**[Acute Mental Health Response to Children Affected by
Terrorism]{.underline}**

**I. Introduction**

In situations of terrorism involving mass casualties and related
threats, consideration of children's acute mental health needs have to
be addressed from several perspectives. Central to these is the notion
that acute mental health services will best be provided not only in the
form of direct clinical interaction with children and their families but
also by a range of emergency responders and community providers with
whom children will have contact. Equally important is the notion that
children's responses to terror and disaster may share aspects of adult
responses, but are distinguished by the developmental contexts in which
children of varying ages experience, mediate and communicate the impact
of overwhelming events.

Two other overarching, guiding principles inform this report. First,
while national expertise may provide useful resources and necessary
support to communities in times of crisis, the best response to a crisis
is a local response. Second, crisis response planning and team building
need to occur prior to critical events. This report will rely on a
definition of Acute Mental Health Response as spelled out in "Mental
Health and Mass Violence" (10/2001, etc.):

"....an early intervention is defined as any form of psychological
intervention delivered within the first four weeks following mass
violence or disasters. Once established, services may remain in place
for the long term. Mental health personnel will provide some of the
components of early intervention, while other components will be
provided by non-mental health personnel."

Early mental health assessment and interventions should first determine
basic needs (e.g., survival, safety, food, shelter, etc.). If these
needs are not addressed first, clinical mental health interventions will
be futile.

Regarding the emotional well-being of children, the following are
critically important basic needs and considerations:

-   Re-uniting with parents, other family members and/or responsible
    care-givers

-   Re-establishing/returning to daily routines as quickly as possible

-   Emotional stabilization of caregivers

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-   In the immediate post-incident phase it is sensible to expect normal
    recovery over time

-   Children may exhibit a broad range of post-event symptoms that do
    not necessarily predict the development of long term/chronic
    psychiatric problems.

-   Anticipating a range of acute symptoms does not presume the
    development of clinically significant disorder except where there is
    a pre-existing condition

-   Early brief and focused psychotherapeutic intervention can reduce
    distress in bereaved spouses, parents and children (CR, 2001)

-   Clinical approaches that address the cognitive, behavior and
    emotional domains of psychological response may help reduce the
    incidence, duration and severity of acute stress disorder,
    post-traumatic stress disorder, depressive and additional anxiety
    disorders.

-   Early interventions in the form of single one-on-one recitals of
    events and emotions evoked by traumatic events do not consistently
    reduce risks for later post-traumatic stress disorder or related
    adjustment difficulties (CR, 2001)

-   The term "debriefing" should be used only to describe operational
    debriefings and are not done for the purposes of preventing or
    reducing mental disorders

Acute and early interventions should be based on the assessment for a
range of factors that place children at greatest risk for post-event
difficulties. These factors include:

-   Acute stress disorder or other clinically significant symptoms
    stemming from the trauma

-   Loss of a parent, family member or friend

-   A pre-existing psychiatric disorder and significant histories of
    loss and trauma

-   Requiring medical or surgical attention

-   Exposure to the incident that is particularly intense and of long
    duration

-   Parents falling into any of the above categories

-   Parents or other significant figures injured or at great risk of
    injury or death as a result of proximity to the events (e.g.,
    working in the area of attack or responding to the event as part of
    emergency services)

-   Daily routines likely to be disrupted in significant and enduring
    ways (e.g., displacement of home, school, etc.,)

-   Families at greatest risk for financial distress secondary to
    disruption of economy, employment

**II. Areas and Challenges**

**A. Preparation and Intervention**

1.  **Coordination of services**

The most difficult time to establish new working relationships is in the
midst of a crisis. Despite recent terrorist incidents, not all states
and state agencies have developed disaster plans. Various state agencies
with preparedness and response obligations may not be familiar with each
other and may have had little opportunity to work together. It is
critical to establish pre-existing person-to-person relationships
between and among existing agencies and groups that will be involved in
acute response. A primary aim of instituting new partnerships is to
determine the capacities and deficits of each of the providers/responder
groups prior to the advent of critical, potentially traumatic events.
Transitions in service delivery, such as passing responsibility from the
American Red Cross to a federally funded disaster mental health program,
are particularly tense. Determining responsibilities, establishing
relationships, and planning for these transitions pre-event could
facilitate cooperation and transitions post event. Interagency
agreements should be formalized as part of the planning process. Too
much time has been spent talking about collaborative links with too few
systematic approaches to establishing them at the federal, state and
local levels. Mental health must be represented in pre-event planning
and preparation.

Collaborations require:

a)  Pre-existing, formal relationships among various mental health
    providers and with other professionals already involved in emergency
    planning for acute response to terror events (e.g., police, fire,
    EMS, state and municipal emergency planners, public health, etc.)

b)  Identification of mental health representative(s) that will
    participate in emergency response planning and as part of emergency
    response teams that are mobilized at the time of an event.
    Participation in both areas should occur at state, regional, and
    local levels

c)  Identification of a network of mental health providers at state and
    local levels who will be part of the first response team in a terror
    event.

d)  Immediate mapping of existing mental health resources at state,
    regional and local levels as well as existing working
    relationships/collaborations among mental health resources and
    services providers relevant to the care of children and families at
    times of terror events (e.g., law enforcement, protective services,
    hospitals and primary care facilities, schools, juvenile justice
    system, government, etc.)

e)  Desired additional collaborative relationships should be identified
    and explained to relevant stakeholders (i.e., existing members of
    the state, regional and local emergency response teams).
    Responsibilities for developing and reporting on new collaborative
    efforts in training and planning of integrated services should be
    assigned.

f)  Practice of communication and mobilization of response team members
    using simulation scenarios should be encouraged.

g)  Materials that educate professionals and parents about recognizing
    and monitoring potential acute and longer-term impact of terror
    events on children's functioning and development as well as
    principles guiding intervention should be prepared in advance.
    (Additional information specific to the nature of attack can be
    added at the time of the event.)

> **2. Training for identified mental health providers**

In addition to the paucity of general mental health resources in many
parts of the country, services for specific, acute mental health needs
of children affected by traumatic events are woefully inadequate. Most
mental health professionals have little, if any experience in
considering the developmental context of the acute mental health needs
of terror/disaster affected children nor of intervention principles or
strategies that might be most beneficial. Training in mental health
disaster management and treatment is needed by many professionals of
many disciplines who will respond to children post- event, including
emergency management first responders, primary care, mental health,
schools, clergy, and the media. Training in triage and referral is
essential for those who will have first contact with children following
an incident.

Those mental health professionals who are knowledgeable about clinical
aspects of acute distress and trauma often have no awareness of the
activities of other professionals involved in first response/early
intervention or of the potential roles these professionals can play in
ameliorating the intensity and duration of the distressing impact of
terror/disaster events. In order to maximize their effectiveness, acute
response providers will need:

a)  Cross-training that familiarizes mental health professionals with
    activities of first providers and others involved in acute response

b)  Familiarizing other professionals with principles of child, family
    and community responses to trauma/overwhelming distress (both
    psychological and physiological) in a developmental context and how
    these principles inform therapeutic interventions---both clinical
    and non-clinical

c)  Since the best response to a crisis is a local response, national
    experts should be identified in advance and prepared to provide
    consultation to local providers regarding optimal post-event care.

d)  Disaster mental health approaches---both the federal disaster mental
    health model and the American Red Cross model---tend to discourage,
    under-recognize, and under-utilize specialized expertise that may
    exist across disciplines. This should be addressed pre event and in
    vetting professionals before they become involved in the aftermath
    of an incident.

e)  Disaster mental health should be incorporated into the clinical
    training of all mental health disciplines.

## 3. Approaches to Treatment/Intervention and Training

Mental health professionals involved in acute/early intervention with
children and families should have training in both clinical and
extra-clinical aspects or response. Training content for mental health
providers should include:

a)  Disaster mental health organization, management, and coordination

    i.  Legislation and authority

    ii. Federal, state, and local relationships

    iii. The American Red Cross

    iv. Provider networks

b)  Response issues and considerations

    i.  Providing for safety and security

    ii. Meeting basic needs

    iii. Obtaining disaster assistance

    iv. Evacuation

    v.  Reuniting families

    vi. Quarantine

    vii. Public education---how to attend to children's emotional
         response including recognizing warning signs and symptoms of
         distress

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c)  Physical reactions and safety

d)  Distinguishing symptoms associated with a biological or a chemical
    agent from those associated with mental conditions

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i.  Biological and chemical agents may cause reactions that are confused
    with psychiatric symptoms

ii. Anxiety and affective reactions may present as somatic complaints

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e)  The range of acute trauma reactions and associated areas of concern

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i.  Normal and pathological reactions and differential diagnostic issues

ii. Differing developmental contexts and modes of presentation

iii. Family, social, and cultural influences

iv. Traumatic bereavement

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f)  Ability of parents and other familiar adults to accurately assess
    the response of children

g)  Mental health interventions tailored to needs of those with normal
    and pathologic reactions

h)  Acute Mental Health Mental Status Examination must include specifics
    concerning acute and post-traumtic symptoms

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i.  Evaluation of dissociative symptoms

ii. Hyperarousal

iii. Sleep disturbance

iv. Extreme anxiety (new generalized anxiety, panic attacks etc.)

v.  Profound appetite loss

vi. Profound mood decrease with neurovegative symptoms

vii. Developmental regression (new onset bowel and bladder difficulties,
     speech loss)

viii. Constant inconsolable tantrums (especially with aggression towards
      self or others)

ix. At present there is not any clear evidence for particular
    psychiatric medication for children who have posttraumatic symptoms.
    However, close collaboration with child psychiatric and primary
    physicians in order to assess specific acute symptoms that are
    amenable to pharmacological intervention (sleep disturbance, panic
    attacks, hyperarousal etc.) can be especially useful and effective
    in the acute phase.

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i)  Assessment of risk factors

j)  Treatment, indications for their use, and limitations in use for
    various interventions including

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i.  Triage and referral

ii. Critical incident stress management

iii. Crisis intervention

iv. Death notification

v.  Supportive approaches

vi. Outreach

vii. Specific treatments such as cognitive, behavioral and dynamic
     therapies

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k)  How to work with the media

l)  Vicarious trauma and needs of providers

m)  Specialized training such as that offered by the American Red Cross

n)  Specific support for Emergency Department staff in hospitals

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i.  Screening instruments and interview techniques in dealing with child
    victims

ii. Up-to-date, centralized referral system

iii. Coordination of emergency medical staff with psychosocial teams

iv. Given that only 24% of children's hospitals in the country have
    mental health services in the ED, prior contact and working
    relationships with outside mental health providers need to be
    established and mobilized at the time of a terror event.

