1. Traumatic Events in the School An Educator’s Guide to Posttraumatic Stress Matt Kliethermes, M.S. Ally Burr-Harris, Ph.D. The Greater St. Louis Child Traumatic Stress Program

2. What is a Traumatic Event? n Involves actual or threatened death or serious injury, or a threat to the person’s physical integrity n Must involve feelings of intense fear, helplessness or horror (children may show disorganized or agitated behavior instead)

3. Types of Traumas n Natural disasters n Kidnapping n School violence n Community Violence n Terrorism n Traumatic death of a student or school employee n Child abuse n Domestic violence n Medical procedures n Victim of crime n Accidents n Homicide n Suicide

4. What Makes a Trauma a Trauma? n Severity of the trauma n Extent of exposure n Parent distress n Proximity to the trauma n Emotional attachment to someone who was injured or killed

5. Factors Related to the Child/Family n Previous exposure to traumatic events n Personal or family history of emotional difficulties n Lack of material and/or social resources n Genetic predisposition

6. What is PTSD?

7. Re-experiencing Symptoms n Indicate that the child is in some way “re-living” the sensations associated with the traumatic event n At least one re-experiencing symptom must be present to diagnose PTSD

8. Re-experiencing Symptoms n Intrusive memories n Repeated nightmares n Hallucinations, flashbacks and play reenactment n Emotional distress when reminded of the trauma n Physical response when reminded of the trauma

9. Avoidance/Numbing Symptoms n Involves tendency to avoid all reminders of the traumatic event n Also involves a general lack of emotional response to what is happening around them n Three or more symptoms must be present to diagnose PTSD

10. Avoidance/Numbing Symptoms n Avoidance of trauma thoughts/feelings n Avoidance of physical reminders of trauma n Memory difficulties related to the event n Withdrawal from important activities n Withdrawal from other people n Restricted range of emotions n Sense of a foreshortened future

11. Hyperarousal Symptoms n These symptoms are indicative of a significant increase in the child’s physical arousal that was not present before the traumatic event. n Two or more symptoms must be present for PTSD to be diagnosed

12. Hyperarousal Symptoms n Sleep difficulties n Irritability and aggression n Concentration difficulties n Hypervigilance n Exaggerated startle response

13. Associated Symptoms n Fears and worries n Depressive symptoms n School difficulties n Physical symptoms n Regressive behaviors n Behavioral difficulties

14. Developmental Differences in Responses to Trauma n Trauma impacts children of all ages n The impact can be similar across ages, but various age groups can have unique responses as well n The responses of different age groups often reflect the child’s stage of development

15. Preschool Children n Regressive Behaviors n Separation fears, fear of the dark n Stranger anxiety n Eating and sleeping disturbances n Physical aches and pains n Crying/irritability n Appearing “frozen” or moving aimlessly

16. Elementary Children n Sadness, crying, irritability, aggression n School avoidance n Physical complaints n Poor concentration n Regressive behavior n Eating/sleeping changes n Attention-seeking behavior n Withdrawal

17. Adolescents n Similar to adult response to trauma n Feelings of shame/guilt n Increased risk-taking behaviors n Withdrawal from peers and/or family n “Pseudomature” behaviors n Substance abuse n Delinquent behaviors n Change in school performance

18. How Common are Traumatic Experiences? n Research has indicated that 69% of the U.S. population has been exposed to one or more life-threatening events. n With regard to children, approximately 14-43% have experienced at least one traumatic event prior to age 18.

19. How Common is PTSD? n On average, 24% of adults exposed to trauma develop PTSD n In children and adolescents, 3 to 15% of girls and 1 to 6% of boys exposed to trauma could be diagnosed with PTSD n These percentages vary depending on the severity of the trauma n As a whole, about 6-8% of children in the U.S. will develop PTSD in childhood

20. Course of PTSD n Symptoms usually begin in the first 3 months after the event, but may be delayed by months or even years n Symptoms may vary over time n About 50% recover in first 3 months n Chronic PTSD most common in response to repeated and multiple traumas, and those involving interpersonal violence

21. What Causes PTSD? n Trauma results in the activation of the body’s “survival systems” n These systems may continue to run even after the trauma has ended n This can result in enduring chemical imbalances and structural changes in the brain n These changes result in the symptoms of PTSD

22. PTSD and other Mental Disorders (Comorbidity) n One study found that 80% of people with a lifetime diagnosis of PTSD also met criteria for another mental disorder n Common comorbid disorders include depression, separation anxiety, general anxiety, attachment disorders, substance abuse, ADHD, ODD, and conduct disorder

23. Helping Traumatized Students n Reinforce ideas of safety and security n Tolerate retellings of the event n Encourage students to talk about their traumatic experience n Remain calm when answering questions and use simple, direct terms n Don’t “soften” the information you give to children

24. Helping Traumatized Students n Help children develop a realistic understanding of what happened n Be willing to repeat yourself n Expect angry outbursts n Normalize “bad” feelings n Avoid exposing children to reminders of the traumatic event

25. Helping Traumatized Students n Maintain normal school routines as much as possible n Address acting out behaviors involving aggression or self-destructive activities quickly and firmly n Be patient with students and yourself n Let your students know you care about them

