Introduction

Human beings react to stress in a myriad of ways and there are many examples of individuals who have endured incredible stressors with resilience and perseverance. However, there are ample clinical and biological data to suggest that stress takes its toll on humans and often manifests as mental health symptoms. Terrorism, in its often random nature, uniformly destructive manifestations, and ties to intense emotions, is an extreme form of stress. From the Latin word terrere (“to frighten”), terrorism is defined as the use of violent acts to coerce and intimidate others, or undermine or destabilize societal order, possibly for political purposes [1]. People who are victims, observers, or even those who hear about terrorist acts are all susceptible to its long term adverse consequences [2]. Over time, the mental health field has recognized the risk of mental health consequences to terrorist victims and studied some of these effects and how to evaluate and treat those who are victimized. One area that has only relatively recently gotten renewed attention is the subject of children and how they are affected by acts of terrorism [3]. It is not difficult to see that children, with their often limited understanding of the concepts behind terrorist acts, might be particularly susceptible to its ill effects. Indeed, studies have shown that children do suffer adverse reactions to being victims or observers of terrorist acts. This paper discusses an approach to identifying, evaluating, and treating children who may suffer these adverse reactions and develop symptoms and sometimes full-blown syndromes.

History of the Research of the Effects of Trauma on Children

Research on the effects of trauma on children is a relatively new area of interest and much of the data is relatively recent. Some of the earliest research was done in the late 1970 s of the impact of threats to the American community living in Afghanistan and Pakistan in 1978 and 1979 [4]. From then, certain authors have taken an interest in ongoing terror in certain regions. Some examples are state sponsored terrorism in Guatemala from 1981 to 1983, terrorist activities in Northern Ireland, and the response to Scud missile attacks in Israel [4].

Specific events have drawn the interest of other authors. This is true of natural disasters and accidents as well as terrorist attacks. There was research spurred on by the Oklahoma City bombing and, of course, the September 11, 2001 terrorist attacks, the two most lethal and deadly attacks in American history. Other traumatic events that have been studied include ongoing terror attacks in Israel and the violent takeover of a school containing over 1,300 children in Beslan, Russia, in 2004. Overall, the impact of trauma has been presented in the context of the relationship to post-traumatic stress disorder (PTSD).

Childhood Reaction to Trauma

There is a growing literature on the effect that various types of trauma have on children. Some of these data are directly applicable to terrorism as it is a form of trauma and other inferences can be extrapolated from what is known about children’s responses to accidents, natural disasters, and war. Studies of children’s reactions to trauma have documented specific symptomatology that is characteristic to a child’s reaction to experiencing or witnessing a trauma. One obvious reaction to violence or threat of violence is anxiety. Children manifest the anxiety in a variety of ways. Young children may have difficulty separating from parents. Older children may become preoccupied with unrelated fears. Children can also manifest somatic complaints as a result of unremitting anxiety.

Children have also been shown to develop depression in response to trauma. Some children develop anger, which can manifest as behavioral problems. Others develop a sense of hopelessness and lack of control. Some have difficulty developing trust in adults.

Various studies have looked specifically at the development of PTSD in children. Studies have shown that from 28 to 50 % of children exposed to trauma develop PTSD [5]. There are several problems with the studies on PTSD. First, there is some disagreement on what constitutes trauma. Some studies limit their definition of trauma to exposure to specific severe unusual traumatic events such as natural disasters, crimes, or terrorist acts. Others include traumas such as sexual abuse or even being the victim of bullying in school. There is also disagreement surrounding the DSM-IV-TR criteria for PTSD and how they are applied to different age groups [6].

One clear trend is that the prevalence of PTSD is greater in samples of children exposed to more severe trauma. Terrorist acts are generally considered to be in the realm of severe trauma and hence, there is a greater likelihood PTSD symptoms being present [7]. Not surprisingly, the level of exposure to trauma also increases the likelihood of symptom development [8]. Level of exposure refers both to proximity to the trauma, whether it is directly experienced and/or directly witnessed, and to duration of exposure including exposure to media coverage. Also, children who experience the loss of a family member are also at greater risk of manifesting symptoms. Interestingly, if the nature of the trauma is political as it is in terrorist acts, the likelihood of symptom development is higher [4].