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o)  Specialized training in school-based crisis response is needed for
    school administrators, teachers, nurses, mental health and related
    professionals, security/law enforcement. (See section below on
    school-based crisis response.)

(Also see attached training outline-Appendix I)

# 

#  4. Credentials

Clinicians who are part of local, state, and federal responses need
training as outlined above in addition to established, documented
professional credentials and licensure in their area of mental health
services and, whenever possible, specifically in child mental health
practice. A mechanism for establishing credentialing should be built
into the recruitment and training of mental health first responders as
described under *Coordination of Services* and should be implemented
well before the critical event. National qualifying standards would be
useful in identifying and registering mental health professionals who
have had significant experience and training in responding acutely to
events involving violence, terror, disaster and mass casualties.

**B. Linkage to existing mental health services**

As part of the mapping of mental health and emergency response services,
agency, clinic, private and hospital-based providers need to be
identified. Relationships between the emergency management team (via the
mental health representatives) need to be established in order to
determine the scope of services that existing mental health providers
could offer at the time of a mass terror/disaster event. This would
include both staffing levels and consultative roles that already exist
among community-based providers and day-care, schools, law enforcement,
fire/EMS, juvenile justice, etc., Similarly, a system of referral for
sub-acute, secondary and tertiary care needs to be established with
community-based mental health services well in advance of events and be
part of simulation exercises developed by the management team, (e.g.,
linkages between hospital emergency rooms and community-based mental
health facilities would be essential in the triage system, especially in
the event of mass casualties and overwhelming demand on ER medical and
psychosocial staff.) In addition to formal linkages, community-based
mental health providers will need to receive training in evaluation,
differential diagnosis and treatment of post-event related difficulties
in new patients and those whose pre-existing difficulties are
exacerbated by terror/disaster events.

Linkages between existing mental health services and those that are part
of the emergency management response approaches are easier said than
done. They need to be mandated and funded as part of federal and state
supported emergency management planning and response.

(Also see Appendix II-Linkage to Existing Mental Health
Services/Administrative)

**C. Assessment instruments**

Uniform clinical screening instruments need to be developed for use by
mental health clinicians and primary health care providers as part of
the evaluation of individual children. Systematic evaluation can serve
two major functions. First, clinical screening instruments used in the
early intervention or peri-traumatic post-event phase will help
establish baselines that will enable clinicians to follow the unfolding
clinical status and recovery of patients. Second, uniform screening
measures can also serve as needs assessments in the larger populations.
If routinely employed in the aftermath of any event of terror and
disaster, screening instruments will be crucial in helping to determine
funding and allocation of personnel and other resources to the most
affected individuals and communities.

## 

1)  Parents and other adults may not recognize the problems or needs of
    traumatized children, due to their own overwhelming problems and
    needs, the failure of children to disclose their distress, or
    purposeful concealment of suffering by children to avoid burdening
    others. Therefore, it is essential that children themselves be
    evaluated.

2)  Acute distress may be ubiquitous following a terrorist incident,
    clouding findings of early screenings and making it difficult to
    identify those with clinically significant problems. On the other
    hand, studies indicate that a child's subjective initial reactions
    are related to later symptoms, suggesting that these early reactions
    may be used to identify children who need ongoing attention.

3)  Studies following the Oklahoma City bombing revealed a small but
    significant relationship between exposure to disaster media coverage
    and posttraumatic stress reactions in children in the general
    community. This does not establish a causal relationship. It is
    quite possible that those with the most intense reactions are drawn
    to media coverage or that other factors underlie the association
    (Pfefferbaum et al., 2001). It is recommended that professionals
    conduct a media history in children they see post event and advise
    parents and caretakers to limit and monitor exposure to media
    coverage, to monitor content and reactions to coverage, and to
    process the trauma and media coverage with the child.

4)  Pre-event surveillance mechanisms and data related to children could
    provide important baseline information following events.

5)  Victims may not access services in the post event environment;
    canceled appointments, late arrivals, and termination of treatment
    are not uncommon. These behaviors may reflect avoidance of mental
    health care or may be due to other priorities associated with
    physical or resource needs. Since many individuals fail to utilize
    services, the earliest encounter and every encounter are crucial.

6)  In a study of Oklahoma City children who were not related to
    survivors or direct victims of the 1995 bombing, Pfefferbaum and
    colleagues (in press) found no correlation between posttraumatic
    stress reactions and seeking counseling for children with the
    highest levels of posttraumatic stress. This suggests that children
    with the greatest need may not be identified in screening.
    Therefore, the most symptomatic children should be assessed
    individually to determine their treatment needs.

**D. School-base Crisis Response**

Schools provide convenient access to children and families in a
developmentally appropriate environment. School personnel are a natural
source of support for children and classrooms provide formal and
informal opportunities for assessing and addressing psychological
responses and for correcting misperceptions. School-based programs can
normalize the trauma experience and minimize the stigma associated with
mental health care. The structure and routine of school are important
aspects of the recovery environment for children.

School-based interventions must not supplant efforts to identify, refer,
and treat children in need of more traditional and intensive treatment.
They should be part of a network that provides not only outreach but
also triage and referral to those with specialized training and
expertise who can offer more comprehensive and intensive treatment.
These linkages can and should be established pre event:

1)  Parents should be included in the child's treatment. If parental
    needs are not addressed, their ability to provide support is
    diminished.

2)  Similarly, the needs of teachers and other school personnel must be
    addressed if they are to be effective in working with children.

3)  School personnel may benefit from education about the presentation
    and management of trauma reactions in children.

4)  Schools may be inundated with outside proposals to provide services
    and conduct research. They must review them to determine their
    appropriateness for the setting and to balance the needs for
    supportive intervention and normalization.

5)  Schools and school districts may want to establish a formal
    mechanism to review such proposals or may rely on existing
    mechanisms.

6)  An organizational model/plan needs to be developed to coordinate
    necessary services and interventions. Safety/security, mental
    health, and public information tasks should be integrated and not
    addressed by separate, independent teams.

7)  Plans and teams should be multidisciplinary and integrated, yet
    adaptable and flexible to the unique needs of each school/district.
    The crisis response plan should outline roles and responsibilities
    of crisis team members, with generic response protocols as well as
    unique adaptations for various types of crisis events (e.g., natural
    disaster, suicide post-intervention, criminal activity).

8)  Community-school partnerships: crisis teams should also incorporate
    the expertise of community professionals from a broad range of
    relevant disciplines (e.g., mental health, public health, medical,
    police, fire, safety, youth groups, etc.).

9)  Relationships should be established prior to a crisis event and
    maintained actively.

10) School crisis response plans should not be developed in isolation
    from the community; community-response plans must incorporate
    schools.

11) Crisis response plans should address the broad range of potential
    events and not be solely designed for rare catastrophic events.
    Crisis response plans and teams should also be mobilized to respond
    to more common crisis events such as the death of students or staff
    from natural or accidental causes. This allows the teams to develop
    and maintain the necessary skills and emerge as a functioning team
    that recognizes the often-profound impact these events may have on
    children and school staff.

**E. Public information**

Decisions about what information to provide about terror threats and the
reality of terror attacks and how to present it should informed by a
psychological understanding about their importance and impact on the
general population. These issues are a crucial part of planning and
coordination of emergency responses. Too often warnings about potential
dangers or announcements made after critical events are delivered in
vague and unclear terms that increase rather than decrease public
concerns about real threats and dangers. The public must able to trust
that that the information they are receiving is both accurate and
straightforward. All information, even if limited, needs to be directly
related to what is known about threats or real events. Even in a time of
crisis, the news media are not governed by public health priorities and
are subject to the same vulnerability and anxiety as the general public.

Establishing pre-existing relationships with media personnel about the
role and impact of their reporting in critical events can help to insure
consideration of the public's mental health while providing up-to-date
news. Spokespersons for the emergency management team should be
identified prior to events and messages delivered should be based on
discussion and consensus amongst the emergency management response team,
insuring that adequate attention is paid to mental health implications
of announcements (e.g., threat warnings) and preparedness activities
(e.g., impact of participation in disaster drills, impact of smallpox
vaccination strategies or troop deployment, etc.). Information should be
provided simply, directly, and without unnecessary detail. Behaviorally
relevant information should be coupled with concrete advice on how to
decrease risk and/or to promote coping.

1)  Develop public information and education and pre-event messages with
    specific content related to mental health concerns, planning, and
    preparedness that is sensitive to and specifically about children
    and families.

2)  Create programs for schools, primary care, and mental health that
    promote the development of resilience.

3)  Relationships with the media should be established prior to an
    event. This should include education and pre-event planning.

4)  Careful consideration of the mental health impact of media coverage
    should be promoted (e.g., work with the media to consider limiting
    graphic footage and link reporting of the event with information
    regarding supportive services).

5)  Ensure that developmentally appropriate information regarding the
    event is readily available for children (with the same timeliness as
    for adults), which can be conveyed directly to children (such as
    through children's television news media for older children and
    adolescents) and via parents, teachers, and other caring adults.

6)  Readily available written information on how to identify adjustment
    difficulties and promote adjustment and coping should be provided
    after a crisis event.

7)  Media campaigns should be employed after a major crisis event to
    normalize adjustment reactions, share information about available
    supportive services, and decrease the stigma associated with help
    seeking after a crisis event.

8)  School-based educational and preparedness programs for children have
    the potential to educate parents and families.

(Also see Appendix III-Guidelines developed by the NCCEV)

**F. Funding Issues**

Federal emergency management and other funding streams need to make
specific provisions for service coordination, training, assessment and
intervention or public information to take place at federal, state and
local levels. Mental health professionals' involvement in state and
local level emergency management planning and implementation needs to be
stipulated as part of federal funding grant requirements. A review of
current federal funding streams for preparation and response to
terrorism at federal, state and local levels has been suggested as an
important activity for the Centers for Disease Control, as a necessary
first step in examining ways of incorporating child mental health
services into subsequent funding initiatives.

***Federal Approach***

Federally funded disaster mental health services are designed to address
mental health problems caused or aggravated by a disaster and prevention
of future problems. They are available to residents of the community in
which the disaster occurred, to those who work in areas impacted by the
disaster, and to those who are present at the disaster.

Built on decades of experience with natural disasters, the federal
approach provides funding, training, and coordination for state and
local agencies. An expanded federal role may be indicated for terrorist
incidents because the target of terrorism is not only those present or
the communities in which the attack occurs but also is the government
and nation at large. Terrorism raises serious national security
concerns, geographic boundaries may not be clear, and morbidity and
mortality may be greater than in other types of disasters.

The federal model focuses on normal reactions and emphasizes crisis
intervention and support services, triage and referral, and outreach and
public education for affected individuals. The program is not meant to
supplant existing services and is not intended to serve those with
serious psychiatric illness. It relies heavily on paraprofessionals and
training is a key component.

