The deadly earthquake and tsunami that struck Japan in March were traumatic experiences for thousands of Japanese children with serious potential implications for their emotional and psychological health. What is not as widely recognized is the distant natural disaster posed risks to children in the United States, whose only exposure to the horrific event more than 5,000 miles away may have been images of the devastation they saw on television.

Just as repeated exposure to violence can trigger a traumatic response in children, so, too can a single violent event —whether they experience such events directly as, for example, a victim of physical abuse, indirectly as a witness to a violent act, or vicariously through simply hearing about or otherwise learning of a traumatic event such as the earthquake in Japan or, closer to home, the terrorist attacks of September 11, 2001.

Until recently, the impact of trauma on young children was not well understood or widely recognized. But among the messages to emerge from years of research and clinical practice is that children are not oblivious to traumatic events and that being exposed to trauma can affect their emotional and mental health.

The impact in some cases can be long lasting. Traumatic events experienced in childhood, for example, are strongly associated with chronic physical illness, as well as with depression and other mental health problems during adulthood, according to the Adverse Childhood Experiences study co-sponsored by the national Centers for Disease Control and Prevention.

Such findings have heightened awareness of the importance of understanding children’s traumatic experiences. In May, childhood trauma—particularly building resiliency in children dealing with trauma—was among the themes of National Mental Health Awareness Month.

The good news is that many children are able to effectively cope with traumatic experiences through their own resilience and the support of parents or other trusted caregivers.

"A parent, big brother, aunt, neighbor, and child caregiver can all be protective factors for children—the child feels secure, has consistent relationships, is not humiliated, gets a chance to experience success. Those are some of the reasons why some children who experience trauma or come out of difficult environments do fine," said Raymond Firth, director of the University of Pittsburgh Office of Child Development’s Division of Policy Initiatives.

For other children who require additional help, such as those who experience severe or chronic trauma, several types of treatment have been demonstrated to be effective.

Children experience trauma in many ways. Sources of trauma include neglect, physical abuse, sexual abuse, psychological abuse, and witnessing domestic violence and other violence, for example, in the child’s community or a school. Bullying is another source of trauma. Others include a traumatic loss of a parent, close friend, or other loved one; injury to a parent or other person close to the child; and being involved in a car accident. Natural disasters, terrorism, and war are other situations that can also trigger a traumatic response in children.

Trauma in children can contribute to the development of post-traumatic stress disorder and a number of other psychiatric disorders, such as depression, generalized anxiety disorder, panic attacks, and substance abuse later in life.

The traumatic loss of a loved one, witnessing domestic violence, and living with a parent whose caregiving ability was impaired were among the most common traumatic experiences reported among children receiving treatment through the National Child Traumatic Stress Initiative, a Substance Abuse and Mental Health Services Administration (SAMHSA) program for raising the standard of care and improving access to services to children who experience trauma. Some 40 percent of these children had experienced four or more types of traumatic events.

Estimates place the number of children who witness their mothers being abused between 3.5 million to 10 million, and about half of those children are abused themselves, according to a 2004 study on violence and trauma by the National Association of State Mental Health Program Directors and the National Technical Assistance Center for State Mental Health Planning.

A glimpse of the impact experiencing trauma can have on children is offered in reports on children receiving services through the Children’s Mental Health Initiative, established in 1992 by the U.S. Congress to create a network of community-based services and supports for children and youth at risk of serious mental health issues. For example, post-traumatic stress disorder or acute stress disorder were diagnosed in 9 percent of those children who had experienced at least one traumatic event. And those who had been exposed to several types of traumatic events tended to have higher levels of depression and anxiety, be more aggressive, and break more rules.

The same 2004 study that estimated the number of children who witness domestic abuse also found that the overwhelming majority children in the juvenile justice system experienced at least one traumatic event and that 18 percent of females and 11 percent of males met the full criteria for post-traumatic stress disorder.

Although a traumatic experience carries the risk of contributing to such problems, different children respond differently, experts say. For most, the effects of a traumatic experience are short-lived. For others, the risk of developing serious, potentially long-term problems is greater.

When it comes to determining how an individual child responds to trauma, studies suggest several factors come into play.

The age of a child is an important factor. It was once thought that experiencing trauma had little effect on young children. But brain research and other studies now offer convincing evidence that young children may in fact be the most vulnerable. One reason is that trauma is capable of altering neurochemical processes and, in turn, affecting the growth, structure, and functioning of the brain, which in young children is rapidly developing.

Threats activate the body’s stress systems, increasing the levels of certain chemicals in the body. Cortisol is one of those chemicals and it can affect the brain. The chemical can, for example, affect the hippocampus, which plays a key role in forming new memories of experienced events and in identifying new events, places, and stimuli. Studies suggest elevated cortisol levels can strengthen memories of emotional events and diminish children’s ability to unlearn memories related to the trauma they experienced.

The risk of such damage is greater when trauma is a repeated experience, which is another factor that influences a child’s response to a traumatic event. In most cases, fear responses are quickly activated, but brief. But with repeated trauma, a child’s fear system can stay activated longer. In such cases, fear might become generalized over time. Abused children, for instance, might experience fear and anxiety when exposed to people who resemble their abusers or places that remind them in some way of where the abuse occurred. If left untreated, such a condition could impair a child’s ability to learn or interact with others.

