Children, Community Violence and Post-Traumatic Stress

Deborah Wasserman

Department of Human Development & Family Science

The Ohio State University

Carol Ford Arkin, Ph.D.

Columbus Children's Hospital

Quick to anger, trouble paying attention, disinterested--these behaviors in children demand adult intervention. Problem behaviors in children derive from many sources. One potential factor affecting too many children today is the physiological and psychological aftereffects of witnessing or being a victim of a traumatic event.

Traumatic stress comes in many forms and a full range of intensities, as do children's responses to it. Not all children who have experienced or witnessed trauma will exhibit behavior problems. Increasing adults understanding of the effects of trauma hopefully will enable them to better help children who experience problems.

RESPONSE TO TRAUMA

Children's responses to trauma may vary according to the source and circumstances of the trauma and the circumstances of the child. Generally speaking, children who experience or witness extreme threat respond with symptoms that fit into four general categories (Terr, 1991; Pynoos and Nader, 1988):

• They may have strong memories that repeatedly intrude on their normal functioning.
• They may engage in endlessly repeated behaviors.
• They may develop trauma-specific fears.
• They may change their attitudes about friends, family, life in general, and the future. They also may desire to be unaware of their feelings.

Although these responses tend to be fairly consistent among children who have experienced traumatic stress, the way they manifest can differ substantially. Repetitive behaviors in one child, for example, may be highly aggressive, whereas in another they may be withdrawn or self-injurious. Some children exhibit few, if any, of these symptoms; others become almost completely debilitated, experiencing all of them persistently. In the latter case, children may be diagnosed with post-traumatic stress disorder (PTSD).

Most children who have experienced trauma will not develop PTSD, although many may demonstrate transitory symptoms. If disturbances persist for longer than one month, parents or caregivers should consult with a mental health professional or pediatrician experienced in working with traumatized children.

WHAT INFLUENCES CHILDREN'S RESPONSES TO TRAUMA?

Many factors, often interrelated, contribute to the type and severity of a child's response to traumatic stress. These factors include the persistence of the trauma, the relationship of the child to the perpetrator, the proximity of the child to the experience, the child's support system, and the basic beliefs the child brings to the task of understanding and coping with the trauma. To understand children's possible responses, it is helpful to consider:

• the child's age,
• whether the trauma was ongoing or one-time,
• the child's relationship to the perpetrator,
• whether the child was a victim, a witness, or connected in some way to the victim,
  adult support,
• other stress factors affecting the child.

THE CHILD'S AGE: Children's responses to traumatic stress tend to be consistent with their developmental age. Toddlers may manifest stress in changes in their relationship to their caregivers, either demanding more attention, showing signs of indifference, or both. Their motor activity may change, and they may become more aggressive (hitting, biting, pinching).

In addition to the behaviors exhibited by toddlers, preschoolers may have physical symptoms, such as headaches, stomachaches, or difficulty using a particular body part. They may engage in endlessly repetitive play; may physically and emotionally avoid any reminders of the incident; or may demonstrate fear, sadness, clingingness, regressive behaviors, and feelings of shame regarding their vulnerability. Children also may enter a dissociative state, which observers often describe as "being in a world of their own" or "being out of touch."

School-aged children typically are more susceptible to traumatic events outside the family and their effects on their caregivers, friends, and their community. They may also be more adult-like in exhibiting their sadness and other mood-oriented symptoms, such as anxiety, depression, guilt, increased inhibition, and hypervigilance. These states can result in changes in play, loss or change in interests, return of old or onset of new fears, sleep disorders, difficulty concentrating, and lack of initiative. School performance and learning may suffer. Often symptoms may mirror those of attention deficit hyperactivity disorder (ADHD) and may respond to ADHD treatment (Schwarz and Perry, 1994).

In addition to the symptoms experienced by younger children, adolescents may exhibit identity, eating, and personality (including multiple personality) disorders and seizure-like states. Suicide attempts, substance abuse, self- mutilation, delinquency, truancy, and destructive sexual behaviors also may occur.

