Children's Reactions to Trauma

by Lynne Lyon, LCSW

updated 2/2014

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Q: How do I know if my child's control issues are related to attachment problems or PTSD and why is attachment therapy recommended for both? What can I do as a parent?

It is helpful to think of both Reactive Attachment Disorder (RAD) and Post-Traumatic Stress Disorder (PTSD) as Complex Trauma, or simply "trauma". An infant or child abandoned by the birth mother; neglected in the orphanage; sometimes abused or injured; then put in the arms of complete strangers from a different culture is going to be traumatized. These children attempt to control because they are afraid to trust the adults around them. Control for them means survival. Giving in to mom or dad may feel like risking death. Research about PTSD has shown that attachment to our family and community can not only mitigate the after effects of a traumatic event, but can also be the worst cause of trauma. Children who were in a single traumatic event which did not involve interpersonal violence, like a hurricane, fared much better when they were with their parents. Those with a secure attachment fared the best. They had a basic trust that the world was a safe place, and even though they might now be in the middle of a storm, it is an unusual event. The children who fared the worst were those who had poor attachments (had fewer feelings of trust) and/or who were taken out of their communities right after the traumatic event, i.e. if they had to evacuate and were separated from their family and community. They had nothing familiar to cling to. Traumatic events which are caused by a close family member and result in physical harm or a major disruption in a child's life circumstances will have a worse effect on the victim than trauma inflicted by a stranger or non-human event. For example, abuse by a parent is a betrayal of trust, and is much worse than being in a hurricane. Someone traumatized by a family member is much more likely to develop PTSD. So any child who has been abandoned and institutionalized is at significant risk for PTSD. They may have little or no attachment or trust to begin with, and when they are adopted, they are separated from their community again, increasing their risk for being traumatized. Professionals have come to refer to the effects of the combination of RAD and PTSD as Complex Trauma.

What Parents Can Do

The central concept that all texts on trauma emphasize is the attachment relationship. For adults, it's the relationship with a therapist or others who can help them process the trauma and learn to trust again. For children, it's us, the parents. So the first thing which must be done for a child with PTSD or RAD is to strengthen and secure their attachment to their parents. Traumatized children try to have control of their environment and the people in them because they are afraid. But a child who is in control, by definition, is not safe. Parents have to provide the structure and routine that will help the child feel safe: a morning routine which is the same for waking, washing, dressing, feeding animals, eating breakfast, and going to school. On weekends, the morning routine can be the same, but instead of school, start chores. Make time each day for free play and special times for cuddling. Have meals at the same time each day, and a comforting bedtime routine. Scheduling something like Chinese food on Friday nights can become a fun ritual. When the day is going to contain a special event, it is important to prepare the child ahead of time by describing the event and explaining what behavior is expected of the child. When the special or new event is something that may be traumatizing for the child, such as starting school or a field trip where the child will be getting on a bus without mom, Deborah Gray, (Attaching in Adoption) recommends drawing a small book that the child can take with her. It is important that the book include a beginning picture of the child at home with her family, and the child returning home to her family at the end.

Set a Limit on Traumatic Re-enactments

Traumatized children will routinely act out their trauma in their play. In order for healing to occur, children need to change the ending to their story.They need to become the hero/heroine, not the victim. Sometimes a child will get stuck in the traumatic re-enactment and doesn't know how to move ahead. Parents should not hesitate to intervene. For example, a child may replay being abandoned by her birthmother and being lost and alone. If the child seems unable to move ahead in developing a corrective version, a new mom can be found for the orphan. A child who is stuck in a kidnapping scenario may need help in imaging how to defeat the bad guy. When a child is playing out abuse by having one toy attack another, Martha Welch, MD recommends that mom rescue and mother both the victim and the perpetrator, since each represents two sides of the child's psyche. That the victim needs rescuing is obvious. That the perpetrator needs rescuing is not so intuitive, but it makes sense, since most violent perpetrators were victims themselves. It is important not to let a child's traumatic play traumatize other children. Deborah Gray recommends that children get a parent or teacher if certain themes such as death, nudity or tragic accidents come into play - or if one of the children gets a scary feeling, even if they do not know why. It may also be necessary to set a limit on the amount of time per day that a child can talk about her trauma. It is easy for certain themes to become obsessions. The child may simply not know how to move on to something else, even when the feelings are not resolved. Parents need to teach this skill of moving on and coming back to difficult feelings. Many of the therapies which are described in the Treatment section are appropriate for children with PTSD, as well as the parenting techniques described in the Parenting section. Deborah Gray has many excellent suggestions in her book Attaching in Adoption.

