9 - Simple Ways for addresses the issue of: Traumatic events in young childhood

Each year in South Africa approximately five million children experience some form of traumatic experience. More than two million of these are victims of physical or sexual abuse. Millions more are living in the terrorizing atmosphere of domestic violence. Natural disasters, car accidents, life-threatening medical conditions, painful procedures, exposure to community violence – all can have traumatic impact on the child. By the time a child reaches the age of eighteen, the probability that any child will have been touched directly by interpersonal or community violence is approximately one in four. Traumatic experiences can have a devastating impact on the child, altering their physical, emotional, cognitive and social development. In turn, the impact on the child has profound implications for their family, community and, ultimately, us all.

Traumatic events in childhood increase risk for a host of social (e.g., teenage pregnancy, adolescent drug abuse, school failure, victimization, anti-social behaviour), neuropsychiatric (e.g., post-traumatic stress disorder, dissociative disorders, conduct disorders) and physical health problems (e.g., heart disease, asthma). The deterioration of public education, urban violence and the alarming social disintegration seen in some of our communities can be linked to the escalating cycles of abuse and neglect of our children. For most children, thankfully, a traumatic event is a new experience. And like all new experiences, the unknown will add to the confusing and frightening circumstances surrounding this overwhelming experience. The trauma may significantly challenge the child’s sense of the world. A flood, car accident, shooting or abuse by a caregiver - all challenge the child’s beliefs about the stability and safety of their world. Very young children may not understand what happened and will be confused or even frightened by the reactions of their siblings or caregivers.

The acute post-traumatic period is characterized by an attempt by the child to reorganize, re-evaluate and restore their pre-traumatic world. Many of the emotional, behavioural and cognitive signs and symptoms of the acute post-traumatic period are due to these efforts. Unfortunately, children often do not have the same capacity to understanding or explaining most traumatic experiences. Young children may make many false assumptions about the event – “the accident came because God was mad.”

As with most situations, children seek answers and comfort from adults around them, yet we often feel helpless in this role. Indeed, most traumatic experiences challenge the most mature and experienced adult. While adults do not have all the answers, they can help children better understand the traumatic event and the ways we respond following trauma.

This simple guide addresses some of the key issues related to the child's complex set of reactions that often follow traumatic events. While focused on caregivers, this information may be helpful to caseworkers, teachers, other family and other adults working and living with traumatized children.

This simple guide is intended to inform and provide general principles -- it is not intended to be comprehensive or to exclude other observations or approaches to helping traumatized children. The more we understand these children and the impact of traumatic experiences, the more compassionate and wise we can be as we try to help these 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 a child senses that his/her 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 often have no good verbal explanations, but listening and not avoiding or over-reacting to the subject and then comforting the child will have a critical and long-lasting positive effect.

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. There is no expectation of perfection; caretakers themselves have often been affected by the trauma and may be overwhelmed, irritable or anxious. If you find yourself being this way, simply help the child understand why, and 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 a hug, a kiss and other physical comfort to a young child can be very reassuring. A good working principle for this is to be physically affectionate when the child seeks it. When the child walks over and touches you, return in kind. The child will want to be held or rocked – feel free. On the other hand, try not to interrupt the child's play or other free activities by grabbing them and holding them. Further, 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 commands very seriously. It reinforces a very malignant association linking intimacy/physical comfort with power (which is inherent in a care giving adult's command to 'hug me').

4. Discuss your expectations for behaviour and your style of 'discipline' with the child. Make sure that there are clear 'rules' and consequences for breaking the rules. Make sure that both you and the child understand beforehand the specific consequences for compliant and non-compliant behaviours. 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 which will make a traumatized child more anxious, fearful, and therefore, more symptomatic. They May be 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 re-enactment (e.g., in play, drawing, behaviours), avoidance (e.g., being withdrawn, daydreaming, avoiding other children) and physiological hyper-reactivity (e.g., anxiety, sleep problems, behavioural 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 behavioural problems. These symptoms will wax and wane - sometimes for no apparent reason. The best thing you can do is to keep some record of the behaviours and emotions you observe (keep a diary) and try To observe patterns in the behaviour.

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,
Activities and so forth, avoid these activities. Try to restructure or limit activities that cause escalation of symptoms in the traumatized child.

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, 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, 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. Each community has agencies, organizations and individuals coping with the same issues. They often have the support you may need to help.