WHETHER THE TRAUMA WAS ONGOING OR ONE-TIME: If the trauma was acute and unanticipated, as might be the case with a drive-by shooting, the child may experience acute and disturbing disruptions of thought patterns. If the trauma was chronic and anticipated, as is most often the case with sexual or physical abuse, researchers and clinicians report a more chronic absence of feeling, sense of rage, and generalized sadness along with fear (Terr, 1991). The two types of trauma can also overlap, resulting in a mixture of symptoms.

THE CHILD'S RELATIONSHIP TO THE PERPETRATOR: Traumas perpetrated by individuals whom a child has learned to trust or depend on create different effects than those perpetrated by strangers. Generally speaking, the more personal the relationship between perpetrator and victim, the more severe the symptoms of the victim.

WHETHER THE CHILD WAS A VICTIM, A WITNESS, OR CONNECTED IN SOME WAY TO THE VICTIM: Studies of one-time, acute events reveal that those physically and emotionally closest to the event's epicenter will have the most severe and longest-lasting symptoms. That is, victims who are emotionally, cognitively, and physically involved with the event and the perpetrator can be expected to respond more strongly than those who are physically, emotionally, or cognitively more distant (Pynoos and Nader, 1988; Schwarz and Perry, 1994; Terr, 1990). Relationship to the event may involve the victim's sense of control over the event; victims with less control may have a stronger symptomatic response (McCormack, Burgess, and Hartman, 1988).

ADULT SUPPORT: At the time of a traumatic event, attention and energy may be focused on the victim, perhaps making it difficult for children who are distressed by witnessing the event to receive the support they need. Moreover, adults who have close relationships with a child victimized by violence may be hampered by their own distress about the occurrence.

Difficulty receiving the support they need may be compounded for children who manifest their grief differently than adults. Children's sadness may be less apparent and less sustained. Some researchers have found that many children have never spoken to anyone about their grief reactions. These researchers surmise that because children's sadness tends to be more hidden, parents and teachers may have more difficulty appreciating the nature and intensity of children's grief reactions (Pynoos and Nader, 1988).

OTHER STRESS FACTORS AFFECTING THE CHILD. Although children have a wide range of response to various traumatic stresses, one fact seems to be well-established: rather than building children's resilience by giving them more expertise, recurrent or multiple traumas multiply the difficulty children experience (Fitzpatrick and Boldizar, 1993; Pynoos and Nader, 1988).

PROVIDING SUPPORT

In addition to providing "first aid" (see section at the end of this article) at the time of the trauma, parents and caregivers can provide ongoing support to children in the ways outlined in the remainder of this article.

HELPING CHILDREN REGAIN A SENSE OF CONTROL: Traumatized children have experienced themselves as helpless and not in control. Healing includes recognizing that those feelings occurred at the time of the trauma, but need not continue into the present. Barbara Oehlberg, in her discussion of "reempowerment" in Making It Better: Activities for Children Living in a Stressful World (1996), suggests asking children open questions, such "Then what happened?" or "I wonder what makes the daddy say that?" to help them process a story and gain a sense of mastery. Oehlberg's book also provides a number of open-ended activities intended to help children draw from their own resources to make sense of their world.

HANDLING DISRUPTIVE BEHAVIOR:Although adults may encounter difficulties when faced with agitated, defiant, or aggressive children, remembering that they are struggling and need adult help is extremely important. Behavior problems are unlikely to decrease through scoldings or appeals to "common sense," and harsh discipline is harmful and inappropriate. On the other hand, overly permissive parenting is not likely to help a child who needs guidance and help with coping. Children need consistent, loving support with clear limits and positive discipline to enforce them.

