first place. However, because many trauma symptoms are less obvious, they are easy to miss or misinterpret-the withdrawn child with the blank facial expression will not be as noticed as the child who wakes up screaming in the middle of the night.

Mental health needs of children in child welfare

It is normal for children to suffer from sleeplessness, lack of concentration, and other stress-related symptoms for several weeks following a very frightening event. People who work with traumatized children have learned that to some extent, the children's ability to rebound from a stressful event (resilience) is generally related to their growing up in a loving, nurturing home or having a teacher, coach, or grandparent who cares about or believes in them. It is also related to the child's temperament, cognitive and social skills, and emotional development. The age of a child, as well as the duration and source of the trauma, affects a child's ability to cope, too.

Children in the child welfare system may be less resilient because they have histories that render them especially vulnerable to the effects of the terrorist attacks. And it gets more complicated when incidents continue, as they have done, with the anthrax scare coming just a month after the initial September 11 attack. Witnessing or experiencing violence can be extremely disturbing to all children with previous histories of trauma who may strongly react as old pain, fear, and insecurities of previous losses are remembered.

Addressing the mental health needs

Past research has documented that exposure to community violence may have enduring consequences on children's development, beginning in the preschool years and continuing through adolescence. This research has also documented that children who are exposed to multiple forms of violence are more at risk of developing psychological consequences than those exposed to single or isolated violent events (either at home or in the community). Therefore, children in inner-city neighborhoods, with high violent crime rates, and with a history of child maltreatment may be in double jeopardy.

The child welfare system, schools, and the network of community-based organizations serving the needs of maltreated children need to be prepared to respond to unique mental health needs of children and youth with previous history of abuse and violence. When children have lived with violence, their reaction to traumatic experiences are likely to be different from that of other children. Watching, hearing, or later learning of a parent being harmed further threatens their fragile sense of stability and security. Children's reactions may take several forms. Some children may become anxious, fearful, or withdrawn, symptoms that are referred to as internalizing problems or taking fears inward. Sadness, fear, guilt, anger, shame, and confusion are often experienced. Other children may externalize their problems, and express their fears by being hostile or using aggression to as a way to solve interpersonal conflict with the adult world or with their peers. The specialized mental health needs of children and families in the child welfare system require consistent, ongoing attention, which cannot be obtained in a single counseling or debriefing session.

Suggestions for families

Children who have been traumatized may react by behaving in ways that show their stress and fear. Here are some ways they behave and how you can help:

Regression. Relate to children at the age level they have returned to and try to gently help them regain their skills.

Separation fears. Be patient. Give children extra time and nurturance during transition periods in the day, especially when they are separating from you and at bedtime.

Fear. Let children know that it is okay to be scared; they do not need to be brave. Let them know that they are not alone and that you are there to protect and love them.

Breaking the rules. Try to maintain the same rules and expectations. Knowing what is expected from them helps children feel safe. Do not use physical punishment, which only shows that it is okay to use violence to solve problems. Instead, use reasoning, distraction, logical consequences, and empathy.

Nightmares. Encourage the child to express his or her worries during the day so that they are not lurking in his or her mind at night. Talk to children about their bad dreams. Help the child come up with an ending that he or she would like. Go over the "good" ending before the child goes to sleep. Also, assure the child that the nightmares will go away with time.

Anniversary reactions. Anniversaries provide an opportunity to acknowledge the feelings that are still there and also talk about new feelings and thoughts.