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Ukrainian students and parents in American schools

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Ukrainian students and parents in American schools

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This article offers multiple opinions on how to help Ukrainian students cope with war-related trauma and the turbulences of starting a new life as a refugee. What impressed me most is the fact that the school districts are inviting parents to work or volunteer at the schools as well. Even though this decision is not up to us as teachers, but I believer that active parent involvement is definitely one of the keys to helping students who have suffered this kind of traumatic experiences.

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The School District That’s Enrolling Ukrainian Refugees—and Hiring Their Parents

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The Topeka, Kan., district has hired Ukrainian refugees in multiple roles, helping provide stability to families uprooted by war.

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One of the schools in Romania has welcomed a number of refugees from Ukraine and has been working on their integration. Besides having suffered traumatic experiences related to war, most Ukrainian children don't speak Romanian or English, so the teachers had to come up with a number of strategies to help these children keep up with their new classmates.  With a focus on small group work, peer learning and interdisciplinary learning as well as extensive use of technology, teachers were able to promote a quick and successful integration of the Ukrainian refugees.

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Supporting the integration of Ukrainian pupils in Romania' schools

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In short, always. Not all students express traumatic stress in manner which is noticed easily by a teacher, caretaker or administrator. Some symptoms of traumatic stress include a distrust of authority or social aversion to intervention itself. Many symptoms can also be masked or buried, but are no less harmful to the development and well being of students. This article makes the argument that we can not wait for symptoms to become evident to take action. Early intervention is the most successful, and effective. Administrators and teachers are often unprepared and unable to recognize issues even when they do express as well. Ergo, we should all be behind an automatic system which checks on every student's well being: Universal screening.

"Universal screening is a proactive approach of using brief and efficient measures to identify students at
risk for future difficulties (Eklund & Dowdy, 2014; Jenkins, Hudson, & Johnson, 2007)."

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Guidance for Trauma Screening in Schools

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Despite a high prevalence, Traumatic stress is rarely screened for.

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Despite a high prevalence, Traumatic stress is rarely screened for.

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How common? " Research to date shows that trauma exposure is common – before the age of 17, approximately two-thirds of youth will be exposed to some form of traumatic event"

How often does this result in traumatic stress? "Of the children who reported at least one traumatic event, 104 (75.4%) endorsed current posttraumatic stress symptoms in the moderate range (total score ≥ 20). Importantly, 9.5% of the entire screened sample was likely to meet DSM-IV diagnostic criteria for PTSD based on the clinical cutpoint"

This study underpins the need for a universal screening system as it notes many times the student in question was not being actively monitored for concerning behavior from a teacher or administrator: "Indeed, anecdotally, several teachers expressed their surprise about some of the children referred for a subsequent school-based group intervention, stating that they had not perceived any difficulties in the children in the school setting despite the child’s self-reported emotional distress and impairment in other areas."

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School Ment Health. Author manuscript; available in PMC 2017 Mar 1.

Published in final edited form as:

Araceli Gonzalez, PhD, Assistant Professor,* Nicholas Monzon, BA, Diana Solis, BA, Lisa Jaycox, PhD, Senior Behavioral Scientist, and Audra K. Langley, PhD, Associate Professor

Abstract

Traumatic childhood events can have a significant impact on overall child functioning. Early identification and intervention could offer significant benefits for children's mental health and educational trajectories, but how to effectively identify young children is a challenge. In this paper, we describe screening for exposure to traumatic events and associated symptoms of posttraumatic stress, and examine differences by child gender and grade level. A total of 402 elementary school children in grades 1-5 participated across four elementary schools. We describe modified administration procedures of screening instruments for these young children. Children who endorsed exposure to one or more traumatic events were individually assessed for posttraumatic stress symptom severity. Thirty-four percent (n=138) of children screened experienced one or more traumatic events, and 75.4% of those exposed to at least one traumatic event endorsed moderate levels or higher of posttraumatic stress symptoms. Internal consistency of the symptom self-report instrument was adequate for children of all grade levels. Posttraumatic stress symptom severity increased for children exposed to more types of events. No gender/grade differences were found in symptom severity. Findings suggest that young children are impacted by traumatic events in relatively high numbers, that they can reliably report their posttraumatic stress symptoms, and that a large portion of those exposed to trauma experience significant distress. These results highlight the importance of early screening and identification of these children to curtail potential risk for future academic, social, and psychological maladjustment.

The need for school-based mental health screenings to identify potential mental health concerns in youth is well-established. There have been several national calls to improve and expand school mental health programs, and suggestions for doing so often involve universal screening to increase identification of child mental health problems in their earliest stages (e.g., Dowdy, Ritchey, & Kamphaus, 2010; Fazel, Hoagwood, Stephan, & Ford, 2014; The President's New Freedom Commission on Mental Health, 2003). Early childhood symptoms may develop into chronic or more severe problems over development and are significantly associated with school functioning years later. Indeed, psychological functioning in early elementary school (1 st grade) has been shown to predict academic achievement years later (4 th grade; Guzman et al., 2011). However, only a small proportion of schools routinely conduct mental health screening ( Romer & McIntosh, 2005). Given that emotional and behavioral symptoms at a young age often predict the development of future psychiatric disorder, early screening and detection is critical in minimizing risk for future emotional, academic, and social difficulties (e.g., Essex et al., 2009; Albers, Glover, & Kratochwill, 2007). Elementary school children are building the foundation for future school functioning as they meet critical educational milestones (e.g., developing literacy and arithmetic skills), screening during this particular developmental period should be an educational and public health priority.

Challenges in screening elementary school children

School-based screenings at any grade level present several practical barriers, including limited funding and staffing to conduct screenings, as well as concerns regarding follow-up after youth are identified ( Levitt, Saka, Romanelli, & Hoagwood, 2007). Self-report of experiences and symptoms may be an efficient way of screening that minimizes required training and burden of administration and scoring. However, screening of young schoolchildren using self-report may present several methodological challenges given children's developmental level. Concerns inherent to self-report measures, including subjectivity, poor reliability, and validity of responses, are heightened in a young age group who may not yet possess the cognitive skills to comprehend complex questions or reflect upon internal experiences. While several tools for assessing psychological symptoms in young children exist, including the use of puppets and stories and play narrative techniques (e.g., Luby, Belden, Sullivan, & Spitznagel, 2007), such approaches may lack feasibility for large-scale screenings in school and clinical settings given the time required for administering and coding child responses. Fortunately, data supporting the reliability and validity of assessment tools with elementary school are increasing; studies have demonstrated acceptable test-reliability and predictive validity with respect to future mental health, and significant concordance with reports of parent and teacher informants ( Ialongo et al., 2001; Luby et al., 2007). While young school children may lack reading skills and vocabulary to complete many assessment instruments independently; alternative modes of administration (e.g., verbal administration) may circumvent concerns about reading levels.

Despite the challenges associated with screening children using self-report instruments, there a number of potential advantages of this method that may justify attempts to navigate these challenges. Traditional school-based referral procedures, including teacher identification and nomination of students, may not adequately identify all youth in need and may be particularly subject to bias ( Husky, Kaplan, McGuire, Flynn, Chrostowski, & Olfson, 2011; Severson, Walker, Hope-Doolittle, Kratochwill, & Gresham, 2007). This method of identification may over-identify youth who have more severe problems and have already demonstrated aspects of adaptational failure (e.g., conduct problems, academic underachievement, poor peer relations) while failing to detect youth with more covert internalizing symptoms (e.g., anxiety and fearfulness, depression) ( Cunningham & Suldo, 2014; Dvorsky, Girio-Herrera, & Sarno Owens, 2014). Consistent with this, internalizing problems, including Posttraumatic Stress Disorder (PTSD), are underrepresented in both school- and clinic-based services ( Garland et al., 2001). This is problematic because these common problems can significantly interfere with several domains of child socioemotional development.

Rationale for screening for trauma exposure in elementary school children

School-based screening for exposure to trauma may be useful for identifying a large number of youth at risk for a variety of negative outcomes and thus may improve efficiency of screening. Research to date shows that trauma exposure is common - before the age of 17, approximately two-thirds of youth will be exposed to some form of traumatic event ( Briggs-Gowan et al., 2010; Copeland et al., 2007; Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009). While not every youth who experiences a traumatic event will develop PTSD, even subclinical or partial PTSD symptoms pose significant risk for the development of several other mental health disorders ( Copeland, Keeler, Angold, & Costello, 2007). Importantly, trauma exposure and associated symptoms have also been linked to poorer functioning in academic settings, including decreased social competence, increased rates of peer rejection, decreased reading ability, lower grade-point average, more days of school absence, and decreased high school graduation rates ( Delaney-Black et al., 2002; Grogger, 1997; Hurt, Malmud, Brodsky, & Giannetta, 2001). Such findings illustrate how this single common risk factor can initiate several maladaptive developmental pathways. A public health approach involving school-based screening for exposure to traumatic events may maximize detection of youth at risk for a broad array of adverse outcomes, and early detection can ameliorate or prevent difficulties in emotional, behavioral, social, and academic functioning.

To date, there are several gaps in the current research base and the full extent of trauma exposure in a general population of elementary school children is unclear. Previous research on level of youth exposure to traumatic events has predominantly focused on adolescent populations and school-based findings in elementary school children have yielded a vast range of estimates, from 14% to 40% ( Alisic, van der Schoot, Ginkel, & Kleber, 2008; Stein et al., 2003). Further, many studies of trauma exposure among children have recruited special populations, such as those with existing psychiatric disorders (e.g., ADHD, oppositional defiant disorder; Ford, Racussin, Daviss, et al., 2000) or survivors of natural disasters or child maltreatment ( Gabbay, Oatis, Silva, & Hirsch, 2004). Studies using specialty samples may produce higher estimates that cannot be generalized to a community sample of school children. Next, age differences in level of exposure are also unclear; while some studies have detected a positive association between age and trauma exposure ( Alisic et al., 2008; Copeland et al., 2007), others have not ( Stein et al., 2003). Finally, while a handful of smaller studies have focused on exposure to very specific events (e.g., natural disaster, terrorism or war trauma), many of the large national surveys of youth trauma exposure have focused on exposure to community violence (e.g., Finkelhor et al., 2009; Freeman, Mokros, & Poznanski, 1993; Kilpatrick & Saunders, 1999; Schwab-Stone, Ayers, Kasprow, & Voyce, 1999). Inquiry about a variety of traumatic events, including both interpersonal (e.g., community trauma, assault) and non-interpersonal (e.g., car accidents, natural disasters, animal attacks) events, would provide more realistic estimates regarding level of trauma exposure in children as well as useful information about the events to which children are most likely to be exposed.

School-based screening for trauma exposure provides access to a general population of children, including those who are not yet exhibiting emotional, behavioral, or academic difficulties. This is critical because early identification and intervention could offer significant benefits for children's mental health and educational trajectories. For instance, the few studies of school-based mental health intervention for trauma-exposed children provide promising support for the benefits of such services, indicating that school-based cognitive-behavioral interventions can effectively reduce posttraumatic stress symptoms in trauma-exposed children and early adolescents of diverse backgrounds ( Langley, Gonzalez, Sugar, Solis, & Jaycox, in press; Kataoka et al., 2003). Identification of children who would benefit from such services may be enhanced using screening procedures rather than traditional referral methods.

Current study

The present study employed a school-based screening approach to identify children exposed to one or more traumatic events and assess subsequent symptoms of posttraumatic stress. This study addresses several gaps in the existing literature by screening a diverse community of elementary school aged children (i.e., non-specialty sample), assessing several types of traumatic events (interpersonal and non-interpersonal), and examining differences in trauma exposure and associated symptoms by gender, grade level, and type of traumatic event. Specifically, our goals are to (a) describe the modified administration procedures for screening children for exposure to traumatic events in the elementary school setting, (b) report the level of trauma exposure in young schoolchildren (grades 1-5) and frequency of exposure to specific types of events, and (c) examine traumatic stress symptom severity of children with trauma exposure, including any potential differences by child gender and grade level. Based on previous work in similar regions, we anticipated that rates of trauma exposure would be comparable to those reported in studies conducting universal screening in middle and high schools. Finally, we did not anticipate detecting gender or grade level differences in trauma exposure or symptom severity. In addition, we conducted a preliminary examination of the reliability of our screening method in young children using developmentally-modified administration of self-report instruments; we anticipated that our modified screening procedures would yield reliable child reports.

Method

Participants

All procedures were approved by the institutional review board. A total of 402 children (1st - 5th grade; 51% boys) participated in screening for exposure to traumatic events during the 2011-2012 and 2012-2013 school years at four elementary schools in a southern California school district. All four schools serve a diverse ethnic and linguistic student body from grades K-5 and qualify as Title I schools under the No Child Left Behind Act of 2001, indicating that at least 40% of the students were eligible for free or reduced lunch. Because we were interested in sampling students across several school campuses, only two grade levels were screened at each school per academic year. The grade levels screened at each school changed from the first to second year to broaden grade level sampling at each school. During the first year, the grade level to be screened was randomized at each school. In the second year, a different grade level was chosen at each school and we ensured that the grade level did not overlap with the students who were screened the previous year in Year 1. In addition, one school was an English/Spanish immersion public school and the school Principal requested that we screen students in grade 2 and older because not all students in 1 st grade had learned to read in English yet.

A total of 1,050 parental consent forms were distributed with 789 (73%) returned and 417 (53%) providing consent for child screening. Of these, 402 children completed the screening for exposure to traumatic events. Parents provided written consent for screening but did not participate in any of the described screening procedures.

To ensure that screening procedures were sustainable, data collection was designed to maximize brevity and accordingly we recorded only gender and grade level for participants. We did not collect racial/ethnic demographic data for the screened sample. However, as a whole, each school is racially/ethnically diverse; three of the four schools have a majority Hispanic or Latino student body (76.9%, 50.5%, and 39%; data obtained from school district records).

Measures

With feasibility and sustainability in mind, assessment measures were selected with consideration of their psychometric properties as well as their low-cost availability and ease of administration and scoring. Several adaptations were made to assessment procedures in order to make them appropriate to the developmental level of children, which we describe in more detail below.

Trauma exposure

The Modified Traumatic Events Screening Inventory for Children - Brief Form (TESI-C-Brief; Daviss et al., 2000; Ford, 2008), child version, was used at baseline to assess exposure to direct or witnessed trauma via 21 items and has been normed and validated with youth ages 6-17, and field tested with children as young as age 3. This measure is typically clinician-administered in interview format for children under age 11. Items query a range of traumatic experiences, including accidental trauma (e.g., car accident, injury), physical abuse, violence, loss of loved ones, and substance abuse exposure. The TESI has been used extensively by the National Child Traumatic Stress Network (SAMHSA) ( Edwards & Rogers, 1997) and reviews of instruments to measure history of traumatic events support its strong psychometric properties, including reliabilities of > .80 and interrater reliability ranging from .73-1.00 (e.g., Ribbe, 1996). Per the request of school administrators, we did not ask children about sexual abuse histories. Parents did not participate in the screening; data provided here are based solely on child report.

Posttraumatic stress symptoms

Those students who endorsed at least one traumatic event on the TESI-C were then administered the UCLA Posttraumatic Stress Disorder Reaction Index (RI) ( Pynoos, Rodriguez, Steinberg, Struber, & Fredrick, 1998), a 20-item child report of posttraumatic stress symptom frequency during the previous month. This measure has been field tested and validated with children as young as age 7. Items correspond to symptoms listed in DSM-IV PTSD criteria and are rated on a 5-point Likert-type scale from Never (0) to Most of the time (4). As described below in Procedures, screening staff used a visual aid to help children comprehend the scaling for each item response. The questionnaire includes subscales corresponding to DSM-IV subdomains (re-experiencing, avoidance/numbing, hyperarousal). The questionnaire was administered verbally by research staff to children who endorsed at least one item on the TESI. This instrument has been used among a variety of samples experiencing a variety of traumas with strong support for internal consistency, test-retest reliability, and convergent validity as evidenced by agreement of cut-off scores with a diagnosis of PTSD ( Steinberg, Brymer, Decker, & Pynoos, 2004). A total score of 38 is most sensitive and specific to a DSM-IV diagnosis of PTSD ( Steinberg et al., 2004), however, children with scores in the 20-25 range may be considered to have moderate symptoms of posttraumatic stress (e.g., Cohen, Mannarino, & Staron, 2006; Langley et al., in press). Given our goal of screening to identify youth at earliest stages of symptoms, in this study we used a RI severity total score of ≥20 to identify children with at least moderate posttraumatic stress symptoms.

