As the parents of the 19 children shot dead Tuesday in Uvalde, TX, by an 18-year-old gunman grapple with unspeakable grief and funeral preparations, the survivors and their families are dealing with their own angst, and likely much more.
While the parents understandably feel lucky that their children made it out, what about the long-term effect on their children of witnessing that carnage, of seeing classmates, friends, teachers die violently as they stood by, helpless and fearful?
The outcome over the next few days, months, and years depends on many things, but how parents address the trauma, both immediately and long-term, can make a huge difference, experts say.
Best case long-term scenario? Survivors can have what experts call post-traumatic growth – reaching out to give back to society, to make the world a better place, changing who they are and their view of the world.
A prime example of post-traumatic growth: A month after a 19-year-old gunman killed 17 people at Marjory Stoneman Douglas High School in Parkland, FL, on Valentine's Day 2018, an army of survivors from that day's bloodbath headed to Washington, DC, for the now-famous March for Our Lives. The student-led demonstration, with hundreds of thousands of supporters marching, called for gun control legislation and an end to gun violence. It remains a vibrant nonprofit organization still advocating for universal background checks and more support of mental health services.
No Sign of Future Violence
While most children and teens who witness school violence won't become high-profile activists as survivors of Parkland and the numerous other school shootings have, neither will they become the next active shooter, mental health experts say. They can't point to a study that follows the gun violence victims that shows who does OK and who doesn't, but they know immediate support and therapy can go a long way toward recovery.
"I can't tell you how any particular child will do," says Robin Gurwitch, PhD, a psychologist and professor at Duke University in Durham, NC. "I can tell you the majority of kids will be OK."
But that doesn't mean a surviving child won’t have behavior and other issues, she says. Research does suggest the next few days, weeks, or months will be rough.
What parents and other caretakers do in the days after the violence will help predict the long-term outcome. Gurwitch and other experts say it's important to first focus on what they call "psychological first aid," then phase in therapy such as trauma-focused cognitive behavioral therapy if and when it's needed.
First, ‘Psychological First Aid’
"Psychological first aid is designed to minimize the impact down the road," Gurwitch says. "Validate that they are feeling scared or worried.”
Some may be angry, another understandable emotion. In the first few days after children witness violence – or even just hear about it – parents should expect clinginess, sleep problems, behavior meltdowns, and crankiness, she says.
"Those kinds of changes are likely to last a few weeks,” she says.
If day-to-day functioning is very difficult, "don't wait for those to pass," Gurwitch says. "Reach out for help. Resources will be available. Check with your pediatrician or family physician."
At home, parents can address specific problems related to the experience, she says. If it's sleep, parents and kids can work together to figure out how to ease sleep, such as listening to their favorite music before bedtime.
While parents may be inclined to baby the kids after the violence, Gurwitch says it's important to maintain routines. So it's not cruel to insist they do their chores.
Things won't be the same.
"Anytime we go through a particular traumatic event, we are changed," Gurwitch says. "The question is, what do we do about it. How do we incorporate that change into who we are and have become."
Also important is figuring out how to make meaning out of what happened.
"I am so impressed by the families at Sandy Hook,” she says, referring to the Connecticut elementary school where a gunman killed 26 in 2012.
They set up foundations and did other advocacy work.
"These types of events are life-changing events," agrees David Schonfeld, MD, a pediatrician and director of the National Center for School Crisis and Bereavement at Children's Hospital Los Angeles. "They will change who children are as people, but it doesn't mean they are damaged for life. They will remember it as long as they live, and it will also change who they are as a person."
While people tend to stress the potential negative effects – and there certainly are some – "some individuals actually emerge from these events with a renewed sense of purpose."
He tells parents: "Yes, your child has changed, and you can't go back. But it doesn't mean they are destined to never be able to cope [with trauma]."
The effects of gun violence on children can be serious and dramatic, research shows.
- Exposure to neighborhood gun violence is linked with an increase in children's mental health issues, researchers have found. Children living within two or three blocks of gun violence had nearly twice the risk of going to the emergency department with a mental health complaint in the 14 days after the shooting.
- Exposure to gun violence should be classified – along with maltreatment, household dysfunction, and other issues known to impact children negatively – as an adverse childhood experience, other experts say.
- Direct gun violence exposure, witnessing it, and hearing gunshots all are associated with children being victimized in other ways, another study found. And that “polyvictimization,” as it is called, was strongly associated with having posttraumatic symptoms.
Adverse childhood events, as these sorts of experiences are known, can have long-lasting effects on physical and mental health, as well as even the economic future of a person, says Hansa Bhargava, MD, a pediatrician and chief medical officer of Medscape, WebMD’s sister site for medical professionals.
“Kids who have suffered through violent events can have brain development affected as well as their immune systems,” she says. “They are more likely to have chronic disease, substance use disorder, sexually transmitted diseases, teen pregnancy, and lifelong depression. A high risk of PTSD is likely for them and their families.”
The Impact of Family Support
The gun violence and deaths are likely to remind children of other losses they have had, Schonfeld says, and that can make it harder to cope.
If the trauma from the Tuesday shootings is "layered" on top of trauma from COVID-19 deaths or other trauma, such as domestic violence, those children may have a harder time, says Allan Chrisman, MD, a retired professor of psychiatry and behavioral sciences at Duke University Health System. But protections like the family response and the community response can build resilience in survivors, he says.
"The way in which parents handle it for themselves will have a huge impact on the kids," he says. "The worst outcomes are linked with [parents saying], 'We don't want to talk about it.'"
The parents are understandably upset, Gurwitch says. It's OK to show sadness, anger, and other emotions, but she tells parents: "It's is not OK to completely decompose." It's important for the children to see parents can pull themselves together.
As time goes on, "a very large percentage will have posttraumatic reactions," Schonfeld says. "Those reactions tend to improve over time."
While people talk about posttraumatic stress disorder (PTSD) directly after an incident such as a school shooting, it isn't officially diagnosed as PTSD until its symptoms have persisted for a month, Schonfeld says. But "that doesn't mean you don’t have a problem" that needs attention from a mental health professional.
“As a country, we are already struggling with a mental health crisis,” Bhargava, author of Building Happier Kids, says. “Events such as this serve to exacerbate even more crisis in a group of innocent children whose only crime was to attend school. We must address the 'epidemic' of gun violence and school shootings head-on. For the sake of our children and their health. For all of us.”
Therapy That Works
Cognitive behavioral therapy (CBT) approaches can ease the trauma, Gurwitch says.
She often recommends one type of CBT called trauma-focused cognitive behavioral therapy. This approach involves children and parents and focuses on safety, coping skills, and gradual exposure. It's a structured and short-term treatment of about eight to 25 sessions.
The therapy helps children address distorted beliefs and learn skills to help them cope with everyday stress. Therapy sessions focus on the specific impact of the trauma for the child or teen. Gradually, the therapist introduces reminders of the trauma and helps the child or teen use coping skills to master their fear or anxiety.