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Psychosomatic Medicine 61:746-754 (1999)
© 1999 American Psychosomatic Society

ORIGINAL ARTICLE

An 18-Month Longitudinal Study of Posttraumatic Disorders in Children Who Were Taken Hostage in Their School

Gilbert Vila, MD, Luc-Michel Porche, MD and Marie-Christine Mouren-Simeoni, MD

From the Department of Child and Adolescent Psychiatry, Necker-Enfants-Malades Hospital, Paris, France.

Address reprint requests to: Dr. Gilbert Vila, Service de Pédopsychiatrie, CHU Necker-Enfants-Malades, 149 rue de Sèvres, 75015 Paris, France.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE: The objective of our investigation was to study the course of direct and indirect posttraumatic disorders over 18 months in children after they were taken hostage in their school.

METHODS: Twenty-six young hostages were evaluated by using standardized clinical interviews and self-administered questionnaires (State and Trait Anxiety Inventory for Children [STAIC]and Revised Impact of Event Scale [IES]) 2, 4, 7, and 18 months after the event. They were compared with 21 children from the same school who were not taken hostage (indirect exposure).

RESULTS: Symptoms of acute stress were observed in 25 (96%) of the children who were directly involved in the traumatic event. After 2 months, 18 children had developed disorders according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, including 7 cases of full posttraumatic stress disorder (PTSD), 11 cases of subclinical PTSD, 3 cases of separation anxiety, 1 case of specific phobia, and 2 cases of major depressive disorder. Anxiety scores (STAIC) decreased between 2 and 4 months and then stabilized, whereas symptoms of avoidance (IES-avoidance) decreased gradually throughout the follow-up period, and symptoms of repetition (IES-intrusion) decreased less markedly. Children who were indirectly exposed to the trauma also manifested protracted posttraumatic symptomatology (two full cases of PTSD and six cases of subclinical PTSD), but their IES-intrusion scores were significantly lower at 7 months than those of children who were directly exposed, and the severity of their symptoms diminished over time. Girls tended to show a higher level of anxiety and more features of intrusion than boys. Psychological debriefing did not prevent occurrence of the disorders, but children who were not debriefed had the worst outcomes.

CONCLUSIONS: Even after a short event and even if they are not directly exposed, children under the age of 9 years can develop high rates of posttraumatic disorders that follow a protracted course despite early intervention and careful monitoring.

Key Words: children • indirect exposure • debriefing • posttraumaticstress disorder • treatment

Abbreviations: DSM-IV = Diagnostic and Statistical Manual of MentalDisorders, fourth edition; IES = Revised Impact of EventScale; Kiddie-SADS-L = Kiddie-Schedule for Affective Disorders andSchizophrenia for School Age Children, Lifetime Version; MDD =major depressive disorder; PTSD = posttraumatic stress disorder; STAIC = State and Trait Anxiety Inventory for Children.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
In children, PTSDs often seem to have a protracted course, even after a single trauma (1–12). The rate of PTSD varies with the nature of trauma and the degree of exposure, which seems to be one of the most important risk factors of PTSD. Terr (3) distinguished Type I disorders in children (after a single, sudden, and unpredictable traumatic event) as well as Type II disorders (the result of chronic and repeated traumas). Indirect traumas have also been observed in subjects who have not been directly exposed to the traumatic event but, for example, have witnessed another person being assaulted or are a relative of a victim (4, 6, 13, 14). Few data are available on indirect trauma. Within a school setting and among indirectly exposed children, Pynoos et al. (15) reported a rate of posttraumatic stress symptomatology of 12% at 1 month, and Amaya-Jackson and March (2) found a rate of 19% at 14 months.

Before treatment is initiated after a group trauma, psychological debriefing could be used to prevent the development of traumatic disorders (7, 13, 16–18), although its effectiveness has not been demonstrated in children (19–21). Pynoos et al. (15, 22) recommended that therapeutic efforts target the children who were most directly exposed to a group traumatic event. However, the issue has been raised of a more global therapeutic approach that would involve all exposed persons (ie, those both directly and indirectly exposed) (23).