Procedures

Written parental consent

Parental consent forms for screening were distributed the first week of the school year (September) and accompanied paperwork that is typically sent home the first week of school (e.g., emergency contact cards). The consent forms included checkboxes where parents could indicate "Yes" they provided consent or "No" they declined consent for their child to participate in screening for exposure to traumatic event, and a signature was required. In this particular school district, all students have a folder that goes home to their caregivers on the same day each week; if signed consent forms were not returned with the initial packet, then a new copy was sent home in the child's weekly folder for up to two weeks, and teachers were asked to provide a verbal reminder to parents if they had any contact with them (i.e., when picking the child up from school). To incentivize the return of consent forms, teachers were informed that the classroom with the highest consent form return rate (regardless of whether the parent provided or declined consent) would earn funds for a pizza party.

School screening

Each of the four schools had three designated full-day screening days, plus a half-day to screen children who were absent on the first three assessment days. Screening occurred during class time and students were not invited to screen during lunch or recess. Research staff screening teams were comprised of one PhD-level clinician who supervised a team of three to five graduate students who completed the screening questionnaires with the children at each school.

On screening days, a team of screeners was provided a large room, or multiple smaller rooms depending on the logistics of each school, where children were screened. Children whose parents/guardian provided written consent were individually retrieved from their classrooms by the screeners and escorted to the screening room, where staff verbally administered the screening instrument. Children first completed the TESI to indicate whether they had experienced certain traumatic events, and children who endorsed experiencing one or more traumatic events in their lifetime complete an additional questionnaire to report the severity of posttraumatic stress symptoms using the RI.

Research staff administering the screening instruments stationed themselves at desks or tables spread out across the room far enough from one another so that students could not hear or see one another's responses. Once screening was completed with each child, children chose a reward from a box of school supplies and small toys and were then escorted by staff back to their classrooms. Research staff attempted to accommodate to any specific teacher requests about when best to and not to pull certain students out of class (e.g., if a student struggled with math and teacher requested that a student not be pulled out of class during the scheduled math time, screening staff made a note and attempted to screen the child during another scheduled activity). Screening staff were instructed to end the assessment on a positive note by asking students about things they enjoy (e.g., their pets, fun activities they have scheduled that week), and not to return children to their classrooms until they observed neutral or positive affect. Total screening duration per student was 5-10 minutes for students who did not endorse a traumatic event and approximately 15-25 minutes for students who endorsed one or more events.

Modified administration of instruments

For consistency, instruments were verbally administered to all children because some of the younger children had not yet developed adequate reading skills. Screening staff met individually with each child and sat side-by-side so the child could read along while screening staff read each item aloud to the child. Children were able to point to their answers or to mark their own answers, depending on their preference.

Several steps were taken to enhance child understanding of each screening measure. To ensure comprehension of the content of the questions on the TESI, screening staff were instructed to ask children if they knew the definitions of certain words (e.g., "violence," "threatened"); if children said "Yes" then screening staff asked the child to define the word, and if they said "No," then screening staff provided the definition. In addition, screening staff queried using specific concrete examples to ensure the child's understanding of the question. For example, there were several instances when a child answered "No" to a question regarding exposure to community violence, but then answered "Yes" when asked if they have heard gunshots in their neighborhood. In addition, because younger children may have literal interpretation of some items, screening staff were instructed to specify "not on TV" for several of the TESI items (e.g., have you seen a serious accident where someone was hurt badly or died?). Lastly, steps were taken to minimize risk of false positive responses given that younger children are likely to make literal interpretations of questions. If a child answered "yes" they had experienced a traumatic event, the child was probed further to assess the intensity of the situation to determine whether the event appeared like an actual traumatic event. For example, if a child endorsed having been hit or pushed, the screener asked follow-up questions to determine the nature of the physical fight (e.g., physical attack from a stranger or peer vs. a minor quarrel with a sibling); if a child said they had been bitten by a dog, the screener probed the severity of the bite (e.g., breaking skin and requiring stitches vs. a puppy nipping the child during play).

Students who endorsed more than one item on the TESI (n = 138) were asked which of the event was most personally upsetting (e.g., "which of these things makes you feel most afraid or sad?") and subsequently completed the RI based on the event that the child endorsed as most upsetting. The RI is a dimensional measure of posttraumatic stress symptom severity, and because children may have difficulty understanding the scaling of each item (0-4), screening staff used a visual graph to represent the five response options on the rating scale. This visual aid was similar to a feelings thermometer commonly used in clinical research and practice with young children ( Silverman & Albano, 1996); it was a sheet of paper displaying five three-dimensional cylinders filled to varying levels to represent the degree of presence or absence of certain symptoms. An empty cylinder corresponded to "0 = Never" or not at all, and a full cylinder corresponded to "4 = Most of the Time" or very much. For each item, children were able to point to the quantity that best described them. To assess children's understanding of the scale, screening staff completing a few practice items with each child (e.g., I like to go to the dentist, or I like recess).

Post-screening referrals

Children identified as having elevated posttraumatic stress symptoms in this study were referred for participation in a school-based cognitive-behavioral intervention for children exposed to trauma at each of their schools ( Langley et al., in press), or another source if desired.

Analyses

All analyses were conducted using SPSS Version 21. ANOVAs were used to check for potential differences between schools. T-tests were used to assess differences between genders and between youth who scored 20 or higher and less than 20 on the Reaction Index (RI). Correlations were used to evaluate the association between grade level and trauma exposure and symptom severity. Chi-squared tests were used to assess differences in types of event between genders, youth above and below the clinical cutpoint of significant posttraumatic stress symptoms, and between schools.

Results

A total of 402 elementary school students in grades 1-5 participated. Student gender and grade level are listed in Table 1 . We checked for differences between schools and found no significant differences between the four elementary schools in terms of proportion of children exposed to one or more events ( Χ ²(3, N =402) = 2.75, p = .124), mean number of traumatic events endorsed among those exposed ( F(3,137) = .476, p = .699), or severity of RI symptoms ( F(3,133) = .151, p = .959). Therefore, we collapsed across school in analyses. In addition, we examined potential differences in level of trauma exposure (TESI total score) between children who participated in the first year of the study and the second year of the study and did not find any differences exposure to traumatic event across the two years ( t ₄₀₀ = −.001, p = .994). Similarly, there were no significant differences in RI score between those who participated in the first and second years of the study ( t ₁₃₂ = −1.23, p = .627). Therefore, we also collapsed across school years in our analyses.

Table 1

Screened

No. exposed to
traumatic
event
(TESI ≥ 1)

No. with
symptoms in
moderate range or
higher (RI ≥ 20)

Year 1

Year 2

Total

Total

235

167

402

138 (34.3%)*

104 (25.9%)

Exposure to traumatic events

Level of exposure

Thirty-four percent (n=138) of children endorsed experiencing one or more traumatic event(s) during their lifetime. Trauma-exposed children reported a range of 1 to 12 types of events, with a reported mean exposure to 2.58 types of events (SD = 1.75) across all schools. Table 2 lists types of events endorsed by order of frequency. The five most frequently reported types of traumatic events were: witnessed/know of family member arrested or deported (28%), witnessed physical (22%) or community violence (21%), victim of physical violence (17%), and witnessed a serious accident (17%). Number of traumatic event types was significantly and positively correlated with posttraumatic stress symptom severity ( r = .39, p < .001).

Table 2

Rank

Type of Traumatic Event

% Endorsing Event

Gender and age differences in frequency and type of exposure to trauma

Out of the 138 children who were exposed to at least one traumatic event, 68 were male and 70 were female ( Table 2 ). There were no significant gender differences in mean number of different types of traumatic events to which they were exposed, t(136) = .540, p = .590. However, there were significant gender differences in exposure to two specific types of events. More boys than girls endorsed experiencing the death of a loved one ( Χ² (1, N = 136) = 9.977, p = .002) and physical harm from another ( Χ² (1, N = 138) = 5.402, p = .020). There was no significant difference between grade level and the mean number of traumatic events ( F(4, 136) = 2.249, p = .067), or in exposure to the top five most frequently reported events (χ ² (4, N=136) = 2.63-3.79, all p = .434-.622). Grade level and mean number of traumatic events were not significantly correlated ( r = .086, p = .319), indicating that exposure to traumatic events did not increase with age in this sample.

Posttraumatic stress symptoms

Reliability

Across all children in this sample, Cronbach's α = .85 for children's report on the RI. Cronbach's alpha for each grade is as follows: 1 st: α = .90; 2 nd: α = .82; 3 rd: α = .87; 4 th: α = .88; 5 th: α = .92, indicating that internal consistency was good to excellent for all grade levels.

Symptom severity

Of the children who reported at least one traumatic event, 104 (75.4%) endorsed current posttraumatic stress symptoms in the moderate range (total score ≥ 20). Importantly, 9.5% of the entire screened sample was likely to meet DSM-IV diagnostic criteria for PTSD based on the clinical cutpoint of total score ≥ 38 that is suggested in some published works ( Steinberg et al., 2004). The 104 children who scored a 20 or above on the RI were compared to the 34 children who endorsed exposure to a traumatic event but whose symptoms of posttraumatic stress were below 20 on the RI. Children who scored below and above the RI cutoff did not differ in school attended ( Χ² (3, N = 135) = 3.609, p = .307) or type of traumatic events endorsed (all ps < .05). By contrast, children who scored above the RI cutoff endorsed a significantly higher number of types of traumatic events ( M = 2.86, SD = 1.792) than children who scored below the cutoff score ( M = 1.77, SD = 1.383), t(133) = −3.094, p = .002.

Gender and age differences in posttraumatic stress symptom severity

There were no significant differences between gender or grade level in symptom severity for total posttraumatic stress (RI Total score) or for any of the RI subscales (re-experiencing, avoidance/numbing, hyperarousal) (all ps > .05). A higher proportion of children in the 3 rd grade scored a RI total score of ≥ 21 than children in the other grades (1 st, 2 nd, 4 th, or 5 th), Χ² (4, N = 135) = 13.549, p = .009; however, the grade level and RI symptom severity were not significantly correlated ( r = −.08, p = .34).

Discussion

The objective of this study was to describe procedures for screening elementary school children for exposure to traumatic events and to report the extent of exposure and severity of posttraumatic stress symptoms. Results indicate that over one-third of elementary school children reported exposure to traumatic events and suffered associated symptoms of posttraumatic stress, and that levels of exposure and symptom severity were similar to those of older elementary schoolmates. Further, a significant portion of trauma-exposed children reported experiencing significant distress.

This study uniquely contributes to research in this area in two primary ways. First, this study provides promising support for successful and reliable screening using children's self-report. Screening procedures with young schoolchildren were successfully implemented using modified administration of instruments. Developmentally-appropriate modifications included verbally administering screening instruments, simplifying language and defining unknown words, distinguishing events that occurred in real life from those viewed on television, and using a visual aid to help students understand and select response options for items assessing symptom severity. Some school-based screening approaches rely on teacher informants, but this method alone may fail to identify youth who are not already exhibiting signs of academic dysfunction ( Albers et al., 2007; Severson et al., 2007). Indeed, anecdotally, several teachers expressed their surprise about some of the children referred for a subsequent school-based group intervention, stating that they had not perceived any difficulties in the children in the school setting despite the child's self-reported emotional distress and impairment in other areas. This underscores the importance of universal screening for early identification of children prior to the expression of overt adaptational difficulties. Taken together, these results suggest that a multi-method, multi-informant approach, including children's report, may hold most promise in identifying children in need.

In addition, children's reports yielded good internal consistency across all grade levels, which is consistent with existing studies that children can reliably report their internalizing symptoms. Indeed, data supporting the reliability and validity of assessment tools with this age group are increasing. Developmentally-appropriate measures using puppets and play narrative have produced significant correlations with other self-reports of children's symptoms, and several studies indicate that young children's self-report of symptoms reliably predict future functioning and significantly correlate with reports from adult informants. Ialongo and colleagues (2001) found that first grade students' self-report of anxiety symptoms demonstrated good test-retest reliability and predicted future academic achievement and symptoms of suicidal ideation and depression better than those reported by adults. Another study or preschool students revealed significant correlations between young students' report of internalizing symptoms and those reported by their parents ( Luby et al., 2007). Taken together, results regarding child-self reports of internalizing symptoms are favorable and suggest a promising avenue for further research.

Second, this study helps to clarify the level of trauma exposure in children by screening a diverse community of elementary school aged children, inquiring about exposure to a variety of interpersonal and non-interpersonal traumatic events, and exploring differences in trauma exposure and symptoms with regard to gender, grade level, and type of traumatic event. Across four elementary schools, 34% of children endorsed exposure to one or more traumatic events during their lifetime. The proportion of trauma-exposed children in this young sample was comparable to those reported in other studies that included adolescent samples, ranging from 25.2% to 72% (e.g., Copeland et al., 2007; Costello, Erkanli, Fairbank, & Angold, 2002; Finkelhor, Ormrod, Turner, & Hamby, 2005; Finkelhor et al., 2009; Kataoka et al., 2003; Stein et al., 2003). The rates in this sample are similar to those reported in a sample from a different southern California school district with predominantly low-income Latino children in elementary and middle school (31-32%; Jaycox et al., 2002; Kataoka et al., 2003), although these previous studies focused on exposure to violence and may be higher when all types of traumatic events are considered. However, these samples were more geographically and racially/ethnically comparable to children in the present study than to other studies of trauma exposure in school children that reported lower rates of exposure. For instance, trauma exposure in the present study is substantially higher than that reported by Alisic and colleagues (2008), who observed a prevalence of 14% in their sample of 1,770 Dutch school children. Differences in these rates may be in part to national differences in community violence and risk for deportation. Further, present findings are inconsistent with previous studies suggesting positive associations between trauma exposure and youth age ( Alisic et al., 2008; Briggs et al., 2013). Present results indicate that elementary school children were similarly affected by trauma exposure and highlight the need to screen younger children to maximize early detection and intervention, although further work is needed to understand family- and community-level factors that are associated with decreased trauma exposure in young children in order to understand these discrepancies.

A contribution of this study is the assessment of level of posttraumatic stress symptoms in addition to extent of exposure. Of the 138 children who endorsed exposure to one or more traumatic events, 75.4% (25.9% of entire screened sample) reported moderate levels of posttraumatic stress symptoms (RI ≥ 20). Notably, over one-third of children exposed to a traumatic event endorsed symptoms in the clinical range that suggests potential diagnosis of PTSD (36.5%; 9.5% of the entire screened sample); this approaches the overall rate of PTSD in a recent meta-analysis of children and adolescents (Alisic, van Wesel, Larsen, Hafstad, Hassanpour, & Smid, 2014). Results of this study are also consistent with previous studies indicating that exposure to multiple events was associated with increased posttraumatic stress severity ( Greeson et al., 2014; Suliman et al., 2009). In this study, symptom severity did not systematically increase with age, suggesting that younger trauma-exposed children reported similar levels of distress than their older schoolmates. Unexpectedly, a slightly but significantly higher proportion of children in 3 rd grade reported symptoms above the clinical cutpoint than did children of other ages (see Table 1 ). This difference was perhaps due to sampling error, as there were no known significant community or school differences to explain this.

