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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Chapter 8. Mental Health Issues

Mental Health and the Role of the Pediatrician

Schools and pediatricians have generally become the de facto mental health providers for children. Children are most likely to receive treatment from primary care physicians for symptoms associated with mental disorders, and most psychotropic drug prescriptions for children and adolescents are prescribed by primary care physicians. In a disaster or terrorist event, the need for mental health services will be far greater and the resources even less adequate. Pediatricians and other health professionals that care for children will play many critical roles in identifying and addressing the mental health needs of children and families in a disaster or terrorist event.

For many, if not most, children affected by a critical event, pediatricians and other health care providers for children will be the first responders. Therefore, pediatricians need to be able to identify psychological symptoms, perform timely and effective triage of mental health complaints, initiate brief supportive interventions, and make appropriate referrals when necessary. Many children (and their parents) with emotional reactions to a disaster (manmade or otherwise) will not identify their problems as psychological in nature. Pediatricians will have to be vigilant for somatization and help children, and their families, recognize and address the underlying psychological cause of these physical complaints. Because children's adjustment depends to a great extent on their parents' own ability to cope with the situation, pediatricians should also attempt to identify parents who are having difficulties adjusting to the event and encourage them to seek support for themselves. Pediatricians can also help families identify and access appropriate supportive or counseling services, and they can help support families who are reluctant to seek mental health services because of misunderstandings related to the nature of the treatment or associated stigma.

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Trauma-Related Disorders

Children are not immune to the emotional and behavioral consequences of disasters and terrorism. Their reactions depend on their own inherent characteristics and experiences and their developmental level, family and social influences, and the nature and magnitude of the event and their exposure to it.

Exposure to disasters and terrorism can be direct, interpersonal, or indirect. Children who are physically present during an incident are directly exposed. Interpersonal exposure occurs when relatives or close associates are directly affected. Indirect exposure occurs through secondary negative consequences of an event such as chaos and disruption in daily activities. Children who are far away from an incident may be remotely affected with fear and generalized distress as they perceive the societal impact of these experiences.

Exposure to media coverage may play a role in the child's reaction to an event. Studies have documented an association between viewing television coverage of terrorist incidents and posttraumatic stress reactions, but these associations do not establish a causal relationship. Aroused children may be drawn to the information provided by the media, and it is possible that other factors are responsible for the link between exposure to media coverage and these emotional states.

Reaction to Disasters and Terrorism

Children may develop psychiatric symptoms and disorders—including posttraumatic stress disorder (PTSD), anxiety, depression, and behavioral problems—after exposure to disasters or terrorist incidents. Grief in these situations can be compounded by the traumatic circumstances associated with the loss.

Risk Factors for Adjustment Difficulties

The following factors are associated with an increased risk of posttraumatic symptoms and other adjustment difficulties:

  • Children or others close to them are direct victims, especially if injury is involved (or the death of significant others).
  • Children directly witness the event, especially if there was exposure to horrific scenes (indirect exposure through the media to these scenes is also associated with increased risk).
  • Children perceive during the event that their life is in jeopardy (even if the perception is inaccurate).
  • Event results in separation from parents or other caregivers.
  • Event results in loss of personal property or other disruption in regular environment.
  • Children have a history of prior traumatic experiences.
  • Children have a history of prior psychopathology.
  • Parents have difficulty coping with the aftermath of the event.
  • Family lacks a supportive communication style.
  • Community lacks the resources to support children after the event.
Posttraumatic Stress Disorder

The essential feature of PTSD is the development of characteristic symptoms after exposure to a traumatic event that arouse intense fear, helplessness, or horror or that lead to disorganized or agitated behavior. Signs and symptoms are categorized into three clusters:

  1. Persistent intrusive re-experiencing (one symptom required for diagnosis):
    • Unwanted memories, images, thoughts, or perceptions of the experience including repetitive play with themes of the trauma.
    • Bad dreams and nightmares.
    • Acting or feeling like the event is recurring, including flashbacks or re-enactment of the experience.
    • Feeling intense distress when reminded of the experience.
    • Physiological reactivity to reminders.
  2. New onset and persistent avoidance and numbing (three symptoms required for diagnosis):
    • Avoiding thoughts, feelings, or conversations associated with the experience.
    • Avoiding activities, places, or people that arouse memories of the experience.
    • Amnesia for important parts of the experience.
    • Loss of interest or involvement in usual activities.
    • Feeling distant and isolated.
    • Decreased range of emotions.
    • Sense of foreshortened future.
  3. New onset persistent hyperarousal (two symptoms required for diagnosis):
    • Sleep difficulties.
    • Irritability and angry outbursts,
    • Difficulty concentrating.
    • Hypervigilance.
    • Exaggerated startle response.

