Medical staff and bereavement parents: asian culture aspects.

Medical staff and bereavement parents: asian culture aspects.

This miscarriage is my fault... I think I'm going crazy.

This miscarriage is my fault

I can't tell you how many women have explained to me what they did to cause their miscarriage, or to ask if their stressful job or glasses of wine were what did it. For a long time, I blamed myself too. Then I learned I had a malformed uterus. All that guilt was for nothing.

 

Let me be the one to tell you: YOU DID NOT CAUSE THIS MISCARRIAGE. 

 

I don't care if you were smoking crack--those babies are born all the time. Stand up on the job all day? Doesn't matter. On bed rest but got up a couple of times to raid the refrigerator or use the bathroom (or even to go out to dinner)? Insignificant. Nature is not perfect. Our genetic code sometimes doesn't work just right. It's terrible; it's sad. I hate it. But it has nothing to do with your sins, your stress, your mistakes, your nutrition, or your relationship. There was nothing you could have done. 

 

I know. Some of you still feel a nagging guilt. But try to put it out of your mind. It really, truly was not your fault. And most likely, it will not happen again.

 

I think I'm going crazy

Remember to give yourself time to handle your grief. IT IS REAL AND VALID. You may want to read some of the other women's miscarriage stories here or on other web sites to help you see that the crazy things you feel are normal. I did and thought many things after my miscarriage that I thought were really unhealthy or insane, including:

 

	Wanting to die to be with my baby
	Cuddling the sonogram pictures like a baby
	Hugging the tree we planted in Casey's memory (in full view of neighbors)
	Getting angry with myself for laughing or having a good time
	Picking fights with my husband for no reason
	Telling perfect strangers about my baby

It may not get much better for a long time. There will probably be a time, about 3-4 months later, that it will actually get worse. Getting pregnant again may not give you the release from grief you seek. Just give yourself time and surround yourself with people who care and understand. Forget the rest of them, for now.

If I could make one recommendation that has helped me tremendously, it would be to put together a memory box of your baby's things, even if it is only sympathy cards and a positive pregnancy test, or just letters you are writing to him/her. For several months, I went into the nursery and opened that box and cried every single day. I found that if I didn't, I felt like I was in a grief-fog all day. The memory box validates my baby's existence. Since I don't have a grave or a container of ashes, I go to it.

www.pregnancyloss.info

Look into the baby's death - Perinatal grief and learn from experiences of parents.

赤ちゃんの死へのまなざし　―両親の体験談から学ぶ周産期のグリーフケア [単行本]

by 竹内正人 (著), 井上文子 (著), 井上修一 (著), 長谷川充子 (著) 

 

The couple who had experience of baby loss expressed their feeling about the event. As it is naturally, the mother and the father had some differences in grieving what described very detailed in this book. Parents did not feel they were well cared from medicals at the tragic moment. Medical staffs as well feel not good about less care, feel guilty, but do not have time to change this attitude and just keep going ahead over the event. Nurse, who was involved also explained her experience and suggested how to establish good relationship with the parents in grief. The interview of Dr. Takeuchi Masato contains of suggestion what is the easier way for medical staff to provide professional care in a perinatal loss event. This book is able to direct of nurse to take care on this type of patient in right way. It helps for medical staff to understand themselves, first of all; to see what they are for parents in grief, and to discover the way how to grow up as professionals. We recommend this book for all medical staff , especially who involved in perinatal and pediatric care.

 

The 7 Stages of Grief

Another classification is knows as "The 7 Stages of Grief":

1. Shock and denial
You will probably react to learning of the loss with numbed disbelief. You may deny the reality of the loss at some level, in order to avoid the pain. Shock provides emotional protection from being overwhelmed all at once. This may last for weeks.
2. Pain and guilt
As the shock wears off, it is replaced with the suffering of unbelievable pain. Although excruciating and almost unbearable, it is important that you experience the pain fully, and not hide it, avoid it or escape from it with alcohol or drugs. You may have guilty feelings or remorse over things you did or didn't do with your loved one. Life feels chaotic and scary during this phase.
3. Anger and bargaining-
Frustration gives way to anger, and you may lash out and lay unwarranted blame for the death on someone else. Please try to control this, as permanent damage to your relationships may result. This is a time for the release of bottled up emotion. You may rail against fate, questioning "Why me?" You may also try to bargain in vain with the powers that be for a way out of your despair ("I will never drink again if you just bring him back")
4. Depression, reflection loneliness
Just when your friends may think you should be getting on with your life, a long period of sad reflection will likely overtake you. This is a normal stage of grief, so do not be "talked out of it" by well-meaning outsiders. Encouragement from others is not helpful to you during this stage of grieving. During this time, you finally realize the true magnitude of your loss, and it depresses you. You may isolate yourself on purpose, reflect on things you did with your lost one, and focus on memories of the past. You may sense feelings of emptiness or despair.
5. The upward turn
As you start to adjust to life without your dear one, your life becomes a little calmer and more organized. Your physical symptoms lessen, and your "depression" begins to lift slightly.
6. Reconstruction and working through
As you become more functional, your mind starts working again, and you will find yourself seeking realistic solutions to problems posed by life without your loved one. You will start to work on practical and financial problems and reconstructing yourself and your life without him or her.
7. Acceptance and hope
During this, the last of the seven stages in this grief model, you learn to accept and deal with the reality of your situation. Acceptance does not necessarily mean instant happiness. Given the pain and turmoil you have experienced, you can never return to the carefree, untroubled YOU that existed before this tragedy. But you will find a way forward. You will start to look forward and actually plan things for the future. Eventually, you will be able to think about your lost loved one without pain; sadness, yes, but the wrenching pain will be gone. You will once again anticipate some good times to come, and yes, even find joy again in the experience of living