An additional contribution of the current study is the focus on the nature of the types of events endorsed by children. In the present study we did not disaggregate type of event to examine symptoms severity by type of trauma exposure (because many children endorsed multiple events and thus overlapped), however, we report on frequency of different events and differences in frequency of exposure to different events by gender and grade level. The most frequently reported type of event reported in this study was traumatic loss or separation (including deportation and arrests). Similarly, 40% of children ages 6-11 in a large national study reported loss and separation ( Briggs et al., 2013). Together, these data suggest that traumatic events in childhood need not be life-threatening or violent to infer risk for later significant clinical symptomatology. This increases awareness of the impact of child separation from parents due to incarceration or deportation if these events are common in a given community. Results also suggest that, even though we did not detect gender differences in frequency of exposure to traumatic events, the types of events to which they are exposed may vary. For example, boys more frequently reported physical harm from others; knowledge regarding gender-specific risks for exposure to certain types of events can inform targeted prevention efforts. Although age-related exposure to different types of events did not emerge in this study, previous national surveys have reported significant developmental trends in exposure to different types of direct and indirect violent victimization ( Finkelhor et al., 2009). This difference may be due in part to our restricted middle childhood age range; additional studies are needed to assess level of exposure to interpersonal and non-interpersonal traumatic events in youth across a child and adolescent development (i.e., 0-17 years).

Limitations

Data collection was designed to maximize brevity of screening procedures in order to support feasibility and future sustainability in a real world setting. Thus, results of the present study should be interpreted in light of the following limitations. These data rely solely on child report, and a comprehensive multi-informant approach may provide more accurate and reliable data regarding the child's emotional and behavioral functioning. Because we only have child report on the experience of specific traumatic events, we are unable to examine the reliability (e.g., kappa) of child report of exposure to traumatic events. Although we provide data to support the racial/ethnic diversity of the schools sampled, racial/ethnic data were not collected for this screened sample. This information would be important for investigating potential group differences in rate of consent and level of trauma exposure. Next, this sample includes more children in 2 nd through 4 th grades with fewer children in 1 st and 5 th grades. Thus, present results may not represent the youngest and oldest elementary school children. A sample with more representative numbers across all grade levels is needed to examine potential developmental differences in trauma exposure and symptoms within this age group. This study may also underestimate the level of trauma exposure in children for two primary reasons. First, participation in this study required written consent from parents or legal guardians and we cannot rule out a selection bias. It is possible that parents of children exposed to trauma opted out of screening so as to preserve family privacy; however, it is also possible that parents of children without trauma histories opted out because they viewed the project as not applicable to their child. Second, at the request of school officials due to concerns about parental reactions, we did not ask children about exposure to sexual trauma. Therefore, our estimates do not include children who have only experienced this type of event.

An additional limitation is that, although the present screening procedures were generally brief, it took up to 25 minutes to complete screening for some children who endorsed traumatic events. This will need to be considered when planning school screening efforts. Notably, however, screening took approximately five minutes for the majority of students, as most children did not endorse any traumatic events. Screening duration was longest for students who endorsed multiple traumatic events, required behavioral management due to distractibility, or who may have been triggered (e.g., appeared sad) and required a few minutes of positive activity before returning to class. In addition, even the longest screening assessments were shorter than the average screening duration of some nationally representative surveys (e.g., 45 mins; Finkelhor et al., 2009).

Finally, the instruments used only provided information regarding the types of traumatic events experienced and did not provide information regarding multiple exposures to the same type of event. This precludes our ability to determine the consequences of repeated or chronic exposure to the same type of event (e.g., physical assault), which may have deleterious effects on developing children. In addition, we inquired about lifetime exposure to different types of events and do not have data about when the events were experienced (i.e., time elapsed since trauma exposure). Further work is needed to determine whether more recent exposure to trauma is associated with greater symptoms in children, as it has been among adults ( Amir, Kaplan, & Kotler, 1996). This would also be helpful in determining the relative associations between type of event and recency of exposure to symptom severity. Relatedly, research is needed to determine whether children's reports are more reliable for recent events. Similarly, we did not collect data regarding a number of other potential vulnerability factors that could aid our understanding of youth at highest risk for trauma exposure, nor did we conduct diagnostic interviews to capture the prevalence of PTSD or assess academic functioning. These data would provide a more comprehensive understanding of the psychological and educational consequences of trauma exposure.

Implications and future directions

The present study has several implications for school-based mental health screening and services. Trauma exposure was higher than reported in some previous studies of schoolchildren, and it is likely that many children would not have been identified by an indicated or teacher-referred screening process. As noted in our Introduction, the detrimental effects of posttraumatic stress and psychological disorders on short- and long-term educational performance are well-documented. Thus, it behooves schools to address both the physical and mental health needs of students to optimize their likelihood of academic success. Early identification is critical to early intervention that may mitigate or alleviate the progression of behavioral and emotional difficulties that may interfere with educational goals. Because the majority of research on trauma exposure in children has been conducted in clinical settings or with adolescent populations, data from this school-based study may be eye-opening and are particularly relevant to school officials and mental health professionals seeking support for bringing mental health resources to their school. This may also underscore the need for wide scale screening (rather than teacher identification) and provide schools with a rationale for increasing the availability of mental health resources and services in elementary schools.

In addition, this study adds to existing data that elementary school children are able to report on trauma exposure and associated symptoms in a reliable manner, and can be screened using relatively brief, previously-validated instruments. Further research is needed to determine whether score cutoffs to identify at-risk youth are similar across child development, and to evaluate whether any particular items produce biased responses from younger children. Current data also suggest that over one-quarter of children exposed to trauma did not develop significant posttraumatic stress symptoms, suggesting resiliency. Future work is needed to examine protective factors in such students to help inform prevention strategies. Finally, in this manuscript we did not disaggregate by type of traumatic event to examine differences in posttraumatic stress symptom severity. However, previous research indicates that different types of traumatic events (e.g., interpersonal vs. non-interpersonal) may present distinct patterns (e.g., increased externalizing symptoms) and severity of posttraumatic stress symptoms ( Luthra et al., 2009; Price, Higa-McMillan, Kim, & Frueh, 2013). Such research might inform prevention efforts targeting trauma-exposed children who may be at highest risk for future maladjustment, and may help to improve accuracy of diagnosis when different symptom profiles are present.

A critical next step is to assess the sustainability of screening procedures and subsequent referral systems and services to ensure that schools are able to continue screenings beyond the duration of an active research protocol. At the end of this study, current investigators held year-end meetings with school administrators and other stakeholders to present results of the study and to discuss sustainability and implementation of the screening and intervention independent of the study team. For example, one school administrator presented the idea of consistently implementing a universal screening for a particular grade level each school year (e.g., at a given school all 2 nd grade students receive mental health screenings each year). Such a plan may be beneficial because it is more feasible than a school-wide screening and focuses on early identification. Several publications offer guidelines and suggested frameworks for developing and implementing sustainable universal screening procedures in school settings, which include suggestions to increase institutional readiness for screening and subsequent referrals for services ( Dowdy et al., 2010; Dvorsky et al., 2014 - we refer readers to these publications for further information). Future work is needed to evaluate the success of such efforts.

In sum, results support calls to increase school-based screening of mental health in elementary school children. While the rationale for such screenings are clear, issues of implementation of screening procedures present challenges for many schools. However, trauma exposure was prevalent and distressing in young students and school-based mental health services may optimize access to children in need. From the school's perspective, early school-based screening is needed to identify children who may be particularly vulnerable to symptoms of posttraumatic stress during a developmental period that may interfere with valuable early educational milestones (e.g., developing reading skills). From a public health perspective, screening for youth with trauma exposure, a risk factor for numerous adverse outcomes, may identify many children who would benefit from prevention and intervention.

Contributor Information

Araceli Gonzalez, California State University, Long Beach, Department of Psychology 1250 Bellflower Blvd., Long Beach, CA 90840-0901.

Nicholas Monzon, California State University, Long Beach, Department of Psychology 1250 Bellflower Blvd. Long Beach, CA 90840-0901.

Diana Solis, UCLA Semel Institute for Neuroscience and Human Behavior 1000 Veteran Avenue, Box 957142 Los Angeles, CA 90095.

Lisa Jaycox, RAND Corporation 1200 South Hayes Street Arlington, VA 22202.

Audra K. Langley, UCLA Departments of of Psychiatry and Pediatrics 1000 Veteran Avenue, Box 957142 Los Angeles, CA 90095.

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Trauma exposure in elementary school children: Description of screening procedures, level of exposure, and posttraumatic stress symptoms

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School Ment Health. Author manuscript; available in PMC 2017 Mar 1. Published in final edited form as: Araceli Gonzalez, PhD, Assistant Professor,* Nicholas Monzon, BA, Diana Solis, BA, Lisa Jaycox, PhD, Senior Behavioral Scientist, and Audra K. Langley, PhD, Associate Professor Traumatic childhood events can have a significant impact on overall child functioning.

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https://answers.childrenshospital.org/suicide-contagion/#:~:text=Suicide%20can%20shake%20an%20entire,simply%20saw%20them%20around%20town.

A real and documented phenomenon where one suicide tends to breed more attempts and successful suicides in a given school, community, or family.

This article does a great job in focusing on students and how to best see to their emotional needs. Of course, this is to stop the contagion from spreading.

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Suicide can shake an entire community. For some kids, a friend or classmate's suicide increases the risk that they may resort to the same behavior. This risk, known as suicide contagion, can affect people who lived down the street from the person who died, went to school with them, or simply saw them around town.

"After suicide, the person's closest friends aren't necessarily the ones at greatest risk," says Kimberly O'Brien, clinical social worker in the Department of Psychiatry and Behavioral Sciences at Boston Children's Hospital. "The kids at greatest risk are the ones who are already emotionally vulnerable and those who believe their classmate solved their problems through suicide." O'Brien is also co-author of Emotionally Naked: A Teacher's Guide to Preventing Suicide and Recognizing Students at Risk with Anne Moss Rogers.

Here, O'Brien and Boston Children's psychologist Erica Lee talk about how a classmate's suicide can affect children and teens and ways parents can help their kids process their feelings.

Risk of contagion in the aftermath of suicide

Any death, particularly a death by suicide, brings up a wide range of feelings: shock, sorrow, anger, and guilt, to name a few. While there's no right or wrong way to feel, some kids are more vulnerable to suicide contagion than others. "If a kid is already struggling with depression, anxiety, or suicidal thoughts, a classmate's suicide can exacerbate those thoughts and feelings," says Lee.

The way people talk about suicide can also increase other students' risk. For instance, the more details about how the person took their life are made public, the greater the risk that other students may engage in similar behavior.

To reduce such risk, parents and school officials can take a cue from the news media's suicide reporting guidelines. The voluntary guidelines aim to reduce the chance of suicide contagion by:

not focusing on the method or location of suicide

not speculating what event or person may have triggered the suicide

not suggesting suicide is an understandable response to difficult feelings

This is not to say that parents should try to gloss over a classmate's death. "Parents should not try to keep the suicide a secret from their kids," says O'Brien. "You don't want to focus on the method of death, but don't take away from the loss of this person by not doing or saying anything."

Self-care for parents in the wake of suicide

It's only natural for parents to have a strong reaction when a child dies by suicide. Ignoring such emotions in an effort to appear strong can backfire. "Kids often monitor their parents for signs of distress," says Lee. "If they think their parent is upset, they might hide their thoughts and feelings rather than upset their parent more."

Taking time to process their emotions also gives parents a chance to think about what they want to say and how they want to say it, adds Lee. "The conversation may be hard to have, but approaching it in a calm, open frame of mind can reassure your child you will work through this together."

Open communication to reduce kids' risk of suicide

O'Brien suggests that parents check in frequently with their child after a classmate's death by suicide. "A kid might feel fine one day, then it may hit them the next day." Conversations should leave room for children to explore their feelings about the person who died, suicide, and their own experiences.

Open communication also includes asking kids if they have suicidal thoughts. "Many parents worry that asking a child if they think about harming themself may 'plant' the idea in their mind," says Lee. It doesn't. By asking the question, parents let children know it's OK to talk about scary feelings.

Tips for talking with tweens and teens about the death of a classmate by suicide

Use clear, straightforward language and leave plenty of room for your child to express their thoughts and feelings.

Open the conversation with questions. For instance, 'What have you heard about what happened?' and 'How are you feeling about what happened?'

Focus on the fact that the person who died had a psychiatric illness that made it hard for them to think clearly.

Avoid judging the person who died or the people close to them. No single event causes suicide.

Be ready to hear what your child is thinking and feeling. Remember, everyone responds differently to suicide.

Offer reassurance. Most people with suicidal thoughts get support that helps them find other ways to cope with emotional pain.

If your child tells you they think about harming themself, feel hopeless, or is in overwhelming emotional pain, seek help from a mental health professional. If you believe your child is in immediate danger, call 911 or bring your child to the closest emergency room.

Honoring the person who died

Grieving after suicide can be complicated. "It's important that kids have a way to honor their friend or classmate without reinforcing the idea that dying is a way to gain attention or love," says Lee.

"To reduce other students' risk, the emphasis should be on suicide prevention," adds O'Brien. She suggests working with an organization like the American Foundation for Suicide Prevention to help raise awareness about suicide. Kids can also participate in a fundraiser like an Out of the Darkness Walk or volunteer for a crisis hotline. Any of these activities can help kids acknowledge a classmate's death while learning about suicide prevention.

If you or your child is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting HOME to 741741.

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When a friend dies by suicide: Preventing suicide contagion - Boston Children's Answers

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Suicide can shake an entire community. For some kids, a friend or classmate's suicide increases the risk that they may resort to the same behavior. This risk, known as suicide contagion, can affect people who lived down the street from the person who died, went to school with them, or simply saw them around town.

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https://www.health.harvard.edu/mind-and-mood/left-behind-after-suicide

Those left behind have much grieving to do. How we help them is of utmost importance. There probably isn’t a more vulnerable population than those who are in close proximity to a suicide.

This article gives a thorough explanation of the grief experienced by these people and way for their loved ones to help.

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Left behind after suicide - Harvard Health

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People bereaved by a suicide often get less support because it's hard for them to reach out - and because others are unsure how to help.Every year in the United States, more than 45,000 people take their own lives. Every one of these deaths leaves an estimated six or more "suicide ...

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1. Academic difficulties:
- Children who have had ACEs may struggle academically as a result of the trauma's impact on their cognitive development and learning capacities. Teachers should be on the lookout for students who appear to struggle with comprehending and retaining knowledge, show little motivation, or are frequently absent.
- Trauma can also have an impact on memory and cognitive functioning, making it more difficult for students to remember knowledge and learn new skills.

2. Behavioral issues:
- ACEs can also cause behavioral problems including anger, defiance, or hyperactivity. Teachers may notice students who struggle to follow rules, are easily distracted, or have angry or frustrated outbursts.
- Children who have suffered trauma may struggle to regulate their emotions and behaviors in the classroom, causing disruptions and academic challenges.

3. Social isolation:
Students who have had ACEs may have difficulty with social relations and may feel lonely or disconnected from their peers. Teachers should be on the lookout for students who appear reclusive, avoid social situations, or struggle to make friends.

4.Physical health problems:
ACEs can also cause physical health problems such as headaches, stomach aches, and other unexplainable illnesses. Students who regularly complain of physical illnesses, appear exhausted or lethargic, or have poor hygiene should be observed by teachers.

5. Assistance from teachers:
Teachers can help traumatized students by providing a safe and predictable atmosphere, positive reinforcement, and opportunities for connection and validation. Additionally, teachers can collaborate with school counselors and mental health professionals to provide students with the necessary support and resources.

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We tend to think of trauma as the result of a frightening and upsetting event. But many children experience trauma through ongoing exposure, throughout their early development, to abuse, neglect, homelessness, domestic violence, or violence in their communities. And it's clear that chronic trauma can cause serious problems with learning and behavior.

