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International Review of Psychiatry, June 2007; 19(3): 263277

ORIGINAL ARTICLE

The psychosocial consequences for children of mass violence, terrorism and disasters

RICHARD WILLIAMS
Professor of Mental Health Strategy in the University of Glamorgan, Honorary Professor of Child and Adolescent Mental Health in the University of Central Lancashire, and Consultant Child and Adolescent Psychiatrist, Gwent Healthcare NHS Trust, Wales, Ty Bryn, St Cadocs Hospital, Lodge Road, Caerleon, Near Newport, Gwent, NP18 3XQ, South Wales, UK

Abstract Children and families are now in the front line of war, conflict and terrorism as a consequence of the paradigm shift in the nature of warfare and the growth of terror as a weapon. They are as vulnerable as are adults to the traumatizing effects of violence and mass violence. Furthermore, employing children as soldiers is not new, but it is continuing and young people are also perpetrators of other forms of violence. This paper summarizes a selection of the literature showing the direct and indirect psychosocial impacts on minors of their exposure to single incident (event) and recurrent or repetitive (process) violence. Additionally, childrens psychosocial and physical development may be affected by their engagement with violence as victims or perpetrators. Several studies point to positive learning from certain experiences in particular communities while many others show the potential for lasting negative effects that may result in children being more vulnerable as adults. The spectrum of response is very wide. This paper focuses on resilience but also provides access to several frameworks for planning, delivering and assuring the quality of community and family-orientated and culture-sensitive responses to peoples psychosocial needs in the aftermath of disasters of all kinds including those in which children and young people have been involved in mass violence.

Keywords: Resilience, conflict, terrorism, child soldiers, development, schools, psychological first aid

Introduction One of the most notorious atrocities in which large numbers of children were exposed to extreme violence was the siege of School Number 1 in Beslan, Russia in 2004. On 1 September, armed militants seized the school. Two days later, a bomb detonated in the sports hall where 1100 pupils, teachers and parents were being held hostage and that explosion triggered a second as children scrambled through the windows. An article (Parfitt, 2004) summarizes what took place and the activities of 48 psychiatrists, psychotherapists and psychologists. No one can doubt the enormity of such an extreme example of childrens exposure to mass violence. While the humanitarian response was

extraordinary in the acute phase, there were dire warnings of how long recovery would take. This review introduces some of the growing volume of papers on how minors respond to mass violence. It provides an entry into the literature on childrens exposure to conflict, war and terrorism and to children as combatants. Certain patterns become clear. As the author subscribes to the view that resilience should be taken as the desirable default condition, that concept is also summarized. Later, the author draws together the range of psychosocial responses and the psychiatric disorders that have been found in children and young people after violence and other traumatic events. Summerfield (2005) and others have coherently expressed their concerns about the risks of

Correspondence: Richard Williams, Ty Bryn, St Cadocs Hospital, Lodge Road, Caerleon, Near Newport, Gwent, NP18 3XQ, South Wales, UK. Tel: 441633436832. E-mail: rjwwilli@glam.ac.uk ISSN 09540261 print/ISSN 13691627 online 2007 Informa UK Ltd. DOI: 10.1080/09540260701349480

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R. Williams be serious and persistent even for preschool children. They say that [d]isasters threaten personal safety, overwhelm defence mechanisms, and disrupt the community and family structures. They may also cause mass casualties, destruction of property and collapse of social networks and daily routines. The psychological trauma arising from the event and its sequelae can wield a severe blow to a childs sense of security and self, including central organising fantasies and meaning structures. Elsewhere (Williams, 2006), the author has drawn attention to publications that focus on children and young people as victims of violence and to the psychosocial impacts of death, divorce, accidents and disaster on them (Bailey & Whittle, 2004; British Journal of Psychiatry, 1998; Landolt, Vollrath, Timm, Gnehm, & Sennhauser, 2005; Shooter, 1997; Stallard, Salter, & Velleman, 2004; Stallard, Velleman, & Baldwin, 1998; Stoddard et al., 2006 Ursano, Fullerton, & Norwood, 2003; Zatzick et al., 2005). In truth, there is a very wide range of violent and traumatic events that may be experienced directly or indirectly by minors. Bullying must be one of the most ubiquitous ways in which children experience threat that amounts to a form of psychological violence. Its substantial effects have been widely and extensively reported and anti-bullying policies in schools are now required by law in a number of countries. Therefore, this topic is not pursued further in this paper. There is a growing literature that describes the immediate, short-term and longer-term psychosocial consequences of childrens experiences of violence and disasters of many kinds including the tsunami, the space shuttle disaster, and posttraumatic symptoms in juvenile offenders (Becker, 2006; Dixon, Howie, & Starling, 2005; Gould & Gould 1991; Journal of the American Medical Association, 2006; Nikapota, 2006; Terr et al., 1996a, b; Wright, Kunkel, Pinon, & Huston, 1989). Depression and PTSD, for example, are reported recurrently in refugee children (Heptinstall, Sethna, & Taylor, 2004) and there are many papers on the effects of personal abuse and domestic violence. Children are exposed to much the same array of domestic violence, mass violence, war and terrorism and disastrous situations as are adults (Ursano et al., 2003), though they are also dependent on adults materially and psychosocially. A moments reflection suggests that children and young people are exposed to violence in a variety of ways with a range of consequences. They are likely to be multiply affected because they may be: (1) Direct victims of violence;

