Thousands of miles lie between the traumatized young refugees of Kosovo and American children exposed to violence and other painful experiences, but the emotional distance between them may not be so great.
That's because children who lose their sense of safety and trust -- whether due to marauding soldiers, neighborhood gangs, a loud and vicious divorce or a car crash -- are in for a potentially difficult time. Unless their inevitable turmoil is addressed, they are at risk of suffering significant emotional and social consequences.
It doesn't really matter what invades the safe haven of a child, according to an evolving consensus of professionals who work with children exposed to trauma. If the invasion is violent or otherwise wounding, and especially if it continues over months and years, many children will face deep and fundamental problems as they grow up.
"A sense of safety is a basic requirement of growing up healthy from a mental health point of view," said Pamela Fischer, a psychologist with the Children's Mental Health Alliance in New York. "In situations where children are exposed to trauma, especially if it's recurring, they are going to be at risk for a host of chronic and acute mental health problems."
The issue of how children respond when they are exposed to trauma and violence -- and why some can express their feelings and heal while others cannot -- has become a hot research topic in recent years. Growing concern over child abuse and the explosion of violence in some inner-city neighborhoods first triggered the work, but the string of school shootings in suburban and rural settings has made it increasingly urgent.
In the wake of these outbreaks, the departments of Justice and Health and Human Services are hosting a three-day conference in Washington to explore the impact of violence on children. Justice Department statistics show that of the 22 million American adolescents between ages 12 and 17 in 1997, 3.9 million had been victims of violent crime and another 9 million had witnessed serious violence.
"What those kids in Kosovo are dealing with is a concentrated version of what kids in too many inner city neighborhoods are dealing with in this country," said Deputy Attorney General Eric H. Holder, who is directing the conference. "They have had too much exposure to violence in their lives, and that has to have a negative impact on them and on our society."
A 1997 study for the National Institute of Justice found that 43 percent of male adolescents and 35 percent of females had witnessed some form of violence--a shooting, knifing, sexual assault, mugging, robbery or threat with a weapon--firsthand.
Trauma, however, does not always involve intentional violence. According to Steven Marans, a Yale child psychoanalyst who will attend the conference, trauma is "a set of psychological and neurophysical responses to an event that is overwhelming and unanticipated."
The National Institute of Mental Health (NIMH) broadly defines childhood trauma to include natural disasters and accidents as well as intentional violence. Mental health professionals note a similar cascade of emotions from domestic trauma in which a child suffers abuse or loses a parent through death or divorce.
Often, Marans continued, "it is very, very difficult for adults to appreciate the range of presentations that children have. Many children have witnessed the worst possible violence between parents and friends, have seen a dead body lying nearby, and can look calm and relaxed. But the trauma may not be expressed in tears, but rather flatness and withdrawal, or maybe symptoms that don't present in full for days and weeks."
A NIMH guide to childhood trauma describes typical reactions for three age groups. Children aged 5 and younger are prone to excessive clinging, crying and screaming, regressive behaviors like bed-wetting and fear of darkness. For children 6 to 11, reactions include anger and fighting, sleep problems, refusal to attend school as well as depression, anxiety and emotional numbing. And for adolescents under 17, responses can range from depression and academic decline to antisocial behavior, withdrawal and extreme feelings of guilt.
"The more direct the exposure to the traumatic event, the higher the risk for emotional harm," the report concludes. "But even secondhand exposure to violence can be traumatic. For this reason, all children and adolescents exposed to violence or a disaster . . . should be watched for signs of emotional distress."
Considerable attention has been focused on the small but significant percentage of children exposed to trauma who will develop the uncontrollable fight-or-flight symptoms of post-traumatic stress disorder, or PTSD.
"There is good evidence now that the cluster of PTSD symptoms first associated with combat veterans is relevant to children exposed to trauma," said Ferris Tuma, who heads the NIMH research program on children and trauma. "The heightened sympathetic nervous system activities, the arousal you see and the over-response to triggers look very similar in adults and in children."
Researchers are also studying the complex issue of why some children seem much more resilient to trauma than others. While much of the work is in progress, Tuma said that some conclusions are possible. For instance, children who have been victims of previous child abuse or other forms of trauma, or have other mental health problems, are likely to suffer most from exposure to violence. Children without strong family support are also more likely to recover poorly from traumatic events.
Similarly, researchers are finding that the long-term consequences of exposure to severe accidents and natural disasters are generally less damaging than exposure to interpersonal violence. "There is clearly a qualitative difference in the psychological impact of trauma at the hands of another human being, especially a family member, as opposed to an accident," Tuma said.
Nonetheless, many of the recommended family responses and professional treatments are similar. For instance, the need to establish a safe space for children is important after an accident, just as it has been in the refugee camps where "safe" places were designated for the children of Kosovo. The NIMH also says that all children exposed to trauma should be encouraged to express their feelings, without judgments from adults. It is normal to feel upset, sad and tearful, they should be told, and there is no need to be "tough." They should not be criticized for regressive behavior and should be given time before returning to old routines.
The NIMH report concludes that children showing signs of avoidance and numbing may need the help of a mental health professional, while more common reactions like re-experiencing the event and the tendency to startle easily generally respond to ongoing support from parents and teachers. For children suffering from PTSD, cognitive-behavior therapy can be useful in exploring why painful feelings persist and medications can reduce overwhelming symptoms of hyper-arousal.
According to Carl Bell, a psychiatrist with the University of Illinois in Chicago and an expert on childhood trauma in inner cities, there are major differences between children exposed to a single or concentrated eruption of violence and those exposed to it chronically.
"Children who live with chronic violence don't show up with PTSD as much as kids in suburban settings," he said. "They show up more with behavior disorders, fighting and drug use and school failure.
With children like that, he said, there's a need for crisis intervention as well as long-term therapies and often medications. "A primary need is to create a safe environment where the child can tell his story, get some help making sense of it, and work to turn the negatives and the helplessness into positives and helpfulness."
Bell pointed out that inner city violence has been scarring American children for years now. Yet there hasn't been a national outcry like the one heard on behalf of the Kosovo children. He said he hoped this week's conference would change that.
Holder agreed. "All the research shows that children exposed to violence as direct victims or as observers suffer as a result," he said. "They are more likely to become people who inflict violence, more likely to achieve at a lower level at school, less likely to become successful and less able to establish strong ties with others. This is a serious problem for all of us."
Further information on childhood trauma can be found on the NIMH Web site at www.nimh.nih.gov.
CAPTION: The varied faces of trauma, clockwise from upper left: An Alabama child is carried through floodwaters from Hurricane Georges last September; classmates mourn two teenagers who died in a car crash in November in Calvert County; a 7-year-old boy is comforted after the killing of his aunt in 1995 in Suitland; and students pray for the victims of shootings in April at Columbine High School in Littleton, Colo.
CAPTION: A grieving 9-year-old boy prays and "plants" a flower on a beach in memory of the people who died in the crash of TWA Flight 800 off Long Island, N.Y., in 1996.