Attention woes in kids with Tourette syndrome likely caused by co-occurring ADHD

Co-occurring attention deficit hyperactivity disorder (ADHD) may be at the root of attention problems in children with Tourette syndrome (TS), according to NIMH-funded researchers. Their findings also support the theory that children with TS develop different patterns of brain activity in order to function at the same level as children without TS. The study was published in the November 2010 issue of the Journal of the American Academy of Child & Adolescent Psychiatry. LCSW Continuing Education
Background
Tourette syndrome is a chronic neurological disorder associated with repetitive, involuntary movements and vocalizations called tics. Many with TS also experience neurobehavioral problems such as inattention, hyperactivity, and impulsivity—symptoms that overlap with ADHD. In fact, researchers estimate that between 50-90 percent of youth with TS also have ADHD.

To explore the role of co-occurring ADHD in TS, Denis Sukhodolsky, Ph.D., of the Yale Child Study Center, and colleagues studied 236 children, of which:

56 had TS only
64 had ADHD only
45 had TS+ADHD
71 had neither and served as a comparison group.
The researchers used well-known, standardized measures to evaluate the children's performance on tasks requiring:

Sustained attention and inhibitory control—Participants were shown various letters on a computer screen and told to press a button when they saw certain letters but not press the button when they saw a non-target letter.
Cognitive inhibition—Participants were shown an array of dots on sheets of paper and asked to name their color (red, green, blue) as quickly as possible. In related tasks, participants were shown pages with similarly arrayed words ("red," "green," "blue") printed in black ink or a mismatched color of ink (such as "red" printed in green ink) and asked to read the words as quickly as possible.
Fine motor control—Participants placed small pegs in a specially designed pegboard in 30-second trials using only their dominant hand, only their non-dominant hand, and both hands at the same time.
Visual-motor integration—Participants copied 24 geometric designs, presented in order of increasing difficulty.
Results of the Study
Children with TS+ADHD showed similar problems with sustained attention as children with ADHD only. However, unlike those with ADHD only, children with TS+ADHD performed at the same level as the comparison group on all other tasks.

Children with TS only performed at the same level as the comparison group in tasks involving response inhibition and visual-motor integration. They performed at a slightly lower level than comparison children on the fine motor control task. Girls with TS only scored higher than boys with TS only on fine motor control tasks using their dominant hands.

Significance
The study helps to identify brain functions specific to particular disorders and the mechanisms underlying these functions.

Similarities in performance between children with TS+ADHD and those with ADHD only suggest that co-occurring ADHD may underlie attention problems in children who have TS, according to the researchers.

The researchers also noted that the children with TS only didn't show impairment in response inhibition, lending support to a theory that such children develop compensatory brain mechanisms in an effort to control involuntary tics. Past imaging studies have shown that, during tasks involving response inhibition, children with TS have greater than normal activity in brain areas associated with cognitive control.

Differences in fine motor skills between girls and boys with TS may indicate differing developmental pathways and patterns of brain growth between the sexes. Because problems with fine motor control in childhood are associated with more severe tics in adulthood, the researchers highlighted this finding as an area for further study.

What's Next
Future studies may help advance the understanding of how TS arises and changes in brain growth and functioning that are associated with the disorder.

Reference
Sukhodolsky DG, Landeros-Weisenberger A, Scahill L, Leckman JF, Schultz RT. Neuropsychological functioning in children with Tourette syndrome with and without attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2010 Nov;49(11):1155-64.

Case-managed Care Improves Outcomes for Depressed Patients with Multiple Medical Conditions

Science Update • December 30, 2010

Case-managed Care Improves Outcomes for Depressed Patients with Multiple Medical Conditions
People with diabetes or heart disease plus depression fare better if their medical care is coordinated by a care manager who also educates patients about their condition and provides motivational support, compared to those who receive care from their primary care physician only, according to an NIMH-funded study published December 30, 2010, in the New England Journal of Medicine.

Background
Coexisting depression is common among patients with diabetes or heart disease, especially if their medical conditions are poorly controlled. Having depression puts these patients at higher risk for poor self-care and more medical complications, and a higher risk for death. Patients dealing with multiple chronic conditions also tend to incur higher medical costs.

