Children can suffer emotional wounds in a disaster

On April 19, 1995, an unemployed security guard with an antigovernment vendetta detonated more than two tons of nitrogen fertilizer mixed with fuel at the Alfred P. Murrah Federal Building in Oklahoma City, killing 168 people. A photographer captured a firefighter emerging from the rubble, his thick arms cradling the broken body of an infant, one of 19 babies and toddlers who lost their lives at the building’s day care center. The image became the emblem of the nation’s horror, recording the bomb’s visible toll on the young.

But terror attacks and natural disasters also take a more subtle toll on children: emotional scars that researchers are still working to understand. At the time of the bombing, most mental health experts assumed that sudden tragedy is a psychological lightning strike, a quick shock that dims over time. Few researchers had interviewed children to learn otherwise.

Scientists have now pieced together a story that is much more complex. And like youth itself, it does not adhere to any single narrative. How children fare, and in what way disaster affects a particular child, is an equation with a lengthy list of variables, including a child’s mental health before the disaster, how directly he or she was affected by the events and even the emotional consistency of parents during and after the catastrophe. Most children work through the stress and move on. But for a disturbingly high number, a disaster changes the psychological trajectory of their lives, perhaps for years.

“We’ve learned that children have a variety of reactions, and they’re not always mild like people once thought,” says Robin Gurwitch, a child psychologist from Duke University Medical Center who was involved in studies in Oklahoma City.

A dose of danger

Just a generation ago, assessments of children who had been through a trauma were largely based on the opinions of adults. In the 1980s, pioneering scientists began to take the unusual step of questioning children directly, and major themes emerged. High among them was the existence of a “dose-response effect,” much like what occurs with medicines. In short, the closer children are to destruction or danger (the greater their “dose” of tragedy), the more likely they are to suffer serious psychological harm.

One of the first studies to demonstrate this followed a tragedy in 1984, when a sniper fired into a Los Angeles school yard, killing one girl and injuring 12 others. Following the attack, a research team led by UCLA psychiatrist Robert Pynoos interviewed 100 children at the school over time to gauge their reactions. More than a year after the shooting, children who were on the playground had persistent post-traumatic stress symptoms, while students who were in the building had recovered, Pynoos and colleagues reported in the American Journal of Psychiatry. Friends of the murdered girl continued to grieve, however, no matter where they had been when she died.

For natural disasters, the dose-response effect can apply across a wide swath of the population. Pynoos and colleagues studied children after an earthquake devastated northern Armenia in 1988. A year and a half after the earthquake, he led a study of 231 children in three cities at different distances from the epicenter: the site of the earthquake, 35 kilometers away and 75 kilometers away. Children closest to the damage experienced the greatest severity of PTSD, depression and separation anxiety, the researchers reported in 1993 in the British Journal of Psychiatry.

“If you’re going to study who is vulnerable to what, you have to study by dose of exposure,” says Pynoos, who is codirector of the National Center for Child Traumatic Stress. After large natural disasters, it’s often estimated that 25 percent of victims experience persistent psychological disturbances, he says, but that number belies the fact that in some circles the effects reach deeper. After the 1994 Northridge earthquake in California, “there were children, parents and teachers in the epicenter that had actually been trapped; 85 percent of them showed severe levels of PTSD five months post-earthquake,” he says.

Studies of other disasters have produced similar findings about the importance of proximity, even among children whose safety is never threatened. One study of more than 3,000 middle and high school students conducted seven weeks after the Oklahoma City bombing found that those who knew someone who was killed were more likely than their peers to experience post-traumatic stress reactions, especially those who had lost a parent or sibling.

Similarly, children who had relatives participating in the manhunt for the perpetrators of the 2013 Boston Marathon bombing were almost six times as likely to have symptoms of PTSD as peers whose relatives were not involved, according to a study published this year in the journal Depression and Anxiety .

While studies have found that kids closest to danger are more likely to suffer, the encouraging news is that for most, the effects tend to diminish over time, even when the damage is cataclysmic. Eight months after the 2011 earthquake and tsunami in Japan, researchers interviewed more than 10,000 child survivors in a hard-hit area called Ishinomaki City. Across all age groups, the children’s scores on a post-traumatic stress questionnaire were better at 20 months than at 8 months after the disaster, the researchers reported last February in PLOS ONE.

Taking science by storm

While symptoms generally subside, a subset of children appear to struggle for years, particularly when they can’t reclaim their normal routines. This point became clear in studies conducted after Hurricane Andrew slammed into Florida’s southern coast on August 24, 1992, with top wind gusts exceeding 250 kilometers per hour. Andrew coalesced into a hurricane only two days before it made landfall, leaving residents little time to prepare. In the aftermath, more than 160,000 people were homeless.

One of the unexpected findings to emerge from Hurricane Andrew was the discovery of large numbers of silent sufferers — children who express their stress in ways adults don’t often recognize, says Annette La Greca, a clinical child psychologist at the University of Miami in Florida. Three months after the storm, she and her colleagues surveyed 568 children at three South Florida elementary schools. Few students, if any, had shown outright distress to their teachers or parents, La Greca says. School officials were convinced that the kids were doing fine.

But when researchers asked the children to respond to a series of questions — such as, “Do you feel more alone inside or alone with your feelings?” or “Have you felt so scared, upset, or sad that you couldn’t even talk or cry?” — they found that about 55 percent of the children were showing moderate to severe signs of post-traumatic stress disorder.

“They clearly were not fine,” La Greca says. “Some of them told us they hadn’t told their parents because their parents were distressed. They didn’t want to burden them.”

A later study of the children at 10 months after the storm, published in 1996 in the Journal of Consulting and Clinical Psychology, found that those most likely to have persistent problems were those whose homes had not been repaired, or who were living with other stresses such as a parent out of work because of the storm.