It has been reported that there are pre-disposing factors that increase the propensity to develop PTSD after traumatic events. Previous exposure to traumatic events, either single or ongoing, conduct problems, and family history of psychiatric problems were all predisposing factors to the development of PTSD [4]. Factors after the trauma, specifically the strength and continuity of familial relationships, were protective against developing PTSD [9]. Family moves and relocation after a traumatic event had no impact on the development of PTSD [10]. Likewise, rates of PTSD were similar in samples of individuals from different ethnicities, cultures, and languages [11].

Parents’ reactions to terrorist acts have a direct impact on the development of symptoms in their children. Parents who are able to restore a feeling of safety and security serve to temper the development of symptoms. Adults who themselves manifest symptoms, especially of anxiety, tend to be less able to provide this protective reassurance to their children [12]. One study, however, found no reciprocal effect between mothers and youths with direct exposure to trauma [13].

One study of children in Bosnia used several instruments to rate levels of PTSD and depression. Investigators reported that witnessing others being wounded, being in a threatening situation, and knowing of the rape of a family member were associated with the presence of PTSD symptoms [14]. In addition, prolonged exposure to deprivation and fear of starvation as well as exposure to indirect violence were related to greater severity of symptoms [14]. A study of children who were victims of a terrorist takeover of their school in Beslan, Russia, in 2004, had higher reported rates of PTSD and greater trauma reminders both 3 months and 3 years after the incident [8, 15].

One interesting aspect of the research on children’s reactions to trauma that was catalyzed by the September 11, 2001 terrorist attacks in the United States is the impact of media coverage. A national survey in the days after the attacks revealed that people across the United States manifested stress reactions as a result of the media coverage of the attacks [16]. The authors concluded that simply watching repeated news coverage of the terrorist act can by itself lead to symptoms, especially if the viewers consider themselves to be similar to those who were directly affected [16]. Interestingly, this phenomenon was already understood as experts advised parents to limit their children’s television viewing in the days after the attacks. The study showed that up to 34 % of parents did restrict their children’s TV watching [16]. Several subsequent studies have also reported that indirect exposure, through media images, to the events of September 11, 2001 could lead to PTSD symptoms in children [17–19].

Other investigators have studied the effects of media exposure on children and adolescents. A study of 95 Israeli pre-school children, ages 1–4 years, reported a rate of 7.4 % who had direct exposure to trauma and 22.3 % rate of children who had exposure to terrorism content on television, with resultant higher rates of internalizing, externalizing and behavioral problems [20]. One study reported that most parents (around 70 %) do not regulate their children’s’ media exposure and that children (ages 7–13 years) with high rates of television viewing (around 2 h a day) have heightened rates of personal perception of risk from world threats (terrorism and natural disasters). This was heightened in children with pre-existing anxiety [21]. In addition, factors such as proximity to the traumatic event may also play a role in increasing worry among children and adolescents [22], as can identification with the victims (e.g. girls becoming more worried than boys after a series of publicized kidnappings) [23]. It is suggested that parents try to limit media exposure to children, even in adolescents as they may be adversely affected by images on television. To quote the authors of a 2002 study of children in Bosnia: “Reducing exposure to indirect violence, such as graphic media coverage of war atrocities, and providing comfort from fears of starvation and freezing, may be functionally as helpful to children’s adjustment as reducing their direct exposure to violence [14].”

The unique aspect of terrorist related trauma is the psychological impact of knowing that it is intentionally inflicted violence. This makes terrorism distinct from natural disasters and accidents. Also, the unpredictable nature of terrorist acts makes it distinct from acts of war where the combatants are usually known to each other. This randomness adds an aspect of uncertainty that has a particularly adverse impact on children.

Likewise, terrorism has an aspect of a potentially ongoing threat. This has proven particularly true of the September 11, 2001 attacks as the wars in Iraq and Afghanistan continue and threats against the United States are ongoing. This ongoing threat creates a sense of vulnerability that children are prone to feel. Even children who were not specifically conscious of the September 11, 2001 terrorist acts may sense the anxiety surrounding the attacks that persists.

