Surviving Childhood: An Introduction to the Impact of Trauma
 

   
 
Lesson 3: After the Trauma: The Costs of Coping

The Pain Remains Long After the Event

After the trauma passes, the child remains. While the mental and physical adaptations used during a traumatic event will slowly subside, there will be residue from the experience. Indeed, for some children, this post-traumatic period is filled with more confusion, emotional pain, distress, and fear. In about 50 percent of the children who have experienced a severe traumatic event, these symptoms become so severe that the children develop serious post-traumatic stress disorders.

This lesson is about the development of these symptoms and what you can do to help children in the post-traumatic period.

Children Re-Experience Trauma

For almost all children, a traumatic experience will play itself out repeatedly in their minds, even after the event has ended. The thoughts, emotions, and feelings of being out of control and threatened will be re-experienced, as will the fear, anxiety, and pain associated with the event. Each time the child has an intrusive thought, a nightmare, or reenacts the event through play, the emotional or affective memory of being in the midst of the threatening event is evoked.

Figure 3-1: How memory is stored in the brain.
Figure 3-1: How memory is stored in the brain.
Figure 3-2: Trauma and memory.
Figure 3-2: Trauma and memory.

A classic set of predictable symptoms and physical changes is evident in the acute post-traumatic period because of memory. Not only can children remember the facts and narrative details of the event, they can recall and relive the emotional and physiological changes that were present in the alarm reaction. In effect, the child has both emotional and state memories from the traumatic event, causing a state of hyperarousal.

This hyperarousal may be characterized by an increased startle response, increased muscle tone, a fast heart rate (tachycardia) and/or elevated blood pressure. Even at rest in the weeks following a traumatic event, children and adolescents often exhibit signs of physiological hyperarousal, such as tachycardia, despite outwardly normal behaviors. The inability to move back down the arousal continuum has profound implications for the child's long-term functioning, which we'll discuss shortly.

Persistent physiological and emotional distress is both physically exhausting and emotionally painful. Because of the pain, discomfort, and emotional and physiological "memories" associated with these recurring intrusive thoughts, a variety of protective avoidance mechanisms are used to escape reminders of the original trauma. These include active avoidance of any reminders of the trauma and the mental mechanisms of numbing and dissociation.

Exercise: Where are different memories stored in the brain?

Reexamine Figure 3-2 at the beginning of this section and correlate it with David's story in Figure 3-3 above. Which specific parts of David's brain are stimulated by his father's presence or scent? Have you ever had a strong reaction yourself to an odor, without having cognitive memories to associate with your response? Or have you ever smelled something that inexplicably brought back an old memory of smelling that same scent elsewhere? If you are able to remember particulars, what part of your brain is at work? Why are the lower parts of the brain often referred to as "primitive?"



 


State and affect memories elicited in a non-conscious state:

David is a 9 year-old boy. From age 2 through 6, he was sexually abused by his father. This abuse induced severe physical injuries. At age 6 he was removed from the family.

At age 8, he was seriously injured in a fall. He suffered from serious brain injury resulting in a coma state for 8 months following the injury.He continues to be difficult to arouse and is non-verbal. He exhibits no form of meaningful communication. In the presence of his biological father, he began to scream, moan, and his heart rate increased dramatically; audiotapes and the scent of his father elicited a similar response. These "memories" are stored in lower parts of the brain and do not require cognitive memory or consciousness to be expressed.


Children's Defense Mechanisms

Children, when faced with reminders of the traumatic event they suffered, may experience so much pain and anxiety that they become overwhelmed. In situations when they cannot physically withdraw from those reminders, they may dissociate. Following a traumatic experience, children may act stunned or numb.

Dissociating children will not readily respond to questions by adults. Their answers to questions will seem unclear, unfocused, or evasive. This is understandable if we remember that while these children are present in body, their minds may be off in another place -- dissociated, trying to avoid the painful reminders of the original trauma.

Figure 3-3: Patterns of dissociation and arousal.
Figure 3-3: Patterns of dissociation and arousal.
Figure 3-4: The adaptive balance.
Figure 3-4: The adaptive balance.

In the first days and weeks following the traumatic event, re-experiencing phenomena, attempts to avoid reminders of the original event, and physiological hyperreactivity are all relatively predictable, highly adaptive physiological and mental responses to a trauma. Unfortunately, the more prolonged the trauma and the more pronounced the symptoms during the immediate post-traumatic period, the more likely it is that there will be long-term chronic and potentially permanent changes in the emotional, behavioral, cognitive, and physiological functioning of the child.

If the post-traumatic stress response lasts longer than one month, it becomes categorized as post-traumatic stress disorder. It is this abnormal persistence of the originally adaptive responses that results in trauma-related neuropsychiatric disorders such as post-traumatic stress disorder (PTSD).

