1. Recognition and Response to Childhood Trauma in the Elementary School Setting Ally Burr-Harris, Ph.D. The Greater St. Louis Child Traumatic Stress Program University of Missouri-St. Louis November 13, 2003

2. Greater St. Louis Child Traumatic Stress Program Member of National Child Traumatic Stress Network (NCTSN) - www.nctsnet.orgwww.nctsnet.org Services provided by Children’s Advocacy Center and Center for Trauma Recovery at UMSL Free assessment and treatment of children and adolescents who have experienced a trauma Consultation and training of education, mental health, and medical professionals in the area of child trauma School-based group therapy for children and adolescents exposed to violence

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

4. 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

5. How Common are Traumatic Experiences? 69% of the general U.S. population report exposure to one or more traumatic events 14 to 43% of children/adolescents report having experienced a traumatic event 23% of national sample of adolescents report being victim or witness of violence Up to 91% of African American youth in urban settings report violence exposure Among refugee children, rates of trauma exposure approach 100% Large-scale traumas in schools are very rare but highly publicized

6. Effects of Trauma on Children Most people experience posttraumatic stress symptoms up to several weeks post-trauma. Approximately 20% of youths exposed to serious trauma have persistent PTSD Rates much higher for severe, chronic, or interpersonal trauma PTSD rates: –School shooting: 77% –Sexual abuse: up to 90% –Murder/sexual assault of parent: up to 100% –Community violence: 35%

7. Effects of Violence Exposure on School Functioning Decreased school performance Decreased school attendance Increased concentration problems Decreased academic and cognitive scores Linked to aggression, conduct problems, social deficits, substance abuse, delinquency, and psychiatric problems

8. Identifying Physical Abuse Bruises, welts, burns, fractures, cuts & abrasions Injuries to multiple body areas Various stages of healing Wearing clothes to cover injuries Reluctance to seek medical help Extensive history of injury Inconsistent/unbelievable explanation of injury Excessive fear of punishment and/or caregiver Wary of physical contact Frequent school absences Running away Child discloses physical abuse

9. Identifying Sexual Abuse Difficulty walking or sitting Sudden refusal to change for gym or to participate in physical activities Inappropriate sexual knowledge/behavior Pregnancy/STD Enuresis/encopresis Frequent urinary tract/vaginal infections Wary of physical contact Running away Abnormal fears about bodily functions (e.g., urination) Child discloses sexual abuse

10. Identifying Neglect Frequent absences from school Begs or steals food/money from classmates Lacks needed medical, visual or dental care Consistently dirty, poor hygiene Insufficient or ragged clothing Abuses alcohol or other drugs Malnourished/constant hunger Tiredness Lack of supervision Child discloses neglect

11. Identifying Emotional Abuse/Neglect Extreme behaviors (e.g., passive-violent) Developmental delays Self-deprecation Overreaction to mistakes Withdrawal Aggressive behavior Pseudomature behavior Negative affect/flat affect Passivity/apathy Poor social skills (e.g., indiscriminately friendly) Child discloses emotional abuse

12. “Something Is Wrong” Indicators Anger/irritability Symptoms of depression/anxiety Sudden changes in behavior Sudden changes in school performance Loss of interest/social withdrawal Self-destructive behaviors Loss of energy Difficulty concentrating/attending Sudden change in activity level

13. Immediate Reactions To A Trauma Or Crisis Intense longing/concern for caregivers or loved ones Emotionally labile Extreme emotions (rage, fear) Tearful, crying Excited Clinging to caregivers Shock, numbness Denial, inability to acknowledge situation Dazed, feelings of unreality, dissociation Confused, disorganized Difficulty making decisions Suggestible Fight or flight mode, physical symptoms

14. Trauma Symptoms in Elementary School Children Sadness, crying, irritability, aggression Increased activity level Poor frustration tolerance Safety-related fears Generalized fear Unable to verbalize distress Nightmares Trauma themes in play/art/conversation School avoidance; decline in school performance

15. Trauma Symptoms in Elementary School Students Physical complaints Poor concentration Regressive behavior (e.g., clingy, wetting bed, babytalking) Eating/sleeping disturbances Attention-seeking behavior Withdrawal Magical thinking related to trauma/death

16. Trauma Symptoms in Middle and High School Students Depression Depression Feelings of shame/guilt Feelings of shame/guilt Detachment, denial of feelings Detachment, denial of feelings Avoidance of trauma cues Avoidance of trauma cues Intrusive images, thoughts, memories Intrusive images, thoughts, memories Withdrawal from peers and/or family Withdrawal from peers and/or family Low energy, loss of interest Low energy, loss of interest Appetite/sleep disturbance Appetite/sleep disturbance Generalized anxiety, safety fears Generalized anxiety, safety fears Foreshortened future Foreshortened future

