The school nurse is often the first stop when children need help with a physical problem. In the aftermath of the September 11th attacks on the World Trade Center and Pentagon, however, children may have physical symptoms that are related to the stress induced by these traumatic events.
Real Life Stories
Jamie, aged 10, was in his class in a school three blocks from the World Trade Center. From their classroom windows, the children and their teacher saw the second plane hit the towers. The school principal contacted the parents who came to pick up their children, and the teacher stayed with them until each parent arrived. Jamie did not show any overt distress, but the next morning he adamantly refused to go to school, claiming he had a stomach ache.
Sylvie, aged 14, has a chronic asthmatic condition. She attends a school at a considerable distance from the site of the tragedy, but all the teenagers watched the planes hit the World Trade Center over and over again on television. After watching and hearing about the clouds of smoke at the site, she began to cough and to catch her breath and then became alarmed that she might be having an asthma attack and has been reluctant to do sports.
Guidelines for intervention
Following are some suggestions that may help school nurses recognize and deal with the causes of children's physical problems and coordinate their responsibilities with other professionals and parents.
- Find out what your school has planned. Check with your administrator for school-wide messages and procedures.
- Be prepared to deal organizationally with greater demands on your services.
- Develop a triage plan so that you are prepared to provide services for those in the greatest need.
- Coordinate your activities and communicate your actions with administration, teachers, mental health staff, and guidance staff.
- Be sure to coordinate and communicate with your own staff, especially if there is a change from your routine operations.
- Be flexible and ready to change operations as the need arises.
- Develop communication with other resources and professionals.
- Contact colleagues in other schools similar to yours to find out if you can use or borrow from their action plan.
- Identify the support people and community resources that might assist you if the need arises.
- Work with mental health experts for advice on students with complex issues, and communicate their advice to the referring providers.
- Identify a referral network for those students who might require more in-depth services.
- Work as a team with your network of referring providers to insure that the students' needs are met.
- Be sure that all students who want, or are referred for, services receive appropriate follow-up. Communicate your diagnosis and its rationale with primary care physicians and parents.
- Develop a good tracking system to insure that referrals and follow-up with other school staff, primary care physicians, other health professionals, and the students' families take place.
- Try to make new activities that are becoming common into routines. For example, write a form letter that can be sent to parents or guardians of students presenting with physical complaints. Be aware of confidentiality requirements.
- Identify students at risk. This includes those students:
- with pre-existing mental health issues
- who witnessed the crisis, with extensive exposure
- with family members involved - missing, hurt, or dead and also who have lost their jobs
- with previous loss and traumatic experiences
- Teachers will be turning to you and school mental health staff with questions and concerns about particular students who seem newly anxious, agitated, or sad.
- Those children who already have some emotional problem will probably have more difficulties than others. A nervous child may have increased worries about safety; a sad child may be more withdrawn; and an active child may be particularly agitated as worries mix with difficulties in behavioral control.
- Be prepared, especially if you work in an elementary school, to see more children with physical complaints such as headaches, stomach aches, nausea, and vomiting.
- Listen carefully to the child or youth's presenting complaint and determine its relationship to September 11th's events.
- Be sure that the physical basis for the presenting complaint is thoroughly examined and ruled out.
- Determine whether the child or youth has previously presented with somatic complaints at the school health clinic or to their primary care physician.
- Allow time for children to tell their stories.
- Be nonjudgmental and supportive.
- If you still have concerns (for example, with the severity of the complaints), or if they progress or do not resolve, make the appropriate referral.
- Take care of yourself and your staff.
Recognizing Posttraumatic Stress Disorder in children and teens
Although many children who witnessed or were directly affected by the attacks on the World Trade Center and the Pentagon may show signs of stress in the first few weeks, most will return to their usual state of physical and emotional health. However, a certain group may develop Posttraumatic Stress Disorder (PTSD) and would benefit from treatment.
Following is a description of Posttraumatic Stress Disorder (PTSD), a condition which may be experienced if an individual develops symptoms after being directly exposed to an extreme traumatic situation involving an actual or threatened death or serious injury, or witnessing such an event, or hearing about such an event in regard to a family member. Sometimes when people experience an event so terrible and frightening that it is difficult for us to imagine, they suffer from shock. People who suffer from a prolonged reaction to such traumatic events may be diagnosed as having PTSD.
Symptoms: Children respond to traumatic situations with intense fear, helplessness or horror. Some show disorganized and agitated behavior; they may regress to earlier behaviors, such as clinging, bedwetting or thumbsucking; they may become irritable and have difficulty in sleeping or concentrating. They may retain memories of the event for a long time. Emotionally, they may become numb or anxious or depressed, moods which may intrude on daily activities and interfere with play, school or family life.
Not everyone who goes through the same experience responds in the same way. Children are born with different tendencies; some are more adaptable, others more cautious. Reactions and recovery are affected by the length and intensity of the traumatic event.
After a trauma, an individual continues to relive the event and to avoid anything that may remind him/her of it. A grief reaction to the loss of a significant person may have some similarities to PTSD, but the symptoms are likely to diminish with time and should be differentiated from other problems that may occur, such as depression.
Prevalence: Until recently, traumatic events have been rare in the lives of most American children. However, each year three million children are diagnosed as having PTSD. Community-based studies show a lifetime prevalence of PTSD ranging from 1 to 14%. Studies of at-risk individuals (combat veterans, victims of criminal violence) show prevalence rates ranging from 3 to 58%. Following a disaster such as the attacks on the Word Trade Center and Pentagon, children and teens most at risk for PTSD are those who directly witnessed the events, were in close proximity to the situation, suffered direct personal physical or emotional trauma (such as the death of a parent), had mental health or learning problems prior to the event, or lack a strong social network. Sometimes a child may be brought to a mental health professional for another illness or problem, when the child may actually be suffering from PTSD.
Treatment Prevention and early intervention are imperative. Parental support influences how well the child will cope in the aftermath of the event. Parents and professionals can help children by
- providing a strong physical presence
- modeling and managing their own expression of feelings and coping
- establishing routines with flexibility
- accepting children's regressed behaviors while encouraging and supporting a return to more age-appropriate activity
- helping them use familiar coping strategies
- helping them share in maintaining their safety
- encouraging them tell their story in words, play or pictures to acknowledge
- normalize their experience.
Discussing what to do or what has been done to prevent the event from recurring and maintaining a stable and familiar environment will help make the child feel safe and more confident.
For children in therapy, cognitive behavioral approaches are the most effective direct treatment. For example, cognitive training is used to help children restructure their thoughts and feelings to they can live without feeling threatened, and in the behavioral technique of flooding, the child is exposed to a situation that creates stress and is then taught how to handle it effectively.
Our experience since September 11, 2001 in work with hundreds of administrators, teachers, other school professionals, parents and children tells us that everyone benefits from information about different reactions to trauma. In particular, school professionals are helped when guided in integrating the vast array of services necessary and available to the school community. The information offered here is excerpted from manuals written and developed by the New York University Child Study Center and available free of charge by clicking here.
A version of this article appeared previously in School Nurse News, v.19 (1), pp. 32-35.
About the Authors
Kenneth Spitalny, M.D., is a Child & Adolescent Psychiatry Fellow, NYU School of Medicine and most recently was Assistant Commissioner, Public Health, New York State Department of Health. He has particular expertise in government response to public health emergencies.
Robin F. Goodman, Ph.D., is a clinical psychologist specializing in bereavement issues.