1. Childhood Trauma Guidelines for Early Childhood Educators
Ally Burr-Harris, Ph.D. & Matt Kliethermes, M.S.
The Greater St. Louis Child Traumatic Stress Program

2. 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)
-not very specific

3. 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
-Traumas can impact entire school, or just one student/family
-Different people may experience the same trauma in different ways
-Children may perceive situations as traumatic that adults do not, and vice versa
-The way a person thinks about the event is important

4. How Common are Traumatic Experiences?
69% of the general U.S. population report exposure to one or more life-threatening traumatic events
14 to 43% of children report having experienced a traumatic event prior to 18.
Up to 91% of African American youth in urban settings report violence exposure
10% of children under 5 witnessed shooting/stabbing
CDF 1995 data: (Children’s Defense Fund, 1998)
1000 child fatalities due to abuse/neglect
Children under 3 comprise 26% of all child maltreatment cases
77% of all child fatalities occured in children 3 and under
50% of police-involved DV cases occurred with kids present
More than 5000 children died from community-related violence
References:
69% data: Resnick et al., 1993
1 to 5 yr. old data: Taylor, Zuckerman, Harik, & Groves, 1994 (47% heard gunshots)
AA data: Osofsky, Wewers, Hann, & Fick (1993); Myers & Thompson Sanders (2000)

5. What Makes a Trauma a Trauma?
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
interpersonal violence particularly traumatizing, tends to result in more long-lasting difficulties also.
less risk if parents can remain calm and provide a supportive environment.

6. Immediate Reactions to Trauma
Intense longing/concern for caregivers
Disbelief, denial about event
Focus on past losses, traumas
Emotional lability (numb<>rage)
Replaying events with intervention fantasies
Misattribution of blame – intense anger
Apparent indifference (minimizing)
Focus on gory, violent, exciting aspects of trauma
-Marans et al., 1995
Lability: numb, tearfulness (not so common), rage, disorganized agitation

7. Effects of Trauma on Children

8. Developmental Differences in Responses to Trauma
Infants and Toddlers (0 to 3)
Preschool Children (4 to 6)
School-age Children (7 to 12)
-Marans & Adelman (1997)
-Scheeringa (1995, 2000)

9. Infants and Toddlers
Pattern #1: Withdraws, rejects affection, stops exploring environment, lacks trust in others,appears “unattached”
Pattern #2: Clingy, anxious, sleep disturbances, toileting problems, temper tantrums, regressed, disorganized, rages/aggression, crying/irritability

10. Preschool Children Regressive behaviors Separation fears
Eating and sleeping disturbances
Physical aches and pains
Crying/irritability
Appearing “frozen” or moving aimlessly
Perseverative, ritualistic play
Fearful avoidance and phobic reactions
Magical thinking related to trauma
preschool children often have a particularly difficult time adjusting to change and loss
often feel helpless, powerless and unable to protect themselves
haven't developed the skills to deal with stressful situations and are dependent on the protection and support of caregivers
therefore are strongly affected by the reactions of caregivers to the event
may "lose" skills or "fall back" to behaviors they had outgrown
may show physical symptoms due to not having verbal skills necessary to express emotions.
fears may not be specifically related to traumatic experience

11. School-Age Children Sadness, crying, irritability, aggression
Nightmares
Trauma themes in play/art/conversation
School avoidance > school failure
Physical complaints
Poor concentration
Regressive behavior
Eating/sleeping changes
Attention-seeking behavior
Withdrawal
Regressive behaviors: increased struggles over schoolwork, chores, self-care, food
have more understanding of the full impact of the event: results in feelings of depression, anxiety, anger, "flatness" and feelings of failure and guilt
Preoccupation with danger, violence, death, and lack of protection
children this age are likely to talk about the event repeatedly. May ask the same questions over and over.