We know little about the natural history of posttraumatic disorders in children, particularly those of prepubertal age, directly or indirectly exposed to a Type I trauma. There are few longitudinal studies using standardized assessment with a homogeneous sample and a comparison group, and the impact of treatment on the course of posttraumatic disorders has not been studied extensively (2, 15, 22). School life is of particular interest for collective trauma in children (3, 4, 6, 8, 9), and it is essential to study the main events in this environment. In this article, we describe, by using data obtained from standardized instruments, the course of psychotraumatic symptoms that developed in children who were involved in a hostage-taking and who were followed from the start by a specialized team and compare direct and indirect trauma. This study explored the occurrence, various DSM-IV categories, and course over 18 months in young school-age children of psychopathological reactions to a major group trauma characterized by a sudden and unpredictable life-threatening event (Terr’s (3) Type I traumatic event). The study assessed the impact of the trauma not only on the children who were taken hostage but also on their schoolmates, who were indirectly involved (children who were present in the school on the day of the violent act) to compare the course of disorders as a function of type of exposure (ie, direct vs. indirect). We also evaluated the effect of sex on the frequency and severity of the disorders and explored previous psychiatric history.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Description of Event and Psychological Interventions
On December 3, 1995, a class of 29 children and their school teacher at a public elementary school in a suburb near Paris, France, were taken and held hostage between 4 PM and 6 PM by a man armed with a gun. Under the threat of his gun, he entered one of the two third-grade classrooms. The classroom contained not only its 23 usual pupils and their teacher but six first-grade pupils as well because of the unexpected absence of the first-grade teacher that day. The teacher and several children were insulted and personally threatened with the gun by the man. Everyone was afraid of being killed when a brief electrical failure occurred and the man cried out. The man, a mentally deranged person who attended a psychiatric day-hospital facility, asked for money, then wanted to see his psychiatric nurse, and then threatened to blow himself up with the hostages. Finally, after some negotiation, he was arrested by the police without violence or resistance. An emergency medical-psychological team came to the school on the day of the event, and a direct school-based intervention was accepted by the local government authorities, the school, and the families. A meeting at the school was organized for the following evening. Twenty-six of the 29 exposed children, their parents, the exposed teacher, and the school principal were present at the meeting. Psychological debriefing (19, 21) was conducted separately with the children and the adults. Six weeks later, a second debriefing session was conducted in the school and was attended by 21 of the 29 children, their parents, and members of the school staff. Ten of the 29 children received individual treatment, three of whom had not participated in the two group debriefing sessions.

Subject Samples
The population consisted of 29 children between the ages of 6 and 91/2 years: 6 were first graders (6–61/2 years old) and 23 were third graders (71/2–91/2 years old). Before the study, the children agreed to participate in the different evaluations and follow-up, and written informed consent was obtained from the parents. Twenty-six children and their parents agreed to participate in the study: 22 third graders (9 girls and 13 boys) and 4 first graders (3 girls and 1 boy). Regarding the three children who did not participate in the study, the parents’ refusal seemed justified in two cases: one child was considered intact and any evaluation or help deemed unnecessary, and the other child had been in psychotherapy for a long time and the parents did not want to interfere with the therapeutic process. Most subjects belonged to middle (N = 16) and low-middle (N = 9) socioeconomic classes (low socioeconomic class, N = 1) and came from diverse ethnic backgrounds: Half of them were of French or European origin, and the other half had North or West African, Asian, Caribbean, or mixed backgrounds.

This population was compared with a control population of 22 children (11 girls and 11 boys) between the ages of 71/2 and 91/2, of similar socioeconomic and ethnic backgrounds, who belonged to another third-grade class in the same school and who were in the school at the time of the hostage-taking incident. Thus, they were involved in the same traumatic event as the other children but were not directly exposed to it (indirectly exposed subjects). Because one family refused to participate in the study, only 21 control children were assessed.

Instruments
We used the Kiddie-SADS-L (R. Klein et al., New York State Psychiatric Institute, unpublished), a semistructured interview for the diagnosis of DSM-IV childhood mental disorders (1) derived from the Kiddie-Schedule for Affective Disorders and Schizophrenia for School Age Children (24, 25). The instrument was translated into French, and its feasibility has been shown by everyday usage in the Child Psychiatry Department of Necker-Enfants-Malades Hospital, Paris, France, for interviews with children and their parents (M.C. Mouren-Siméoni and R. Gittelman-Klein et al., unpublished). We defined subclinical PTSD as an incomplete form of PTSD with at least DSM-IV criteria A (trauma exposure) and F (impairment) of PTSD, a duration of more than 1 month if the assessment was made 1 month after the hostage-taking (criteria E of PTSD), and at least one item of criteria B, two items of criteria C, and one item of criteria D (clinical symptoms).