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Post-Traumatic Stress Disorder: A Parent-Oriented Checklist

from Attaching in Adoption by Deborah Gray, MSW, MPA

  1. Children have been in an extraordinarily frightening situation that filled them with fear and dread - to the extent that they may not have been able to move or talk.
  2. They are having dreams that cause them to wake up in terror. They seem to be recalling parts of a real experience.
  3. They have tantrums or shut down in fear over incidents that remind them of the traumatic event.
  4. Children complain of someone trying to harm them, and may seem to see that person's face through the window, in a crowd, etc. The "someone" is related to the trauma.
  5. They act blank at times, and seem to lose their place in time. They are frightened rather than daydreaming.
  6. They rage after being exposed to something that reminds them of the frightening situation - hitting, punching and seeming to fight for their lives.
  7. They have symptoms of being on high alert - not getting asleep easily or sleeping through the night, jumping at sudden noises, watching for clues of danger, concentrating poorly.

Trauma: Children's Reactions and Parental Support

Adapted from Children in Trauma by Cynthia Monahon

Infancy to 2.5 Years

General Trauma Reactions

Memory for Trauma

Parental Support

Disruption of sleeping and toileting

Startle response to loud/unusual noises; hypervigilance

"Freezing" (sudden immobility of body)

Fussiness, excessive crying, and neediness

Loss of acquired speech and motor skills

Separation fears and clinging to caretakers

Withdrawal; lack of responsiveness

Avoidance of or alarm response to specific trauma-related reminders involving sights, smells and physical sensations

Memory of trauma may be evident in behavior or play

Snatches of incomplete memory or visual images may remain in memory and be given verbal description by toddlers

Maintain child's routines around sleeping and eating

Avoid unnecessary separations from important caretakers

Provide additional soothing activities

Maintain calm atmosphere in child's presence

Avoid exposing child to reminders of trauma

Expect child's temporary regression; don't panic

Help verbal child to give simple names to big feelings; talk about event in simple terms during brief chats

Give simple play props related to the actual trauma to a child who is trying to play out the traumatic situation; a doctor's kit, a toy ambulance, toy dog, lots of beds & babies for orphanage

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2.5 to 6 Years

General Trauma Reactions

Memory for Trauma

Parental Support

Repeated retelling of traumatic event

Behavior, mood and personality changes

Obvious anxiety and fearfulness

Withdrawal and quieting

Specific, trauma-related fears; general fearfulness

Post-traumatic play often obvious

Involvement of playmates in trauma-related play at school and day care

Regression to behavior of younger child

Loss of recently acquired skills (language, toileting, eating, self-care)

Separation anxiety with primary caretakers

Loss of interest in activities

Sleep disturbances; nightmares, night terrors, sleepwalking, fearfulness of going to sleep and being alone at night

Confusion and inadequate understanding of traumatic events most evident in play rather than discussion

Unclear understanding of death and the causes of "bad" events

Magical explanations to fill in gaps in understanding

Complaints about bodily aches, pains, or illness with no medical explanation

Visual images and unpleasant memories of trauma that intrude in child's mind but will seldom be discussed spontaneously

Hyperarousal/hypervigilance

Loss of energy and concentration at school

Fear of trauma's recurring

Increased need for control

Vulnerable to anniversary reactions set off by seasonal reminders, holidays, and other events

Memory of at least some visual images from traumatic event is likely for youngest children; many demonstrate recall in words and play

At the older end of this age range, children are more likely to have lasting, accurate verbal and pictorial memory for central events of a recently occurring trauma

Listen to and tolerate child's retelling of event

Respect child's fears; give child time to cope with fears

Protect child from re-exposure to frightening situations and reminders of trauma, including scary TV programs, movies, stories, and physical or locational reminders of trauma

Accept and help the child to name strong feelings during brief conversations (the child cannot talk about these feelings or the experience for long)

Expect and understand child's regression while maintaining basic household rules

Expect some difficult or uncharacteristic behavior

Set firm limits on hurtful or scary play and behavior

Avoid nonessential separations from important caretakers with fearful children

Maintain household and family routines that comfort the child

Avoid introducing new and challenging experiences for child

Provide additional nighttime comforts when possible; family bed, night lights, stuffed animals, physical comforting after nightmares

Explain to child that nightmares come from the fears a child has inside, that they aren't real, and that they will occur less and less over time

Provide opportunities and props for trauma-related play Use detective skills to discover triggers for sudden fearfulness or regression

Monitor child's coping in school and day care by communicating with teaching staff and expressing concerns

Listen for child's misunderstandings of a traumatic event, particularly those that involve self-blame and magical thinking

Gently help child develop a realistic understanding of event Remain aware of your own reactions to the child's trauma Provide reassurance to child that feelings will diminish over time

Be mindful of the possibility of anniversary reactions

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6 to 11 Years

General Trauma Reactions

Memory for Trauma

Parental Support

Repeated retelling of recent traumatic event

Obvious anxiety and fearfulness

Specific post-traumatic fears

Post-traumatic reenactments of traumatic event that may occur secretly and involve siblings or playmates

