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Treating Children in Crisis Bobbi O’Kelley, MSCP Behavioral Health Clinician and Intake Manager North Star Hospital, Bragaw Campus April 2008. Treating Children in Crisis.

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Treating Children in CrisisBobbi O’Kelley, MSCPBehavioral Health Clinician and Intake ManagerNorth Star Hospital, Bragaw CampusApril 2008

treating children in crisis
Treating Children in Crisis
  • The word “crisis” was selected in this title to provide an all-encompassing word to describe children in distress…whether it be physical, emotional, psychological or otherwise (often times, all of the above).
  • This presentation primarily focuses on assisting children who experience psychological and/or emotional distress.
behavioral health perspectives

The term “Behavioral Health” has grown in popularity to describe various aspects of the psychology field including:

  • psychiatric disorders
  • substance abuse disorders
  • co-occurring (psychiatric and substance abuse) disorders – sometimes referred to as “dual diagnosis”
presentation points of interest
Presentation Points of Interest
  • Understanding Trauma and PTSD
  • Distinguishing Acuity Level in a Crisis
  • Treatment Options
  • De-escalation Techniques
  • After Care
  • Q & A
  • Quiz
  • References
  • Resources
what s in it for you
What’s in it for you?
  • The ideas contained in this presentation are designed to equip you with tools and knowledge that will assist you to effectively intervene with children in crisis or distress.
  • It is NOT designed for you to practice psychotherapy with children in crisis or distress, a separate approach that requires specialized training/education.
what is trauma
Typical traumatic events are natural calamities, violence, serious accidents, the death, injury, or serious illness of next of kin, and war-related stress.

Trauma is a painful emotional experience, or shock, that creates substantial and often lasting damage to the psychological development and well-being of the individual.

What is Trauma?
types of trauma in more detail
Types of Trauma in more detail
  • Examples of Natural Disasters

Earthquakes Tornadoes

Floods Mudslides

Volcanoes Avalanches

Fires Hurricanes

Tsunamis Heat Waves

types of trauma in more detail cont
(Types of Trauma in more detail Cont.)
  • Well Known Global Disasters


Hurricane Katrina (‘05)

Tsunami – Indian Ocean/SE Asia (‘04)

Earthquakes: Alaska ’64,

San Francisco, Kobe, Pakistan

Pandemic Flu – 1918, 1968


9-11 Twin Towers Attack (‘01)

Plane crash



types of trauma in more detail cont1
(Types of Trauma in more detail Cont.)

Beyond natural disaster or war,

trauma comes in a variety of

“packages” including, but not limited to:

- domestic violence

- seeing someone (or animal) die or get injured

- heightened conflict between any two or more persons

- seeing or being in a vehicle, airplane or ATV accident

- experiencing or seeing abuse of any kind, including neglect

- rape or sexual exploitation

- school violence

- scary movies/films

what is trauma cont
Traumatic events are exceptional situations of helplessness & distress that a person experiences at first hand, witness or hears about, and which jeopardize the physical and/or psychological integrity of the individual or those close to him/her.

Trauma can appear after a single event, a series of events, or a particularly upsetting period of life of a traumatic nature.

(What is Trauma? Cont.)
post traumatic stress disorder
Post-Traumatic Stress Disorder

How do you know when a child has PTSD?

in this section you will learn what to look for when determining if a child suffers from ptsd
In this section, you will learn what to look for when determining if a child suffers from PTSD

Helpful points to remember

  • If a child has endured a traumatic event, or series of events, s/he may not necessarily have a diagnosis of PTSD but may still be in crisis.
  • It is helpful to understand the signs and symptoms of PTSD in order to best assist those responding to trauma.
  • It is a good idea to do a thorough screening for each child as trauma, like grief, is processed differently depending on the individual.
ptsd signs and symptoms per the dsm iv tr
PTSDSigns and Symptoms per the DSM-IV-TR