www.recover-from-grief.com/index.html

The Asahi newspaper article comment by Dr. Takeuchi Masato about a water contamination in Tokyo area.

The Asahi newspaper article comment by Dr. Takeuchi Masato about a water contamination in Tokyo area

"Even we have a lot of scientific data it is not good enough to relief of ourselves. We have no previous experience to be in this situation, so, just information based on medicine and science cannot make us feel safe and stable. The best what medical staff should do is affording an opportunity for their patients to express their worry and hope. Just let them be naturally as they are."

Bereavement, Sorrow, Grief

Based on the book by Elisabeth Kuber-Ross and David Kessler

“On Grief and Grieving”

Also known as the 'grief cycle', it is important to bear in mind that Kübler-Ross (1) did not intend this to be a rigid series of sequential or uniformly timed steps. It's not a process as such it's a model or a framework. People do not always experience all of the five 'grief cycle' stages. Some stages might be revisited. Some stages might not be experienced at all. 

Denial

Denial is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. It's a defense mechanism and perfectly natural. Some people can become locked in this stage when dealing with a traumatic change that can be ignored. Death of course is not particularly easy to avoid or evade indefinitely. (1)

When person is in denial, he (she) may respond at first by being paralyzed with shock or blanketed with numbness. It is still not denial of the actual death, even though someone may be saying, “I can not believe”. They are saying this first of all because it is too much for their psyche. Denial helps to unconsciously manage their feelings. This first stage of grieving helps them to cope and make survival possibility. These felling are important; they are psyche’s protective mechanism. To fully believe at this stage would be too much. The denial often comes in the form of questioning reality: Is it true? Did it really happen? As denial fades, it is slowly replaced with the reality of the loss. (2)

 

Anger

Anger can manifest in different ways. People dealing with emotional upset can be angry with themselves, and/or with others, especially those close to them. Knowing this helps keep detached and non-judgmental when experiencing the anger of someone who is very upset. (1)

This stage present itself in many ways: anger at who person lost, anger at person did not take better care of whom has lost or anger at the doctor or nurse who could be able to be more attentive or kind, may be angry that bad things could happen to someone who meant so much to the person.

Anger does not to be logical and valid. Person may know something logically, but emotionally, all he (she) knows is that it was not supposed to happen or at least with him (her) and now.

Most of all, the person in lost may be angry at this unexpected, undeserved and unwanted situation.

Anger is a necessary stage of the healing process. Be willing to feel your anger, even though it may seem endless. More the person truly feels anger, the more it will begin to dissipate and he (she) more will be heals.

There are many other emotions, but anger is the emotion we and most used to managing. We often choose it to avoid the feelings underneath until we are ready to face them. It is a useful emotion until you have moved past the first waves of it.

Anger has o limits. It can expend not only to your friends, the doctors, your family, yourself, to God, and your loved one who died. 

Anger is pain, grieving person’s pain, your pain. It is natural to feel deserted and abandoned, but we are live in society that fears anger. Some people may feel grieving person’s anger is harsh or too much. But grieving person’s job is firs of all to allowing themselves to be angry even scream if they needs. Anger can be an anchor, giving temporary structure to the nothingness of loss. At first grief feels like being lost at sea; no connection to anything. Than person gets angry at someone and suddenly has a structure – he (she) anger toward them. The anger becomes a bridge over the open sea, a connection from the grieving person and others. Even anger is the most immediate emotion, but as the person deals with it, then will find other feelings hidden. Anger means the grieving person are progressing and should not be criticized by anyone. (2)

There are some situation when anger are getting endless, then person should think how to deal with “permanent anger”.

 

Bargaining

Traditionally the bargaining stage for people facing death can involve attempting to bargain with whatever God the person believes in. People facing less serious trauma can bargain or seek to negotiate a compromise. For example "Can we still be friends?.." when facing a break-up. Bargaining rarely provides a sustainable solution, especially if it's a matter of life or death. (1)

“I will never hate my morning sickness again if my pregnancy, my baby will just back to me”. Guilt is often bargaining’s companion. The “if only” cause the person to find fault with him(her)self and what he (she) could has done differently.  

Bargaining can help grieving person’s mind move from one stage of loss to another; fills the gaps that strong emotions generally dominate, with often keep suffering at a distance.