Fear of trauma's recurring

Intrusion of unwanted visual images and traumatic memory that disrupt concentration and create anxiety, often without parents' awareness

Loss of ability to concentrate and attend at school

"Spacey" or distractible behavior

Behavior, mood, or personality changes

Regression to behavior of younger child

Toileting accidents

Withdrawal and quieting or excesses of aggression and limit testing

Loss of interest in previously pleasurable activities Sleep disturbances: nightmares, sleepwalking, night terrors (rare for this age), difficulties falling or staying asleep

Complaints about bodily aches, pains, or illness with no medical explanation

Concern about personal responsibility for trauma

Hyperarousal/hypervigilance

Acute awareness of parental reactions; wish to protect parents from their own distress

Frightened by intensity of own feelings

Vulnerability to anniversary reactions set off by seasonal reminders, holidays, or other events

Child is likely to have detailed, long-term memory for recent traumatic event

Factual accurate memory may be embellished by elements of fear or wish; perception of duration may be distorted

Listen to and tolerate child's retelling of event

Respect child's fears; give child time to cope with fears

Increase monitoring and awareness of child's play, which may involve secretive reenactments of untreated trauma with peers and siblings; set limits on scary or hurtful play

Permit child to try out new ideas to cope with fearfulness at bedtime: extra reading time, radio on, listening to a tape in the middle of the night to undo the residue of fear from a nightmare

Reassure the older child that feelings of fear or behaviors that feel out of control or babyish (e.g. night wetting) are normal after a frightening experience and that the child will feel more like him/herself with time

Encourage child to talk about confusing feelings, worries, daydreams, mental review of traumatic images, and disruptions of concentration by accepting the feelings, listening carefully, and reminding child that these are normal but hard reactions following a very scary event

Maintain communication with school staff and monitor child's coping with demands at school or in community activities

Protect child from re-exposure to frightening situations and reminders of trauma, including scary television programs, movies, stories, and physical or locational reminders of trauma Expect and understand child's regression while maintaining basic household rules

Expect some difficult or uncharacteristic behavior

Listen for child's misunderstandings of a traumatic event, particularly those that involve self-blame and magical thinking

Gently help child develop a realistic understanding of event Remain aware of your own reactions to the child's trauma

Provide reassurance to child that feelings will diminish over time

Provide opportunities for child to experience control and make choices in daily activities

Be mindful of the possibility of anniversary reactions

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11 to 18 Years

General Trauma Reactions

Memory for Trauma

Parental Support

Trauma-driven acting out behavior: sexual acting out or reckless, risk taking behavior

Efforts to distance from feelings of shame, guilt, and humiliation

Flight into driven activity and involvement with others or retreat from others in order to manage inner turmoil

Accident proneness

Wish for revenge and action-oriented responses to trauma

Increased self-focusing and withdrawal

Sleep and eating disturbances; nightmares; hypervigilance

Acute awareness of and distress with intrusive imagery and memories of trauma

Vulnerability to depression, withdrawal, and pessimistic world view

Personality changes and changes in quality of important relationships evident

Flight into adulthood seen as way of escaping impact and memory of trauma (early marriage, pregnancy, dropping out of school, abandoning peer group for older set of friends)

Fear of growing up and need to stay within family orbit

Acute awareness of distress with intrusive imagery and memories of trauma

Vulnerability to flashback episodes of recall

May experience acute distress encountering any reminder of recent trauma

Encourage younger and older adolescents to talk about traumatic event with family members

Provide opportunities for young person to spend time with friends who are supportive and meaningful

Reassure young person that strong feelings - whether of guilt, shame, embarrassment, or wish for revenge - are normal following a trauma

Help young person find activities that offer opportunities to experience mastery, control, and self-esteem

Encourage pleasurable physical activities such as sports and dancing

Address acting out behavior involving aggression or self-destructive aspects quickly and firmly with limit setting and professional help

Monitor young person's coping at home, school, and in peer group

Take signs of depression, accident proneness, recklessness, and persistent personality change seriously by seeking help

Help young person develop a sense of perspective on the impact of the traumatic event and a sense of the importance of time in recovering

Encourage delaying big decisions

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Goob: "I fell asleep in the 9th inning and missed the winning catch. Then I got beat up. Afterwards, the coach pulled me aside and told me to let it go. I don’t know, he’s probably right."

Bowler Hat Guy (Villain): "NO! Everyone will tell you to let it go and move on, but don’t! Instead, let it fester and boil inside of you. Take these feelings and lock them away. Let them fuel your actions. Let hate be your ally, and you will be capable of wonderfully horrid things!"

from Meet the Robinsons (2007, movie)