over-medicalizing our concepts of, and responses to trauma and, through globalisation of psychiatry, of being too ready to impose Western concepts and practices on non-Western societies after major disasters. This paper provides an evidenced framework for a stepped approach to intervention. Children, violence, trauma and disasters The World Health Organisation (WHO) defined disaster as a severe disruption, ecological and psychosocial which greatly exceeds the coping capacity of the affected community (World Health Organisation, 1992). Trauma in children can be defined as any condition which seems to be unfavourable, noxious or drastically injurious to . . . development (Greenacre, 1942; Shaw & Harris, 2003). Shooter (2005) has advanced trauma as one model by which to understand the impact of disaster and violence on children. He opines that . . . there is no hierarchy of atrocity for those involved. Quoting Pfefferbaum (1998), he points out that massed events scar the memory of the individuals and communities they touch, they have the capacity to forever change the character and life style of individuals and communities, and they confront ones perceptions of the world and individual and collective vulnerability and strength. Overtly, the literature reports experience and findings of research fact. Some papers openly recognize, while evidently inherent in others is a sense of the greater repugnance that most societies feel when children are involved in, affected by, or, particularly, when they are the perpetrators of violence (Meyer, 2007). Thirty years ago, Edwards (1976) stated that [u]sually children show a remarkable resilience to civilian disasters. While this statement holds enduring truth, it is also open to misunderstanding. Shaw and Harris state (2003), [i]t is surprising how often children and adolescents are reported to adapt to the conditions of war with little evidence of manifest distress. . . . [E]xposure to war with its multiple adversities is a significant interference with . . . childrens development. However, . . . the cognitive immaturity, plasticity and adaptive capacities . . . of children . . . have often veiled the effects of war . . . and [t]here is a conflicting and controversial literature debating the existence, frequency, and configuration of psychiatric morbidity in children exposed to war (Shaw & Harris, 2003). Lubit and Eth (2003) and Ursano and Norwood (2003) say, [i]t is widely believed that children are more resilient than adults. In reality, however, they are more vulnerable than adults to the traumatic events, chaos, and disruptions experienced in disasters. They cite evidence that the effects can

The psychosocial consequences for children of mass violence, terrorism and disasters (2) Indirect victims (as a consequence of the effects that violence has on adults and through compromising the abilities of carers and parents to look after, protect, and nurture their children); (3) Perpetrators of violence (including, specifically, as child soldiers). As much violence involves children directly or indirectly, it may not only have an impact on their current psychosocial needs and longer-term psychosocial consequences, but it may also imperil their development. Mass violence may have additional deleterious effects on children through impacts on their psychosocial development at sensitive times and this, in turn, may have cyclical effects on their reactions to continuing or repeated violence. The notion of resilience to disaster, violence and all manner of traumatic events is essentially a developmental one. There is copious evidence suggesting that childrens experiences have important formative influences on their development of resilience during childhood but also that this may affect them during later adulthood. Children are, inevitably, in the process of developing resilience when and if they are engaged in violent and disastrous circumstances.

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including children, are now deliberate targets of the new paradigm. In support of these assertions, Some approximated facts relating to the decade 1993 to 2003 are . . .: (1) Two million children were killed and six million children were injured or permanently disabled in war zones. (2) Of war-exposed survivors, one million children were orphaned and 20 million displaced to refugee camps or other camps. (3) Civilians comprise 80 to 90% of all who die or are injured in conflicts mostly children and their mothers (Barenbaum, Ruchkin & Schwab-Stone, 2004; Dyregrov, Raundalen, Lwanga, & Mugisha Williams, 2006). In summary, there is mounting evidence that, with changing paradigms of conflict and war and the rapid emergence of terrorism as a major concern in the early 21st century, children are increasing involved, directly and indirectly, in mass physical and psychological violence.

Children exposed to war An excellent summary of the literature to 2003 on the psychosocial aspects of children exposed to war is provided by Barenbaum et al. (Barenbaum et al., 2004). Other authors have reviewed the relationship between pre-school childrens direct and indirect exposure to trauma in war zones and their emotional problems (Lasser & Adams, 2007; Thabet, Karim, & Vostanis, 2006). Shooter (2003) draws attention to study of survivors of the Holocaust (Kestenberg, 1992; Sigal, 1991), adolescents displaced in Bosnia (Becker, Werne, Vojvoda, & McGlashan, 1999) and under siege in Sarajevo (Husain, 1998), war-torn Beirut (Deeb, Khat, & Courbagi, 1997), the troubles in Northern Ireland (Daly 1999), and children of the Gaza Strip (Thabet & Vostanis, 2000). Osofsky et al. (Osofsky, Wewers, Hann, & Fick, 1993) have reported that direct or indirect exposure of AfricanAmerican children to violence was related to their own reports of distress and their parents observations of them being distressed (Barbarin, Richter, & deWet, 2001). Laufer and Solomon point out (2006) that studies of young people in conflict in Ireland, Rwanda and the former Yugoslavia indicate that they suffer a wide range of problems consequent on their exposure to war and violence. By bringing together a number of sources (e.g., Barbarin et al., 2001; Laufer & Solomon, 2006), the author summarizes the reported effects of warfare on children as