After a death, bargaining often moves from the past to the future. We may bargain that we will see our loved ones again in the haven. (2)

Depression

Also referred to as a preparatory grieving. In a way it's the dress rehearsal or the practice run for the 'aftermath' although this stage means different things depending on whom it involves. It's a sort of acceptance with emotional attachment. It's natural to feel sadness and regret, fear, uncertainty, etc. It shows that the person has at least begun to accept the reality. (1)

This depression is not a sign of mental illness; it is the appropriate response to a great loss. In grief, depression is a way for nature to keep the person protected by shutting down the nervous system so that he (she) can adapt to something they feel they cannot handle. 

When depression follows loss, there are specific sorrows that can be identified. In more serious and long-lasting depression, it is difficult to receive support. I this case antidepressant medications may be useful; to help lift someone out of what seems to be a bottomless depression. Some people feel that medications simply put a floor in for them to deal with their depression.

As difficult as it is to endure, depression has elements that can be helpful in grief. It slows us down and allows us to take real stock of the loss. It make us rebuild ourselves from the ground up. It clears the deck for growth.

A mourner should be allowed to experience his sorrow, and he will be grateful for those who can sit with him without telling him not to be sad. No matter what our surroundings may hold, we feel alone. This is what hitting the bottom feels like. (2)    

Acceptance

Again this stage definitely varies according to the person's situation, although broadly it is an indication that there is some emotional detachment and objectivity. People dying can enter this stage a long time before the people they leave behind, who must necessarily pass through their own individual stages of dealing with the grief. (1)

Acceptance is not of being all right or okay with what has happened. Most people do not ever feel okay or all right about the loss of a loved one. This stage is about accepting the reality that the person’s loved one is physically gone and recognizing that new reality is the permanent reality. This is the time to learn to live with it.

Healing looks like remembering, recollecting, and reorganizing. As we heal, we learn who we are and who our loved one was in life. In a strange way, as we move though grief, healing bring us closer to the person we loved.    

Finding acceptance may be just having more good days than bad. As the grieving person is begun to live again and enjoy the life, he (she) often feel that is betraying their loved one. The person who lost can never replace what has been lost, but can make a new connection, new meaningful relationships. (2)

1. http://www.businessballs.com/elisabeth_kubler_ross_five_stages_of_grief.htm

2. On grief and grieving // Elisabeth Kübler-Ross and David Kessler, Scribner, 2005, 235 p.

Words of sympathy

Most of the trite sayings below seem to imply that the mourner should get past it or somehow avoid the pain of loss. This is not realistic or healthy, and certainly not helpful.

• I know how you feel.
• It's just God's plan.
• Just look at all the things you have to be thankful for.
• He's in a better place now.
• God needed another angel.
• She's not suffering anymore.
• He's at peace now.
• It was for the best.
• Life is for the living.
• You've still got your_____(other kids, spouse).
• Don't cry... crying only upsets you.
• All things must pass.
• She led a full life.
• God will never give you more than you can handle.
   

And it's time to move on:

• Get a hold of yourself.
• It's time to get on with your life.
• Pull yourself up by your bootstraps.
• Keep a stiff upper lip.
• You are so strong, you can handle this.
• You must be strong for the kids.
• You'll get over it in time.
• You'll be okay in a year.
• This will soon end.
• You'll be fine.
• Time heals all wounds.
• Put this behind you and get on with your life.
• Isn't it time you got back to normal?
   

And the prize-winners for mean and thoughtless things to say:

• "You're young, you can always have more children".
• "There are more fish in the sea" (lost a spouse).
• "Well, you need to be the man of the house now" (to 12 year old boy).
  
  [Yes, people really do say things like that].
•  
recover-from-grief.com

Couples May Change After Miscarriage

Pregnancy Loss Can Strengthen Relationship, or Tear It Apart

 

By Jeanie Lerche Davis
WebMD Health News

 

Oct. 8, 2003 -- Pregnancy loss can greatly affect a couple's relationship. It can either tear them apart, or bring them closer together. A new study shows the outcome all depends on how they handle it. "This is an outcome of pregnancy loss that has not yet been named, but it can have a serious effect on a couple's relationship," says researcher Kristin M. Swanson, RN, PhD, professor of family and child nursing at the University of Washington School of Nursing in Seattle.

Her study appears in this month's Psychosomatic Medicine.

Since 1982, Swanson has been studying this issue -- how women and men can get through miscarriage.

Research of first-time fathers shows the baby does not become real -- or at least a man does not consider himself a father -- until the first time he holds the baby in his arms, Swanson tells WebMD.

Thus, when there is pregnancy loss, he and she will have very different experiences, she explains. "His physical reminder of the pregnancy is seeing her. But she has experienced the baby biologically everyday. That baby has been inside her. Therefore, their reactions are different when the fetus is lost."

Men, Women, and Pregnancy Loss

Swanson bases her current insights on surveys completed by 185 women after their pregnancy loss -- one week, six weeks, one month, and one year later.