Figure 3-5: Symptoms of PTSD.
Figure 3-5: Symptoms of PTSD.

PTSD is a diagnostic label that has typically been associated with combat veterans. More recently it has been well-described in children who are survivors of physical abuse, sexual abuse, exposure to community or domestic violence, natural disasters, motor vehicle accidents, and a host of other traumatic events.

Children who survive a traumatic event and have persistence of this low-level fear state may be behaviorally impulsive, hypervigilant, hyperactive, withdrawn, depressed, or have sleep difficulties (including insomnia, restless sleep, and nightmares), and anxiety. In general, these children may show some loss of previous functioning or a slow rate of acquiring new developmental tasks. Traumatized children may also seem to regress and retain persistent physiological hyperreactivity (such as fast heart rate or borderline high blood pressure).

Who Develops PTSD?

Whether or not someone develops PTSD following a traumatic event is related to a variety of factors. The more life-threatening the event, the more likely a child is to develop PTSD. The more the event disrupts the child's normal family or social experience, the more likely he or she is to develop PTSD. Having an intact, supportive, and nurturing family appears to be a relative protective factor.

Unfortunately, a great majority of children who survive traumatic experiences also have a concomitant major disruption in their way of life, their sense of community, or their family structure. These children are thus exposed to a variety of ongoing provocative reminders of the original event (e.g., ongoing legal actions or high press visibility). The frequency with which children develop post-traumatic stress disorders following comparable traumatic events is relatively high (45-60 percent).

Children who survive traumatic events and exhibit this diverse set of symptoms and physical signs are frequently able to meet diagnostic criteria for attention deficit hyperactivity disorder, anxiety disorder NOS, major depressive disorder, conduct disorder, and a variety of Axis I DSM III-R diagnoses. Knowing that the symptoms exhibited are reflective of core changes related to the event will help the professionals and caregivers involved provide better care for these children.

Figure 3-6: Rachel's story.
Figure 3-6: Rachel's story.

Hallmark Symptoms of PTSD :

RE-ENACTMENT

  • Play
  • Drawing
  • Nightmares
  • Intrusive ideations

AVOIDANCEř

  • Being withdrawn
  • Daydreaming
  • Avoiding other children

PHYSIOLOGICAL HYPERREACTIVITY

  • Anxiety
  • Sleep problems
  • Hypervigilance
  • Behavioral impulsivity


 



How Can You Apply Your Knowledge?

Basic Guidelines for Those Living or Working With Traumatized Children:

1. Don't be afraid to talk about the traumatic event. Children do not benefit from "not thinking about it" or "putting it out of their minds." If children sense that caretakers are upset about the event, they will not bring it up. In the long run, this only makes the child's recovery more difficult. Don't bring it up on your own, but when the child brings it up, don't avoid discussion. Listen to the child, answer questions, and provide comfort and support. We may not have good verbal explanations, but listening and not avoiding or overreacting to the subject, and then comforting the child, will have a critical and long-lasting positive effect.

  1. 2. Provide a consistent, predictable pattern for the day. Make sure the child has a structure to the day and knows the pattern. Try to have consistent times for meals, school, homework, quiet time, playtime, dinner, and chores. When the day includes new or different activities, tell the child beforehand and explain why this day's pattern is different. Don't underestimate how important it is for children to know that their caretakers are in control. It is frightening for traumatized children (who are sensitive to control) to sense that the people caring for them are, themselves, disorganized, confused, and anxious. Adults are not expected to be perfect; caregivers themselves have often been affected by the trauma and may be overwhelmed, irritable, or anxious. If you find yourself feeling this way, simply help the child understand why, and explain that these reactions are normal and will pass.

3. Be nurturing, comforting, and affectionate, but be sure that this is in an appropriate context. For children traumatized by physical or sexual abuse, intimacy is often associated with confusion, pain, fear, and abandonment. Providing hugs, kisses, and other physical comfort to younger children is very important. A good working principle for this is to be physically affectionate when the child seeks it. If the child walks over and touches you, return it in kind.

Try not to interrupt the child's play or other free activities by grabbing them and holding them, and be aware that many children from chronically distressed settings may have what we call attachment problems. They will have unusual and often inappropriate styles of interacting. Do not tell or command them to "give me a kiss" or "give me a hug." Abused children often take words very seriously, and commands reinforce a very malignant association linking intimacy/physical comfort with power (which is inherent in a caregiving adult's command to "hug me").

4. Discuss your expectations for behavior and your style of discipline with the child. Make sure that the rules and the consequences for breaking the rules are clear. Make sure that both you and the child understand beforehand the specific consequences for compliant and non-compliant behaviors. Be consistent when applying consequences. Use flexibility in consequences to illustrate reason and understanding. Utilize positive reinforcement and rewards. Avoid physical discipline.