Changing paradigms of conflict, warfare and violence Smith (2005) has pointed to a paradigm shift in the nature of warfare. Since the Second World War, the world has moved away from industrial warfare to confrontations that move into conflict and back again without war being formally declared. In the last few decades, there has been a significant change in the nature and intensity of war. Armed conflicts around the world have been increasingly characterized by low intensity and episodic conflict, the employment of guerrilla armies, and the victimization of the civilian population (Greenacre, 1942). The battleground for these confrontations and conflicts . . . lies within civilian domains rather than on discrete battlefields. Thus, in most human conflicts, there are interactions between the direct effects of warlike and terrorist actions on local environments resorting in hazardous situations for the health, wealth and social welfare of local populations, which are, thereby, precipitated into much greater devastation or catastrophe (Karam & Ghosn, 2003). Resident and displaced populations, refugees, and famine-affected peoples are caught up in conflict (Tai-Ann Cheng & Chang, 1999) (Williams, 2006). There are some periods in the last 30 years and some places in the world where children have known little but war. Some have suggested that civilians,

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R. Williams were related to the sexual attitudes subscale, directed towards poorer adjustment. Post-traumatic stress reactions were also associated with poorer adjustment on the emotional tone subscale. The findings also emphasized the importance of a school performance factor because it had most interactions with other factors. This supports current wisdom on endeavouring to use educational performance as a screening measure in post-trauma scenarios and schools as important places for intervention (Kia-Keating & Ellis, 2007; Kirkley & Medway, 2001; Lasser & Adams, 2007). Terrorism and children While Alexander and Klein state that the aims of terrorism do not require massive casualties for their fulfilment (Alexander & Klein, 2003, 2005), terrorism is mass violence because of the destructive psychological effects on large numbers of people, including children, that its perpetrators desire. Alexander and Klein (2003) opine that terrorism has the following aims: . Creating mass anxiety, fear and panic; . Creating helplessness, hopelessness and demoralization; . Destroying our assumptions about personal security; . Disruption of the infrastructure of society, culture or city; and . Demonstrating the impotence of the authorities to protect the ordinary citizen and his or her environment. These are very similar to the effects that research has shown that physical traumatic and violent events may have on people and societies. A report (McLellan, 2001) stated that Among those affected by the Sept 11 terrorist attack on New Yorks World Trade Center are thousands of children who have lost one or both of their parents in the buildings collapse. Other professionals warned Congress that resources are generally inadequate to meet the anticipated unprecedented demand for psychiatric services . . .. These children are the victims of mass violence. The US Department of Justice defines terrorism as the the unlawful use of force or violence against persons or property to intimidate or cover as the government, the civilian population, or any segment thereof, in pursuance of political or social objectives (US Department of Justice, 1996). Lubit and Eth (2003) provided a summary of responses of children to many kinds of disaster and a commentary on the events on and after the September 11, 2001. Subsequent research examined exposure to the attack and changes in cigarette smoking and drinking in 2731 New York high-school

covering a very wide range of feelings and behaviours including: . . . . . . . . . . . . . . . . . . . . Loneliness, misery, crying and sadness; Anxiety; Depression; Loss of a wish to engage in pleasure, restricted activities, apathy; Emotional numbness; Inattention, difficulties in concentrating, learning problems; Disrupted sleep and nightmares; Anger and tantrums; Disobedience, violence, risk taking; Intrusive images, heightened arousal, irritability; Re-enactment or re-living of distressing incidents; Separation anxiety, fears of being alone; Fear of death; Pretending not to care; Worries about safety; Anxious attachment; Imitative aggressive play and counter-phobic bravado; Emotional withdrawal from or aggression towards peers; Somatic symptoms; Truncated moral development.

South African children have been exposed to violence through victimization and through the affects of ambient community danger. Barbarin et al. (2001) quote research showing links between their proximity to violent events and degree of psychosocial distress. They propose a principle of social propinquity in which expectations of directly experiencing violence increase when it occurs to someone with whom a child has a relationship or identifies. Thus, violence affecting families appears to have greater effects than violence in the community. They report research on the effects of direct and vicarious political, family and community violence on the adjustment of 625 black South African children whose families were interviewed when they were 5 years old. Ambient community violence was most consistently related to childrens psychosocial outcomes. Resources in the form of individual child resilience, maternal coping, and positive family relationships were found to mitigate the adverse impact in all assessed domains of childrens functioning. More recently, Begovac et al. have reported research on 322 adolescents from BosniaHerzegovina and Croatia (Begovac, Rudan, Begovac, Vidovic, & Majic, 2004). They found more than four war stressors in 60% and nearly 14% had high levels of post-traumatic stress reactions. They said [t]he most interesting finding . . . was that refugee status and war stressors

The psychosocial consequences for children of mass violence, terrorism and disasters students six months afterwards (Wu et al., 2006). Increased drinking was associated with direct exposure. Increased smoking was marginally significantly associated with posttraumatic stress disorder. The authors recommend that targeted substance-use interventions are considered for youth after large-scale disasters. Other researchers concluded that, although there was only a slight increase in the incidence of recurrent abdominal pain in the six months after September 11 2001, the terrorist attacks did have a negative impact on recurrent abdominal pain in susceptible children. They concluded Affected individuals . . . were likely to have been overwhelmed by the blitz of media coverage and feelings of increased vulnerability (Gobble, Swenny, & Fishbein, 2004). Other papers suggest that, in certain circumstances, adolescents may experience growth in response to exposure to terror. Laufer and Solomon (2006) studied 2999 Israeli adolescents. Two-thirds had experienced one terror incident and one quarter had been exposed to more than three different terror incidents. Around 41% reported mild to severe posttraumatic symptoms while nearly 75% reported feelings of growth. Religious adolescents and girls reported more feelings of growth. While Yehuda and Hyman (Yehuda & Hyman, 2007) have shown that there have been few studies of the impact of terrorism specifically on children, they show that the predictors of chronic posttraumatic symptoms in children include the severity of the traumatic event and the developmental stage of each child in addition to dose factors relating to the degree of exposure to the relevant event. Furthermore, they found the amount of family support available during and after the experiences and degree of life disruption and social disorganization are important predictors. Pine et al. (Pine, Costello, & Masten, 2005) have reviewed the literature on trauma, proximity to the traumatizing event and the effects of war and terrorism on childrens developmental psychopathology. They derive the following six fundamental principles for understanding, researching and intervening to protect children. (1) The nature of the threats must be considered. (2) Development and planning of the terrorism will influence child and family reactions, protections and developmental sequelae. (3) The experiences and consequences for the children in the context of terrorism will be mediated and moderated by family, peer and school systems, and particularly by the quality of relationships in these systems.

