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 persons physical
  integrity
• Involves feelings of intense fear, helplessness
  or horror (children may show disorganized or
  agitated behavior instead)

3
Types of Traumas

• 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

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 (numbltgtrage)
• 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 gt 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.

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When Trauma Interferes with Attachment

• Pervasive Neglect and Persistent Disruption in
  Caregiving
• Chronic institutionalization and/or neglect
• RAD, Inhibited Type
• Doesnt 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

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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
• Dont 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

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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 childs 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 childs 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 deceaseds death
• Experience a continued supportive adult presence
  in the future

38
Helping Grieving Children

• Dont 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 cant breathe, walk,
  move, eat or do any of the things he/she could do
  when alive. Its forever and he/she will never be
  alive again.
• Use childs (familys) 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

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Were done!

• Referrals for Assessment/Treatment
• Children/Adolescents [phone]
• Adults [phone]
• Questions/References
• Ally Burr-Harris at Burrharrisa_at_msx.umsl.edu