Wayne Katon, M.D., of the University of Washington, and colleagues at Group Health Research Institute in Seattle developed a team-based intervention approach—TEAMcare—that aimed to improve medical outcomes and ease depression symptoms among these patients. They tested the intervention in a randomized controlled trial of 214 participants in 14 primary care clinics in Washington state. The participants all had poorly controlled diabetes and/or heart disease with coexisting depression.

Half of the patients were randomized to a 12-month trial of TEAMcare, in which a medically supervised nurse care manager coordinated their care with their primary care provider (PCP) and other medical professionals. The nurse care manager also helped patients set goals for controlling their medical conditions, provided motivation and education about taking their medications correctly, consulted with patients' PCPs about changes in medications recommended by supervisors, and encouraged better self-care. The other half of the participants received usual care, in which their PCP consulted with them about depression care and medical disease control, but they did not have a nurse care manager coordinating their care.

Results of the Study
Overall, patients in the TEAMcare intervention fared better than those in usual care. Symptoms of depression eased in the TEAMcare group more so than in the usual care group. Patients in the TEAMcare intervention also showed greater improvements in blood glucose levels, blood pressure and "bad" cholesterol levels, compared to patients in usual care. Patients in TEAMcare were also more likely to have their medications adjusted, indicating a desire to fine-tune their care to achieve better results. TEAMcare patients also reported greater satisfaction with their medical care and a higher quality of life.

Significance
Previous research suggests that patients who are more satisfied with their medical care tend to be more motivated to take better care of themselves and therefore have better outcomes. According to the researchers, TEAMcare offers a promising way of improving outcomes in patients with multiple medical illnesses and depression because it provides systematic patient support as well as assistance to PCPs.

The researchers also note that patients with multiple medical conditions tend to have high health care costs. The study results suggest that a proactive, coordinated intervention like TEAMcare may facilitate better, more efficient care of these patients in particular.

What's Next
TEAMcare was tested among a specific population enrolled in one health plan, using highly trained nurse care managers. Further study is needed to determine whether the approach can be cost-effectively applied to broader populations, and whether less experienced nurse care managers could be used without sacrificing quality of care.
CEUs for MFTs
Reference
Katon WJ, Lin EHB, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D. Multi-condition collaborative care for chronic illnesses and depression. New England Journal of Medicine. Dec. 30, 2010.

Most Children with Rapidly Shifting Moods Don’t Have Bipolar Disorder

Relatively few children with rapidly shifting moods and high energy have bipolar disorder, though such symptoms are commonly associated with the disorder. Instead, most of these children have other types of mental disorders, according to an NIMH-funded study published online ahead of print in the Journal of Clinical Psychiatry on October 5, 2010. Continuing Education for Social Workers
Background
Some parents who take their child to a mental health clinic for assessment report that the child has rapid swings between emotions (usually anger, elation, and sadness) coupled with extremely high energy levels. Some researchers suggest that this is how mania—an important component of bipolar disorder—appears in children. How mania and bipolar disorder are defined in children is important because rapid mood swings and high energy are common among youth.

Furthermore, many experts believe that overdiagnosis and misdiagnosis of bipolar disorder in youth may play a role in the increasing numbers of children being diagnosed with and treated for bipolar disorder. In choosing proper treatment, it is important to know whether children with rapid mood swings and high energy have an early or mild form of bipolar disorder, or instead have a different mental disorder.

In the Longitudinal Assessment of Manic Symptoms (LAMS) study, Robert Findling, M.D., of Case Western Reserve University, and colleagues assessed 707 children, ages 6-12, who were referred for mental health treatment. Of the participants, 621 were rated as having rapid swings between emotions and high energy levels, described as "elevated symptoms of mania" (ESM-positive). Parents of the other 86 children did not report rapid mood swings. These participants were deemed ESM-negative.

Results of the Study
At baseline, all but 14 participants had at least one mental disorder, and many had two or more. Attention deficit hyperactivity disorder (ADHD) was the most frequent diagnosis, affecting roughly 76 percent in both the ESM-positive and ESM-negative groups. However, only 39 percent were receiving treatment with a stimulant, the most common medication treatment for ADHD, at the start of the study.

Only 11 percent of those with rapid mood swings and high energy (69 out of 621) and 6 percent of those without these symptoms (5 out of 86) had bipolar disorder, meaning that only this small percentage had ever experienced a manic episode, as defined by the current diagnostic system. Of the children with rapid mood swings and high energy, another 12 percent (75 children) had a form of bipolar disorder that includes much shorter manic episodes.