26. How to Talk (and Listen) to Traumatized Children n Children need to have their feelings accepted and respected n Listen quietly and attentively n Acknowledge their feelings with a word or two n Give their feelings a name n Give them their wishes in fantasy n Show empathy

27. Responses That ARE NOT So Helpful n Denial of feelings n Philosophical response n Advice n Too many questions n Defense of the other person n Pity n Amateur Psychoanalysis

28. Correcting Distorted Beliefs n Point out the child’s distorted belief by briefly summing it up n Label how you think they might feel n Validate their feeling; show empathy n Let them know how it makes you feel to hear the distorted belief n Suggest a healthier belief; keep it brief

29. Helping Parents of Traumatized Children n Be sure to communicate with parents n Encourage parents to listen to their children closely about the trauma n Encourage parents to set aside special time for their children n Recommend that parents maintain normal family routines n Encourage parents to remain calm

30. Identifying Students Who May Need Professional Help n Poor educational performance n Continued high levels of emotional response n Signs of depression and withdrawal n Thoughts of harm to self or others n Increased use of drugs or alcohol

31. Identifying Students Who May Need Professional Help n Significant, chronic changes in behavior n Failure to attend to personal hygiene n Chronic symptoms of PTSD (lasting longer than three months)

32. Taking Care of Yourself n Alleviate additional stress n Request temporary relief from the classroom if needed n Make sure your own family is safe n Participate in staff debriefing sessions n Schedule time away from work to talk about your own experiences regarding the trauma

33. Taking Care of Yourself n Be aware of your limitations n Pick your battles n Surround yourself with people who make you feel good and on whom you have the same effect n Take care of yourself physically n DON’T BE A SUPERHERO

34. Trauma and Students with Disabilities n Research suggests that children with disabilities are more at risk for trauma n Approximately twice as likely to experience maltreatment n Common disabilities seen in trauma victims include behavior disorders, speech and language disorders, mental retardation, learning disorders and hearing impairment

35. Why are Children with Disabilities at Risk? n Increased dependency on caregivers n Lack of control and choice over their own lives n Compliance and obedience are stressed as good behavior n Isolation and rejection by peers can increase their responsiveness to attention and their desire to please others

36. Why are Children with Disabilities at Risk? n May lack knowledge about appropriate social behavior, particularly with regard to sexualized behaviors n Children with language difficulties may have difficulty disclosing abuse n Disabilities may result in increased stress in family environments n Care and treatment may result in being placed in potentially harmful situations

37. How Does Trauma Impact Children with Disabilities? n Children with disabilities tend to show many of the same difficulties as non- disabled children n May be an even more severe impact because these children may lack some protective features other children have n No research has suggested that having a disability protects from the impact of trauma in any way

38. How Does Trauma Impact Children with Disabilities? n Common symptoms include withdrawal, changes in eating and sleeping habits, increased aggression, self-destructive behaviors, sexualized behavior, poor self esteem, nightmares and a sense of vulnerability n Many also experience the symptoms of PTSD discussed earlier

39. Helping Children with Disabilities Cope with Trauma n Pre-existing symptoms may get worse n Consider “mental age” n Consider language abilities n Try to alleviate social isolation n Maintain structure and routine n Provide appropriate information n Be patient n Make mental health referrals if needed

40. Traumatic Loss and Grief n Commons symptoms of grief include great sadness and longing, feelings of anger, sleep problems, loss of appetite, weight loss, preoccupation with death, difficulty concentrating on activities n May have unusual sensory experiences n Symptoms should no longer interfere with daily activities after 6 months, but may persist in some form for years

41. Grief in Infants and Toddlers n Experience a sense of “goneness” n Often react to loss of caregiver with sleep disturbance, change in eating patterns, fussiness, bowel and bladder disturbances, and difficulty being comforted n May have difficulty reattaching to remaining or new caregivers

42. Grief in Preschoolers n Often believe death is reversible- ”Magical Thinking” n Regressive behaviors n Reenact death in play n May express wanting to die or to go to heaven to be with the deceased n Symptoms of grief may be inconsistent

43. Grief in School Children n May see death as something tangible n Begin to understand permanency of death, but may behave as though the deceased were still alive at times n May show aggression and other behavioral difficulties n May be anxious about wellbeing of other family members n Magical thinking remains prevalent

44. Grief in Adolescents n Understand death intellectually, but struggle with the “why” of death n May show risk-taking behaviors n Often withdraw from peers and family n Often display considerable anger n May show typical adult symptoms of grief (e.g., deep sadness, sleep and appetite problems, poor concentration)

45. Tasks of Mourning n Accept the reality of the loss n Experience fully the pain of the loss n Adjust to an environment and self- identity without the deceased n Convert the relationship from one of live interactions to one of memory n Find meaning in the deceased’s death n Experience a continued supportive adult presence in the future

46. Traumatic Bereavement n Grief and trauma often go together n Traumatic bereavement occurs when the traumatic nature of memories associated with the loved one’s death interfere with positive remembering of the deceased, which is an important component of the mourning process n This is not a common response, but indicates a need for professional help

47. Helping Grieving Students n Don’t be afraid to talk about the death n Be prepared to discuss the same details over and over again n Be available, nurturing, reassuring and predictable n Help other students learn how to respond n Consider modifying your lesson plan