The following materials were provided to participants in the December 3, 2001, "Hot Topics" teleconference jointly sponsored by the National Association of Psychiatric Health Systems (NAPHS) and the American Hospital Association (AHA) by guest speaker Mary Margaret Kerr, Ed.D.


COPYRIGHT M.M. KERR 2001

CHILDREN AND TRAUMA: 
WHAT YOU CAN DO TO HELP

Mary Margaret Kerr, Ed,D.
Dr. Kerr is Director of Outreach Services for STAR-Center.  This Center, funded by the Commonwealth of Pennsylvania, has responded to crises such as the TWA 800 and USAir 427 crashes and the Oklahoma City bombing.   To reach the Center, call 412/624-0725 or e-mail kerrmm@msx.upmc.edu.

Introduction

We say that a person has experienced or witnessed a trauma when they have been exposed---firsthand or indirectly---to an unexpected event that seriously threatened, injured, or killed someone. The key elements of a trauma (1)  include:

    1. Unpredictability
    2. Helplessness
    3. Fear
    4. Horror

Understanding how these elements affect children and teens is our first step, so let’s begin with unpredictability.

Unpredictability means that the event caught the person by surprise. Being caught off guard and vulnerable is distressing. How distressing depends on the event itself and the child or teen’s direct exposure, temperament, previous experiences, maturity, knowledge, and supports.

For example, young children often experience events as traumatic, because they do not yet have the information and experience to anticipate situations. Consequently, they may find a normal situation to be stressful because they have never previously experienced it. Consider the apprehension with which many children face injections or blood tests, or x-rays. Over time, most children overcome their fear, as these medical procedures become more familiar. Put another way, maturity prepares us for many situations that might otherwise surprise us. On the other hand, a disaster can initially overwhelm even the most mature child or teen, because it is too shocking for them to manage.

Helplessness is the partner of scary surprises. Trauma victims need to regain control; empowering them is one of our first goals. For example, pediatric nurses talk through procedures with their young patients and offer them choices whenever possible: "You can look or close your eyes. It is okay to cry. You can keep your stuffed animal with you, if you want. Would you rather have your medicine in a pill or syrup?"

Fear is a natural reaction to the horror a child experiences during a trauma. Again, each child will respond according to past experiences, age, cognitive abilities, and emotional maturity. It’s important to remember that the experience of trauma is individual; what may terrify one child may be manageable for another. These disparities often confuse parents attempting to console siblings whose behavioral and emotional reactions require different supports.

Mental health specialists describe two stress-related "disorders": Acute Stress Reaction and Post-Traumatic Stress Disorder, or PTSD (2). While it is helpful to have a clear description of these two disorders, one should not "medicalize" a young person’s reactions to stress. This could make individuals feel that something is wrong with them, or that they have somehow failed. On the other hand, identifying stress reactions is helpful to trauma victims, who often respond, " Oh, so I am not the only one who feels this way. That makes me feel better."

In summary, we suggest that you become familiar with the signs of acute stress reactions so that you can spot problems requiring specialized treatment or support. On the other hand, avoid giving children and teens the message that their responses are unusual or "sick." In the next section, you will learn more about common responses to trauma.

Typical Responses to Trauma

Those who experience trauma often have one or more emotional, physical, behavioral or cognitive reactions. Many of these reactions echo the essential elements of the traumatic experience, as you can see below.

Shock and Surprise

    • Upset with changes in routine
    • Need to control what happens
    • Wanting more frequent communications with parents
    • Asking questions repeatedly to get information about what is about to happen
    • Dependent on routines at school and at home
    • Nervousness; hypervigilance (easily startled)
    • Less willing to try unpredictable social situations or new experiences, including academic assignments and tests, sports competitions, public performances
    • Moodiness
    • Anger

Helplessness

    • Irritable when not given choices or power in decisions
    • "Bossy" with family and friends
    • Critical of others; judgmental; argumentative
    • Stubbornness; insistence on having own way
    • Inflexibility; narrowed focus on self
    • Showing off, risk-taking behaviors

Fear

    • Absentmindedness, inability to concentrate
    • Poor appetite; nervous eating
    • Frightened by: darkness, monsters, strangers, "bad guys", reminders of the event
    • Using alcohol and other drugs to calm one’s fears
    • Anxious when separated from parents or caregivers
    • Fearful of going to school
    • Concerns about own health and that of loved ones
    • Demanding reassurance and attention

Horror

    • Thoughts about death and dying;
    • Disbelief; "numb" feeling; in a daze
    • Nightmares; difficulty falling asleep; other sleep disturbances
    • Intrusive thoughts; preoccupation with the event
    • Flashbacks
    • Fascination with morbid details of the event
    • Acting out aspects of the event in imaginative play
    • Questioning repeatedly about the details of the event
    • Making jokes about the event
    • Sadness

Other signs of acute stress include general anxiety, guilt, withdrawal from others, and not wanting to engage in favorite activities (known as anhedonia).

What You Can Do

Parents, friends, teachers, and others can really help children and teens through a traumatic event, especially if they know a little about trauma and its effects. Using the four elements of the experience as our guide, we want to respond in such a way as to diminish these feelings of 1) shock and surprise, 2) helplessness, 3) fear, and 4) horror. Here are some suggestions.

