Reaction to National Crises In Children

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Reaction to National Crises In Children
Adolescents with Psychiatric Problems
Alan Apter Schneider Children's Medical Center of
Israel
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REACTIONS TO NATIONAL CRISES IN CHILDREN
ADOLESCENTS

• PSYCHIATRIC DISORDERS IN CHILDHOOD
• NATIONAL CRISES (WAR, TERRORISM, NATIONAL
  STRUGGLE)

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INTERNALIZING DISORDERS

• ANXIETY DISORDERS
• DEPRESSION

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DEFINITIONS

• ANXIETY IS THE PSYCHOLOGICAL COMPONENT OF THE
  PHYSIOLOGICAL RESPONSE TO DANGER.
• FEAR IS WHEN THE STRESS IS OBJECTIVE

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Developmental anxiety in children

• Stranger anxiety (8 months)- social anxiety
  disorder
• Separation anxiety (14 months)- separation
  anxiety disorder panic disorder agoraphobia
• Phobic anxiety (36 months)- specific phobias

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ORIGINS

• Originally when the membrane of a unicellular
  organism was touched this gave rise to change in
  the internal chemistry of the cell.
• This prepared the cell for fight or flight
• Teloreceptors enable danger to be sensed from afar

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THE SYMPATHETIC NERVOUS SYSTEM

• THE NERVOUS SYSTEM IS DIVIDED INTO THE VOLOUNTARY
  AND INVOLOUNTARY (AUTONOMOUS).
• THE INVOLOUNTARY SYSTEM IS DIVIDED INTO
  PARASYMPATHETIC AND SYMPATHETIC

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SYMPATHETIC NERVOUS SYSYTEM

• THE PARASYMPATHETIC NERVOUS SYSYTEM DEALS WITH
  EVERYDAY LIFE (EATING, BREATHING, URINATING)
• THE SYMPATHETIC NERVOUS SYSTEM (SNS) IS ACTIVATED
  IN TIMES OF DANGER-THUS IT IS INVOLVED IN ANXIETY

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SYMPTOMS OF ANXIETY

• 1. ACUTE SNS ACIVITY-PANIC ATTACK
• A discrete period in which there is sudden
  onset of apprehension, fearfulness or terror,
  often associated with feelings of impending doom.
  There may be shortness of breath, palpitations,
  chest pain or discomfort, choking or smothering
  sensations and a fear of going crazy or losing
  control.

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SYMPTOMS OF ANXIETY

• 2. Chronic SNS activity
• High pulse rate (palpitations)
• Fast breathing (tachypnoea)
• High blood pressure
• Dilatation of pupils
• Secretion of gastric acid (stomach pains)

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SYMPTOMS OF ANXIETY

• 3. Increased (involuntary) muscle tension
• Headaches
• Backaches
• Tics
• Twitching
• Sighing (diaphragmatic tension)

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SYMPTOMS OF ANXIETY

• 4. Psychological symptoms
• Worrying
• Hypervigilence
• Intrusive thoughts
• Nightmares

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SYMPTOMS OF ANXIETY

• Behavioral symptoms
• Compulsions
• Phobia

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Anxiety disorders in children

• Separation anxiety disorder
• Post traumatic stress disorder
• Acute stress disorder
• Obsessive compulsive disorder

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Anxiety disorders in children

• Panic disorder
• Agoraphobia
• Specific phobia
• Social phobia

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POSTTRAUMATIC STRESS DISORDER

• CRITERIA A
• The individual experienced, witnessed or was
  confronted with an event or events that involved
  actual or threatened death or serious injury or a
  threat to the physical integrity of self or
  others associated with intense fear, helplessness
  and horror
• CHILD Disorganized/agitated behavior

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POSTTRAUMATIC STRESS DISORDER

• CRITERIA B (Reexperiencing) (2 or more s/s)
• Recurrent images, thoughts, perceptions
• Recurrent distressing dreams
• Reliving of the traumatic experience
• Psychological distress to traumatic reminders
• Physiological distress to traumatic reminders
• Children repetitive play dreams without
  recognizable content trauma renactments

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POSTTRAUMATIC STRESS DISORDER

• CRITERIA C (Avoidance) ) 3 or more s/s
• Avoid thoughts, feelings, conversations
• Avoid activities, places or people
• Inability to recall aspects of trauma
• Decreased interest in significant activities
• Feelings of detachment/estrangement
• Decreased range of affects
• Sense of foreshortened future