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(4) Individual differences in vulnerabilities and capabilities will influence child responses and recovery patterns. (5) Interventions can be directed at different phases of terrorism, different processes, and different kinds of children, in different situations. (6) Front-line responders need to know differences between normal and pathological responses to traumatic events as well as strategies for prevention.

Child soldiers It is a war crime to recruit children under 15 to armed forces or employ them in combat and 18 is the minimum age at which people may be directly involved in warfare. Nonetheless, in her review (Cohn, 2006) of a recent book on child soldiers (Rosen, 2005), Cohn quotes a report to the UN Security Council in 2005 listing 54 parties to 11, then current, conflicts that recruit children. Others have suggested that . . . 300 000 children, sometimes as young as six years old, actively participate in . . . military conflicts at any one time (Barenbaum et al., 2004; Brett & McCallin, 1998). They may be employed in a number of logistic roles as well as in combat. Cohn (2006) says humanitarian actors are now focusing on improving monitoring and enforcement of international law and the commitments made in recent years by non-State armed groups to refrain from child soldier use. Rosen, she says, lays out the long history of child soldering, showing . . . that hundreds of thousands of children served in the Union and Confederate armies of the American Civil War, more than are alleged to be fighting in all contemporary wars. His research also supports the conclusion that ready access to small arms does not explain the attraction of children for recruiters. Barenbaum et al. (2004) suggest that there may be a range of economic, cultural, social and political pressures acting on children to become combatants. They include loss of caretakers, provision of food and money, revenge, and pursuit of ideology and religion. Barenbaum et al. also summarize childrens indoctrination and hardening through emotional punishment, violence and enforced killings, sometimes of family members. While, the author found no recent strong research on the outcomes for children who are agents of mass violence, Shaw and Harris (2003) observe that The child who was forced to participate in military activities and atrocities is similar to other victims of overwhelming disastrous life events. They say that The essence of a traumatic situation is the particular meaning that the experience has for

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R. Williams (peers, religious leaders, family, and community members) are essential to influence the views and the decisions of young people inclined to enlist. Resilience How is it that some children appear more resilient than do others to the risks posed by their exposure to violence and other traumas? Recently, Condly (Condly, 2006) has reviewed resilience relating to children. He quotes Janoff-Bulman (Janoff-Bulman, 2006) who proposes three fundamental assumptions that all people hold: the world is essentially a good place; life and events have meaning and purpose; and ones own person is valuable or worthy. Occasionally, he says, events transpire that are so hurtful to persons that their fundamental worldview is questioned and altered. Traumatic events effect great damage not so much because of the immediate harm they cause but also because of the lingering need to re-evaluate ones view of oneself and the world (Condly, 2006). Certainly, events of the nature of those that reviewed in this paper rank of that enormity. Condly says Resilience can be thought of as an enduring characteristic of the person, a situational or temporal interaction between the person and the context, or a unitary or multifaceted construct, and it can be applied to social, academic or other settings. This concept implies the ability to withstand or recover relatively quickly from difficult conditions. In technology, it refers to the capacity of a material to spring back into shape after deformation. The author defines it, from a psychological perspective, as a persons capacity for adapting psychologically, emotionally and physically reasonably well and without lasting detriment to self, relationships or personal development in the face of adversity, threat or challenge. Resilience has certain hallmarks. First, it is entirely consistent that resilient people experience short-term adverse reactions to traumatic events; this does not imply that they are not resilient and resilient people may show quite strong reactions to traumatic events or processes. Nonetheless, their upset and decomposition is usually temporary, and resilient people are able to return to their usual activities after a brief period for recovery. Second, resistance (i.e. not reacting psychologically to a traumatic experience) is not the same as resilience. Resilience is not about avoiding short-term distress or other post-traumatic reactions, but concerns how people adapt to them. Third, it is important to distinguish resilience from recovery. The concept of recovery in mental healthcare implies in the context of this paper that a person has developed a sustained medium-term or more severe response to trauma