Coping with Shock and Surprise

  • Plan daily activities ahead, telling the child when and how things will happen. "There will be a lot of grown-ups at our house. They are coming to tell us they feel sad, too. You should say hello to them, but then you can go back to playing video games."
  • Stick with as many routines as possible, including times when the child can play and relax. Don’t abandon normal school or household rules (e.g., bedtime, chores).
  • If routines must change, explain why (e.g., change in babysitter, location, or transportation) "I have to help the people who are looking for Daddy. That means that I am going to be home very late. You will stay at Aunt Jane’s. Uncle Frank will take you to your soccer practice after school. He knows to meet you at the school office.."
  • Use familiar objects to ease the transition to new surroundings (e.g., stuffed animal, blanket, toys). "What do you want to take with you to the hospital?"
  • Anticipate any future surprises with the young person. "Our apartment is not going to look the same as before the crash. There will be a lot of dust and dirt. There will be broken windows and furniture. It might be scary at first to see it that way. But we will do it together. We may have to stay somewhere else until it is repaired."
  • Role-play how the child or teen can respond to others’ reactions. "Kids at school may say bad things about the accident. They may even blame kids from another country for causing it. Let’s figure out what you can say if that happens."
  • Identify visual and auditory signals that may cause the child to remember the incident. Help the child cope with these reminders. For example, school fire drills are likely to upset a teen traumatized by a fire. A child whose relative perished in a plane crash may be startled by the sound of planes overhead.
  • Whether you are a parent or professional, show children that you are still in charge. Young people of all ages need to know there are competent adults taking care of them. If you are not able to compose yourself and take on your normal supervisory role, get another adult to step in.
  • Be careful about sharing your own feelings of shock and surprise, especially with younger children. Identify private times when you can "debrief" with other adults.

Helplessness

  • Give the child choices whenever you can. "Would you rather eat dinner now or in a little while?" " Do you want to go the funeral or stay here?" "Do feel like talking now or would you rather play outside?" Asking, "How would you like for this to happen?" is a good question to ask a student returning to school or to a disaster site after a traumatic event.
  • Recognize bossiness and controlling behavior as a natural reaction. Teenagers may be irritable and argumentative. As one crisis responder put it, "They have lost so much. They need to win a few power struggles. Let them have the last word."
  • Watch for risk-taking behaviors such as driving carelessly, using alcohol and other drugs, playing dangerously, trying "stunts." Young people may unconsciously feel a need to prove that they are invincible and powerful.

Fear

  • Pay close attention to separations from parents and loved ones: going and coming from school, parental departures for business travel, feeling lost in a large or unfamiliar public place. Even teens may become distressed and irritable if a parent is late picking them up or if they don’t know their parents’ whereabouts. Use frequent communications to reassure children that they have not been abandoned.
  • Be prepared to offer supports as children revisit old fears. "Would you like to sleep with the light on?" "You said that your tummy feels weird. Are you worried about something?" "Thunder is just a noise. It doesn’t mean there will be a flood."
  • Listen for children’s explanations so that you can detect how they are reassuring themselves. "No one would want to bomb our house, because none of the important government people live here." If there is nothing harmful in their rationales, support them.
  • Prepare children for common stress reactions to reduce their fears that they are "losing it." Sleep and appetite changes, inability to concentrate, intrusive thoughts and other common reactions can overwhelm and isolate a child. As appropriate, let the child’s peers know that these are common reactions and invite their assistance. "When she gets quiet and starts to drift off and think about the accident, we just try to get her talking again, " said one helpful teen about her injured friend.
  • Imaginary play is helpful to children. Often children will re-enact a scary situation and "rewrite the ending" so they feel less vulnerable. Angry children may vent their rage on their stuffed animals or make-believe friends.
  • Factual information can bolster children’s sense of well-being. "The reason Dad and I have check-ups is so we can find out if we need to take medicine for anything. We just had our check-ups and we are healthy." " The police would not let us go on this road if they thought the building would fall."
  • Help children identify their own coping skills. "You always find a way to make your little brother laugh. That is a good way to help him." " Playing baseball has always helped you get your mind off big problems." " Talking seems to help you figure out what to do when things are confusing and scary." " You have a special gift for figuring out how other people might be feeling."

Horror

    • Don’t feel that every question must be answered. When horrific events take place, adults may feel they need to explain them. This is an undue burden. It is all right to say something like, "We are not sure why this happened. But people are doing everything to be sure it does not happen again."
    • Set limits on the details shared with children and teens, and limit their exposure to media coverage of the event.
    • Remind children how rare catastrophes are. "Most people would never do something like this. " "A tornado is so unusual."
    • Be hopeful, emphasizing opportunities to help others. Show children and teens how they can help in the aftermath. "Would you like to get some friends together to draw cards for the children in the hospital? "We can have a car wash to raise money for relief efforts."

Summary

Acute stress reactions are common among children and adolescents who have experienced or witnessed a horrible and sudden event that left them feeling helpless and fearful. Adults---even those never trained in crisis responding---can provide marvelous support to children as they start the path to recovery. While a few children and teens will require specialized help when symptoms do not diminish over time, most children find great comfort and strength in those adults closest to them.

1 See American Psychiatric Association, Diagnostic and Statistical Manual IV, 1994, p. 431.
2 American Psychiatric Association, Diagnostic and Statistical Manual-IV, 1994.

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