The symptoms must last for more than 1 month and must cause clinically significant distress or impaired functioning. Because of developmental influences, symptoms in young children may not correspond exactly to those in adults.

Other Conditions

Other conditions, especially anxiety and affective disorders, are common after crisis events and may occur independently or together with PTSD. These conditions may precede, follow, or develop at the same time as PTSD. Establishing the temporal relationship in onset of disorders may aid in treatment. For example, PTSD stems from the primary traumatic event, while depression may result secondarily from persistent severe PTSD symptoms, intervening stresses, or unresolved grief. Fear and avoidance of situations reminiscent of the trauma may persist for years.

Behavioral Reactions

Signs of trauma may be evident in children's behavior, mood, and interactions with others. Traumatized children may adopt behavior more appropriate of younger children. Although they may not share their concerns and they may be especially compliant in the aftermath of an incident, compliant behavior does not mean the child is unaffected. Withdrawal is a cause for concern as it may represent a symptom of PTSD, and it potentially distances the child from adults who could provide support and assistance. Girls are more likely to express anxiety and sadness; boys tend to exhibit more behavior problems.

The child's reaction will reflect his or her developmental level. Infants may experience sleep and feeding problems, irritability, and failure to achieve developmental milestones. Problems in preschool children include separation anxiety, dependence, clinging, irritability, misbehavior, sleep disturbance, and withdrawal. Problems in school-aged children include irritability, somatic complaints, withdrawal, misbehavior, and change in academic performance. Problems in adolescents include anxiety, irritability, isolation and withdrawal, guilt, anger and hate, and preoccupation with death.

Grief and Traumatic Grief

Although grief is not a mental disorder, it may require professional attention, especially if it is complicated by depression or PTSD. Traumatic deaths are of particular concern in disasters because of the implications for assessment, which should include an evaluation of the circumstances of the death and the child's exposure, and for treatment, which should address trauma symptoms as well as grief. In some ways, any death may be perceived by survivors as subjectively traumatic; however, five factors have been described that are likely to be present in death circumstances that are considered "traumatic deaths":

  • Sudden, unanticipated deaths.
  • Deaths involving violence, mutilation, and destruction.
  • Deaths that are perceived as random or preventable, or both.
  • Multiple deaths.
  • Deaths witnessed by the survivor that are associated with a significant threat to personal survival or a massive or shocking confrontation with the death and mutilation.

Deaths that occur in the context of a disaster or terrorist situation often meet these criteria and pose an increased risk of traumatic grief. Referral to a pediatric mental health professional is often indicated in these situations.

Assessment and Treatment

Assessment and treatment of children after a disaster will vary, depending on the characteristics of the disaster and the child's exposure, the setting, and the length of time since the event.

Early Interventions

In the acute-impact and early post-impact phases, supportive interventions should ensure the child's safety and protection from additional harm, address immediate physical needs, provide reassurance, minimize exposure to traumatic aspects of the event, validate experiences and feelings, and restore routine. Children benefit from accurate information, but it should be age-appropriate and measured. If possible, pediatric mental health professionals can help other health professionals and family members with the process of death notification. Reuniting family members is a priority.

Assessment and Screening

Assessment should include a history of the child's exposure and reactions. When children or their close family members have been directly exposed, the children may require more comprehensive assessment. Children with less direct exposure may also need attention. Children and their parents should be educated about trauma reactions and coping, and they may welcome opportunities to ask questions and correct misperceptions. Children may not spontaneously describe their feelings, and adults may underestimate trauma in children. Therefore, it is essential to ask children directly about their experiences. Observation and the use of projective techniques, such as play and the use of art, aid in assessment and are useful in treatment as well.

