Working With Children After Traumatic Events

Article by Dr Richard W. Baggé

I. General Principles

A. Children and adolescents (and adults) need to be understood in relationship to the stage of their development.
B. The younger the child, the more dependent their response will be on the parent’s response.
C. Children generally know more than we think and think more than we know about what is happening.
D. Each child in a family may respond quite differently to the same event.

II. The impact of trauma on children (modified from Meichenbaum, p. 528)

A. Most responses are “usual” reactions to abnormal situations.  Further evaluation and treatment is indicated when there are particularly intense reactions and/or situations in which the reaction continues well beyond the time that most children have resumed their normal activities.  Prolonged impairment in day-to-day functioning should be assessed by some one knowledgeable about children’s responses to traumatic events..

B. Behavior disturbances are less intense and psychological problems are seen less common in children than might be expected after natural disasters.  In the majority of cases disturbances are short-lived.

C. The impact of the parents’ response to the disaster may be more important than the impact of the disaster itself on the child.

III. Guidelines for Working with Children after Traumatic Events: How do we help?
(Portions of this section are modified after Mabe)

A. The re-establishment of security in a fundamental way is extremely important

  1. The child needs to know that reasonable steps are being taken to ensure their security
  2. Long-term effects are related to
    a. Repeated trauma
    b. No security
    c. Lack of subsequent nurture and soothing
    d. It is hard for the child in the situation in which the surviving parent is grieving and unavailable to the children
  3. Re-establish normalcy as quickly as possible
    a. School
    b. Chores
    c. Discipline
    c. Normal routine as much as possible even if not back in the home
  4. Fear of separation from the parent is a big issue.  This can be compounded by the need of the main caretaker to be elsewhere
    a. If a child will need someone to care for them for a while, it is better if a familiar person does it and that they come to the child’s home which gives a better sense of continuity and security
    b. A familiar home would be the next best (e.g. a grand parent’s home that they frequently visit)
  5. For the older child and younger teen a conflict may arise between the need to be independent/self-sufficient and their need for help in traumatic situations
    a. Help them understand the normal aspects of the situation
    b. It is not unusual for there to be some regression

B. Communication

  1. Facts
    a. They need to know what has happened.  They can be told what happened in an age appropriate fashion.  They don’t need to know all of the details.  If they are not told something they will fill in the blanks.
    b. Often the imagination is worse than the reality
  2. Thoughts
    a. Give them a chance to ask questions
  3. Feelings
    a. Children need to know why their parents are upset.
    b. “What have I done?” may be their response.  They need to understand other people’s emotions to help them not be confused.
  4. Children will often have to be prompted to talk about these things
    a. Children will have a natural tendency to cut and run or drop a bomb, or not talk
    1) Cut and run:  i.e. avoid dealing with the thoughts and feelings
    2) Drop a bomb behaviorally – become angry, blow up
    b. Young children and early school age children may clam up.  You could give an example of types of things you have heard other children say and feel, such as being fearful and sad.
    c. The older child/adolescent may not want to talk to adults.  Encourage them to talk to their friends without cutting them off.
  5. Debriefing
    a. Debriefing is helpful, especially to correct distorted perceptions
    b. It is helpful to do some debriefing soon after an event but it can be overdone in the early phases with children.  Repeated discussions may make them more fearful. (picking at a scab)
    c. Distortions
    1) Children may distort what they heard or saw or think happened
    2) Common distortions
    a) It’s my fault  – it was because of what I did (the child may have been very angry at dad when he left)
    b)  Feeling that everything is out of control.  Help them to think about what is under their control
    c) We all may go back and forth between these things
  6. The individual needs to find a means of expression by which they can change their “pain, internal conflicts, and feelings into words and other forms of expression.”  Art, drawing, painting, journaling, drama, and story-telling are     helpful  as soon as the individual is capable of meaningful interaction with the medium.    (Adapted from McRee, 1990)
  7. Don’t minimize the seriousness of an event.  Explain in an age appropriate fashion.

C. Permission to mourn and not to mourn

  1. It is OK to be sad and to not feel like doing normal things for a while
  2. Conversely it is not a problem or disrespectful to go out and play, (i.e. take a break from the mourning)

D. Time Perspective

  1. Children do not have a perspective on a crisis that an adult has of working through events and knowing that it is not an endless process.
  2. The child may feel like it is never going to get better.
  3. It is helpful to tell a child that it is not going to be like this for ever.