Trauma is particularly challenging for educators to address because kids often don't express the distress they're feeling in a way that's easily recognizable - and they may mask their pain with behavior that's aggressive or off-putting. As Nancy Rappaport, MD, a child and adolescent psychiatrist who focuses on mental health issues in schools, puts it, "They are masters at making sure you do not see them bleed."

Identifying the symptoms of trauma in the children can help educators understand these confusing behaviors. And it can help avoid misdiagnosis, as these symptoms can mimic other problems, including ADHD and other behavior disorders.

In brief, the obstacles to learning experienced by these children include:

Trouble forming relationships with teachers

Poor self-regulation

Negative thinking

Hypervigilance

Executive function challenges

Trauma and trouble forming bonds

Children who have been neglected or abused have problems forming relationships with teachers, a necessary first step in a successful classroom experience. They've learned to be wary of adults, even those who appear to be reliable, since they've been ignored or betrayed by those they have depended on.

"These kids don't have the context to ask for help," notes Dr. Rappaport, a school consultant and associate professor of psychiatry at Harvard Medical School. "They don't have a model for an adult recognizing their needs and giving them what they need."

Many of these children haven't been able to develop secure attachments to the adults in their lives, adds Jamie Howard, PhD, a clinical psychologist and head of the Trauma and Resilience Service at the Child Mind Institute. They need help to let other adults into their lives. "Kids who've never developed that early template that you can trust people, that you are lovable and that people will take care of you," Dr. Howard explains, "need support to form that kind of relationship."

One of the challenges in giving that support is that when kids misbehave, our schools often use disciplinary systems that involve withdrawing attention and support, rather than addressing their problems. Schools have very little patience for kids who provoke and push away adults who try to help them.

Instead of suspending children, Dr. Rappaport argues, schools need to work with them on changing their behavior. When a student is acting up in class, she explains, teachers need to recognize the powerful feelings they are expressing, if inappropriately.

Rather than jumping right into the behavior plan - deducting points or withdrawing privileges or suspending - Dr. Rappaport stresses the importance of acknowledging the emotion and trying to identify it. "I can see that you are REALLY angry that Andrew took the marker you wanted!" she suggests. "If you're wrong about what the student is upset about, he's likely to correct you."

Acknowledging and naming an emotion helps children move towards expressing it in a more appropriate way. Communicating that you "get" them is the necessary first step, she explains, to helping kids learn to express themselves in ways that don't alienate and drive away people who can help them.

Traumatized children often have trouble managing strong emotions. As babies and toddlers, children learn to calm and soothe themselves by being calmed and soothed by the adults in their lives, Dr. Howard notes. If they haven't had that experience, because of neglect, "that lack of a soothing, secure attachment system contributes to their chronic dysregulation."

In the classroom, teachers need to support and coach these children in ways to calm themselves and manage their emotions. "We need to be partners in managing their behavior," Dr. Rappaport explains. "Co-regulation comes before self-regulation. We need to help them get the control they need to change the channel when they're upset." They need coaching and practice at de-escalating when they feel overwhelmed, she adds.

Another challenge to traumatized kids is that they develop the belief that they're bad, and what's happened to them is their fault. This leads to the expectation that people are not going to like them or treat them well. As Dr. Howard puts it, "I'm a bad kid. Why would I do well in school? Bad kids don't do well in school."

Traumatized kids also tend to develop what Dr. Howard calls a "hostile attribution bias" - the idea that everyone is out to get them. "So if a teacher says, 'Sit down in your seat," they hear it as, 'SIT DOWN IN YOUR SEAT!'" she explains. "They hear it as exaggerated and angry and unfair. So they'll act out really quickly with irritability."

As Dr. Rappaport puts it: "They see negative where we see neutral." To counter this negative thinking, these students a narrative about themselves that helps them understand that they're not "bad kids." And learning to recognize their negative patterns of thought, like black and white thinking, is a step towards being able to change those patterns.

Dr. Rappaport notes that children from abusive homes are sometimes unable to participate in classroom activities because they are paralyzed by fear of making a mistake, and that can make them appear to be oppositional. "A mistake that might seem trivial to us becomes magnified," she explains, "if their experience has been that minor mistakes incurred adult anger or punishment."

They need not only support to have incremental successes they can build on in the classroom, but help to see that in this setting, making a mistake is considered a necessary part of learning.

One of the classic symptoms of trauma is hyper-vigilance, which means being overly alert to danger. "It's physiological hyper-arousal," explains Dr. Howard. "These kids are jumpy, they have an exaggerated startle response. They can have some big, out-of-control seeming behaviors, because their fight or flight response has gone off."

This can look like hyperactivity, she adds, leading kids who have been traumatized to be misdiagnosed with ADHD. Being chronically agitated can lead to difficulty with sleeping and chronic irritability.

In workshops, Dr. Rappaport coaches teachers on how to help kids to settle down when something in the classroom triggers an emotional outburst. When a child is escalating, the key, she says, is to "match their affect, but in a controlled way."

The goal is to connect to their big feeling. "If you can connect with what they're trying to tell you, they may settle. It can work even if you just make a guess - you don't have to be right, they can correct you."

Executive function challenges

Chronic trauma affects children's memory, their ability to pay attention, plan, think things through, and other executive functions. Kids who have ADHD as well as trauma may be especially impaired in these skills.

Difficulty planning impacts not only completing tasks in school, but a child's ability to plan his behavior, rather than acting impulsively, and deciding on the best way to communicate his needs and feelings.

One of the things that tends to upset kids who've been traumatized is difficulty predicting the future - not knowing what is coming is unsettling for children and creates anxiety. These kids can benefit, Dr. Rappaport notes, from repeated dry runs of what's coming up and what they should expect.

Another executive function that may be weak is the ability to self-narrate - to mentally talk themselves through what they need to do as they are carrying out a task. It's a skill young children learn from listening to their parents talk to them when they are babies, and, she notes, if they haven't had the experience they may need help developing the skill.

Focus on positive attention

In addition to connecting with kids who've been traumatized, and helping them build missing skills, Dr. Rappaport emphasizes the importance of giving them as much positive attention as possible.

Kids who have experienced chronic neglect tend to be better at getting attention by provoking the adults they depend on than by complying with expectations. "Negative attention is fast, predictable and efficient," she notes. "We need to make positive attention as fast, predictable and efficient."

But she adds that positive attention includes not only praising them for desired behavior but expressing warmth and kindness that aren't necessarily earned.

Surprising kids with "random acts of kindness" can help wean them from habits of acting out to get attention. "When a kid is acting out and sucking the oxygen out of a classroom," she notes, "some teachers have found it works to set their phones to buzz every 5 minutes to give the kid positive attention."

Dr. Rappaport offers tools for understanding ahd managing disruptive behavior in the classroom in her book, The Behavior Code: A Practical Guide to Understanding and Teaching the Most Challenging Students, written with behavioral analyst Jessica Minahan.

How does trauma affect behavior in kids?

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How Trauma Affects Kids in School - Child Mind Institute

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We tend to think of trauma as the result of a frightening and upsetting event. But many children experience trauma through ongoing exposure, throughout their early development, to abuse, neglect, homelessness, domestic violence, or violence in their communities. And it's clear that chronic trauma can cause serious problems with learning and behavior.

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"The Impact of Adverse Childhood Experiences (ACEs) on Community Action for Prevention and Mitigation"

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"The Impact of Adverse Childhood Experiences (ACEs) on Community Action for Prevention and Mitigation"

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1. Definition and Prevalence:
Adverse childhood experiences (ACEs) are stressful childhood experiences that might involve abuse, neglect, and household dysfunction. ACEs is more common than we might expect, with nearly two-thirds of individuals reporting at least one ACE.
2. Health Effects:
ACEs can have substantial and long-term consequences for a person's physical and mental health. These events can raise the likelihood of chronic diseases, mental illness, substance abuse, and other problems.
3. Prevention and Mitigation:
It is critical to take preventive strategies, such as supporting families and communities and giving access to mental health resources, to prevent ACEs from forming in the first place. There are also strategies that reduce the harmful consequences of ACEs, such as trauma-informed care and resilience building.
4. Community Action:
ACEs require a collaborative effort from people, families, communities, and policymakers. We must work to help communities take action to prevent and mitigate ACEs while also encouraging healing and resilience.

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Adverse childhood experiences (ACEs) can have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. CDC works to understand ACEs and prevent them.

Adverse Childhood Experiences (ACEs) Prevention Strategy Plan [3 MB, 20 Pages]
This resource outlines CDC's specific goals and objectives for ACEs prevention and response. The goals and objectives aim to prevent ACEs before they happen, identify those who have experienced ACEs, and respond using trauma-informed approaches in order to create the conditions for strong, thriving families and communities where all children and youth are free from harm and all people can achieve lifelong health and wellbeing.

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Adverse childhood experiences (ACEs) can have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. CDC works to understand ACEs and prevent them. Adverse Childhood Experiences (ACEs) Prevention Strategy Plan [3 MB, 20 Pages] This resource outlines CDC's specific goals and objectives for ACEs prevention and response.

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What a teacher can do in the classroom when support from the school and parents is limited. 

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What a teacher can do in the classroom when support from the school and parents is limited. 

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1. As others have said already: create a safe and predictable classroom environment: Traumatic stress can make students feel unsafe and unsure of what to expect. Creating a classroom environment that is consistent, predictable, and safe can help students feel more secure. This can include things like having a consistent routine, clearly communicating expectations, and creating a calming atmosphere with soft lighting and soothing music.

2. Use trauma-informed language: Trauma-informed language is language that acknowledges the impact of trauma and avoids triggering or re-traumatizing students. For example, instead of saying "calm down," you could say "take a deep breath." Instead of saying "stop crying," you could say "it's okay to feel your emotions." This type of language can help students feel more understood and supported.

3. Offer choice and control: Traumatic stress can make students feel like they have no control over their lives. Offering choice and control in the classroom can help students feel more empowered. This can include things like allowing students to choose their own assignments or seating, or giving them options for how they want to participate in class.

4. Use mindfulness and relaxation techniques: Mindfulness and relaxation techniques can help students manage their stress and anxiety. These techniques can include deep breathing, guided meditation, yoga, or progressive muscle relaxation. You can integrate these techniques into your lessons or offer them as a standalone activity.

5. Seek out additional resources: If you have limited support from the school, it's important to seek out additional resources on your own. Like reading the rest of this Padlet for example.

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Lesser known symptoms of traumatic stress

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Lesser known symptoms of traumatic stress

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While some of the more common signs, such as difficulty concentrating, mood swings, and irritability, are well-known, there are some lesser-known signs that you should also be aware of.
It's important to note that these signs alone do not necessarily indicate traumatic stress, and that it's always best to approach each student as an individual with unique needs.

Here are some lesser-known signs we should still look out for:

1. Difficulty with organization: Trauma can make it difficult for students to organize their thoughts and materials. They may have trouble keeping track of assignments, notes, and schedules.

2. Changes in eating habits: Traumatic stress can cause changes in appetite, leading to either overeating or undereating. Keep an eye out for sudden weight gain or loss.

3. Excessive tiredness: Trauma can be mentally and physically exhausting. Students who are dealing with traumatic stress may seem tired all the time, even if they are getting enough sleep.

4. Excessive worry: Traumatic stress can make students feel like they are in danger all the time, leading to excessive worrying about safety, health, and other issues.

5. Physical complaints: Traumatic stress can cause physical symptoms such as headaches, stomach aches, and other complaints. If a student is frequently complaining about physical symptoms without an obvious cause, it may be a sign of trauma.

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Trauma symptoms can manifest themselves in many different ways in students.

Physical
- Increased somatic complaints
- Over-reacting or under-reacting to stimuli
- Increased activity levels
- Withdrawal from other people and activities

Cognitive
- Recreating the traumatic event or avoiding topics that serve as reminders
- Difficulties with executive function
- Worry and fear about safety of self and others
- Dissociation

Social and Emotional
- Rapid changes in heightened emotions
- Change in ability to interpret or respond appropriately to social cues
- Difficulties with emotion regulation and impulse control
- Emotional numbness, isolation and detachment

Language and Communication
- Language development delays and challenges
- Difficulties with expressive and receptive language
- Difficulties with nonverbal communication
- Use of hurtful language

Learning
- Absenteeism and changes in academic performance/engagement
- Difficulties with authority, redirection or criticism
- Difficulties listening and concentrating during instruction
- Difficulties with memory
- Difficulties generalizing learned material in different contexts

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Here, I will write some steps that I, a teacher, would take:

- If I see a student perhaps acting differently to normal. I would educate myself on what the symptoms being displayed might be a sign of.

- After doing said research, I would then research the best methods of approaching a student that is perhaps feeling very sensitive at this time. Only to be used as a basic though, the ordeal must be taken as an individual case.

- I would then have some discussions with the student in the hope of finding out the trigger behind their changed behavior. This does not have to be the exact trauma that has occurred, perhaps the student doesn't want to reveal all, but maybe they can tell us some of their feelings.

- I would make the student that stress happens to us as individuals, but stress also happens to everyone and that we all grieve in different ways. I would just ensure that they know they are not alone and I, the teacher, am their to support.

- I would look to identify some coping mechanisms in the classroom. If a moment of trauma reappears, what is the best approach at the moment to calm things down? This is crucial to be discussed with the student so that you are both aware of the steps in a time of need.

- Lastly, I would ensure we have the next moment to reflect scheduled in. Trauma is not a consistent thing and should be regularly addressed.

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Helping students cope with anxiety, depression

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Relationships with caring, responsive adults and early positive experiences build strong brain architecture for children.

Significant stress from ongoing hardship or threat (e.g., exposure to violence, extreme poverty, or maltreatment) disrupts the biological foundations of learning, behavior, and health, with lifelong consequences.

Providing the right ingredients for healthy development—including protective factors that can counterbalance the effects of adversity—from the start produces better outcomes than trying to fix problems later.

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SSET is designed for children in late elementary school through early high school (ages 10-16) who have experienced events such as witnessing or being a victim of family, school, or community violence, being in a natural or man-made disaster, being in an accident or fire, or being physically abused or injured, and who are experiencing moderate to severe levels of post-traumatic stress symptoms. SSET was developed and tested in middle schools serving diverse, multicultural, and multilingual students—predominantly Latino, African American, Caucasian, and Asian. It is designed to be used in schools with children from a variety of ethnic and socioeconomic backgrounds and acculturation levels.

Key components:
• Psychoeducation
• Relaxation training
• Cognitive coping
• Gradual exposure to trauma reminders
• Trauma narrative
• Problem Solving

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Children and teens can have extreme reactions to trauma, but some of their symptoms may not be the same as adults. Symptoms sometimes seen in very young children (less than 6 years old), these symptoms can include:

Wetting the bed after having learned to use the toilet

Forgetting how to or being unable to talk

Acting out the scary event during playtime

Being unusually clingy with a parent or other adult

Older children and teens are more likely to show symptoms similar to those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. They may also have thoughts of revenge.

For adults, there are 4 types of symptoms. These include re-experiencing, avoidance, arousal and reactivity, and cognition and mood symptoms.

Re-experiencing symptoms include:

Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating

Bad dreams

Frightening thoughts

Avoidance symptoms include:

Staying away from places, events, or objects that are reminders of the traumatic experience

Avoiding thoughts or feelings related to the traumatic event

Arousal and reactivity symptoms include:

Being easily startled

Feeling tense or “on edge”

Having difficulty sleeping

Having angry outbursts

Cognition and mood symptoms include:

Trouble remembering key features of the traumatic event

Negative thoughts about oneself or the world

Distorted feelings like guilt or blame

Loss of interest in enjoyable activities

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National Institute of Mental Health (NIMH)

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Overview

Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event.

It is natural to feel afraid during and after a traumatic situation. Fear triggers many split-second changes in the body to help defend against danger or to avoid it. This "fight-or-flight" response is a typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people recover from initial symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened, even when they are not in danger.

