Responding To Trauma In The School Setting

1. Responding To Trauma In The School Setting School Crisis Response & Crisis Preparedness Conference St. Charles County Crisis Response Team October 10, 2003 Ally Burr-Harris, Ph.D. and Matt Kliethermes, Ph.D. The Greater St. Louis Child Traumatic Stress Program National Child Traumatic Stress Network (NCTSN)

2. Greater St. Louis Child Traumatic Stress Program • Member of National Child Traumatic Stress Network (NCTSN) - www.nctsnet.org • Services provided by Children’s Advocacy Center and Center for Trauma Recovery at UMSL • Free assessment and treatment of children and adolescents who have experienced a trauma • Consultation and training of education, mental health, and medical professionals in the area of child trauma • School-based group therapy for children and adolescents exposed to violence

3. What is a Traumatic Event? • Involves actual or threatened death or serious injury, or a threat to the person’s physical integrity • Involves feelings of intense fear, helplessness or horror (children may show disorganized or agitated behavior instead)

4. Natural disasters Kidnapping School violence Community Violence Terrorism/War Homicide Physical Abuse Sexual Abuse Domestic violence Medical procedures Victim of crime Accidents Suicide of loved one Extreme Neglect Types of Traumas

5. How Common are Traumatic Experiences? • 69% of the general U.S. population report exposure to one or more traumatic events • 14 to 43% of children/adolescents report having experienced a traumatic event • 23% of national sample of adolescents report being victim or witness of violence • Up to 91% of African American youth in urban settings report violence exposure • Among refugee children, rates of trauma exposure approach 100% • Large-scale traumas in schools are very rare but highly publicized

6. Effects of Trauma on Children and Adolescents • Most people experience posttraumatic stress symptoms during a trauma and in the weeks that follow. • Approximately 20% of youths exposed to serious trauma have persistent PTSD • Rates much higher for severe, chronic, or interpersonal trauma • 77% of youths who witnessed school shooting reported PTSD symptoms

7. Effects of Violence Exposureon School Functioning • Decreased school performance • Decreased school attendance • Increased concentration problems • Decreased academic and cognitive scores • Linked to aggression, conduct problems, social deficits, substance abuse, delinquency, and psychiatric problems

8. In A Moment, In a Heartbeat …Everything Changes…

9. Paducah, Kentucky

12. Be prepared for a crisis • Expect the unexpected • Be ready to implement crisis plan • Learn about common trauma reactions • Know yourself (strengths, limitations) • Know your students • Risk factors • Level of dependency (e.g., child with disability, younger child) • Build supportive relationships with students before a crisis

13. Immediate Reactions To A Trauma Or Crisis • Intense longing/concern for caregivers or loved ones • Emotionally labile • Extreme emotions (rage, fear) • Tearful, crying • Excited • Clinging to caregivers • Shock, numbness • Denial, inability to acknowledge situation • Dazed, feelings of unreality, dissociation • Confused, disorganized • Difficulty making decisions • Suggestible • Fight or flight mode, physical symptoms

14. Trauma Symptoms inElementary School Children • Sadness, crying, irritability, aggression • Increased activity level • Poor frustration tolerance • Safety-related fears • Generalized fear • Unable to verbalize distress • Nightmares • Trauma themes in play/art/conversation • School avoidance; decline in school performance

15. Trauma Symptoms in Elementary School Students • Physical complaints • Poor concentration • Regressive behavior (e.g., clingy, wetting bed, babytalking) • Eating/sleeping disturbances • Attention-seeking behavior • Withdrawal • Magical thinking related to trauma/death

16. Trauma Symptoms in Middle and High School Students • Depression • Feelings of shame/guilt • Detachment, denial of feelings • Avoidance of trauma cues • Intrusive images, thoughts, memories • Withdrawal from peers and/or family • Low energy, loss of interest • Appetite/sleep disturbance • Generalized anxiety, safety fears • Foreshortened future