Women answered two basic, open-ended questions:

• How has your miscarriage affected your relationship with your partner?
• How has your miscarriage affected your sexual relationship?

One year after the loss, 28% were pregnant, 29% were trying to get pregnant, and 34% were avoiding pregnancy.

How women perceived changes in their relationships varied greatly, Swanson reports. One year after pregnancy loss:

• 23% said their interpersonal relationship with their husband was closer, but only 6% said their sexual relationship was closer.
• 44% felt the interpersonal relationship had returned to premiscarriage status; sexually, 55% thought their sexual bond had also returned.
• 32% felt more distant from their husbands interpersonally; 39% felt more distant sexually.

Those who felt closer or "back to normal" were more likely to be pregnant again. They had more emotional strength; they also said their partners were able to share feelings about the loss.

When relationships had grown more distant, partners had done less to show they cared. Women in distant relationships reported more negative feelings --depression, anger, confusion, and tension.

"Women who were sexually more distant avoided intercourse, experienced less desire, and saw sex as a functional necessity, fearful reminder of loss, and source of tension," writes Swanson.

Women in distant relationships may have felt abandoned, she says. When men shared their feelings, women felt it helped them pull through a difficult time. Words of Wisdom

In counseling couples, Swanson finds that "naming what they have lost" helps them get to the heart of issues surrounding pregnancy loss.

Women will say, "I lost my baby."

But for men, the answer varies: For some, it's 'I lost a baby;' for others, it's 'a future baby.' "Or, if you give them more time, they will say, 'I lost her, she's just not herself, I want her to get back to how she was,'" Swanson tells WebMD.

The bottom-line message: If men don't respond, the relationship will be at risk. "Show her you care, be extra attentive," says Swanson. "You can bring your relationship closer if you can keep communication open." 

Doctors, Midwives, Nurses Can Help

Whoever is involved at the hospital -- doctor, nurse, midwives -- can help grieving parents get through this trauma of pregnancy loss, says Nadine Kaslow, PhD, a professor of psychology at Emory University School of Medicine in Atlanta.

"Doctors can talk to couples, prepare them that this is a difficult time emotionally, tell them it's really important that they talk about what miscarriage means to them," Kaslow tells WebMD. "Talk to them realistically about what has happened. Then make an appointment to see them back in a month, together." Follow-up is very important, she says.

A nurse or midwife can also offer guidance and encourage couples to talk about their feelings about the pregnancy loss. "Give them ideas of how to cope effectively, that what a miscarriage means is different things to different people," she advises.

Sometimes, it helps couples to have a ceremony or ritual to mark the loss -- just as you would a newborn that has died, Kaslow says. "You do grow attached to the fetus."

Sometimes, couples go to their church. Others donate nursery items and toys to charity. Others may buy a teddy bear or another symbol to mark that presence in their lives, she says.

Sure, women can find support through groups and other women who have been through pregnancy loss. But the reaction of her partner is the most critical to the relationship. Just remember, he may grieve the loss in a different way. Try to get him to open up, to talk about it, Kaslow says. 

For guidance on providing help following disaster.

Developed jointly with the National Child Traumatic Stress Network, PFA is an evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism. It is for use by first responders, incident command systems, primary and emergency health care providers, school crisis response teams, faith-based organizations, disaster relief organizations.

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Children in Natural Disasters

Children in Natural Disasters:
An Experience of the 1988 Earthquake in Armenia
Anait Azarian, Ph.D., E.T.S.
Vitali Skriptchenko-Gregorian, Ph.D.

Natural disasters are an inevitable part of human life. One primary way to manage the aftermath of such destruction is to learn from it. The 1988 earthquake in Armenia is unique in some ways. This disaster produced an unprecedented worldwide response to its traumatic consequences. In all, 111 countries, 7 international organizations, and 53 national chapters of the Red Cross provided help to Armenia. More than 3,600 foreign specialists worked in the disaster area, among them 1,500 rescuers and firefighters from 15 countries. There were 230 physicians, surgeons, psychiatrists, and psychologists from 12 countries (Grigorova et al., 1990). Krimgold (1989) reported about 22 rescue teams from 21 countries involved in the search and rescue of victims. The traumatic effects resulting from the earthquake have been presented in numerous publications. The goal of this article is to review and outline some of the major findings from the Armenian earthquake with a primary focus on the psychological impact in young survivors.

The Traumatic Event

On December 7, 1988, a devastating earthquake suddenly struck over 40% of the territory of Armenia, former USSR. At that time, this part of Armenia had a population of eleven million, among them were 400,000 children (Grigorova et al., 1990). The first tremor of 6.9 on the Richter scale was followed, after 4 minutes, by the second one with a magnitude of

5.8 (Comfort, 1990; Verluise, 1995). Four principal towns of the affected territory and 58 villages were severely damaged (Pesola, et al., 1989; Hadjian, 1993). Nearly 70% of buildings were destroyed (Abrams, 1989) and a maximum intensity of possible destruction, 10 points on the MKS scale, was observed in the town of Spitak, near the quake epicenter (Cisternas et al., 1989). Initially, Soviet officials estimated 55,000 fatalities (Krimgold, 1989), but then reported 24,986 deaths (Grigorova et al., 1990). More plausible estimation showed a figure of 100,000 fatalities (Verluise, 1995). More than half a million people were left homeless (Noji et al., 1990; Kalayjian, 1995).

