Traumatic events and children: how early childhood educators can help.

The terrorist attacks of September 11, 2001, directly or indirectly affected thousands of people, including young children. Many children lost their parents or other loved ones. Many parents lost their jobs, or their lives changed dramatically in some other way. Considering these widespread effects, it is almost impossible to present an accurate estimate of how many people were affected by the September 11th attacks. Terrorist attacks, of course, are not the only cause of psychological trauma in young children. Other causes include natural disasters (e.g., earthquakes, tornadoes, or floods); man-made disasters (e.g., acts of war, accidents, hostage situations, school shootings); the sudden death of a family member or loved one; or exposure to physical, sexual, or emotional abuse (Brown, 1996; Fitzpatrick & Boldizar, 1993; Richards & Bates, 1997).

In this article, the author seeks to examine children's responses to traumatic events and common symptoms of posttraumatic stress disorder (PTSD). Once teachers recognize and understand the possible cognitive, affective, behavioral, and physiological-somatic effects of trauma, they will be ready to try the different strategies and activities described here to help children cope with the negative effects of trauma.

POSTTRAUMATIC STRESS DISORDER

The American Psychiatric Association (1994) defines PTSD as "the development of characteristic symptoms following exposure to an extreme traumatic stressor" (p. 424). PTSD criteria include: 1) exposure to a remarkable, distressing traumatic event; 2) one or more symptoms of persistent reexperiencing; 3) three or more symptoms of persistent avoidance of stimuli associated with the trauma; 4) two or more symptoms of persistent increased arousal; 5) duration of the disturbance for longer than 1 month; and 6) clinically significant disturbance or impairment in social, occupational, or other important areas of functioning caused by the disturbance (American Psychiatric Association, 1994).

Methods for assessing or screening for PTSD in children, depending on their age, include structured interviews, questionnaires, self-report scales, inventories, and psychophysiological evaluation (Greenwald & Rubin, 1999; McNally, 1996; Sauter & Franklin, 1998). Children with PTSD need professional help. However, not every child who experiences a traumatic event develops PTSD (or may not meet the requirements for diagnosis). Nevertheless, these children may be adversely affected by the traumatic events.

Prevalence

Estimates of PTSD prevalence among children vary widely across studies. For example, Pynoos and colleagues (1987) reported a prevalence rate as high as 94 percent, whereas Earls, Smith, Reich, and Jung (1988) cited the lifetime prevalence of PTSD occurring in children as 62.5 percent. In their comprehensive literature review, Saigh, Green, and Korol (1996) reported that the lifetime prevalence of PTSD is between 5.6 percent to 32.0 percent in children who survive disasters. Sauter and Franklin (1998) ascribe these extreme differences in the prevalence rate of PTSD to the type of trauma being reported and the diagnostic criteria being used.

Lifetime prevalence of PTSD varies, depending on the type of traumatic event in specialized populations (i.e., trauma victims) and the general population. For example, women tend to display more PTSD symptoms related to childhood sexual abuse, compared to men (Finkelhor, Hotaling, Lewis, & Smith, 1990). According to the National Center for Posttraumatic Stress Disorder (NCPTSD, 2001), children who experience traumatic events before age 11 are more likely to display psychological symptoms associated with PTSD than those who experience traumatic events at a later age. The Center also estimates that PTSD occurs in 32 to 60 percent of the adults and 29 to 95 percent of the children affected by traumatic events. Following the 1988 earthquake in Armenia, Goenjian and Pynoos (1995) studied 111 children (ages 8-16) and found that 18 months after the disaster, 70 percent of the children met the criteria for PTSD.

Protective and Risk Factors

Reactions to traumatic events differ, depending on protective and risk factors. While protective factors promote or maintain healthy development, risk factors increase the likelihood of psychological disorders. Protective factors may be individual (high IQ; competencies in academic, artistic, athletic, or mechanical domains); familial (the presence of at least one loving, dependable parent; socioeconomic advantage; or social support from an extended family network); or superordinate (involvement with prosocial institutions, peer relations) (Masten & Coatsworth, 1998; Rutter, 1990). Risk factors can be organic (birth defects, neurological damage, malnutrition); intrapersonal (low IQ, low self-esteem, poor self-control); interpersonal (parental neglect or abuse, poor peer relations); or superordinate (poverty, race) (Kazdin, Kraemer, Kessler, Kupfer, & Offord, 1997). Other factors, including age, gender, the severity of the trauma, and parental distress, have been directly related to PTSD (Falasca & Caulfield, 1999; Milgram, Toubiana, Klingman, Raviv, & Goldstein, 1988; Pynoos et al., 1993).

