"Helping Children Cope with Crises"

Parents often do not know how to discuss catastrophic events with their children.
This article will be helpful to all parents and to agencies developing seminars.

GUIDELINES FOR HELPING CHILDREN COPE WITH CRISES Prepared by ROBERT ABRAMOVITZ, M.D. CHIEF PSYCHIATRIST Jewish Board of Family and Children's Services Director Center for the Development of Traumatic Stress Programs The re-occurrence of another shooting incident confronts parents and educators with the need to offer reassurance and safety to our children in a world that seems filled with insecurity. Responses to crises, such as the shooting in Los Angeles, need to be divided into three categories: Psychological safety Physical safety Re-assurance/explanation The primary goal is to prevent frightening feelings from becoming overwhelming, as this leads to helplessness or impulsive, emotion focused coping, rather than problem focused coping. PSYCHOLOGICAL SAFETY This refers to the ability to manage the scary feelings engendered when a child hears about, witnesses or directly experiences an event that threatens their physical or emotional safety. Anxiety and fear are normal and necessary emotions that serve to alert us to danger. However, if our fight or flight alarm reaction is turned on too often or too long, it can interfere with adaptive coping. Our message to children can't be "don't be afraid," instead, it must be "how can I help you feel safe, in spite of having distressing feelings?". We are trying to promote the capacity to adaptively manage problematic emotional reactions so they don't disrupt the ability to think and respond. To accomplish this we must first validate the child's feelings by helping him/her put them into words and/or play action. The goal is to reinforce their developing capacity to regulate any disruptive emotional or somatic reactions by encouraging as much expression as possible. Meeting this goal is not a new expectation. Parents can draw on their prior experience of having automatically comforted their children when they were infants. The soothing physical responses they provided, such as picking them up; hugging and stroking them, combined with comforting sounds and words, helped the child to learn to feel safe and to regulate their reactions when they were distressed. As they get older, responses need to become more and more verbal and aimed at engaging them in active interaction with the parent and others. This helps children learn that personal relationships and social support provide strong barriers to feeling overwhelmed. Importantly, children need the opportunity to be heard, so they can talk about the feelings, thoughts and physical reactions they are having to the event. Just the willingness of the parent to "be there" and to listen, listen, listen provides an important service. If a child can't put these reactions into words, he should not be pressed to talk. Instead, other avenues of expression like drawing can be offered. Many apparently silent children will readily share what is on their mind, when asked to talk about their picture. It is also necessary to validate their reactions with statements such as, "I can understand that seeing something like that (i.e. a shooting scene on tv news) would make you feel scared, lets see what we can do to help you feel better?" The offer to help the child feel better needs to build on his or her previous successful efforts to cope with distressing reactions. Thus a parent might say "remember when you were worried (scared etc whatever word they use to describe their current feeling) and you did (X or Y), do you think doing that would help?" If the child doesn't feel previous coping strategies will help or they don't have much prior experience to draw on, then the parent can make suggestions posed as questions, i.e. "what if we try ...?" or "would it help if I....?" Following up with a response gives them children the opportunity to learn new coping skills. Possibile responses include: Parent and child spending more time together, whether interacting or quietly doing separate activities near one another Limiting exposure to distressing images on TV Using relaxation techniques like deep breathing or progressive relaxation exercises Drawing a picture that expresses something related to the event and then discussing with the child what they feel their picture conveys Doing something physical to discharge tension, like exercising or walking Listening to music or a relaxation tape Older children and adolescents can take part in organized community activities directed towards responding to the problematic situation. In order for caregivers to be responsive in the above manner, they need to have their own feelings appropriately regulated. Children and adolescents are very good at sensing the emotional reactions of adults and our fear can be contagious. Thus it's important that adults let kids know that these events also upset us -- that's part of the validation process -- but at the same time we can model how to cope effectively. Trying to "be strong" or keep a stiff upper lip or providing false reassurance doesn't work. Children need to see that we don't feel helpless or overwhelmed or stuck. Trying out options that lead to doing something organized and planned is important: we don't need a guarantee of success. PHYSICAL SAFETY This refers to efforts to make the child's environment as safe and secure as possible without totally constraining freedom of movement. Parents need to work with staff at the programs their children attend to make sure that adequate safeguards are in place. They may want to visit the facility with the child to let them see what steps have been taken and to give them a chance to ask questions and to let them tell their parent and teacher if they feel comfortable entering or re-entering the program. All efforts at mature coping should be supported. Parents need to take their cues from the child as to whether they need to accompany the child to school and how long this should occur. If the child feels comfortable going back in the company of friends rather than with the parent, that should be supported. Bedtime can be a time of increased vulnerability even when the child feels otherwise safe. Parents need to stay with children until they fall asleep, while working with the child to handle this time on their own. REASSURANCE AND EXPLANATION Often when something bad happens, the first reaction of adults is to want to reassure a child or explain why the event occurred, while this is a natural urge, it needs to be put on hold until we have listened to the child's reaction. Children of different ages see the world differently than adults: consequently our fears and concerns may not reflect what they are thinking and feeling. Children and adolescents often get a different message from premature attempts to reassure them. Rather than being comforted, they feel the adults are not interested in hearing how they really feel. Once their actual concerns are known, reassurance can be provided by letting the child know where and how to reach you during the day, as children often have unrealistic concerns about their parents well being after a frightening incident. Explanation can be used to correct misunderstandings, such as the tendency to mis-interpret a pounding heart as a sign of a serious physical problem, rather than a typical physical response to stress. Parents and teachers can monitor children's responses to the event and to any interventions by paying attention to: Persistent fears Trouble sleeping Difficulty concentrating Avoidance of settings where problems occurred Irritability Jumpiness-tendency to startle easily Withdrawal/loss of interest in play or friends Physical reactions, i.e. stomach aches, headaches, loss of appetite, pounding heart The reactions listed above are normal in the immediate aftermath of a traumatic crisis, however if they persist for more than four weeks and/or are disruptive to the child's social/mental/ or physical functioning a mental health referral is recommended.