individuals and the difficulty in processing the experience into their preconceived cognitive views of the world. Their experience is that childrens psychological responses to overwhelming stress are determined by: . . . . Biological factors; Psychosocial factors; Level of emotional and cognitive development; Degree (i.e. intensity and duration) of exposure to the stressor; . Degree of injury or life-threat; . Losses of family members; and . Disruption of continuity of community/schools/ family. Shaw and Harris (2003) draw attention to: the particular threats of children being perpetrators of violence and of their exposure to violence and brutality while they are learning control of their own impulses and aggression; child victims propensity to outbursts of hostility and aggression; and the effects of undermining childrens illusions of safety when mutilation, death and the limitations of the protective power of loving parents become apparent. They conclude that there is considerable variation in childrens responses. Bringing their findings together with others, those responses turn on: . The intensity, type, duration of the traumatic experience; . The degree of participation in forced military activities; . Victimization by mutilation; . Witnessing killing of parents, family members and other villagers; . The increased risk of displacement faced by child combatants and the difficulties of returning child soldiers to their communities given the events in which they have been involved; . The childrens developmental phases; and . Childrens fantasy lives and their interpretation of events. Barenbaum et al. (2004) summarize evidence suggesting that childrens subsequent moral responsiveness may be related to the length of time that they spent in an armed group and whether they saw themselves as victims, were able to express remorse, or continued to use violence habitually as a means of exerting control. Cohn (2006) says Humanitarian advocates should heed Rosens message about the means relied on to end child soldering and should take note of the importance of understanding the choices young people make in specific, complex political situations or complex settings. Perhaps local initiatives involving key members of children ecologies

The psychosocial consequences for children of mass violence, terrorism and disasters that may well compromise the persons ability to cope. Other characteristics of resilience that emerge from Condlys review of the literature are that it is: . Developmental; . Continuous; . Dynamic;   Passive it acts by increasing a persons ability to withstand trauma; and/or Active it acts by people shaping the environment to minimise their interaction with trauma;
than insecurely attached individuals . . .. Again, this research points to resilience having dynamic, developmental and relational characteristics.

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The nature of psychosocial problems affecting children and adolescents The author of this paper has taken the position that it is wise to assume that children are as likely as are adults to develop psychosocial and/or psychopathological reactions to violence, trauma and disaster. However, the situation can appear complex. This is because childrens reactions are individual and vary according to age and developmental level, their proximity to the events and to family members and whether those family members have been directly affected or not, the losses they have suffered, and also the specifics of the situation. Furthermore, as shown here, the responses of children turn on how families and communities respond. Impact and burden: Direct and indirect effects Children may be directly or indirectly affected by violence. Indirect impacts may be consequent upon the burden falling on their parents, family members or other caregivers. Given the differing sensitivities of adults to recognizing childrens problems at home and/or at school, and the impact of violence, trauma and disaster on them, parents sensitivities to their children may be unchanged, reduced or heightened as a result of violence (Angold, Messer, Stangl, et al., 1998). Therefore, even if children are not directly affected, their lives may be changed by the burden of looking after them that falls on their parents in circumstances in which these adults are facing their own huge dilemmas. Usually, given their dependency, children suffer both direct and indirect effects. Developmental level Shooter (2005) draws attention to the developmental of view of responses experienced by children and adolescents proposed by Shaw (Shaw, 2000). He says, drawing on Shaw (2000) and Sugar (Sugar, 1997), that Pre-school children are said to be less aware of the nature and meaning of threat, rely on parental-referencing, and may become disorganized in their emotions and behaviour, and lose some of their developmental capacities such as bowel and bladder control. School-aged children have greater cognitive appreciation of the dangers, may be disrupted in their sleep, appetite and

. Interactive; . Related to attachment capabilities; and . Gender-related. Through research on children and how they deal with obstacles and hostile environments, Garmezy (Garmezy, 1991) has identified three factors that are found in all definitions of resilience. Based on Condlys review, those factors are: . Factor 1: Intelligence and temperament
There is research evidence showing that resilient children tend to possess an above average intelligence and a temperament that endears them to others. In Condlys opinion, the combination of these two features is particularly important.

. Factor 2: Family relationships and level of support available from family


There is support for the notion that the roles of families in the development of resilience are most important early in life and decline as children grow older.

. Factor 3: External support from other persons and institutions


Support of specific types for families is a major discriminating factor in resilient urban children who have experienced life stresses. These positive social supports must actively include the children at risk and are best when whole families are supported. Recently, research has examined why . . . the long-term impact of the attack [on the World Trade Center on September 11 2001] was less pervasive than anticipated for most survivors (Fraley, Fazzari, Bonanno, & Dekel, 2006). One study examined the role that individual differences in adult attachment style played in peoples adaptation. The findings were that . . . securely attached individuals exhibited fewer symptoms of PTSD and depression

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R. Williams Thus, there is also no reason to believe that children are not subject to the full range of individual reactions summarized by Alexander and Klein (2003) which include the following: . . . . . . . . . Stunning and numbness; Anxiety and fear; Horror and disgust; Anger and scapegoating; Paranoia; Loss of trust; Demoralization, hopelessness and helplessness; Survivor and performance guilt; and False attributions.

