Children and Traumatic Events:

Understanding a Chaotic World

Donna Gaffney, DNSc, PMHCNS-BC, FAAN

Project Rebirth, New York, New York Board member, NAGC

Goals
1: Describe children's concepts of trauma and traumatic events

2: Discuss how to talk to children about traumatic events

3: Define self-care strategies for children confronted with traumatic events

Children of the Kindertransport

Children after El Salvador earthquake

The Most Vulnerable

Greater susceptibility to injury and their dependence on others for livelihood, decision making, and emotional support.

Caring for children in the aftermath of a traumatic event involves psychological and social challenges stemming from their level of cognitive ability, emotional vulnerability, and dependence upon the support of family members.
Children

require special attention and procedures after a traumatic event, and they are often identified as a population that should be prioritized during relief efforts.
US Army

What does a traumatic event mean to a child?

Loss of safety and security Actual or perceived loss of parents/caregivers Helplessness Fear for their own lives Witnessing death, harm and destruction
Photo: Marcello Casal Jr/ABr

The shock of the unimaginable creates memories that are indelible and intrusivemuch like a flashbulb in our brains.

Photo: Master Sgt. Jeremy Lock, USAF

Disruption of life is devastating to children and families

Familiar and favorite objects look different or have disappeared The known becomes the unknown Safety is challenged Change in day to day structure may create more anxiety Life is different The return to normal is replaced with a new normal
Photo Marco Dormino/ The United Nations

The Difference Between Stress and Trauma

Traumatic events are intense and extreme versions of stressful events, they can be life threatening or potentially life threatening. The event causes the child to feel fear, hopelessness and horror and threatens psychological and physical well-being.

The effects that surround a stressful event are alleviated when the stressor is removed while the emotions evoked by a traumatic event last long after the event is over.
Memory of the traumatic event lingers on, physiological arousal continues and the body never fully recovers

A History of Trauma

The symptoms of traumatic stress were noted as early as the Civil war. The condition was called Soldiers Heart.

Photo: NARA

Hysteria

Sigmund Freud was the first to suggest that hysterical behavior was related to a premature sexual encounter.
Anna O

Shell Shock

Trauma was not addressed again until World War I. Soldiers brains were thought to have been shocked by exploding shells during battle.

Battle Fatigue

The effects of trauma were noted in combat soldiers during World War II.

Post-traumatic Stress Disorder

Upon their return from Viet Nam in the mid 1960s veterans complained of flashbacks, hyperarousal and inability to function in day to day life.

Rape Trauma Syndrome

Women, spurred by the success of the Viet Nam Vets, started to meet in groups to Break the Silence of Rape in the late 1970s

Children and Trauma

Children in war addressed by Margaret Mead in 1945 The separation of children from family proved more disruptive than the London blitz.

Children and Trauma

The trauma of illness and hospitalization was identified in 1952

Children and Trauma

First identified in 1874 and treated through the Society for the Prevention of Cruelty to Animals Child abuse not recognized as a public health problem until 1975

Children and Trauma

Lenore Terr studied the children of Chowchilla in 1977

Research on Children and Trauma

Research on the long term and immediate effects of trauma began in the in the last 20 years Natural Disasters

Research on Children and Trauma

Community violence

Photo: Mikael Ejdemyr

Research on Children and Trauma

The effects of war on children and families

Children in Hiding World War II Northern Ireland Israel

Research on Children and Trauma

Children as witnesses to Domestic Violence

Research on Children and Trauma

How children have responded to witnessing the 9/11 attacks, Losing family members and Talking about 9/11.

The Brain Responds to Threat

Activation of a cascade of neurochemicals through the brain and the body Preparing the human for survival
Freezing Flight Flight Tending

Followed by a return to homeostasis

Traumatic responses can alter. . .

Physiological reactions Affective responses Cognitive Processing

Memory Time Distortion Splitting of affective and cognitive elements of the experience

leading to behavioral and interpersonal changes

Children and Trauma

Traumatic events in childrens lives - Any direct or witnessed event that threatened his/her own and/or his/her caregivers physical and/or emotional integrity (Pynoos, 1990)

Children exposed to traumatic events are at high risk for developing post-traumatic distress, maladjustment and PTSD The symptomatic picture is different in children in comparison to adults, especially for young children

Types of Trauma
Need to differentiate between: Familial and non-familial events (attachment figure or friend vs. foe)- identity of the perpetrator Acute trauma which is violent and sudden (plane crash, car accident, bombings, 9/11, natural disasters) and Chronic trauma which is subtle and cumulative (various forms of terror threats, domestic violence) and their combination Collective Trauma (war, persecution, terrorism, genocide) and individually endured (rape, assault, physical and sexual abuse) Human (Intentional and unintentional) and non-human causes occurring in infancy, childhood or adolescence.