Different Stages of Childhood

Another factor to consider in an approach to children who are victims of terrorist acts is the fact that the term “childhood” encompasses a long period of life and that individuals react differently based on which stage of life within this period they are in when exposed to the trauma and when actually evaluated. Certainly, a clinician will recognize that the reaction of a pre-school age child will be quite different from a middle adolescent. It is important to keep this heterogeneity in mind when reviewing the literature on childhood reactions to trauma. In other words, pay attention to whether a particular study includes a certain age range or combines statistics among all age groups.

The research on childhood reaction to terrorist acts that has been done has shown that childhood reactions do differ from the reactions of adults [24]. This highlights the importance of conducting additional research with a focus on children to help guide the appropriate approach to (1) diagnosis, by identifying symptoms characteristic of children’s reactions, and (2) the correct mode of treatment, by elucidating what kinds of treatment are most effective as children develop.

Evaluation

Probably the most important thing to keep in mind when approaching the evaluation of children is that the symptoms to look for and the form of the evaluation will differ based on the age of the child. In this section, certain differences will be highlighted among three different groups, pre-school age children (ages 5 and under), school age children (ages 6–11), and adolescents (ages 12 and up) [25]. Despite these divisions and the usefulness of characterizing different groups, it is important to keep in mind that each child should be evaluated based on his or her own developmental level which may not adhere absolutely to numerical age.

In each group direct evaluation of the child is a very important component of the evaluation. In pre-school age children, the reaction to experiencing or witnessing a terrorist act often involves regression. These children may manifest thumbsucking, bedwetting, increased fear of the dark, and greater difficulty in separating from parents or other caregivers. They may manifest stranger anxiety, a fear of animals or monsters, or fear of symbols or objects without an obvious connection to the terrorist act [25].

School age children may develop attention problems and school work may suffer [25]. They may demonstrate symptoms of anxiety such as school avoidance or somatic complaints (frequent headaches or stomachaches). They may start to discuss irrational fears, unrelated to the terrorist event, of events that are extremely unlikely to occur if not impossible to happen. School age children may begin to have sleep problems or complain of nightmares. Finally they may display evidence of irritability and begin to have uncharacteristic anger outbursts. These episodes may be limited to a particular setting (home versus school) but more likely will be present in all settings.

Not surprisingly, the reaction of adolescents tends to be more similar to adults. They may complain of intrusive thoughts about the terrorist event or display hyper-vigilant behavior. They may experience emotional numbing more characteristic of a depressive response. Adolescents may also report increasing rates of suicidal ideas [26]. Adolescents can also have nightmares and sleep disturbances. A study of Israeli adolescents reported that older age was associated with higher rates of suicidal ideation but lower PTSD. This study found, however, that exposure to terrorism increased rates of PTSD and functional impairment in all adolescents [27].

Finally, adolescents are more likely to attempt to cope with their symptoms with the abuse of substances. Studies have reported increased use of alcohol, illicit drug and nicotine in adolescents after terrorist attacks in Israel and after September 11, 2001 [28–31]. Hence, an evaluation for substance abuse should be a standard part of the evaluation of an adolescent. A careful review of the degree and types of substances before and after the event should be done. Often, the response to a terrorist event will be to increase the amount and frequency of substance use to address developing symptoms. Furthermore, the kind of substance can be a clue to self medicating of symptoms. For example, whereas use prior to experiencing a traumatic event can be more characteristic of recreational use and the pursuit of a “high,” use after the development of symptoms will be aimed at deadening pain and use will be more uniform.

Once again, it is important to stress that despite the guidelines of what symptoms are more frequent in each age group, it is important to keep in mind that each child should be evaluated individually based on his or her particular history or situation. Substance abuse in a school age child should not be missed even though it may be less common than in adolescents.

Once a direct interview of the child has been completed, the next phase of the evaluation should be a thorough assessment of the primary caregiver or caregivers. Attention should be given both for their reactions to the terrorist act and for their reporting of their observations of the child. Each of these components is vital to the evaluation. First, the caregivers’ own reactions are important because research has shown that impairment in caregivers in the aftermath of a trauma directly influences the degree of impairment in the child. Not only will the detection of difficulty in the parent be an indication of potential problems in a child, but it can also help guide appropriate intervention. In other words, an important component of treatment for an affected child may be concurrent treatment of their primary caregiver.