12. When Stress Symptoms Become a Disorder
Acute Stress Disorder (ASD)
Posttraumatic Stress Disorder (PTSD)
Depression
Anxiety
Attachment problems (RAD)
Behavior problems

13. Primary Symptoms of ASD and PTSD
Reexperiencing
Avoidance
Hyperarousal
Dissociation

14. Re-experiencing Symptoms
Child “re-lives” sensations of traumatic event through intrusive memories, nightmares, flashbacks, hallucinations, and reenactment
Emotional and physical distress when reminded of the trauma
a. intrusive memories may show up in child's play, child may repetitively express aspects of the event in play
b. in children nightmares may not be specific to the trauma
c. child may engage in a behavioral reenactment of the trauma
e.g., kid drawing planes crashing into WTC, kid playing out murder of parent with dollhouse, kid rubbing adult’s crotch

15. Avoidance Symptoms
Avoid all reminders of the traumatic event in an effort to reduce distress
Avoidance of feelings through emotional “shut down” (a.k.a. dissociation)
Withdrawal
Sense of a foreshortened future
avoidance symptoms are reinforcing b/c results in temporary stress reduction and they tend to generalize
have difficulty remembering specific aspects of the trauma
withdrawal from school activities is very common in children
e.g., refuses to discuss, won’t walk by locker of dead classmate
foreshortened future: e.g., my family’s gonna die soon too

16. Dissociation Feelings of unreality (“in a daze”)
Emotional numbing, detachment

17. Hyperarousal Symptoms
Significant increase in physical arousal
that was not present before trauma
Sleep difficulties, irritability, aggression,
concentration difficulties, motor rest-
lessness, hypervigilance,
exaggerated startle response
-difficulty falling and staying asleep
-Hypervigialnce: investigating every sound at night
-Exaggerated startle: door slamming (reminds kid of gunshot)
-concentration difficulties may look very similar to AD/HD
-hyperarousal symptoms were adaptive during the event, but are now maladaptive

18. Acute Stress Disorder (ASD)
Symptoms of reexperiencing, avoidance, hyperarousal, and dissociation (feelings of unreality or emotional numbing)
Within the first month after a traumatic event
In adults, ASD predisposes person for PTSD. Prospective data on kids not yet available.

19. Posttraumatic Stress Disorder (PTSD)
Symptoms of reexperiencing, avoidance/dissociation, hyperarousal
Symptoms present one month after traumatic event

20. Associated Symptoms of PTSD
Fears and worries
Depressive symptoms
School difficulties
Physical symptoms
Regressive behaviors
Behavioral difficulties
- generalized fears; separation anxiety, fear of the dark, etc
-physical symptoms may be physical responses they had during the event (e.g., nausea, pain).

21. How Common is PTSD?
On average, 24% of adults exposed to trauma develop PTSD
In children and adolescents, 3 to 15% of girls and 1 to 6% of boys exposed to trauma could be diagnosed with PTSD
As a whole, about 6-8% of children in the U.S. will develop PTSD in childhood
About 50% recover in the first 3 months
*murder or sexual assault of parent- up to 100%
*One quarter to one third of all traffic-injured children and 15% of their parents develop PTSD. 28% of kids (5 to 17) met ASD criteria and 23% of parents after child was in traffic accident. Parents more likely to report distress if child involved in motor-vehicle-pedestrian crash. (Winston et al., 2002)
*sexual abuse- up to 90%
*school shooting- 77%
*community violence- 35%
*Course of PTSD: Symptoms usually begin in the first 3 months after the event, but may be delayed by months or even years
Symptoms may vary over time; 50% recover in first 3 months
Chronic PTSD most common in response to repeated and multiple traumas, and those involving interpersonal violence

22. Other Stress-Related Disorders
80% of people with PTSD also meet criteria for another mental disorder
Other disorders include adjustment disorder, depression, separation anxiety, general anxiety, attachment disorders, ADHD, and other behavior disorders.
comorbidity may occur in two directions:
1. Preexisting disorders may make a person more susceptible to experiencing trauma (e.g., ADHD, substance abuse)
2. Trauma may make people more vulnerable to other disorders (e.g., depression, separation anxiety)
-PTSD/ADHD: restlessness, hyperalertness, poor concentration, behavior problems, impulsivity, distractibility. ADHD meds can exacerbate symptoms if PTSD.
-PTSD/Bipolar: Sexually reactive behavior, rage/irritability, mood changes, depression/withdrawal.
-PTSD/OCD can have intrusive thoughts but PTSD is trauma-related thoughts.
-Adjustment Disorder if sub-trauma or if only meeting partial PTSD symptoms
-Flashbacks can be experienced as hallucinations in PTSD but symptoms are trauma-related.
-60 to 80% of BPD patients report a history of CSA. BPD may be severe, chronic manifestation of PTSD. Predominant dissociative and interpersonal problems of chronic PTSD may need to be resolved before personality disorder diagnosis can be made (Goodwin, 1985; Herman et al., 1989; Stone, 1990).

