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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they may be withdrawn or self-injurious.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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