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How Do Young Kids and Teens Respond to Trauma? Is Posttraumatic Stress Disorder (PTSD) a Concern?
There is a wide range of emotional and physiological reactions that children may display following disaster. Based on previous research we know that more severe reactions are associated with a higher degree of exposure (i.e. life threat, physical injury, witnessing death or injury, hearing screams, etc), closer proximity to the disaster, history of prior traumas, female gender, and poor parental response and parental psychopathology.
Findings from a study following the Oklahoma City bombing indicate that more severe reactions were related to female gender, exposure through knowing someone injured or killed, and bomb-related television viewing/media exposure (Pfefferbaum et al., 1999; Pfefferbaum et al., 2000).
Below are some common reactions that children and adolescents may display when traumatized (Dewolfe, 2001; Pynoos & Nader, 1993):
Young Children (1-6)
1. Helplessness and passivity; lack of usual responsiveness
2. Generalized fear
3. Heightened arousal and confusion
4. Cognitive confusion
5. Difficulty talking about event; lack of verbalization
6. Difficulty identifying feelings
7. Sleep disturbances, nightmares
8. Separation fears and clinging to caregivers
9. Regressive symptoms (e.g. bedwetting, loss of acquired speech and motor skills)
10. Unable to understand death as permanent
11. Anxieties about death
12. Grief related to abandonment of caregiver
13. Somatic symptoms (e.g. stomach aches, headaches)
14. Startle response to loud/unusual noises
15. "Freezing" (sudden immobility of body)
16. Fussiness, uncharacteristic crying, and neediness
17. Avoidance of or alarm response to specific trauma-related reminders involving sights and physical sensations
School-aged Children (6-11 years)
1. Responsibility and guilt
2. Repetitious traumatic play and retelling
3. Reminders trigger disturbing feelings
4. Sleep disturbances, nightmares
5. Safety concerns, preoccupation with danger
6. Aggressive behavior, angry outbursts
7. Fear of feelings and trauma reactions
8. Close attention to parents' anxieties
9. School avoidance
10. Worry and concern for others
11. Changes in behavior, mood, and personality
12. Somatic symptoms (Complaints about bodily aches, pains)
13. Obvious anxiety and fearfulness
14. Withdrawal and quieting
15. Specific, trauma-related fears; general fearfulness
16. Regression to behavior of younger child
17. Separation anxiety with primary caretakers
18. Loss of interest in activities
19. Confusion and inadequate understanding of traumatic events most evident in play rather than discussion
20. Unclear understanding of death and the causes of "bad" events
21. Magical explanations to fill in gaps in understanding
22. Loss of ability to concentrate and attend at school, with lowering of performance
23. "Spacey" or distractible behavior
Pre-adolesents and Adolescents (12-18 years)
1. Self-consciousness
2. Life-threatening reenactment
3. Rebellion at home or school
4. Abrupt shift in relationships
5. Depression, social withdrawal
6. Decline in school performance
7. Trauma-driven acting-out behavior: sexual acting out or reckless, risk-taking behavior
8. Effort to distance from feelings of shame, guilt, and humiliation
9. Flight into driven activity and involvement with others or retreat from others in order to manage their inner turmoil
10. Accident proneness
11. Wish for revenge and action-oriented responses to trauma
12. Increased self-focusing and withdrawal
13. Sleep and eating disturbances; nightmares
How to talk to your child
Create a safe environment:
One of the most important steps you can take is making children feel safe. If possible, children should be in a familiar environment with people that they feel close to. Keep your child's routine as similar as possible. There is comfort in having things be consistent and familiar.
Provide reassurance to children and extra emotional support:
Adults need to create an environment in which children feel safe enough to ask questions, express feelings, or just be by themselves. Let your children know they can ask questions. Ask your children what they have heard and how they feel about it. Reassure your child that they are safe and that you will not abandon them.
Be honest with children about what happened:
Provide accurate information, but make sure it is appropriate to their developmental level. Very young children may be protected because they are not old enough to be aware that something bad has happened. School age children will need help understanding what has happened. You might want to tell them that there has been an unexpected disaster, and that many people have been hurt or killed. Adolescents will have a better idea of what has happened. Talk to them about terrorism and how the United States responds to terrorism. It may be appropriate to watch selected news coverage with your adolescent and then discuss it.
Tell children what the government is doing:
Reassure children that the state and federal government, the police, firemen, and the hospitals are doing everything possible. Explain that people from all over the country and from other countries are offering their services.
Be aware that children will often take on the anxiety of the adults around them:
Parents have a difficult job of finding a balance between sharing their own feelings with their children while at the same time not placing their anxiety on their children. For many, the attack on the United States was inconceivable. Our sense of safety and freedom was shattered. Many parents may feel scared and fearful of another attack. Others may be angry and revengeful. Parents must deal with their own emotional reactions before being able to help children understand and label their feelings. If you are frightened, tell your child, but also talk about your ability to cope and how you as a family can help each other.
Try and place the attack in perspective:
Although you yourself may be anxious or scared, children need to know that what they witnessed or heard about regarding the attack is a rare event. Most people will never be attacked by terrorists and the world is generally a safe place.
What can parents do?