The STAIC (26), translated into French, includes two scales of 20 items each describing psychic manifestations of anxiety: the State scale describes the current state of anxiety and the Trait scale describes a general tendency to react with anxiety to stressful events; this instrument has been validated for children aged 8 to 12 years (26). Each item is scored from 1 to 3, the total score for each scale thus ranging from 20 to 60; the cutoff score for pathological anxiety in 8- to 12-year-old children (DSM-IV anxiety disorders for nonreferred children), as validated in French for STAIC-Trait, is 34, with a sensitivity of 0.63 and a specificity of 0.75 (G. Vila and C. Nollet-Clémençon et al., unpublished).

The IES was developed and validated for adults by Horowitz et al. (27) and then translated into French and validated on a French population (28). This scale includes 15 items: 7 items explore intrusive reexperience of the traumatic event, and 8 items explore conscious avoidance of stimuli or situations associated with the trauma. Intrusion and avoidance make up the subscores, which yield an overall IES score. In the French version as it applies to adults, Hansenne (28) computed a pathological cutoff score of 42 (total) for the differentiation of subjects with and without PTSD, with a sensitivity of 95% and a specificity of 100%. The IES has been used in children from the age of 8 years; Yule et al. (4) observed an elevation of scores in posttraumatic situations that is comparable with that found in adults. In a French study of 8- to 12-year-old subjects (29), children who were exposed to an industrial disaster had significantly higher IES total scores than nonexposed children (27.4 ± 14.3 vs. 17.2 ± 10.0).

Procedure
Overall, children who were exposed to the traumatic event were assessed in the school with two types of instruments. Self-administered questionnaires (IES and STAIC) were completed by each subject in the presence of a clinician, who made sure the subject understood the items. On a practical level, these instruments could not be appropriately used with the four first graders (6–7 years old). The Kiddie-SADS-L interviews were all administered by the same clinician. The data derived from the semistructured interviews with the parents and child was complemented by the nonstandardized information provided by teachers, parents, and peers during the different meetings at school during the follow-up period (debriefing sessions and meetings with staff). The interviewer was blind to the results of the questionnaires. Each time, the children and parents were interviewed on the recent events in the life of the child.

These data were collected four times, 2 months (6–8 weeks), 4 months (16–18 weeks), 7 months (28- 30 weeks), and 18 months (82–84 weeks) after the incident. The children of the nonhostage group were not assessed at 2 months. Each time, one to several children taken hostage could not be evaluated because they were absent from school or not permitted by their parents to participate in the assessment: at 2 months, one child (absence); at 4 months, two children (one absence, one refusal); at 7 months, nine children (six absences, three refusals); and at 18 months, five children (five refusals based on parental impression that the child was free of psychological problems). In the other group (indirectly exposed children), 20 of 21 children were evaluated at 4 months, 17 were evaluated at 7 months, and 18 were evaluated at 18 months (1–4 refusals).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
DSM-IV Diagnoses
The DSM-IV disorders that were initially diagnosed in the directly exposed children were subclinical PTSD lasting for a minimum of 2 days (17 of 22 third graders and all 4 first graders; ie, 81% of the 26 children) associated with disturbances of emotions (primarily symptoms of separation anxiety and of generalized anxiety) and conduct (opposition, tantrums, restlessness). In addition, three children (12%) immediately developed a PTSD, one child had a full acute stress disorder (4%), and one child (4%) had no disorder (Table 1).


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  		Table 1. Summary of Therapeutic Interventions and Course of DSM-IV Posttraumatic Disorder Diagnoses for Directly Exposed Children During the First Month and 2, 4, 7, and 18 Months After Trauma
 
Seven (4 boys and 3 girls) of the 26 children who were taken hostage (27%) exhibited at one time or another a full PTSD (Table 1). During the follow-up period, the rate of subclinical PTSD evolved from 24% (6 of 25 children) at 2 months to 34% (8 of 24 children) at 4 months. Six of 17 children (32%) evaluated at 7 months and 8 of 21 (38%) evaluated at 18 months still displayed symptoms of a subclinical PTSD. Two confirmed cases of separation anxiety disorder were diagnosed at 2 months, and another case was diagnosed at 4 months; all three cases were associated with symptoms of PTSD (Table 1). One case of MDD was diagnosed at 2 months, and another case was diagnosed at 7 months. Nine of 14 boys (64%) and 5 of 12 girls (42%) developed a PTSD or a subclinical PTSD during the 4 months after the hostage-taking, but the rate of PTSDs and of all posttraumatic disorders did not significantly differentiate boys from girls. Ten of 15 children (66%) of foreign origin vs. 4 of 11 (36%) of French origin developed a PTSD or subclinical PTSD during the 4 months after the hostage-taking.

