Traumatized Children

When Children Grieve

Supporting Our Grieving Youth

Identifying Seriously Traumatized Children:
Tips for Parents and Educators

National Association of School Psychologists

Events such as the Oklahoma City bombing, terrorist attacks in New York and Washington, DC, and even natural disasters such as tornadoes and floods place everyone at risk for some degree of trauma reaction. It is normal and expected that most children will experience some symptoms of acute distress—shock, crying, anger, confusion, fear, sadness, grief and pessimism. Depending on circumstances, particularly the additional trauma of loss of family members, most children will experience a gradual lessening of these symptoms over the days and weeks following the event and will be able to resume normal routines and activities with little change in performance. However, a large-scale crisis event places a significant number of children are at risk for severe stress reactions.

It is important to recognize that severe psychological distress is not simply a consequence of experiencing a threatening and/or frightening event; it is also a consequence of how a child experiences the event, coupled with his or her own unique vulnerabilities. If a child you are teaching or caring for has had experiences and risk factors such as those described below, you may need to consider a referral to a mental health professional such as a school psychologist or a private practitioner.

The Child’s Experience With Trauma

How traumatic is the event for a given child? The degree of psychological distress is associated with several factors:

Exposure. The closer a child is to the location of a threatening and/or frightening event, and the longer the exposure, the greater the likelihood of severe distress. Thus children living near, or whose parents work at or near, the site terrorist attacks, a school shooting, or a severe tornado are at greater risk than children living far away. However, for many children, the length of exposure is also extended by repeated images on television, regardless of their location.
Relationships. Having relationships with the victims of a disaster (i.e., those who were killed, injured, and/or threatened) is strongly associated with psychological distress. The stronger the child’s relationships with the victims, the greater the likelihood of severe distress. Children who lost a caregiver are most at risk.
Initial reactions. How children first respond to trauma will greatly influence how effectively they deal with stress in the aftermath. Those who display more severe reactions (e.g., become hysterical or panic) are at greater risk for the type of distress that will require mental health assistance.
Perceived threat. The child’s subjective understanding of the traumatic event can be more important than the event itself. Simply stated, severely distressed children will report perceiving the event as extremely threatening and/or frightening. Among the factors influencing children’s threat perceptions are the reactions of significant adult caregivers. Events that initially are not perceived as threatening and/or frightening may become so after observing the panic reactions of parents or teachers. In addition, it is important to keep in mind that children may not view a traumatic event as threatening because they are too developmentally immature to understand the potential danger. Conversely, unusually bright children may be more vulnerable to stress because they understand the magnitude of a disaster.

Personal Factors Related to Severe Distress

Personal experiences and characteristics can place children at risk for severe stress reactions following traumatic events. These include the following

Family factors. Children who are not living with a nuclear family member, have been exposed to family violence, have a family history of mental illness, and/or have caregivers who are severely distressed by the disaster are more likely themselves to be severely distressed.
Social factors. Children who must face a disaster without supportive and nurturing friends or relatives suffer more than those who have at lease one source of such support.
Mental health. The child who had mental health problems (such as depression or anxiety disorders) before experiencing a disaster will be more likely to be severely distressed by a traumatic event.
Developmental level. Although young children, in some respects, may be protected from the emotional impact of traumatic events (because they don’t recognize the threat), once they perceive a situation as threatening, younger children are more likely to experience severe stress reactions than are older children.
Previous disaster experience. Children who have experienced previous threatening and/or frightening events are more likely to experience severe reactions to a subsequent disaster event severe psychological distress.

Symptoms of Severe Stress Disorders

The most severely distressed children are at risk for developing conditions known as Acute Stress Disorder (ASD) or Posttraumatic Stress Disorder (PTSD). Only a trained mental health professional can diagnose ASD and/or PTSD, but there are symptoms that parents, teachers, and caregivers can look out for in high-risk children. Symptoms for ASD and PTSD are similar and include:

Re-experiencing of the trauma during play or dreams. For example, children may: repeatedly act out what happened when playing with toys; have many distressing dreams about the trauma; be distressed when exposed to events that resemble the trauma event or at the anniversary of the event; act or feel as if the event is happening again.
Avoidance of reminders of the trauma and general numbness to all emotional topics. For example, children may avoid all activities that remind them of the trauma; withdraw from other people; have difficulty feeling positive emotions.
Increased "arousal" symptoms. For example, children may have difficulty falling or staying asleep; be irritable or quick to anger; have difficulty concentrating; startle more easily.

