Terrorist Attacks and Children
A National Center for PTSD Fact Sheet
by Jessica Hamblen, Ph.D.

On Tuesday, September 11, 2001, the nation was shocked by the news of a terrorist attack on the United States. Two airliners crashed into the World Trade Center, and one struck the Pentagon. There were reports of people jumping out of the World Trade Center to their death. As adults, many of us gathered around televisions and radios seeking information and discussing the tragedy with our friends, family, and co-workers. But how should we speak to our children about this event? Should we shield them from such horrors or talk openly about them? How can we help children make sense of a tragedy that we ourselves cannot understand? How will children react? How can we help our children recover? Fortunately, there have been few terrorist attacks on the United States. One consequence of this is that there is little empirical research to help us answer the above questions. Instead, information from related events can be used to provide answers.

How do children respond to trauma?

There is a wide range of emotional and physiological reactions that children may display following disaster. From previous research, we know that more severe reactions are associated with a higher degree of exposure (i.e., life threat, physical injury, witnessing death or injury, hearing screams, etc.), closer proximity to the disaster, a history of prior traumas, being female, poor parental response, and parental psychopathology.

Findings from a study following the Oklahoma City bombing indicate that more severe reactions were related to being female, knowing someone injured or killed, and bomb-related television viewing and media exposure (Pfefferbaum et al., 1999; Pfefferbaum et al., 2000).

Below are some common reactions that children and adolescents may display (Dewolfe, 2001; Pynoos & Nader, 1993).

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 and other sleep disturbances
• Separation fears and clinging to caregivers
• Regressive symptoms (e.g., bedwetting, loss of acquired speech and 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 or unusual noises
• "Freezing" (sudden immobility of body)
• Fussiness, uncharacteristic crying, and neediness
• Avoidance of or alarm response to specific trauma-related reminders involving sights and physical sensations

School-aged Children (6-11 years)

• Feelings of responsibility and guilt
• Repetitious traumatic play and retelling
• Feeling disturbed by reminders of the event
• Nightmares and other sleep disturbances
• Concerns about safety and preoccupation with danger
• Aggressive behavior and angry outbursts
• Fear of feelings and trauma reactions
• Close attention to parents' anxieties
• School avoidance
• Worry and concern for others
• Changes in behavior, mood, and personality
• Somatic symptoms (complaints about bodily aches and pains)
• Obvious anxiety and fearfulness
• Withdrawal
• Specific trauma-related fears; general fearfulness
• Regression (behaving like a younger child)
• Separation anxiety
• Loss of interest in activities
• Confusion and inadequate understanding of traumatic events (more evident in play than in discussion)
• Unclear understanding of death and the causes of "bad" events
• Giving magical explanations to fill in gaps in understanding
• Loss of ability to concentrate at school, with lowering of performance
• "Spacey" or distractible behavior

Pre-adolescents and Adolescents (12-18 years)

• Self-consciousness
• Life-threatening reenactment
• Rebellion at home or school
• Abrupt shift in relationships
• Depression and social withdrawal
• Decline in school performance
• Trauma-driven acting out, such as with sexual activity and reckless risk taking
• Effort to distance oneself from feelings of shame, guilt, and humiliation
• Excessive activity and involvement with others, or retreat from others in order to manage inner turmoil
• Accident proneness
• Wish for revenge and action-oriented responses to trauma
• Increased self-focusing and withdrawal
• Sleep and eating disturbances, including nightmares

How should you talk to your child?

Create a safe environment.
One of the most important steps you can take is to help children feel safe. If possible, children should be placed in a familiar environment with people that they feel close to. Keep your child's routine as regular as possible. Children find comfort in having things be consistent and familiar.

Provide children with reassurance and extra emotional support.
Adults need to create an environment in which children feel safe enough to ask questions, express feelings, or just be by themselves. Let your children know they can ask questions. Ask your children what they have heard and how they feel about it. Reassure your child that they are safe and that you will not abandon them.

