Childhood Trauma

1. Childhood Trauma Guidelines for Early Childhood Educators Ally Burr-Harris, Ph.D. & Matt Kliethermes, M.S. The Greater St. Louis Child Traumatic Stress Program

2. What is a Traumatic Event? • Involves actual or threatened death or serious injury, or a threat to the person’s physical integrity • Involves feelings of intense fear, helplessness or horror (children may show disorganized or agitated behavior instead)

3. Natural disasters Kidnapping School violence Community Violence Terrorism/War Homicide Physical Abuse Sexual Abuse Domestic violence Medical procedures Victim of crime Accidents Suicide of loved one Extreme Neglect Types of Traumas

4. How Common are Traumatic Experiences? • 69% of the general U.S. population report exposure to one or more life-threatening traumatic events • 14 to 43% of children report having experienced a traumatic event prior to 18. • Up to 91% of African American youth in urban settings report violence exposure • 10% of children under 5 witnessed shooting/stabbing

5. What Makes a Trauma a Trauma? • Previous trauma exposure • Severity of trauma • Extent of exposure • Proximity of trauma • Understanding and personal significance • Interpersonal violence • Parent distress, parent psychopathology • Separation from caregiver • Previous psychological functioning • Genetic predisposition • Lack of material/social resources

6. Immediate Reactions to Trauma • Intense longing/concern for caregivers • Disbelief, denial about event • Focus on past losses, traumas • Emotional lability (numb<>rage) • Replaying events with intervention fantasies • Misattribution of blame – intense anger • Apparent indifference (minimizing) • Focus on gory, violent, exciting aspects of trauma -Marans et al., 1995

7. Effects of Trauma on Children

8. Developmental Differences in Responses to Trauma • Infants and Toddlers (0 to 3) • Preschool Children (4 to 6) • School-age Children (7 to 12) -Marans & Adelman (1997) -Scheeringa (1995, 2000)

9. Infants and Toddlers • Pattern #1: Withdraws, rejects affection, stops exploring environment, lacks trust in others,appears “unattached” • Pattern #2: Clingy, anxious, sleep disturbances, toileting problems, temper tantrums, regressed, disorganized, rages/aggression, crying/irritability

10. Preschool Children • Regressive behaviors • Separation fears • Eating and sleeping disturbances • Physical aches and pains • Crying/irritability • Appearing “frozen” or moving aimlessly • Perseverative, ritualistic play • Fearful avoidance and phobic reactions • Magical thinking related to trauma

11. School-Age Children • Sadness, crying, irritability, aggression • Nightmares • Trauma themes in play/art/conversation • School avoidance > school failure • Physical complaints • Poor concentration • Regressive behavior • Eating/sleeping changes • Attention-seeking behavior • Withdrawal

12. When Stress Symptoms Become a Disorder • Acute Stress Disorder (ASD) • Posttraumatic Stress Disorder (PTSD) • Depression • Anxiety • Attachment problems (RAD) • Behavior problems

13. Primary Symptoms of ASD and PTSD • Reexperiencing • Avoidance • Hyperarousal • Dissociation

14. Re-experiencing Symptoms • Child “re-lives” sensations of traumatic event through intrusive memories, nightmares, flashbacks, hallucinations, and reenactment • Emotional and physical distress when reminded of the trauma

15. Avoidance Symptoms • Avoid all reminders of the traumatic event in an effort to reduce distress • Avoidance of feelings through emotional “shut down” (a.k.a. dissociation) • Withdrawal • Sense of a foreshortened future

16. Dissociation • Feelings of unreality (“in a daze”) • Emotional numbing, detachment

17. Hyperarousal Symptoms • Significant increase in physical arousal that was not present before trauma • Sleep difficulties, irritability, aggression, concentration difficulties, motor rest- lessness, hypervigilance, exaggerated startle response

18. Acute Stress Disorder (ASD) • Symptoms of reexperiencing, avoidance, hyperarousal, and dissociation (feelings of unreality or emotional numbing) • Within the first month after a traumatic event

19. Posttraumatic Stress Disorder (PTSD) • Symptoms of reexperiencing, avoidance/dissociation, hyperarousal • Symptoms present one month after traumatic event

20. Associated Symptoms of PTSD • Fears and worries • Depressive symptoms • School difficulties • Physical symptoms • Regressive behaviors • Behavioral difficulties

21. How Common is PTSD? • On average, 24% of adults exposed to trauma develop PTSD • In children and adolescents, 3 to 15% of girls and 1 to 6% of boys exposed to trauma could be diagnosed with PTSD • As a whole, about 6-8% of children in the U.S. will develop PTSD in childhood • About 50% recover in the first 3 months

22. Other Stress-Related Disorders • 80% of people with PTSD also meet criteria for another mental disorder • Other disorders include adjustment disorder, depression, separation anxiety, general anxiety, attachment disorders, ADHD, and other behavior disorders.