Conflict may arise in the aftermath of an event due to disparate
cultures of disaster mental health and traditional treatment providers,
public health and medical models, and clinicians and researchers.

***Administration***

Use of federal funding requires adherence to administrative conditions
that may be difficult to meet and that may interfere with efficient and
effective service provision.

Federal funding requests typically require an assessment of need, which
may be difficult in the chaos of the post disaster environment,
especially if the threat continues.

Available funding may arrive late, creating concerns about the extent to
which services that must be provided early will be covered and
complicating the organization and administration of services.

Subcontracts with local entities may help in establishing and
coordinating the network of care. These local provider agencies may need
oversight and technical assistance.

A committee on unmet needs, with representatives from various agencies
that provide post incident support, can identify and address unusual
uncovered needs of victims including financial, legal, social, and other
concerns.

While the extensive use of paraprofessionals may be necessary, untrained
providers may not recognize significant psychopathology especially in
children. The emphasis on normal reactions and a policy against
supporting comprehensive psychological evaluation and treatment further
exacerbate the potential to miss children most in need of services. This
argues for the utilization of trained child specialists in the triage
process and in a supervisory capacity.

Federal funding does not traditionally provide for treatment, as opposed
to crisis intervention and support services, potentially ignoring those
with the greatest need. Regulations that limit interventions to a set
number or type of intervention confuse the needs of clients and
providers. Decisions about treatment, referral, and termination of care
should be based on the needs of the client at any given time, not on
seemingly arbitrary rules that suggest that the number of sessions and
the treatment modality (e.g., individual, group, or psychoeducation).

Reimbursement for providers that is based on the number of sessions
provided creates incentives to hold onto clients without regard for
their needs and tends to discourage referral even when needed.

***Recommended Modifications***

Federal guidelines and regulations regarding use of funding should be
examined and modified to increase flexibility with respect to services.
A longer period of service with specialized treatment services may be
needed to address terrorist victims.

Mental health service and delivery should be guided by the degree to
which psychopathology is expected and by the factors that influence it
in the post event recovery environment. Large-scale, human-caused
disasters may result in greater psychiatric impairment of direct victims
than do natural disasters (North et al., 1999), though studies of
children are lacking. A recent empirical review of the disaster mental
health literature supports this suggestion. In an analysis of 160
samples of disaster survivors, those who experienced mass violence were
far more likely to be severely or very severely impaired than those who
experienced either natural or technologic disasters (Norris et al.,
2002). This suggests a need to review priorities in the focus of care
and the allocation of resources, increase flexibility and application of
current regulations, and/or develop additional mechanisms for federal
support to address the needs of terrorism victims.

**References**

American Psychological Association (1997) *Final report: Task force on
the mental health response to the Oklahoma City bombing*.

Consensus Meeting (October 2001) Mental Health and Mass Violence. USDOJ,
NIMH, CDC, etc.,

Hoven (2002) Testimony regarding unmet mental health needs of New York
City public school children as a result of the September 11^th^ attacks
on the World Trade Center. U.S. Senate Health, Education, Labor and
Pensions Committee Hearing.

Norris et al. (2002) 60,000 disaster victims speak. Part I: An empirical
review of the empirical literature, 1981-2001. *Psychiatry*
65(3):207-239.

North et al. (1999) Psychiatric disorders among survivors of the
Oklahoma City bombing. *JAMA* 282(8):755-762.

Pfefferbaum et al. (1999) Posttraumatic stress responses in bereaved
children after the Oklahoma City bombing. *Journal of the American
Academy of Child and Adolescent Psychiatry* 38(11):1372-1379.

Pfefferbaum et al. (2001) Television Exposure in children after a
terrorist incident. *Psychiatry* 64(3):202-211.

Pfefferbaum et al. (in press) Case finding and mental health services
for children in the aftermath of the Oklahoma City bombing. *The Journal
of Behavioral Health Services & Research*.

Stuber et al. (2002) Determinants of counseling for children in
Manhattan after the September 11 attacks. *Psychiatric Services*
53(7):815-822.

**Appendix I-Training Outline**

# 

# What is Psychological Trauma?

## Overwhelming, unanticipated danger that cannot be mediated/processed in way that leads to fight or flight

## Immobilization of normal methods for decreasing danger and anxiety

## Neurophysiological dysregulation that compromises affective, cognitive and behavioral responses to stimuli

# 

# What is Psychological Trauma?

## Events are not traumatic, but they are potentially traumatogenic.

## There are types of events that are more likely to be traumatic than others

## However, the individual's subjective experience is likely the most salient factor 

## An upcoming exam may cause stress in one child, but not in another or the World Trade Center attack may cause serious symptoms in one while being mildly disturbing to another

## 

# Event Factors

## How directly events affect their lives:

## Physical proximity to event

## Emotional proximity to event (threat to child, parent versus stranger)

## Secondary effects-of primary importance (does event cause disruption in on-going life)

## 

# Individual Factors

## Genetic vulnerabilities and capacities

## Prior history (i.e. consistent stress or one or more stressful life experience/s)

## History of psychiatric disorder

## Familial health or psychopathology

## Family and social support

## Age and developmental level

## 

# Developmental Phase

## Children have different paradigmatic reactions to stressful events at different developmental phases

## Children are more sensitive to different events and situations at different phases of development

# Posttraumatic psychopathology

## Childhood Disorders:

### Posttraumatic Stress Disorder

### Reactive Attachment Disorder 

### Depressive disorders

### Attention Deficit Disorders 

### Anxiety and Phobic Disorders

### Somatization Disorders

### Changes in personality and identity (chronically angry, impulsive, bitter, anxious, distrustful and pessimistic) (DESNOS, Complex PTSD)

### Conduct disorder/delinquency

# 

# Acute Stress Disorder (ASD)

## Avoidance of Internal/External Reminders

## Hyperarousal (Anxious, Irritable, Insomnia, Poor Concentration, Hypervigilant, Reactive)

## Significant psychosocial and health impairment

## 

# ASD

## 3+ of 5 Dissociative Sx (Detached, Dazed, Derealization, Depersonalization, Amnesia)

## Recurrent Unwanted Memories Awake/Asleep or Biopsychological in response Distress 2nd Reminders

## Duration 2-30 days

## 

# Posttraumatic Stress Disorder (PTSD)

## Recurrent Unwanted Memories Awake/Asleep or Biopsychological Distress 2nd Reminders

## Avoidance of Internal/External Reminders, Emotional Numbing, Social Detachment, Amnesia

## Hyperarousal (Anxious, Irritable, Insomnia, Poor Concentration, Hypervigilant, Reactive)

## Significant psychosocial/healthcare impairment

## Duration 30+ days (may be delayed or chronic)

## 

# 

# 

# 

# 

# 

# Traumatic Grief

## [Traumatic Loss]{.underline}

## Sudden unexpected death of significant other(s)

## [Traumatic Grief]{.underline}

## Terror: yearning, searching

## Horror: preoccupation, crying, denial 

## Numbing: stunned, disbelief, denial, dysphoria

## Distinct from Depression (which involves apathy, guilt, hypochondriasis, insomnia, anxiety, suicidality, hostility, loneliness, & worthlessness, as well as dysphoria, denial)

# 

# Post Traumatic Disorders: Not Automatic & More than PTSD

## Most adults and children recover without a lasting post-traumatic psychiatric disorder

## In adults 10-20% develop depression or PTSD (often both)

## In adults subclinical depression or substance use common

## Classic PTSD not common in children-but incidence increases with age (especially adolescents) 

## 

# Current Knowledge

## We know very little about what is the most effective forms of crisis and early intervention

## Few controlled treatment studies

## We know more about what doesn't work

## Know some about treatment of children with ASD and PTSD symptoms

# 

# Symptomatic Sexually Abused Preschoolers

## Cognitive-Behavioral Therapy (CBT) versus Nondirective Therapy in a controlled trial found that the CBT group maintained symptom reduction at one year after completion at a greater 

## Inclusion of the non-offending parent in the treatment process was an important element that increased treatment efficacy. (Cohen & Mannarino, 1997, 1998)

# 

# Treatment of PTSD and ASD

## Various forms of exposure therapy

## Anxiety management training and parental psychoeducation and training? (Bryant, Sackville, Dang, Moulds, & Guthrie, 1999; Cohen, Berliner, & Mannarino, 2000; Gist & Devilly, 2002; National Institute of Mental Health, 2002; Ruggiero, Morris, & Scotti, 2001) 

# 

# Treatment of PTSD and ASD

## Treatment elements included interventions fall under the framework of CBT and sometimes Eye Movement Desensitization and Reprocessing Therapy (EMDR). 

## EMDR is no more effective that other forms of exposure therapies. (Cohen et al., 2000; P. R. Davidson & Parker, 2001) 

# 

# Crisis and Early Intervention

## Scant research and inconclusive results and controversial findings. 

## Widely held that early identification; intervention and continued follow-up are valuable methods to prevent the onset of posttraumatic sequalae. (Creamer, 1996; Gordon, Farberow, & Maida, 1999)

## Principals were employed September 11th attacks considered optimal practice for individuals and groups exposed to potentially traumatizing episodes of violence. 

# 

# Crisis and Early Intervention

## One time interventions show no evidence of effectiveness (Gist & Devilly, 2002)

## No evidence that debriefings models are effective and may be harmful (Gist & Devilly, 2002; Mayou, Ehlers, & Hobbs, 2000) 

## Concerns that group models model have contamination effects (Laor, 2002) 

# 

# Treatment of ASD

## Exposure Therapies (CBT and EMDR) show some effectiveness

## Exposure to trauma memories should be done only if initiated by the client and in a manner that enhances self-regulation, not simply catharsis or habituation 

# Event Factors

## How directly events affect their lives:

## Physical proximity to event

## Emotional proximity to event (threat to child, parent versus stranger)

## Secondary effects-of primary importance (does event cause disruption in on-going life)

## 

# Individual Factors

## Genetic vulnerabilities and capacities

## Prior history (i.e. consistent stress or one or more stressful life experience/s)

## History of psychiatric disorder

## Familial health or psychopathology

## Family/parental and social support

## Age and developmental level

## 

# Rationale

## Engagement

## Assessment

## Monitoring

# 

# Engagement

## Early engagement provides the opportunity for on-going follow up contact and monitoring of children, their families and ecologically relevant issues that may impact symptom formation and functioning 

# 

# Assessment

## Assess children's risk factors early and thereby identify children who have known vulnerabilities before they manifest difficulties. 

## Treaters and others may put extra special efforts towards working with these high-risk children and their families in an effort to decrease the likelihood that they will develop posttraumatic symptoms. 