academic performance, and lapse into a variety of anxiety, depressive and somatic disorders. Adolescents may show more adult-like responses, with an open fear of death, or a hedonistic resort to impulse, delinquent, sexual, substance misusing, acting-out behaviours that add to the danger . . . They are less willing to share their feelings than younger children and are particularly dependent on their peer-group reaction. They may lose faith in all adult security and sink, ultimately, into an apathetic or angry rejection of authority. The nature of the trauma Shaw and Shaw (Shaw & Shaw, 2004), drawing on Terrs work (Terr, 1991), have endeavoured to differentiate the impact of trauma on children on the basis of the traumatic situation and its duration. They talk of event trauma, referring to sudden, unexpected occurrences that are limited in time and space and process trauma, characterized by continuing exposure to enduring stress such as war and abuse. Event trauma, they say, may produce classical post-traumatic symptomatology as well as specific fears, anxiety and depressive symptoms, repetitive and regressive behaviours, loss and grief and developmental effects as well as changed attitudes to self and others. They suggest that process trauma may produce posttraumatic stress symptoms but also a spectrum of developmental, emotional and behavioural problems that are associated with chronic stress and interweaving of the dramatic experiences into the emerging personality (Shaw & Shaw, 2004). Staged or phased responses Another consideration is the passage of time after major violence or traumatic events. Tyhurst (Tyhurst, 1951) produced his description of a triphasic response to trauma in 1951. Subsequently, Raphael produced her curve of adjustment (Raphael, 1986). That, too, shows a phasic process through which the people may pass in their adjustment after disastrous circumstances. Importantly, she confirms that some peoples adjustment after disaster may be at a higher level that it was beforehand. Positive changes include improved and closer relationships, revised life values, and identification of new strengths and ways of coping. Adjustment is not linear. Therefore, what one may see when looking at children after episodic or recurrent violence depends on where they are in their personal trajectory of recovery that involves responding to the impact, recoil afterwards followed by a longer period of adjustment.

Normal reactions Similarly, the concept of resilience implies that childrens feelings and behaviour may regress or change and their performance may deteriorate in the immediate aftermath of traumatic events followed by a relatively prompt recovery phase in which resilient children return to more ordinary patterns of feeling and behaving. In the acute phase, certain reactions are commonplace in adults and in children and constitute what might be termed normal reactions in so far that they usually ameliorate with passage of time and provision of family and community support. Thus, while children may prove remarkably resilient to the impacts on them of traumatic events, they may commonly show some temporary reactions as a component of their resilience. Those patterns of response, taken from Alexander, are summarized in Figure 1 and Table I below. As shown in this paper, particular patterns of response depend on developmental level, culture, and family and community support (Alexander, 2005). Direct impacts on children As time passes, children may return to previous or changed patterns of adjustment but they may also develop more enduring symptoms of psychopathology. Elsewhere (Williams, 2006), the author has summarized the acute, medium and longer-term psychopathology that children may show. Conventional Western diagnoses include: . acute stress responses; . chronic stress responses; . psychiatric disorders including:      emotional anxiety and phobic disorders; mood and particularly depressive disorders; adjustment disorders; substance misuse; conduct disorder;

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Table II. Pre-school children. Reproduced from Williams (2006) and (Barenbaum et al., 2004; Lubit & Eth, 2003; Sphere Project, 2004; Ursano & Norwood, 2003; Ursano et al., 2003; World Health Organisation, 2005c). Irritable, crying excessively Clinging Intense fear and insecurity Excessively dependent behaviour Fear of water including water used for domestic purposes Excessive quietness and withdrawn behaviour Thumb-sucking, bedwetting, excessive temper tantrums Play activities spontaneously involving aspects of the disaster Frightening dreams and waking frequently

Figure 1. Normal Alexander (2005).

responses.

Contents

derived

from

Table III. School-age children. Reproduced from Williams (2006) and (Barenbaum et al., 2004; Lubit & Eth, 2003; Sphere Project, 2004; Ursano & Norwood, 2003; Ursano et al., 2003; World Health Organisation, 2005c). Feeling nervous and unable to concentrate Attention and learning problems Loss of interest in studies, school refusal, reduced academic performance Withdrawal Guilt Feelings of failure Anger, rage and aggression Fearfulness, anxiety or suspiciousness Low mood, decreased activity and interaction level Irritability, arousal, insomnia and loss of appetite Recurrent fear Recurrent memories or fantasies of events leading to avoidance of reminders Reactivation or intensification of specific fears Fantasies of playing rescuer Intensely pre-occupied with details of events Unexplained abdominal pain, headache, vomiting, rapid breathing or fainting Dependent and regressed behaviour

Table I. Normal reactions to trauma. Contents derived from Alexander (2005). Emotional reactions Shock and numbness Fear and anxiety Helplessness and/or hopelessness Fear of recurrence Guilt Anger Anhedonia Social reactions Regression Withdrawal Irritability Interpersonal conflict Avoidance Cognitive reactions Impaired memory Impaired concentration Confusion or disorientation Intrusive thoughts Dissociation or denial Reduced confidence or self-esteem Hypervigilance Physical reactions Insomnia Hyperarousal Headaches Somatic complaints Reduced appetite Reduced energy

   

somatoform disorders; attention deficit hyperactivity disorder; posttraumatic stress disorder (PTSD); and affect regulation problems.

Table IV. Adolescents. Reproduced from Williams (2006) and (Barenbaum et al., 2004; Lubit & Eth, 2003; Sphere Project, 2004; Ursano & Norwood, 2003; Ursano et al., 2003; World Health Organisation, 2005c). Similar to children In addition, young people may claim that there is nothing wrong Young people may show: . Diffuse excitation; . Oppositional behaviour; . Changes in preferred relationships; . Risk-taking.