Finally, three of the seven children (47%) who had developed a full PTSD suffered from preexisting disorders: one case of mild generalized anxiety disorder and moderate social phobia, one case of generalized anxiety disorder, and one case of dysthymic disorder (with delayed onset PTSD associated with an MDD for the two latter cases). One of 19 children without a PTSD (5%) did not develop any posttraumatic disorder despite a preexisting specific phobia. The children did not have preexisting PTSD.

The DSM-IV disorders that were diagnosed in the other class of third graders and their evolution over the follow-up period are presented in Table 2. There was no significant difference between the directly and indirectly exposed children with respect to the rate of posttraumatic disorders at 4, 7, or 18 months (Table 3).


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  		Table 2. Summary of Course of DSM-IV Posttraumatic Disorder Diagnoses for Indirectly Exposed Children 4, 7, and 18 Months After Trauma
 

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  		Table 3. Comparison of Clinical Course of DSM-IV Disorders Occurring After the Trauma (Raw Frequencies and Percentages) in Children Who Were Directly and Indirectly Exposed to the Hostage-Taking Incident at 4, 7, and 18 Months
 
Quantitative Evaluations Based on Self-Administered Questionnaires (STAIC and IES)
Table 4 presents the means and standard deviations of the scores obtained on self-administered questionnaires 2, 4, 7, and 18 months after the hostage-taking incident. Table 5 presents the scores obtained at 4, 7, and 18 months by the indirectly exposed children on the self-administered questionnaires (STAIC and IES). At 7 months, the directly exposed children had significantly higher IES-intrusion scores than children in the control group.


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  		Table 4. Clinical Course of Third Graders Who Were Taken Hostage: Results (means and SDs) From Spielberger’s Anxiety Questionnaires (STAIC-State and Trait) and From Posttraumatic Stress Questionnaires (Total IES, IES-Intrusion, and IES-Avoidance Scores) at 2, 4, 7, and 18 Months
 

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  		Table 5. Progression of Scores (Means and SDs) on Self-Administered Questionnaires of Anxiety (STAIC-State and -Trait and IES) in Indirectly Exposed Third Graders Assessed 4, 7, and 18 Months After Trauma
 
There were no significant differences between boys and girls, for the two groups, on the series of STAIC and IES evaluations, except for total IES score (40.2 ± 12.1 vs. 28.6 ± 11.1; Mann-Whitney U test, p = .04) and IES-intrusion score (17.7 ± 6.5 vs. 10.8 ± 6.1; Mann-Whitney U test; p = .03), which were higher at 2 months, and the STAIC-State scores, which were higher at 7 months (33.2 ± 8.7 vs. 27.0 ± 8.4; Mann-Whitney U test; p = .03), in directly exposed girls as compared with directly exposed boys.

Relations Between Qualitative (DSM-IV Diagnoses) and Quantitative (Scores on Self-Administered Questionnaires) Evaluations
The self-administered questionnaire scores of children with and without a posttraumatic disorder were compared using the Mann-Whitney U test (Table 6). Mean scores of children with a DSM-IV diagnosis were higher in directly and indirectly exposed children than in children with no posttraumatic disorder at each assessment.


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  		Table 6. Relationshipsa Between DSM-IV Diagnoses and Spielberger STAIC-State and -Trait Questionnaire Scores and IES Scores for Directly and Indirectly Exposed Children
 
Psychomedical Interventions and Course of Posttraumatic Disorders
Table 1 summarizes for each case the course of the disorders that occurred after the traumatic experience, specifying whether the child received early debriefing (24 hours after the event), delayed debriefing (6 weeks after the event), or specialized treatment for posttraumatic disorders. The vast majority of involved children (24 of 26) received at least one of these interventions. Debriefing sessions did not systematically prevent the occurrence of psychotraumatic disorders because approximately half of the debriefed children developed some disorders. However, the two children who did not participate in the debriefing sessions (cases 13 and 16) had an unsatisfactory outcome for PTSD percentage (two cases of PTSD for 2 nondebriefed children vs. four cases of PTSD for 24 debriefed children at 7 months, two-tailed Fisher’s exact test = 0.04; two cases of PTSD for 2 nondebriefed children vs. five cases of PTSD for 22 debriefed children at 18 months, two-tailed Fisher’s Exact Test = 0.07) and questionnaire scores at 4 months (Table 7). A third child who did not receive any treatment (case 6) also had a poor psychiatric outcome at 7 months (PTSD and MDD) despite his participation in the two debriefing sessions. Finally, the clinical course of children who received specialized treatment for their posttraumatic disorders (cases 2, 5, 8, 15, 20, and 23) seemed good to very good. These children all participated in the debriefing sessions, followed by various modalities of treatment.