Be honest with children about what happened.
Provide accurate information, but make sure it is appropriate to their developmental level. Very young children may be protected because they are not old enough to be aware that something bad has happened. School age children will need help understanding what has happened. You might want to tell them that there has been a terrible accident and that many people have been hurt or killed. Adolescents will have a better idea of what has occurred. Talk to them about terrorism and how the United States responds to terrorism. It may be appropriate to watch selected news coverage with your adolescent and then discuss it.

Tell children what the government is doing.
Reassure children that the state and federal government, police, firemen, and hospitals are doing everything possible. Explain that people from all over the country and from other countries are offering their services.

Be aware that children will often take on the anxiety of the adults around them.
Parents have difficulty finding a balance between sharing their own feelings with their children and not placing their anxiety on their children. For many, the attack on the United States was inconceivable. Our sense of safety and freedom was shattered. Many parents may feel scared and fearful of another attack. Others may be angry and revengeful. Parents must deal with their own emotional reactions before they can help children understand and label their feelings. Parents who are frightened may want to explain that to their child, but they should also talk about their ability to cope and how family members can help each other.

Try to put the attack in perspective.
Although you yourself may be anxious or scared, children need to know that the attack is a rare event. They also need to know that most people will never be attacked by terrorists and the world is generally a safe place.

What can parents do?
(Excerpted from Monahon, 1997)

Infancy to two and a half years:

• Maintain child's routines around sleeping and eating.
• Avoid unnecessary separations from important caretakers.
• Provide additional soothing activities.
• Maintain calm atmosphere in child's presence.
• Avoid exposing child to reminders of trauma.
• Expect child's temporary regression; don't panic.
• Help verbal child to give simple names to big feelings; talk about event in simple terms during brief chats.
• Give simple play props related to the actual trauma to a child who is trying to play out the frightening situation (e.g., a doctor's kit, a toy ambulance).

Zero-to-Three has published excellent guidelines for parents whose very young children (ages 0 to 3) might have been exposed to media or conversations about the recent terroristic events.

Two and a half to six years:

• Listen to and tolerate child's retelling of the event.
• Respect child's fears; give child time to cope with fears.
• Protect child from re-exposure to frightening situations and reminders of trauma, including scary TV programs, movies, stories, and physical or locational reminders of trauma.
• Accept and help the child to name strong feelings during brief conversations (the child cannot talk about these feelings or the experience for long).
• Expect and understand child's regression while maintaining basic household rules.
• Expect some difficult or uncharacteristic behavior.
• Set firm limits on hurtful or scary play and behavior.
• If child is fearful, avoid unnecessary separations from important caretakers.
• Maintain household and family routines that comfort child.
• Avoid introducing experiences that are new and challenging for child.
• Provide additional nighttime comforts when possible such as night lights, stuffed animals, and physical comfort after nightmares.
• Explain to child that nightmares come from the fears a child has inside, that they aren't real, and that they will occur less frequently over time.
• Provide opportunities and props for trauma-related play.
• Try to discover what triggers sudden fearfulness or regression.
• Monitor child's coping in school and daycare by expressing concerns and communicating with teaching staff.

Six to eleven years:

• Listen to and tolerate child's retelling of the event.
• Respect child's fears; give child time to cope with fears.
• Increase monitoring and awareness of child's play which may involve secretive reenactments of trauma with peers and siblings; set limits on scary or hurtful play.
• Permit child to try out new ways of coping with fearfulness at bedtime: extra reading time, leaving the radio on, or listening to a tape in the middle of the night to erase the residue of fear from a nightmare.
• Reassure the older child that feelings of fear and behaviors that feel out of control or babyish (e.g., bed wetting) are normal after a frightening experience and that he or she will feel better with time.