General Signs/Symptoms

  • Distress affecting social, occupational or other major areas of functioning
  • The person experienced or

witnessed a life-threatening event

  • Duration of disturbance exceeds one month
general signs symptoms cont
  • Social, Occupational and Other Areas of Functioning Affected may include:
    • Tantrums (beyond normal development)
    • Disinterest in once-enjoyed activities
    • Difficulty making/keeping friends
    • Minimal interaction with others
    • Increased sibling rivalry
    • Poor concentration
    • Limited or no play
    • Dropping grades
    • Restlessness
a tragic day for susie
A Tragic Day for Susie

Scenario: Susie is 7 years old. She remembers the way the raindrops hit the harbor’s calm waters that morning. As she was getting her red rubber boots and yellow slicker on, Susie heard a loud thunderous sound followed by yelps not only in her house but out on the street. Susie dashed outside to find the villagers running and shouting “tsunami!” while the family radio reported a recent earthquake 150 miles southeast of this ordinarily peaceful community. Susie knew something was terribly wrong. It dawned on her that her dad, uncle, and little brother had left early that morning to go fishing. Susie would soon find out that they, and 15 other villagers, had perished leaving her, her mom and new baby brother...

ptsd signs symptoms cont revisiting the event s
(PTSD Signs/Symptoms cont.)Revisiting the Event(s)
  • Recurrent distressing recollections

of event i.e. images, thoughts

  • Acting or feeling as if the

traumatic event was

recurring i.e. flashbacks

  • Intense psychological distress

at exposure to cues that

resemble event

  • Repetitive play in which themes

of trauma may be expressed

revisiting the event s continued
(Revisiting the Event(s) Continued)

Using Susie’s story…

Example of distressing recollections of event:

Susie cannot stop hearing the radio blaring news of the earthquake in her mind.

Example of acting or feeling as if the

traumatic event was recurring:

Susie’s heart rate begins to race at the sight of the ocean’s (usual) waves rolling in.

revisiting the event s continued1
(Revisiting the Event(s) Continued)

Example of intense psychological distress at exposure to cues:

Every time Susie puts her red boots and yellow slicker on, she feels like disaster is imminent.

Example of repetitive play in which themes

of trauma may be expressed:

Susie makes a boat out of clay and uses her Barbie doll to pretend to save her dad, uncle and brother.

ptsd signs symptoms cont behavioral functional impairments
Disorganized or agitated behavior

Response includes intense horror, helplessness or fear

Persistent avoidance of stimuli associated with trauma

Symptoms of increased arousal i.e. poor sleep and concentration, anger

(PTSD Signs/Symptoms cont.)Behavioral/Functional Impairments
behavioral functional impairments continued
(Behavioral/Functional Impairments Continued)

Example of Disorganized or agitated behavior:

Upon cleaning her room, Susie experiences unexplained rage and throws all of her clothes on the floor.

Example of horror, helplessness or fear:

Susie goes for a walk with her mom and baby brother on the docks and begins screaming uncontrollably when the rain starts to fall.

behavioral functional impairments continued1
(Behavioral/Functional Impairments Continued)

Example of Persistent avoidance of stimuli associated with trauma:

Susie gets invited to go fishing every week-end for a month and vehemently refuses to go each time.

Example of Symptoms of increased arousal:

Susie establishes a pattern of not falling asleep right away at bedtime frequently calling for her mom and needing reassurance.

ptsd types
PTSD Types

Onset and Duration of PTSD

Acute: when the duration of symptoms is less than 3 months.

Chronic: when the symptoms last 3 months or longer.

Delayed Onset: at least 6 months have passed between the traumatic event and the onset of the symptoms.

ptsd types1
PTSD Types
  • In cases of trauma addressed so far, i.e. natural disaster, acute type would be most pertinent for the purposes of this training.
  • If a child’s PTSD has evolved from acute to chronic type, longer term psychotherapy is likely needed/recommended.
  • Immediate intervention would not be relevant for delayed onset type.
recognizing acuity in trauma
Recognizing Acuity in Trauma

Questions to ask in a crisis:

- Can this crisis be

managed safely at home?