Compared to children without rapid mood swings and high energy, those with these symptoms:

Reported more symptoms of depression, anxiety, manic symptoms, and symptoms of ADHD
Had lower functioning at home, school, or with peers
Were more likely to have a disruptive behavior disorder (oppositional defiant disorder and/or conduct disorder).
Significance
Given that 75 percent of ESM-positive youth did not meet the diagnostic criteria for any bipolar disorder, the researchers suggest that bipolar disorder may not be common among children who experience rapid swings between emotions and high energy levels. Nevertheless, children with these symptoms experience significant impairments due to mood and behavior problems.

The researchers also noted that ESM-positive and ESM-negative youth were prescribed psychotropic medications—including antipsychotics—at similar rates. Further study may provide insight into how serious mental illnesses should be treated in children.

What's Next
The study participants will be re-assessed every 6 months for up to 5 years, allowing the LAMS researchers to determine which children with rapid mood swings and high energy develop bipolar disorder later in life. Such research may inform efforts to identify early markers or predictors of the illness as well as possible protective factors.

Reference
Findling RL, Youngstrom EA, Fristad MA, Birmaher B, Kowatch RA, Arnold E, Frazier TW, Axelson D, Ryan N, Demeter CA, Gill MK, Fields B, Depew J, Kennedy SM, Marsh L, Rowles BM, Horwitz SM. Characteristics of Children With Elevated Symptoms of Mania: The Longitudinal Assessment of Manic Symptoms (LAMS) Study. J Clin Psychiatr. Epub 2010 Oct 5.

Violence and Mental Illness: The Facts

The discrimination and stigma associated with mental illnesses largely stem from the link between mental illness and violence in the minds of the general public, according to the U.S. Surgeon General (DHHS, 1999). The belief that persons with mental illness are dangerous is a significant factor in the development of stigma and discrimination (Corrigan, et al., 2002). The effects of stigma and discrimination are profound. The Presidents New Freedom Commission on Mental Health found that stigma leads others to avoid living, socializing, or working with, renting to, or employing people with mental disorders - especially severe disorders, such as schizophrenia. It leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking and wanting to pay for care. Responding to stigma, people with mental health problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment (New Freedom Commission, 2003).

This link is often promoted by the entertainment and news media. For example, Mental Health America, (formerly the National Mental Health Association) reported that, according to a survey for the Screen Actors? Guild, characters in prime time television portrayed as having a mental illness are depicted as the most dangerous of all demographic groups: 60 percent were shown to be involved in crime or violence. Also most news accounts portray people with mental illness as dangerous (Mental Health America, 1999). The vast majority of news stories on mental illness either focus on other negative characteristics related to people with the disorder (e.g., unpredictability and unsociability) or on medical treatments. Notably absent are positive stories that highlight recovery of many persons with even the most serious of mental illnesses (Wahl, et al., 2002). Inaccurate and stereotypical representations of mental illness also exist in other mass media, such as films, music, novels and cartoons (Wahl, 1995).

Most citizens believe persons with mental illnesses are dangerous. A longitudinal study of American?s attitudes on mental health between 1950 and 1996 found, ?the proportion of Americans who describe mental illness in terms consistent with violent or dangerous behavior nearly doubled.? Also, the vast majority of Americans believe that persons with mental illnesses pose a threat for violence towards others and themselves (Pescosolido, et al., 1996, Pescosolido et al., 1999).

As a result, Americans are hesitant to interact with people who have mental illnesses. Thirty-eight percent are unwilling to be friends with someone having mental health difficulties; sixty-four percent do not want someone who has schizophrenia as a close co-worker, and more than sixty-eight percent are unwilling to have someone with depression marry into their family (Pescosolido, et al., 1996).

But, in truth, people have little reason for such fears. In reviewing the research on violence and mental illness, the Institute of Medicine concluded, ?Although studies suggest a link between mental illnesses and violence, the contribution of people with mental illnesses to overall rates of violence is small,? and further, ?the magnitude of the relationship is greatly exaggerated in the minds of the general population (Institute of Medicine, 2006). For people with mental illnesses, violent behavior appears to be more common when there?s also the presence of other risk factors. These include substance abuse or dependence; a history of violence, juvenile detention, or physical abuse; and recent stressors such as being a crime victim, getting divorced, or losing a job (Elbogen and Johnson, 2009).