Screening to identify children at risk and those needing referral can be conducted with symptom rating scales (such as the University of California, Los Angeles [UCLA] PTSD Reaction Index), which typically measure the type and degree of exposure, subjective reactions, personal consequences, PTSD symptoms, and other related symptoms such as fear and depression, grief, and functioning. Group interviews, conducted in classrooms or other small clusters, may also be used to assess the need for more comprehensive individual evaluation and to begin the process of healing after large-scale or mass casualty events.


Treatment should be guided by the child's exposure and reactions. Directly traumatized and bereaved children should be seen individually, but groups are useful for identifying children in need of more comprehensive evaluation and treatment. Cognitive behavioral therapy and educational information provide structure and support and may be used in individual or group sessions after disasters.

Group sessions are ideal for providing age-appropriate explanations of acute and longer term reactions, reactions to traumatic reminders, secondary effects, anniversaries, and coping. Some children are uncomfortable sharing in a group, and group discussions may traumatize the children again through re-exposure to their own experiences or through exposure to the experiences of others. Groups vary with respect to structure and may include play, art, and other projective techniques. Parallel parent groups provide a means to address parental reactions and concerns and to discuss effective management. These groups also provide an opportunity to teach parents how to parent their traumatized child.

The family has a major role in the child's adjustment to trauma, and parents should be included in treatment. Often, more than one family member will be traumatized, although specific aspects of exposure may differ among family members. Helping parents resolve their own emotional distress can increase their perceptiveness and responsiveness to their children. Parents may also benefit from psychoeducation about symptoms, how to manage symptoms effectively, and ways to decrease traumatic reminders and secondary stresses.

Medication is rarely indicated in children after disasters but might be used for those with severe reactions. Consultation with a child psychiatrist is recommended when medication is being considered. When used, medication should be coupled with psychotherapeutic interventions such as play therapy or cognitive behavioral approaches. Specific symptoms determine whether to use a drug, which drug to use, and how long to use it. Comorbid conditions should be considered in selecting an agent. Selective serotonin reuptake inhibitors may be effective in treating childhood PTSD and comorbid anxiety and depression (also: the section on medication, later in this chapter).

School-based Interventions

Schools are an excellent setting to deliver mental health services to children and families after a disaster. They provide access to children, encourage normalcy, and minimize stigma. PTSD and associated symptoms are likely to emerge in the school setting. For example, intrusive thoughts and difficulty concentrating may interfere with academic performance and social adaptation. Therefore, school consultation about the consequences of trauma and the recovery process may be indicated. School-based interventions, which can include curricular materials and activities, should be appropriate for the setting and should not supplant efforts to identify and refer children in need of more intensive individual evaluation and treatment.

Long-term and Staged Interventions

Long-term interventions may be necessary, especially for children with direct or interpersonal exposure and for those with enduring symptoms, pre-existing or comorbid conditions, prior or subsequent trauma, or family problems. New issues related to trauma may emerge as children mature. Thus, developmentally appropriate staged interventions, which anticipate and address the course of recovery, should be considered during developmental transitions and at marker events such as anniversaries.

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Death Notification and Pediatric Bereavement

Considerations in Notifying Individuals About an Unexpected Death

At the time of a disaster or terrorist attack, it is very unlikely that pediatric health care providers will have the time and resources to deliver death notification in an optimal manner. Nonetheless, sensitivity to the issues discussed here can help minimize the short- and long-term impact on survivors.