- Is the child at imminent

risk for further harm?

- What supports and/or

resources are currently in

place for this child?

recognizing acuity or potential for harm
Recognizing Acuity or Potential for Harm
  • When you are making a determination about whether or not the child can be kept safe at home, it is important to obtain information from the child (if the child is able to communicate) and from the caregiver or parent directly.
  • Be alerted to statements like (parent): “my child is totally out of control” or “as soon as I turn my back, my child does something dangerous”; (child) “I just don’t see any point in living anymore” or “at least if I died, I could be with my sister again”. These statements, or variations of statements like these, should be taken seriously.
  • A child or caregiver/parent revealing the potential for harm to self or others should be calmly met with compassion and concern by the provider.
how might you know that there is imminent risk for the child
How might you know that there is imminent risk for the child?
  • Suicidal or homicidal statements/gestures
  • Self-harming statements/gestures
  • Reports of high risk behaviors
  • Self-Medicating
  • Aggressive toward others
  • Active psychosis i.e. hallucinations
  • Unable to manage self-control; impulsive
  • Depressive symptoms affecting basic functioning
  • Unsafe and/or destructive behaviors in the community

* Corresponding examples on next slide…

imminent risk for the child cont
(imminent risk for the child cont.)

Detailed Scenarios of High Risk Behaviors:

  • The child states “I wish I was dead”
  • Cuts are discovered on the child’s arm
  • Neighbor reports that the child snuck out at midnight
  • The child comes home reeking of marijuana
  • Principal and teacher report fist fight at lunch
  • The child reports hearing voices others can’t hear
  • Shopkeeper nabs child for shoplifting soda
  • Sleep and diet take a turn for the worse
  • Policeman arrests the child for slashing tires
treatment options
Treatment Options

- Inpatient Hospitalization

- Medication

- Crisis Intervention

- Safety Planning

- Outpatient Counseling/Therapy

- Play Therapy

- Art Therapy

- Family Therapy

- School Counselor

- Pastoral Counseling

treatment options cont
(Treatment Options Cont.)

Inpatient Hospitalization

Medication: a tool prescribed by a psychiatrist, or regular doctor, to stabilize mood, assist with anxiety, help sleep, and/or curb other symptoms

Crisis Intervention: provider or parental efforts to safely lessen the intensity of an emergency situation

Safety Planning: a measure or tool created in conjunction with a treatment team, i.e. nurse, doctor, & therapist, to teach a child and family how to safely manage a crisis

treatment options cont1
(Treatment Options Cont.)

Outpatient Counseling/Therapy

Play Therapy: A more natural means of expression to work through traumatic or other issues

Art Therapy: Art supplies are used to assist children work through traumatic or other issues

Family Therapy: Assist child & family members with tools, i.e. communication, to more effectively cope at home

treatment options cont2
(Treatment Options Cont.)

School Counselor – this avenue provides an outlet in which to obtain support in

the school setting

Pastoral Counseling – reflective of

the family belief structure, pastoral

counseling can serve as spiritual

support and guidance

de escalation techniques and tips assisting children with coping skills
De-Escalation Techniques and TipsAssisting Children with Coping Skills

Self Time-out


Deep Breathing

de escalation techniques cont
(De-Escalation Techniques Cont.)

Self Time-out: Suggesting a self time-out allows the child to remove him or herself from a situation that is creating distress.

Journaling: Encouraging writing as a tool to express thoughts and feelings can be a helpful alternative to spoken communication.

Deep Breathing: Taking deep breaths is helpful to a child that is growing agitated or angry – 10 deep breaths can do wonders!

de escalation techniques cont ideas for providers

Validation of Feelings


Guided Imagery


(De-Escalation Techniques Cont.)Ideas for Providers
ideas for providers cont
(Ideas for Providers Cont.)