In addition:

•"Research has shown that the vast majority of people who are violent do not suffer from mental illnesses (American Psychiatric Association, 1994)."
•". . . The absolute risk of violence among the mentally ill as a group is still very small and . . . only a small proportion of the violence in our society can be attributed to persons who are mentally ill (Mulvey, 1994)."
People with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime (Appleby, et al., 2001). Researchers at North Carolina State University and Duke University found that people with severe mental illnesses, schizophrenia, bipolar disorder or psychosis, are 2 ½ times more likely to be attacked, raped or mugged than the general population (Hiday, et al., 1999).

People with mental illnesses can and do recover. People with mental illnesses can recover or manage their conditions and go on to lead happy, healthy, productive lives. They contribute to society and make the world a better place. People can often benefit from medication, rehabilitation, talk therapy, self help or a combination of these. One of the most important factors in recovery is the understanding and acceptance of family and friends. LPC CEUs
•"Most people who suffer from a mental disorder are not violent there is no need to fear them. Embrace them for who they are normal human beings experiencing a difficult time, who need your open mind, caring attitude, and helpful support (Grohol, 1998)."

References

American Psychiatric Association. (1994). Fact Sheet: Violence and Mental Illness. Washington, DC: American Psychiatric Association.

Appleby, L., Mortensen, P. B., Dunn, G., & Hiroeh, U. (2001). Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study. The Lancet, 358, 2110-2112.

Corrigan, P.W., Rowan, D., Green, A., et al. (2002) .Challenging two mental illness stigmas: Personal responsibility and dangerousness. Schizophrenia Bulletin, 28, 293-309.

DHHS. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. http://www.surgeongeneral.gov/library/mentalhealth/toc.html

Elbogen, E.B. & Johnson, S.C. (2009). The Intricate Link Between Violence and Mental Disorder Results >From the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry, 66(2):152-161.

Grohol, J. M. (1998). Dispelling the violence myth. Psych Central. Available: http://psychcentral.com/archives/violence.htm

Hiday, V.A., Swartz, M.S., Swanson, J.W., et al. (1999). Criminal victimization of persons with severe mental illness. Psychiatric Services, 50, 62?68.

Institute of Medicine, Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: Institute of Medicine, 2006.

Mental Health America. American Opinions on Mental Health Issues. Alexandria: NMHA, 1999.

Mulvey, E. P. (1994). Assessing the evidence of a link between mental illness and violence. Hospital and Community Psychiatry, 45, 663-668.

New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003.

Pescosolido, B.A., Martin, J.K., Link, B.G., et al. Americans? Views of Mental Health and Illness at Century?s End: Continuity and Change. Public Report on the MacArthur Mental health Module, 1996 General Social Survey. Bloomington: Indiana Consortium for Mental Health Services Research and Joseph P. Mailman School of Public Health, Columbia University, 2000. Available: http://www.indiana.edu/~icmhsr/amerview1.pdf

Pescosolido, B.A., Monahan, J. Link, B.G. Stueve, A., & Kikuzawa, S. (1999). The public?s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health, 89, 1339-1345.

Wahl, O. (1995). Media Madness: Public Images of Mental Illness. New Brunswick, NJ: Rutgers University Press.

Wahl, O.F., et al. (2002). Newspaper coverage of mental illness: is it changing? Psychiatric Rehabilitation Skills, 6, 9-31.

For more information on how to address discrimination and social exclusion, contact the SAMHSA Resource Center to Promote Acceptance, Dignity, and Social Inclusion Associated with Mental Health (ADS Center), a program of the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services at http://promoteacceptance.samhsa.gov, e-mail promoteacceptance@samhsa.hhs.gov, or call 800?540?0320.

Early Mental Health Intervention Reduces Mass Violence Trauma

Early psychological intervention guided by qualified mental health caregivers can reduce the harmful psychological and emotional effects of exposure to mass violence in survivors, according to a national conference report released today. Experts emphasized that although more research is needed, existing data, including studies of other kinds of traumatic events, as well as clinical experience, provide useful guidance to the mental health community in responding to mass violence.

"School violence, shootings in the workplace, and terrorist acts have increased Americans' exposure to mass violence during the past decade, and psychological interventions are increasingly among the first responses to it. It is vital to the health and well-being of the American people that effective interventions reach the people who need them in a timely and efficient manner," said LTC (Dr.) Elspeth C. Ritchie, U.S. Army, chairperson of the planning committee for the conference.