  • Verify the identity of the deceased and identify the next of kin.
  • Establish contact as soon as possible. Do not delay contact waiting for a time thought to be more convenient for the survivors (e.g., if the death occurs in the middle of the night, do not wait until the following morning).
  • Contact the next of kin. Phone calls can be used to contact next of kin, but death notification is preferably done in person. Alternatively, someone (e.g., police) can be sent to the home of the next of kin to ask them to come to the hospital for notification purposes.
  • Minimize the likelihood that you will be compelled to notify the family members of the death over the phone. If you contact the survivor(s) by phone to request they come to the hospital, try to contact the family before the death has been declared (i.e., during resuscitation) or have someone else who has not been directly involved in the care call on your behalf. Someone not directly involved in the care could make a statement such as: "I know that your husband was seriously hurt in the bombing, but I don't have any further information. If you come to the hospital now, someone who has been taking care of your husband will be available to talk with you when you arrive." If family members demand information on the phone, the caller can state: "I would prefer to talk with you about this in person when you arrive at the hospital."
  • Consider inviting additional family members or friends to accompany the next of kin to the hospital for notification. If a child has died, it is best to notify both parents at the same time. When any family member has died, survivors may benefit from being told with at least one other family member or friend present. Family members and friends can provide support to the next of kin and help notify other relatives and friends (instead of the entire burden being placed on one survivor).
  • Before notifying the family, briefly review the basic facts, including the name of the deceased, the relationship to individual(s) that will be notified, the basic circumstances of injury and death, and the nature of medical care provided. For example, the individual was in a building when a bomb detonated and was found under rubble; cardiopulmonary resuscitation (CPR) was done until arrival in the emergency department, where after an attempt at resuscitation, he was pronounced dead. Identify who else will participate in the notification, and consider planning in advance how to initiate the conversation.
  • When the family arrives at the hospital (or site where death notification will be occurring), have them escorted to a private location if possible. Try to inform them in as private a site as possible; if there is no opportunity for a private room, make every reasonable effort to maximize privacy (e.g., use a curtain or notify the family while standing behind the building instead of in front). Do not inform family members in view of the media; anticipate the presence of media and try to offer survivors the opportunity to maintain their privacy as much as possible immediately after notification.
  • If possible, have the notification conducted by a physician who was involved in the care, especially if he or she knows the family or had some direct involvement. Comments such as "I was with your husband when he first arrived at the hospital. He was not conscious at the time and therefore was not feeling any pain" can be very helpful to families. Inform the patient's primary care provider whenever possible.
  • Consider involving at least one other professional on the health care team, such as a social worker, chaplain, nurse, etc. If more than one family member is receiving the notification, conducting the notification with another professional is especially helpful; however, one staff person should be in charge of the discussion. Try to include at least two staff people for notification, even when notification is conducted in the field, but limit the number of staff to those directly involved. It can be overwhelming for a family member to be notified by a large team.
  • Introduce yourself and any other member(s) of the health care team who are participating by name and title and offer to shake hands.
  • Offer seating to the survivors. Sit close to them and face them so that eye-to-eye contact can be easily maintained.
  • Refer to the deceased by name and/or relationship to the survivor (e.g., "Mr. Smith" or "your husband"). Avoid referring to the person as "the deceased" or "the victim."
  • If children are included, involve professionals with training and experience in working with children in the notification process. Notification of the death of a family member is preferably provided to children by family members (such as the surviving parent), rather than by professionals unknown to the child. However, parents may wish for professionals to be present when children are told to provide support and to help answer questions.
  • Remember that informing survivors of a death is a process, not an act. Pacing of the discussion is important. Do not start by stating that the individual is dead because survivors are unlikely to hear any further information.
  • Start by asking the family what they have already been told or know. Then provide a brief description of the circumstances of the injury and the relief efforts. This information helps the survivors understand the context of the death; not knowing what happened introduces a discontinuity in the history that impairs adjustment. After giving brief background information, it is useful to give a "warning notice" and then proceed fairly quickly to stating that the individual died. Ideally, the family will be present during the resuscitation efforts, and medical staff can provide the background information when the resuscitation begins and return to deliver updates that may serve as a "warning notice." For example, "The team has given several medications to try to get your husband's heart starting again, but so far there has not been any response."
  • An example of a notification initiated after a death might be: "There was an explosion 2 hours ago that we believe was caused by a bomb in the building where your husband works. The explosion started a fire that spread rapidly. Firefighters arrived on the scene within several minutes, but the exits were blocked and flames spread quickly. Many individuals were unable to get out of the building before they were overwhelmed by smoke. I am sorry to say that your husband did not get out of the building in time. We believe he died as a result of the smoke from the fire. His body was recovered by a firefighter, and we identified him by the wallet that we found in his pocket. We found your phone number in the wallet. I am very sorry to have to be telling you this news."
