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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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