The report calls on the scientific community to develop a national research program to examine the relative effectiveness of early mental health interventions following exposure to mass violence. Early intervention is defined as any form of psychological intervention delivered within the first four weeks following mass violence or disasters. Examples of early interventions include brief, focused psychotherapeutic intervention and selected cognitive behavioral approaches.

The report says that some interventions—including mass education via media outlets—although beneficial, have the potential for unintended harm. The report recommends that the leadership select professionals who have the training, expertise, accountability, and responsibility required to provide these interventions. Also, the report cites some evidence that early intervention in the form of a single one-to-one recital of events and discussion of emotions evoked by a traumatic event does not consistently reduce risk and may even put some survivors at heightened risk for later developing mental health problems.

The report is targeted to those who deliver these interventions to emotionally distressed persons following mass violence, to those who research these issues, and to employers who want to help workers who have experienced this type of emotional trauma. It is also intended to aid officials who must decide what mental health help to include in the local, state, and national responses to survivors of mass violence and terrorism. Prepared by 58 mental health researchers and clinicians from the U.S. and five other countries, the report details what is effective, what is not, and what questions require further research.

The report provides guidance on screening for mass violence trauma-related mental health problems, on follow-up with trauma-exposed persons, and on the expertise, skills, and training for providers of early intervention services. The report also addresses what is known about timing for various types of early interventions.

Participants agreed that it is sensible to expect persons to recover from the trauma of mass violence, although some groups may be more vulnerable, such as those with preexisting mental disorders. They also agreed that most survivors who show no clinically significant symptoms for approximately two months generally do not require follow-up and that participation of survivors in early intervention sessions should be voluntary.

The report includes an outline of a sample training program for an early intervention workforce. Recognizing that persons who arrive first at a scene of mass violence may not be trained to provide early mental health interventions, participants recommended that early response personnel be trained to make appropriate referrals when additional expertise is needed. MFT CEUs
Entitled “Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence. A Workshop to Reach Consensus on Best Practices," the report was developed by the National Institute of Mental Health (NIMH) at the National Institutes of Health in the U.S. Department of Health and Human Services, the U.S. Departments of Defense, Justice, and Veterans Affairs, and the American Red Cross.

Mental Health and Mass Violence

Americans have been exposed to increased levels
of mass violence during the past decade. School
violence, shootings in the workplace, and terrorist
acts both here and abroad—all have affected
individuals, families, communities, and our
country. This report addresses the urgent need to
evaluate the various psychological interventions
that are increasingly among the first responses to
these traumatic events. MFT Continuing Education
At a workshop, 58 disaster mental health experts from
six countries were invited to address the impact of
early psychological interventions and to identify
what works, what doesn’t work, and what the
gaps are in our knowledge. Prior to the workshop,
leading mental health research clinicians from the
United States, Australia, and the United Kingdom
prepared a review of the published, peer-reviewed
literature (tables appear in Appendix G and
references appear in Appendix I).
For the purpose of this workshop and report, 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 have
mental health implications but will be provided by
non-mental health personnel.
Workshop participants examined research on
critical issues related to the following questions:
What early interventions can be recommended
in mass violence situations?
What should the key operating principles be?
What are the issues of timing of early
intervention?
What is appropriate screening?
What is appropriate follow-up, for whom,
over what period of time?
What expertise, skills, and training are
necessary for early interventions, at what
level of sophistication?
What is the role of research and evaluation?
What are the ethical issues involved in early
interventions?
What are the key questions for the field of
early intervention that have not yet been
thoroughly researched?
There was general majority consensus among
participants on many points. Where significant
differences in opinion existed, participants were
invited to provide minority opinions (see
Appendix F). Some of those issues have been
reframed as research or ethical questions that can
benefit from further scientific inquiry and
discourse (see pp. 11-12).