Age and gender. Green and her colleagues (1991) rated the clinical reports of 179 children (ranging from 2 to 15 years old) and found a higher incidence of PTSD among females, and a lower frequency among younger children (2-7 years) as compared to the older children (8-15 years). Studies also show that girls display higher frequency of PTSD symptoms (Milgram et al., 1988; Pynoos et al., 1993).

Trauma exposure severity. Trauma exposure severity and parental distress (Falasca & Caulfield, 1999) have been found to be positively correlated with risk for childhood PTSD (Foy, Madvig, Pynoos, & Camilleri, 1996; Kratochwill, 1996).

After the attacks of September 11, people around the world, including young children, watched the television news and witnessed endless replays of the destruction rendered by the attacks. It has been suggested that turning off the television during the news or limiting the amount of time spent watching television may limit young children's exposure to such traumatic events. Older children might benefit from adult supervision when watching the news; they should be encouraged to express their ideas and join any subsequent discussion (University of Illinois Extension, 2002).

Children's Responses to the Traumatic Events

If a traumatic event results in changes in living conditions, such as after the loss of a loved one or family property, life may never return to "normal." It is important to know that everyone who experiences such traumatic events is not affected in the same way; some never experience trauma-related problems, while others may exhibit different, less severe symptoms of PTSD (American Psychiatric Association, 1994). Armsworth and Holaday (1993) examined the effects of psychological trauma on children and adolescents, and categorized these effects as cognitive, affective, behavioral, and physiological-somatic effects. These effects are summarized briefly below.

Cognitive effects. After a traumatic event, such as an earthquake, children may believe that the disaster will happen again, or they may even feel that they are responsible for the disaster. Other cognitive responses to trauma may be confusion, academic difficulties, learning difficulties, developmental delays, diminished language and communication skills, and lowered IQ (Armsworth & Holaday, 1993; Richards & Bates, 1997).

Affective effects. Children who have been exposed to a traumatic event may become emotionally upset or disturbed. They may display nighttime fears, anger, irritability, lower tolerance for stress, nervousness, compulsiveness, helplessness, and/or powerlessness (Armsworth & Holaday, 1993; Richards & Bates, 1997).

Behavioral effects. The behavior of children who have experienced significant trauma can shift from quiet to loud, outgoing to shy, and confident to afraid. They may refuse to go to school. Children with PTSD may display developmentally regressive behaviors such as enuresis, thumb sucking, or loss of previously learned academic and social skills. Older children and adolescents may try drugs, drink alcohol, or even attempt suicide. Other typical maladjustive responses to trauma include self-abusiveness, self-destructiveness (including increased risk-taking behavior), and behavioral patterns that reflect anxious/avoidant attachments or anxious/resistant attachments (Armsworth & Holaday, 1993; Gordon, Farberow, & Maida, 1999; Motta, 1994; Richards & Bates, 1997).

Physiological-somatic effects. Children under extreme stress may display several somatic symptoms, such as high fever, vomiting, and headaches (Gordon et al., 1999). Reminders of the traumatic event may result in hyperarousal, low tolerance for stress, sleep disorders, fatigue, eating disorders, and biochemical alterations in the brain (Armsworth & Holaday, 1993; Richards & Bates, 1997).

Symptoms may not appear immediately after the event. For example, one 10-year-old boy was only three blocks away from the World Trade Center when the second plane hit. Although he did not show any stress symptoms the first day, the next morning he refused to go to school, claiming that he had a stomachache (Spitalny, Gurian, & Goodman, 2002).

SUPPORT FOR CHILDREN WHO EXPERIENCED TRAUMATIC EVENTS

The regularity and order that families and schools bring to a child's life are critical. After a traumatic event occurs, parents and/or teachers will probably be the first to notice symptoms of PTSD (Crosse, 1996; Richards & Bates, 1997). If symptoms do appear, they are likely to become evident either immediately or between 3 to 6 months after the event (American Psychiatric Association, 1994). Exposure to abuse or domestic violence is highly correlated with low academic performance, learning problems, depression, regression, and behavioral and emotional problems (Fisher, 1999).

After large-scale disasters, such as earthquakes, floods, or war, the family may experience economic difficulties and may be forced to live in temporary housing. Such disruptions may have long-term effects on children's development (Gordon et al., 1999). Parents' and teachers' reactions to traumatic events also can affect children's responses to traumatic events. Falasca and Caulfield (1999) indicate that a caregiver may adversely affect children by acting overwhelmed, depressed, or helpless. In addition, some parents may feel unsure of the best way to react to their child's trauma-related behaviors (Munson, 1995).

