In his ten years of medical experience, including working on the front lines of Ground Zero during the weeks after the World Trade Center tragedy, Dr. David Marks has witnessed today's children having to cope with stresses that their parents never had.

The statistics are disturbing - one out of three American children suffers from stress-related illnesses such as headaches, stomachaches, chest pains, dizziness, sleep and eating disorders and depression. In this groundbreaking book, Dr. David Marks shows how much of this suffering can be avoided, and treated without medication.

In today's mobile and global society children experience stresses resulting from an overload of organized activities, excessive pressure to succeed, ongoing exposure to violence, and perhaps the most stressful event of all: the catastrophic day of September 11, 2001, that forever changed the lives of American youth.

In this practical and informative book, Dr. Marks explains how parents and care-givers can help children of all ages cope with different types of stresses that, if not released or resolved, will result in harmful behaviors and illnesses. He explores the mind/body connection offering an engaging look at what can be done to treat and prevent stress reactions and suggests practical ways for parents to ease the stress level on their children.

Dr. Marks' findings are supported by the latest medical and psychological research and humanized by anecdotes of his experiences dealing with children as a physician and as a father.

from Chapter One - A New World Disorder

Casualties

"My belly hurts," said Cindy, a four-year-old from New Jersey.

Her mom turned to the pediatrician and added, "She's also had diarrhea every few days or so, and she's been wetting the bed."

"How long has she had the symptoms?" the doctor asked.

"I think it's been about a month now," the mom answered.

The doctor visit took place in the middle of October, a little more than a month after the World Trade Center attacks.

Her story came to me as an example of a child who experienced physical effects from the insecurity and anxiety in the chaos around her. Cindy's mom did not link the terrorist attacks and her daughter's symptoms, and at four years old, Cindy was unable to verbalize her anxiety.

Ten-year-old William was able to talk about his fears, but like most ten-year-olds, he didn't. Instead, within weeks of the terrorist attacks, William developed an itchy, scaly rash on the back of his knees and on both of his forearms. The itching was so bad that it kept him up at night. The more he scratched, the more his skin itched.
William had suffered from eczema when he was younger, but the rash had not appeared in the previous two years. Because of the timing of this outbreak, his parents suspected a tie to the World Trade Center attacks. They tried to talk to him about the attacks and about any concerns he might have, but William was tight-lipped and denied any worries.

The doctor agreed that William's eczema was probably anxiety related. In addition to treating the rash with prescription ointments, he encouraged William's parents to continue to talk to their son about the attacks and to reassure him, through their words and actions, that he is safe.

At the time of this writing, William, Cindy and their parents are still struggling with the consequences of the new world disorder. So are thousands of other families across the country, including my own. Jacob is no longer blinking, but he still occasionally draws morbid pictures. Becca woke up with terrible nightmares almost every night the first couple of weeks after September 11; the terrors have now decreased in frequency, but every once in a while she'll still wake up crying from a bad dream.
Children react differently to a disaster, depending upon their distance from it, their age, previous experience with disasters, emotional maturity, temperament and personality. However, disasters cause common feelings in almost all children and adults.5 They make us feel as though we're not in control of our lives. Indeed, disasters are, by their very nature, out of our control. They make our world seem unstable because they throw off our routines and destroy our sense of trust. They make us feel unsafe.

Terrorism is about making people afraid: afraid to fly, to go to work, to live a normal life. If you want to know how much our lives have changed since September 11, just look at the signs of fear pervading our society. Adults have become so scared to fly that some entertainers wouldn't even attend the Emmy Awards ceremony because they would have had to take a cross-country flight; some people now wear gloves to open their mail; some New Yorkers are moving out of the city; the National Guard patrols our airports; twenty-four-hour cable news channels fill their airtime with talk about the possibility that terrorists have suitcase-sized nuclear bombs. Other adults are less frightened about their safety than they are about whether they will still have jobs tomorrow.

Terrorism scares kids, too. Young children, including those in elementary or middle school, may worry that Mom or Dad is going to be taken away from them or that tall buildings aren't safe because an airplane is likely to hit them. Children may also worry about their family's financial situation if they hear parents voicing concerns. Teenagers may share some of these concerns, but with an added worry that they could be drafted into the military now that we are engaged in a war that may take years to win.

Fear, loss of control, instability and insecurity can cause a great deal of stress in children, especially when the adults around them are having trouble coming to terms with their own reactions.

Children who survived, witnessed, watched or found out about the World Trade Center disaster were probably as stressed out about it as you or I. They can show the effects of that stress in a variety of ways. Here's what you might expect.Children suffering from post-traumatic stress disorder (PTSD) have similar symptoms, which should come as no surprise. According to the National Center for Post-Traumatic Stress Disorder, "The diagnosis of PTSD requires that an individual experience an event that involves a threat to one's own or another's life or physical integrity and that they respond with intense fear, helplessness or horror."6 By that definition, we are all probably at risk for developing some PTSD symptoms. Although few studies of PTSD in children are available, existing research indicates that 77 percent of children and adolescents exposed to a school shooting and 35 percent of urban youth exposed to community violence develop PTSD.7

We don't want our children to become part of these statistics. We need to look out for the signs and symptoms of posttraumatic stress.

A 9-1-1 for 9/11

Knowing what to do or say to your children after a traumatic event is not always easy. Let's face it, this territory is new for most of us. Terrorism, threats and safety concerns used to be something that happened to "them" in some faraway country. We are entirely unprepared to deal with this new reality, but deal with it we must, or our children will suffer.