Signs and Symptoms

Risk Factors

Treatments and Therapies

Join a Study

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow's medical breakthroughs. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

Learn More

Federal Resources

National Center for PTSD: Part of the U.S. Department of Veterans Affairs, this website has targeted information for anyone interested in PTSD (including veterans, family, and friends) and for professional researchers and health care providers. The site also offers videos and information about an online app called PTSD Coach.

Clinician's Guide to Medications for PTSD: This material was developed for researchers, providers, and helpers by the U.S. Department for Veterans Affairs.

Research and Statistics

Journal Articles: References and abstracts from MEDLINE/PubMed (National Library of Medicine).

PTSD Statistics: This webpage provides information on the statistics currently available on the prevalence of PTSD among adults and adolescents in the U.S.

Last Reviewed: May 2022
Unless otherwise specified, NIMH information and publications are in the public domain and available for use free of charge. Citation of NIMH is appreciated. Please see our Citing NIMH Information and Publications page for more information.

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Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event. It is natural to feel afraid during and after a traumatic situation. Fear triggers many split-second changes in the body to help defend against danger or to avoid it.

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Trauma is an emotional response to a terrible event

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Trauma is an emotional response to a terrible event

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Adverse Childhood Experiences (ACEs) are stressful or traumatic experiences that occur during childhood or adolescence. These experiences can include physical, emotional, or sexual abuse; neglect; household dysfunction, such as substance abuse or domestic violence; and parental separation or divorce.

ACEs can have a profound and lasting impact on children's physical and mental health, and can increase the risk of a wide range of negative health outcomes, including chronic disease, mental illness, and substance abuse. ACEs have also been linked to social and economic problems, such as poverty, homelessness, and incarceration.

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Trauma is an emotional response to a terrible event like an accident, crime, or natural disaster. Reactions such as shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships, and physical symptoms.

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Parental separation can come in many different ways, and can impact children in many different ways.

- Perhaps the parents ended on bad terms and neglected the child at many times during the process.
- Did the parents physically, and/or verbally fight in front of the child
- Was the child receiving the brunt of increased aggression?
- Is the child now not seeing one parent?
- Has the child been entirely neglected by one parent?

All of these questions could result in different responses, so the teacher must be flexible to individual cases.

Children that have separated parents are at increased risk of the following:
- depression
- aggression
- low self-esteem
- motivation

What are some symptoms to look out for?

- Is the student entirely disengaged at school? Is the schoolwork now deemed unimportant to the child?
- Have the values of the child changed?
- Is the child being overly aggressive in situation that don't justify such aggression?
- Is the child distancing them from close relationships?
- Is the child becoming overly attached to the teacher?

What are some strategies to helping the child?

- If possible, communicate with both parents to get an understanding of the situation, so that you can better frame your response.

- Provide yourself as a bedrock of support for the child.

- Understand their situation, listen to them, and work on goals together.

- Be an adult role model for the child when required.

- Attempt to track things with the child, so that you can adjust your strategies when required.

- If the situation is really dire, perhaps look to bring in professionals to help.

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Why Teachers Need To Know About Your Divorce – DadsDivorce LIVE

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What are Adverse Childhood Experiences and How Prevalent Is Trauma?

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What are Adverse Childhood Experiences and How Prevalent Is Trauma?

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A review of research between 1990 and 2015 found the following statistics regarding the prevalence of various traumatic events in school-age children:

13%-17% of girls and 3%-5% of boys had experienced sexual abuse.

69%-71% of students had experienced assault or physical abuse.

70% had witnessed violence.

18% had lost a loved one due to crime or vehicular homicide.

29% had experienced bullying.

22% had experienced disasters.

One consequence of these traumas is post-traumatic stress disorder (PTSD). The US Department of Veteran Affairs’ National Center for PTSD reports that 3%-15% of girls and 1%-6% of boys who experience trauma develop PTSD. These alarming percentages highlight the importance of trauma-informed teaching strategies to more effectively address the challenges students confront because of past and ongoing traumas.

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Every student enters a classroom with a history. Sometimes that history consists of the typical, if not uneventful, ups and downs of childhood. Other times, that history may include tragedy-many students experience sexual abuse, the loss of a parent, homelessness, and violence. Such tragedies can traumatize students, affecting their ability to perform well in school.

Today's education leaders must recognize the prevalence of trauma and its impact on learning. With knowledge about how trauma affects children's development, educators are better positioned to attend to the needs of all students.

How Prevalent Is Trauma Among Students?

The Adverse Childhood Experiences (ACE) Study, a 1998 landmark study, transformed people's understanding of just how common trauma is, spawning the development of trauma-informed approaches in disciplines ranging from medical care to education. In the ACE Study, 61% of adults reported having experienced at least one trauma during childhood, and almost 1 in 6 reported experiencing four or more traumas.

Trauma can have devastating consequences in people's lives. According to the Centers for Disease Control and Prevention (CDC), in addition to increasing children's risk of developing a broad assortment of chronic diseases later in life, toxic traumatic stress can change the development of children's brains and affect their attention levels, decision-making capacities, and learning abilities.

Educators can expect two-thirds of their students to have experienced one or more traumatic events by age 16. How those experiences manifest in student behavior or learning abilities can vary considerably according to age and personality. For example, elementary school students can experience anxiety and fear and struggle to concentrate, while middle school and high school students can experience depression, self-harm, and misuse alcohol or drugs.

A review of research between 1990 and 2015 found the following statistics regarding the prevalence of various traumatic events in school-age children:

13%-17% of girls and 3%-5% of boys had experienced sexual abuse.

69%-71% of students had experienced assault or physical abuse.

70% had witnessed violence.

18% had lost a loved one due to crime or vehicular homicide.

29% had experienced bullying.

22% had experienced disasters.

One consequence of these traumas is post-traumatic stress disorder (PTSD). The US Department of Veteran Affairs' National Center for PTSD reports that 3%-15% of girls and 1%-6% of boys who experience trauma develop PTSD. These alarming percentages highlight the importance of trauma-informed teaching strategies to more effectively address the challenges students confront because of past and ongoing traumas.

Trauma's Impact in the Classroom

The harm trauma inflicts on students' lives often carries over into the classroom. Though many children show only some dysfunction as a result of their traumatic experiences, others exhibit significant learning impairments. Trauma-related symptoms can interrupt key areas of a student's education, including relationships, behavior, and academic performance.

Trauma's Impact on Student Relationships

Trauma can make it hard for children to form bonds. For example, students who have experienced neglect or abuse from adults might have difficulty building trust, or they may feel wary of asking for the help they need. However, forming positive relationships with teachers can play an important role in student success.

Students with trauma often need guidance and support in building trusting relationships with teachers and their classmates. Unfortunately, one obstacle to getting the guidance and support they need can be their behavior. When students misbehave, schools often discipline them in ways that isolate them or withdraw support. This approach can further hinder ACE-affected students from bonding with their teachers.

Trauma's Impact on Student Behavior

Traumatic experiences affect students' ability to regulate their emotions. In healthy environments, adults calm and soothe young children, which teaches them to calm and soothe themselves. However, children who have experienced neglect or abuse often do not receive such support and thereby don't learn how to manage their emotions. The inability to manage emotions can lead to outbursts and other behavior problems in the classroom.

Students with traumatic histories may also experience higher levels of fear and anxiety, which can make it difficult for them to control their behavior. Additionally, trauma can skew a child's ability to interpret social cues and express feelings appropriately, which again can lead to disruptive behavior and is often associated with academic difficulties.

Rather than responding with frustration and harsh punishment, educators can coach students to calm themselves and adjust their responses. By helping students de-escalate their feelings of emotional overload, teachers can direct them to healthier responses and improve their chances of engaging in learning.

Trauma's Impact on Students' Academic Performance

Trauma can plague students with intrusive thoughts that distract them from absorbing information in lessons, paying attention in class, or studying. The disruptive behavior students with traumatic histories often display interrupts instruction and leads to more suspensions and expulsions, further reducing their instructional time. Compared with their peers, students with these troubled backgrounds tend to have:

Lower grade-point averages

Higher high-school dropout rates

Poorer employment rates

Trauma can also affect children's executive functions, limiting their comprehension, memory, organization, and engagement. With reduced capacities in those areas, students can struggle with reading, writing, math, and classroom discussions. Trauma can also delay and thwart their development of language skills and hamper their ability to synthesize information or see cause-and-effect relationships. Such problems make success in school particularly challenging.

Trauma-Informed Teaching Strategies

As students with trauma often experience feelings of anxiety and lack of control, classroom environments that help reduce stress and guide students toward open, trusted relationships can mitigate the problems that stem from traumatic histories. Trauma-informed teaching strategies foster predictability. They build a sense of stability for students, help cultivate self-worth, and give students opportunities to better regulate their emotions and improve their focus.

Relationship Building

Trauma-informed teaching creates a space for students to build trust and recognizes that content may need to come after the forging of relationships. Trusted relationships often begin with getting to know one another personally. Activities that encourage students to share elements of who they are, such as their favorite songs and interests, help establish a foundation for relationships. For example, community circle conversations can guide students through discussions in which they share their ideas, express their concerns, and connect with peers and teachers.

Teachers can also cultivate trust and build rapport with increased one-on-one interaction. This creates a chance for them to have conversations with students related and unrelated to school. In this way, teachers can help give students a sense of belonging and support.

Restorative Approaches to Discipline

All too often schools mete out punishment for bad behavior without helping students reflect on or adjust their actions. Restorative approaches shift the discipline focus to be positive and supportive rather than punitive. Students with traumatic backgrounds need this kind of support to heal and restore their faith in fairness. They also often need opportunities to rebuild positive relationships with authority figures, and restorative discipline does just that.

Restorative discipline can take many shapes. For example, for younger students, teachers can create "fairness committees." These committees, made up of students and teachers, let students explain themselves when they've done something wrong. Then, instead of doling out a punishment, the committee helps students make amends.

To complement restorative discipline, educators can implement other important restorative strategies, such as meditation, counseling, and team-building exercises. These activities augment students' abilities to reflect on their behaviors, self-regulate, and build trust.

Opportunities to Build Self-Efficacy

Students with traumatic histories often have low self-esteem. They can also feel uncertain about their environments and unable to control them. Giving these students regular opportunities to cultivate self-efficacy, or a belief in themselves and their abilities to meet the challenges in front of them, can prove to be healing.

Trauma-informed teaching should give students responsibility and opportunities to achieve. Both responsibility and achievement help students feel in charge of themselves and promote feelings of self-worth and competence. Several techniques can improve students' chances of success while encouraging accountability.

For example, schools can encourage classroom policies that allow students to submit work for early feedback before receiving final grades or revise their work until they earn a desired score. These policies give students multiple chances to show what they've learned, improve their grades, and ultimately build an image of themselves as capable learners. These policies also reduce stress because they let students see a path to reaching competency.

Learn How to Put Trauma-Informed Teaching Into Action

Educators can create safe learning environments for students with trauma by implementing thoughtful programs that make use of trauma-informed teaching strategies. Explore how American University's School of Education prepares educators to use creative approaches to reach all students through its online degree programs.

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Trauma-Informed Teaching Strategies | American University

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How does trauma-informed teaching help educators meet student needs? Explore how an EdD in Education Policy and Leaderships equips educators to address trauma.

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Emotional abuse involves consistent emotional mistreatment of a child. It can involve deliberately isolating a child, scaring or humiliating them, blaming , or manipulation.

Causes of emotional abuse include:
-Threatening a child
-Humiliating a child
-Blaming and scapegoating
-Not promoting a child's development
-Isolation or being absent
-Ignoring
-Not showing any emotions toward a child

Signs of emotional abuse:
-not confident or self-assured
-Cant control emotions
-Lack of positive relationships
-Acts inappropriately

Possible Response Strategies to emotional abuse (or other traumatic experiences):
-Show the child that you are listening to them and allow them to express their emotions related to the experience
-Take their situation seriously
-Give them extra attention
-Be sensitive to their needs
-Encourage group activities and place the student with emotionally intelligent students
-Be open
-Report the situation to another authority

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Explore our guide on identifying emotional abuse, its impact, and steps for reporting. Get the support you need to protect children from harm.

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Preventing traumatic stress for school students 

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Preventing traumatic stress for school students 

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Preventing traumatic stress in elementary school students is not always possible, as traumatic events can occur unexpectedly and are often out of our control. However, there are some strategies that schools and teachers can use to help reduce the risk of traumatic stress and promote a safe and supportive learning environment:

1. Create a Safe and Supportive School Environment: A safe and supportive school environment can help reduce the risk of traumatic events occurring in the first place. This can include developing a culture of respect and inclusion, having clear policies for behavior and safety, and providing mental health services and resources.

2. Build Resilience: Teaching students skills to cope with stress and adversity can help build resilience and reduce the risk of traumatic stress. This can include teaching coping skills such as deep breathing, mindfulness, or problem-solving strategies.

3. Encourage Positive Relationships: Encouraging positive relationships between students and teachers, as well as between peers, can help promote a sense of safety and security in the school environment.

4. Address Bullying and Harassment: Bullying and harassment can cause significant emotional distress and can lead to traumatic stress. Schools should have clear policies for addressing and preventing bullying and harassment.

5. Provide Support and Intervention: If a traumatic event does occur, it's important to provide support and intervention as quickly as possible. This can include counseling services, support groups, and crisis intervention.

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Learn about the signs of traumatic stress, its impact on children, treatment options, and how families and caregivers can help.

Types of Traumatic Events

Childhood traumatic stress occurs when violent or dangerous events overwhelm a child's or adolescent's ability to cope.

Traumatic events may include:

Neglect and psychological, physical, or sexual abuse

Natural disasters, terrorism, and community and school violence

Witnessing or experiencing intimate partner violence

Commercial sexual exploitation

Serious accidents, life-threatening illness, or sudden or violent loss of a loved one

Refugee and war experiences

Military family-related stressors, such as parental deployment, loss, or injury

In one nationally representative sample of young people ages 12 to 17:

8% reported a lifetime prevalence of sexual assault

17% reported physical assault

39% reported witnessing violence

Also, many reported experiencing multiple and repeated traumatic events.

It is important to learn how traumatic events affect children. The more you know, the more you will understand the reasons for certain behaviors and emotions and be better prepared to help children and their families cope. Learn more about the types of trauma and violence and types of disasters.

Signs of Child Traumatic Stress

The signs of traumatic stress are different in each child. Young children react differently than older children.

Preschool Children

Fearing separation from parents or caregivers

Crying and/or screaming a lot

Eating poorly and losing weight

Having nightmares

Elementary School Children

Becoming anxious or fearful

Feeling guilt or shame

Having a hard time concentrating

Having difficulty sleeping

Middle and High School Children

Feeling depressed or alone

Developing eating disorders and self-harming behaviors

Beginning to abuse alcohol or drugs

Becoming sexually active

For some children, these reactions can interfere with daily life and their ability to function and interact with others.

Impact of Child Traumatic Stress

The impact of child traumatic stress can last well beyond childhood. In fact, research shows that child trauma survivors are more likely to have:

Learning problems, including lower grades and more suspensions and expulsions

Increased use of health services, including mental health services

Increased involvement with the child welfare and juvenile justice systems

Long term health problems, such as diabetes and heart disease

Trauma is a risk factor for nearly all behavioral health and substance use disorders.

What Families and Caregivers Can Do to Help

Not all children experience child traumatic stress after experiencing a traumatic event, but those who do can recover. With proper support, many children are able to adapt to and overcome such experiences.

As a family member or other caring adult, you can play an important role. Remember to:

Assure the child that he or she is safe. Talk about the measures you are taking to get the child help and keep him or her safe at home and school.

Explain to the child that he or she is not responsible for what happened. Children often blame themselves for events, even those events that are completely out of their control.