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  		Table 7. Comparison After Debriefing (4 Months After Hostage-Taking) of Mean Questionnaire Scores of Debriefed and Nondebriefed Children
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
This descriptive study contributed to the understanding of the natural course of psychotraumatic disorders by following, over a period of 18 months, children who directly and indirectly suffered a traumatic event as a group and who received specialized treatment. There is no other study about a collective hostage-taking in a school. School life has a particular interest for collective trauma, and it is essential to study the main events in this specific environment. The use of semistructured interviews based on the Kiddie-SADS-L yielded reliable DSM-IV diagnoses. Other instruments have been used for the same purpose by different authors (11, 13–15, 22, 30). To our knowledge, our study is the only one that used a diagnostic interview method to generate DSM-IV diagnoses in children. A limitation of this assessment was that the level of impairment (social or academic functioning) of the children was not assessed by a standardized measure. Because the teacher was directly involved in the hostage-taking, we thought that her way of grading her pupils could have been influenced by her subjective perception of the children’ disorders and her own trauma. We used other tools as well to obtain dimensional measures (IES and STAIC) according to Yule’s recommendations (18).

Approximately half of the directly exposed children continued to have posttraumatic symptoms after the first month, a percentage that remained roughly the same throughout the period of follow-up. Taken together, 27% of the children (7 of 26) received a diagnosis of PTSD at one time or another during the 18-month follow-up period, the course of the disorder being of relatively brief duration (2–4 months) in at least half of the cases. This rate is markedly higher than the lifetime prevalence of 6.3% noted before the age of 18 in US studies of the general population of youngsters with the same socioeconomic background as the children in our study (16, 17). However, it seems that some of the healthier children opted out of the study (26 of 29 children were included), thereby possibly leading to some degree of bias toward overrepresentation of psychopathology in this group. According to Yule et al. (4), 50% of the exposed children continued to display PTSD 5 to 9 months after the trauma, and Schwarz and Kowalsky (6) reported a rate of 27% 6 to 14 months after the event. But, according to Amaya-Jackson and March (2), 60% of the pupils involved in a school shooting had full PTSD 14 months after the event. There is a wide variety of prevalence percentages in different studies of PTSD; these are difficult to compare because of different methodologies and various traumas. The type of trauma is important as an etiopathogenic factor, but for the same trauma, even absolutely major events, the entire exposed population never develops a PTSD; one has to consider risk and resilience factors and to undertake systematic studies on these issues (18, 21, 29). In our study, it would also have been interesting to assess indirect PTSD of the parents and family support.

Three of the indirectly exposed children (15%) developed PTSD. In two cases, the disorder occurred immediately after the event, and in one case the child required specialized psychiatric treatment; the disorder subsided between 7 and 18 months in both instances. The third case was a mild but confirmed case of delayed onset PTSD that occurred at 6 months and remitted spontaneously at 18 months. Thus, children who are not directly involved in a traumatic event are at risk of developing a posttraumatic disorder. As shown by Schwarz et al. (6, 13), the level of subjective involvement and the intensity of the emotional reaction play a role in the dimension of "exposure" to the trauma, which is as important as the physical proximity to the vital threat. For instance, those children who spontaneously mentioned they had a friend or a person they knew well who was taken hostage felt "exposed" to the trauma, just as March et al. (31) and Saigh (32) described in their studies. Yule et al. (4) call it "exposure by proxy," which leads to a "phenomenon of near miss," a source of genuine posttraumatic symptomatology. Rates of posttraumatic disorders in indirectly exposed children (approximately 40% at 4 months, 30% at 7 months, and 11% at 18 months) were lower and less persistent than in directly exposed children (stable rates around 50%) but not significantly.

The K-SADS-L was administered by the same clinician, who was not blinded to the status of the children (hostage vs. nonhostage group); this is a potential source of bias. The nonhostage group seemed to have a lesser degree of severity according to IES results. Pynoos et al. (15, 22) reported rates of posttraumatic stress symptomatology of 12% at 1 month and Amaya-Jackson and March (2) found rates of 19% at 14 months in indirectly exposed children in school settings. One possible reason for these results is that the course of the disorder is not as protracted when exposure is less intense (22, 33). Finally, even if one follows the recommendations of Nader et al. (14) and Pynoos et al. (15, 22) to target for therapeutic interventions children who were physically (and most directly) exposed to a group trauma, more global interventions should attempt to reach all children and families involved (23).