“We were surprised how many kids were experiencing difficulty but didn’t feel like they could talk to their parents about it,” says Mitchell Prinstein, now a psychology professor at the University of North Carolina at Chapel Hill, who had started a graduate position in La Greca’s lab a week before Hurricane Andrew.

Even uninjured children, or those whose homes were intact, were still disturbed that their lives were not the same. “They were going to school in portable trailers outside a pile of rubble that used to be their school,” Prinstein says. That’s one reason he and other researchers now say that rebuilding schools and playgrounds, as well as reestablishing connections to friends as quickly as possible, helps children recover.

A minority of children may endure symptoms for years. In the Miami team’s studies of Hurricane Andrew, 18 percent of the children were still having problems 10 months after the storm. One of La Greca’s graduate students found that among those kids still coping with symptoms of post-traumatic stress 10 months after the hurricane, 60 percent still had symptoms four years later. That result, she says, implies that those who do not recover quickly may be at higher risk for persistent struggles.

Similar smoldering effects for some children were found after Hurricane Katrina in New Orleans, which in 2005 replaced Andrew as the nation’s most costly natural disaster. Once the storm retreated, levees protecting the low-lying city failed, flooding 80 percent of New Orleans and Saint Bernard Parish. Three years later, about 11.5 percent of children were still experiencing emotional disturbances from the storm, according to a study published in 2010 in the Journal of the American Academy of Child & Adolescent Psychiatry. In the normal population, prevalence of emotional disturbances among children is less than half that high.

“You see three distinct patterns,” La Greca says, summarizing data she described in 2013 in Child & Youth Care Forum. “There are children who are doing fine across the board, maybe 40 to 45 percent. Another 30 to 35 percent started out distressed but bounce back. It was only 18 to 20 percent who had elevated distress long term. That’s the group, from a clinical perspective, we’d like to be able to identify early on.”

This remains a major goal: predicting which children are the most susceptible and in need of attention. Studies have found that a child’s mental state before a disaster affects how he or she fares after. More than a year before Andrew hit, La Greca had by chance conducted a study of 92 elementary school children, grades 4 through 6, documenting their mental health.

After Hurricane Andrew, children who were more prone to anxiety before the hurricane were more likely to have symptoms of post-traumatic stress after the storm, according to findings that La Greca and her colleagues reported in the Journal of Consulting and Clinical Psychology.

Added stresses

Children also have slower recoveries when misfortune doesn’t stop with the initial event. Stressed parents may start to argue or get divorced. Pets can die or disappear. Following Katrina, many businesses and homes sat as abandoned reminders, crime rates soared and many families were repeatedly displaced.

Researchers found that some children were transferred to a new school nine times in the course of a year. Four years after the storm, relocated kids whose families were unable to return were more likely to show symptoms of post-traumatic stress, depression and trauma than those who had returned to their zip code, according to a 2013 study of 795 children published in the Journal of Traumatic Stress. But the effect varied by age, with younger children seeming more adaptable to relocation.

While most children are resilient, each renewed stress makes feelings of post-traumatic stress and depression harder to overcome, says Joy Osofsky, head of pediatric mental health at Louisiana State University School of Medicine in New Orleans.

“For the children who experienced Katrina, there’s been a lot of disruption for a long period of time,” she says. Louisiana’s coast continues to be battered. Hurricane Rita made landfall a month after Katrina in 2005; then came Hurricane Gustav in 2008 and the Deepwater Horizon oil spill in 2010. Even though those disasters did not cause damage on the scale of Katrina, children who had lived through it were already vulnerable.

The effects of disasters can have unexpected physical consequences as well: a study published in May in the journal Psychological Trauma: Theory, Research, Practice and Policy found that eight months after Hurricane Ike hit Galveston, Texas, in 2008, children were more likely to become sedentary, especially those who reported the greatest struggles with post-traumatic stress reactions. Children who had lived through the hurricane reported an average of 41 sedentary after-school hours per week; the average is less than 30.

Even though subsequent disasters can’t be anticipated, preparing for them can help ease the effects. How children react depends largely on the adults around them, according to several studies. When parents are prepared and are calm (or as calm as can be expected), children, who take their cues from adults, might be more relaxed themselves.

Researchers from the University of Queensland and colleagues in Brisbane, Australia, surveyed more than 800 elementary school children three months after a minicyclone hit in 2008 with winds up to 130 kilometers per hour. In February, they reported in the Journal of Child and Adolescent Psychopharmacology that, after accounting for other variables, children who perceived a change in their parents’ behavior — such as becoming more protective or communicating a lingering sense of danger — were more likely to suffer post-traumatic stress.

UCLA’s Pynoos acknowledges that it can be tough for parents to keep cool in the face of imminent danger, but after the disaster they can revisit those frightful moments and restore trust. The importance of parent stability also underscores the need to support families and to maintain a social fabric following the event. During the evacuation of a high school near the World Trade Center on 9/11, Pynoos says, the principal made sure the building was emptied smoothly and that children with disabilities were helped out of the building. She stood by the door, spoke to all students as they left and made sure no child walked away without a buddy for the journey home, he says. “That was very important.”

Work like this will continue to gain importance, as an estimated 175 million children may be exposed to disasters by the end of the decade, according to the advocacy group Save the Children. As the planet warms, scientists are predicting that some hurricanes could become even fiercer, floods and severe weather more frequent. “With climate change, there will be likely over time an increase in extreme weather events,” says Miami’s La Greca. Images of distressed children will always be in the news, but how they respond is coming into better focus.

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This article appears in the December 13, 2014, issue with the headline, “Emotional Wounds: For some children, the effects of a disaster reach deeper than anticipated.”