ASD is distinguished from PTSD primarily in terms of duration. Symptoms of ASD occur within four weeks of the traumatic event, but then go away. If a youngster is diagnosed with ASD and the symptoms continue beyond a month, your child’s mental health professional may consider changing the diagnosis to PTSD.

Know the Signs and Get Help if Necessary

Parents and other significant adults can help reduce potentially severe psychological effects of a traumatic event by being observant of children who might be at greater risk and getting them help immediately. Knowledge of the factors that can contribute to severe psychological distress (e.g., closeness to the disaster site, familiarity with disaster victims, initial reactions, threat perceptions and personal vulnerabilities) can help adults distinguish those children who are likely to manage their distress more or less independently from those who are likely to have difficulties that may require mental health assistance.

The mental health service providers who are part of the school system—school psychologists, social workers and counselors—can help teachers, administrators and parents identify children in need of extra help and can also help identify appropriate referral resources in the community. Distinguishing “normal” from extreme reactions to trauma requires training and any concern about a child should be referred to a mental health professional.

For further information about the signs and symptoms of AST and PTSD in children and adolescents, please refer to the National Center for PTSD at the following website: http://www.ncptsd.org/facts/specific/fs_children.html or the National Association of School Psychologists www.nasponline.org

Adapted from “Identifying Psychological Trauma Victims,” by Stephen E. Brock . In Best Practices in School Crisis Prevention and Intervention, edited by S. E. Brock, P. J. Lazarus, and S. J. Jimerson (2001), National Association of School Psychologists. Modified from the article posted on the NASP website in September 2001.

Helping Children Cope with Loss, Death and Grief

Excerpt from National Association of School Psychologists (www.nasponline.org)

Death and Grief: Supporting Children and Youth
Death and loss within a school community can affect anyone, particularly children and adolescents. Whether the death of a classmate, family member, or staff member, students may need support in
coping with their grief. Reactions will vary depending on the circumstances of the death and how wellknown the deceased is both to individual students and to the school community at-large. Students who
have lost a family member or someone close to them will need particular attention. It is important for adults to understand the reactions they may observe and to be able to identify children or adolescents
who require support. Parents, teachers, and other caregivers should also understand how their own grief reactions and responses to a loss may impact the experience of a child.

GRIEF RESPONSES IN CHILDREN:
There is no right or wrong way to react to a loss. No two individuals will react in exactly the same way. Grief reactions among children and adolescents are influenced by their developmental level, personal characteristics, mental health, family and cultural influences, and previous exposure to crisis, death, and loss. However, some general trends exist that can help adults understand typical and atypical reactions of bereaved children. Sadness, confusion, and anxiety are among the most common grief responses and are likely to occur for children of all ages.

The Grief Process
Although grief does not follow a specified pattern, there are common stages that children and adolescents may experience with varying sequencing and intensity. The general stages of the grief process are:
· Denial (unwillingness to discuss the loss)
· Anger or guilt (blaming others for the loss)
· Sorrow or depression (loss of energy, appetite, or interest in activities)
· Bargaining (attempts to regain control by making promises or changes in one’s life)
· Acceptance or admission (acceptance that loss is final, real, significant, and painful)

Grief Reactions of Concern

The above behaviors are expected and natural reactions to a loss. However, the following behaviors may
warrant further attention:

Preschool Level:
· Decreased verbalization
· Increased anxiety (e.g., clinginess, fear of separation)
· Regressive behaviors (e.g., bedwetting, thumb sucking)

Elementary school level:
· Difficulty concentrating or inattention
· Somatic complaints (e.g., headaches, stomach problems)
· Sleep disturbances (e.g., nightmares, fear of the dark)
· Repeated telling and acting out of the event
· Withdrawal
· Increased irritability, disruptive behavior, or aggressive behavior
· Increased anxiety (e.g., clinging, whining)
· Depression, guilt, or anger

Middle and high school level:
· Flashbacks
· Emotional numbing or depression
· Nightmares
· Avoidance or withdrawal
· Peer relationship problems
· Substance abuse or other high-risk behavior

Signs That Additional Help Is Needed
Adults should be particularly alert to any of the following as indicators that trained mental health professional (school psychologist or counselor) should be consulted for intervention and possible referral:

Severe loss of interest in daily activities (e.g., extracurricular activities and friends)
Disruption in ability to eat or sleep
School refusal
Fear of being alone
Repeated wish to join the deceased
Severe drop in school achievement
Suicidal references or behavior

Risk Factors for Increased Reactions
Some students (and adults) may be a greater risk for grief reactions that require professional intervention. This includes individuals who:

Were very close to the person(s) who died
Were present when the person died
Have suffered a recent loss
Have experienced a traumatic event
Are isolated or lack a personal support network
Suffer from depression, Posttraumatic Stress Disorder, or other mental illness

Keep in mind that groups, particularly adolescents, can experience collective or even vicarious grief. Students may feel grief, anxiety or stress because they see classmates who were directly affected by a loss, even if they didn’t personally know the deceased. Additional risk factors include the deceased being popular or well-known, extensive media coverage, a sudden or traumatic death, homicides or suicides.