# 

# Monitoring

## Symptoms related to traumatic events may appear at almost any time after an event and may be triggered by secondary reminders that were previously unrecognized. (J. R. Davidson, 2001; McFarlane, 2000; North et al., 2002) 

## Continued monitoring allows for treatment to take place early in symptom formation and before they become potentially refractory.

# Role of Parents

## At no time is the role of parents as mediators of experience more essential and necessary than at periods of real danger to life and limb. Parents are forced to play multiple roles in not only ensuring their own physical safety and that of their children, but also in ameliorating the accompanying psychological danger that ensues.

# 

# Parents and Families Mediate Experience for Children

## Follow up from SCUD missile attacks (1996 Laor et. al)

## 

### Children under 6 did as well as their primary caregiver.

### Children 8-12 trended toward primary caregiver, but not statistically significant

### 12 and up faired as well as pairs

# 

# Role of Parents

## Among the risk factors that may be both most amenable to early intervention efforts as well as most salient in preventing poor outcomes for children is helping parents to have more capacity to understand the impact of exposure on their children and take supportive steps to mediate it. (J. E. Richters & P. E. Martinez, 1993)

# 

# Role of Parents

## Identification of parental difficulties and treatment if necessary is essential

## May be more effective than treatment of child in certain situations (e.g. very young children)

## 

# Role of Parents

## Supplying parents with developmentally framed psychoeducational information about children and adult's typical reactions to upsetting and overwhelming events, helping them understand what behaviors are worrisome or not and providing parenting and management techniques are some of the useful practices that providers should adopt. 

# 

# Physical Displacement and Social Disruption

## Physical displacement and social disruption has been found to be the highest correlated factor related to outcome after traumatic events. (Laor, Wolmer, & Cohen, 2001; Laor et al., 1997; Laor, Wolmer, Mayes, Golomb, & et al., 1996; Lonigan et al., 1994) 

# 

# Physical Displacement and Social Disruption

## Advantage in recognizing this risk for a particular family and bringing community and other resources to bear 

## May include housing displacements, economic hardship due to job loss or expenses associated with the event, isolation from friends and extended family related to the many issues that may be associated with the episode of violence etc. 

# 

# Physical Displacement and Social Disruption

## School provides needed support and structure

## When children are removed from their school environment they lose many of the resources of known adults, friends and schoolmates on whom they often rely. 

# 

# Continuing Threat

## Children's worry about their safety can be a powerful contributor to or source of depressive and anxiety symptoms and may also lead to oppositional and aggressive behavior as children's anxiety leads to a misunderstanding of environmental cues in an attempt to reassert some sense of control. (Ford, 2002) 

# 

# Continuing Threat

## Early intervention strategies are well placed to identify and assess the nature, degree and reality of the threat and, in turn, help the child and family cope with the current situation as best as possible 

# 

# Continuing Threat

## If the threat is imagined or greatly exaggerated, psychotherapeutic treatments may be very useful

## However if credible, early interveners should work with law enforcement and court personnel to ensure the child and families' physical and emotional safety 

# 

# Principles of Intervention

## Do no harm

## Child Development is basis of intervention

## Parents or primary caretakers are essential therapeutic agents.

## Restoration of external structure and authority

## Amelioration of threat

## 

# Principles of Intervention

## Do not assume knowledge of what is the most salient event, image or idea for the individual

## Early responses require collaboration with first responders and others (police, fire-rescue, EMS, Red Cross, courts etc.)

## 

# Immediate Interventions

## For children who are direct witnesses or victims

### Ensure physical health: Have medical personnel check if concern

### First and foremost: reunite with known caring adults (especially parents)

### If adults not available keep with teachers, friends and peers 

### Move to safe place when possible, but in group or with family

### 

### [Early Treatment an Intervention ]{.underline}

## Psychotherapeutic interventions in the absence of structure and organization will not be effective.

### Provide real and concrete information about event, explain actions of authorities

### Provide basic necessities

# 

# Clinical Early Intervention Goals

## Help child/ren regain a sense of control and efficacy in the face of feeling overwhelmed and helpless

## Engaging child/ren and family 

## Assessment of risk factors

## Monitoring and Follow-up

## 

## 

# Psychotherapeutic Interventions

## 

## Must facilitate developmentally-appropriate expression (e.g., drawing, play) 

## Must focus on age-relevant categories/themes (i.e., basic schemata, e.g., safe-unsafe)

## Must not encourage premature closure/decisions or expose the child to information/affect overload

# 

# Key Elements of Early Intervention

## Engagement: Empathic, non directive inquiry (not what happened?, but how are you feeling)

## 

## Support: Confer control in therapeutic contact (initiating drawings VS. 100 questions)

## Follow the child's lead 

## 

# Key Elements of Early Intervention

## Somatic: Discern if physical concerns. Are they due real injury or toxic exposure requiring medical intervention or psychosomatic to psychological trauma 

## Affect: Identify, label and link to ideation and somatic experience (noting differences from beginning to end of contact and with reports about pre-morbid functioning)

## Cognition: Assess quality and nature of thought processes and link to affective impact of event and associated ideas

# 

# Key Elements of Early Intervention

## Psycho-education: Explain the normal post-traumatic response (what to expect, what is normal and when additional support/intervention is needed)

## Follow-up: Arrange for series of contacts to assess symptoms and adaptive functioning

# 

# Early Interventions if Symptomatic

## Step 1: Slow Down (Take a time out; Calm your body; One thought at a time)

## Step 2: Orient Yourself (Bring your mind & body back to the present time/place)

## Step 3: Self Check (How much distress? How much control? The worst ever?)

## 

# Early Intervention: Collaboration

## Early interventions require collaboration among:

### Medical personnel

### Mental health professionals

### Law Enforcement

### Firefighters

### EMS

### Courts

### Schools

# Schools

## Schools are uniquely positioned to provide normalization and security to children.

## Schools provide an optimal location for discussion, peer and adult support.

## Requires that teachers and staff be prepared and able to engage

## Within classroom discussions are best

## Schools should remain open whenever possible

# 

# Schools

## In order for schools to support children who are having stress reactions, staff must have support and be aware of own responses to stress inducing event

## Organization among staff is essential to work with situations that may cause stress reactions

**Appendix II-** **Linkage of Acute Mental Health Care to Existing
Mental Health Programs** (from Betty Pfferbaum)

Given that the federal model is not intended to supplant other services
and that it does not provide for treatment or services for those who
develop psychiatric disorders, linkage to existing mental health
programs is essential. Unfortunately, erosion of the public health and
mental health infrastructure has diminished the ability of current
programs to provide care under normal circumstances. The added burden of
a terrorist incident will further tax existing systems.

Existing programs potentially provide a needed source of clinicians to
assist in the planning process pre event, in disaster mental health
training, and in service delivery and supervision post event.

Provider networks are needed to serve those with a range of responses.
Interagency service agreements should be established prior to an attack
and should encourage cooperative relationships among providers and
provider groups. Planning should include information and decisions about
how the network will function.

Referral to existing programs post event should be guided by the
presence or risk of clinically significant psychopathology rather than
by arbitrary requirements such as the number of individual sessions.
Using support services as treatment in individuals with significant
psychopathology, commonly in a group format, may not only fail to
address their needs but may retraumatize them by exposing them to the
traumatic experiences of others and to memories of their own experience
they are not ready to face, especially if they have prominent avoidance
and numbing. This does not mean that outreach, counseling, and
supportive services are unimportant. Instead, it underscores the need
for provider networks and increased attention to triage and referral in
disaster mental health service planning and training.

A policy against record keeping in the federal model was established out
of concern for confidentiality and about the ethics of entering clients
into a mental health system without their own explicit intent to do so.
Stigma associated with mental health care adds to the concern. Failure
to maintain records, however, creates problems between disaster and
traditional mental health providers and agencies, as traditional
providers are required to maintain records.

Evaluation of disaster mental health and traditional services is greatly
needed. While evaluation processes may increase the burden on disaster
mental health programs initially, these programs are in an ideal
position to conduct this work and will both advance the field and
conserve resources in future incidents.

The American Psychological Association's (1997) review of the mental
health response to the Oklahoma City bombing raised questions about the
effectiveness of the school-based services because few children were
referred, but absent an assessment of need, any conclusions must be
tentative. For example, while less than 7% of the children in a study by
Pfefferbaum and colleagues (1999) had sought counseling at seven weeks,
more than 40% of those who lost an immediate family member,
approximately 15% of those who lost another relative, and approximately
8% of those who lost a friend or acquaintance had sought counseling at
the time of the assessment. Hoven's (2002) study of children in New York
City after the September 11 attacks revealed that two-thirds or more of
those with probable PTSD had not sought counseling from school-based or
other providers. Twenty percent of the children in the New York City
study by Stuber and colleagues (2002) had received counseling, much of
which occurred in schools. Future studies and programs established post
incident should address service needs for children with various types
and degrees of exposure.

**Appendix III-Guidelines**

A.  One page informational summary on expectations following 9/11

B.  Parent Guide for talking with children about 9/11

C.  Parent Guide for talking with children about anthrax

D.  Parent Guide for talking with your children about war

E.  Teachers Guide for talking with students about war

**[A]{.underline}**.

![](media/image1.png){width="1.7395833333333333in"
height="1.09375in"}![](media/image2.png){width="4.259722222222222in"
height="1.0944444444444446in"}

In the wake of our national tragedy, we join you in your concerns about
how best to address the needs of our children. Seeing frightening or
distressing events such as those shown on television or other media can
take away a child's basic sense of safety and security, just as it does
for adults. We all share in the terrible sense of loss. As adults,
though, it is our job to try our best to support each other and our
children and come together as individuals, families, communities and a
nation to cope with these events.

As a parent, listening to your child and understanding what your child
feels are the first steps to help them. Identifying and naming their
feelings helps children start to understand and cope with their
feelings. It is particularly important to help them realize now what
will keep them safe in their own lives and reassure them.

***What Can You Expect?***

Children communicate their upset feelings in many different ways. Over
the next days and weeks, you may see the following reactions in your
children:

-   Questions of local safety and security

-   Anger and thoughts about revenge

-   Fighting with peers, parents, or other adults or not being able to
    get along

-   Frequent nightmares or waking in the night

-   Wanting to stay close by their parents

-   Easily startled, jumpy, or uneasy

-   Irritability, fussiness, difficult to soothe

-   Using play to act out the events over and over

-   Seeming more quiet, withdrawn, upset

-   Tearfulness, sadness, talking about scared feelings or scary ideas

-   Problems paying attention or behavior problems at home or at school

-   Daydreaming or being distracted

***How Can You Help?***

For some children, going over the events with the adults they trust can
help them feel less alone. Giving them time to talk about their
questions and concerns can be very helpful. For other children, talking
about what happened may be very hard. They may show their distress in
other ways, such as upsetting behaviors. Recognizing your child's many
different reactions can be the most important beginning to helping your
child recover.