Be patient. There is no correct timetable for healing. Some children will recover quickly. Others recover more slowly. Try to be supportive and reassure the child that he or she does not need to feel guilty or bad about any feelings or thoughts.

Review NCTSI's learning materials for parents and caregivers, educators and school personnel, health professionals, and others.

Treatment for Child Traumatic Stress

Even with the support of family members and others, some children do not recover on their own. When needed, a mental health professional trained in evidence-based trauma treatment can help children and families cope with the impact of traumatic events and move toward recovery.

Effective treatments like trauma-focused cognitive behavioral therapies are available. There are a number of evidence-based and promising practices to address child traumatic stress.

Each child's treatment depends on the nature, timing, and amount of exposure to a trauma.

Review Effective Treatments for Youth Trauma - 2004 (PDF | 55 KB) at the National Child Traumatic Stress Network.

Families and caregivers should ask their pediatrician, family physician, school counselor, or clergy member for a referral to a mental health professional and discuss available treatment options.

More Ways to Find Help

Many U.S. agencies and other groups offer research and support related to child traumatic stress.

Government Websites

Other Organizations

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Recognizing and Treating Child Traumatic Stress

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Learn about the signs of traumatic stress, its impact on children, treatment options, and how families and caregivers can help.

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What Behaviors Should Teachers Look Out For?

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What Behaviors Should Teachers Look Out For?

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Some classroom signs of trauma:

Extreme shyness and difficulty engaging with others

Disproportionate reactions to setbacks and unexpected changes

Trouble managing strong emotions (extreme anger, excessive crying, etc.)

Clinginess

Difficulty transitioning from one activity to the next

Forgetfulness

Frequent complaints of feeling sick

Difficulty focusing

Lack of safety awareness

Missed deadlines

Poor academic performance

Apathy and lack of effort

Perfectionist tendencies

Physical and/or verbal aggression

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Trauma-Informed Practices

Trauma may look different from student to student, so it's prudent to always use trauma-responsive practices.

Many educators ask, "How do I know if a student has experienced trauma, and what does trauma look like in the classroom?" It's important to remember that trauma looks different for each and every person-from the experiences themselves, to their emotional impacts, to the ways in which they manifest themselves, to what is needed to heal from them.

Educators may never have a clear answer as to whether or not a student has experienced trauma, nor a full picture of a student's emotional well-being or needs. Given these limitations, we must always embody trauma responsiveness in all of our interactions with students to ensure that we are providing support to any and all students.

How Does Trauma Impact the Brain?

The National Child Traumatic Stress Network defines a traumatic event as any "frightening, dangerous, or violent event that poses a threat to a child's life or bodily integrity." This extends to events that impact the ones around them, such as the loss of a loved one or witnessing harm being done to another person.

Because the primary goal of a person's brain and body is survival, when a student experiences a traumatic event-a perceived threat to their life-the brain and body react immediately and aggressively to avoid this harm by directing their energy toward keeping them alive. This puts the student into a state of anxiety and stress. Their brain hyper-focuses on the danger and is unable to think about much of anything else until it has passed.

Even when it has passed, the brain and body may remain on alert in case another threat is coming. For students who have or are experiencing frequent trauma, it becomes increasingly difficult to ever feel safe, no matter where they are or what is happening around them.

What does this feel like? Think about what happens in your own body and the pattern of your thoughts when you experience stress. Now, think about how it would be to experience that stress in a classroom while seeing and hearing all of the people around you, trying to think about and process the curriculum, and managing all of the classroom rules and expectations. Would you be able to focus on your learning? What about if something unexpected happened, or if a classmate said something unexpected? How would you react?

We all experience these states of stress sometimes. Students who have experienced or are experiencing trauma are perpetually in this state of survival brain, amplified. Consistently experiencing trauma, especially while the brain is still developing, prevents the brain from being able to focus on and process learning and to build the executive functioning skills to productively manage upsetting and unexpected events around them, including those that others might deem to be minor.

These students have neither the space nor the brain capacity to learn how to effectively manage their strong emotions, and they may develop unproductive coping strategies.

What Does This Look Like in the Classroom?

When a student is experiencing trauma, you may see signs of it in the classroom, but you will likely never have a clear yes or no answer-nor is it your job to seek one or to provide counseling on one. Educators are mandated reporters and are obligated to report any evidence or suspicion of trauma, but educators should not probe the student to tell us more.
Some classroom signs of trauma:

Extreme shyness and difficulty engaging with others

Disproportionate reactions to setbacks and unexpected changes

Trouble managing strong emotions (extreme anger, excessive crying, etc.)

Clinginess

Difficulty transitioning from one activity to the next

Forgetfulness

Frequent complaints of feeling sick

Difficulty focusing

Lack of safety awareness

Missed deadlines

Poor academic performance

Apathy and lack of effort

Perfectionist tendencies

Physical and/or verbal aggression

Without professional training and certification, this questioning may bring more harm and trauma to the student, despite our intentions. Instead, as educators, knowing the signs and symptoms of trauma can be helpful to shift our mindsets toward embodying trauma responsiveness into the essence of who we are as teachers.

What have you (or colleagues, or administrators, or district policies) attributed these behaviors to in students in the past?

How were you trained to respond to these behaviors? How did you respond?

How did this response affect the student? (Did it de-escalate the situation and empower the student with more productive strategies to use in the future? How did it make the student feel about themselves and about their place in the classroom?)

When we know the effects of and signs of trauma, we can detach students' behaviors from being immutable parts of their character and instead think of the behaviors as learned coping mechanisms to keep the students safe while under immense stress from their environments and experiences. When we know the effects of and signs of trauma, we can move away from disciplining unproductive coping mechanisms. We can support students with unlearning the responses that do not serve to push them toward their goals and that do not keep them safe. We can use our expertise to teach and practice new responses that will better serve our students and our classrooms.

How effective was this response? (Did it de-escalate the situation and empower the student with more productive strategies to use in the future? How did it make the student feel about themselves and about their place in the classroom?)

Would you respond the same way again?

If not, what can you commit to doing differently next time to ensure that every child-no matter the context and no matter the situation-feels seen, empowered, and safe in your classroom?

Take a moment to pause and reflect on the experiences you have had with students demonstrating any of these signs.

Now, think about these experiences in light of our learning on how trauma impacts the brain and may influence behavior. If this student had experienced trauma, consider the following questions:

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Trauma-Informed Practices Trauma may look different from student to student, so it's prudent to always use trauma-responsive practices. Many educators ask, "How do I know if a student has experienced trauma, and what does trauma look like in the classroom?"

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Effects of Adverse Childhood Experiences and Trauma on Students

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Effects of Adverse Childhood Experiences and Trauma on Students

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Adverse Childhood Experiences (ACEs) can have significant impacts on children's physical, emotional, and mental health. The stress caused by ACEs can activate the child's fight, flight or freeze response, which, if activated too often or for too long, can lead to changes in brain development and chemistry. This can cause the following impacts:

1. Physical health problems: Children who have experienced ACEs are at an increased risk for chronic illnesses such as heart disease, stroke, diabetes, and cancer later in life.

2. Emotional and mental health issues: ACEs can lead to emotional and mental health issues such as depression, anxiety, post-traumatic stress disorder (PTSD), and substance abuse.

3. Behavioral issues: Children who have experienced ACEs may exhibit challenging behaviors such as aggression, defiance, and impulsivity.

4. Learning difficulties: ACEs can affect a child's cognitive development, leading to learning difficulties and academic problems.

5. Social problems: ACEs can lead to social problems such as difficulty building and maintaining healthy relationships, and a lack of trust in others.

It's important to note that the effects of ACEs can vary depending on the child's age, the type of ACE experienced, the frequency and duration of exposure, and the child's support system. However, addressing ACEs and providing support and intervention can help mitigate these negative impacts and improve a child's overall well-being.

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The Truth About Adverse Childhood Experiences (ACEs) - Families Thrive

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The Robert Wood Johnson Foundation is part of a growing network of leaders working to increase awareness and understanding of the impact of adverse childhood experiences (ACEs) and the need to develop effective innovative interventions. Learn more about ACEs and share the infographic below with oth

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Students who experience traumatic stress during elementary school can experience a range of effects 

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Students who experience traumatic stress during elementary school can experience a range of effects 

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Students who experience traumatic stress during elementary school can experience a range of effects that can impact their emotional well-being, social functioning, and academic performance. Some common effects of traumatic stress in elementary school students include:

1. Emotional Distress: Traumatic stress can cause significant emotional distress, such as anxiety, fear, sadness, and anger. Children may struggle to manage their emotions and may have frequent outbursts or become withdrawn and isolated.

2. Behavioral Issues: Students who have experienced trauma may exhibit behavioral issues such as aggression, hyperactivity, defiance, or self-harm.

3. Difficulty with Relationships: Children who have experienced trauma may have difficulty forming and maintaining relationships with peers and adults. They may be withdrawn or avoid social interactions, leading to feelings of loneliness and isolation.

4. Academic Struggles: Traumatic stress can impact a child's ability to learn and succeed in school. Children may struggle with academic performance, memory, and attention.

5. Physical Symptoms: Trauma can also manifest in physical symptoms such as headaches, stomach aches, or fatigue. These symptoms can impact a child's ability to concentrate and participate in class.

6. Post-Traumatic Stress Disorder (PTSD): In some cases, traumatic stress can lead to the development of PTSD. Symptoms of PTSD can include flashbacks, nightmares, hyper-vigilance, and avoidance behavior.

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The National Child Traumatic Stress Network

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Provides school administrators, teachers, staff, and concerned parents with basic information about working with traumatized children in the school system.

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Childhood trauma can have a range of emotional, behavioral, and physical impacts on children, depending on the type and severity of the trauma and the child's individual coping mechanisms and support systems.

Trauma can result in a range of reactions, including anxiety, depression, anger, dissociation, hypervigilance, and avoidance.

Children who experience trauma may also have difficulty with emotional regulation, self-esteem, social skills, and academic performance.

Trauma can impact children's physical health as well, resulting in problems such as headaches, stomachaches, fatigue, and poor sleep.

Children who have experienced trauma may engage in risky behaviors or develop substance abuse problems as a way of coping with their emotional pain.

Children who experience trauma may also have difficulty with attachment and may struggle to form healthy relationships with peers and caregivers.

Schools can play a critical role in identifying and supporting children who have experienced trauma, through interventions such as trauma-informed classrooms, counseling services, and referral to community resources.

Teachers and staff can help support children who have experienced trauma by being aware of the signs of trauma, providing a safe and supportive classroom environment, and connecting children with appropriate resources and services.

Supportive relationships with caring adults can be a critical protective factor for children who have experienced trauma, helping to mitigate the negative impacts of trauma and build resilience.

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1. Look beyond the behavior: When children experience trauma, it can affect their social, emotional, behavioral, and academic abilities. Therefore, it is important to approach their behavior with curiosity and openness instead of jumping to conclusions and labeling them as problematic.

2. Build relationships: Establishing strong connections with students who have experienced trauma is crucial for their resilience. Building bonds with them and their families can help teachers understand their needs and provide effective support.

3. Create a safe environment: Students need to feel secure and connected to their peers and adults in the classroom to learn. Teachers play a vital role in creating a welcoming and safe environment for all students.

4. Meet students where they are: Students who have experienced trauma may require special accommodations in the classroom. Creating a "safe space" or allowing them to make phone calls when they get anxious can help them feel more settled and secure.

5. Be predictable: Having a clear and predictable routine in the classroom can provide students with a sense of stability and control, which is crucial for those who have experienced trauma.

Overall, adopting a trauma-informed approach in the classroom requires teamwork and sharing knowledge and strategies with colleagues. These techniques not only benefit students who have experienced trauma but can also help all students build resilience, confidence, and well-being.

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All children face disappointment and fears, but some students deal with more serious, often traumatic, hardships at home. The term "trauma" can encompass many situations, explains Lori Sanchez, Ed.D. "In the past, when you talked about a child experiencing trauma, you assumed abuse or neglect," she says. "Now we understand that trauma can mean a lot of things-families dealing with divorce, serious illness, a natural disaster, a military deployment, and more." Of course, you can't undo the painful experiences your students have gone through, but you can make a difference in their learning and their resilience by bringing innovative strategies into your classroom.

To help students deal with stressful situations at home, many schools are using innovative trauma-informed strategies. Here are some of the most effective tools for teachers.

Look beyond the behavior

Research has shown that traumatic experiences alter the brain and can affect children socially, emotionally, behaviorally, and academically. It's a quadruple whammy. Toxic levels of stress and anxiety shape behavior and may make kids appear angry, depressed, checked out, uncooperative, or distracted, says psychologist Jamie Howard, PhD, of the Child Mind Institute in New York City. "When you adopt a trauma-informed perspective, you approach that student's behavior with openness and curiosity," she says.

"Rather than jumping to the conclusion that she's a problem, ask yourself, 'What happened to this child and why is she behaving this way?' " Howard recalls one student she worked with who didn't want to go to the front of the classroom to write on the board. "He seemed defiant, but actually it was scary to him to have his back exposed to the whole room," she says. It turns out he had an unstable home life and was bringing some of his fears and insecurities into the classroom.

Build relationships

You already know how important it is to have good relationships with your students. But for children who have been affected by trauma, strong connections are vital. Rich relationships with teachers help children form the foundations of resilience.

Building bonds is a central component of August Spiegelberg's classroom at Bruce Vento Elementary in St. Paul, Minnesota, where more than 90% of the students qualify for free or reduced lunch. Spiegelberg regularly invites one or two of his fourth graders to eat lunch with him, using the opportunity to get to know them better. "I ask questions and then set them up to answer what they feel comfortable sharing," he says. He also tries to form relationships with the student's whole family. "But when a parent isn't super responsive, I try even harder to build a relationship with the child. The better we know students, the better we can teach them."

Create a safe environment

You play a critical role in making your students feel welcome in your classroom. "Students have to feel secure and connected, both to adults and to peers, in order to learn," says Susan Cole, director of the Trauma and Learning Policy Initiative in Boston.

That's the kind of environment seventh-grade teacher Lauren Jansen, EdD, fosters at North Middle School in O'Fallon, Missouri. "I'm keenly aware of how my students interact with each other," she says. "When I see anything negative beginning to happen, like one student picking on another one, I stop it immediately and have a conversation with the child, reminding them why it's not OK. My classroom is a place where students know they can be themselves and won't be made fun of."

It's also key to recognize that any student, regardless of their home life, can grow scared and anxious by a national news story such as a school shooting or a devastating hurricane. To ease children's fears in the wake of a tragedy like this, talk about the news as a group (in an age-appropriate way, of course), and reassure them that they're not in danger.

Meet students where they are

To help a student experiencing trauma feel settled in the classroom, you might need to make special accommodations. When Lori Sanchez, EdD taught sixth grade, she came up with creative solutions for students who were dealing with the aftermath of trauma.

She remembers one student who had been abandoned as a baby. Although the child was living with wonderfully supportive adoptive parents, she would periodically burst into tears in the middle of class, afraid that her parents were going to leave her. Sanchez kept a phone on her desk and allowed the girl to call her parents whenever she got anxious. "Just knowing the phone was there was enough to calm her," she says.

Perhaps you have a student in your class who's cranky and disruptive in the morning because he doesn't have a regular bedtime, or who melts down easily because her parents are fighting. Setting up a "safe space" in your classroom, where a child can take a short break to calm down, de-stress, and even take a short nap if they're tired, can make a world of difference.

Be predictable

Feeling out of control is one of the hallmarks of traumatic experiences, so adhering to a clear, predictable routine in your classroom provides students with a sense of stability. Tammi Mueller, a first-grade teacher at Riceville Community School in Riceville, Iowa, has students who live in foster care, a situation that often involves trauma and disruption. "I try to keep a scheduled classroom to help anchor the kids," she says. "I have a visual schedule at the front of the room, and I keep to a routine as much as possible. If I have to change things, I make sure I tell them."