  • After notifying the survivor(s) of the death, pause to allow both the information to be processed and emotions to be expressed. Do not try to fill the silence, even though it may seem awkward. Listen more than you speak. Silence is often better than anything you can say. Stay with the family members as they are reacting to the news, even if they are not talking.
  • Use clear and simple language. Avoid euphemisms such as terminated, expired, or passed away. State that the individual died or is dead.
  • Don't provide unnecessary graphic details. Begin by providing basic information and allow the individual to ask questions for more details.
  • Don't lie or speculate. If you do not know the answer to a question, say so. Try to get the answer if possible.
  • Be conscious of nonverbal communication and cues, both those of the family as well as your own.
  • Be aware of and sensitive to cultural differences. If you do not know how a particular culture deals with a death, it is fine to ask the family. Be particularly attentive to difficulty speaking or understanding English. If there is any doubt whether the family members are fluent in English, make sure to have a professional translator present unless you are fluent in the family's preferred language. Using family and friends as unofficial translators often leads to inadequate translation in the general medical setting. Such reliance on family and friends as translators for death notification is particularly burdensome to them and should be avoided.
  • Consider the use of limited physical contact (e.g., placing a hand on the family member's shoulder or providing a shoulder to cry on). Monitor the individual's body language and if at all in doubt whether such contact would be well received, ask first.
  • Realize that the individual may initially appear to be in shock or denial. Expect additional reactions, such as sadness, anger, guilt, or blame. Acknowledge emotions and allow them to be expressed without judgment.
  • Do not ignore or dismiss suicidal or homicidal statements or threats. Investigate any such statements (often this will be facilitated by the involvement of mental health professionals) and if concerns persist, take appropriate action.
  • Just before and during the notification process, try to assess if the survivors have any physical (e.g., severe heart disease) or psychological (e.g., major depression) risk factors, and assess their status after notification has been completed.
  • If possible, write down your name and contact information in case the family wants further information at a later time. If the situation is not appropriate for providing your name and contact information, then consider how the family may be able to obtain additional information in the future (even months later). For example: "I work as a volunteer for the Red Cross. Here is my name and the contact information for the Red Cross Chapter. If later you wish more information about what happened to your husband, you can call them at this number and they should be able to look at the records." Survivors may not be ready to think of or ask questions and may later regret not asking for critical information.
  • Do not try to "cheer-up" survivors by making statements such as "I know it hurts very much right now, but I know you will feel better within a short period of time." Instead, allow them their grief. Do not encourage them to be strong or to cover up their emotions by saying "You need to be strong for your children; you don't want them to see you crying, do you?"
  • Feel free to express your own feelings and to demonstrate empathy, but do not state you know exactly how family members feel. Comments such as "I realize this must be extremely difficult for you" or "I can only begin to imagine how painful this must be to hear" can demonstrate empathy. Avoid statements such as "I know exactly what you are going through" (you can't know this) or "You must be angry" (let the individual express his or her own feelings; don't tell the person how to feel) or "Both my parents died when I was your age" (don't compete with the survivor for sympathy). Provide whatever reassuring information you may be able to, such as "It appears your husband died immediately after the explosion. It is unlikely he was even aware of what happened and did not suffer before he died." However, do not use such information as an attempt to cheer up family members (e.g., "You should be happy, many people suffered painful burns or were trapped under rubble for an hour before they died. At least your husband didn't experience that.")
  • Feel free to demonstrate that you are upset as well—it is fine to cry or become tearful. If you feel, though, that you are likely to become overwhelmed (e.g., sobbing or hysterical), then try to identify someone else to do the notification.
  • After you have provided the information to the family and allowed adequate time for them to process the information, you may wish to ask questions to verify comprehension.
  • Offer the family the opportunity to view the body of the deceased and to spend some time with their loved one. Before allowing the family to view the body, the health care team should prepare it for viewing by others. A member of the health care team should escort the family to the viewing and remain present, at least initially.1
  • Help families figure out what to do next. Offer to help them notify additional family members or close friends. Tell them what needs to be done regarding the disposition of the body. Check to see if they have a means to get home safely (if they have driven to the notification, they may not feel able to drive back safely), and inquire if they have someone they can be with when they return home.
  • Help survivors identify potential sources of support within the community (e.g., member of the clergy, their pediatrician, family members, or close friends).
  • Take care of yourself. Death notification can be very stressful to health care providers. Health care providers need to explore and come to understand their own reactions to patient death and associated emotions, which may include sadness, anger, guilt, or a sense of responsibility. It is important to provide informal support and debriefing to professionals who provide death notification, especially if related to tragic deaths or when multiple deaths are involved (as would be anticipated in a major disaster or terrorist event).

