Primary care providers are thefirst responders for many childrenwho are clearly manifestingemotional and psychologicalreactions to the recentterrorist attacks and ongoing threatsof terrorism and war. You can facilitatetimely and appropriate referral tomental health services for such childrenand their parents. Bear in mind,however, that many children and parentswho would benefit from supportiveservices and/or counseling will notbe self-identified. Thus, all cliniciansneed to maintain a heightened awarenessfor trauma-related symptoms,such as somatization, and help thesefamilies begin to address the underlyingpsychological issues.
Primary care providers are the first responders for many children who are clearly manifesting emotional and psychological reactions to the recent terrorist attacks and ongoing threats of terrorism and war. You can facilitate timely and appropriate referral to mental health services for such children and their parents. Bear in mind, however, that many children and parents who would benefit from supportive services and/or counseling will not be self-identified. Thus, all clinicians need to maintain a heightened awareness for trauma-related symptoms, such as somatization, and help these families begin to address the underlying psychological issues.
Children depend on the adults around them to help them be and feel safe and secure. For primary care providers, it is prudent to remind parents that they need to take care of themselves first so they will be able to care for their children. Unfortunately, mental health problems are still highly stigmatized in our country, even in times of national crisis. This stigma becomes an enormous barrier for patients seeking traditional mental health care. We need to help families realize that the important question is not whether they or their children need counseling-but whether they might benefit from it.
Given the scope of the need and the barriers to the delivery of traditional mental health services, it is important to develop alternative models of providing traumarelated supportive care. Primary care practitioners can collaborate with schools and local agencies to identify early adjustment reactions and to provide supportive services in the community. We clinicians can join with school and community leaders to promote psychoeducational services as a means of primary prevention in school and within our own practices.
Because of time constraints, much of the educating we do must come in the form of written communication. The National Center for Children Exposed to Violence (NCCEV) is an excellent resource for such communications. The address is:
Child Study Center
Yale University School of Medicine
230 S Frontage Rd
PO Box 207900
New Haven, CT 06520-7900
The NCCEV's Web site, www.nccev.org, features "In the Aftermath of Crisis: A Parent's Guide for Talking to Their Children." (This guide can be found by clicking on the section entitled "In the aftermath of terrorism" on the home page.) The information it contains may help parents talk to their children about crisis. A separate parent guide provides advice on talking with children about death.
Some suggestions on how parents can talk with their children in times of crisis follow.
HOW CAN PARENTS HELP IN TIMES OF CRISIS?
Parents can begin to assist their child by explaining-as simply and directly as possible-the events that occurred. They can encourage their child to ask questions, and they should try to answer those questions directly. Parents can provide ongoing support and assistance as the child begins to understand the crisis and the response to it.
Silence doesn't mean disinterest. Children readily pick up cues when an adult is uncomfortable discussing a topic. Children also tend to ask direct and frequently poignant questions-questions that adults wonder if they can answer even for themselves and, in fact, frequently do not wish to even consider. The discomfort that ensues may be misinterpreted by the child as a sign that his or her questions are inappropriate and that they should not be raised again. Silence after a difficult conversation is not necessarily a sign that a child is too young to understand what has happened or that he or she is disinterested in talking about it.
Adults may wish that their child were unaware of-or somehow spared from-the impact of a national crisis. This represents more of a wish than a reality. Like adults, children are better able to cope with a crisis if they feel they understand it.
Listen for the underlying fears. Most children will have heard about the events on television, at school, or from friends. Much of what they have learned will be inaccurate, or accurate information may have been misunderstood. Parents should start by asking their child what he has already heard and what understanding he has reached. As the child explains, adults should listen for misinformation, misconceptions, and underlying fears or concerns. Parents must be careful not to assume that children's concerns are the same as those of adults. Misinformation or misunderstandings may lead to unique fears that can be addressed through clarification and honest reassurance.
HOW MUCH INFORMATION IS TOO MUCH?
The amount of information that will be helpful to a child depends, in part, on his age. Older children generally want and will benefit from additional information. Adults need to take their cues from the child as to how much information to provide.
Parents should remember that the goal is to help their child feel he understands what is going on-not to tell him everything that is known. In preparing children for an appendectomy, for example, health care providers know that they need to provide enough information so that the child has a basic sense of what will be occurring, and why it is being done. The child does not need to be so well informed that he could substitute if the surgeon becomes unavailable!
Graphic details and unsettling images, such as those often shown on television, are generally best avoided. Parents should consider limiting the amount of television viewing of terrorist events-particularly for a younger child. When an older child watches television, parents should try to watch along with the child and use the opportunity to discuss what is being seen and how it makes them and their child feel.
WHAT IF CHILDREN APPEAR DISINTERESTED?
In the aftermath of a crisis, children may demonstrate a variety of reactions, ranging from excitement to anxiety. Many children appear disinterested. There are many possible explanations for this apparent disinterest. Young children may not know or understand what has happened or its implications. Older children and adolescents, who are used to turning to their peers for advice, may initially resist invitations from parents to discuss events and their personal reactions.
Parents should not force discussion with their child, but instead extend the invitation on multiple occasions. In the interim, parents can provide an increased physical and emotional presence and wait for their child to accept the invitation when he is ready.
My 12-year-old daughter provided another explanation of why children (and adults) may appear disinterested. On September 11th, she voiced concern that some of her peers seemed to be showing little empathy for the loss of life, worrying instead about whether their homework for that evening was canceled or a quiz the following day postponed. But over the ensuing weeks, she too noted a growing sense of personal disinterest. Since there was little she could do to provide assistance to those directly affected by the terrorist attacks-and nothing she felt she could do to change the situation-she simply chose to turn her attention back to her regular daily affairs.
In contrast, she commented that as a physician, I was lucky. People were asking for my assistance and there were at least things I could try to do to help. Her comments underscore the need for adults to help children identify concrete actions they can take to help those affected by the recent events.
DOCTORS CAN HELP
Our profession provides us with a unique opportunity to help children and families in times of greatest need. During a national crisis, when we too are personally affected, this professional responsibility of helping our patients and their families may seem like a burden. I hope that we can see this opportunity as a privilege of our profession and feel lucky that, at a time when most people feel particularly helpless, there are so many ways we can help others.