Fortunately, school systems may provide effective support for children who have experienced traumatic events. Despite the unpredictable nature of traumatic events, teachers and school counselors, as well as parents, may be able to help children manage. They can teach children coping skills such as how to summon help and how to give help (e.g., age-appropriate first aid), provide information on survival behaviors (e.g., practicing what to do in an emergency), and promote physical health (Crosse, 1996). Pope and Campbell (1992) found that a school-based interdisciplinary team was successful in providing support for children who displayed symptoms of PTSD after a hostage crisis. Three months after the intervention program had been completed, most of the students could function more effectively. Another study reported that although psychological debriefing did not prevent the occurrence of PTSD, it lessened the severity of symptoms (Vila, Porche, & Mouren-Simeoni, 2000).

WHAT CAN TEACHERS DO?

Although children who experience trauma require help from a professional counselor, psychologist, or therapist, early childhood educators also have a responsibility to intercede. They can try to understand what the children have experienced, recognize the signs of distress, and learn when to refer children for additional help. Teachers can help children to recover from a trauma by providing a sense of security and regularity in their classrooms, and by offering classroom activities that facilitate coping with traumatic events.

Providing a Sense of Security and Regularity in Classrooms

Establishing and practicing an evacuation plan can save the lives of young children and minimize the effects of trauma. For example, during the attacks of September 11, kindergarten teachers in New York City and in Washington, D.C., quickly evacuated the surrounding buildings, stayed calm, explained to children about the smoke, and reassured them that firefighters would help them (Geddes, 2002). Teachers need to provide a classroom environment that bespeaks safety and security. While children might need extra understanding and patience, teachers should maintain their typical expectations for students' behavior and performance. Providing structured, stable, and predictable routines, consistent rules, and immediate feedback will help children to feel more secure after a traumatic event.

Teachers' own psychological health. Before beginning to help children who are experiencing PTSD, teachers should acknowledge their own fears and feelings. Teachers are equally likely to be affected by emergencies and disasters (especially those of a large scale). Or, they may need to deal with personal trauma-related difficulties. The following strategies are helpful for teachers in coping with traumatic events: 1) acknowledging their feelings of anger, frustration, fear, sadness, or helplessness; 2) talking to friends, colleagues, or relatives about their feelings; and 3) managing stress by using relaxation techniques, exercising, and remembering to have fun (University of Illinois Extension Disaster Resources, 1998).

Classroom Activities That Facilitate Coping With Traumatic Events

Educators can teach coping strategies that restore or increase a child's level of functioning after a trauma. Specific strategies depend on the age of the children, and may include play-based and physical activities, discussion group activities, art activities, storytelling and writing activities, and multidisciplinary projects. Although most of these activities could be used in the aftermath of a wide variety of tragic events, they may not be appropriate for children who are victims of sexual abuse. Those children often require cognitive-behavioral therapy (King, 2000; Paolucci & Violato, 2001).

Play-based and physical activities. Children in an early childhood education setting need opportunities to use toys and other materials to reenact events from a disaster or traumatic event. Such play can help children to integrate their experiences and express their feelings. The play materials should be selected according to their recreational and therapeutic value (Gordon et al., 1999). Suggested materials may include rescue vehicles (such as ambulances, helicopters, or police cars) or dolls and family figures. With the help of these props, children can express their sadness over the loss of loved ones. Physical activities are another way to relieve tension and anxiety. Appropriate, gentle physical contact during times of stress can give children a sense of security.

Discussion group activities. Teachers can encourage anxious children to share their experiences and feelings in a group discussion. Such discussions are a good way to validate feelings about the experience, and children can learn from each other. By hearing about each other's feelings, children have the opportunity to share and reduce their fears and anxieties, and to learn from each other. Teachers can share their own feelings and fears with children. It is important to end group discussions on a positive note, promoting a sense of security or preparedness (Gordon et al., 1999).

Art activities. Art therapy and drawing is also recommended for children who experience different kinds of abuse in their home. This therapy gives the children an opportunity to symbolically express their fears, longings, and feelings (Gordon et al., 1999; Kent, 2002; Stronach-Buschel, 1990).

Coloring and drawing activities can stimulate children to draw, write, or talk about their experiences. Teachers can ask children to draw whatever comes to mind, or give them a question or topic to draw about. Teachers may also encourage children to develop skits or puppet shows about what happened during or after traumatic events.

After the attacks of September 11, many children around the country expressed their feelings by drawing pictures (examples of these drawings can be found at the Federal Emergency Management Agency's Web site at www.fema.gov/kids/k2k_sch1.htm). Many children drew pictures to say "thank-you" to the firefighters or rescue dogs. Depending on the children's age, teachers can combine a drawing activity with a short trip to the local fire station, for example.