Shaw and Shaw remind us that psychiatric co-morbidity is the rule rather than the exception (Shaw & Shaw, 2004) and this particularly includes when PTSD is the primary diagnosis. Acute stress responses Elsewhere (Williams, 2006), the author has summarized the indicators of acute stress responses. Reproduced here are Tables II, III and IV. They draw on a variety of sources (Barenbaum et al., 2004; Sphere Project, 2004; Ursano et al., 2003) and particularly (Lubit & Eth, 2003; Ursano & Norwood, 2003),

including, particularly, the WHO/SEARO Physicians Manual (2005). Posttraumatic stress disorder Posttraumatic stress disorder (PTSD) is established as a condition that occurs often in children and

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Table V. Domains of psychological development. Reproduced from Williams (2006) and (Dalgleish et al., 2005; Lubit & Eth, 2003; Ursano & Norwood, 2003; Ursano et al., 2003). Affect control Identity Perception of the world Perception of self, self-esteem and self-efficacy Trust Safety Interpersonal skills Interpersonal relations Moral development

adolescents as well as adults. It has been described as occurring after physical and sexual abuse, witnessing violence and many other circumstances, including suggestions of intergenerational transmission of trauma (Lev-Wiesel, 2007). The prevalences reported are variable. Good overviews of PTSD in children and adolescents are provided by Yule (2001) and Tareen, Garralda, and Hodes (2007). Recently Kremen et al. (2007) have suggested that cognitive ability pre-trauma is a risk or protective factor for PTSD. Referring to their sample of 2386 male Vietnam-era twin veterans, they say, [l]ower cognitive ability may be a marker of less adaptive coping . . . and [t]he variance in PTSD explained by preexposure cognitive ability is accounted for entirely by common genetic factors. The National Collaborating Centre for Mental Health has produced a guideline for the National Institute for Clinical Excellence (National Collaborating Centre for Mental Health, 2005; Royal College of Paediatrics and Child Health, 2006) that includes a chapter on children. Recently, concerns have been raised that population-based surveys may overestimate the prevalence of PTSD in children (Barenbaum et al., 2004) and that PTSD may not be a sufficient model to explain responses to trauma and a traumatic event alone is an insufficient cause of PTSD (Levin, 2006). While PTSD has provided a prompt for looking much more seriously at the responses of people to traumatic events, critics have expressed concerns lest focussing on PTSD runs the risks of eclipsing other approaches, the full range of disorders and/or co-morbid conditions. Effects on psychological and emotional development As this review has shown, violence may have lasting effects on childrens psychological and emotional development. Tables V and VI, which are derived from several sources (Dalgleish, Meiser-Stedman, & Smith, 2005; Lubit & Eth, 2003; Ursano & Norwood, 2003; Ursano et al., 2003), were published in 2006 (Williams, 2006), and are reproduced here to summarize the potential impacts of trauma, including violence, on childrens development. Interventions A culturally sensitive approach Elsewhere (Williams, 2006), the author has drawn attention to the importance of cultural sensitivity in mounting services for children and families after disasters, including their experience of violence. There is a tension between opinion leaders in the field. Advocates of cross-cultural universality argue

Table VI. Domains of emotional development. Reproduced from Williams (2006) and (Dalgleish et al., 2005; Lubit & Eth, 2003; Ursano & Norwood, 2003; Ursano.et al., 2003). Direct effects Problems with reflecting on and managing own feelings Painful memories Regression Fear Fantasies of retaliation Poor impulse control Preoccupation with/compulsive repetition of aggression Substance misuse Risk-taking Failing to meet childrens needs Loss and grief Effects of adults own distress Effects of adults changed views of the world Loss of routine Loss of places of education and social gathering Effects of circumstances on the pace of social, educational and psychological development Magical thinking

Indirect, or secondary, effects are due to or intensified by:

that syndromes hold true across cultures. They tend to recommend full application of screening, assessment, diagnostic and intervention techniques that have been developed in Western approaches to mental healthcare. Proponents of cultural specificity argue that the significance of experiences and symptoms should be understood in relationship to the culture from which individuals come. Thus, Barenbaum et al. (2004) say that in order to provide culturally sensitive assessment and treatment, it is essential to understand cultural practices and have local knowledge of the community. Delivery of mental health intervention in non-Western settings needs to incorporate prevailing cultural norms, including spiritual or religious involvement, basic ontological beliefs, and related issues. They conclude their paper by saying that Culturally sensitive diagnostic

The psychosocial consequences for children of mass violence, terrorism and disasters approaches are needed to assess trauma symptoms and associated impairment. Immediate relief operations can start with non-specific interventions to help groups of affected individuals organize around issues of feeling safe and promote perspectives for the future that involve mastery and engagement in rebuilding. It is important to instruct parents and teachers in recognizing childrens distress and applying appropriate strategies to address childrens needs. Intervention considerations and their scope should be community orientated to prevent normalization of life and active child involvement. Therefore, the approach summarized here incorporates those principles and the author advocates a stepped approach to interventions comprising the following: (1) Promoting resilience through psychological first aid. (2) Provision of first level psychosocial services by primary responders supported by expert advisers. (3) Delivering community mental health services. (4) Providing specialist psychiatric and psychotherapeutic services. This stepped approach is consistent with the strategy for responding to bioterrorism advocated by Shaw and Shaw (Shaw & Shaw, 2004) in which they offer advice on handling the Pre-Event, Event and PostEvent Phases and offer tasks for parents and schools. A practical handbook on helping trauma-exposed children and adolescents has been written by Greenwald (Greenwald, 2004) and the American Academy of Child and Adolescent Psychiatry has produced a series of leaflets for the public (American Academy of Child and Adolescent Psychiatry, 2006a, b, c).