In children, traumatic experiences, in addition to increasing the risk for PTSD, depression and anxiety, appear to interfere with the developmental course: Affronting childrens sense of safety, wellbeing, and bodily integrity

Affecting interpersonal relatedness, sense of self and future

Interfering with brain functioning (memory, attention and learning), and emotion regulation

A Childs Response is not the Result of a Singular Event

A complex interaction:
The significance of the event in the life of the child (Proximal contact, loss) Individual characteristics
Developmental stage Cognitive abilities Age and gender Family loss and injury Displacement of school, community Media and Strangers

The environment

What factors determine a childs response to a traumatic event?

Proximity to the event may not tell the entire story

Not proximal to the event but proximal to the consequences of the event Children more distant from the attack may witness a more global view of the event.
It was just like a movie, like Die Hard.

Cognitive Stage

Causal Thinking

Developmental Fears

Significance of the event in the childs life

Traumatic loss
3250 children lost parents from the three attacks on 9/11 Trauma symptoms associated with the circumstances of a parents death can impair the ability to navigate the grieving process.
The traumatic nature of the loss is an obstacle as the child tries to accept the reality and permanence of the death, cope with painful emotions, adjust to life changes resulting from the loss, and make meaning of the death Cohen & Mannarino, 2004

Family members who are also profoundly affected and themselves suffering
Two months after September 11, a predictor of child mental health service utilization was parental PTSD symptoms. Stuber et al. (2002)

The environment
Ongoing disruptions (home, school) Support Education

The childs exposure to the event

Direct, severe or family exposure

following the 1993 bombing of the WTC in New York City,
PTSD symptom reports of youth who had been trapped inside the WTC (i.e., exposed youth) with PTSD symptom reports of youth who attended nearby schools but were not at the site of the attack at 3 and 9 months.

Rates of PTSD symptoms were higher among the exposed youth at three and nine months following the attack. The exposed youth also evidenced more disaster-related fears unrelated to terrorism than the comparison youth Koplewicz et al.(2002)

The Consequences of Trauma

Following the Oklahoma City bombing:

3,218 children in grades 612 were found to have substantial levels of persistent hyperarousal
34.7% trembling or shakiness 46.2% reported fast beating heart, 39.0% reported jumpiness
Pfefferbaum, Nixon, Krug, et al. (1999)

After the Pentagon attacks on September 11th Nearly 73% of children reported at least one symptom of PTSD 2-3 months later

60% reported at least three PTSD symptoms

Over 20% of this sample reported such re-experiencing the attacks, finding myself thinking about the attack when trying to do other things, And hyperarousal symptoms
i.e. feeling easily startled, and having problems falling asleep.
Phillips, Prince, & Schiebelhut, 2004

In NYC, six months after September 11, 2001

10.6% of 8,236 school children reported they experienced re-experiencing, avoidance, and hyperarousal symptoms.

The authors of the study suggested that these children may have a probable diagnosis of post-traumatic stress disorder
Hoven et al. (2005)

Determinants of severity of traumatic experience in young children

The most potent variable that predicted the development of PTSD in young children (under age four) was not an event that threatened their own body, but whether they had witnessed a threat to their caregiver Keren, Isr J Psychiatry Relat Sci. 2000;37(3):236-46.

The Availability of Human Bonds for Children Coping with Traumatic Events
Margaret Mead, Anna Freud and Dorothy Burlingaham (194143): The disruption of family ties is more traumatic to children than the events of war Coates (2003): Trauma and human relatedness may be understood as inversely related. The greater the strength of the human bonds connecting the individual to others, and the more these bonds are accessible in times of danger, the better the individual can cope with the trauma and recover

Parents as a Defensive Shield

Parental emotional reactions mediate child PTSD Parental reactions predict child post-traumatic distress more than the level of exposure and the severity of the event There is a relationship between specific parental and family characteristics and child adaptation post-trauma

Risk Factors for PTSD

Previous trauma Stage of development Cognitive & emotional Cultural/spiritual beliefs The nature & magnitude of the trauma Human inflicted The degree of exposure Directly affected-illness, injury Loss (Parent, home, school) Continued disruption in life Support systems Personality type and coping styles Prior individual and relational factors (related to vulnerability and resilience: attachment,
temperament, individual disorders, family stresses, morality and religion and their interaction).