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POSTTRAUMATIC STRESS DISORDER

• CRITERIA D (INCREASED AROUSAL) gt2 S/S
• Insomnia
• Irritability
• Difficulty concentrating
• Hypervigilence
• Exaggerated startle response

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PTSD IN PRESCHOOL CHILDREN

• Sleep and Appetite Disturbances
• Fear of the dark
• Separation anxiety
• Nightmares
• Regressive behaviors
• Hypervigilence
• Behavioral reenactments

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PTSD SCHOOL AGE CHILDREN

• Re-experiencing symptoms
• Disorganized/confused behaviors
• Somatic complaints
• Arousal symptoms
• Disruptive behaviors
• Spectrum of anxiety symptoms
• Decreased academic performance

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PTSD IN ADOLESCENCE

• CLASSICAL PTSD SYMPTOMS
• Anxiety
• Depression
• Guilt, anger, fear, disillusionment
• Fears of a foreshortend future
• Flight into action oriented behaviors
• Narrowing the scope of life

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DIFFERENCES BETWEEN CHILD AND ADULT PTSD

• Egocentric theories of causality
• Cognitive Perceptual distortions
• Traumatic play/behavioral reenactments
• Rarely flashbacks
• Developmental effects

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CONDUCT DISORDER
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Conduct Disorder

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ADHD

• ADHD is the most commonly diagnosed behavioral
  disorder of childhood
• Estimated to affect from 3-10 of school-aged
  youth worldwide
• Many patients have persistent features and
  impairment well into adulthood

ADHD Practice Parameters. JAACAP 19973689S.
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Co-occurring Disorders in Children (n579)
Oppositional Defiant Disorder 40
Tics 11
ADHD alone 31
Conduct Disorder 14
Anxiety Disorder 34
MTA Cooperative Group. Arch Gen Psychiatry
1999 5610881096
Mood Disorders 4
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An example from Ethiopia

• A month before, the Guideboso tribe of Afar, was
  ambushed at Kurbugi by the Issa tribe over
  grazing land.
• The conflict, dating back to before the time of
  the Prophet Mohammed, was over grazing land and
  watering holes.
• Amina's son already seeks revenge,
• as if to make the point clear 13-year-old Arasa
  Daoud's ambitions are homicidal, "I want a gun to
  kill the Issa and loot his cattle."

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NATURAL DISASTERS

• HURRICANE
• EARTHQUAKE
• FLOOD
• PANDEMICS

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MAN MADE DISASTERS
POLITICAL UPHEAVAL
AIRPLANE CRASHES
WAR
TERRORISM
AGGRESSIVE ASSAULTS
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What does danger mean for a child?

• Objective" and "subjective" dangers may be
  weakly correlated.
• Children may feel safe when they "ought" to be
  afraid, or feel endangered when, in fact, they
  are at negligible risk of harm.

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What does danger mean for a child?

• This issue is important because war represents
  the coincidence of many dangers for children.
• Danger is a judgment about the social meaning of
  risk and an authorization for effective and moral
  response.

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What does danger mean for a child?

• When our sense of security as a nation is shaken,
  we must be prepared to discuss the events with
  our children.
• Undoubtedly the crisis will be broadcast on
  national television as it happens.

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What does danger mean for a child?

• Our television screens, newspapers and internet
  could be flooded with terrible images.
• You may be anxious and worried, but calmness in
  adults is important to the children who look to
  them for direction.

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War and Violence

• Family violence and trauma is passed down through
  generations.
• Adults who were abused as children are more
  likely to perpetuate this violence upon their own
  children ( Cicchetti Carlson, 1989).
• Violence within families can perpetuate violence
  on the next generation

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QUESTIONS

• What are the effects of war and political
  violence on a 3-year-old child
• How do they differ from the effects on a
  10-year-old?
• What do children understand about their world
  when that environment is filled with chaos and
  violence?
• What happens to the development of the moral
  self and to the child's developing social
  competencies?

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QUESTIONS

• Understand the immediate and perhaps short-term
  psychological and physical effects of war and
  violence
• Understand the broader psychological context
  around which war and violence are presented and
  interpreted by children.

