Helping Traumatized Children: An Overview For Caregivers
By: Bruce D. Perry, M.D., Ph.D.
1. Should I talk about the traumatic event?
Do not be afraid to talk about the traumatic event. Children do not benefit from 'not thinking about it' or 'putting it out of their minds.’ If a child senses that her caregivers are upset about the event, she will not bring it up. In the long run, this only makes the child's recovery more difficult. A good rule of thumb is to let the child guide when you talk about it. If the child doesn’t ask about or mention it, don’t bring it up on your own, but when the child brings it up or seems to be thinking about it (see below), don't avoid discussion.
Listen to the child, answer questions, provide comfort and support. We often have no adequate explanations about senseless death or traumatic events. It is just fine to tell children that you do not know why something happened or that you get confused and upset by it, too. In the end, listening and comforting a child without avoiding or over-reacting will have long-lasting positive effects on the child’s ability to cope with trauma.
2. How should I talk about the event?
Use age-appropriate language and explanations. The timing and language used are important. Immediately following the trauma, the child will not be very capable of processing complex or abstract information (see Table). As the child gets further away from the event, she will be able to focus longer, digest more and make more sense of what has happened. Sometimes young children act as if they have not ‘heard’ anything you have said. It takes many individual many moments of sad clarity or the reality of the trauma to actually sink in for young children. Between these moments of harsh reality, children use a variety of coping techniques – some of which can be confusing or upsetting for adults.
During this long process, the child continues to ‘re-experience’ the traumatic event. In play, drawing and words, the child may repeat, re-enact and re-live some elements of the traumatic loss. Surviving adults will hear children ask the same questions again and again. They may be asked to describe ‘what happened’ again and again. The child may develop profound ‘empathic’ concerns for others experiencing trauma, including cartoon characters and animals. "Is Mickey Mouse scared?" Or as they put their stuffed animals under the bed, they may explain "They have to go hide because the bad guy is coming with a gun."
The child will experience and process the very same material differently at different times following the trauma. In the long run, the opportunity to process and re-process many times will facilitate healthy coping. This re-processing may take place throughout the development of a given child. Even years after the original trauma, a child may ‘revisit’ the loss and struggle to understand it from their current developmental perspective. An intensity of emotional feelings will often be seen on various anniversary dates following the trauma (e.g., one week, one month and one year). Children may develop unusual fears of specific days – "Bad things happen on Fridays."
One of the most important elements in this process is that children of different ages have different styles of adapting and different abilities to understand abstract concepts often associated with trauma such as death, hate or the randomness of a tornado’s path or a drunk driver hitting their car.
3. Should I talk to others about the traumatic event?
Yes. Inform adults and children in the child's world what has happened. Let teachers, counselors, parents of the child's friends and, if appropriate, the child's peers know some of the pain that this child is living with. Sometimes this can allow the people in the child's life to give them the small amount of tolerance, understanding or nurturing that will smooth the way. People can often be intolerant or insensitive when dealing with the traumatized child "Isn't it about time they got over this?" When you see that this is occurring don't be shy about taking this person aside and educating them about the long-lasting effects of traumatic events and the long process of recovery.
4. How long do these reactions last?
An acute post-traumatic change in feeling, thinking and behaving is normal – persistence or extreme symptoms are not. Many clinicians working with traumatized have noted that the persistence of symptoms beyond three months is associated with increased risk for problems. If symptoms of re-experiencing, avoidance, fearfulness, sleep problems, nightmares, sadness or poor school or social functioning persist beyond three months, they need to be addressed. If they persist for six months or if the symptoms interfere with any aspect of functioning, you should have the child see a professional. If the child is in therapy, communicate this with the therapist. Find out if school performance has been affected. Watch for changes in patterns of play and loss of interest in activities. Be observant. Be patient. Be tolerant. Be sympathetic. These children have been terrified and hurt.
In many cases, some form of post-traumatic symptom can last for many years. Indeed, more than thirty percent of children living through traumatic stress develop some form of post-traumatic stress disorder (PTSD). This is a chronic disorder requiring the attention of mental health professionals.
5. Do children understand events accurately?
Young children often make false assumptions about the causes of major events. Unfortunately these assumptions may include some sense that they were at fault for the event -- including the death of a loved one. Adults often assume that causality is clear -- dying in a car accident, being shot in a drive-by shooting, dying in a fire. The child may very easily distort an event and make the wrong conclusions about causality. Mom died in the car accident because she was coming to get me at school. The other driver was mad at her. My brother is dead because he was helping me with my homework. The person that shot my brother was shooting at me and hit my brother because he was in my room. The tornado was God's way of punishing my family. In many of these distorted explanations, children assume some degree of responsibility for some element of the traumatic event. This can lead to very destructive and inappropriate feelings of guilt.
Be clear. Explore the child's evolving sense of causality. Correct and clarify as you see false reasoning develop. Over time, the ability of the child to cope is related to the ability of the child to understand. While some elements of trauma seem beyond understanding, this can be explained to a child -- some things we don't know. Don't let the child develop a sense that there is a secret about the event -- this can be very destructive. Let the child know that adults can not and will not understand some things either.
6. Do all children have problems after traumatic events?
The majority of children experiencing trauma will have some change in their behaviors and their emotional functioning. In addition to the symptoms listed above, these children will often be more irritable, tired and regressed.