CHILDREN'S RESPONSE TO TRAUMA Preschool Through Second Grade Symptomatic Response     First Aid 1. Helplessness and passivity.   1. Provide support, rest, comfort, food, opportunity to play or draw. 2. Generalized fear.   2. Re-establish adult protective shield. 3. Cognitive confusion (e.g., do not understand that the danger is over).   3. Give repeated concrete clarifications for anticipated confusions. 4. Difficulty identifying what is bothering them.   4. Provide emotional labels for common reactions. 5. Lack of verbalization-selective mutism, repetitive nonverbal traumatic play, unvoiced questions.   5. Help to verbalize general feelings and complaints (so they will not feel alone with their feelings). 6. Attributing magical qualities to traumatic reminders.   6. Separate what happened from physical reminders (e.g., a house, monkeybars, parking lot). 7. Sleep disturbances (night terrors and nightmares; fear of going to sleep; fear of being alone, especially at night).   7. Encourage them to let their parents and teachers know. 8. Anxious attachment (clinging, not wanting to be away from parent, etc.).   8. Provide consistent caretaking (e.g., assurance of being picked up from school, knowledge of caretakers whereabouts). 9. Regressive symptoms (thumb sucking, enuresis, regressive speech).   9. Tolerate regressive symptoms in a time-limited manner. 10. Anxieties related to incomplete understanding about death; fantasies of "fixing up" the dead; expectations that a dead persons will return, e.g., an assailant.   10. Give explanations about the physical reality of death.   Robert S. Pynoos, Kathi Nader, "Children Exposed to Community Violence" Third Through Fifth Grade Symptomatic Response     First Aid 1. Preoccupation with their own actions during the event; issues of responsibility and guilt.   1. Help to express their secretive imaginings about the event. 2. Specific fears, triggered by traumatic reminders or by being alone.   2. Help to identify and articulate traumatic reminders and anxieties; encourage them not to generalize. 3. Retelling and replaying of the event (traumatic play); cognitive distortions and obsessive detailing.   3. Permit them to talk and act it out; address distortions, and acknowledge normality of feelings and reactions. 4. Fear of being overwhelmed by their feelings (of crying, of being angry).   4. Encourage to express fear, anger, sadness, etc., in your supportive presence in order to prevent feeling overwhelmed. 5. Impaired concentration and learning.   5. Encourage to let their parents and teachers know when thoughts and feelings interfere with learning. 6. Sleep disturbances (bad dreams, fear of sleeping alone).   6. Support them in reporting dreams; provide information about why we have bad dreams. 7. Concerns about their own and others' safety, e.g., worry about siblings.   7. Help to share worries; reassure with realistic information. 8. Altered and inconsistent behavior, (e.g., unusually aggressive or reckless behavior, inhibitions).   8. Help to cope with the challenge to their own impulse control (e.g., acknowledge, "It must be hard to feel so angry"). 9. Somatic complaints.   9. Help to identify the physical sensations they felt during the event. 10. Close monitoring of parent's responses and recovery; hesitation to disturb parent with own anxieties.   10. Offer to meet with children and parent(s), to help children let parents know how they are feeling. 11. Concern for other victims and their families.   11. Encourage constructive activities on behalf of the injured or deceased. 12. Feeling disturbed, confused and frightened by their grief responses; fear of ghosts.   12. Help to retain positive memories as they work through the more intrusive traumatic memories.   Robert S. Pynoos, Kathi Nader, "Children Exposed to Community Violence" Adolescents (Sixth Grade and Up) Symptomatic Response     First Aid 1. Detachment, shame and guilt (similar to an adult response).   1. Encourage discussion of the event, feelings about it, and realistic expectations of what could have been done. 2. Self-consciousness about their sense of fears, vulnerability, and other emotional responses; fear of being labeled abnormal.   2. Help them understand the adult nature of these feelings, encourage peer understanding and support. 3. Post-traumatic acting out (e.g., drug use, delinquent behavior, sexual acting out).   3. Help to understand the acting out behavior as an effort to numb their responses to, or to voice their anger over, the event. 4. Life threatening re-enactment; self-destructive or accident prone behavior.   4. Address the impulse toward reckless behavior in the acute aftermath; link it to the challenge to impulse control associated with violence. 5. Abrupt shifts in interpersonal relationships.   5. Discuss the expectable strain on relationships with family and peers. 6. Desires and plans to take revenge.   6. Elicit their actual plans of revenge; address the realistic consequences of these actions; encourage constructive alternatives that lessen the traumatic sense of helplessness. 7. Radical changes in life attitudes, which influence identity formation.   7. Link attitude changes to event's impact. 8. Premature entrance into adulthood (e.g., leaving school or getting married), or reluctance to leave home.   8. Encourage postponing radical decisions, in order to allow time to work through their responses to the event and to grieve.   Robert S. Pynoos, Kathi Nader, "Children Exposed to Community Violence"