23. When Trauma Interferes with Attachment
Pervasive Neglect and Persistent Disruption in Caregiving
Chronic institutionalization and/or neglect
RAD, Inhibited Type
Doesn’t attach; withdraws
Multiple placements
RAD, Disinhibited Type
Attaches indiscriminantly/superficially
Ref. Zeanah & Boris (2000)
Chronic institutionalization/Neglect: RAD, Inhibited
No preferred attachment figure
Restricted attachment behaviors (comfort seeking, affection, help-seeking)
Restricted exploration
Emotionally blunted
No response to social overtures
Emotional dysregulation
Multiple placements: RAD, Disinhibited
Seek proximity and comfort indiscriminantly, even from strangers
Lack expected social wariness around unfamiliar adults
Vulnerable to victimization

24. When Trauma Interferes with Attachment
Fear Related to the Caregiver
Frightening caregiver (child abuse)
Hypercompliant, frozen watchfulness
Frightened caregiver (domestic violence)
Dysfunctional/erratic attention-seeking (not comfort-seeking) from distressed, unreliable caregiver
Frightening Caregiver:
excessive vigilance, hypercompliance, inhibited exploration
does not cling to caregiver, vigilant of caregiver
emotionally constricted
terrified of displeasing caregiver - avoiding harsh, punitive response
relationship-specific pattern (may also be cue specific -- when parent is angry)
Frightened Caregiver
disruption in proximity-seeking, exploration is unchecked by normal proximity- seeking behavior.
dangerous/provocative behaviors around attachment figure
aggression towards self/caregiver rather than comfort-seeking
dysfunctional attention-seeking from distressed, distracted, unreliable caregiver

25. When Trauma Interferes with Attachment
Death/Loss of Caregiver
More devastating in early childhood than any other time in life span
Presence of other attachment figures can buffer impact of loss
Sequence of Behaviors
Protest
Despair
Detachment
Protest: Significant distress related to loss of proximity to caregiver
Despair: signs of hopelessness, depression
Detachment: Withdraws from social interactions; difficulty establishing/maintaining subsequent attachment relationships

26. When Trauma Interferes with Attachment
General Acute Trauma
Disrupted attachment is usually temporary and responsive to treatment
Possible behaviors: Clingy, whining, separation anxiety, stranger anxiety, hypervigilance, frozen watchfulness, excessive worry about well-being of others, resists leaving “secure” places

27. Helping Traumatized Children
Maintain normal routines as much as possible
Tolerate retellings of the event
Encourage children to express their traumatic experience
Handle disturbing reenactments carefully
Remain calm when answering questions and use simple, direct terms
Don’t “soften” the information you give to children
Avoid exposing children to unnecessary trauma reminders (e.g., media)
Give examples of how you can redirect trauma reenactment so that it can be helpful to the child
e.g., Jimmy upsetting other kids because playing out domestic violence scene in classroom
Teacher can give him nonviolent resolution options
“Guns are too scary. Let’s use a magic wand instead.”
“No play killing. You can use your magic wand and turn him into a frog or a stone instead.”
Don’t tolerate the play. “Jimmy, no guns and killing in class. Let me help you think of something else you can pretend.”
Encourage safety resolution. “Why don’t we pretend like the danger’s over and we’re in a very safe place. No kids have to be scared. The grownups keep the kids safe. What else could we have in our safe place?”
Allow child to play in this way only when 1:1 with teacher. “Jimmy, I know you’re wanting to play this way, but you have to wait til your special time with Miss Nellie because it’s scaring the other children.”

28. Helping Traumatized Children
Help children develop a realistic understanding of what happened
Gently correct misattributions (e.g., self-blame) about trauma
Be willing to repeat yourself
Normalize “bad” feelings
Expect angry outbursts
Address acting out behaviors involving aggression or self-destructive activities quickly and firmly
Be patient with children and yourself
Soothing behaviors: holding, rocking, nursing, gentle talaking, verbal empathy, physical proximity -- particularly when child is responding to trauma reminders

29. Helping 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
Use security items and goodbye rituals to ease separation
Distract with pleasurable activities*
Let the child know you care
*normally occurring
This page of recommendations is particularly applicable to attachment-related concerns.