Area of Consensus
Key Operating Principles of
Early Intervention
Workshop participants identified key components
of early psychological interventions as including
preparation, planning, education, training, and
service provision evaluation. It is essential that
these components be operationalized and used for
service delivery, research, education, and
consultation activities. Participants also indicated
that early mental health assessment and
intervention should focus on a hierarchy of needs,
e.g., survival, safety, food, shelter, etc. (see
Appendix A).
Conference participants agreed that:
A sensible working principle in the immediate
post-incident phase is to expect normal
recovery;
Presuming clinically significant disorder in
the early post-incident phase is inappropriate,
except when there is a preexisting condition;
Participation of survivors of mass violence in
early intervention sessions, whether
administered to a group or individually,
should be voluntary.
The term “debriefing” should be used only to
describe operational debriefings (see Appendix
D). Although operational debriefings can be
described as “early interventions,” they are
done primarily for reasons other than
preventing or reducing mental disorders.
Guidance on Best Practice Based
on Current Research Evidence
Thoughtfully designed and carefully executed
randomized controlled trials have a critical role in
establishing best practices. There are, however, few
randomized controlled trials of psychological
interventions following mass violence. Existing
randomized controlled trial data, often from studies
of other types of traumatic events, suggest that:
Early, brief, and focused psychotherapeutic
intervention can reduce distress in bereaved
spouses, parents, and children.
Selected cognitive behavioral approaches may
help reduce incidence, duration, and severity
of acute stress disorder, post-traumatic stress
disorder, and depression in survivors.
Early interventions in the form of single oneon-
one recitals of events and emotions evoked
by a traumatic event do not consistently
reduce risks of later post-traumatic stress
disorder or related adjustment difficulties.
There is no evidence that eye movement
desensitization and reprocessing (EMDR) as
an early mental health intervention, following
mass violence and disasters, is a treatment of
choice over other approaches.
Other practices that may have captured public
interest have not been proven effective, and some
may do harm.

Terrorist Attacks and Children

Jessica Hamblen, Ph.D.
When terrorist attacks occur, our children may witness or learn about these events by
watching TV, talking with people at school, or over hearing adults discussing the events. For
instance, the September 11th, 2001 attacks and the Oklahoma City bombing received
widespread attention and media coverage and many children were exposed. But how should
we speak to our children about these events when they occur? Should we shield them from
such horrors or talk openly about them? How can we help children make sense of a tragedy
that we ourselves cannot understand? How will children react? How can we help our children
recover? Fortunately, there have been relatively few terrorist attacks. One consequence of this is that there is little empirical research to help us answer the above questions.

Information from related events can be used to provide answers.
How do children respond to terrorism?
There is a wide range of emotional, behavioral, and physiological reactions that children may
display following a terrorist attack. From previous research, we know that more severe
reactions are associated with a higher degree of exposure (i.e., life threat, physical injury, witnessing death or injury, hearing screams, etc.), closer proximity to the disaster, a history of prior traumas, being female, poor parental response, and parental mental health problems. There is some research on children from the September 11th, 2001 attacks and the Oklahoma City Bombing. In a national sample of adults surveyed 3-5 days after the September 11th attacks, 35% of parents reported that their children had at least one stress symptom and almost half reported that their children were worried about their own safety or the safety of a loved one. Two factors related to increased stress symptoms were 1) amout of television coverage viewed by the child, and 2) parental distress. Children who watched the most coverage were reported to have more stress symptoms than those who watched less coverage. Similiarly, parents who endorsed more stress symptoms were also more likely to
report that their children were upset, indicating a relationship between parental and child
distress. Findings from a study following the Oklahoma City bombing indicate that more severe
reactions were related to being female, knowing someone injured or killed, and bomb-related
television viewing and media exposure.