17. Trauma Symptoms in Middle and High School Students • Physical ailments/complaints • Increased anger, irritability, aggression • Agitation • Peer problems (e.g., fighting) • Decreased interest in opposite sex • Increased risk-taking, rebellious behaviors • “Pseudomature” behaviors • Substance abuse • Decline in school performance/attendance

18. Risk Factors for Post-Trauma Adjustment Problems • Previous trauma exposure • Severity of trauma • Extent of exposure • Proximity of trauma • Understanding and personal significance • Interpersonal violence • Parent distress, parent psychopathology • Separation from caregiver • Previous psychological functioning • Genetic predisposition • Lack of material/social resources

19. Protective Factors for Post-Trauma Adjustment • Strong academic and social skills • Active coping, self-confidence • Social support • Family cohesion, adaptability, hardiness • High neighborhood/school quality • Strong religious beliefs, cultural identity • Effective coping and support by parents

20. During the Crisis • Implement school crisis response plan • Ensure safety and support of students • Remain with students if possible • Use calming techniques • Model adaptive coping • Provide developmentally appropriate information to students • Provide realistic, concrete reassurance

21. Stress Reduction During Crisis • Distraction • Disruption • Diffusion • Running Commentary (to self) • Separate from situation briefly • Progressive muscle relaxation • Breathing techniques • Positive self-talk • Visualization

22. Psychological First AidDuring and After the Crisis • First week after trauma • Triage/ Risk Screening • Classroom Crisis Intervention • Crisis debriefing • Psychoeducational • Skill-building • Support-oriented • Regain sense of control/mastery • Plan for gradual return of normal activities

23. Triage and Risk Screening • Physical exposure • Direct: victims, eyewitnesses • Perimeter: close to chaos (sights, smells, sounds) • Campus: no direct exposure; may be affected by others’ reactions • Off Campus: not at school during incident

24. Triage and Risk Screening • Reactivity to trauma reminders • Previous trauma exposure • Subjective appraisal of threat during trauma • Emotional exposure • Relationship with victim • Personal significance of trauma • Loved one within physical proximity • Past history of serious emotional problems

25. Classroom Crisis Intervention • Designed to assist staff/ students in coping with trauma • Structured session(s) 24 to 72 hours after trauma • Facilitators: Trained counselors, classroom teacher • Effective in reducing distress, establishing connections, reducing isolation, accelerating normal recovery, and helping to identify those most at risk • Not effective at reducing risk for PTSD for high-risk students • Problematic if varied exposure levels or too soon after trauma

26. Classroom Crisis Intervention:Components • Provide accurate, developmentally appropriate information • Share thoughts, feelings, and needs for safety or resolution related to trauma • Nonverbal sharing exercise allows for individualized attention • Teaching phase: • stress reduction • coping strategies • normalization of reactions • recovery predictions

27. Comforting Traumatized Children • Reinforce ideas of safety and security • Allow them to be more dependent temporarily if needed • Follow their lead (hugs, listening, supporting) • Use typical soothing behaviors (rest, comfort, food, hugs, stuffed animal, music) • Use security items and goodbye rituals to ease separation with younger children • Distract with pleasurable activities* • Let the child know you care *normally occurring

28. Controlling Child’s Environment • Maintain normal routines as much as possible • Reduce class workload as needed • Avoid exposing children to unnecessary trauma reminders (e.g., media) • Minimize contact with others who upset child • Guide other children in supporting child • Give trauma cues positive change

29. Discussing the Trauma with Children • Encourage children to express their traumatic experience but don’t pressure • Be an active listener • Remain calm when answering questions and use simple, direct terms • Don’t “soften” the information you give to children • Help children develop a realistic understanding of what happened • Gently correct trauma-related distortions • Be willing to repeat yourself • Normalize “bad” feelings

30. Intervening with Traumatized Children • Identify triggers (e.g., trauma cues) that upset child and plan ahead • Defuse anger • Address acting out behaviors involving aggression or self-destructive activities quickly and firmly • Model/coach adaptive coping with upsetting feelings • Set up behavior management plan reinforcing adaptive coping and appropriate behavior • Do not tolerate inappropriate negative behavior (harassment, bullying, threats) • Avoid traumatizing classmates during trauma reenactments/discussions • Be patient and calm