Storytelling and writing activities. Storytelling (or writing, if the child is capable of writing) helps children to express their fears or thoughts. To initiate storytelling or writing, teachers can ask children to talk/write about a specific topic such as: how did they feel during or after the traumatic event, how can they help their family if another disaster strikes, or what did they learn from the traumatic event. For this type of activity, the prompt "Tell-a-story" is appropriate. Teachers may initiate the activity by asking children to describe, "What happened after the traumatic event occurred?" or "How did you feel about you and your family?" Children also can be asked to write letters to victims or to rescue workers.

Bibliotherapy. Bibliotherapy is the use of books for social/emotional and character development, as well as for solving personal social/emotional problems (Riordan & Wilson, 1989). Books can help children work through a crisis. With the help of books, children can: 1) learn how others confronted and solved similar problems; 2) see how others have faced anxieties and frustrations, hopes, and disappointments; and 3) gain insight into alternative solutions to problems (McCarty & Chalmers, 1997). (See the children's books listed in Appendix A.)

Projects or multidisciplinary units. Teachers can use the topic of disasters as a way of integrating learning across the curriculum. Students can apply math, science, and language skills as they explore the causes and consequences of natural disasters.

Class or group activities in which children organize or build projects can give children a sense of mastery and a chance to make sense of confusing events. Projects also give children the opportunity to use their skills and to help their families, schools, or communities prepare for or recover from natural disasters. For more information about creating and conducting a project, see Young Investigators: The Project Approach in the Early Years (Helm & Katz, 2001).

CONCLUSION

Teachers may be among the first adults to note symptoms of posttraumatic stress in a child, and they also represent an important part of a child's support system. Depending on the type of trauma, appropriate intervention programs can be planned to help children overcome the negative effects of posttraumatic stress. Parent-teacher collaboration is also crucial to monitor a child's progress, both at home and school.

APPENDIX A

Recommended Resources on Children and Trauma

Children's Books
A Terrible Thing Happened
Margaret M. Holmes (Author), Cary Pillo (Illustrator)
Washington, DC: Magination Press. (2000)
ISBN 1557987017
Age Range: 4 to 8

I Don't Have an Uncle Phil Anymore
Marjorie White Pellegrino (Author), Christine Kempf
(Illustrator)
Washington, DC: Magination Press. (1999)
ISBN 1557985596
Age Range: 4 to 10

Let's Talk About Feeling Sad
Joy Berry (Author), Maggie Smith (Illustrator)
New York: Scholastic. (1996)
ISBN 0590623877
Age Range: Preschool

September 11, 2001: A Simple Account for Children
Nancy Poffenberger (Author), (Illustrated by
Val Gottesman and students of Lotspeich School)
Cincinnati, OH: Fun Publishing Company. (2002)
ISBN 0938293125
Age Range: 6 to 11

One April Morning: Children Remember the
Oklahoma City Bombing
Nancy Lamb and Children of Oklahoma City (Authors),
Floyd Cooper (Illustrator).
New York: Lothrop, Lee & Shepard. (1996)
ISBN 068814666X
Age Range: 5 and up

Lucy and the Liberty Quilt
Victoria London (Author), Angela Liang (Illustrator)
Frisco, TX: Sparklesoup Studios. (2001)
ISBN 0971477604
Age Range: 7 to 12

Play Lady (English & Spanish)
Eric Hoffman (Author), Suzanne Tornquist (Illustrator),
Carmen Sosa Masso (Translator).
St. Paul, MN: Redleaf. (1999)
ISBN 1884834612
Age Range: 5 to 8

When Dinosaurs Die: A Guide to Understanding Death
Laurie Krasny Brown (Author), Marc Tolan Brown (Illustrator)
New York: Little, Brown. (1998)
ISBN 0316109177
Age Range: 3 to 7

Sunny: The Death of a Pet
Judith E. Greenberg and Helen H. Grey (Authors),
photographs by Barbara Kirk
New York: Franklin Watts. (1986)
ISBN 0531101029
Age Range: 5 to 11

Books on Children's Drawings
Jones, F. (1997). A circle of love: The Oklahoma City bombing
through the eyes of our children. Oklahoma City, OK:
Feed the Children.
Koplewicz, H. S., & Goodman, R. F. (Eds.). (1999). Childhood
revealed: Art expressing pain, discovery and hope.
New York: Harry N. Abrams.
UNICEF. (1993). I dream of peace: Images of war by children
of former Yugoslavia. (Preface by Maurice Sendak.) New
York: HarperCollins.