Explaining Death to Children

Children's understanding of death may be very different from that of adults. Children have had far less personal experience of loss and have accumulated less information about death. They can also have difficulty understanding what they have seen and what they are told unless the basic concepts related to death are explained to them. Adults will need to provide especially young children with both the basic facts about what happens to people after they die, as well as the concepts that help them to explain those facts. For example, young children may be told that after people have died, their body is buried in a cemetery or turned to ashes that can then be buried or scattered. Children can be very distressed by these facts unless they are helped to understand the concept that at the time of death, all life functions end completely and permanently—the body can no longer move, and the person is no longer able to feel pain. That is why it is okay to bury or cremate the body.

Children need to understand four concepts about death to comprehend what death means and to adjust to a personal loss: irreversibility, finality, inevitability, and causality (Table 8.1). Most children will develop an understanding of these concepts between ages 5 and 7, but this varies widely among children of the same age or developmental level, based in part on their experience and what others have taught them. When faced with a personal loss, some children 2 years old or younger may demonstrate at least some comprehension of these concepts. Adults should not underestimate the ability of young children to understand what death means if it is explained to them properly. Therefore, it is best to ask children what they understand about death, instead of assuming a level of comprehension based on their age. As children explain what they already understand, it will be possible to identify their misunderstandings and misinformation and to correct them accordingly.

When providing explanations to children, use simple and direct terms. Be sure to use the words "dead" or "died" instead of euphemisms that children may find confusing. If young children are told that the person who died is in "eternal sleep," they may expect the deceased to later awaken and be afraid to go to sleep themselves. This description does little to help children understand death and may cause more confusion and distress. Religious explanations can be shared with children of any age, but adults should appreciate that religious explanations are generally very abstract and therefore difficult for young children to comprehend. It is best to present both the facts about what happens to the physical body after death, as well as the religious beliefs that are held by the family.

Even when children are given appropriate explanations, they still may misinterpret what they have been told. For example, some children who have been told that the body is placed in a casket worry about where the head has been placed. After explanations have been given to children, it is helpful to ask them to review what they now understand about the death.

Common Reactions Among Children Who Have Experienced a Personal Loss

Like adults, children may be reluctant to talk about a death. They may at first be shocked by the news or fail to understand its implications. Young children have difficulty sustaining strong emotions, so they may appear upset for a brief period of time and then return to play. They may also use play or other creative activities, such as artwork or writing, to both express and work through their feelings associated with a loss. By observing play and the products of children's creative activities, we may find some clues as to what is bothering them, but it is important not to jump to conclusions about the meaning or relevance of what is observed.

Soon after notification, children often ask questions about the deceased and the meaning it has for them personally. These questions may cause surviving family members distress because they often are particularly poignant. Children pick up readily on the cues from others in their family that adults are made uncomfortable by these inquiries. They may conclude that such questions are unwelcome, inappropriate, or even represent misbehavior and stop asking. The silence that results is not an indication that children do not understand what has happened or have already coped. Rather, it may be a sign that they are trying to protect their parents who appear overwhelmed or that they do not feel comfortable asking questions or expressing their emotions, leaving them to deal with both alone. Therefore, it is important for adults to explicitly invite children to share their questions and feelings. Often it is helpful for an adult who is familiar with child development and who knows the child personally to provide an additional outlet for discussion. The child's pediatrician or a social worker from the child's school, for example, may be in a good position to start such a conversation.

Older children and adolescents may initially decline the assistance of adults because they are more accustomed to turning to peers for support and to address issues of concern. It is important to extend an open invitation to these young people to talk with you when they have questions or want to talk about the situation and to help them identify other adults in their lives they can turn to for support and assistance (e.g., a chaplain, coach, or teacher).

Even in the setting of a natural disaster or terrorist event, children may still wonder if they were in some way responsible for the death. After a traumatic death, such guilt feelings may increase posttraumatic symptoms and complicate the grieving process. Young children in particular have a very limited understanding of why things occur and tend to be self-centered. As a result, they often use magical thinking to explain situations that they do not understand. This may result in extreme feelings of personal responsibility for a death that has occurred, even in situations when there is absolutely no logical reason why the child should feel responsible.