After a tragedy such as this, many children and adults will appear very
distressed -- often this is a "normal" reaction to an "abnormal"
situation. But if you think your child is still having difficulties
after several days and is having trouble in school, at home, or with
peers, then help from someone who has experience working with children
in such situations may be useful to you and your child. You can contact
the National Center for Children Exposed to Violence
([www.nccev.org](http://www.nccev.org/)) at 1-877-49-NCCEV (62238) or
203-785-7047 for help or to answer your questions.

# B. 

![](media/image1.png){width="1.7395833333333333in"
height="1.09375in"}![](media/image2.png){width="4.259722222222222in"
height="1.0944444444444446in"}

***In the Aftermath of Crisis:*** ***Parents' Guide for Talking to their
Children***

***Updated September 26, 2001***

-   ***Why should I talk about this with my children?***

In the wake of our national tragedy, we join you in your concerns about
how best to address the needs of our children. The frightening or
distressing events we have recently experienced and the ongoing threat
of war can take away a child's basic sense of safety and security, just
as it does for adults. We all share in the terrible sense of loss and
ongoing worries about safety for ourselves and those we care about. As
adults, though, it is our job to try our best to support each other and
our children and come together as individuals, families, communities and
a nation to cope with these events. Parents are the central sources of
safety and security for their children. Children of different ages see
what happens, understand it and react to it differently. As adults we
must remember that we cannot assume that our children\'s worries are the
same as our own. If you feel too anxious or overwhelmed, ask a relative
or a friend to talk to your children and find someone you can talk to as
well. When we as parents are able to listen to our children to
understand their feelings and worries, we can help them make sense of
them.

-   ***What questions are children likely to have?***

    -   ***What happened?***

Like adults, children are better able to deal with a situation if they
feel they understand it. They want \-- and need \-- information just
like adults. Begin by asking your children what they already understand
about the situation. They have likely heard about it on TV, at school,
or from their friends. Much of their information, though, may not be
accurate. As they explain what they know about the situation, you can
figure out what it is they don't already know or understand. Look for
misunderstandings or frightening rumors. Tell the truth; do not mislead
them.

The amount of details that children will find useful will depend on
their age. The older the child is, the more details will likely be
discussed. Provide the basic information in simple and direct terms and
then ask for questions. Take your cues from your child in determining
how much information to provide. Provide reassurance whenever possible
and remind them that they are not at great risk of danger.

-   ***How could something like this happen?***

Our government is working to figure out how to prevent something like
this from happening again and to help the world become safer and more
peaceful as soon as possible. But when children ask this question after
a crisis, often they are really looking for reassurance that they are
now safe. Take this question as an opportunity to reassure children of
the steps we are all taking now to keep them safe. Terrorist acts such
as this and ongoing concerns about the need for armed combat remind us
all that we are never completely safe -- but now is the time to reassure
children that, in reality, they should feel safe in school, in their
home, and in their community.

-   ***What could I (or someone else) have done to prevent this?***

After a tragic event, we all wonder what we and others could have done
to prevent this from happening. Even when it is obvious that there is
nothing your children could have done to prevent or minimize the crisis,
they may still feel helpless and wish they could change what happened,
especially if they know someone who was injured or killed. Many more
people are wondering who else might be at fault -- they may be angry
with the government, at adults they trust to protect them (including
their parents), and others for failing to prevent this crisis. Let
children know that this is a normal reaction; we all wish that there is
something we could have done to prevent this tragedy. Perhaps the most
important thing is to concentrate on what can be done now to help those
most directly affected and to ensure safety in our communities.

-   ***Whose fault is it?***

It is understandable that people would be angry at the individuals who
commit acts of terrorism. But sometimes people are also angry at those
people that are easier to find and blame -- such as people who look like
they [might]{.underline} belong to the group that [might]{.underline}
have been responsible. Children should be told that although it is
normal to feel angry, at this time it is important to remember that
these acts of terrorism were committed by a small number of people who
do not represent a particular race or ethnic group. The United States is
a country that prides itself in having members of many different races
and ethnic backgrounds. This is a time to join together as a country,
not to search to blame members of our country. It is important to let
children know that our government is taking action to defend our country
against those who threaten us.

-   ***What does this mean to me? How is this going to change my
    life?***

This is a question that we all struggle to answer not only for our
children but also for ourselves. Especially in difficult times, children
may act immaturely. Children are often very concerned about themselves.
When there is a tragic event, they may become even more concerned about
what affects them personally. Adults who do not understand this may see
this as being selfish or uncaring. It is important to make your children
feel comfortable in asking questions and expressing their feelings. You
are starting a conversation that you hope will continue for weeks and
months as they begin to better understand and cope with the recent
events. Expect your children to think more about themselves, at least at
first. Once they feel that their needs are being met, they are more
likely to think about helping others.

-   ***What can I do to help?***

Once children start to feel safe and understand what is going on, many
will want to try to help. While there may be little that they can do now
to help the immediate victims of this crisis, there is a lot they can do
to help. They can start by taking care of themselves -- telling you when
they are upset or worried, being honest and open. They can also offer
help to other members of their community -- their friends and
classmates, their teacher, and other adults. Over time, they can think
about how they, along with other members of their community, might be
able to do something helpful for the victims and survivors.

-   ***How do I answer these questions? I don't want to make things
    worse, so should I say nothing instead?***

Often what children need most is someone who they trust who will listen
to their questions, accept their feelings, and be there for them. Don't
worry about knowing exactly the right thing to say -- there is no answer
that will make everything okay. Listen to their concerns and thoughts,
answer their questions with simple, direct and honest responses, and
provide appropriate reassurance and support. While we would all want to
keep our children from ever having to hear about something like this,
reality does not allow this. Silence won't protect them from what
happened, only prevent them from understanding and coping with it.
Remember that listening, answering, and reassuring should be at the
level of the child\'s understanding.

-   ***What if this discussion upsets them?***

During these discussions, children may show that they are upset -- they
may cry, get anxious or cranky, or show you in some other way that they
are upset. Remember, it is really the events that are upsetting them,
not the discussion. Talking about the events gives them a chance to show
you how upset they really are. This is the first step to starting to
cope and adjust. Feel free to pause the conversation to provide support
and comfort to your children and ask if they wish to continue the
discussion at another time. But make sure that they realize it is okay
to show you when they are upset. Otherwise, they may try to hide their
feelings and will then be left to deal with them alone.

-   ***What if they don't ask any questions -- should I bring it up?
    What if they don't seem to want to talk about it?***

When a major crisis of this nature occurs, it is a good idea to be ready
to talk with your children. At first, older children may tell you that
they don't want to or need to discuss it. In most cases it is not a good
idea to force them to talk with you, but instead keep the door open for
them to come back and discuss it later. Keep an invitation open, but
wait until they accept. Often children find it easier to talk about what
other children are saying or feeling instead of talking about
themselves. Think about how your children dealt with prior crises in the
past and consider trying now what helped them when they were upset or
worried before.

-   ***What if my child doesn't seem upset by the recent events?***

> Many children may appear disinterested in the recent crisis and even
> irritated by the continued attention focused on these events. The size
> and scope of a child's world is smaller than that of an adult \-- the
> crisis may simply not have affected them directly; they may be far
> more concerned about what affects their own life. Especially for young
> children, they may not yet understand, or even know, much of what has
> occurred or what it represents. They may be concerned, but afraid to
> ask questions or to share their feelings. Children find it difficult
> to hold strong emotions continually for a long period of time. They
> may visit their concerns briefly, but then turn to play or involve
> themselves in schoolwork before they allow themselves to feel
> overwhelmed. They may express their feelings indirectly through play
> or through changes in their behavior. For all of these reasons, it is
> easy for adults to underestimate children's reactions.

-   How do I know if my child needs more help than I can provide? Where
    would I go for such help?

When there is a tragedy of this size, it is important to remember that
most children (and adults) are having "normal" reactions to a very
abnormal situation -- even if they seem very upset. But if your children
continue to seem very upset for several days -- especially if they are
upset or worried about many things, or they are having (more) trouble in
school, home or with their friends, then it is a good idea to speak with
someone outside the family for advice. You may wish to speak with your
children's teacher or school counseling services, pediatrician, mental
health counselor or member of the clergy for advice. Please remember
that you shouldn't wait until you think they NEED counseling -- you
should take advantage of counseling and support whenever you think it
will be helpful.

-   ***What if I have more questions? Where can I turn for answers?***

You may have many more questions or concerns. If you would like further
information, please feel free to contact the National Center for
Children Exposed to Violence ([*www.nccev.org*](http://www.nccev.org/))
at 1-877-49-NCCEV (62238)

***[GUIDELINES]{.underline}***

-   What worries us as adults is probably very different from what
    worries our children.

-   What children worry about will vary depending on their age.

-   If you listen to your children\'s questions and observe their
    behavior you will have a better idea of what they are concerned
    about.

-   Because children depend on the adults around them for safety and
    security, it is important for the adults to take care of themselves
    in order to take care of the children.

***INFANTS***

Infants depend totally on the adults who look after them. They sense the
emotions of their caregivers and react accordingly. If the adult is calm
and confident the child will feel secure; if on the other hand, the
adult is anxious and overwhelmed, the infant will feel unprotected.

When adults are overtly anxious and distressed, infants may react.
Infants may respond with fretful fussing, difficulty to be soothed,
sleep and eating disturbances or may withdraw and seem lethargic and
unresponsive.

Adults can help by remaining calm and maintaining ordinary routines of
life.

***TODDLERS***

At this age children have begun to interact with a broader physical and
social environment. They still depend on the adults that look after them
and therefore will respond to the situation depending on how adults
react. As with infants, if the adult is calm and confident the child
will feel secure; if on the other hand, the adult is anxious and
overwhelmed, the toddler will feel unprotected.

Common reactions include disturbances in eating, sleeping and toileting,
increased tantrums, irritability and defiance. They may also become more
passive and withdrawn. It is also very common for children to become
clingier.

Adults can help by remaining calm and maintaining ordinary routines of
life. At his age, children have access to television. Television can
generate anxiety because of the repetitive and graphic images it
projects. Exposure should be limited as much as possible.

***PRESCHOOL CHILDREN***

At this age children usually have become part of a social group beyond
their family. Their language, play, social, and physical skills are more
advanced. Through their play, talk and behavior, they show their ideas
of good and bad, their pride in all the things they can do with their
bodies and their fears about possible injury.