SUPPORTING GRIEVING CHILDREN AND YOUTH

How adults in a family or school community grieve following a loss will influence how children and youth grieve. When adults are able to talk about the loss, express their feelings, and provide support for children and youth in the aftermath of a loss, they are better able to develop healthy coping strategies. Adults are encouraged to:

Talk about the loss. This gives children permission to talk about it, too.
Ask questions to determine how children understand the loss, and gauge their physical and emotional reactions.
Listen patiently. Remember that each person is unique and will grieve in his or her own way.
Be prepared to discuss the loss repeatedly. Children should be encouraged to talk about, act out, or express through writing or art the details of the loss as well as their feelings about it, about the deceased person, and about other changes that have occurred in their lives as a result of the loss.
Give children important facts about the event at an appropriate developmental level. This may include helping children accurately understand what death is. For younger children, this explanation might include helping them to understand that the person’s body has stopped working and will never work.
Help children understand the death and intervene to correct false perceptions about the cause of the event, ensuring that they do not blame themselves or others for the situation.
Provide a model of healthy mourning by being open about your own feelings of sadness and grief.
Create structure and routine for children so they experience predictability and stability.
Take care of yourself so you can assist the children and adolescents in your care. Prolonged, intense grieving or unhealthy grief reactions (such as substance abuse) will inhibit your ability to provide adequate support.
Acknowledge that it will take time to mourn and that bereavement is a process that occurs over months and years. Be aware that normal grief reactions often last longer than six months, depending on the type of loss and proximity to the child.
Take advantage of school and community resources such as counseling, especially if children and youth do not seem to be coping well with grief and loss.

TIPS FOR CHILDREN AND TEENS WITH GRIEVING FRIENDS AND CLASSMATES
Seeing a friend try to cope with a loss may scare or upset children who have had little or no experience with death and grieving. Some suggestions teachers and parents can provide to children and youth to deal with this “secondary” loss:

Particularly with younger children, it will be important to help clarify their understanding of death. See tips above under “helping children cope.”
Seeing their classmates’ reactions to loss may bring about some fears of losing their own parents or siblings. Children need reassurance from caretakers and teachers that their own families are safe. For children who have experienced their own loss (previous death of a parent, grandparent, sibling), observing the grief of a friend can bring back painful memories. These children are at greater risk for developing more serious stress reactions and should be given extra support as needed.
Children (and many adults) need help in communicating condolence or comfort messages. Provide children with age-appropriate guidance for supporting their peers. Help them decide what to say (e.g., “Steve, I am so sorry about your father. I know you will miss him very much. Let me know if I can help you with your paper route….”) and what to expect (see “expressions of grief” above).
Help children anticipate some changes in friends’ behavior. It is important that children understand that their grieving friends may act differently, may withdraw from their friends for a while, might seem angry or very sad, etc., but that this does not mean a lasting change in their relationship.
Explain to children that their “regular” friendship may be an important source of support for friends and classmates. Even normal social activities such as inviting a friend over to play, going to the park, playing sports, watching a movie, or a trip to the mall may offer a much needed distraction and sense of connection and normalcy.
Children need to have some options for providing support—it will help them deal with their fears and concerns if they have some concrete actions that they can take to help. Suggest making cards, drawings, helping with chores or homework, etc. Older teens might offer to help the family with some shopping, cleaning, errands, etc., or with babysitting for younger children.
Encourage children who are worried about a friend to talk to a caring adult. This can help alleviate their own concern or potential sense of responsibility for making their friend feel better. Children may also share important information about a friend who is at risk of more serious grief reactions.
Parents and teachers need to be alert to children in their care who may be reacting to a friend’s loss of a loved one. These children will need some extra support to help them deal with the sense of frustration and helplessness that many people are feeling at this time.

Adapted from “Death and Grief in the Family: Tips for Parents” in Helping Children at Home and School
III, NASP, 2010 and from materials posted on the NASP website after September 11, 2001.
© 2010, National Association of School Psychologists, 4340 East West Highway, Suite 402,
Bethesda, MD 20814, www.nasponline.org

lisa@griefspeaks.com