E. It is helpful to:

  1. Involve the child if possible
    a. It is very productive to give the child something to do and if possible something that will be helpful in the situation.
    b. They will feel even more powerless if they are sent off for someone else to take care of them.
    c. If possible an adult needs to give them the opportunity to be helpful. If a child can’t be at an event (e.g., a funeral) have them do some action which helps them to be involved.  (e.g. write a letter to be placed in the casket of a deceased parent.)
  2. Be attentive to the children’s needs
    a. The following may be indicative of their struggle with the traumatic experience:
    1) Sleep problems
    2) Appetite changes
    3) Injuring self
    4) Self-depreciation remarks/attitude
    5) Regression
    6) Increased irritability/frustration
    7) Oppositonal behavior
    8) School problems
    9) Loss of affectionate behavior
    10) Not returning to a more normal function in a reasonable amount of time. (Note there is a difference between returning to function and getting through the grief)
    11) Depression and suicidal ideas
    b. Help them have something to look forward to:  e.g. a trip to the game park, restaurant, etc.
    c. Remember that children are comforted by being held and spending time with them.
  3. Directing a child to God
    a. God is the watchman who never sleeps Psalm 121: 4  Behold, he that keepeth Israel will neither slumber nor sleep.
    b. 1 Peter 5:7 Cast all your anxiety on him because he cares for you.
    c. Psalm 23:1 The LORD is my shepherd, I shall not be in want.  2 He makes me lie down in green pastures, he leads me beside quiet waters, 3 he restores my soul.  He guides me in paths of righteousness for his name’s sake.
    d. Psalm 46: 1 God is our refuge and strength, an ever-present help in trouble.
    e. Proverbs 3: 5 Trust in the LORD with all your heart and lean not on your own understanding; 6 in all your ways acknowledge him, and he will make your paths straight.

F. Religious language and euphemisms

  1. Be careful with spiritual language or euphemisms especially around children.
    Examples in the case of a death
    1) The person is going to be with God. A child’s response might be
    a) Are they being forced?
    b) Did they leave intentionally?
    2) They’re resting with God.

G. What do you tell a child that has been injured?

  1. They need to understand what has happened to them in language they can understand and at a level and content that is appropriate.
  2. The pain issue is very important.  A child is not very good at letting people know he is in pain
  3. Aftermath issues important for the child to understand.  Going home from the hospital is often just the beginning of the recovery process.

H. Examples of helpful statements in talking with children: (Pynoos, 1994 in Meichenbaum p. 531)

  1. “If you see something terrible happen to someone you may see pictures of it in your mind for longer than you think.”
  2. “It is pretty hard to concentrate as well right after going through something as frightening as this.”
  3. “It is hard not to have your mommy or daddy be able to get to you right away when the earthquake started.”
  4. “It is hard to walk by that building that fell down without thinking about what happened during the earthquake.”
  5. “We are all likely to get more afraid the next time there is a high wind.”
  6. “It’s okay if things don’t seem as much fun as they used to, for now.  This is a lot to go through.”
  7. “It helps to let someone know when something reminds you of what happened, because even your mommy or daddy taking your hand at that moment can make you feel better.”
  8. “If you are having bad dreams, it helps to let your parents know.”
  9. “If your are having pictures of what happened bother you at school which make it hard for your to learn, it will help to let your teacher know.”

IV.   Age differences in the way children respond to trauma/disasters (adapted from McRee, 1990)

A. Children and adolescents of all ages may experience fears of future traumas/disasters, problems with school, regressive behaviors, sleep problems including nightmares and night terrors, fear of abandonment, and fear of places or situations associated with the trauma.

B. Preschool (ages 1-5)

  1. Typical responses include regressive behaviors such as a reversion to or increase in thumb-sucking, crying, fears (of darkness, storms, strangers, etc.), loss of bowel and bladder control (bed-wetting or soiling when previously trained), stammering or other speech difficulties, and problems with separation from parents. Other symptoms might include nervousness, being irritable, an increase in physical complaints (especially 4 and 5 year olds), changes in appetite, daydreaming and distractibility.
  2. This age group is especially sensitive to issues of security.  Abandonment can become a major fear, (e.g. in an evacuation where there may be the sudden loss of home, school, family members, friends, pets and toys, etc.)
  3. Because of their dependence on adults, they will look to them for comfort and stability and therefore be more subject to the adult’s response to the events.

C. Ages 5-10

  1. The child can become irritable, whine a lot, be very clingy (may shadow the parent, avoid school etc.), aggressive, increased competition for parents’ attention
  2. Appetite changes, sleep disturbances (nightmares, night terrors), physical complaints (e.g. headaches, leg pain), bowel or bladder problems, etc.  Sleep problems may result from fear of the reoccurrence of dreams.
  3. Fears (e.g. darkness, parent leaving, etc.)
  4. Social withdrawal from friends
  5. Poor school performance
  6. Regressive behavior is seen most often in this group. Loss of a pet or a special toy or possession may be especially hard.

D. Preadolescent/adolescent (ages 11-18)

  1. Sleep disturbances, appetite changes, easily distracted, a decline in productive work, irritable, headaches, vague aches and pains, etc.
  2. Social behavior: may be rebellious at school and at home (refusal to do chores, delinquent behavior, fighting), school problems, including poor classroom performance, withdrawal from friends and family, attention-seeking behavior.
  3. Peer responses are very important.  The individual wants to know that their responses are appropriate and similar to what others are experiencing.
  4. May have a tendency to impulsive and risk-taking behavior.