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Table VII. Children Reproduced from Williams (2006) and the Sphere Project (2004). Ensure infants/children should remain close to their mothers/families Ensure adequate nutrition and meet all physical needs Encourage and help families to re-establish childrens previous routines with eating, playing, studying, sleeping and interacting with others Engage children in activities: drawing, storytelling, drama, games (do not encourage too strongly children to express disaster-related feeling; allow children control over the decision whether or not to think about the trauma and to express feelings about it) Encourage the families (in groups) to facilitate the play activities specially the group games of the children Advise families/community leaders to recommence teaching school-age children until they are able to return to their usual schools Advise parents and families not to discourage children when they verbalize their feelings

Table VIII. Adolescents. Reproduced from Williams (2006) and the Sphere Project (2004). Ensure privacy and confidentiality while interviewing adolescents Be cautious about gender sensitivity issues (including interaction with and physical touching) Help adolescents to decide their future courses of action Encourage secondary and higher-education students to continue formal education Involve young people in forming community groups Encourage older adolescents to participate in humanitarian activities

Psychological first aid It is clear that there is much in common with the approach recommended by Sphere and the contents of psychological first aid (PFA) (Alexander, 2005). Several organizations have produced summaries of PFA as applied to children (e.g. National Child Traumatic Stress Network and National Center for PTSD, 2006). The author supports recommendations for adopting the principle of an initial four week period of watchful waiting for children after violence and disaster and prior to specialist intervention. This is because it is difficult to distinguish the reactions of people who are resilient, but experiencing immediate responses to the events that have affected them, from those who have an acute stress response, and from the reactions of the children who are developing longer-term problems, including psychiatric disorders. The author does not recommend that children do not receive services in those four weeks but that the services provided should follow the principles of Psychological First Aid and those of the Sphere Project.

Promoting resilience The Sphere Project (2004) has codified a corporate and clinical governance framework. It advises that special measures be taken with respect to children and adolescents and they are summarized in Tables VII and VIII. Pursuit of those objectives should do much to promote childrens resilience and recovery in the face of violence. Evidently, there are individual, family and community levels for action. Some sources suggest that many of childrens psychosocial needs in the aftermath of trauma can be met by providing: safety and removal of the threat; water, food and sanitation; physical healthcare; family- and school-based social and education interventions (Williams, 2006).

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Table IX. Psychological first aid. Reproduced from Alexander (2005). Comfort and consolation Protection from further threat and distress Immediate physical care Goal-oriented and purposeful behaviour Helping reunion with loved ones Sharing the experience (but not forced) Linking survivors with sources of support Facilitating a sense of being in control Identifying those who need further help (triage)

Table X. Prevention-intervention plan. Reproduced for Shaw and Harris (2005). Phase I Assessment and evaluation Physical and nutritional status Emotional and mental status Coping and adaptive style Severity, duration and type of traumatic exposure Inventory of losses Childs definition of the situation Phase II Participation in therapeutic programme Security and protection Normal school experience Social and group activities Recreational opportunities Range of therapeutic experiences Ongoing assessment Phase III Reintegration into the community

Providing psychological and psychiatric services In response to the tsunami in South East Asia, the World Health Organisation has produced a stepped model of care relating to the psychosocial consequences of that disaster (Williams, 2006; World Health Organisation, 2005a,b). That model holds many lessons for service design and delivery more generally. It is based on: a first, general level of self, family and community care; a second level of primary mental healthcare provided by trained community workers; a third level of secondary mental healthcare delivered by psychologists and other staff; and a fourth level of very specialised interventions delivered by psychiatrists. Shaw and Harris (2003) offer a PreventionIntervention Plan for children traumatized by war that is mildly adapted and summarized here.

Conclusion ODonnell, Joshi, and Lewin, (2007) point to the high frequency with which inner-city and rural youth witness violence or are affected to the point of feeling unsafe (ODonnell et al., 2007). Children and young people are direct and indirect victims of mass

violence and displacement, but they may also be the perpetrators of war as soldiers. The author has used a selection of the literature to characterize the psychosocial impacts on young people together with a warning that all must take very seriously the cultural contexts in which violence takes place when trying to understand its effects and when agencies and practitioners propose to intervene. Collectively, many societies find untoward events that involve or impact on children particularly troubling and abhorrent. There appears a prevalent view in many societies of the innocence of childhood and of the vulnerability of children (Meyer, 2007). Yet, there are also many awful things that societies do to put children more at risk and lapses in their care of children. Children are developing people and their experiences in combination with their genetics are vitally formative in shaping the adults that they become. This paper has shown how childrens emotional, social cognitive development may be affected. Most impacts are short term, but some may be longer-term and profound. The negative developmental effects appear more likely if children experience repeated or repetitive process trauma or live in unpredictable climates of fear. Children and young people may be remarkably resilient. Resilience is a developmental characteristic and peoples development in that respect may be adversely affected by their exposure to overwhelming events during childhood. This may affect, in turn, how people respond to challenge and adversity later when adults. The legacy of traumatic experiences in childhood may be very wide ranging from strengthening development through to long-term impairment. So much appears to turn on how adults respond (Nugent, Ostrowski, Christopher, & Delahanty, 2007; Ostrowski, Christopher, & Delahanty, 2007). ODonnell et al. (2007) draw attention to the importance of training in developmental responses for providers of services for children. This paper summarizes a framework for response. It is intended to be stepped, proportionate, phased, responsive and strategic. The WPAWHO Joint Statement on the Role of Psychiatrists in Disaster Responses (Mezzich, 2007) recommends priority activities for psychiatrists working in acute phases of disasters. The statement envisages that, after the acute phase, psychiatrists should play a major role in (re)building community mental health services to address the increased prevalence of mental disorders in affected populations. This paper advocates a strongly communityand family-orientated approach. Schools can and should have a major influence on endeavouring to restore normality and are places in which a huge amount of restorative work to promote recovery can be done.

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