Fortunately, however, for the majority of these children these symptoms are short-lived. Some children may exhibit no easily observable changes in their thinking, feeling or behaving. In general, the more threatened a child felt, the closer they were to injury or death, the more the event disrupted or traumatized their family or community, the more likely there will be symptoms. In some cases, children’s symptoms do not show up for many weeks or even months after the traumatic event, confusing many caregivers. Indeed, in these cases, caregivers or teachers may not even make a connection between the symptoms and the traumatic event.
How can I help?
1. Don’t be afraid to talk about the traumatic event. Children do not benefit from 'not thinking about it' or 'putting it out of their minds'. If a child senses that his/her caretakers are upset about the event, they will not bring it up. In the long run, this only makes the child's recovery more difficult. Don't bring it up on your own, but when the child brings it up, don't avoid discussion, listen to the child, answer questions, provide comfort and support. We often have no good verbal explanations, but listening and not avoiding or over-reacting to the subject and then comforting the child will have a critical and long-lasting positive effect.
2. Provide a consistent, predictable pattern for the day. Make sure the child has a structure to the day and knows the pattern. Try to have consistent times for meals, school, homework, quiet time, playtime, dinner and chores. When the day includes new or different activities, tell the child beforehand and explain why this day's pattern is different. Don't underestimate how important it is for children to know that their caretakers are 'in control.' It is frightening for traumatized children (who are sensitive to control) to sense that the people caring for them are, themselves, disorganized, confused and anxious. There is no expectation of perfection; caretakers themselves have often been effected by the trauma and may be overwhelmed, irritable or anxious. If you find yourself being this way, simply help the child understand why, and that these reactions are normal and will pass.
3. Be nurturing, comforting and affectionate, but be sure that this is in an appropriate 'context.’ For children traumatized by physical or sexual abuse, intimacy is often associated with confusion, pain, fear and abandonment. Providing 'hugs', kisses and other physical comfort to younger children is very important. A good working principle for this is to be physically affectionate when the child seeks it. When the child walks over and touches you, return in kind. The child will want to be held or rocked – feel free. On the other hand, try not to interrupt the child's play or other free activities by grabbing them and holding them. Further, be aware that many children from chronically distressed settings may have what we call attachment problems. They will have unusual and often inappropriate styles of interacting.
Do not tell or command them to 'give me a kiss' or 'give me a hug.' Abused children often take commands very seriously. It reinforces a very malignant association linking intimacy/physical comfort with power (which is inherent in a caregiving adult's command to 'hug me').
4. Discuss your expectations for behavior and your style of 'discipline' with the child. Make sure that there are clear 'rules' and consequences for breaking the rules. Make sure that both you and the child understand beforehand the specific consequences for compliant and non-compliant behaviors. Be consistent when applying consequences. Use flexibility in consequences to illustrate reason and understanding. Utilize positive reinforcement and rewards. Avoid physical discipline.
5. Talk with the child. Give them age appropriate information. The more the child knows about who, what, where, why and how the adult world works, the easier it is to 'make sense' of it. Unpredictability and the unknown are two things which will make a traumatized child more anxious, fearful, and therefore, more symptomatic. They may be more hyperactive, impulsive, anxious, aggressive and have more sleep and mood problems. Without factual information, children (and adults) 'speculate' and fill in the empty spaces to make a complete story or explanation. In most cases, the child's fears and fantasies are much more frightening and disturbing than the truth. Tell the child the truth, even when it is emotionally difficult. If you don't know the answer yourself, tell the child. Honesty and openness will help the child develop trust.
6. Watch closely for signs of re-enactment (e.g., in play, drawing, behaviors), avoidance (e.g., being withdrawn, daydreaming, avoiding other children) and physiological hyper-reactivity (e.g., anxiety, sleep problems, behavioral impulsivity). All traumatized children exhibit some combination of these symptoms in the acute post-traumatic period. Many exhibit these symptoms for years after the traumatic event. When you see these symptoms, it is likely that the child has had some reminder of the event, either through thoughts or experiences. Try to comfort and be tolerant of the child's emotional and behavioral problems. These symptoms will wax and wane - sometimes for no apparent reason. The best thing you can do is to keep some record of the behaviors and emotions you observe (keep a diary) and try to observe patterns in the behavior.
7. Protect the child. Do not hesitate to cut short or stop activities that are upsetting or re-traumatizing for the child. If you observe increased symptoms in a child that occur in a certain situation or following exposure to certain movies, activities and so forth, avoid these activities. Try to restructure or limit activities that cause escalation of symptoms in the traumatized child.
8. Give the child 'choices' and some sense of control. When a child, particularly a traumatized child, feels that they do not have control of a situation, they will predictably get more symptomatic. If a child is given some choice or some element of control in an activity or in an interaction with an adult, they will feel more safe, comfortable and will be able to feel, think and act in a more 'mature' fashion. When a child is having difficulty with compliance, frame the 'consequence' as a choice for them - "You have a choice- you can choose to do what I have asked or you can choose….." Again, this simple framing of the interaction with the child gives them some sense of control and can help defuse situations where the child feels out of control and therefore, anxious.
9. If you have questions, ask for help. These brief guidelines can only give you a broad framework for working with a traumatized child. Knowledge is power; the more informed you are, the more you understand the child, the better you can provide them with the support, nurturing and guidance they need. Take advantage of resources in your community. Each community has agencies, organizations and individuals coping with the same issues. They often have the support you may need.