We can help our children through uncertain and chaotic times. As I learned with my young children, you almost certainly can't keep them from finding out about the World Trade Center attacks, anthrax scares, plane crashes or threats of more terrorism. Kids are way too smart for that. In fact, if you try to hide the truth you may do more harm than good. You can, however, shape the way they interpret the information they receive. Parents take on many roles in our child's life; in this case, we become spin doctors.

Kids need time to express their feelings, which is part of the cathartic process after a traumatic event. Younger children, especially those whose vocabulary is not sophisticated enough to deal with a trauma of this proportion (and whose really is?), may be clingy. Let them cling. Sometimes a hug is worth more than a thousand words.

Letting children draw—art therapy—is another form of catharsis that may help children work through their fears. Although I was initially horrified when I saw Jacob's drawings of the disaster, I quickly realized that art was his way of expressing himself without letting down his six-year-old boy, macho, nothing-can-hurt-me, becoming-
independent exterior.

Children old enough to speak will probably also need to talk about their feelings. Your response should be age-appropriate for the child. Grade-school children may have questions about the disaster. Use simple, clear language to answer their questions. Don't lie to them or tell them there's nothing to worry about, but don't tell them more than they want to hear. Trying to put your child's feelings into words may also help. Try something like, "It's so sad that all those people died when the buildings fell down," or "It's normal to be scared after seeing those planes crash." Don't make light of the situation because your children will see right through you. Also do not make promises you can't keep. If you tell a child, "Don't worry, that won't happen again," and another terrorist crashes a plane into a building, your child's trust may end up in ruins.

The situation may be reversed in adolescents and teenagers. They may play down their concerns. You should encourage them to talk about their feelings. Older children who repress fear often act out and misbehave. They may also be more susceptible to depression.

One sixteen-year-old girl I heard about was profoundly affected by the events of September 11, but she tried to ignore her fear and insecurity. When her parents tried to talk to her about the attacks, she told them, "I'm fine. I just want things to go back to normal." She tried to pretend they were. A couple of weeks later, she started complaining of vague aches and pains over her entire body. First her legs hurt, then her arms and back took turns hurting. She also became very tired. Her doctor examined her and took blood tests and X-rays. They were all normal. The doctor's diagnosis: post-traumatic stress disorder. The girl's parents agreed. She is now in counseling to deal with her anxiety.

When I tell parents this story, some of them flinch. As one father asked, "How am I supposed to help my child through this when I can barely comprehend it, much less deal with it myself?"

Avoiding tough issues is not part of the parental job description. If you are having trouble dealing with the traumatic events yourself, communicating that trouble to an older, mature child may be okay. He will instinctively know anyway. However, don't lay all of your psychological burdens on him. Instead, use your feelings to show him that what he is going through is normal, and that healing will be possible over time.8

Some psychologists also suggest you give your child a sense of control over the situation. For example, nightmares and insomnia are quite common during a national crisis. If your child suffers from these symptoms, ask her, "What will make you feel better?" If she asks to sleep with you for a while, let her. Something as simple as reading an extra bedtime story could help. When you involve your children in the healing process, you help them recover the sense that they have some control over their lives.9

As part of being a spin doctor, you should try to monitor the flow of information your child receives. You can't stop children from talking to their friends. Indeed, such communication is often part of the healing process. However, limiting your child's exposure to the media can be a good idea. In the immediate aftermath of the World Trade Center attacks, the twenty-four-hour-a-day television coverage (to which, I must admit, I contributed), and the repeated airing of the gruesome attack footage, nearly sank the entire country into a mass depression. We should not let that happen to our children. Keep young children from watching news broadcasts. I was told about one set of parents who came up with a slick way to do this without calling attention to their concern: they scheduled an activity like story time, or arts and crafts during the news.

My family substitutes other activities instead of watching the news. I don't even want my children watching me on television because so many of my reports these days are about bioterrorism, PTSD, the war, etc. However, my children are young and their lives are still (relatively) controllable. Limiting media exposure for older children and teenagers is harder. The most important thing you can do is monitor the amount and type of their exposure, especially the Internet. If what they are watching, reading or surfing seems to make them more anxious, you may need to step in and impose some limits on their activities. As children grow older, they will like your intervention less. However, your involvement may prevent chronic anxiety and depression.

There are other steps you can take.

• Stick to a routine as much as possible. All humans, especially children, find comfort in routines. They add to a sense of security.
• Do activities that reinforce the idea that one person can make a difference in providing hope and healing. These kinds of activities include raising money to help victims' families or writing letters of support to survivors.
• Make sure your child eats a well-balanced diet and has plenty of opportunity to rest. These factors help children ward off the physical effects of stress.
• Find ways to show your kids you love them.

This book does not pretend to provide all the answers. However, I hope that it can help you help your children cope with the daily stress they will face in the aftermath of the attacks on our country. Some of these stresses are obvious and dramatic—a product of the new world disorder; others are more subtle—a result of the pressures we knowingly or unknowingly place on our children. In either case, stress can build up and have a devastating impact on a child as he or she grows up.
Every generation hopes that their children will live better lives than they did. That's the American way, the dream that continues to beckon to people the world over. September 11 does not change that dream; the events of fall 2001 only make the dream more difficult to achieve. I hope this book will contribute in some small way to keeping that dream alive for all of us parents.

¬2002. All rights reserved. Reprinted from Raising Stable Kids in an Unstable World by David Ryan Marks, M.D. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, without the written permission of the publisher. Publisher: Health Communications, Inc., 3201 SW 15th Street, Deerfield Beach, FL 33442.