UNDERSTANDING REPETITIVE PLAY: The play of traumatized children may include acting out aspects of the event or themes from it. Some children may engage in endless, unvaried, repetition of the same play. Although self-expression may be constructive, caregivers need to balance between excessively encouraging or discouraging these activities (Schwarz and Perry, 1994). Caregivers should supervise play, for example, and be attuned to the possibility that it can become too disturbing for the child or for the child's playmates.

TUNING INTO THE CHILD'S NEEDS AND PACE FOR DEALING WITH STRESS: While providing opportunities for children to express themselves, parents and caregivers need to be careful not to push too hard to extract a story or otherwise pressure the child. Allow children to feel safe, accepted, and ready to talk at their own pace. On the other hand, putting the burden solely on children to bring up their feelings, or avoiding the subject altogether and assuming children will "work things out on their own" does not give children the support they need. If adults never broach a subject, children may think that it is somehow taboo or that their feelings are abnormal or bad and should not be discussed.

GOING BEYOND THE NUCLEAR FAMILY: Families that have experienced trauma may find it helpful to reach outside the family for supportive relationships for themselves and their children. An adult mentor, for example, can make an enormous difference in a child's life.

COPING OVER TIME: As children mature, gaining more sophisticated emotional and cognitive abilities, they may reprocess an earlier trauma. Caring adults should be aware of this possibility, and be ready to listen and possibly make referrals to appropriate professionals, whenever the need arises.

SPECIAL SECTION

FIRST AID AT THE TIME OF STRESS

Coping with the traumatic stress of a child at the time of the stress is critical; unaddressed traumatic stress increases the likelihood of the child developing PTSD. The following suggestions by Pynoos and Nader (1988) include a list of "first aid" for trauma victims:

1. Provide support, rest, comfort, food, and the opportunity to play or draw.
2. Reassure children that they are safe and that you will help them.
3. Reassure children that the event was not their fault.
4. Help children understand what has happened by giving them opportunity to talk about the event. Clarify, then reclarify any existing confusions.
5. Give children the opportunity to talk about their feelings. Providing emotional labels for common reactions is helpful. Reassure children that it is okay for them to be upset.
6. Do not insist that children talk before they are ready or more than is comfortable for them.
7. Help children understand that the event is over, especially in the presence of physical reminders of the incident.
8. Encourage children to let their parents, teachers, or other adults they trust know about what happened.
9. Provide consistent and reassuring caretaking, such as picking children up from school or letting children know the whereabouts and availability of a significant adult.
10. Understand that children may exhibit behaviors they have already grown out of (for example, bedwetting) and tolerate those behaviors for a limited amount of time.
11. Help children dealing with death understand its finality. Do not talk about death with euphemisms, such as "He went away" or "She is sleeping."

REFERENCES

Fitzpatrick, K. M. & Boldizar, J. P. (1993). The prevalence and consequences of exposure to violence among African-American youth. JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY, 32, 424-430.

Garbarino, J. (1995). RAISING CHILDREN IN A SOCIALLY TOXIC ENVIRONMENT. Jossey-Bass; San Francisco.

Heergaard, M. (1991) WHEN SOMETHING TERRIBLE HAPPENS: CHILDREN CAN LEARN TO COPE WITH GRIEF. Woodland Press, Minneapolis.

Oehlberg, B. (1996). MAKING IT BETTER: ACTIVITIES FOR CHILDREN LIVING IN A STRESSFUL WORLD. St. Paul: Red Leaf Press.

Pynoos, R. S. & Nader, K. (1988). Psychological first aid and treatment approach to children exposed to community violence: research implications. JOURNAL OF TRAUMATIC STRESS, 1(4), 445-473.

Schwarz, E. D., & Perry, B. D. (1994). The post-traumatic response in children and adolescents. PSYCHIATRIC CLINICS OF NORTH AMERICA, 17 (2), 311-327.

Terr, L. C. (1991). Childhood Traumas: An outline and overview. AMERICAN JOURNAL OF PSYCHIATRY, 148, 10-20.

Original Article