The presence of acute symptoms was obvious in 96% of the children who were directly involved in the trauma: 81% of the children had a subclinical PTSD of marked severity, 4% (one case) had an acute stress disorder, and 12% immediately developed a full PTSD. Few comparable data have been published on the short-term clinical course of these symptoms. Pynoos et al. (15) found, during the first month, a high rate of full PTSD (approximately 60%) in elementary school children who were directly exposed to a deadly shooting in the school, whereas more than 90% of the children developed unspecified but marked symptomatology. There are no data on the rates of acute stress disorder in children, but it was rare in its complete form in our study (the number of dissociative symptoms was seldom sufficient to meet the criteria). It is interesting to note that the child whose initial disorder was the most severe (acute stress disorder with some dissociative symptoms) displayed, despite ongoing treatment, the most delayed onset of PTSD with no symptom-free period; however, even if he was interviewed on recent life events at each assessment, he might have denied and hidden another trauma that occurred during the follow-up period. The seven children who displayed PTSD had symptoms of posttraumatic stress on the first two assessments (subclinical PTSD at 0 and 2 months). Yule (18) and Amaya-Jackson and March (2) also noted a period of "latency" before the delayed occurrence of the posttraumatic stress disorder, which would therefore permit the screening of high-risk subjects. In other studies (33, 34), the anxiety scale (Revised-Children manifest anxiety scale [R-CMAS]) predicted the level of traumatic stress several months later (assessed by IES). The ease of administration of the STAIC-Trait to large samples would thus make it an interesting instrument in the identification of those young subjects who need close monitoring after a group trauma. The good relation between DSM-IV clinical diagnoses and self-administered questionnaire scores also confirms results from other studies (22, 30, 35, 36); these questionnaires seem to have thus some "on-site" validity and could be fruitfully used as a screening device in prepubertal children.

There was no evidence of significant sex differences in the rates of DSM-IV disorders. Compared with boys, girls of the directly exposed group tended to have higher IES scores and higher levels of anxiety. One could surmise that, in our culture, girls recognize and express more readily their anxiety than boys. But, the small size of our sample prevented us from statistically confirming the greater vulnerability of girls, which several authors have demonstrated in this respect (4, 12, 30, 31, 37, 38).

Compared with subjects who did not develop a PTSD in our study, those who did tended to have higher rates of preexisting disorders, this being recognized as a risk factor for PTSD (2, 39, 40). The small sample size and the retrospective nature of the diagnoses warrant cautious interpretation of these results.

Early debriefing does not prevent the occurrence of posttraumatic disorders, as Yule et al. (4, 18) observed in the case of adolescents, but nondebriefed children had the worst outcomes. The vast majority of children who received psychiatric treatment improved or remitted, but in the absence of a control group (exposed children who randomly did not participate in debriefing sessions), we cannot determine whether treatment was effective in reducing the intensity or duration of the disorders. Yule et al. (4) observed that IES-intrusive symptoms improved significantly in subjects who went through debriefing sessions in their school 10 days after the event and who subsequently participated in group therapy. Nevertheless, as pointed out by Klingman (23) and Gillis (41), our early interventions did facilitate the detection of high-risk children and their referral to potentially useful therapeutic services.


   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The results of this study demonstrate that young children are not protected from psychotraumatic syndromes: Many elementary school–age children developed clinically confirmed disorders when faced with a traumatic event of average intensity and involving no physical injury. In addition, other children from the same school suffered from the same disorders, although to a lesser degree, despite the fact that they were not directly involved in the assault, a finding that pleads in favor of a broader application of therapeutic services to all "involved" children. The natural course of the disorders and the availability of useful therapeutic programs suggest that it is worthwhile and probably necessary to maintain monitoring at least 6 months after the traumatic event. Furthermore, it would be valuable to assess more precisely the effectiveness of certain treatment modalities, such as debriefing sessions, when group interventions are called for; but we are aware that on a practical level such interventions are difficult to implement in catastrophic situations and that ethical issues prevent us from not giving psychiatric care to part of the victimized population.

Received for publication October 2, 1998.

Accepted for publication August 13, 1999.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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