You can't adopt a trauma-informed approach in your classroom all on your own. It takes teamwork and sharing what you know with colleagues. "Meet with the educators and others in your school and start a study group," advises Susan Cole. Think about strategies for working with a small team and get the support of your principal. The best news is that trauma-sensitive techniques don't just benefit kids who are struggling; they help all your students build resilience, confidence, and well-being.

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Trauma-Informed Strategies to Use in Your Classroom | Resilient Educator

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All children face disappointment and fears, but some students deal with more serious, often traumatic, hardships at home. The term "trauma" can encompass many

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Children as young as 9 and 10 are thinking about and attempting suicide, yet the adults around them are often unaware of their struggles.

Suicide is the second leading cause of death for young people ages 10-24 in the U.S.

Risk factors for suicide in children and teens include depression, anxiety, trauma, bullying, substance abuse, and social isolation.

Some warning signs that a child or teen may be struggling with suicidal thoughts include changes in behavior or personality, talking about suicide or death, expressing feelings of hopelessness, and withdrawing from social activities.

Adults can help prevent suicide in children and teens by building relationships with them, listening to their concerns, and taking their mental health seriously.

Schools can also play a role in suicide prevention by providing mental health services and support, creating safe and inclusive environments, and educating students, staff, and families about the warning signs of suicide and how to get help.

It's important to address suicide prevention in a sensitive and responsible way, and to avoid glamorizing or sensationalizing suicide in the media or in conversation.

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Educators trying to halt the skyrocketing number of young people killing themselves need to intervene far earlier than they might think: A new study finds children as young as 9 and 10 report suicidal thoughts and self-harm.

Suicide among young people has reached a 30-year high, according to data from the Centers for Disease Control and Prevention. Suicide rates for teens ages 15 to 19 jumped by 76 percent from 2007 to 2017, but suicide rates for younger adolescents, ages 10 to 14, nearly tripled during that time. And the CDC has found 10 to 15 percent of middle and high school students consider killing themselves at some point.

But in a new study, published Friday in JAMA Network Open, brain researchers Deanna Barch and Diana Whalen of the Washington University in St. Louis found some tweens harbored those destructive thoughts years before.

Of more than 11,800 children ages 9-10 participating in the longitudinal Adolescent Brain Cognitive Development study, Barch and Whalen found 2.4 percent to 6.2 percent of the children reported thinking about or planning suicide. A little more than 1 percent of the children actually attempted to kill themselves, but nearly 1 in 10 reported "non-suicidal self-injury" such as cutting, pinching, and burning.

An even more chilling finding: More than 3 out of 4 times a child had suicidal thoughts or destructive actions, her caregivers had no idea.

"I think there has been a belief that we don't need to ask kids this age about suicidal thoughts or ideation if they're distressed because, you know, well, kids don't experience that yet," said Barch, a psychiatry professor and chair of the department of psychological and brain sciences at Washington University.

"It is certainly the case that the rates for children are lower than they sadly will be when they're adolescents. But they're non-trivial by any means," she said. "And to me, the take-home message here is that, if you have kids that seem to be having mental health problems or seeming really distressed, [you] should be regularly asking about suicidal ideation."

That's as important for teacher and principals as for parents, as unlike adults, who tend to commit suicide during summer months, children are most likely to kill themselves during the school year.
If you are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741
Three common misconceptions may lead parents and teachers to overlook warning signs that a younger student may be experiencing suicidal thoughts:

Misconception: Younger Students Don't Understand What Suicide Is

Adults can mistakenly believe that elementary-age children don't comprehend the permanence of death well enough to really consider suicide in the same way a teenager or adult would. But in prior research, Whalen found even early elementary children who are depressed or suicidal have a more accurate understanding of death than children who are psychologically healthy. "I don't think it's that they say, 'I want to kill myself,' but they don't really get what that means. I think they do," Barch said.

Misconception: Younger Students Don't Have the Same Kinds of Problems as Suicidal Teenagers

Tweens and teens gave similar reasons for feeling suicidal or wanting to harm themselves, Barch found.

"Kids may be having suicidal thoughts or even acting on them because they're having conflict with their family or friends, they're being bullied," Barch said. "The specifics are going to be developmentally different: The kind of conflict or difficult family situation you have when you're 9 or 10 might look different than when you're 15 or 16. Difficulties with your friends when you're 9 or 10 might look different than when you're 15 or 16. But it is still, I think, a reflection of kids having significant distress, depression, feeling like they're in really difficult life circumstances."

The study found children with a lot of family conflict were significantly more likely to have thoughts of suicide or to harm themselves.

Misconception: Children Have to Be Depressed to Consider Suicide or Self-Harm

Children in the study who reported suicidal thoughts or harmful behaviors were more likely to have a family history of depression or suicide, or to have depression or anxiety problems themselves.

But as Barch noted above, children frequently reported thinking about suicide in the context of stressful or sad situations. "Suicide can happen in the context of things other than full-blown depression. We also see kids who are experiencing distress because of anxiety, or because of peer or family or other environmental things who don't meet the criteria for depression," she said. "We shouldn't assume that if a child doesn't appear depressed, that that means there's no possible way they could be having suicidal ideation."

The study found no difference in suicidal thoughts or destructive actions by race, but students in poverty were significantly more likely to think of or actively try to kill themselves or to self-harm without intending suicide.

Among younger students, there were no differences in actual suicide attempts between boys and girls, but boys were significantly more likely than girls to think about and plan suicide as well as to cut, burn, or otherwise harm themselves. That was a surprise, Barch said, because gender differences flip after puberty, with adolescent girls more likely to self-harm and consider or attempt suicide.

Earlier this month the CDC released a report finding the national suicide rate for adults has increased by 1.4 percent between 2017 and 2018, but the 2018 data for children and teens has not yet been released. The ABCD study will continue to track the students over time, to try to identify factors that may predict which students will recover from suicidal thoughts or develop them over time.

In the end, the findings suggest educators and parents should take more time to listen to students and ask follow-up questions. "Kids are under a lot of pressure. Parents are under a lot of pressure as well. Society has put a lot of pressure to achieve more," said Susan Tellone, the clinical director of the Society for the Prevention of Teen Suicide.

"If a child comes to you, you don't shut down that conversation," Tellone said. "You use three words. You say 'Tell me more.'"
For more on how educators can help prevent child and adolescent suicides, see: Related:
Do you have a question about education research, or just want to know what the evidence says about that pesky instructional problem? Let me know! Drop me a line at ssparks@epe.org.

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Children as Young as 9 and 10 Think About Killing Themselves. Adults Around Them Have No Clue.

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Educators trying to halt the skyrocketing number of young people killing themselves need to intervene far earlier than they might think: A new study finds children as young as 9 and 10 report suicidal thoughts and self-harm. Suicide among young people has reached a 30-year high, according to data from the Centers for Disease Control and Prevention.

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1. Develop a trusting relationship: It is essential to develop a trusting relationship with the child so they feel safe and comfortable disclosing their experiences.

2. Encourage open communication: Teachers should encourage open communication with the child to help them express their feelings and emotions. This can be done through active listening and providing a non-judgmental environment.

3. Provide support: Teachers should provide emotional support and a safe environment to help the child feel secure. This can be done through validating their experiences and providing reassurance.

4. Refer to professional services: Teachers should refer the child and their family to professional services such as counseling and therapy. They can also work with school psychologists and social workers to provide support.

5. Educate yourself: It is important for teachers to educate themselves on the signs of child sexual abuse and how to respond appropriately. This can be done through attending training sessions and reading up on the topic.

6. Follow mandated reporting laws: Teachers are mandated reporters, which means they are required by law to report any suspected cases of child abuse. It is important to follow these laws and report any suspected abuse to the appropriate authorities.

Overall, it is crucial for teachers to provide a safe and supportive environment for sexually abused children. They should encourage open communication and provide emotional support while also referring them to professional services and following mandated reporting laws. By doing so, teachers can help these children overcome their trauma and lead healthier, happier lives.

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Vol. 20, No. 2
April 2015

We know children who experience sexual abuse can be further traumatized by CPS assessments and law enforcement investigations. We also know that without appropriate treatment, survivors of child sexual abuse are at increased life-long risk for a broad array of physical and mental health problems, as well as future victimization (Hilaski, et al., 2008; O'Brien & Scher, 2013; Sachs-Erisson, et al., 2009; all cited in Flick, et al., 2014).

What can child welfare workers and agency leaders do to ensure their involvement minimizes trauma and promotes healing?

1. Practice self-care. We can't take care of others unless we care for ourselves. Workers and agencies must find ways to integrate self-care into their normal routines. Hearing horrific details of child sexual abuse, feeling the pressure of added legal scrutiny, managing uncertainty and ambiguity, and experiencing intense reactions towards the alleged offender and other family members--all this can cause workers to dread and distance themselves emotionally from these cases (van Dernoot Lipsky, 2009). Yet child sexual abuse victims need an authentic connection with an engaged and caring worker who will advocate for and support them. Professionals themselves need support and protection from the damaging effects of secondary traumatic stress. For more on this, visit http://bit.ly/1COZSUn.

2. Reduce the trauma of the investigative process. The following steps reduce the negative impact on a child while the interdisciplinary process unfolds (Aprile, et al., 2009; Saywitz & Comparo, 2014; Staller & Faller, 2010; all cited in Flick, et al., 2014):

Have the law enforcement officer testify at the probable cause hearing, not the child.

3. Let children talk. Sometimes workers feel anything related to the abuse is a forbidden topic if there is an on-going investigation, says Jeanne Preisler, Coordinator of Project Broadcast, North Carolina's federally-funded initiative to build a trauma-informed child welfare system. "You're not conducting an interview and you don't want to probe, but the child may mention things or want to tell you how they're feeling. They may spontaneously disclose things that they haven't said to others." Children may also express feelings of guilt and responsibility, not only for the abuse but also for the upheaval that followed their disclosure. Families that have experienced sexual abuse often have cultures of secrecy and shame, and children are frequently given the message that they are to blame for what has happened (Sgroi, 1982).

As a child welfare professional, you may provide a safe place for the child to express their true feelings, and you can send the child the message that she is not to blame for what has happened. It is possible to listen empathically and reduce children's sense of shame without compromising the investigation.

4. Attend to psychological and physical safety. In child sexual abuse cases our attention is understandably focused on physical safety: making sure the alleged abuser has no unsupervised contact or access to the child. Yet it's important to remember that to heal, children have to feel safe.

Various factors can contribute to children continuing to worry even after being removed from an abusive situation, including "valid fears about their own safety or the safety of loved ones, difficulty trusting adults to protect them, hyperawareness of potential threats, and problems controlling their reactions to perceived threats" (NCTSN, 2013). Further complicating the situation, children may face "people, situations, places, or things that remind them of traumatic events," causing them to "experience intense and disturbing feelings tied to the original trauma. These 'trauma reminders' can lead to behaviors that seem out of place, but were appropriate--and perhaps even helpful--at the time of the original traumatic event" (NCTSN, 2013).

Talk with children about people, places, and situations that make them feel worried, and those that make them feel safe. Some children more easily share their ideas about a "safe home" by creating a drawing in which they draw or list inside the house things that make them feel safe, and draw or list worrisome things outside the house.

Since children may not even be aware their reactions are related to trauma, you can also educate caregivers to look for patterns of difficult or confusing behavior that may be related to trauma reminders. Caregivers need education to help them interpret children's problematic behaviors as trauma reactions, rather than labeling the child as "bad" or "manipulative."

5. Advocate for and support effective treatment. The good news for children who experience sexual abuse is that there are effective, evidence-based treatments available. One effective model becoming increasingly available in our state is Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). To find therapists certified in TF-CBT, visit the NC Child Treatment Program's provider map: www.childtreatmentprogram.org/NCCounties/Index.rails

What about when TF-CBT is not available, or not appropriate for a particular child? DSS agencies are important voices to advocate for increasing the availability and funding for TF-CBT and other trauma-informed treatments. Your Managed Care Organization (MCO), System of Care agencies, and current providers are all important partners in bringing effective, high quality treatment to your community.

Once children access treatment, as a child welfare professional you are a consultant for the therapist, just as they are a consultant for you in understanding what is happening for the child and how best to help. Social workers can:

Ensure the therapist has the information needed for a comprehensive assessment and treatment plan;

Promote the use of a trauma- and evidence-informed approach; and

Monitor whether the child is making measurable progress over time.

See the box below for questions to ask therapists, and the following interview on the next page for tips on collaboratively supporting children's treatment and healing.

Building a strong therapeutic relationship. Trauma treatment requires the skillful development of a clinical relationship with the child and caregivers.

Psycho-education about normal responses to trauma. Most trauma-informed therapy includes a component that helps the child and caregivers understand normal reactions to trauma.

Parent support, conjoint therapy, or parent training. Caregivers are typically powerful mediators of the child's treatment and recovery. Involving caregivers is a vital element of trauma treatment.

Emotional expression and regulation skills. Helping the child to identify and express powerful emotions related to the trauma and to regulate or control their emotions and behavior is an important element of trauma-informed therapy.

Anxiety management and relaxation. It is often necessary to teach the child (and sometimes the caregiver) skills and tools for mastering the overwhelming emotions associated with trauma and its reminders.

Cognitive processing or reframing. Many children form destructive misunderstandings in the aftermath of the trauma. Therapy often helps correct these misattributions.

Construction of a coherent trauma narrative. Trauma treatment often includes building the child's capacity to talk about what happened in ways that do not produce overwhelming emotions and that make sense of the experience. This sometimes involves gradual exposure to traumatic reminders while using newly acquired anxiety management skills.

Personal safety training and other empowerment activities. Trauma treatment often teaches children strategies that give them a sense of control over events and risks.

Resiliency and closure. Treatment often ends on a positive, empowering note, giving the child a sense of satisfaction and closure as well as increased competency and hope for the future.

References for this and other articles in this issue

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Providing a Trauma-Informed Response to Child Sexual Abuse

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Vol. 20, No. 2 April 2015 We know children who experience sexual abuse can be further traumatized by CPS assessments and law enforcement investigations. We also know that without appropriate treatment, survivors of child sexual abuse are at increased life-long risk for a broad array of physical and mental health problems, as well as future victimization (Hilaski, et al., 2008; O'Brien & Scher, 2013; Sachs-Erisson, et al., 2009; all cited in Flick, et al., 2014).

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1. Early identification and intervention: Children who have experienced neglect should be identified as early as possible, and receive appropriate intervention and support. This includes regular health check-ups, developmental screenings, and referrals to mental health services as needed.

2. Strengthening families: Addressing the underlying issues that contribute to neglect can help prevent future occurrences. Family-focused interventions, such as parenting classes and family therapy, can help improve parent-child relationships and provide parents with the tools they need to better care for their children.

3. Trauma-informed care: Neglect often results in trauma for children, and trauma-informed care can help address the emotional and psychological impacts of neglect. This approach involves creating a safe and supportive environment for the child, providing opportunities for the child to express themselves, and developing a treatment plan that addresses their specific needs.

4. Education and training: Professionals who work with children, including teachers, healthcare providers, and social workers, should receive training on how to identify and respond to neglect. This can help ensure that children receive appropriate interventions and support as early as possible.

5. Collaboration and coordination: Effective responses to neglect require collaboration and coordination across multiple systems, including child welfare, healthcare, and education. This can help ensure that children receive comprehensive support and that there is a coordinated approach to addressing their needs.

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1. Seek support from mental health professionals: Trauma can be a complex issue to deal with, and it is often best addressed with the help of a mental health professional. Therapists and counselors can provide specialized support to help children cope with the effects of trauma.

2. Use coping skills: Coping skills can be an effective tool for children to manage their emotions and reduce stress. Examples of coping skills include deep breathing, meditation, exercise, or engaging in a hobby or activity that the child enjoys.