30. 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
All feelings can be accepted, but certain behaviors can and should be limited
Reference: How to Talk So Kids Will Listen and Listen So Kids Will Talk by Adele Faber & Elaine Mazlish (1980).

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

32. 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
Go through example of child who's brother died after being hit by a car.
"I should have done something to keep my brother from being hit by that car. Now he's gone and everyone's really sad
-wow, you think you didn't do enough to protect him, and it's your fault he died
-you must feel really sad and guilty, I can tell you really miss your brother too.
-It makes me feel bad that your brother died too. I wish I could bring him back for you, but I can't
-It makes me feel sad to hear you blaming yourself
-no one could have predicted a car was going to run off the road and hit your brother. You did everything you could to help him by running and calling I think it was very brave that you did that, and shows how much you love your brother

33. 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 the 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 child
Assist in developing plan for behavior mgmt.

34. Grief in Infants and Toddlers
Experience a sense of “goneness”
Sleep/appetite disturbance
Fussy, irritable
Bowel/bladder disturbances
Difficult to comfort
May have difficulty reattaching to new caregivers

35. Grief in Preschoolers Magical thinking (e.g., death is reversible)
Regressive behaviors
Reenact death in play
May express desire to die as well
Symptoms of grief may be inconsistent
Appetite/sleep disturbance
Short attention span: playing one minute, crying another

36. Grief in School Children
More likely to show depression, sadness
May see death as something tangible
Preoccupation with death
Begin to understand permanency of death, but may still behave as though deceased were still alive
May show aggression, other behavioral difficulties, concentration difficulties
May be anxious about wellbeing of other family members
Magical thinking remains prevalent
Across ages, unusual sensory experiences are common. Sxs should no longer interfere with daily activities after 6 months, but may persist in some form for years.

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

38. 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 child in developing grieving rituals and in finding meaning
Help others learn how to respond
be honest, open, and clear: Do not "cover up" or try to make the death "easier to swallow"
Children will fill in the details with their imagination: these details will often be wrong and more frightening than what actually happened.
Don't force the child to talk, but make yourself available
Use words that are real and accuarate. Answer each question as they asked. It’s normal for rapid shifts between sadness and playing in young children.

39. Talking about Death with a Young Child
“Died” means person is not alive anymore. His/her body stopped working. He/she can’t breathe, walk, move, eat or do any of the things he/she could do when alive. It’s forever and he/she will never be alive again.
Use child’s (family’s) own belief system when discussing afterlife

40. Talking about Death with a Young Child
Share memories and talk about the person who died when appropriate
Gently remind children ALL feelings (anger, sadness, confusion, fear, relief, guilt) are okay.
Use reminders like “you did not cause this” or “it is not your fault.”

41. When to Refer Child for Psychiatric/Psychological Care
Showing these changes for more than 3 months after trauma…
Behavior/Academic problems at school
Angry outbursts
Withdrawal from usual activities/play
Frequent nightmares, sleep disturbance
Physical problems (nausea, headaches, weight gain/loss)
Depression, hopelessness
for some children these strategies will not be enough
Volunteer firefighter analogy

42. When to Refer Child for Psychiatric/Psychological Care
Showing these changes for more than 3 months after trauma
Intense anxiety or avoidance behavior triggered by trauma reminders
Continued worry about event (primary focus)
Failure to attend to personal hygiene
Excessive separation difficulties
Continued trauma themes in play
-DO NOT diagnose a child for their parents

43. When to Refer Child for Psychiatric/Psychological Care
Significant ASD symptoms within first month of trauma
Unable to grieve/mourn because of trauma-related distress
Inappropriate social behaviors (e.g., sexual)
Unable to regulate emotions
Strong resistance to affection/support from caregivers
Dangerous behaviors to self/others

44. We’re done! Referrals for Assessment/Treatment:
Children/Adolescents (314)
Adults (314)
Questions/References:
Ally Burr-Harris at