Photo: Gannett

Childrens Posttraumatic Symptoms

Children may exhibit PTSD classic symptoms

re-experiencing; numbing; avoidance; arousal but also a wide range of symptoms of post traumatic distress and defensive attempts: anxieties, developmental regressions, social withdrawal, physical and emotional deregulation, hyperactivity, acting out and risk-taking

Younger children show more circumscribed or vague symptoms than older ones
more somatic complaints and somatic rare phenomena (bruxism, alopecia) more regressive behaviors and more regulatory difficulties in sleep, mood, attention and behavior They report less symptoms of re-experiencing or of numbing and avoidance. Thus their problems may not be identified as trauma related.

Minimizing the Effects of Trauma in Children

Photo: Erik C. Barker, US Navy

If children can be identified immediately after experiencing a traumatic event and given strategies to cope with that event they will be less vulnerable to the use of destructive behaviors.

What Do Children Need From Caregivers in The Aftermath?

Modeling of coping behavior, efficacy and inspiring optimism and hope. Organizing and safely structuring the childs environment Building a sense of connection with meaningful others and of agency Helping the child regulate emotions by being attentive and physically and emotionally available to protect and sooth

Communicating about confusing, fearful things, anxieties and problem-solving Creating a coherent, sensible, emotionallybalanced and empowering trauma narrative.

Turning traumatic memories which are disjointed, confusing, uncontrollable and emotionally unregulated, into normal memories which are embedded in a narrative that can be processed and controlled.

Talking to Children
About Traumatic Events

Photo by Wendy Ewald with students at Central Intermediate School, the African American Alphabet in I Wanna Take Me A

Picture, Teaching Photography and Writing to Children

Children are not miniature adults

Developmental Considerations

Key Points

Parents, Teachers and Other Adults

The Setting

Introductions

Getting Started

Thoughts, Feelings, Actions

Talking with Children

Children do not have the capacity to process information in the same way as adults Yet they are keen observers of the world No matter how much we shield them, they notice things and form their own conclusions

Talking. . .

Cognitive stage is the most crucial determinant of how grief, loss and trauma are processed AND how we talk to children

Talking. . .

Children should not be approached in the immediate aftermath of a traumatic event

A time for observation Talk to others who can respectfully comment on their experience Revealing pain and vulnerability can complicate resolution of trauma Give parents, schools information

Keep the conversation moving!

When to stop. . .

Ask. . .What would you do?

Groups. . .can be challenging!

Childrens Needs

When to end. . .

Remember the childs viewpoint!

Building Community
Sharing the experience with others creates a sense of community. Providing social support

Beyond Talking

Doing Good

Making a contribution helps to overcome the sense of helplessness

Offering help Making cards Writing letters Raising money

TSgt Prentice Colter, USAF

. . . a Way To Be Helpful!

Art and the Creative Therapies

Allow children to express their feelings in their own words and images

Art and the Creative Therapies

Their drawings reveal:

their feelings their understanding of a traumatic event Allowing for dialogue on two levels- emotional and cognitive

Art and the Creative Therapies

Drawings can be displayed in a communal location A sense of pride for those who offer words of comfort and support

Art and the Creative Therapies

Children may be able to express their fears and worries far easier in images

Child & Young Adult Literature

Read the book out loud( class, group) Parents and children read books together Therapeutic adjunct

Photo therapy

Children learn how to use a camera Work together in groups Visualize & photograph how they will represent a letter Write about their picture I Feel Better When

Pets and Animals

Comfort comes in many different sizes and shapes

Story-Telling and Metaphors

Carrying our Baggage Children must carry their suitcase full of experiences with them through the rest of their lives

How we pack the suitcase of memories is important

. . .what we choose to remember, what we choose to leave behind.

Taking short cuts, Pushing things away without thought results in . Everything spilling out when we are least prepared.

Grounding experiences . . .
Reconnect us to what is familiar and stable.

Places of Comfort in Nature

Beaches Mountains Gardens Forest Preserves

Movement , Meditation and Mindfulness

Exercise Yoga Dance Games

Gardening and Building

A sense of accomplishment
A Beginning A Middle An End

A Grounding experience

Journaling

Allows the child or teen to tell their own story Another way to express emotions, ask questions Provides and opportunity to revisit earlier times

Music and Rhythm

Comfort Social Support Fun Familiar activities or learning something new

Puppets and Toys

Infusing life into inanimate objects Telling their story Safety Retelling the trauma Working through different endings

Finding sanctuary?
A physical and emotional place of safety and security.
Respite from outside threats. Offers comfort and familiarity. Facilitates healing and growth.