(Excerpted from Monahan, 1993)
Infancy to Two-and-a-Half Years:
1. Maintain Child's routines around sleeping and eating
2. Avoid unnecessary separations from important caretakers
3. Provide additional soothing activities
4. Maintain calm atmosphere in child's presence
5. Avoid exposing child to reminders of trauma
6. Expect child's temporary regression; don't panic
7. Help verbal child to give simple names to big feelings; talk about event in simple terms during brief chats
8. Give simple play props related to the actual trauma to a child who is trying to play out the frightening situation (a doctor's kit, a toy ambulance)
Two-and-a-Half to Six Years:
1. Listen to and tolerate child's retelling of event
2. Respect child's fears; give child time to cope with fears
3. Protect child from re-exposure to frightening situations and reminders of trauma, including scary T.V. programs, movies, stories, and physical or location reminders of trauma
4. Accept and help the child to name strong feelings during brief conversations (the child cannot talk about these feelings or the experience for long)
5. Expect and understand child's regression while maintaining basic household rules
6. Expect some difficult or uncharacteristic behavior
7. Set firm limits on hurtful or scary play and behavior
8. Avoid nonessential separations from important caretakers with fearful children
9. Maintain household and family routines that comfort child
10. Avoid introducing new and challenging experiences for child
11. Provide additional nighttime comforts when possible: night lights, stuffed animals, physical comforting after nightmares
12. Explain to child that nightmares come from the fears a child has inside, that they aren't real, and that they will occur less and less over time
13. Provide opportunities and props for trauma-related play
14. Use detective skills to discover triggers for sudden fearfulness or regression
15. Monitor child's coping in school and day care by communication with teaching staff and expressing concerns
Six to Eleven Years:
1. Listen to and tolerate child's retelling of event
2. Respect child's fears; give child time to cope with fears
3. Increase monitoring and awareness of child's play, which may involve secretive reenactments of trauma with peers and siblings; set limits on scary or hurtful play
4. Permit child to try out new ideas to cope with fearfulness at bedtime; extra reading time, radio on, listening to a tape in the middle of the night to undo the residue of fear from a nightmare
5. Reassure the older child that feelings of fear or behaviors that feel out of control or babyish (e.g. night wetting) are normal after a frightening experience and that the child will feel more like himself or herself with time
Eleven to Eighteen Years:
1. Encourage younger and older adolescents to talk about traumatic event with family members
2. Provide opportunities for young person to spend time with friends who are supportive and meaningful
3. Reassure young person that strong feelings-whether of guilt, shame, embarrassment, or wish for revenge-are normal following a trauma
4. Help young person find activities that offer opportunities to experience mastery, control and self-esteem
5. Encourage pleasurable physical activities such as sports and dancing.
How Common Is It For children to Develop PTSD?
Although many children will display some of the symptoms listed above, a significant minority of children will develop posttraumatic stress symptoms. Findings from Oklahoma City indicate that:
1. Children who lost an immediate family member, friend, or relative were more likely to report immediate symptoms of PTSD than non-bereaved children.
2. Arousal and fear were significant predictors of PTSD symptoms seven weeks after the bombing (Pfefferbaum et al., 1999).
3. Two years after the bombing, 16% of children who lived approximately 100 miles from Oklahoma City reported significant PTSD symptoms related to the event (Pfefferbaum et al, 2000). This is an important finding because these youth were not directly exposed to the trauma and were not related to killed or injured victims.
4. PTSD symptomatology was predicted by media exposure and indirect interpersonal exposure, such as having a friend who knew someone killed or injured.
5. No study specifically reported on rates of PTSD in children following the bombing. However, studies have shown that as many as 100% of children who witness a parental homicide or sexual assault, 90% of sexually abused children, 77% exposed to a school shooting, and 35% of urban youth exposed to community violence develop PTSD.
Due to the nature of the September 11 attack, we would predict very high rates of PTSD in children who lost a family member or witnessed the plane crashes and after-effects. Based on research from Oklahoma City, high rates of PTSD may also be related to exposure to media coverage and to children who have a friend or family member that was killed or injured.
When should you seek professional help for your child?
Many children and adolescents will display some of the symptoms listed above. They will likely recover in a few weeks with social support and the aid of their families. Many of the above suggestions will help children recover more quickly. For others, however, they may develop PTSD, depression, or anxiety disorders. Parents of children with prolonged reactions or more severe reactions may want to seek the assistance of a mental health counselor. It is important to find counselor who has experience working with children as well as with trauma.
References:
DeWolfe, D. (2001). Mental Health Response to Mass Violence and Terrorism: A Training Manual for Mental Health Workers and Human Service Workers.
Monahan, C. (1993). Children and Trauma: A Parent's Guide to Helping Children Heal. Lexington Books, New York, NY.
Pfefferbaum , B., Nixon, S., Tucker, P., Tivis, R., Moore, V., Gurwitch, R., Pynoos, R., & Geis, H. (1999). Posttraumatic stress response in bereaved children after Oklahoma City bombing. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1372-1379.
Pfefferbaum, B., Seale, T., McDonald, N., Brandt, E., Rainwater, S., Maynard, B., Meierhoefer, B. & Miller, P. (2000). Posttraumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion. Psychiatry, 63, 358-370.
Pynoos, R. & Nader, K. (1993). Issues in the treatment of posttraumatic stress in children and adolescents. In J.P. Wilson and B. Rapheal (Eds.), International Handbook of Traumatic Stress Syndromes (pp. 535-549). New York: Plenum.
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