Common reactions include disturbances in eating and sleeping,
bed-wetting, increased tantrums, irritability and defiance. Changes in
play may include more aggressive pretend play, play that re-enacts the
frightening events or inability to play. Children can have difficulties
separating from parents or caregivers; they can also make a big fuss
about small injuries. Preschoolers may be very preoccupied with
questions related to who did it and what will happen to them.

Adults can help by remaining calm and maintaining routines. Caregivers
can become aware of the specific worries of each child by listening to
their comments and questions and observing their play and other
behavior. Once adults understand the child\'s worries they can answer
questions, correct misunderstandings and reassure the child. Exposure to
television should be limited. An adult should be present to monitor and
protect the child from the overwhelming graphic images and to talk bout
what they are watching.

***SCHOOL-AGE CHILDREN***

At this age children become more independent, they are more able to talk
about their thoughts and feelings, they play with their friends and
participate in groups. Ideas of what is fair and just become important
and they can cope with difficulties with better skills. School-age
children are more involved in learning, sports and recreational
activities.

Common reactions at this age include a need to stay close to parents and
an inability to participate in ordinary activities. They can become too
preoccupied with the events and ideas about revenge and punishment.
School-age children can, like younger kids, experience nightmares, find
it difficult to go to bed or wake up in the middle of the night. They
may also change their eating habits. They can begin to have difficulties
at school and can become anxious and aggressive.

Adults can become aware of the specific worries of individual children
by listening to their comments and questions, observing changes in their
play and other behaviors. Attention should be given to answer questions
with accurate information and relate it to the child\'s worries.
Friends\' ideas should be discussed and misinformation corrected. As
with younger children, exposure to television news should be limited. An
adult should be present to monitor and protect the child from the
overwhelming graphic images and to talk about what they are watching.

***ADOLESCENTS***

Adolescents can feel out of control due to the many changes that are
happening in their bodies. They struggle to become independent of their
families and to define themselves. The world of peers and teachers
becomes central. It is common for adolescents to have conflicts with
parents, teachers and other authority figures. There is a tendency to
deny or exaggerate what happens around them and to feel that nothing can
harm them.

Common reactions may include too much preoccupation with what is
happening; they can feel frightened and out of control and can easily
feel completely helpless or imagine themselves as unrealistically strong
and powerful. Adolescents can also become even more judgmental and
critical of the adults around them and those dealing with the crisis
situation. They may also act in ways that can put themselves and others
in danger. When faced with tragic events, their usual sense that nothing
can harm them is lost, making them feel very unsafe.

Adults can help by using the adolescents\' ability to think and talk to
discuss their thoughts, feelings and worries. Some teenagers may feel
more comfortable talking in groups with their peers and or with
teachers. Adults should be aware that drastic changes in adolescents\'
behaviors might indicate their distress. Forcing adolescents to talk
about their feelings may cause more harm than good, and adults should
make sure that adolescents have a variety of opportunities to talk to
whom they want and when they are ready.

You may have many more questions or concerns. If you have concerns about
your child contact your child\' pediatrician, teacher or mental health
professional. If you would like further information, please feel free to
contact the National Center for Children Exposed to Violence
([*www.nccev.org*](http://www.nccev.org/)) at 1-877-49-NCCEV (62238) or
(203) 785-7047.

# 

**[C.]{.underline}**

![](media/image1.png){width="1.7395833333333333in"
height="1.09375in"}![](media/image2.png){width="4.259722222222222in"
height="1.0944444444444446in"}

# 

# Responding to Children's Questions and Concerns about Anthrax

Many parents and adults are concerned about the recent threats of
bioterrorism by the spread of Anthrax through the mail system. First it
is important to understand some of the basic facts about the Anthrax
threat, and then it is essential that before we talk with our children,
we are aware of our own fears about the threat. Children take their cues
from their parents and important adults on how to respond to anxiety
provoking situations. We must remember that, as adults, it is not only
our job to protect our children, but also to help them feel as safe and
secure in a sometimes-threatening world.

# What is known about the current Anthrax situation?

1.  As of November first, there are fewer than 20 total cases of Anthrax
    and most of them have been non-fatal. Only one child has been
    diagnosed with Anthrax. While the idea of the fact that someone is
    trying to harm us by causing a fatal illness is unfathomable the
    threat of Anthrax to the average citizen continues to be
    infinitesimally small especially when compared to the rates of
    automobile fatalities, accidental injuries in the home, etc.

2.  Anthrax infections have been limited to New York City, Northern New
    Jersey, Boca Raton, Florida and the Washington D.C. metropolitan
    area. All contaminated letters have been mailed to media personnel
    or political leaders.

3.  The vast majority of infections have occurred in people who are
    known to have direct contact with mail in which Anthrax spores were
    concealed.

4.  Even the most dangerous form of Anthrax infection (inhaled form) is
    treatable when caught early on and new early and rapid detection
    methods have recently been developed.

The threat from Anthrax infection has greatly diminished and the efforts
towards insuring our security seem to have been effective.

# My children aren't talking about Anthrax, how do I introduce the subject?

It is important to remember that children differ greatly depending on
their age and developmental level. Some children may be hearing about
Anthrax on the news or at school, while other children may not be aware
of the threat at all. If your children haven't mentioned that they are
concerned about the Anthrax scares, then perhaps they are not.

Younger children, especially, may not be aware of the Anthrax threat. It
is more likely that younger children will respond to their parent's and
other adults' worries than they are to the news. You may ask older
children (approximately 4^th^ grade and up) about their thoughts about
the news. It is often easier for children to discuss their ideas and
feelings when they are asked about their classmates and friends (e.g.
what are the kids at school saying about...?). If they don't raise
concerns about Anthrax and are not demonstrating behavioral changes
(See: [In the Aftermath of Terrorism: A Summary]{.underline}) then there
is no reason for you to introduce the subject. Remember the goal of the
Anthrax mail is to induce fear, not to infect and kill large numbers of
people. Fear often overwhelms reason, but try to think rationally when
dealing with your children. It is essential to recognize and then
separate fear from the when talking to our children.

Try to take your cues from your child about what is worrying them. Don't
assume that you know what your child's fears and concerns are without
first talking to them. If your child is worried about Anthrax, ask them
what they know about it and then tell them the facts. It is important to
reassure children that they probably are very safe from the threat of
Anthrax. Instilling unnecessary fear and anxiety in your children is not
helpful and will not help to protect them from any potential threat.

Telling your children the facts about Anthrax in an age appropriate
manner and letting them know that there is little to worry about should
help relieve their anxiety and fear. However, if you are fearful and
anxious, regardless of what you say, your children will be more affected
by your mood than by your words. If you are feeling anxious then try to
have someone else talk with your children.

And finally, be thoughtful about where your children are getting their
information. If children are watching the news or reading about
terrorism scares in the media, parents should guide them in this
process. One may even consider turning off the news if it seems to cause
more worry. If your children are going to watch the news, watch it with
them and use it as an opportunity to engage in some family discussion.

1.  **[We live in one of the areas mentioned and my kids are talking
    about it all the time usually by joking, what do I tell
    them?]{.underline}**

Again, the risks of many dangerous things are much greater than Anthrax,
for instance, getting hit by a car or being in a car accident. There are
things that one does to be safe that minimizes the risk such as looking
both ways when crossing the street and using cross walks. Although
unnecessary, if you are worried about Anthrax through the mail, you may
want to take some precautions such as asking your children to let you go
through the mail first. Do not open any suspicious looking letters and
report any highly unusual mail to your post office or local law
enforcement personnel. Although this level of concern is not warranted,
if you want to minimize your and your family's risk you can wear latex
gloves when handling the mail and wipe envelopes lightly with a bleach
solution. This will kill any Anthrax that has contaminated the external
surface of any mail. But remember, the risk of Anthrax to you and your
family is incredibly small.

2.  **[My child is acting more worried and irritable, but is not saying
    anything about Anthrax, what should I do?]{.underline}**

It is hard to know if children who are responding in this way are
reacting specifically to Anthrax fears or to the general anxiety in the
adults and peers around them. If you notice some concerning or unusual
behaviors in your children, you can point out these behaviors and ask
them if they have any ideas about what they are about. If they are
unable to answer the question, you may ask them if they have been
listening to the news or if they have been worried about anything that
is going on in the world. If they respond with a yes, then starting a
conversation about what their fears and concerns are would be a good
place to start. If they have specific concerns about the threats of
Anthrax or other forms of terrorism, then find out what their
understanding of these issues is, and then correct any erroneous
assumptions or ideas they may have. If your children indicate that they
have concerns and fears, you can provide them with some basic
information and do your best to reassure them. However, do not overwhelm
your children with more information or too many details beyond what they
are asking. Consider who your child is\-- you know him or her better
than anyone else. Think about what your child can handle and what level
of information would be most appropriate.

Remember that the Anthrax scare may be a way of talking about other
worries that your child is either unaware of or unable to talk about. Be
careful to allow for other issues to come up that might not be related
to Anthrax. Creating an open, trusting atmosphere where your child can
come to you and talk about their fears and concerns is the goal. As a
parent or significant adult, children will look to you for guidance and
cues on how to respond to potentially scary things in the world around
them. Show your children, by your example, how to be appropriately
concerned, but not to let fear and unnecessary anxiety overwhelm you.
And finally, remember that if you are having a hard time, you should
seek out assistance and support for yourself. If we give into the
terror, then we will not be able to help our children.

3.  **[What if I've tried all these things, but I still have serious
    worries and concerns about how my child is coping?]{.underline}**

If you have serious concerns about your child's behavior and do not feel
able to help, do not worry alone. Contact your pediatrician or qualified
child mental health care provider.

**[D.]{.underline}**

# ![](media/image3.png){width="1.7389763779527558in" height="1.0929133858267717in"}

***Parents' Guide for Talking to their Children about War***

***Why should I talk about this with my children?***

With increasing news about war and with talk about the threats of
terrorism, children, their parents and caregivers may feel uncertain and
robbed of a basic sense of safety and security. We all share concerns
about the horrors and dangers of war and terrorism. However, as adults
and parents, it is our job to help our children and each other cope as
best as we can with concerns that will confront us as individuals,
families, communities and as a nation.

Your calm ability to listen to your children's concerns is one of the
most powerful ways of helping them to learn, understand and feel safe
and secure in the most important part of their world\-\--their families.

***When using these guidelines what should I keep in mind?***

-   Children whose family members or friends are directly involved in
    the war or are in the military will be more directly impacted.

-   Ongoing threats of terrorism may add to children's distress related
    to the war and war may heighten concerns about terrorism.

-   Children who have experienced trauma and loss or have longstanding
    emotional problems are most vulnerable during periods of new
    threats.

