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to anger, trouble paying attention, disinterested--these
behaviors in children demand adult intervention.
Problem behaviors in children derive from many
sources. One potential factor affecting too
many children today is the physiological and
psychological aftereffects of witnessing or
being a victim of a traumatic event.
Traumatic stress comes in many
forms and a full range of intensities, as do
children's responses to it. Not all children
who have experienced or witnessed trauma will
exhibit behavior problems. Increasing adults
understanding of the effects of trauma hopefully
will enable them to better help children who
experience problems.
RESPONSE TO TRAUMA
Children's responses to trauma
may vary according to the source and circumstances
of the trauma and the circumstances of the child.
Generally speaking, children who experience
or witness extreme threat respond with symptoms
that fit into four general categories (Terr,
1991; Pynoos and Nader, 1988):
- They may have strong memories that repeatedly
intrude on their normal functioning.
- They may engage in endlessly repeated behaviors.
- They may develop trauma-specific fears.
- They may change their attitudes about friends,
family, life in general, and the future. They
also may desire to be unaware of their feelings.
Although these responses tend
to be fairly consistent among children who have
experienced traumatic stress, the way they manifest
can differ substantially. Repetitive behaviors
in one child, for example, may be highly aggressive,
whereas in another they may be withdrawn or
self-injurious. Some children exhibit few, if
any, of these symptoms; others become almost
completely debilitated, experiencing all of
them persistently. In the latter case, children
may be diagnosed with post-traumatic stress
disorder (PTSD).
Most children who have experienced
trauma will not develop PTSD, although many
may demonstrate transitory symptoms. If disturbances
persist for longer than one month, parents or
caregivers should consult with a mental health
professional or pediatrician experienced in
working with traumatized children.
WHAT INFLUENCES CHILDREN'S
RESPONSES TO TRAUMA?
Many factors, often interrelated,
contribute to the type and severity of a child's
response to traumatic stress. These factors
include the persistence of the trauma, the relationship
of the child to the perpetrator, the proximity
of the child to the experience, the child's
support system, and the basic beliefs the child
brings to the task of understanding and coping
with the trauma. To understand children's possible
responses, it is helpful to consider:
- the child's age,
- whether the trauma was ongoing or one-time,
- the child's relationship to the perpetrator,
- whether the child was a victim, a witness,
or connected in some way to the victim,
adult support,
- other stress factors affecting the child.
THE CHILD'S AGE:
Children's responses to traumatic
stress tend to be consistent with their developmental
age. Toddlers may manifest stress in changes
in their relationship to their caregivers, either
demanding more attention, showing signs of indifference,
or both. Their motor activity may change, and
they may become more aggressive (hitting, biting,
pinching).
In addition to the behaviors
exhibited by toddlers, preschoolers may have
physical symptoms, such as headaches, stomachaches,
or difficulty using a particular body part.
They may engage in endlessly repetitive play;
may physically and emotionally avoid any reminders
of the incident; or may demonstrate fear, sadness,
clingingness, regressive behaviors, and feelings
of shame regarding their vulnerability. Children
also may enter a dissociative state, which observers
often describe as "being in a world of
their own" or "being out of touch."
School-aged children typically
are more susceptible to traumatic events outside
the family and their effects on their caregivers,
friends, and their community. They may also
be more adult-like in exhibiting their sadness
and other mood-oriented symptoms, such as anxiety,
depression, guilt, increased inhibition, and
hypervigilance. These states can result in changes
in play, loss or change in interests, return
of old or onset of new fears, sleep disorders,
difficulty concentrating, and lack of initiative.
School performance and learning may suffer.
Often symptoms may mirror those of attention
deficit hyperactivity disorder (ADHD) and may
respond to ADHD treatment (Schwarz and Perry,
1994).
In addition to the symptoms
experienced by younger children, adolescents
may exhibit identity, eating, and personality
(including multiple personality) disorders and
seizure-like states. Suicide attempts, substance
abuse, self- mutilation, delinquency, truancy,
and destructive sexual behaviors also may occur.
