About 140 children in preschool through 3rd grade were in their classrooms at the Islamic Center of San Diego on Monday when police say two teenage gunmen killed three people.

The victims were all men with deep ties to the mosque and the community. Police say their fast actions to call 911, lockdown the building and confront the gunmen kept the school children safe. The San Diego police chief said the gunmen came within 15 feet of being able to access the classrooms. The perpetrators, who according to NPR reporting apparently were influenced by white supremacist ideology, died by self-inflicted gunshot wounds, police say.

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As communities that have weathered such attacks know, the impact of these acts of violence can extend well beyond those who are injured or killed. Researchers and healthcare providers say those who witnessed the shooting — children and adults — and those grieving the deaths of the three men are most at risk to experience mental health symptoms in the immediate aftermath.

Symptoms to look for in children

Children are particularly vulnerable and proximity to a destructive event matters.

“Individuals who were actually in the buildings and who were directly exposed, those are the individuals that we’re most concerned about,” says psychologist Julie Kaplow, executive vicepresident for Trauma and Grief Programs and Policy at the Meadows Mental Health Policy Institute in Texas. “We know that proximity to that kind of event is one of the strongest predictors of post-traumatic stress.”

People might find themselves struggling with “acute stress reactions,” says Kaplow, which tend to occur in the months after a shooting. Those symptoms can include, “feeling like the event is happening all over again, flashbacks, nightmares, avoidance, not wanting to think about or talk about what happened.”

Children, too, can have nightmares and flashbacks. Symptoms can also show up in a child’s behaviors.

“A lot of the behaviors that we see, including in younger children, are things like excessive clinginess, not wanting to separate from their caregiver or another caring adult,” says Kaplow. “They may often show irritability or behavioral regressions.”

For example, a child who was potty trained may start having accidents, or a child who was sleeping on their own becomes scared to do that.

Children nearby may be affected, too

Kids in the larger community, who weren’t at the site of a shooting can also find themselves struggling. A 2023 study by the Children’s Hospital of Philadelphia found that kids within a five-block-radius of a shooting were more likely to show up in hospital emergency rooms in the weeks after a shooting with symptoms of anxiety and suicidal thoughts.

Those with previous traumas are more likely to experience anxiety and other symptoms. “This kind of an event can actually bring up traumatic memories for those who were either victims of a mass shooting or other types of shootings, or even just general losses that they may have had in the past,” says Kaplow.

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It’s important to identify kids who are struggling and connect them to mental health care, says Kaplow. “The silver lining of really tragic community-level situations like this is that often the behavioral health providers in the community will rally together to be able to provide more immediate care,” she says, especially to families directly affected.

Another resource for kids is the Lucine Center for Grief and Trauma, she says. It “provides teletherapy to children and adolescents who’ve experienced any form of trauma or the death of a loved one.”

How to buffer the trauma

Parents and other caregivers can also play ahuge role in helping buffer kids from this kind of trauma. And it starts with helping kids regain a sense of safety, says Dr. Vera Feuer, a child and adolescent psychiatrist and chief clinical officer at the Child Mind Institute in New York.

“Even if it’s not a full sense of physical safety, it’s a sense of psychological safety at least,” Feuer says, “so that they feel that when they’re frightened, when they have a difficult time, they have us to come to.”

1. Keep communication open

“I think that as caring adults with the best of intentions, sometimes we avoid mentioning the situation or talking about the situation because, you know, we’re worried that somehow we’re going to make kids more anxious,” says Kaplow.

But it’s better to communicate with them openly, say Feuer and Kaplow.

“They might have concerns and they might have questions,” says Feuer. “It’s always OK to come to mom to talk about these things when you don’t understand something, when you’re confused, when you’re scared. It establishes that environment [of safety].”

Parents can open the discussion by saying something like, “‘I know that this very scary, tragic thing happened,'” suggests Kaplow, “‘What questions or worries do you have for me? What have you been thinking about it?'”

That helps the child have some sense of “control over the conversation,” she adds. “So you’re meeting them where they are and you’re allowing them to express whatever questions they might have and directly address any concerns they might have.”

1. Calibrate how much information you share

“Sometimes as caregivers, we may provide too much information where that can feel really overwhelming,” says Kaplow. Or parents might give too little information, which might send the message that the topic is not one to discuss openly.

It’s best to tailor the information you share based on your child’s age, says Feuer.

She also suggests asking your child what they think happened. “It’s important to hear from them what they think happened,” she says, “so that you can then gently correct misconceptions. Give accurate information, and then see if they have questions that you can answer in a way that they understand.”

And if a child didn’t see the violence or its aftermath, don’t provide any horrific detail that they don’t need to know, adds Feuer.

1. Focus on safeguarding actions that can be taken

When children experience or hear about a violent incident, parents tend to reassure them by promising them things like, “We live in a safe neighborhood. This will never happen to us,” says Feuer. But in the long run, those kinds of responses are unhelpful, she notes, “because it undermines trust.”

Instead, she suggests explaining to kids what the family as a whole can do to be safe. That teaches kids to focus on what they can control, which is helpful at times when they feel helpless and anxious about things being out of their control.

“Feeling like there’s chaos, feeling like there’s something beyond us that we absolutely cannot control is what creates the most anxiety and the most the loss of the sense of safety,” explains Feuer.

1. Practice techniques to stay calm 

Trauma and stress essentially “lights the brain on fire,” explains Feuer, which feeds fear and anxiety.

So, it’s important to teach children tools that can help their brains rest and recharge so they can feel calmer. Rest is important, says Feuer, and so are things that can distract the brain from those unpleasant feelings.

It’s also important to teach kids grounding techniques to help calm their anxiety.

A useful grounding tool uses our five senses – sight, touch, smell, sound and taste. Start by naming five things you can see, four things you can touch, three things you can hear, two things you can smell and one thing you can taste.

Other tools might include deep breathing, taking a walk, or listening to music. Help your child figure out what works for them, suggests Feuer. And practice them yourself to model for your kids. Even better, practice as a family.

1. Put on your own oxygen mask first 

“This image of a parent putting on the oxygen mask first on the airplane [has] been used over and over again,” says Feuer. But the concept is important because parents can’t help their children fully if they are struggling themselves.

So, she advises parents to also acknowledge how they too might be affected in the aftermath of a violent attack like the one in San Diego, and to do what they need to work through their own trauma and feelings.

“Especially with trauma, we know that processing, talking about it, connecting with people is a really important part of reestablishing a sense of control and safety,” she says.