Below are some common reactions that children and adolescents may display.
Young Children (1-6 years)
• Helplessness and passivity; lack of usual responsiveness
• Generalized fear
• Heightened arousal and confusion
• Cognitive confusion
• Difficulty talking about event; lack of verbalization
• Difficulty identifying feelings
• Nightmares and other sleep disturbances
• Separation fears and clinging to caregivers
• Regressive symptoms (e.g., bedwetting, loss of acquired speech and motor skills)
• Inability to understand death as permanent
• Anxieties about death
• Grief related to abandonment by caregiver
• Somatic symptoms (e.g., stomach aches, headaches)
• Startle response to loud or unusual noises
• "Freezing" (sudden immobility of body)
• Fussiness, uncharacteristic crying, and neediness
• Avoidance of or alarm response to specific trauma-related reminders involving sights
and physical sensations
School-aged Children (6-11 years)
• Feelings of responsibility and guilt
• Repetitious traumatic play and retelling
• Feeling disturbed by reminders of the event
• Nightmares and other sleep disturbances
• Concerns about safety and preoccupation with danger
• Aggressive behavior and angry outbursts
• Fear of feelings and trauma reactions
• Close attention to parents' anxieties
• School avoidance
• Worry and concern for others
• Changes in behavior, mood, and personality
• Somatic symptoms (complaints about bodily aches and pains)
• Obvious anxiety and fearfulness
• Withdrawal
• Specific trauma-related fears; general fearfulness
• Regression (behaving like a younger child)
• Separation anxiety
• Loss of interest in activities
• Confusion and inadequate understanding of traumatic events (more evident in play
than in discussion)
• Unclear understanding of death and the causes of "bad" events
• Giving magical explanations to fill in gaps in understanding
• Loss of ability to concentrate at school, with lowering of performance
• "Spacey" or distractible behavior
Pre-adolescents and Adolescents (12-18 years)
• Self-consciousness
• Life-threatening reenactment
• Rebellion at home or school
• Abrupt shift in relationships
• Depression and social withdrawal
• Decline in school performance
• Trauma-driven acting out, such as with sexual activity and reckless risk taking
• Effort to distance oneself from feelings of shame, guilt, and humiliation
• Excessive activity and involvement with others, or retreat from others in order to
manage inner turmoil
• Accident proneness
• Wish for revenge and action-oriented responses to trauma
• Increased self-focusing and withdrawal
• Sleep and eating disturbances, including nightmares

Tips for talking with your children about terrorism
Create a safe environment.
One of the most important steps you can take is to help children feel safe. If possible, children should be placed in a familiar environment with people that they feel close to. Keep your child's routine as regular as possible. Children find comfort in having things be consistent and familiar. Provide children with reassurance and extra emotional support.
Adults need to create an environment in which children feel safe enough to ask questions,
express feelings, or just be by themselves. Let your children know they can ask questions. Ask your children what they have heard and how they feel about it. Reassure your child that they are safe and that you will not abandon them. Be honest with children about what happened. Provide accurate information, but make sure it is appropriate to their developmental level. Very young children may be protected because they are not old enough to be aware that something bad has happened. School age children will need help understanding what has happened. You might want to tell them that there has been a terrible accident and that many people have been hurt or killed. Adolescents will have a better idea of what has occurred. It may be appropriate to watch selected news coverage with your adolescent and then discuss it. Tell children what the government is doing. Reassure children that the state and federal government, police, firemen, and hospitals are doing everything possible. Explain that people from all over the country and from other countries offer their services in times of need. Be aware that children will often take on the anxiety of the adults
around them. Parents have difficulty finding a balance between sharing their own feelings with their children and not placing their anxiety on their children. For example, the September 11 th attack on the United States was inconceivable. Our sense of safety and freedom was shattered. Many parents felt scared and fearful of another attack. Others were angry and revengeful. Parents must deal with their own emotional reactions before they can help children understand and label their feelings. Parents who are frightened may want to explain that to their child, but they should also talk about their ability to cope and how family members can help each other. Try to put the event in perspective.
Although you yourself may be anxious or scared, children need to know that attacks are rare
events. They also need to know that the world is generally a safe place.

