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Quick reference medical handouts used by Pediatric offices

Children and Terrorism

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

How do children respond to trauma?

There is a wide range of emotional and physiological reactions that children may display following disaster. Findings from a study following the Oklahoma City bombing indicate that more severe reactions were related to female gender, exposure through knowing someone injured or killed, and bomb-related television viewing/media exposure.

Below are some common reactions that children and adolescents may display:

Young Children (1-6)

    • Helplessness and passivity; lack of usual responsiveness
    • Generalized fear
    • Heightened arousal and confusion
    • Cognitive confusion
    • Difficulty talking about event; lack of verbalization
    • Difficulty identifying feelings
    • Sleep disturbances, nightmares
    • Separation fears and clinging to caregivers
    • Regressive symptoms (e.g. bedwetting, loss of acquired speech and motor skills)
    • Unable to understand death as permanent
    • Anxieties about death
    • Grief related to abandonment of caregiver
    • Somatic symptoms (e.g. stomach aches, headaches)
    • Startle response to loud/unusual noises
    • "Freezing" (sudden immobility of body)
    • Fussiness, uncharacteristic crying, and neediness
    • Avoidance of or alarm response to specific trauma-related reminders involving sights and physical sensations

School-aged Children (6-11 years)

    • Responsibility and guilt
    • Repetitious traumatic play and retelling
    • Reminders trigger disturbing feelings
    • Sleep disturbances, nightmares
    • Safety concerns, preoccupation with danger
    • Aggressive behavior, angry outbursts
    • Fear of feelings and trauma reactions
    • Close attention to parents' anxieties
    • School avoidance
    • Worry and concern for others
    • Changes in behavior, mood, and personality
    • Somatic symptoms (Complaints about bodily aches, pains)
    • Obvious anxiety and fearfulness.
    • Withdrawal and quieting
    • Specific, trauma-related fears; general fearfulness.
    • Regression to behavior of younger child.
    • Separation anxiety with primary caretakers.
    • Loss of interest in activities.
    • Confusion and inadequate understanding of traumatic events most evident in play rather than discussion.
    • Unclear understanding of death and the causes of "bad" events.
    • Magical explanations to fill in gaps in understanding.
    • Loss of ability to concentrate and attend at school, with lowering of performance.
    • "Spacey" or distractible behavior.

Pre-adolesents and Adolescents (12-18 years)

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

How to talk to your child?

    • Create a safe environment. One of the most important steps you can take is making children feel safe. If possible, children should be in a familiar environment with people that they feel close to. Keep your child's routine as similar as possible. There is comfort in having things be consistent and familiar.
    • Provide reassurance to children and extra emotional support. Adults need to create an environment in which children feel safe enough to ask questions, express feelings, or just be by themselves. Let your children know they can ask questions. Ask your children what they have heard and how they feel about it. Reassure your child that they are safe and that you will not abandon them.
    • Be honest with children about what happened. Provide accurate information, but make sure it is appropriate to their developmental level. Very young children may be protected because they are not old enough to be aware that something bad has happened. School age children will need help understanding what has happened. You might want to tell them that there has been a terrible accident and that many people have been hurt or killed. Adolescents will have a better idea of what has happened. Talk to them about terrorism and how the United States responds to terrorism. It may be appropriate to watch selected news coverage with your adolescent and then discuss it.
    • Tell children what the government is doing. Reassure children that the state and federal government, the police, firemen, and the hospitals are doing everything possible. Explain that people from all over the country and from other countries are offering their services.
    • Be aware that children will often take on the anxiety of the adults around them. Parents have a difficult job of finding a balance between sharing their own feelings with their children while at the same time not placing their anxiety on their children. For many, the attack on the United States was inconceivable. Our sense of safety and freedom was shattered. Many parents may feel scared and fearful of another attack. Others may be angry and revengeful. Parents must deal with their own emotional reactions before being able to help children understand and label their feelings. If you are frightened, tell your child, but also talk about your ability to cope and how you as a family can help each other.
    • Try and place the attack in perspective. Although you yourself may be anxious or scared, children need to know that what they witnessed or heard about regarding the attack is a rare event. Most people will never be attacked by terrorists and the world is generally a safe place.

What can parents do

Infancy to Two and a Half Years:

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

Two and a Half to Six Years:

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

Six to Eleven Years:

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

Eleven to Eighteen Years:

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

How many children develop PTSD?

Although many children will display some of the symptoms listed above, a significant minority of children will develop posttraumatic stress symptoms. Findings from Oklahoma City indicate that:

  • Children who lost an immediate family member, friend, or relative were more likely to report immediate symptoms of PTSD than nonbereaved children.
  • Arousal and fear were significant predictors of PTSD symptoms seven weeks after the bombing.
  • Two years after the bombing, 16% of children who lived approximately 100 miles from Oklahoma City reported significant PTSD symptoms related to the event. This is an important finding because these youth were not directly exposed to the trauma and were not related to killed or injured victims.
  • PTSD symptomatology was predicted by media exposure and indirect interpersonal exposure such as having a friend who knew someone killed or injured.
  • No study specifically reported on rates of PTSD in children following the bombing. However, studies have shown that as many as 100% of children who witness a parental homicide or sexual assault, 90% of sexually abused children, 77% exposed to a school shooting, and 35% of urban youth exposed to community violence develop PTSD.

Due to the nature of this attack, we would predict very high rates of PTSD in children who lost a family member or witnessed the plane crashes and after effects. Based on research from Oklahoma City, high rates of PTSD may also be related to exposure to media coverage and to children who have a friend or family member that was killed or injured.

When should you seek professional help for your child?

Many children and adolescents will display some of the symptoms listed above. They will likely recover in a few weeks with social support and the aid of their families. Many of the above suggestions will help children recover more quickly. For others, however, they may develop PTSD, depression, or anxiety disorders. Parents of children with prolonged reactions or more severe reactions may want to seek the assistance of their child's doctor or a mental health counselor. It is important to find counselor who has experience working with children as well as with trauma. Referrals can be obtained though the American Psychological Association at 1-800-964-2000.

Courtesy of the National Center for Post Traumatic Stress Disorder


As a reminder, this information should not be relied on as medical advice and is not intended to replace the advice of your child’s pediatrician. Please read our full disclaimer.

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