APPENDIX B

For Further Reading

Alexander, D.W. (1999). Children changed by trauma: A healing guide. Oakland, CA: New Harbinger Publications.

Gordon, N. S., Farberow, N. L., & Maida, C. A. (1999). Children & disasters. Philadelphia: Brunner/Mazel.

Greenman, J. (2002). What happened to the world? Helping children cope in turbulent times. Watertown, MA: Bright Horizons.

Klicker, R. L. (2000). A student dies, a school mourns: Dealing with death and loss in the school community. Philadelphia: Accelerated Development.

La Greca, A. M., Silverman, W. K., Vernberg, E. M., & Roberts, M. C. (Eds.). (2002). Helping children cope with disasters and terrorism. Washington, DC: American Psychological Association.

Macksoud, M. (2000). Helping children cope with the stresses of war: A manual for parents and teachers. New York: UNICEF.

Monahon, C. (1997). Children and trauma: A guide for parents and professionals. San Francisco: Jossey-Bass.

APPENDIX C

Web Resources

Web Sites Related to Posttraumatic Stress Disorder

* National Center for PTSD www.ncptsd.org

* National Institute on Mental Health (NIMH) www.nimh.nih.gov

* NOAH: New York Online Access to Health www.noah-health.org

* Federal Emergency Management Agency (FEMA) for Kids www.fema.gov/kids

Children and Traumatic Events

* Helping Children and Adolescents Cope With Violence and Disasters--NIMH www.nimh.nih.gov/publicat/violence.cfm

* Helping Children After a Disaster-American Academy of Child & Adolescent Psychiatry www.aacap.org/publications/factsfam/disaster.htm

* Helping Children Cope With Disaster--DisasterRelief.org www.disasterrelief.org/Library/Prepare/ chilcope.html

* Disaster: Helping Children Cope--National Mental Health and Education Center www.naspcenter.org/safeschools/coping.html

* Reactions and Guidelines for Children Following Trauma/Disaster--American Psychological Association http://helping.apa.org/daily/ptguidelines.html

* Helping Young Children Cope With Trauma--American Red Cross www.redcross.org/services/disaster/keepsafe/ childtrauma.html

* Helping Children Cope With Tragedy www.pta.org/parentinvolvement/tragedy/index.asp

Bias/Intolerance

* When Hurt Leads to Hate: Preventing Your Child's Feelings of Anger From Leading to Actions of Bias and Hate--NYU Child Study Center www.aboutourkids.org/articles/hate.html

* A National Tragedy: Promoting Tolerance and Peace in Children--National Association of School Psychologists www.nasponline.org/NEAT/tolerance.html

* Talking to Your Child About Hatred and Prejudice--National PTA www.pta.org/parentinvolvement/helpchild/ respectdiff/resources/talking.asp

* When Hate Hits Home: Talking to Your Kids About Terrorism--Tolerance.org www.tolerance.org/news/article_tol.jsp?id=272

Terrorism

* How To Help After the Terrorist Attacks--KidsHealth www.kidshealth.org/kid/misc/attacks_help.html

* Talking to Children About Terrorism: By the Numbers--Purdue University www.ces.purdue.edu/terrorism/children/ numbers_pf.html

* Tragic Times, Healing Words: Helping Children Cope--Sesame Street Workshop www.sesameworkshop.org/parents/advice/article/ 0,4125,49560,00.html

* Terrorist Attacks and Children-National Center for PTSD www.ncptsd.org/facts/disasters/ fs_children_disaster.html

For Teachers

* After a Disaster: A Guide for Parents and Teachers--Center for Mental Health www.mentalhealth.org/publications/allpubs/KEN01-0093/default.asp

* A National Tragedy: Helping Children Cope, A Guide for Parents and Teachers--National Association of School Psychologists www.nasponline.org/NEAT/terrorism.html

* For Teachers: Talking About the Terrorist Attacks--KidsHealth www.kidshealth.org/parent/misc/ teachers_tragedies.html

* Strategies To Assist Children Manage Stress--North Carolina State University www.ces.ncsu.edu/depts/fcs/humandev/ disas3.html

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Author's Note: Correspondence concerning this article should be addressed to Kazim Alat, Indiana University, School of Education, Department of Curriculum & Instruction, 201 North Rose Avenue, Bloomington, IN 47405-1006. E-mail: [e-mail]

Kazim Alat

Kazim Alat is a graduate student in the Department of Curriculum and Instruction, Early Childhood Education doctorate program, Indiana University, Bloomington, Indiana.