-   Reactions will vary from child to child depending upon a variety of
    factors including their personality, age, developmental level and
    personal history.

-   Not all children will appear to be affected by news of the war. For
    some children, especially younger ones, it is not helpful to "force
    the issue" if it does not appear to have an impact.

-   When thinking about how to talk to your children, take your lead
    from them in terms of what they need and what they are thinking and
    feeling*.*

-   Helping children deal with a difficult event is hard work---parents
    should seek help and support from other adults when needed.

![](media/image3.png){width="1.0in" height="0.5799212598425196in"}

***What reactions may I notice in my child?***

There is no one way in which children express worries and fears at times
of greater stress. Here are some examples of how children communicate
their upset feelings:

-   Irritability or difficulty in being calmed and soothed.

-   Tearfulness, sadness, talking about scary ideas or scary feelings

-   Anger directed towards specific communities or ethnic groups

-   Fighting with peers, parents or other adults or not being able to
    get along

-   Changes in sleep patterns, nightmares or waking in the night

-   Wanting to stay close to their parents' or refusing to go to school

-   Physical complaints such as stomach-aches, headaches or changes in
    toileting habits

***How can I help my children?***

For some children, talking about their concerns with the adults they
trust can help them feel less alone. Giving them time to ask questions
can be very helpful. For some children, talking might be very hard.
Recognizing your children's many different reactions can be the most
important beginning to helping your children.

***General guidelines***

> ***Television and Information***

-   Watching too much television coverage of war, violence and
    terrorism, especially graphic images, can be harmful to children of
    all ages. Monitor and limit the amount of news coverage they watch.

-   Pre-school and younger school-age children will be especially
    worried the more war news they see and hear.

-   If your school-age and older child is interested in watching news
    about the war, watch with them when you can so that you can talk
    about what you have seen and heard.

> ***Talking about the daily events***

-   Do not assume that you know what your children are thinking and
    feeling

-   Create a safe and comfortable environment to talk to them.

-   Take cues from them in terms of how much they want to discuss what
    is going on in the world.

-   It is important that routine and structure are maintained in
    children's lives and that they continue to enjoy life, with their
    friends and family.

> ![](media/image3.png){width="1.0in" height="0.5799212598425196in"}
>
> ***What if I feel overwhelmed?***

-   In difficult and stressful times, children look to their parents and
    other significant adults in their lives to know how to cope.

-   If you feel overwhelmed or upset, your children are likely to be
    sensitive to this. Infants and very young children also react
    strongly to changes in their parents' mood and emotional state.

-   If you feel upset and overwhelmed by your own fears and concerns,
    don't struggle alone. Get the help and support you need from a
    trusted friend, professional or clergy.

***What questions are children likely to have?***

-   ***Are we safe and can we be attacked?***

When children ask questions about safety, often they are really looking
for reassurance that their immediate world of family, friends, and other
important figures in their lives are safe now. The amount of details
about safety and security in the broader world that children will find
useful will depend on their age. Should these questions emerge, ask
first for your children's ideas so that you can respond to the details
of their concerns. It is impossible for us, as adults, to predict the
length or impact of war, but we can tell children of our hopes that the
war will end quickly and that, here at home, parents, caregivers,
teachers, and other adults including our national leaders are doing
everything possible to keep them safe.

-   ***Whose fault is it?***

Many adults have very strong feelings about our country going to war.
Parents should respond honestly to questions about their views of the
war that their children may ask. Whatever the political views, parents
can also remind their children that while it is normal to feel angry in
a time of war, it is important to remember that we are not fighting a
war with a particular race or ethnic group. The United States is a
country that prides itself in having members of many different races and
ethnic backgrounds.

-   ***What does this mean to me? How is this going to change my
    life?***

During stressful times, children may become even more concerned about
what affects them personally than usual. Expect your children to think
more about themselves, at least at first. Once they feel that their
needs are being met, they are more likely to think about helping others.
Teenagers may also be struggling with ideas such as being drafted or
volunteering. Using available facts and carefully listening to them and
engaging them in meaningful conversation may help them make sense of
some of those questions.

![](media/image3.png){width="1.0in" height="0.5799212598425196in"}

-   ***How can I help?***

Some children may want to express personal opinions about the war or to
find ways of helping the country at this time of crisis. They can start
by taking care of themselves -- telling you what's on their minds, about
their views, their fears and their hopes. They can also offer help by
listening to the views and feelings of other members of their community
-- their friends and classmates, their teacher, and other adults. Over
time, they can think about how they, along with other members of their
community, might be able to do something helpful for our armed forces
and their families as well as for the Iraqi children and families who
will also suffer the effects of war.

***As a parent, how do I answer these questions? I don't want to make
things worse, so should I say nothing instead?***

Often what children need most is someone whom they trust who will listen
to their questions, accept their feelings, and be there for them. Don't
worry about knowing exactly the right thing to say -- *there is no
answer that will make everything okay*. Silence won't protect them from
what is happening, but silence will prevent them from understanding and
coping with it. Remember that listening, answering, and reassuring
should be at the children's own level.

***What if this discussion upsets them?***

It is important to remember that war is upsetting. While not always
easy, talking is an important means of sharing your feelings and
learning how to cope and adjust with loss. It is okay if your children
get upset when talking about scary or disturbing things. As a parent,
you can then reassure them and help them to feel safe and secure. Make
sure your children realize it is okay to show you when they are upset.
Otherwise, they may try to hide their feelings and will then be left to
deal with them alone.

***What if they don't ask any questions -- should I bring it up? What if
they don't seem to want to talk about it?***

When upsetting things happen, it is a good idea to be ready to talk with
your children. At first, older children may tell you that they don't
want to or need to discuss it. It is often easier to begin discussions
by asking your children what their friends and classmates are thinking,
feeling and saying about the war. In most cases it is not a good idea to
force your children to talk with you, but instead keep the door open for
them to come back and discuss the war and concerns about it later.

![](media/image3.png){width="1.0in" height="0.5799212598425196in"}

**What if my children don't seem upset by events around the war?**

Many children may appear disinterested and even irritated by the
continued attention focused on the war. The size and scope of a child's
world is smaller than that of an adult \-- the situation may simply not
have affected them directly and they appropriately may be far more
concerned about their own life. Young children may not understand, or
even know, much about what has happened or what it means. Other children
may be concerned, but afraid to ask questions or to share their
feelings. Children may visit their concerns briefly, but then turn to
play or involve themselves in schoolwork rather then letting themselves
feel overwhelmed. Paying attention to changes in behavior and mood as
well as asking about children's ideas are the first steps to recognizing
whether and when they may have concerns about the war.

**How do I know if my children need more help than I can provide? Where
would I go for such help?**

War evokes a range of upsetting but "normal" reactions. If your children
continue to seem to be particularly or unusually upset for several days
-- especially if they are upset or worried about many things, or if they
are having trouble in school, home or with their friends \-- then it is
a good idea to speak with someone outside the family for advice. You may
wish to speak with your children's teacher or school counseling
services, pediatrician, or a mental health counselor for advice.
Remember, you don't need to wait until your children show signs of being
very troubled. Seek advice whenever you think it might be helpful.

**What if I have more questions? Where can I turn for answers?**

You may have many more questions or concerns. If you are concerned about
your children, please contact a trusted professional in your community.
If you would like further information, you may also contact the National
Center for Children Exposed to Violence through our website at
[www.nccev.org](http://www.nccev.org/) or by calling 1-877-49-NCCEV
(62238).

![](media/image3.png){width="1.0in" height="0.5799212598425196in"}

***DEVELOPMENTAL GUIDELINES***

-   What worries us as adults is probably very different from what
    worries our children.

-   What children worry about will vary depending on their age.

-   If you listen to your children\'s questions and observe their
    behavior, you will have a better idea of what they are concerned
    about.

-   Because children depend on the adults around them for safety and
    security, it is important for the adults to take care of themselves
    in order to take care of the children.

### Infants

Infants depend totally on the adults who look after them. They sense the
emotions of their caregivers and react accordingly. If the adult is calm
and confident, the child will feel secure; if on the other hand, the
adult is anxious and overwhelmed, the infant will feel unprotected.

When adults are overtly anxious and distressed, infants may react.
Infants may respond with fretful fussing, difficulty being soothed, or
sleep and eating disturbances, or they may withdraw and seem lethargic
and unresponsive.

Adults can help by remaining calm and maintaining ordinary routines of
life.

### Toddlers

At this age children have begun to interact with a broader physical and
social environment. They still depend on the adults that look after them
and therefore will respond to the situation depending on how adults
react. As with infants, if the adult is calm and confident, the child
will feel secure; if on the other hand, the adult is anxious and
overwhelmed, the toddler will feel unprotected.

Common reactions include disturbances in eating, sleeping and toileting,
increased tantrums, irritability and defiance. They may also become more
passive and withdrawn. It is also very common for children to become
more clingy.

Adults can help by remaining calm and maintaining ordinary routines of
life. At this age, children have access to television. Television can
generate anxiety because of the repetitive and graphic images it
projects. Exposure should be limited as much as possible.

![](media/image3.png){width="1.0in" height="0.5799212598425196in"}

### Preschool Children

At this age, children usually have become part of a social group beyond
their family. Their language, play, social, and physical skills are more
advanced. Through their play, talk and behavior, they show their ideas
of good and bad, their pride in all the things they can do with their
bodies and their fears about possible injury.

Common reactions include disturbances in eating and sleeping,
bed-wetting, increased tantrums, irritability and defiance. Changes in
play and drawings may include more aggression, fighting, or
re-enactments of the frightening events. Some children may show their
upset through their inability to take part in play and other activities
that usually give them pleasure. Children can have difficulties
separating from parents or caregivers; they can also make a big fuss
about small injuries. Preschoolers may be very preoccupied with
questions related to who did it and what will happen to them.

Adults can help by remaining calm and maintaining routines. Caregivers
can become aware of the specific worries of individual children by
listening to their comments and questions and observing their play and
other behavior. Once adults understand children\'s worries, they can
answer questions, correct misunderstandings and offer reassurance.
Exposure to television should be limited. An adult should be present to
monitor and protect children from the overwhelming graphic images and to
talk about what they are watching.

### 

### School-age Children

At this age, children become more independent; they are more able to
talk about their thoughts and feelings, play with friends and
participate in groups. Ideas of what is fair and just become important
and they can cope with difficulties with better skills. School-age
children are more involved in learning, sports and recreational
activities.

Common reactions at this age include a need to stay close to parents and
an inability to participate in ordinary activities. They can become too
preoccupied with the events and ideas about revenge and punishment.
School-age children can, like younger kids, experience nightmares, find
it difficult to go to bed or wake up in the middle of the night. They
may also change their eating habits. They can begin to have difficulties
at school and can become anxious and aggressive.