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QUESTIONS

• Widespread and long-term effects of exposure to
  violence on the psychological well-being of
  children.
• Children do NOT recover quickly and completely
  from exposure to natural and man-made disasters (
  Terr, 1983).
• Need to develop wide-ranging public mental health
  measures in response to the profound exposure to
  violence that children around the world
  experience.

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Context

• Conflict is politicized for children
• Use and organization of children for ideological
  purposes.
• Children are no longer passive observers and
  recipients of the chaos of war
• Socialized to be the vanguard of political change
  ( Baker, 1991).

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THE GULF WAR AS A CASE STUDY

• Television brought images of physical destruction
  and human emotion that were powerful and
  upsetting.
• The greatest number of causalities were
  civilians.
• Among these civilians were children.
• Forgotten was the psychological suffering
  associated with war and exposure to violence

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Iraq
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IRAQ

• Seven-year-old Ibrahim Muhammed spends nearly ten
  hours a day on the street distributing printed
  verses of the Koran to earn money for his family.
  
• Since his father was killed by American troops
  during a clash with insurgents, Muhammed has
  become the man of the family, and must help to
  support his mother and younger sisters.
• He earns at least 2,000 dinars, just over one US
  dollar, per day from drivers and passers-by. This
  is known as a gift, since tradition dictates
  that the verses of the Koran cannot be sold for
  commercial profit.
• Muhammed has little choice. My mother is
  unemployed and my uncle doesnt help us out, he
  said.

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IRAQ

• The violence plaguing Iraq has killed so many men
  that families find themselves without the male
  head of the household, who is generally the main
  breadwinner.
• The economy has gone into decline since the fall
  of Saddam Husseins regime.
• Many children have been forced to drop out of
  school to help make ends meet for their families.
  

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IRAQ

• Across Iraqi cities, children can be seen at
  traffic lights selling cigarettes, boxes of
  tissues and other small items.
• Nine-year-old Hammoodi Abdul-Wahab sells tissues,
  which he buys at 450 dinars per box and sells for
  500. He works from 7 am to 7 pm, but sells only
  10 boxes a day. He also begs, which earns him
  about 1,000 dinars a day.
• I want to go to school like my friends, but my
  father forces me and my four brothers to go out
  and sell things down town, he said.

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THE TERRORIST

• As a child abused/emotionally humiliated
• Deep mistrust of others
• Loaths passivity/victimization
• Turns passivity/victimization into
  activity/sadism/victimizer
• Hatred/violent tendencies toward others
• Malignant narcissism
• Amoral in the service of their goals
• Akhtar, 1999

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Epidemiology

• The plague of suicide terrorism (Pape, 2003)

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Group for the Advancement of Psychiatry (GAP)

• The Self-Psychology theory of Kohut
• Real or imagined threat or injury to the nation
  that may be perceived by the individual as a
  danger or humiliation to the self
• Narcissistic rage the case of the Palestinians

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Ali Imawi a description of a suicide terrorist
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Indoctrination

• Educational process carried out by schools,
  media, parents and friends in which a person is
  convinced of the importance of the cause and of
  the means necessary for its implementation
  (Merari, 1998)

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The Palestinian educational system

• In the light of incitement and hatred
• -The Jewish people
• -Jerusalem
• -Zionism
• -Jihad
• -Israel
• -The right to return

The Jewish people
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An excerpt from the textbook Our beautiful
languagefor the 2nd grade, Part I, p. 72)
(An excerpt from the textbook Our beautiful
language
After three hours, one of the soldiers looked at
them and said No visits permitted today
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Excerpts from the textbook Our beautiful
language for the 7th grade, Part I, p. 98
A question to be answered by students on a poem
named the shahid Which of the following is the
meaning of the expression honorable death? -
a)death from illness - b)sudden death -
c)martyrdom (shahada) while defending the homeland

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An excerpt from the textbook Our beautiful
languagefor the 2nd grade, Part I, p. 88)
Israeli soldiers watching while a bulldozer
demolishes houses
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Short term indoctrination

• Mission oriented persuasion
• Charismatic political, military or religious
  leader
• Final trigger effect

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The making of the living Martyr

• Intensive religious preparation
• Isolation
• Points of no return (the video testament )

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Conclusions

• The complex interaction of many forces in
  homicide-suicide
• Probably no specific profile compared to general
  population
• Look at the cannon and not at the missile
  (Barco,2002)
• Media and Educational interventions are paramount
• The shifting focus from personality to process