31. Facilitating Trauma Resolution • Use play, art, stories to assist with trauma resolution • Normalize symptoms/reactions • Reinforce positive messages • Positive reminiscing of deceased • Encourage constructive activities • Teach tolerance and respect • Recovery events

32. How to Talk (and Listen) to Traumatized Children • Children need to have their feelings accepted and respected • Listen quietly and attentively • Acknowledge their feelings with a word or two • Give their feelings a name • Give them their wishes in fantasy • Show empathy

33. Responses That ARE NOT So Helpful • Denial of feelings • Philosophical response • Advice • Too many questions • Defense of the other person • Pity • Amateur Psychoanalysis

34. Common Trauma-Related Distortions in Youth • Self-blame • Guilt, survivor guilt • Overgeneralization of danger/risk • Shame/embarrassment b/c of trauma • Shame over PTSD symptoms • Hero fantasies related to trauma • Omen formation • Foreshortened future • Magical thinking

35. Correcting Distorted Beliefs • Point out the child’s distorted belief by briefly summing it up • Label how you think they might feel • Validate their feeling; show empathy • Let them know how it makes you feel to hear the distorted belief • Suggest a healthier belief; keep it brief

36. Helping Grieving Children • Don’t be afraid to talk about the death • Be prepared to discuss the same details over and over again • Be available, nurturing, reassuring and predictable • Assist youths in developing grieving rituals and in finding meaning • Help other students learn how to respond • Anticipate need for extra support when child faces loss reminders (e.g., holiday)

37. Helping Grieving Children • Assist younger children in understanding finality of death. • Use youth’s (family’s) own belief system when discussing afterlife • Share memories and talk about the person who died when appropriate • Gently remind children ALL feelings are okay. • Use reminders like “you did not cause this” or “it is not your fault.”

38. Helping Parents of Traumatized Children • Communicate with parents frequently about child • Encourage parents to listen to child closely • Encourage parents to set aside special time for child • Recommend maintenance of normal routine • Encourage parents to remain calm and to get help for themselves if needed • Normalize child’s emotional/behavioral difficulties after trauma • Model soothing behaviors with younger children • Assist in developing plan for behavior mgmt.

39. Group Exercise • Supportive listening techniques

40. When to Refer for Psychological Care • Appear depressed, withdrawn, noncommunicative • Strong resistance to affection/support from caregivers • Suicidal or homicidal ideation • Dangerous behaviors to self/others • Increased usage of alcohol or drugs • Rapid weight gain or loss • Significant behavioral changes or problems (e.g., sexual) • Discontinue attending to hygienic needs • Significant acute stress symptoms

41. When to Refer for Psychological Care Showing these changes for more than 1 month after trauma • Intense anxiety or avoidance behavior triggered by trauma reminders • Unable to regulate emotions (crying, angry outbursts) • Poor academic performance and decreased concentration • Continued worry about event (primary focus) • Excessive separation difficulties • Physical complaints (nausea, headaches) • Continued trauma themes in play • Unable to grieve/mourn death of loved one

42. Taking Care of Yourself • Alleviate additional stress • Request temporary relief from classroom if needed • Make sure your own family is safe • Participate in staff debriefing sessions • Schedule time away from work to talk about your own experiences • Limit exposure to media coverage

43. Taking Care of Yourself • Be aware of your limitations • Pick your battles • Prioritize where you are putting your energy • Surround yourself with people who make you feel good and on whom you have the same effect • Take care of yourself physically • DON’T BE A SUPERHERO

44. Group Exercises • Case examples: • Identify and Discuss • Risk factors • Symptoms • Supportive strategies

45. We’re done! Email Ally Burr-Harris, Ph.D., at Burrharrisa@msx.umsl.edu for additional questions, references, or referrals.