What can parents do?
(Excerpted from Monahon)
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 a verbal child to give simple names to big feelings; talk about event in simple
terms during brief chats.
• Give simple play props related to the actual trauma to a child who is trying to play out
the frightening situation (e.g., a doctor's kit, a toy ambulance).
Zero-to-Three has published excellent guidelines for parents whose very young children (ages
0 to 3) might have been exposed to media or conversations about the September 11 th
terroristic attacks.
Two and a half to six years:
• Listen to and tolerate child's retelling of the event.
• Respect child's fears; give child time to cope with fears.
• Protect child from re-exposure to frightening situations and reminders of trauma,
including scary TV programs, movies, stories, and physical or locational reminders of
trauma.
• Accept and help the child to name strong feelings during brief conversations (the child
cannot talk about these feelings or the experience for long).
• Expect and understand child's regression while maintaining basic household rules.
• Expect some difficult or uncharacteristic behavior.
• Set firm limits on hurtful or scary play and behavior.
• If child is fearful, avoid unnecessary separations from important caretakers.
• Maintain household and family routines that comfort child.
• Avoid introducing experiences that are new and challenging for child.
• Provide additional nighttime comforts when possible such as night-lights, stuffed
animals, and physical comfort after nightmares.
• Explain to child that nightmares come from the fears a child has inside, that they
aren't real, and that they will occur less frequently over time.
• Provide opportunities and props for trauma-related play.
• Try to discover what triggers sudden fearfulness or regression.
• Monitor child's coping in school and daycare by expressing concerns and
communicating with teaching staff.
Six to eleven years:
• Listen to and tolerate child's retelling of the event.
• Respect child's fears; give child time to cope with fears.
• Increase monitoring and awareness of child's play which may involve secretive
reenactments of trauma with peers and siblings; set limits on scary or hurtful play.
• Permit child to try out new ways of coping with fearfulness at bedtime: extra reading
time, leaving the radio on, or listening to a tape in the middle of the night to erase the
residue of fear from a nightmare.
• Reassure the older child that feelings of fear and behaviors that feel out of control or
babyish (e.g., bed wetting) are normal after a frightening experience and that he or
she will feel better with time.
Eleven to eighteen years:
• Encourage adolescents of all ages to talk about the traumatic event with family
members.
• Provide opportunities for the young person to spend time with friends who are
supportive.
• Reassure the young person that strong feelings-guilt, shame, embarrassment, or a
wish for revenge-are normal following a trauma.
• Help the young person find activities that offer opportunities to experience mastery,
control, and self-esteem.
• Encourage pleasurable physical activities such as sports and dancing.
How many children develop PTSD after a terrorist attack?
• The above symptoms are normal reactions to trauma and do not necessarily mean
that a child has acquired a disorder. However, a significant minority of children will
develop posttraumatic stress symptoms after a terrorist attack. Findings from
Oklahoma City indicate that:
• Children who lost a friend or relative were more likely to report immediate symptoms
of PTSD than non-bereaved children.
• Arousal and fear presenting seven weeks after the bombing were significant predictors
of PTSD.
• Two years after the bombing, 16% of children who lived approximately 100 miles
away from Oklahoma City reported significant PTSD symptoms related to the event.
This is an important finding because these youths were not directly exposed to the
trauma and were not related to people who had been killed or injured.
• PTSD symptomatology was predicted by media exposure and indirect interpersonal
exposure, such as having a friend who knew someone who was killed or injured.
• No study specifically reported on rates of PTSD in children following the bombing.
However, studies have shown that as many as 100% of children who witness a
parental homicide or sexual assault, 90% of sexually abused children, 77% of children
exposed to a school shooting, and 35% of urban youth exposed to community violence
develop PTSD.
When should you seek professional help for your child?
Many children and adolescents will display some of the symptoms listed above as a result of
terrorist attacks. Most children will likely recover in a few weeks with social support and the
aid of their families. Many of the above suggestions will help children recover more quickly.
Other children, however, may develop PTSD, depression, or anxiety disorders. Parents of
children with prolonged reactions or more severe reactions may want to seek the assistance of
a mental-health counselor. It is important to find a counselor who has experience working with
children as well as with survivors of trauma. Referrals can be obtained through the American
Psychological Association at 1-800-964-2000. Also visit the website of the National Child
Traumatic Stress Network
References
1.Schuster, M.A., Stein, B.D., Jaycox, L.H., Collins, R.L., Marshall, G.N., Elliott, M.N., et al.
(2001). A National Survey of stress reactions after the September 11, 2001 terrorist attacks.
New England Journal Medicine, 345, 1507-1512.
2. Pfefferbaum, B., Nixon, S., Tucker, P., Tivis, R., Moore, V., Gurwitch, R., Pynoos, R., &
Geis, H. (1999). Posttraumatic stress response in bereaved children after Oklahoma City
bombing. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1372-
1379.
3. Pfefferbaum, B., Seale, T., McDonald, N., Brandt, E., Rainwater, S., Maynard, B.,
Meierhoefer, B. & Miller, P. (2000). Posttraumatic stress two years after the Oklahoma City
bombing in youths geographically distant from the explosion. Psychiatry, 63, 358-370.
4. DeWolfe, D. (2001). Mental Health Response to Mass Violence and Terrorism: A Training
Manual for Mental Health Workers and Human Service Workers.
5. Pynoos, R. & Nader, K. (1993). Issues in the treatment of posttraumatic stress in children
and adolescents. In J.P. Wilson & B. Rapheal (Eds.), International Handbook of Traumatic
Stress Syndromes (pp. 535-549). New York: Plenum.
6. Monahon, C. (1997). Children and Trauma: A Guide for Parents and Professionals. San
Francisco: Jossey Bass
MFT CEUs