WHETHER THE TRAUMA
WAS ONGOING OR ONE-TIME: If the
trauma was acute and unanticipated, as might
be the case with a drive-by shooting, the child
may experience acute and disturbing disruptions
of thought patterns. If the trauma was chronic
and anticipated, as is most often the case with
sexual or physical abuse, researchers and clinicians
report a more chronic absence of feeling, sense
of rage, and generalized sadness along with
fear (Terr, 1991). The two types of trauma can
also overlap, resulting in a mixture of symptoms.
THE CHILD'S RELATIONSHIP
TO THE PERPETRATOR: Traumas perpetrated
by individuals whom a child has learned to trust
or depend on create different effects than those
perpetrated by strangers. Generally speaking,
the more personal the relationship between perpetrator
and victim, the more severe the symptoms of
the victim.
WHETHER THE CHILD
WAS A VICTIM, A WITNESS, OR CONNECTED IN SOME
WAY TO THE VICTIM: Studies of
one-time, acute events reveal that those physically
and emotionally closest to the event's epicenter
will have the most severe and longest-lasting
symptoms. That is, victims who are emotionally,
cognitively, and physically involved with the
event and the perpetrator can be expected to
respond more strongly than those who are physically,
emotionally, or cognitively more distant (Pynoos
and Nader, 1988; Schwarz and Perry, 1994; Terr,
1990). Relationship to the event may involve
the victim's sense of control over the event;
victims with less control may have a stronger
symptomatic response (McCormack, Burgess, and
Hartman, 1988).
ADULT SUPPORT:
At the time of a traumatic event, attention
and energy may be focused on the victim, perhaps
making it difficult for children who are distressed
by witnessing the event to receive the support
they need. Moreover, adults who have close relationships
with a child victimized by violence may be hampered
by their own distress about the occurrence.
Difficulty receiving the support
they need may be compounded for children who
manifest their grief differently than adults.
Children's sadness may be less apparent and
less sustained. Some researchers have found
that many children have never spoken to anyone
about their grief reactions. These researchers
surmise that because children's sadness tends
to be more hidden, parents and teachers may
have more difficulty appreciating the nature
and intensity of children's grief reactions
(Pynoos and Nader, 1988).
OTHER STRESS FACTORS AFFECTING
THE CHILD. Although children have a wide range
of response to various traumatic stresses, one
fact seems to be well-established: rather than
building children's resilience by giving them
more expertise, recurrent or multiple traumas
multiply the difficulty children experience
(Fitzpatrick and Boldizar, 1993; Pynoos and
Nader, 1988).
PROVIDING SUPPORT
In addition to providing "first
aid" (see section at the end of this article)
at the time of the trauma, parents and caregivers
can provide ongoing support to children in the
ways outlined in the remainder of this article.
HELPING CHILDREN
REGAIN A SENSE OF CONTROL: Traumatized
children have experienced themselves as helpless
and not in control. Healing includes recognizing
that those feelings occurred at the time of
the trauma, but need not continue into the present.
Barbara Oehlberg, in her discussion of "reempowerment"
in Making It Better: Activities for Children
Living in a Stressful World (1996), suggests
asking children open questions, such "Then
what happened?" or "I wonder what
makes the daddy say that?" to help them
process a story and gain a sense of mastery.
Oehlberg's book also provides a number of open-ended
activities intended to help children draw from
their own resources to make sense of their world.
HANDLING DISRUPTIVE
BEHAVIOR:Although adults may encounter
difficulties when faced with agitated, defiant,
or aggressive children, remembering that they
are struggling and need adult help is extremely
important. Behavior problems are unlikely to
decrease through scoldings or appeals to "common
sense," and harsh discipline is harmful
and inappropriate. On the other hand, overly
permissive parenting is not likely to help a
child who needs guidance and help with coping.
Children need consistent, loving support with
clear limits and positive discipline to enforce
them.
UNDERSTANDING REPETITIVE
PLAY: The play of traumatized
children may include acting out aspects of the
event or themes from it. Some children may engage
in endless, unvaried, repetition of the same
play. Although self-expression may be constructive,
caregivers need to balance between excessively
encouraging or discouraging these activities
(Schwarz and Perry, 1994). Caregivers should
supervise play, for example, and be attuned
to the possibility that it can become too disturbing
for the child or for the child's playmates.