The children suffered more than adults because they were in school at the time of the quake. According to the Armenian National Mental Health Research Center (Miller et al., 1993) almost 2/3 of total deaths were children and adolescents. School and kindergarten buildings were inadequately designed and could not withstand such a devastating force (Allan, 1989; Noji, 1989; Pomonis, 1990; Hadjian, 1993). For example, there was a school with 302 children, of whom 285 (94%) died (Noji et al., 1990). In all, 380 children's and youth institutions were seriously damaged or totally destroyed (Engholm, 1991; Grigorian, 1992). In Spitak and Leninakan, out of 131 schools and kindergartens, 105 were destroyed (Goenjian, 1993). After the quake, 32,000 children were temporarily evacuated into different parts of the Soviet Union and 6,000 were lost in the post-disaster chaos; however, many were later found and brought back to their families (Grigorova et al., 1990).

The quake caused an extremely stressful situation with mass death and widespread, abrupt collapse of community life. The traumatic impact of the quake was so profound that even trained foreign rescuers experienced distressing feelings and sleep disturbances nine months after returning home (Lundin & Bodegard, 1993). Also, Yacoubian & Hacker (1989) observed that American adolescents with Armenian background, despite their considerable remoteness from the site of total catastrophe, showed posttraumatic symptoms such as survivor's guilt, psychic numbing, and rage when they had seen television reports from Armenia.

Traumatic Stressors

Goenjian with colleagues (1994) noted that the high levels of severe traumatic stress after the quake in Armenia may have been the product of the multiplicity of "disaster-related traumatic experiences" rather than the magnitude of the quake, per se. It was also pointed out (Azarian & Skriptchenko-Gregorian, 1992, 1997; Azarian et al., 1994) that many of the children's traumatic experiences with the Armenia quake was the result of the cumulative impact of multiple disaster stressors and its subsequent secondary effects. Children simultaneously experienced a profound influence of multiple quake stressors including: a) psychophysiological stressors (e.g., strange and terrifying growling noise that came from underground, screams of agony from all around, sights of buildings collapsing, the odor of burning fires and dust, and the pain due to injuries); b) information stressors that continued the terror ("What is going on?," "How can I escape?", "Where are my parents?"). The panic and confusion of adults who were present had left most of the children's important questions unanswered; c) emotional stressors (e.g., threat of death and damage, the fear for one's self and for parents, frustration due to witnessing helpless adults); d) social stressors (i.e., the sudden realization that one has no school, and/or home, and/or friends).

As a result, one year after the disaster, 89.9% of young survivors still experienced a strong fear of vibrations, 81.1% - the fear of a new quake, 58.7% - a fear of loud noises, 49.5% - a fear of buildings, and 26.5% exhibited school avoidance (Azarian & Skriptchenko-Gregorian, 1997). Goenjian (1993) found that two years after the quake, Armenian children continued exhibiting a high rate of recurrent, intrusive quake-related recollections of: smell 40%; sounds 62%; visual images 72%; and persistent thoughts 78%. Literally, the body remembers disaster strikes.

Very often, as with falling dominoes, ripple effects occurred psychologically when the secondary effects of the quake arose. Being in the school many children, at first, experienced a psychophysiological impact of the quake (e.g., pain, terrible vibrations, frightening noise). Likewise, this impact became the cause for more emotional effects. For instance, the children became afraid of the school buildings themselves (i.e., an emotional domino). The fear continued to increase and created behavioral changes such as avoidance and refusal to attend school (i.e., a behavioral domino). Furthermore, their behavioral disturbances adversely influenced their relations with teachers, classmates, and parents, creating different kinds of antisocial actions (i.e., a social domino). These dominoes collected in their impact and burdened the children's well-being with diverse psychosomatic symptoms such as headaches, loss of appetite, and sleep disturbances (i.e., psychosomatic domino) and caused difficulties with concentration and memory with impairment in school performance exhibited (i.e., cognitive domino).

Najarian et al., (1996) explored a secondary effect of the quake in subsequent pathological symptomatology in Armenian children. Soviet authorities believed that temporary relocation of Armenian children from the disaster zone would be beneficial for their mental health. Najarian and his colleagues' study did not confirm this hypothesis that post-disaster evacuation of young survivors would reduce their symptoms. Children relocated after the quake had the same high rates of PTSD, depression, and behavioral difficulties as children who remained in the destroyed city. The authors reported that two and half years after the quake, both groups demonstrated similar high rates on the re-experiencing category (100% and 96%) and arousal category (92% and 96%).