23. When Trauma Interferes with Attachment • Pervasive Neglect and Persistent Disruption in Caregiving • Chronic institutionalization and/or neglect • RAD, Inhibited Type • Doesn’t attach; withdraws • Multiple placements • RAD, Disinhibited Type • Attaches indiscriminantly/superficially

24. When Trauma Interferes with Attachment • Fear Related to the Caregiver • Frightening caregiver (child abuse) • Hypercompliant, frozen watchfulness • Frightened caregiver (domestic violence) • Dysfunctional/erratic attention-seeking (not comfort-seeking) from distressed, unreliable caregiver

25. When Trauma Interferes with Attachment • Death/Loss of Caregiver • More devastating in early childhood than any other time in life span • Presence of other attachment figures can buffer impact of loss • Sequence of Behaviors • Protest • Despair • Detachment

26. When Trauma Interferes with Attachment • General Acute Trauma • Disrupted attachment is usually temporary and responsive to treatment • Possible behaviors: Clingy, whining, separation anxiety, stranger anxiety, hypervigilance, frozen watchfulness, excessive worry about well-being of others, resists leaving “secure” places

27. Helping Traumatized Children • Maintain normal routines as much as possible • Tolerate retellings of the event • Encourage children to express their traumatic experience • Handle disturbing reenactments carefully • Remain calm when answering questions and use simple, direct terms • Don’t “soften” the information you give to children • Avoid exposing children to unnecessary trauma reminders (e.g., media)

28. Helping Traumatized Children • Help children develop a realistic understanding of what happened • Gently correct misattributions (e.g., self-blame) about trauma • Be willing to repeat yourself • Normalize “bad” feelings • Expect angry outbursts • Address acting out behaviors involving aggression or self-destructive activities quickly and firmly • Be patient with children and yourself

29. Helping Traumatized Children • Reinforce ideas of safety and security • Allow them to be more dependent temporarily if needed • Follow their lead (hugs, listening, supporting) • Use typical soothing behaviors • Use security items and goodbye rituals to ease separation • Distract with pleasurable activities* • Let the child know you care *normally occurring

30. How to Talk (and Listen) to Traumatized Children • Children need to have their feelings accepted and respected • Listen quietly and attentively • Acknowledge their feelings with a word or two • Give their feelings a name • Give them their wishes in fantasy • Show empathy

31. Responses That ARE NOT So Helpful • Denial of feelings • Philosophical response • Advice • Too many questions • Defense of the other person • Pity • Amateur Psychoanalysis

32. Correcting Distorted Beliefs • Point out the child’s distorted belief by briefly summing it up • Label how you think they might feel • Validate their feeling; show empathy • Let them know how it makes you feel to hear the distorted belief • Suggest a healthier belief; keep it brief

33. Helping Parents of Traumatized Children • Communicate with parents frequently about child • Encourage parents to listen to child closely • Encourage parents to set aside special time for the child • Recommend maintenance of normal routine • Encourage parents to remain calm and to get help for themselves if needed • Normalize child’s emotional/behavioral difficulties after trauma • Model soothing behaviors with child • Assist in developing plan for behavior mgmt.

34. Grief in Infants and Toddlers • Experience a sense of “goneness” • Sleep/appetite disturbance • Fussy, irritable • Bowel/bladder disturbances • Difficult to comfort • May have difficulty reattaching to new caregivers

35. Grief in Preschoolers • Magical thinking (e.g., death is reversible) • Regressive behaviors • Reenact death in play • May express desire to die as well • Symptoms of grief may be inconsistent • Appetite/sleep disturbance

36. Grief in School Children • More likely to show depression, sadness • May see death as something tangible • Preoccupation with death • Begin to understand permanency of death, but may still behave as though deceased were still alive • May show aggression, other behavioral difficulties, concentration difficulties • May be anxious about wellbeing of other family members • Magical thinking remains prevalent

37. Tasks of Mourning • Accept the reality of the loss • Experience fully the pain of the loss • Adjust to an environment and self-identity without the deceased • Convert the relationship from one of live interactions to one of memory • Find meaning in the deceased’s death • Experience a continued supportive adult presence in the future

38. Helping Grieving Children • Don’t be afraid to talk about the death • Be prepared to discuss the same details over and over again • Be available, nurturing, reassuring and predictable • Assist child in developing grieving rituals and in finding meaning • Help others learn how to respond

39. Talking about Death with a Young Child • “Died” means person is not alive anymore. His/her body stopped working. He/she can’t breathe, walk, move, eat or do any of the things he/she could do when alive. It’s forever and he/she will never be alive again. • Use child’s (family’s) own belief system when discussing afterlife

40. Talking about Death with a Young Child • Share memories and talk about the person who died when appropriate • Gently remind children ALL feelings (anger, sadness, confusion, fear, relief, guilt) are okay. • Use reminders like “you did not cause this” or “it is not your fault.”

41. When to Refer Child for Psychiatric/Psychological Care Showing these changes for more than 3 months after trauma… • Behavior/Academic problems at school • Angry outbursts • Withdrawal from usual activities/play • Frequent nightmares, sleep disturbance • Physical problems (nausea, headaches, weight gain/loss) • Depression, hopelessness

42. When to Refer Child for Psychiatric/Psychological Care Showing these changes for more than 3 months after trauma • Intense anxiety or avoidance behavior triggered by trauma reminders • Continued worry about event (primary focus) • Failure to attend to personal hygiene • Excessive separation difficulties • Continued trauma themes in play

43. When to Refer Child forPsychiatric/Psychological Care • Significant ASD symptoms within first month of trauma • Unable to grieve/mourn because of trauma-related distress • Inappropriate social behaviors (e.g., sexual) • Unable to regulate emotions • Strong resistance to affection/support from caregivers • Dangerous behaviors to self/others

44. We’re done! Referrals for Assessment/Treatment: Children/Adolescents (314) 516-6798 Adults (314) 516-6737 Questions/References: Ally Burr-Harris at Burrharrisa@msx.umsl.edu