Often such feelings of guilt are irrational. "If only I hadn't gone to school that day, my dad would never have gone to the office and wouldn't have been killed by the bomb," "I was mean to my father yesterday and that's probably why he died," etc. Understandably, children are often reluctant to share their guilt feelings with adults; adults may not anticipate these feelings (or be burdened with their own guilt feelings). It may be helpful to reassure children of their complete lack of responsibility, even if they do not express feelings of guilt, and there is no logical reason why you might anticipate they would feel guilty.

At the time of a traumatic loss, children often think first about their own needs. Parents should be warned that this self-centeredness is not a sign that children are selfish; more likely, it is a sign that they are under considerable stress and in need of more support and assistance.

Children often regress in response to the stress of a personal loss. Children who had been successfully toilet-trained may now begin to wet their bed; children who had not had difficulty attending daycare may now begin to show separation problems; children who had good social skills may now argue more or have difficulty getting along with peers. Children and adolescents may also develop somatic complaints, such as headaches, stomach aches, or generalized fatigue.

A disaster or terrorist event may uncover children's concerns about another loss or personal crisis that has not been fully resolved. Children may react strongly to the death of someone that they did not know well or perhaps did not know at all. Or, children may be more preoccupied with their own personal crises than they are affected by the death of someone in their family or community.

Indications of the Need for Referral

Not every child who has experienced the death of a family member or friend requires professional counseling, and in the setting of a major disaster or terrorist event, such resources are unlikely to be available. It generally is helpful though for children who have experienced the death of a family member or friend to speak with someone outside of the immediate family who understands child development and can attend to the child's needs (without being burdened with his or her own grief), such as their pediatrician or a school counselor or social worker. When a community disaster or crisis has occurred, it is important to help establish access to supportive services within community sites, such as schools, to provide services to larger numbers of children.

Significant stigma continues to be associated with receiving mental health services, and this stigma remains even in the setting of a major crisis event. Parents and other caregivers need to understand that even though bereavement is a normative experience, it still can be profoundly difficult. People, including children, can be helped through supportive services and, when indicated, group or individual counseling.

Children who have extreme reactions (e.g., anxiety, posttraumatic symptoms, depression, or thoughts of suicide), atypical reactions (e.g., appearing happy or disinterested), or prolonged reactions (e.g., prolonged sleep problems or somatization) should be evaluated by their pediatrician and likely referred to a mental health professional experienced in the management of pediatric bereavement. Children should be referred who are having difficulty returning to their normal daily routines several weeks after the death or are demonstrating the new onset or worsening of problems interacting with peers. Children who are experiencing traumatic grief may require treatment of posttraumatic symptomatology before they are able to continue with normal grieving.

Soon after a death has occurred, many children may find comfort in returning to school, spending time with their friends, and taking part in the same activities that they did before the death. Allowances and adjustments should be made for a time (such as extra help with homework because of difficulty concentrating and learning) so that they can return to their day-to-day life as soon as possible. Some children may resist returning to school or resuming their regular daily activities. They may be fearful to leave other family members, worrying that they may die in their absence or that grieving family members may need their support. These children require reassurance of the safety and well-being of surviving family members and encouragement to return to school. Other grieving family members, especially parents or guardians, should receive the support and assistance they need, so that the children do not feel it is their responsibility.

Attendance of Children at Funerals and Memorial Services

Children can be told in simple terms what to expect at a funeral or memorial service. If an open casket or gravesite ceremony is planned, children should be told and given explanations about what this involves. Children can be invited to participate to their level of comfort but should not be forced or coerced to attend. They should be encouraged to ask questions, which should be answered simply and honestly but without unnecessary details. At the ceremony, children should be accompanied by an adult they know and like (who is not personally grieving to the same extent as close family members) who can monitor the child's reactions, answer questions, and step out of the ceremony with the child if the child appears distressed or indicates a desire to leave. Even if children play quietly in the lobby of a funeral home, they may still have a sense of having participated in the ritual. Children who are not allowed to attend the funeral or memorial service often feel angry and hurt and lose out on the benefits of religious, family, and community support. They also may create fantasies about what occurs during funerals that are actually more frightening than the reality. It is also helpful if children can perform a small task at the funeral, such as handing out Mass cards at the entrance of the funeral home or selecting flowers to be placed near the coffin. Such tasks should be predominantly symbolic, of the child's choosing, and not overwhelming for the child.

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