The trauma field observers (Libaridian, 1989; Azarian, 1990a; Giel, 1991; Grigorian, 1992; Kalayjian, 1995; Verluise, 1995) noted that to better understand the particular severity of the disaster's mental morbidity, it is important to consider the impact of quake stressors against the specific pre-disaster and post-disaster situations in Armenia. The inability of the local and state authorities to organize the disaster response deepened the level of stress for many quake survivors over subsequent "weeks and months" (Comfort, 1990). Certain historical and socio-political factors included: a) persistent pain and suffering due to the Ottoman Turkish Genocide of Armenians in 1915; b) deep frustration after Gorbachev's rejection of Armenia and Nagorno Karabagh reunion; c) anger because of atrocities against Armenians in Azerbaijan; d) massive exodus of Armenian refugees from Azerbaijan to Armenia; e) the collapse of the Soviet Union; f) war between Armenia and Azerbaijan and; g) total transportation and energy blockade of Armenia. These issues exacerbated and stigmatized the traumatic impact of the quake for vulnerable adult victims and indirectly affected their children.

The prolongation of post-quake stress was also associated with some cultural factors in Soviet Armenia such as: a) emphasis on silent heroic suffering; b) denial of pain and weakness; c) reluctance to tell children the truth about family losses and inability to provide appropriate grieving guidance. Typically, the grieving process was disrupted and/or incomplete and children were oftentimes repeatedly traumatized by their inconsolable parents, neighbors, or teachers (Giel, 1991; Goenjian, 1993; Greening, 1990; Azarian & Skriptchenko-Gregorian, 1997).

Posttraumatic Reactions

The complex interaction between physiological, psychological, social, and cultural factors produced and perpetuated the long-lasting posttraumatic reactions in Armenian children. Thus, Grigorian (1992), who visited Armenia within a month after the quake, observed in the children considerable withdrawal, frequent nightmares, "silence" about parents who had died in the quake, and survivor's guilt. Eighty six percent of the children assessed six to eight weeks after the quake, displayed at least 4 out of 10 of the following symptoms: separation anxiety that intensified during the evening, school avoidance, refusal to be alone, conduct disorders, sleep disturbances, nightmares, frequent awakenings, regressive behaviors (i.e., enuresis), hyperactivity, concentration impairment, and somatic complaints (Kalayjian, 1995). The observations that were made approximately one year after the disaster (Miller et al., 1993) showed strong persistence of affective, cognitive, and behavioral posttraumatic symptoms in the quake children. They manifested numerous quake-related fears and guilt, social withdrawal and changed attitudes about people, life, and the future (e.g., distrust, pessimism, hopelessness) as well as frequent psychosomatic complaints, high irritability, and aggression.

The field reports made four months after the quake by psychologists and psychiatrists from Medicins du Monde and Medicins Sans Frontieres, demonstrated that the most frequent problems in children (ages 3-18) were: behavioral - 57.1%; fears and phobias - 48.3%; sleep disturbances - 34.1%, anxiety and depression - 22.1% (Moro, 1994). An assessment of a group of 839 young survivors (ages 3-17), examined one year after the disaster, revealed a very high frequency of phobic, somatic, emotional, and behavioral symptoms in traumatized children (Azarian & Skriptchenko-Gregorian, 1997). For example, 77.8% of them experienced anxiety; 66.0% were afraid to be alone; 65.7% feared death; 57.1% had frequent nightmares; 67.8% lost energy and 52.3% had poor appetite. Aggressiveness was found in 45.3% of subjects, sadness in 41.6%, guilt feelings in 31.0%, and suicidal thoughts in 15.5%. Most frequent among somatic complaints were headaches 46.8%, enuresis 35.7%, and nausea 31.8%.

One and a half years after the quake, 231 children (ages 8-16) were assessed for frequency and severity of their posttraumatic reactions (Pynoos et al., 1993). Their reactions had been found to be pervasive, severe, chronic, and correlated with a) the proximity to the quake epicenter; b) the degree of exposure to the quake stressors; and c) the extent of loss of family members. The authors concluded that the range, severity and persistence of posttraumatic reactions in the Armenian children far exceeded those in children of many other disasters (e.g., the 1980 earthquake in Italy and the 1989 hurricane Hugo in the USA). The next assessment (N=49; age 11-13) made two and half years after the quake, demonstrated that Armenian children who survived the quake and did not receive any psychological treatment were still experiencing recurrent frightening dreams, a sense of guilt, sadness, and hopelessness (Najarian et al., 1996). They continued to exhibit aggressive behavior, withdrawal, a decrease in academic performance, anxiety reactions to quake reminders, and numerous somatic complaints.

Posttraumatic Stress Disorder

Field diagnostic assessments also showed a persistence of high rates of PTSD in traumatized Armenian children. Thus, it was reported that from 179 subjects assessed within a few months after the quake, 72% received a diagnosis of PTSD, 8% conversion disorder, and 7% depression (Grigorian, 1992). Kalayjian (1995) gives numbers of PTSD frequency in children at that time as 86% for children and 83% for adolescents. Goenjian (1993) writes that of 65 evaluated children (3rd month after the quake), 85.0% met criteria for PTSD and of 98 children (age 5-16) evaluated one month later in the same city of Leninakan, 61.0% met criteria for a PTSD diagnosis. According to Goenjian's (1993) information, one year after the quake in a randomly selected group of pupils in a Leninakan school (age 15-16), 56.0% met criteria for PTSD. One and half years after the disaster, 111 Armenian children (age 8-16) were assessed by DSM-III-R criteria for PTSD, and 78 (70.3%) were given this diagnosis (Pynoos et al., 1993).

