Children in Natural Disasters: An Experience of the 1988 Earthquake in Armenia

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.

References

Abrams, J. I. (1989). Detection and extrication in the Armenian earthquake. International workshop on earth-quake injury epidemiology for mitigation and response, 435-449. Baltimore, MD: The John Hopkins University.

Allan, R. (1989). The Armenian earthquake - The UK response. Disaster Management, 1(4), 10-17.

Azarian, A. G. (1990a). Stressful situation in Armenia. In Anait Azarian (Ed). Psychological Treatment of Children and Adolescents. Studies of the Children's Psychotherapy Center, 6-19. Yerevan, Armenia: Research Institute of Pedagogical Sciences (in Russian).

Azarian, A. G. (1990b). A complex approach to the methods of psychological treatment of children and adolescents. (in Russian).

Azarian, A. G., & Skriptchenko-Gregorian, V. G. (1992). Natural disasters result in multifaceted PTSD that demand a complex approach to treatment. The Brown University Child and Adolescent Behavior Letter, Special Supplement.

Azarian, A. G., & Skriptchenko-Gregorian, V. G. (1997). Traumatization and stress in children and adolescents of natural disasters. In Thomas W. Miller (Ed.). Children of Trauma. Madison, CT.

Azarian, A. G., Lipsitt, L. P., & Skriptchenko, V. G. (1996a). Behavioral psychopathology in infants of disaster. Presented at 10th Biennial International Conference on Infant Studies, April 18-21, 1996, Providence, RI, USA.

Azarian, A. G., Miller, T. W., & Skriptchenko-Gregorian, V. G. (1996b). Baseline assessment of children traumatized by the Armenian earthquake. Child Psychiatry and Human Development, 27(1), 29-41.

Azarian, A. G., Skriptchenko-Gregorian, V. G., Miller, T. W., & Kraus, R. F. (1994). Childhood trauma in victims of the Armenian earthquake. Journal of Contemporary Psychotherapy, 24(2), 77-85.

Azarian, A. G., Lipsitt, L. P., Miller, t. W., & Skriptchenko-Gregorian, V. G. (1997). Toddlers remember disaster trauma. In Linda Williams & Victoria Banyard (Eds.), Trauma and Memory. London, England: Sage (in press).

Cisternas, A., Philip, H., Bousquet, J. C., et al., (1989). The Spitak (Armenia) earthquake of 7 December 1988: field observations, seismology and tectonics. Nature, 339, 675-679.

Comfort, L. K. (1990). Turning conflict into cooperation: Organizational designs for community response in disasters. International Journal of Mental Health, 19(1), 89-108.

Engholm, C. (1991). The Armenian Earthquake. Lucent Books.

Gergerian, E. L. (1995). Eye movement desensitization and reprocessing (EMDR). In Anie Sanentz Kalayjian, Disaster and Mass Trauma, 117-122. Long Branch, NJ: Vista Publ.

Giel, R. (1991). The psychosocial aftermath of two major disasters in the Soviet Union. Journal of Traumatic Stress, 4(3), 381-392.

Goenjian, A. (1993). A Mental health relief programme in Armenia after the 1988 earthquake. British Journal of Psychiatry, 163, 230-239.

Goenjian, A. K., Najarian, L.M., Pynoos, R. S., et al. (1994). Posttraumatic stress disorder in elderly and younger adults after the 1988 earthquake in Armenia. American Journal of Psychiatry, 151, 895-901.

Goenjian, A. K., Pynoos, R. S., Steinberg, A. M., et al. (1995). Psychiatric comorbidity in children after the 1988 earthquake in Armenia. Journal of the American Academy of Child and Adolescent Psychiatry, 34(9), 1174-1184.

Greening, T. (1990). PTSD, the Armenian earthquake, and Primo Levi. Journal of Traumatic Stress, 3(4), 613-615.

Grigorova, L. F., Gasparian, A. A., & Manukian, L. H. (1990). Armenia, December, 88, Yerevan, Armenia: Hayastan (in Russian).

Grigorian, H. M. (1992). The Armenian earthquake. In Linda S. Austin (Ed.). Responding to Disaster, pp.157-167. Washington, DC: American Psychiatric Press.

Hadjian, A. H. (1993). The Spitak, Armenia earthquake of 7 December 1988 - Why so much destruction? Soil Dynamics and Earthquake Engineering, 12, 1-24.

Kalayjian, A. S. (1995). Disaster and Mass Trauma. Long Branch, NJ: Vista Publishing.

Krimgold, F. (1989). Search and rescue. Earthquake Spectra, 23, 136-149.

Libaridian, G. J. (1989). Armenian earthquakes and Soviet tremors. Transaction Social Science and Modern Society, 26, 59-63.

Lundin, T., & Bodegard, M. (1993). The psychological impact of an earthquake on rescue workers. Journal of Traumatic Stress, 6,129-139.

Miller, T. W., Kraus, R. F., Tatevosyan, A. S., & Kamenchenko, P. (1993). Post-traumatic stress disorder in children and adolescents of the Armenian earthquake. Child Psychiatry and Human Development, 24, 115-123.

Moro, M. R. (1994). Earthquake in Armenia: Establishment of a psychological care center. In Colette Chiland & J. Gerard Young (Eds.), Children and Violence, pp.125-144. Northvale, NJ: Jason Aronson Inc.

Najarian, L.M., Goenjian, A. K., Pelcovitz, D., et al. (1996). Relocation after a disaster: Posttraumatic stress disorder in Armenia after the earthquake. Journal of the American Academy of Child and Adolescent Psychiatry, 35(3), 374-383.

Noji, E. K. (1989). The 1988 Earthquake in Soviet Armenia: Implications for earthquake preparedness. Disasters, 13(3), 255-262.

Noji, E. K., Kelen, G. D., Armenian, H. K., et al., (1990). The 1988 earthquake in Soviet Armenia: A case study. Annals of Emergency Medicine, 19, 891-897.

Pesola, G., Bayshtok, V., & Kvetan, V. (1989). American critical care team at foreign disaster: The Armenian experience. Critical Care Medicine, 17(6), 582-585.

Pomonis, A. (1990). The Spitak (Armenia, USSR) earthquake: Residential building typology and seismic behavior. Disasters, 14(2), 89-114.

Pynoos, R.S., Steinberg, A. M., & Goenjian, A. (1996). Traumatic stress in childhood and adolescence. In Bessel A. van der Kolk, Alexander C. McFarlane, & Lars Weisaeth (Eds.), Traumatic Stress, pp. 331-358. New York: The Guilford Press.

Pynoos, R. S., Goenjian, A., Tashjian, M., et al. (1993). Post-traumatic stress reactions in children after the 1988 Armenian earthquake. British Journal of Psychiatry, 163, 239-247.

Skriptchenko-Gregorian, V. G., Azarian, A. G., DeMaria, M. B., & McDonald, L. D. (1996). Colors of disaster: The psychology of the "Black Sun". The Arts in Psychotherapy, 23(1), 1-14.

Verluise, P. (1995). Armenia in crisis: The 1988 earthquake. Detroit, MI: Wayne State University Press.

Yacoubian, V. V., & Hacker, F. J. (1989). Reactions to disaster at a distance. Bulletin of the Menninger Clinic, 53, 331-339.