17. Trauma Symptoms in Middle and High School Students Physical ailments/complaints Physical ailments/complaints Increased anger, irritability, aggression Increased anger, irritability, aggression Agitation Agitation Peer problems (e.g., fighting) Peer problems (e.g., fighting) Decreased interest in opposite sex Decreased interest in opposite sex Increased risk-taking, rebellious behaviors Increased risk-taking, rebellious behaviors “Pseudomature” behaviors “Pseudomature” behaviors Substance abuse Substance abuse Decline in school performance/attendance Decline in school performance/attendance

18. Risk Factors for Post-Trauma Adjustment Problems 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

19. Protective Factors for Post- Trauma Adjustment Strong academic and social skills Active coping, self-confidence Social support Family cohesion, adaptability, hardiness High neighborhood/school quality Strong religious beliefs, cultural identity Effective coping and support by parents

21. Comforting 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 (rest, comfort, food, hugs, stuffed animal, music) Use security items and goodbye rituals to ease separation with younger children Distract with pleasurable activities* Let the child know you care *normally occurring

22. Controlling Child’s Environment Maintain normal routines as much as possible Reduce class workload as needed Avoid exposing children to unnecessary trauma reminders (e.g., media) Minimize contact with others who upset child Guide other children in supporting child Give trauma cues positive change

23. Discussing the Trauma with Children Encourage children to express their traumatic experience but don’t pressure Be an active listener Remain calm when answering questions and use simple, direct terms Don’t “soften” the information you give to children Help children develop a realistic understanding of what happened Gently correct trauma-related distortions Be willing to repeat yourself Normalize “bad” feelings

24. Intervening with Traumatized Children Identify triggers (e.g., trauma cues) that upset child and plan ahead Defuse anger Address acting out behaviors involving aggression or self-destructive activities quickly and firmly Model/coach adaptive coping with upsetting feelings Set up behavior management plan reinforcing adaptive coping and appropriate behavior Do not tolerate inappropriate negative behavior (harassment, bullying, threats) Avoid traumatizing classmates during trauma reenactments/discussions Be patient and calm

25. Facilitating Trauma Resolution Use play, art, stories to assist with trauma resolution Normalize symptoms/reactions Reinforce positive messages Positive reminiscing of deceased Encourage constructive activities –Teach tolerance and respect –Recovery events

26. 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

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

28. Common Trauma-Related Distortions in Youth Self-blame Guilt, survivor guilt Overgeneralization of danger/risk Shame/embarrassment b/c of trauma Shame over PTSD symptoms Hero fantasies related to trauma Omen formation Foreshortened future Magical thinking

29. Correcting Distorted Beliefs Point out the child’s 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

30. Helping Grieving Children Don’t 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 youths in developing grieving rituals and in finding meaning Help other students learn how to respond Anticipate need for extra support when child faces loss reminders (e.g., holiday)

31. Helping Grieving Children Assist younger children in understanding finality of death. Use youth’s (family’s) own belief system when discussing afterlife Share memories and talk about the person who died when appropriate Gently remind children ALL feelings are okay. Use reminders like “you did not cause this” or “it is not your fault.”

32. 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 child Recommend maintenance of normal routine Encourage parents to remain calm and to get help for themselves if needed Normalize child’s emotional/behavioral difficulties after trauma Model soothing behaviors with younger children Assist in developing plan for behavior mgmt.

33. When to Refer for Psychological Care Appear depressed, withdrawn, noncommunicative Strong resistance to affection/support from caregivers Suicidal or homicidal ideation Dangerous behaviors to self/others Increased usage of alcohol or drugs Rapid weight gain or loss Significant behavioral changes or problems (e.g., sexual) Discontinue attending to hygienic needs Significant acute stress symptoms

34. When to Refer for Psychological Care Showing these changes for more than 1 month after trauma Intense anxiety or avoidance behavior triggered by trauma reminders Unable to regulate emotions (crying, angry outbursts) Poor academic performance and decreased concentration Continued worry about event (primary focus) Excessive separation difficulties Physical complaints (nausea, headaches) Continued trauma themes in play Unable to grieve/mourn death of loved one

35. We’re done! For additional questions, references, or referrals, contact Ally Burr-Harris, Ph.D. Phone: 314-516-5440 Email: Burrharrisa@msx.umsl.eduBurrharrisa@msx.umsl.edu