CHILDREN STRUGGLE IN AFTERMATH OF MARATHON ATTACK

THE BOSTON GLOBE

They weren’t among the wounded, or didn’t seem to be. But for many of the children who witnessed the bombs, the inner aftershocks just won’t go away.

In the panicked moments after he heard the bombs explode, Cole Keenan saw the plumes of smoke, watched in fear as throngs of spectators began rushing toward him, and worried about his mother, who was running the Marathon and approaching the finish line.

The 11-year-old from South Boston began running, too, until his grandparents caught him, pushed him against a wall to protect him from the possibility of a another blast, and then rushed him into the basement of the nearby Apple store, where he watched as another boy cried uncontrollably.

Since that day, the straight-A math whiz has struggled to do basic multiplication and concentrate on his homework. He has hid under his covers after hearing loud noises. He had his first fistfight, has awoken from nightmares about terrorist attacks, and has experienced recurring bouts of nausea, headaches, anxiety, and a persistent despondency.

“He had become so withdrawn he didn’t want to go to his baseball games,” said Leanne Keenan, his mother. “He just wanted to lay in bed. It was really hard for him.”

The months since the bombings have helped many distance themselves from the terror they experienced that afternoon, but for some of the hundreds of children who had the day off from school and stood beside the barricades on Boylston Street with their families, the explosions had an impact whose dimensions are deep but, in many ways, still undefined. Many of them still struggle to comprehend what they witnessed and how cheers of joy so quickly became cries of fear.

Some still dread large crowds and cringe at loud, unexpected noises. There are increasing signs that the stress and sleeplessness of the weeks immediately after the attacks and a range of emotions from irritability to despair can now be diagnosed in some children as post-traumatic stress disorder.

Researchers at Boston University are surveying children who were near the bombings and finding that about 10 percent are showing elevated symptoms of PTSD, on par with what studies found among schoolchildren in New York City after the Sept. 11 attacks and about double the rates in communities that haven’t experienced a major tragedy, they said.

Symptoms such as hypervigilance, overwhelming anxiety, and trouble relaxing — all signs of PTSD — have been found to be higher among children who witnessed the blasts than those who didn’t, according to preliminary results from the survey of more than 300 children. They have appeared in about a quarter of the children who witnessed gruesome injuries, spectators running in panic, or medical personnel treating the wounded, and in about half of those who knew someone injured or killed, the survey found.

Boston University’s School of Education is conducting a separate survey of local teachers to assess the impact of the bombings on children. Their preliminary results show 19 percent of 154 teachers who responded to their survey say their students seemed sadder and 14 percent saw grades drop after the attacks.

They noted that students living in communities subject to lock-down orders while police searched for Dzhokhar Tsarnaev have also struggled. In those communities, one-third of 83 teachers said they saw the need to send more students to see psychologists, counselors, or social workers; in communities where residents could leave their homes, only 7 percent of teachers made more mental-health referrals after the attacks.

“The psychological toll can be just as debilitating as physical injuries, when considering that PTSD is associated with a host of long-term negative outcomes, including substance abuse, depression, and elevated rates of suicide,” said Jonathan Comer, an assistant professor in the Early Childhood Interventions Program at Boston University, who is overseeing the study of children with PTSD. “It’s also associated with poorer educational outcomes, including decreased academic performance and increased dropouts.”

Stuart Goldman, a senior associate pediatric psychiatrist at Boston Children’s Hospital, said adults with children who witnessed the bombings or were close to the shootout in Watertown should remain vigilant about what media their children consume and how they discuss the attacks. He noted that children with fertile imaginations, especially those with preexisting anxiety issues, may be the most vulnerable.

“I expect kids to have nightmares, trouble separating from parents, and extra cautiousness,” he said. “That’s normal. But if they’re still having these problems [after more than three months], they should talk to their pediatricians to get the support they need.”

Some children who witnessed the attacks may be too young for anyone to fully understand the extent of the impact upon them.

Gianna Napoli, who was standing across the street from where the second bomb exploded, fell down as a horde of spectators started screaming and running toward her. The 3-year-old from Roxbury now cries inconsolably when she hears fireworks — she hid beneath a table on July 4 — and has awoken in fear from her first nightmares.

In a recording her mother made a few hours after the attacks, Gianna described how she thought “marathon means run away.”

She described hearing “the boom” of the explosion. “It scared us,” she said. “All the people ran away outside. They just didn’t like that.”

She continues to associate the word marathon with loud noises and people running in fear. “She was robbed of her innocence that day,” said Kim Napoli, her mother. “She knows things can go wrong.”

Gavin Fratto, also age 3, was approaching the grandstands with his father and grandparents to watch his mother cross the finish line when the first bomb detonated. Four days later, at their home in Watertown, he and his family had to spend the entire day indoors as police combed their neighborhood for Tsarnaev.

Over the past few months, the boy has repeatedly surprised his parents, asking, “Do you remember the bombs, the big boom?” or “Did they catch the bad guys?”

Gavin still gets frightened by loud noises and has come to recognize pictures of Tamerlan Tsarnaev, said Courtney Fratto, his mother.

When her son brings up the Marathon, she changes the subject. “We just reassure him that we’re safe,” she said.

For Dave McGillivray, who for decades has served as race director of the Boston Marathon and whose home is filled with Marathon paraphernalia, there’s no way to change the subject. His young children were sitting in the stands by the finish line during the attacks.

Afterward, his son Luke, 7, told McGillivray he didn’t want him to organize the Marathon anymore.

“There was a time when I thought I would have to take all the stuff in my house and bury it in the basement,” he said. “It’s difficult. This is what I do for a living. It’s omnipresent.”

Luke resisted going to school for a time and until recently remained skittish around large crowds. About a month ago, he asked his father to take him home during the third inning of a Red Sox game.

“I feel pretty good where’s he’s at now, but my concern is that I don’t know much about PTSD,” McGillivray said. “You don’t know how these things will manifest themselves.”

For many children, as for many adults close to the attacks, the passage of time and new memories have helped.

Natalie Stavas, a pediatric resident at Boston Children’s Hospital and a first responder to the bombings who helped treat the wounded after running 26 miles, said she hopes to help salve some of the pain by organizing a run for children near the finish line.

“I think we need to demystify running and let kids know that it’s a safe place to cheer on their families,” she said.

For Cole Keenan, Boylston Street remains a place he would rather avoid. He has found solace this summer learning to sail and playing baseball, though he recently had another scare when ambulances came to the field after a friend’s father had a heart attack.

He knows his mother, who like thousands of other runners never crossed the finish line, will have an opportunity to run again next year. He says he’s OK with that, but he’ll be rooting for her from a distance.

“I wouldn’t want to be there,” he said. “I think it would just scare me and make me sad.”