Example of what you might say to a child by using a normalizing technique…

“Susie, it is normal to

feel angry when those you love die.”

ideas for providers cont1
(Ideas for Providers Cont.)

Example of what you might say to a child by using validation of feelings…

“It’s okay to cry and

feel sad. I see that

you are upset and

having a hard time.”

ideas for providers cont2
(Ideas for Providers Cont.)

Redirection: An example would be to take a child who is angry and direct them to a different activity i.e.

“let’s go over here and water paint.”

Guided Imagery: This may take a little more

prep, i.e. using a CD, to assist the child to

“visit” a place that is calm and peaceful.

Reflection: This simply means that you echo

what the child expresses, i.e. “I hear that you

feel sad, Susie…”

creative outlets for children cont
(Creative Outlets for Children Cont.)

“The most effective kind of

education is that a child

should play amongst

lovely things”

- Plato

after care considerations
After-Care Considerations

If a child has been hospitalized for acute symptoms/behaviors…

- Assist family with discharge planning

- Discuss child’s support system

- Address medication and outpatient services

- Recommend family therapy

- Create a safety plan

Q & A

Are there any


are you ready to take the quiz
Are you ready to take the Quiz?

1.The term “behavioral health” is best

described by the following (select one):


b. psychiatric disorders

c. substance abuse and

co-occurring disorders

d. b and c

e. none of the above

quiz cont
(Quiz Cont.)

2. “PTSD” stands for (select one): a. post-traumatic stress


b. post test savory dessert

c. post-traumatic stress


d. post-traumatic strain


e. none of the above

quiz cont1
(Quiz Cont.)

3. A child that merely witnesses, but does

not experience first-hand, a traumatic

event would not develop PTSD.

(select one)



quiz cont2
(Quiz Cont.)

4. Which of the following

PTSD types is most

pertinent to providers

intervening in a crisis?

a. acute

b. delayed onset

c. chronic

d. b and c

e. none of the above

quiz cont3
(Quiz Cont.)

5. A child who sees an image of

a traumatic event in her dream

state likely suffers from…

a. behavioral impairments

b. general signs and symptoms

c. revisiting the event

d. a and b

e. none of the above

quiz cont4
(Quiz Cont.)

6. Examples of Imminent Risk include all

examples except the following (select one):

a. expressing wanting to die

b. consuming alcohol as a minor

c. riding a four-wheeler

d. spray-painting graffiti after curfew

e. skipping two meals a day

quiz cont5
(Quiz Cont.)

7. Family Therapy is only utilized in an inpatient hospital setting.



quiz cont6
(Quiz Cont.)

8. All of the following examples are

de-escalation techniques except

one (select one):

a. journaling

b. deep breathing

c. watching television

d. self time-out

quiz cont7
(Quiz Cont.)

9. The following statement is an example of what type of technique?

“Joey, it is common to feel sad

when your puppy runs away.”

a. reflection

b. guided imagery

c. validation of feelings

d. insensitivity

e. normalizing

quiz cont8
(Quiz Cont.)

10. Discussing a child’s support system

is an important after-care consideration

following hospitalization.





books on the subject
Books on the Subject

Young Children and Trauma: Intervention and Treatment by Joy D. Osofsky

Helping Children Cope With Disasters and Terrorism by Annette M. LA Greca,

Wendy K. Silverman, Eric M. Vernberg, and Michael C. Roberts

Trauma in the Lives of Children: Crisis and Stress Management Techniques for

Counselors, Teachers, and Other Professionals by Kendall Johnson and Charles Figley

Children and Trauma: A Guide for Parents and Professionals by Cynthia Monahon

Understanding and Assessing Trauma in Children and Adolescents: Measures, Methods,

and Youth in Context (Psychosocial Stress Series) by Kathleen Nader

Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems

Therapy Approach by Glenn N. Saxe, B. Heidi Ellis,

and Julie B. Kaplow

I Am a Survivor: A Child's Workbook About Surviving

Disasters by Wendy Deaton and Kendall Johnson