Other factors that are considered in assessing a child’s response to a traumatic experience include the proximity and severity of the traumatic event, whether the child has experienced previous traumatic events, and family characteristics, such as a history of domestic violence, other family dysfunction, and disrupted relationships with parents or other key caregivers.

Children’s responses may be influenced by several such factors. For example, children who experience trauma directly are typically at higher risk of developing serious traumatic reactions or post-traumatic stress disorder than children who experience trauma in other ways. But with a particularly vulnerable child, the way the child experiences trauma is only one of several important considerations in assessing the child’s response.

“With vulnerable children it also has to do with their past experiences,” said Christopher Peterson, MD, a child and adolescent psychiatrist and associate professor of psychology at Pennsylvania State University. “Did they have traumatic experiences in the past? That would make them more vulnerable to having a more serious reaction in the future. What kind of upbringing did they have? Did they have a secure attachment to their caretaker and was that disrupted? If they had a disrupted childhood—maybe a mother was hospitalized for quite awhile—do they feel there is somebody stable whom they can count on? If that has been disrupted, they are more vulnerable to trauma in the future.”

Science and experience offer a number of lessons about helping children deal with traumatic experiences. Among them is that children—even very young children—are not oblivious to such experiences or immune from the harm that a traumatic event can cause.

Another is that it is important to take steps to address a child’s traumatic experience and the earlier those steps are taken the better. Effective responses range from parents calmly offering support and understanding to treatment administered by mental health professionals. “Simply removing these children from a dangerous environment isn’t enough,” Firth said.

In most cases, professional help is not needed. Resiliency among children is associated with several protective factors, such as a supportive family environment, nurturing caregiver skills, stable family relationships, optimistic beliefs and values, open communication, and consistent household rules and monitoring of the child.

Families who offer support, understanding, and a sense of safety as early as possible can often limit the effect of trauma on a child. “Children are very resilient and with adequate support from their family will over two to four weeks recover most if not all of their functioning and kind of get back to their life,” said Dr. Petersen.

“Often, just some basic things will help—talking with them and appreciating what their understanding is of what happened, letting them know what the reality is, and offering them reassurance, but within what is truthful. Those can go a long way in helping a child to deal with the anxiety, depression, and stress of the traumatic reactions they might have.”

Some children, however, will need the help of mental health professionals, particularly those who experience chronic trauma or are otherwise severely traumatized. Effective treatment recognizes the fact that there isn’t one therapy that is the right fit for all children and considers several factors, including a child’s age and developmental stage.

Although most therapies have been more thoroughly studied with adults than with children, a growing body of evidence suggests that several types of individual and group therapy have been used effectively to help children deal with trauma and support them through that process.

Trauma-Focused Cognitive Behavior Therapy, for example, is one of the most frequently used treatments with children and youth who range in age from 3 to 18 years. The short-term intervention encourages them to become more aware of how their thoughts about the traumatic event affect their reactions and behaviors. Child-Parent Psychotherapy is mostly used to address the needs of infants, toddlers and preschool-aged children by focusing on the way the traumatic event has affected the parent-child relationship. Structured Psychotherapy for Adolescents Responding to Chronic Stress, an example of a group intervention, seeks to help older children cope effectively with their traumatic experience and establish supportive relationships.

An important aspect of helping a child deal with trauma is recognizing signs that the experience has affected the child in some way. In most cases, symptoms will dissipate over a period of two to four weeks.

Among the more common signs are refusal to go to school, clinging behavior with a parent or other close caregiver or adult, persistent fear, loss of concentration, jumpiness, behavioral problems, sleep disturbances, withdrawal, and physical complaints, such as stomach aches or headaches. “You don’t have to be a psychiatrist or clinical social worker to see those things,” Dr. Petersen said. “Any parent or teacher with their eyes wide open will appreciate that those things are going on and they can ask questions to better determine what the concerns are.”

Children who experience a single traumatic event and children who are exposed to repeated trauma might show many of those same symptoms. However, some children may develop acute stress disorder or post-traumatic stress disorder. Signs for post-traumatic stress disorder include a child seeing the traumatic event happening again, acting out the event while playing, fearing things and places linked to the event, being easily frightened, having a difficult time trusting people, and acting out in anger.

The signs may be different in older children than in younger children. Teenagers, for example, are more likely to show signs of depression than young children. With young children, irritability and an increase in activity level and agitation are more likely to be seen than sadness.

In deciding whether a child’s problem is severe enough to seek professional help, both the severity of the symptoms and how long symptoms persist are informative. “If children are having severe difficulties in the first 30 days after a traumatic event they should see someone,” said Dr. Petersen. “And if children are still having difficulty functioning after 30 days—even if it is only in some areas—they should see someone for evaluation and possibly treatment.”

Sources used to produce this report include the following:

• National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. developingchild. harvard.edu/library/reports_and_working_papers/working_papers/wp9/
• National Scientific Council on the Developing Child (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3.developingchild.harvard.edu/index.php/library/reports_and_working_papers/working_papers/ wp3/