Adults can become aware of the specific worries of individual children
by listening to their comments and questions, or by observing changes in
their play and other behaviors. Attention should be given to answer
questions with accurate information and relate it to the children\'s
worries. Friends\' ideas should be discussed and misinformation
corrected. As with younger children, exposure to television news should
be limited. An adult should be present to monitor and protect children
from the overwhelming graphic images and to talk about what they are
watching.

![](media/image3.png){width="1.0in" height="0.5799212598425196in"}

### Adolescents

Adolescents can feel out of control due to the many changes that are
happening in their bodies. They struggle to become independent of their
families and to define themselves. The world of peers and teachers
becomes central. It is common for adolescents to have conflicts with
parents, teachers and other authority figures. There is a tendency to
deny or exaggerate what happens around them and to feel that nothing can
harm them.

Common reactions may include a preoccupation with what is happening;
they can feel frightened and out of control and may feel completely
helpless or imagine themselves as unrealistically strong and powerful.
Adolescents can also become even more judgmental and critical of the
adults around them and those dealing with the crisis situation. They may
also act in ways that can put themselves and others in danger, such as
increased experimentation with alcohol and drugs, reckless driving or
other behaviors, which may serve an attempt to avoid feeling vulnerable
and small. When faced with tragic events, adolescents' usual sense that
nothing can harm them is lost, making them feel very unsafe.

Adults can help by using the adolescents\' more advanced ability to
think and talk to discuss their thoughts, feelings and worries. Some
teenagers may feel more comfortable talking in groups with their peers
and/or with teachers. Adults should be aware that drastic changes in
adolescents\' behaviors might indicate distress. Forcing adolescents to
talk about their feelings may cause more harm than good; instead, adults
should make sure that adolescents have a variety of opportunities to
talk to whom they want and when they are ready.

**[E.]{.underline}**

![](media/image1.png){width="1.7395833333333333in"
height="1.09375in"}![](media/image2.png){width="4.2625in"
height="1.0979166666666667in"}

***In the Setting of War:***

***Teachers' Guide for Talking to Your Students***

**Purpose:**

These guidelines address teachers' questions and concerns arising from
the recent onset of war. They offer teachers assistance in the following
areas: 1) How to identify and address signs of adjustment difficulties
in your students and 2) How to facilitate conversations about the war in
classrooms with your students.

**While looking through these guidelines, it is important to keep in
mind:**

-   Children whose family members or friends are involved in armed
    conflict or in military service may be more directly impacted.

-   Children who experienced a recent loss or trauma, even if not
    related to war, may be more directly impacted by the war as well.

-   Ongoing threats of terrorism may add to children's distress related
    to the war and the recent war may heighten children's concerns about
    terrorism.

-   Teachers, parents, and students may benefit from thoughtful
    discussions about the war and the effects it is having on them.

-   Reactions vary from child to child.

-   In order to be able to help their students, teachers themselves need
    to be supported.

***What should we expect to see in our students during wartime?***

-   During war, children may experience a recurrence of some of the
    feelings associated with a prior loss or tragedy. Children with
    continuing distress related to 9/11 or other crises may be
    particularly impacted.

-   During war, children may have heightened concern about their
    personal safety, either related to the risk of terrorist events or
    representing a more general sense of increased anxiety.

-   Reactions of children and adults may vary widely.

-   Some signs of children's distress to look for include the sudden
    appearance or noticeable change of:

    -   Depressed or irritable mood

    -   Oppositional and defiant attitude

    -   Attentional or other behavioral problems

    -   Difficulties with classmates and peer group

    -   Social isolation or withdrawal

    -   Dramatic changes in academic performance

    -   Physical complaints

    -   Changes in appetite

    -   Sleep disturbances

-   The extent and nature of these potential difficulties may be related
    to many factors, including:

    -   Age and developmental level

    -   Personal history (e.g., prior trauma, loss, or emotional
        difficulties)

    -   Support from peers, parents, and school staff

-   Some children who are not directly impacted by the war may not be
    interested in discussing the events and may prefer to remain focused
    on the typical concerns of childhood.

-   It is important to find ways within the school to recognize the
    events without imposing personal emotions or expectations on either
    students or staff.

-   Children do not always demonstrate their feelings directly and we
    should pay special attention to signs of concern or distress.

-   Heightened media coverage of the war and associated events (such as
    terrorist threats or acts) may increase reactions in children.
    Parents should monitor and supervise their television watching, and
    especially for younger children, consider limiting the amount of
    television exposure.

-   The use of live television in classroom settings should be actively
    discouraged. If appropriate, media coverage can be videotaped and
    previewed prior to its viewing in class by students.

***How can discussion about the war be helpful to children?***

-   Group discussions facilitated by trusted and knowledgeable adults,
    such as within classrooms, can be a safe environment where children
    can ask questions that are personally relevant and come to
    understand what has happened and what is likely to happen.

-   Discussion allows children to explore how they are feeling, and to
    think about what might help them feel better. Peers can often
    provide each other with helpful ways to deal with feelings related
    to the war.

-   Children may have similar needs as adults in times of crisis, but
    they often meet those needs in very different ways. It is important
    to find out from your students what concerns they have and how they
    might feel their needs could be met.

# *What should teachers keep in mind when conducting these discussions?*

-   Different groups of children and adults will have different needs
    and wishes.

-   Teachers must remember that children who are either directly
    impacted by the war (e.g., those who have friends of family members
    who are involved in armed conflict or in military service) or who
    have experienced prior traumatic experiences (e.g., 9/11) may have
    difficulty with discussions about the war. Teachers should not
    assume that their students could discuss an ongoing war with the
    same level of objectivity that they might be able to discuss a past
    historical event.

-   Students (and their families) may not wish to disclose to the school
    that family members are involved in the war or in military service.
    Teachers should conduct all classroom discussions assuming that some
    of their students may be personally impacted. While it is helpful to
    identify children with relevant experiences, it is not necessary nor
    appropriate to pursue their identification to the extent it
    interferes with the rights of children and families to maintain
    privacy.

-   Teachers should be careful not to impose their own political beliefs
    on students.

-   Both students and staff may have very different perspectives on the
    appropriateness of war. These differences of opinion should be
    respected and attempts should not be made to either actively promote
    or discredit one viewpoint. Tolerance for differences of opinion
    should be promoted. Children (and adults) may have different ways of
    demonstrating their love and concern for their country and may not
    wish to participate in any one particular patriotic display and
    should not be forced or coerced to do so.

-   Discussion of community assets, strengths and values can be very
    important in helping to foster children's hope for the future.

-   Children may find it comforting if they can figure out ways they can
    help others at this time. Adults should encourage children to think
    about how they might be helpful and allow the children to decide
    what will be most meaningful for them. Although adults can offer
    suggestions of activities, they should resist the desire of telling
    students what they should do to provide assistance to others.
    Activities that promote active student involvement in delivering
    services (as opposed to solely fund-raising) may be more meaningful
    to students and therefore more helpful.

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-   Such activities may occur in concert with activities aimed at
    helping students understand and adjust to the war.

    -   It is important to remember that those children who are grieving
        their own personal losses (unrelated to the war) may resent what
        they perceive as excessive attention to losses related to the
        war.

    -   Students (and staff) may be inclined in times of war to become
        less tolerant of cultural and ethnic diversity and may view
        those who are different from them with more suspicion and even
        frank hostility. It is important to actively challenge these
        tendencies and to work to promote increased support for
        individuals of foreign descent. Teachers need to actively work
        to create an environment within their classrooms and throughout
        the school where all students feel safe. While children should
        feel comfortable expressing their views, hostile comments need
        to be challenged and should not be ignored.

***How do you go about planning school activities?***

-   Begin by initiating conversations with students in groups, such as
    in classrooms or in after-school groups.

-   It is important to involve students in the planning process, but
    equally as important for us as adults to provide guidance, structure
    and support to children.

-   Consider the children's ages and developmental levels when planning
    activities.

-   If you have a School Crisis Response Team you should use it as a
    resource when planning your school's response.

-   Schools that are affiliated with military bases may benefit form
    additional services and should collaborate with support staff at the
    military base to the extent possible.

***How can teachers handle this sensitively?***

-   Activities within an individual classroom may impact other students
    and staff as well as children's families at home.

-   Parents and caregivers should be informed about discussions and
    activities that are planned.

-   School discussions and activities often help to initiate discussions
    at home where children may be most comfortable talking about the war
    and their associated feelings.

-   Parents should be invited to share with school personnel any
    concerns or relevant family experiences including:

    -   Direct impact on family and friends.

    -   Earlier or recent trauma or losses

    -   Involvement of family members in other high-risk professions
        (e.g., police, firefighters, EMS).

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-   Open discussion communicates to children that adults are available
    for further discussion and support.

-   Any discussions that teachers have with children in the classroom
    should be conducted as if there were students who were directly
    impacted by the war or any associated events, even if you are not
    aware of any -- some children and their families may choose to keep
    their experiences and concerns private.

-   Teachers should look for signs of distress in students, such as
    agitation, acting-out, or other unexpected behaviors.

If you are aware of any children who are directly impacted by the war
efforts or who have suffered personal losses (such as related to 9/11)
it is important to talk to them and their caregivers, if possible prior
to the start of classroom discussions. Students should be reassured that
no one will disclose their personal experiences and that there is no
obligation for them to share their personal experiences or feelings. We
need to remember that many children and their families choose not to
disclose personal losses or experiences and make our best efforts to
respect their privacy.

***What should I do if I find this work difficult?***

-   Some teachers and staff may find it difficult to discuss the war,
    especially if they are dealing with concerns about their own family
    members of friends or if they have experienced personal losses.

-   This is difficult work for all of us and we need to think about what
    our own feelings are in relation to the events.

-   Remember that children look to us, as adults, for guidance and
    support during difficult times. We need to think about how our own
    reactions may impact the children.

-   Providing an opportunity for faculty and staff to talk about their
    own reactions prior to talking with students may be useful to them
    personally and will better prepare them to meet the children's
    needs.

-   Children's questions may sometimes catch us off guard and make us
    confront issues we would rather not think about.

-   Adults should seek out support from other adults and colleagues when
    needed.

-   Having a plan to address these concerns in advance will help make
    the task easier.

-   If the task seems overwhelming to you, share it with a colleague, or
    invite someone else into your classroom to conduct discussions with
    your students.

***Where can I find additional information?***

If you have additional concerns please contact a trusted medical or
mental health professional in your community. You may also obtain
additional information on the impact of violence and trauma on children
on the website of the National Center for Children Exposed to Violence
at **[www.nccev.org]{.underline}**.