| 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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