Eleven to eighteen years:

• Encourage adolescents of all ages to talk about the traumatic event with family members.
• Provide opportunities for the young person to spend time with friends who are supportive.
• Reassure the young person that strong feelingsguilt, shame, embarrassment, or a wish for revengeare normal following a trauma.
• Help the young person find activities that offer opportunities to experience mastery, control, and self-esteem.
• Encourage pleasurable physical activities such as sports and dancing.

How many children develop PTSD?

The above symptoms are normal reactions to trauma and do not necessarily mean that a child has acquired a disorder. However, a significant minority of children will develop posttraumatic stress symptoms (for more on Posttraumatic Stress Disorder, see PTSD in Children and Adolescents and Treatment for PTSD). Findings from Oklahoma City indicate that:

• Children who lost a friend or relative were more likely to report immediate symptoms of PTSD than non-bereaved children.

• Arousal and fear presenting seven weeks after the bombing were significant predictors of PTSD (Pfefferbaum et al., 1999).

• Two years after the bombing, 16% of children who lived approximately 100 miles away from Oklahoma City reported significant PTSD symptoms related to the event (Pfefferbaum et al, 2000). This is an important finding because these youths were not directly exposed to the trauma and were not related to people who had been killed or injured.

• PTSD symptomatology was predicted by media exposure and indirect interpersonal exposure, such as having a friend who knew someone who was killed or injured.

No study specifically reported on rates of PTSD in children following the bombing. However, studies have shown that as many as 100% of children who witness a parental homicide or sexual assault, 90% of sexually abused children, 77% of children exposed to a school shooting, and 35% of urban youth exposed to community violence develop PTSD.

Due to the nature of this attack, we predict very high rates of PTSD in children who lost a family member or witnessed the plane crashes and after-effects. Based on research from Oklahoma City, we can predict that PTSD may develop in children exposed to media coverage or who had a friend or family member that was killed or injured.

When should you seek professional help for your child?

Many children and adolescents will display some of the symptoms listed above as a result of the terrorist attacks. Most children will likely recover in a few weeks with social support and the aid of their families. Many of the above suggestions will help children recover more quickly. Other children, however, may develop PTSD, depression, or anxiety disorders. Parents of children with prolonged reactions or more severe reactions may want to seek the assistance of a mental-health counselor. It is important to find a counselor who has experience working with children as well as with survivors of trauma. Referrals can be obtained through the American Psychological Association at 1-800-964-2000. For more information, please see our Seeking Help fact sheet.

FOR MORE INFORMATION ABOUT TALKING TO KIDS ABOUT THESE EVENTS, SEE:

American Psychological Association

National Institute of Mental Health

American Academy of Child and Adolescent Psychiatry

Federal Emergency Management Agency

Sesame Street

Twin Cities Public Television

Harvard University

Mentalhealth.org

Disaster Training International

For a site for CHILDREN to visit, see:

Federal Emergency Management Agency

For teachers and schools:

The Child Trauma Academy

References:

DeWolfe, D. (2001). Mental Health Response to Mass Violence and Terrorism: A Training Manual for Mental Health Workers and Human Service Workers.

Monahon, C. (1997). Children and Trauma: A Guide for Parents and Professionals. San Francisco: Jossey Bass

Pfefferbaum, B., Nixon, S., Tucker, P., Tivis, R., Moore, V., Gurwitch, R., Pynoos, R., & Geis, H. (1999). Posttraumatic stress response in bereaved children after Oklahoma City bombing. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1372-1379.

Pfefferbaum, B., Seale, T., McDonald, N., Brandt, E., Rainwater, S., Maynard, B., Meierhoefer, B. & Miller, P. (2000). Posttraumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion. Psychiatry, 63, 358-370.

Pynoos, R. & Nader, K. (1993). Issues in the treatment of posttraumatic stress in children and adolescents. In J.P. Wilson & B. Rapheal (Eds.), International Handbook of Traumatic Stress Syndromes (pp. 535-549). New York: Plenum.

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