Helping Children Cope with Trauma

While Friday's mass-shooting in Newtown, CT, has been devastating for a great many people, it may be particularly traumatic for the children who survived - not only because they were exposed to the trauma of a shooter in their school, but also because of how children experience traumas and crises. Essentially, a trauma or crisis is anything that overwhelms our ability to cope. The less we are able to understand and process what has happened, the more overwhelmed we feel. We may consequently feel helpless, out of control, fearful, angry, depressed, guilty or ashamed.

Children often have difficulty verbally expressing their emotions, and may find the swirl of emotions they experience during a crisis to be confusing, adding to the intensity of distress they feel. Children are particularly susceptible to crises involving loss and separation, since losses pose a threat to their safety and security. Significant losses may result in feelings of rejection or abandonment, depression, anger, guilt and confusion.

Children also think differently about the world, which leads to particular difficulties understanding and processing traumatic events. Specifically:
-  Children tend to personalize things, and may therefore blame themselves for things outside their control.
-  They also tend to interpret things literally and think concretely, which makes it hard for them to conceptualize traumatic events or realities such as death. For the same reason, children may have difficulty understanding adults' euphemistic ways of talking about bad things, leading to confusion and misunderstandings.
-  Children sometimes have difficulty distinguishing fantasy from reality. They may imagine frightening or unrealistic outcomes, or attribute experiences to supernatural or fantastical causes. As part of this, children may engage in "magical thinking," and believe their own thoughts and feelings can lead to negative outcomes in the outside world (contributing to self-blame for negative events outside their control).

Given all of these unique issues that may affect how children experience trauma, it is important for adults to know how to help them. To be most helpful to children, adults first need to recognize and manage their own emotional reactions. Be mindful of the messages nonverbal signals communicate. Then, with your responses in check, take the following steps:

1) Elicit the child's thoughts and feelings about their experience. Validate the feelings that they are experiencing, and help them label their emotions. Work to understand how the child is thinking about the experience, being mindful of the possibility that they may personalize or apply fantasy or magical thinking to explain events.

2) Soothe the distress. Be consistent and reassuring. Children learn coping skills from adults who model coping, and soothe them during times of crisis. Like all of us, it will be hard for children to think clearly until the intensity of distress has passed.

3) Promote objectivity. Help the child recognize the reality of the situation, and dispute any illogical explanations, particularly self-blaming. Reassure the child that s/he is safe and secure.

4) Engage in problem solving to address any ongoing concerns or immediate issues

5) Watch for signs that the child may continue to be affected by a trauma, and seek mental health services if the child is extremely fearful, angry, or cries frequently; becomes unusually clingy or isolative, or loses interest in things s/he used to enjoy; has difficulty concentrating or making decisions; shows changes in sleep or eating; has a decline in school performnce; or complains of physical symptoms such as headaches or stomachaches.

There were 28 lives lost

Last Friday's mass-shooting at a Connecticut elementary school was a tragedy that has rocked the region, nation, and world. The brutal deaths of 20 first-graders, 6 and 7 years old, is unfathomable. It is a source of immense sorrow and grief, and enough to inspire dread in the hearts of parents everywhere.

There are so many questions for mental health to consider in such circumstances: how to intervene in times of crisis so that the risk of PTSD is minimized; how to talk with children about loss, danger and safety; how to help survivors (children, teachers, and first responders, as well as parents and families who lost loved-ones) be resilient in the face of their horrific experiences.

However, before tackling any of that, I feel the need to address something that has bothered me in media coverage of the event. Most of the news stories have talked about the 26 who lost their lives at Sandy Hook Elementary School. The fire department set up 26 Christmas trees between the school and the fire house. And while the school shooting is perhaps the most tragic part of Friday, and the most outside of our framework for "typical" homicides (if one can ever say such a thing is "typical"), it's important to remember that 28 people died that day - 28 untimely, preventable, and therefore tragic deaths.

In addition to the 20 students and 6 school personnel, the 20-year-old shooter and his mother also died. It may not be politically correct to speak about these deaths, since the young man was responsible for all the other deaths, and his mother owned the guns and almost seen as "guilty by association," but both still died unnecessarily. And both likely died in a significant amount of mental and emotional pain.

From what we have heard, the shooter, Adam Lanza had a history of mental illness. We do not yet know if he was receiving treatment, and what type. He was only 20 years old - barely an adult himself, and at an age when many new symptoms of mental illness can begin to emerge. For him to decide that the only way out of his pain was to massacre children and then kill himself, we have to conclude that he must have been in significant anguish.

His mother likely experienced years of anguish trying to help him cope with his symptoms, and receive needed services in a country where such services are not consistently available, and those who need them are stigmatized. If she was awake before she was killed, she also likely experienced a flood of emotions: horror, terror, anguish that her son would become a killer...we can only imagine.

Both of these people died tragically and deserve to be remembered in the death toll. As we think about what we will do differently to increase safety in the future, we need to think not just about school safety and gun control, but how we identify, respond to and provide for the needs of youth and families at risk for significant mental illness, or violent behavior (while not equating mental illness with risk of violence). We will have succeeded when no one experiences the kind of pain that would lead them to consider mass-shootings. After all, prevention is our best defense.

War and Peace (of Mind)

Today is Veteran's Day in the U.S., and therefore an important opportunity to think more about the needs of vets - particularly this year, as we move toward the end of military action in Iraq. There are a lot of people facing the challenge of reintegrating into civilian life after months or years of service. There are a lot of people still struggling to reintegrate, many years after facing combat in past wars. There are also too many who have been unable to make the transition, and have died of suicide or substance abuse - the invisible casualties of war.

My father's best friend committed suicide not long after returning from Vietnam. My friend's father coped with life after Vietnam by never speaking about it, ever. A student I worked with, attending college on the GI bill, couldn't sleep in a double room, and often had to leave class because he was having a flashback. Other vets I've treated have minimized and normalized their difficulties, seemingly in defense against the stigma of PTSD within the military - all while using substances daily, and suffering setbacks in relationships and career as a result of their anger.

We need to work harder to remove the stigma from PTSD, for all survivors of trauma, but especially for veterans. We need to communicate more effectively that the symptoms are perfectly normal and understandable responses of the human body to an abnormal and often incomprehensible life-threatening experience. When the experience lasts longer, the body's responses are more debilitating.

We also need to work harder to notice and help vets cope with symptoms that don't meet the threshold for diagnosing PTSD - just because the symptoms don't qualify for a diagnosis does NOT mean that they don't cause significant distress and impair functioning. Disproportionate anger can be a form of hypervigilance. Nonchalance, inappropriate humor, and lack of motivation or interest can all result from overall numbing. Reexperiencing may be flashbacks and nightmares, but less dramatically, can also be rumination, risk-taking, engaging in conflict, or warding against such symptoms with the artificial numbing of drugs and alcohol.

Finally, we need to make it easier for those who have sacrificed part of their lives for the country to obtain the opportunities so many of us take for granted - the opportunity for an education, to find meaningful work, to have safe housing and assistance acclimating to the nuances of civilian life: utilities, taxes, banking, credit, health care....

What else should we be doing, as a social worker, or as a society, to help our veterans transition to civilian life in sustainable and satisfying ways?