The reason that the caregivers’ observations are so important is that children, especially those suffering the ill effects of being victimized, may not be able to give complete histories or an accurate report of their symptoms. Some of the symptoms characteristic of children’s reaction to trauma (sleep disturbances, school problems, separation difficulty) are more likely to be observed by parents than reported directly by the child. Obviously, the report of the parents will be especially important in younger children, but the importance of this collateral information should not be overlooked even in older children and adolescents.

For the reasons outlined above about the limited ability of children to report their symptoms, a thorough evaluation should also include other collateral sources of information. Teachers can be an important source of information in school age children and adolescents. In some cases peers can be a source of information but one should also take into account the impact of repeated interview if peers have also been exposed to the terrorist violence, which is quite likely. In pre-school age children, babysitters, nannies, and grandparents can all serve as adjunctive sources of information.

Treatment

The research on treatment of children exposed to terrorism is quite limited, but certain extrapolations from what is known about the approach to victims of other traumas as well as basic mental health interventions can be made. First, a useful aspect of treatment can be a thorough community-wide needs assessment. Identifying all those within a community who are at risk for developing symptoms can help guide treatment [32]. The advantage of community based interventions is that it fosters interpersonal ties and combats feelings of isolation or the idea, common especially in children, that they are going through things alone and that what they are experiencing is unique [33]. The community based interventions should focus both on the trauma itself and potential losses. These interventions include psycho-education, cognitive restructuring, and coping skills management. The interventions should target a restoration of sleep, the re-establishment of feelings of safety and protection, and should include parents and caregivers. Early interventions are especially important since it has been shown that acute reactions are associated with long-term maladjustment [24]. Educating parents using Coping and Media Literacy (CML) can reduce stress and threat perception among children and parents [34]. CML is an approach that emphasizes “modeling, media literacy, and contingent reinforcement” and involves having parents watch news clips with their children and discussing the child’s reaction during and after the clip and having the parents educate the child about the content of the news and probe about the child’s concerns regarding the risk of actual harm [34]. Individual treatment should include a direct exploration of the trauma, the correction of any misattributions associated with the trauma, and should offer specific stress reduction techniques [25]. It is also important to consider the cultural (including political and religious) beliefs of the child or adolescent and how this may affect his or her response to terrorism [35].

There are limited data on psychological interventions for children exposed to terrorism. A review of studies reported few usable investigations but report common use of group cognitive behavioral therapy (CBT) [36]. Since that review, the CATS Consortium studied trauma-specific (12–20 sessions) and brief (4 sessions) CBT for 306 youths ages 5–21 affected by the September 11, 2001 terrorist attack [37]. It reported improvement in trauma symptoms in both groups with no statistically significant difference between the two CBT treatment groups. This study supports the notion of implementing some form of behavioral therapy, regardless of specificity, but more research needs to be done on children and adolescents who have specific exposure to terrorist attacks. Other treatment modalities include medications for severe symptoms along with some mention of possible eye-movement desensitization and reprocessing in certain cases [25]. A review of the literature found scant support for the use of SSRIs for the treatment of PTSD in children [38]. Use of agents such as propranolol to prevent development of PTSD in exposed children also remains controversial [38–40]. As stated previously, more research about specific treatment modalities is needed.

Conclusion

There is a growing interest in the impact of trauma on children and specifically the impact of terrorist acts on children. While there is a gradually expanding body of research on the effects of trauma on children, specific research on the effect of terrorist acts is needed. It is important to keep in mind that children react differently to trauma than adults. Furthermore, children of different ages have characteristic reactions to trauma and unique manifestations of symptoms. A thorough evaluation includes interviews with the child with a focus on symptoms of mood disorders, anxiety disorders, substance use disorders, and any changes in functioning appropriate to the child’s developmental level. Evaluations should also include interviews with primary caregivers, and auxiliary sources of information. The research on treatment is especially sparse but should focus on early identification and intervention. More research on the specific types of intervention that are most useful is needed.