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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another they may be withdrawn or self-injurious.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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