TUNING INTO THE
CHILD'S NEEDS AND PACE FOR DEALING WITH STRESS:
While providing opportunities for children to
express themselves, parents and caregivers need
to be careful not to push too hard to extract
a story or otherwise pressure the child. Allow
children to feel safe, accepted, and ready to
talk at their own pace. On the other hand, putting
the burden solely on children to bring up their
feelings, or avoiding the subject altogether
and assuming children will "work things
out on their own" does not give children
the support they need. If adults never broach
a subject, children may think that it is somehow
taboo or that their feelings are abnormal or
bad and should not be discussed.
GOING BEYOND THE
NUCLEAR FAMILY: Families that
have experienced trauma may find it helpful
to reach outside the family for supportive relationships
for themselves and their children. An adult
mentor, for example, can make an enormous difference
in a child's life.
COPING OVER TIME:
As children mature, gaining more sophisticated
emotional and cognitive abilities, they may
reprocess an earlier trauma. Caring adults should
be aware of this possibility, and be ready to
listen and possibly make referrals to appropriate
professionals, whenever the need arises.
SPECIAL SECTION
FIRST AID AT THE TIME OF STRESS
Coping with the traumatic stress
of a child at the time of the stress is critical;
unaddressed traumatic stress increases the likelihood
of the child developing PTSD. The following
suggestions by Pynoos and Nader (1988) include
a list of "first aid" for trauma victims:
- Provide support, rest, comfort, food, and
the opportunity to play or draw.
- Reassure children that they are safe and
that you will help them.
- Reassure children that the event was not
their fault.
- Help children understand what has happened
by giving them opportunity to talk about the
event. Clarify, then reclarify any existing
confusions.
- Give children the opportunity to talk about
their feelings. Providing emotional labels
for common reactions is helpful. Reassure
children that it is okay for them to be upset.
- Do not insist that children talk before
they are ready or more than is comfortable
for them.
- Help children understand that the event
is over, especially in the presence of physical
reminders of the incident.
- Encourage children to let their parents,
teachers, or other adults they trust know
about what happened.
- Provide consistent and reassuring caretaking,
such as picking children up from school or
letting children know the whereabouts and
availability of a significant adult.
- Understand that children may exhibit behaviors
they have already grown out of (for example,
bedwetting) and tolerate those behaviors for
a limited amount of time.
- Help children dealing with death understand
its finality. Do not talk about death with
euphemisms, such as "He went away"
or "She is sleeping."
REFERENCES
Fitzpatrick, K. M. & Boldizar,
J. P. (1993). The prevalence and consequences
of exposure to violence among African-American
youth. JOURNAL OF THE AMERICAN ACADEMY OF CHILD
AND ADOLESCENT PSYCHIATRY, 32, 424-430.
Garbarino, J. (1995). RAISING
CHILDREN IN A SOCIALLY TOXIC ENVIRONMENT. Jossey-Bass;
San Francisco.
Heergaard, M. (1991) WHEN SOMETHING
TERRIBLE HAPPENS: CHILDREN CAN LEARN TO COPE
WITH GRIEF. Woodland Press, Minneapolis.
Oehlberg, B. (1996). MAKING
IT BETTER: ACTIVITIES FOR CHILDREN LIVING IN
A STRESSFUL WORLD. St. Paul: Red Leaf Press.
Pynoos, R. S. & Nader,
K. (1988). Psychological first aid and treatment
approach to children exposed to community violence:
research implications. JOURNAL OF TRAUMATIC
STRESS, 1(4), 445-473.
Schwarz, E. D., & Perry,
B. D. (1994). The post-traumatic response in
children and adolescents. PSYCHIATRIC CLINICS
OF NORTH AMERICA, 17 (2), 311-327.
Terr, L. C. (1991). Childhood
Traumas: An outline and overview. AMERICAN JOURNAL
OF PSYCHIATRY, 148, 10-20.
http://www.hec.ohio-state.edu/famlife/bulletin/volume.3/bull33f.htm
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