Najarian et al., (1996) found in Armenian children a greater severity of re-experiencing symptoms than of symptoms of avoidance and hyperarousal. Pynoos et al. (1993) noted that "fear of quake recurrence after reminders" was the best predictor of PTSD in Armenian children and avoidance of reminders and related loss of interest in significant activities were important indicators across all different categories of severity of children's posttraumatic response. Moreover, guilt (Pynoos et al., 1993; Azarian et al., 1994; Goenjian et al., 1995; Azarian & Skriptchenko-Gregorian, 1997) and trauma re-experiencing through disaster play and drawing (Goenjian, 1993; Kalayjian, 1995; Skriptchenko-Gregorian et al., 1996; Azarian et al., 1996b) were found as important diagnostic symptoms among young survivors of the quake. Also observed was repetitive playing of monotonous "quake" and "cemetery" plays, which lacked joy, pleasure, and creativity, and spontaneously produced similar, gloomy, black-white-red drawings of the devastating disaster. It is probable that children manifested fears, sadness, and anger related to the quake experience and compulsively, but ineffectively, tried to process the trauma.

Goenjian et al. (1995) presented important findings that indicated the existence of a high cooccurrence of PTSD and depressive disorder in young survivors of the Armenian quake. For example, in a group of 63 children examined one and a half years after the quake, 95% had PTSD, 76% depressive disorder, and 71% had both PTSD and depression. The authors consider the degree of direct exposure to the traumatic quake experience as a major contributor to the severity of PTSD, separation anxiety, and depression. Symptoms of these disorders can interact to aggravate and prolong each other. Thus, severe PTSD complicated Armenian children's grieving and as a result caused secondary depression and an increase of depressive symptoms over time. Separation anxiety exacerbated some PTSD symptoms in the children, particularly arousal symptoms (Pynoos, Steinberg & Goenjian, 1996).

Age and Gender Differences

During the quake in Armenia, even very young children were traumatized and exhibited posttraumatic symptoms. Moro (1994) observed that toddlers under three years of age mostly had functional disturbances for which no organic cause was identified such as sleep problems, anorexia, vomiting, and dermatological lesions. Infants frequently exhibited behavioral changes and aggravated relations with mothers. Posttraumatic symptoms of avoidance and increased arousal were more frequent than trauma re-experiencing symptoms found in elder school-aged children and adolescents. Thus, in a group of 21 infants examined six months after the quake (age up to 2 years at the time of the quake), only 23.8% demonstrated trauma re-experiencing through behavioral re-enactments or spot verbal recollections of the event, while 80.9% exhibited persistent avoidance behaviors and/or physical symptoms of increased arousal and exaggerated startle reactions (Azarian et al, 1996a). Such prevalence of young children's behavioral psychopathology was likely attributed to stress conditioning. For example, a novel, intense and unexpected stimulus (i.e., during the quake, the mother grabs the child from his bed), applied against the external background of profound stress (i.e., the mother presses the child to her chest, runs from the collapsing building, and falls with the child on the stairs) and specific internal state of the child (i.e., the child was sleeping in his bed), evoked very persistent and aversive avoidant behavior in response to any attempt by the child's mother to take him into her hands. The dominance of the posttraumatic behavioral psychopathology in infants of the quake can also be attributed to their particular developmental stage; "fight-escape-freeze" type defense mechanisms are primarily available. Young children's ability to re-experience and re-process trauma through remembering and verbalizing comes later with their maturation. Thus, the study of toddler-survivors of the quake (N=90; age up to 4 years) found that six months after the disaster 53.3% of them had verbal memory of what they personally experienced during the quake (Azarian et al., 1996b; 1997) For these children, the age threshold of recalling the traumatic experience was age 2 years at the disaster time. Behavioral forms of disaster memory still prevailed: 90.0% of them showed avoidant behaviors, increased arousal and unusual startle reactions, much less played or drew quake trauma (34.4%) or had dreams of it (18.9%). The later increase in ratio of explicit/implicit forms of young children's traumatic memory leads to an assumption that significantly traumatized infants may manifest the full range of PTSD symptoms complying with all needed criteria of the disorder, but not at the time of trauma. Consequently, PTSD in traumatized infants may often go unrecognized and misdiagnosed. Although specially designed studies of gender differences in posttraumatic symptomatology in children of the Armenian quake were not conducted, some data and observations are worthy to mention.

It was found that girls tended to score slightly, but significantly higher than boys within a sample selected for assessment of postquake symptoms of PTSD (Pynoos et al., 1993; Goenjian et al., 1995). The girls reported more fears, "bad" dreams, and distress while thinking about the quake experience. The authors are not sure whether these scores reflected differences in fear-related symptoms between girls and boys or a more willingness of girls to report their concerns.