V. Thoughts on helping a child by age grouping (A. – C. adapted from McRee, 1990)

A. Preschool (ages 1-5)

  1. Encourage expression of how they are thinking and feeling about the event through:
    a. Play
    b. Re-enactment
    c. Story telling (have them tell stories)
    d. Picture drawing / art
  2. Encourage them to talk about how they feel about special losses, including pets and toys
  3. Provide comfort and assurance especially through things or activities that are familiar
  4. Provide structure and re-establish routines such as meal times, devotions, bedtime routines, etc.
  5. Children will need ongoing explanations and clarifications of what happened.

B. Ages 5-10

  1. Be patient with their demanding behavior.
  2. Encourage them to talk with parents and friends about what happened and how they feel.
  3. Responsibilities both at home and at school may need to be modified for a period  of time.  Structure needs to be maintained but not made too demanding.
  4. Providing more attention can increase comfort and security.

C. Preadolescent/adolescent (ages 11-18)

  1. Activities that encourage the resumption of routines, especially group activities
    a. Resumption of extracurricular activities: social activities, sports, clubs, etc.
    b. Returning to school
    c. Resumption of family routines
  2. Opportunity to talk about the experience, fears and other feelings (this should be encouraged but not forced)
    a. With peers in groups, perhaps in a school setting (they may not want to talk to adults)
    b. With the family
    c. Include discussion of fears of the future and what plans might be helpful for future events
  3. Look for opportunities for involvement in positive ways to overcome some of the effects of the trauma.  Having no way to respond positively may delay recovery.
  4. They may want to be “strong” for the sake of the family/parents and in that way never deal with their own feelings and thoughts.

D. Safety measures can be planned and practiced for future circumstances.  Have the  child participate in this planning to the degree that might be appropriate without putting responsibility on them.

E. Children at boarding schools are aware of dangerous situations that their parents are in and this may adversely affect school performance, social interactions, increase homesickness, fears, etc.

VI. When to be more concerned about your child and to consider getting help.

A. Signs of distress in traumatized children (Terr: 1994, as quoted in Miechenbaum p. 528)

  1. Strongly visualized or repeatedly perceived memories
  2. Repetitive behaviors
  3. Trauma-specific fears and separation anxiety (e.g. fears on leaving parents or friends)
  4. Changed attitudes about people, aspects of life, and the future
  5. Loss of acquired developmental skills

B. Symptoms that last a long time and do not seem to be resolving are more serious

  1. PTSD in children: The symptoms are similar to symptoms that adults experience but younger children tend not to experience flashbacks.  They may have recurrent dreams or nightmares in which various parts of the experience are relived.  Anxiety, depression, and regressive behavior are usually seen in children with this disorder.  They will often have exaggerated startle responses and difficulty falling asleep.
  2. Depression:  The symptoms are similar to those seen in adults, but they are more often associated with behavior problems, especially aggressiveness and physical  complaints. Children will have at least some of the following: appear sad and depressed, do not enjoy things, speak poorly of themselves, be withdrawn, have poor school performance, be indecisive, irritable and easily angered, aggressive, have morbid ideas and possibly suicidal thoughts, and have problems with sleep, appetite, and are easily fatigued.
  3. Separation anxiety is characterized by:
    a. Unrealistic worry about important people (usually parents) leaving or being  harmed
    b.  Fear of being taken away or lost
    c. Unwillingness to go to school in order to remain with an important figure
    d. Avoidance of being alone, may shadow an adult while at home.
    e. Inability to work or play without an important person around.
  4. General anxiety: The child may worry and be preoccupied with a fear of  accidents, activities at school or in sports

VI. References

Green, B. L.  et. al. “Children of Disaster in the Second Decade:  a 17-Year Follow-up of Buffalo Creek Survivors,”  in  Journal of the American Academy of Child and Adolescent Psychiatry 33:1  pp. 71-79 (1994)

Jensen, P. and Shaw, J.  “Children as Victims of War:  Current Knowledge and Future Research  Needs.”  Journal of the American Academy of Child and Adolescent Psychiatry  32:4  pp.  697-708 (1993)

Mabe, A.  These points were taken from a personal conversation with Alex Mabe, Ph. D. Personal friend, colleague and mentor, Medical College of Georgia  11/97

McRee, C. et. al.  “Techniques and Materials used in Psychiatric assistance for Children and Families in Three Disaster Areas,  North Carolina Journal of Mental Health, 11:27  pp. 39-44, 1990

Meichenbaum, D.  A Clinical Handbook/Practical Therapist Manual, Institute Press, Waterloo, Ontario, Canada, 1994

Zivcic, I.  “Emotional Reactions of Children to War Stress in Croatia.”  Journal of the American  Academy of Child and Adolescent Psychiatry  32:4  pp. 709-713 (1993)