Sanctuary
Children find sanctuary through Play Learning Social supports

Children can find sanctuary in the world around them through experiences that are grounding.

Growth and resilience in nature Sights and sounds of nature The wonders of learning Literature that is comforting and/or therapeutic Interaction with others Play, drama and art

Use Metaphors From Nature:

The Safety of My Cocoon

We are all vulnerable in the beginning, when we are young, and growing up in the world.
Photo: Audrius Meskauskas

When confronted with painful events we keep ourselves in a safe and warm cocoon. We know that we need time to grow and protect ourselves . . . until we are ready to emerge. . .
Photo: Captain Tucker

. . . With glorious beauty and new strengths.

Photo: Derek Ramsey

Recognize potential for loss of place and functioning in society

Consider if the locale is urban or rural Capitalize on cultural strengths Help build resilience Embrace spirituality

Build and encourage community supports

Help Build Self-esteem and Promote Resilience

Photo: Sara Nelson

Photo: Marcello Casal Jr/ABr

The ability to thrive, mature and succeed in spite of challenges and obstacles. Not absolute protection against the effects of trauma, It does help children move towards growth and positive physical and mental health.

Resilient Children

Memory of images of helpful, sustaining people Awareness of feelings A desire and ability to help others Altruism A feeling of competence

Photo: Gannett

The Characteristics of Resilience

Resourcefulness Recognition and use of support systems Curiosity and intellectual mastery Compassion and caring for others

Photo: Gannett

The Characteristics of Resilience

What Children Need To Build Resilience

Safety and security (home & community) Reassurance Familiar and regular activities Factual information Active listeners Available parents and caregivers Limited exposure to the media Extra time, attention, affection Play and school And . . .

Helping Young People Understand Trauma and How it Affects our Bodies and Brains

The Brain Responds to Threat

One

goal:

To prepare us for survival

Freezing we instantly check where the danger is and if we can get away.

Then Comes Fight or Flight

Followed by a return to normal

Traumatic responses cause changes in. .

Our
heart rate, respirations, dilated pupils, dry mouth

Body

 Fear, helplessness, horror

Our Moods and Emotions

 Memory fragmented, out of sequence

Time is distorted

Our Thinking

these

responses do not mean a person is mentally ill this is how all human beings react to a traumatic event!

 The

way a traumatic event affects us depends on:

The definition of the event Our own interpretation of the event Our emotional response to the event

Trauma and memory

Unwanted Traumatic Memories

Reminders Nightmares can be worse than reality Flashbacks see, hear, smell, or feel fragments of original sensations Physical reactions- (tremors, sweat, inc. HR) when faced with reminders

Suppressing and avoiding trauma thoughts

Research studies show that suppressing memories of any type result in a rebound effect Although not thinking about painful thoughts seems to be a reasonable way to copetrying to forget actually makes it worse.
Wegner, 1994

Calming images Relaxation breathing

What to do..

Think back to when you were little.

How about now?

What Works for You???

A Lesson from Afar

The stronger more mature penguins take up the periphery buffeting the herd against hostile conditions

The physically ill and more vulnerable chicks are herded towards the center.

Simply: Cold Penguins to the Middle.

Resources

The National Child Traumatic Stress Network. http://www.nctsnet.org/nccts/nav.do?pid=hom_main David Baldwin Trauma Pages http://www.trauma-pages.com/disaster.php Center for Traumatic Stress in Children and Adolescents http://www.pittsburghchildtrauma.org Cohen, E. (2008). Parenting in the throes of traumatic events: Relational risks and protection processes. In: J. Ford, R. Pat-Horenczyk & D. Brom (Eds.) Treating traumatized children: Risk, resilience and recovery. Routledge. The Dart Center- Children and Trauma http://dartcenter.org/topic/childrentrauma Fendya, D. (2006) When Disaster Strikes Care Considerations for Pediatric Patients, 13 J. TRAUMA NURSING 161, 161. INST. OF MED., EMERGENCY CARE FOR CHILDREN: GROWING PAINS 234 (2007). Psychological First Aid, Field Operations Guide. http://www.nctsnet.org/nctsn_assets/pdfs/PFA_InfoBrief_FINAL.pdf