Conversely, there were more boys than girls among patients of psychotherapy centers, who were brought in by their parents due to postquake disturbances. There were reports of about 55.5% (Moro, 1994) and 55.0% (Azarian et al., 1994) of males identified as patients. This difference may reflect more concern and readiness to seek professional help among Armenian parents due to behavioral problems and aggression which prevailed in boys than fears and bad dreams common with young female survivors. Cultural factors in Armenia (i.e., no previous experience of communal or private psychotherapy services) might have contributed to gender differences in the reporting of posttraumatic symptoms as well as, perhaps, the actual reports of these symptoms by survivors.

Quake Trauma Treatment

Armenian children experienced substantial, unprecedented trauma due to the quake. It was estimated that there was a need for 600 school psychologists in Armenia to diagnose and treat young victims of the disaster (Grigorian, 1992). At the same time there were only 39.2 physicians for every 10,000 people in Armenia, and 98% of the survivors did not have a mental health provider (Kalayjian, 1995). Prior to the quake, Armenian psychiatrists worked primarily with severe mental disorders in hospitals. Outpatient clinics, psychotherapists and social workers did not exist and psychologists usually were involved in research and teaching.

In a rapid response to the large-scale quake traumatization, some new forms of treatment were established in Armenia. For example, the Psychiatric Outreach Program was organized by Armenian diaspora in the USA (Goenjian, 1993). This program involved obtaining mental health professionals from the USA and Europe to provide posttraumatic assessment and treatment of victims and training for local psychologists and teachers to continue the mental health care in two children's psychotherapy clinics (which opened under the program auspices in Spitak and Leninakan). The Psychological Care Center for children was opened in the quake zone by the international organization based in France (Medicins Sans Frontieres) (Moro, 1994). The center adapted to the existing situation: for two years it was supervised by psychologists from France who trained a team consisting of local psychologists and educators, then the center was placed under the direction of the Armenian Ministry of Education. The Children's Psychotherapy Center in Kirovakan was founded by local Armenian psychologists with the financial and training assistance of the Swiss organization "SOS Armenie" (Azarian, 1990a).

The centers reported good attendance. For example, there were 170 consultations during the month of June, 1990 and 400 group sessions in November, 1991 in the MSF center (Moro, 1994). During the period from April, 1989 to December, 1991, almost 2,500 patients attended the Children's Psychotherapy Center in Kirovakan (Azarian & Skriptchenko, 1992). Due to constant caseload overburdening, group therapy was chosen as the primary mode of treatment for children, although individual and family sessions as well as parental self-help group sessions were also provided. The successful treatment of young patients' posttraumatic symptoms was achieved by using various therapeutic modalities including: a) play therapy and drawings; b) somatic focusing; c) systematic desensitization; d) trauma exploring and reappraising (Goenjian, 1993); e) family behavioral modification; f) art therapy for sad and guilty feelings; g) work with children's traumatic dreams (Moro, 1994); h) logotherapy; i) biofeedback; j) stress inoculation training (Kalayjian, 1995) and; k) eye movement desensitization and reprocessing (Gergerian, 1995). The trauma of disaster occurs along all sensory channels, and thus, should be treated likewise, in multi-modal fashion. The healing of isolated, frequently repressed traumatic experiences in survivors is best accomplished through the use of interventions consistent with the sensory channels (i.e., auditory, visual, tactile, etc.) that were predominantly exposed to the traumatic event. Use of these principal sensory modes was achieved at the Children's Psychotherapy Center through visits of young patients to a number of psychotherapeutic rooms with different audio and visual characteristics and mechanisms for healing impact (Azarian, 1990b; Azarian & Skriptchenko-Gregorian, 1992, 1997). Multifaceted treatment plans were developed in the Center for various groups of patients. For example, fear of the quake was the most frequent problem that the Center therapists had manage. In order to reduce this persistent symptom, the treatment team used special imitating physical games, the synthesis of relaxation and aromatherapy, video portrait and makeup activities, and drawing and animated cartoons to facilitate systematic desensitization. This type of intervention (i.e., exposure-based) utilized all of the children's sensory modalities (balance, touch, smell, sight, hearing).

Summary

The 1988 earthquake struck in the wrong place and at the wrong time. At that moment, Armenia was completely unprepared and its population was in its most vulnerable state. The quake impact in Armenian children warns that single disasters can became a total "psychiatric calamity" (Pynoos et al., 1993) for the whole young generation of an affected nation - from infants to adolescents. Massive, profound, and long-lasting traumatization of children during a natural catastrophe demands an immediate response. Related factors to evaluate include: the numbers of traumatized children, their cultural background, geographic location and political situation, secondary adversities and comorbidity factors. Multifaceted approaches to treatment should address devastating psychophysiological impacts of all multiple stressors of the particular disaster.

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©1998 by The American Academy of Experts in Traumatic Stress, Inc.