5. Talk with the child. Give them age appropriate information. The more the child knows about who, what, where, why, and how the adult world works, the easier it is to make sense of it. Unpredictability and the unknown are two things that will make a traumatized child more anxious, fearful, and, therefore, more symptomatic. They may become more hyperactive, impulsive, anxious, and aggressive, and have more sleep and mood problems. Without factual information, children (and adults) speculate and fill in the empty spaces to make a complete story or explanation. In most cases, the child's fears and fantasies are much more frightening and disturbing than the truth. Tell the child the truth, even when it is emotionally difficult. If you don't know the answer yourself, tell the child. Honesty and openness will help the child develop trust.

6. Watch closely for signs of reenactment (e.g., in play, drawing, behaviors), avoidance (e.g., being withdrawn, daydreaming, avoiding other children) and physiological hyperreactivity (e.g., anxiety, sleep problems, behavioral impulsivity). All traumatized children exhibit some combination of these symptoms in the acute post-traumatic period. Many exhibit these symptoms for years after the traumatic event. When you see these symptoms, it is likely that the child has had some reminder of the event, either through thoughts or experiences. Try to comfort and be tolerant of the child's emotional and behavioral problems. Again, these symptoms will wax and wane -- sometimes for no apparent reason. Record the behaviors and emotions you observe and try to notice patterns in the behavior.

7. Protect the child. Do not hesitate to cut short or stop activities that are upsetting or re-traumatizing for the child. If you observe increased symptoms in a child that occur in a certain situation or following exposure to certain movies or activities, avoid them. Try to restructure or limit these activities to avoid re-traumatization.

8. Give the child choices and some sense of control. When a child, particularly a traumatized child, feels that they do not have control of a situation. they will predictably get more symptomatic. If a child is given some choice or some element of control in an activity or in an interaction with an adult, they will feel safer and more comfortable and will be able to feel, think, and act in a more mature fashion. When a child is having difficulty with compliance, frame the consequence as a choice for them: "You have a choice -- you can choose to do what I have asked or you can choose . . ." Again, this simple framing of the interaction with the child gives them some sense of control and can help defuse situations where the child feels out of control, and therefore anxious.

9. If you have questions, ask for help. These brief guidelines can only give you a broad framework for working with a traumatized child. Knowledge is power: the more informed you are and the more you understand the child, the better you can provide them with the support, nurturing, and guidance they need. Take advantage of resources in your community. In the final course lesson, we will talk about how to access some of these resources. While each community has agencies, organizations, and individuals coping with the same issues, you may need assistance finding the expertise that can help traumatized children.



 



Quiz 1 of 3

QUIZ

Choosing from the following list, tell what kind of memory is involved in the following examples of "recall."

1. Playing piano:
Cognitive
Emotional
Moto-vestibular
State

2. Typing:
Cognitive
Emotional
Moto-vestibular
State

3. Performance Anxiety:
Cognitive
Emotional
Moto-vestibular
State

4. Increased heart rate after car-backfire:
Cognitive
Emotional
Moto-vestibular
State

5. Describing a perpetrator to the police:
Cognitive
Emotional
Moto-vestibular
State

6. Nostalgia:
Cognitive
Emotional
Moto-vestibular
State

7. First Impressions:
Cognitive
Emotional
Moto-vestibular
State




 



Quiz 2 of 3

QUIZ

Choosing from the following list of symptom types, tell what category of symptoms each of the following falls into.

1. Nightmare:
Re-enactment
Aviodant
Physiological hyperarousal

2. Sweaty Palms:
Re-enactment
Aviodant
Physiological hyperarousal

3. Daydreaming/Tuning Out:
Re-enactment
Aviodant
Physiological hyperarousal

4. Intrusive Ideations:
Re-enactment
Aviodant
Physiological hyperarousal

5. Aggressive Play:
Re-enactment
Aviodant
Physiological hyperarousal

6. Increased Heart Rate:
Re-enactment
Aviodant
Physiological hyperarousal




 



Quiz 3 of 3

QUIZ

Identify the following statements as either True or False.

1. Doctors cannot always predict what symptoms and physical changes might present in any given individual's acute post-traumatic period.
True
False

2. Hypervigilance is a dissociative behavior.
True
False

3. Tachycardia (a fast heart rate) is one of the characteristics of physiological hyperarousal.
True
False

4. Children may experience so much pain and anxiety as a result of a traumatic event that they become overwhelmed and dissociate.
True
False

5. Dissociation is more common in older children, whereas hyperarousal is more common in younger children.
True
False

6. A post-traumatic stress response lasting longer than six weeks becomes characterized as Post-Traumatic Stress Disorder (PTSD).
True
False




 



   
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