3. Develop a support network: Having a supportive community can make a significant difference for children coping with trauma. This can include family members, friends, teachers, coaches, and other trusted adults.

4. Establish a routine: A routine can provide children with a sense of stability and predictability, which can be particularly important in the aftermath of a traumatic event. This can include regular meal times, consistent bedtimes, and designated times for homework and other activities.

5. Practice self-care: Encouraging children to take care of themselves can help them manage the effects of trauma. This can include healthy eating, getting enough sleep, and engaging in physical activity.

6. Encourage open communication: Encouraging children to talk about their thoughts and feelings can help them process the effects of trauma. It is important to create a safe and supportive environment for children to share their experiences.

7. Provide a safe and secure environment: Children who have experienced trauma may feel a sense of insecurity or danger. It is important to provide a safe and secure environment to help them feel protected and reduce their anxiety.

Overall, the key solutions for helping children cope with the effects of trauma involve providing support, establishing routines, and promoting self-care and healthy coping skills. It is also important to seek the help of mental health professionals and create a safe and supportive environment for children to process their experiences.

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Students who have been involved in accidents or who have suffered injuries may experience traumatic stress.

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ADAA provides this Website blogs for the benefit of its members and the public. The content, view and opinions published in Blogs written by our personnel or contributors - or from links or posts on the Website from other sources - belong solely to their respective authors and do not necessarily reflect the views of ADAA, its members, management or employees. Any comments or opinions expressed are those of their respective contributors only. Please remember that the open and real-time nature of the comments posted to these venues makes it is impossible for ADAA to confirm the validity of any content posted, and though we reserve the right to review and edit or delete any such comment, we do not guarantee that we will monitor or review it. As such, we are not responsible for any messages posted or the consequences of following any advice offered within such posts. If you find any posts in these posts/comments to be offensive, inaccurate or objectionable, please contact us via email at [email protected] and reference the relevant content. If we determine that removal of a post or posts is necessary, we will make reasonable efforts to do so in a timely manner.

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How to Cope with Trauma After an Accident

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ADAA Blog Content and Blog Comments Policy ADAA provides this Website blogs for the benefit of its members and the public. The content, view and opinions published in Blogs written by our personnel or contributors - or from links or posts on the Website from other sources - belong solely to their respective authors and do not necessarily reflect the views of ADAA, its members, management or employees.

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Childhood abuse or neglect: Survivors of childhood abuse or neglect can experience traumatic stress.

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Child abuse and neglect are serious public health problems and adverse childhood experiences (ACEs). They can have long-term impacts on health, opportunity, and wellbeing. This issue includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (such as a religious leader, a coach, a teacher) that results in harm, the potential for harm, or threat of harm to a child. There are four common types of abuse and neglect:

Physical abuse is the intentional use of physical force that can result in physical injury. Examples include hitting, kicking, shaking, burning, or other shows of force against a child.

Sexual abuse involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities. Please see CDC's Preventing Child Sexual Abuse webpage for more information.

Emotional abuse refers to behaviors that harm a child's self-worth or emotional well-being. Examples include name-calling, shaming, rejecting, withholding love, and threatening.

Neglect is the failure to meet a child's basic physical and emotional needs. These needs include housing, food, clothing, education, access to medical care, and having feelings validated and appropriately responded to.

For more information about preventing child abuse and neglect definitions please see Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements [4.12 MB, 148 Pages, 508] .

Child abuse and neglect are common. At least 1 in 7 children have experienced child abuse or neglect in the past year in the United States. This is likely an underestimate because many cases are unreported. In 2020, 1,750 children died of abuse and neglect in the United States.

Children living in poverty experience more abuse and neglect. Experiencing poverty can place a lot of stress on families, which may increase the risk for child abuse and neglect. Rates of child abuse and neglect are 5 times higher for children in families with low socioeconomic status.

Child maltreatment is costly. In the United States, the total lifetime economic burden associated with child abuse and neglect was about $592 billion in 2018. This economic burden rivals the cost of other high-profile public health problems, such as heart disease and diabetes.

Children who are abused and neglected may suffer immediate physical injuries such as cuts, bruises, or broken bones. They may also have emotional and psychological problems, such as anxiety or posttraumatic stress.

Over the long term, children who are abused or neglected are also at increased risk for experiencing future violence victimization and perpetration, substance abuse, sexually transmitted infections, delayed brain development, lower educational attainment, and limited employment opportunities.

Chronic abuse may result in toxic stress, which can change brain development and increase the risk for problems like posttraumatic stress disorder and learning, attention, and memory difficulties.

Child abuse and neglect are preventable. Certain factors may increase or decrease the risk of perpetrating or experiencing child abuse and neglect. To prevent child abuse and neglect violence, we must understand and address the factors that put people at risk for or protect them from violence. Everyone benefits when children have safe, stable, nurturing relationships and environments. CDC developed Child Abuse and Neglect Prevention Resource for Action [4 MB, 50 Pages] to help communities use the best available evidence to prevent child abuse and neglect. This resource is available in English and Spanish [21MB, 52 Pages, 508] and can impact individual behaviors and relationships, family, community, and societal factors that influence risk and protective factors for child abuse and neglect.

Different types of violence are connected and often share root causes. Child abuse and neglect are linked to other forms of violence through shared risk and protective factors. Addressing and preventing one form of violence may have an impact on preventing other forms of violence.
See Child Abuse and Neglect Resources for publications, data sources, and prevention resources for preventing child abuse and neglect.

1. Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Child Abuse and Neglect Prevention Resource for Action: A Compilation of the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Note: The title of this document was changed in July 2023 to align with other Prevention Resources being developed by CDC's Injury Center. The document was previously cited as "Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities".

2. Leeb RT, Paulozzi L, Melanson C, Simon T, Arias I. Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements, Version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008.

3. Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of Childhood Exposure to Violence, Crime, and Abuse: Results from the National Survey of Children's Exposure to Violence. JAMA Pediatr. 2015;169(8):746-754. doi:10.1001/jamapediatrics.2015.0676

4. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. (2022). Child Maltreatment 2020. Available from https://www.acf.hhs.gov/cb/researchdata technology/statistics-research/childmaltreatment.

5. Klika JB, Rosenzweig J, Merrick M. Economic burden of known cases of child maltreatment from 2018 in each state. Child and adolescent social work journal. 2020 Jun;37(3):227-34.

6. Centers for Disease Control and Prevention.(2022). Health and Economic Costs of Chronic Diseases. Available from https://www.cdc.gov/chronicdisease/about/costs/index.htm

7. Shonkoff J, Garner A, & Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246.

8. Preventing Multiple Forms of Violence: A Strategic Vision for Connecting the Dots. (2016). Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

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Fast Facts: Preventing Child Abuse & Neglect

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Adolescents and adults are often unaware that teens experience dating violence

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Students who have experienced natural disasters such as hurricanes, tornadoes, earthquakes, or wildfires may experience traumatic stress.

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Students who have experienced medical trauma, such as hospitalization, surgery, or serious illness, may experience traumatic stress.

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We don't talk about medical trauma all that often. But for many, trauma at the hands of healthcare professionals is real - and knowing how to heal matters.

Sometimes trauma occurs in situations that are easy to recognize, like natural disasters or abusive relationships. Other times, it happens in places we go to get better, like hospitals, doctor's offices, and urgent care facilities.

What happens when those who are supposed to help you at your most vulnerable cause trauma instead?

For people who've experienced some form of medical trauma - including myself - it can bring up a lot of conflicting feelings.

In my case, it's likely the medical professionals were just trying to do their jobs. But to the 3-year-old version of me, the lifesaving procedure I underwent was a violating and confusing experience I ended up carrying with me for years.

The umbrella of medical trauma is broad. That means people who've experienced it will have many different stories and perspectives.

For example, any life-threatening illness could cause medical trauma. And in the United States alone, millions of people survive cancer, heart attacks, and strokes each year.

Medical trauma can affect anyone, and for many different reasons. And while the impacts of the trauma can be long-lasting, many care approaches offer relief and healing.

When people talk about medical trauma, they might use the phrase "medical PTSD." There are differences between these terms:

Medical PTSD. This refers to symptoms that meet the criteria for post-traumatic stress disorder (PTSD) originating from trauma in a medical setting.

Medical trauma. This is trauma that occurs in a medical setting. While not an official diagnosis itself, medical trauma can lead to conditions like PTSD, anxiety, depression, or chronic pain.

If you're in therapy and wondering which phrase might fit you best, this difference might matter: PTSD is an actual diagnosis and medical trauma is used more broadly.

There's still a lot of overlap, and using one term or the other to describe yourself doesn't mean your experience was any "easier" or "harder" than anyone else's.

It's important to note that trauma is subjective. This means that if you experienced an event as traumatic, then you've experienced trauma. No one else gets to decide whether you've experienced trauma, because they're not you.

This also makes trauma - particularly medical trauma - complex. When you're trying to heal, your care approach is going to look vastly different from someone else's because you'll have different reactions, experiences, and triggers.

Because medical trauma is something not many people talk about or acknowledge, some experts refer to it as disenfranchised trauma. Disenfranchised, or unacknowledged, trauma can be tricky because people might not understand it or take it seriously.

In a medical system that's often trained to treat only physical symptoms, emotions can get left out of the equation. Someone may be dealing with complex emotions after a medical procedure, but they're usually sent home without any further care once they're able to take care of themselves physically.

So, what can medical trauma look like?

If you've experienced medical trauma, you might show physical and emotional signs. These signs can show up in specific situations that remind your body of the original trauma.

My therapist once explained it to me like this: When we go through trauma, our senses are still taking in a lot of information - even if we don't realize it at the time. But after the trauma, our bodies remember. We've stored away the sensory information we took in during the traumatic event.

When we encounter another situation with similar sensory information (like a certain smell or sound) it causes our alarm bells to go off. The body says, "We're in danger. It's time to lock down!" And that's when your body might freeze or flinch.

While many settings and experiences can trigger stress for people with medical trauma, some common ones are:

doctor's offices

dentist's offices

places with bright lights

being touched

specific scents, like the scent of disinfectant

Some symptoms and signs of medical trauma could include:

People experience medical trauma for many different reasons. While it's impossible to list them all, your own experience will likely inform which settings currently cause you to experience symptoms (and what kind of symptoms you have).

Sometimes medical trauma results from negligence. Other times, it comes from a lack of understanding or even a lack of empathy. It can even occur when there's nothing anyone could have done to prevent the traumatic event.

Some experiences that might lead to medical trauma include:

being on dialysis

giving birth or having a cesarean delivery

being intubated

experiencing cancer

being hospitalized for a medical condition

undergoing surgery

having health complications as a child

having a heart attack or stroke

living with chronic pain or medically unexplained symptoms

Whether your visit to the hospital was planned or unplanned, trauma can still occur.

For example, almost 1 in 3 births in the United States is through cesarean delivery, and most of these were by necessity, not choice. This means many births involve an unplanned invasive surgery.

When it comes to how medical trauma happens, the answer also varies. Here are a few examples:

A medical professional ignored you when you said you were in pain.

You received a lower standard of care due to your race or ethnicity.

A medical professional didn't take concerns about your symptoms seriously.

No one told you what to expect before undergoing a medical procedure.

Your wishes weren't respected in the operating room.

You were separated from your primary support person, like a partner or family member, during your procedure.

Carrying trauma as a result of a medical procedure can leave you in the same place as many other trauma survivors - trying to manage symptoms that make it harder to live the way you want.

It isn't easy, but it is possible to heal from these experiences.

Trauma a sense of foreshortened future, which is a belief that life won't move forward in the way you might otherwise hope. It can cause you to believe you won't live much longer or that you won't be able to reach life milestones.

If you carry trauma, you'll probably know that its effects can be physical and mental. For example, you might experience pain or tension along with anxiety and nightmares. When it comes to healing, it can help to make sure that your treatment takes your full range of symptoms into account.

Working with a mental health professional is one way to manage trauma. Some common forms of trauma therapy include:

Somatic therapy. Somatic therapies, like somatic experiencing, take a body-based approach to healing trauma. If you have a difficult time talking about your experience, this therapy could be especially helpful since you won't be required to talk about it (although you can).

Eye movement desensitization and reprocessing (EMDR). This form of therapy uses specific eye movements or other repetitive movements to help you reprocess traumatic memories.

Cognitive behavioral therapy (CBT). Trauma-focused CBT in particular has been to help reduce PTSD symptoms.

If you want a deeper dive on managing the effects of trauma, this article is a good place to start.

For many people planning to get some kind of medical care - whether it's a routine procedure or a surgery - bringing in an ally can help mitigate some potential trauma.

In fact, shows that a lack of support during vulnerable medical situations like childbirth is connected to a higher chance of PTSD.

Clinical social worker Ellie Somers, MSW, LCSW-C shares that it often becomes necessary for a friend or family member to act as an advocate in hospital settings when their loved one isn't in a position to advocate for themselves.

In addition, Somers explains, "Some medical settings have people in place specifically to advocate for patients. For example, if [you're] in a hospital you can ask to speak with the social worker or nurse case manager, who can assist with articulating your concerns in ways that might be better received by the clinicians."

Somers also adds that some hospitals have an internal ombudsman - that is, a professional advocate who's there to make sure your needs are being met.

Even if you know you'll technically be able to speak up for yourself the entire time, it can help to bring an ally with you as back up.

A medical ally might be someone who's well-versed in your needs and wishes, and may be able to act as a buffer between you and a healthcare professional if your needs aren't being respected.

Living with the effects of medical trauma can make you feel foggy, tired, dissociated, and a whole host of other feelings. Depending on the circumstances of your trauma, you might also be carrying grief, anger, or other intense emotions.

Healing isn't a linear process, but it is possible with time and patience. If you think you've experienced medical trauma and want more info, the below resources are a good place to start.

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Medical Trauma Exists, and It's More Common Than You Might Think

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We don't talk about medical trauma often, but trauma at the hands of healthcare professionals is real - and healing is possible.

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Students who have witnessed violence, whether in the home or community, may experience traumatic stress.

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Caroline was having a hard time getting her daughter to go to school. The night before, her daughter saw the news about a terrorist bombing that had occurred that day where several children and adults were killed and schools were immediately closed.

Her daughter had a difficult time sleeping and was refusing to eat her breakfast. When Caroline asked her daughter what was wrong, she replied in a hushed tone,

"I'm scared mommy. If I go to school, will somebody come in and shoot me? I don't want to die."

Though Caroline was reacting to news here in the United States, she could just as easily have been reacting to the recent bombing at the Ariana Grande concert in Manchester, England - and its coverage in the media. Both underscore children's constant exposure to troubling events and depictions of violence throughout the world.

As researchers and clinicians who have studied the problem of violence over the past three decades, we have witnessed a steady increase in levels of children's exposure to violence and its damaging effect on their mental health.

How does this exposure to violence affect children and adolescents - especially their mental health? And how should we handle the increased fear and insecurity that results from such events?

Exposure to violence

Today, children use many different forms of media and at unprecedented levels - 92 percent of teens go online daily and 24 percent are online constantly. As a result, children get exposed to violence through multiple media. So, even when violence happens in another part of the world, children are exposed to the event and its consequences immediately, intensely and repeatedly as a result of media exposure.

And there is increasing evidence that exposure to violence in everyday life has a significant impact on children's mental health.

But then, children today are growing up in a world where fear and insecurity rule over confidence and safety. This is not just driven by media but also by what they experience in the real world.

So, in addition to terrorist acts, children could witness or be victims of violence in many other ways. For example, when we surveyed high school students, between 13 and 45 percent reported they had been beaten up at school. Between 23 and 82 percent said they had witnessed someone else being beaten up at school in the past year.

We have also seen how school shootings with multiple victims have increased in prevalence in the past five years.

Here is what happens to children

Children who report high levels of exposure to violence (either as witness or victim) report the highest levels of depression, anger and anxiety.

Our study with children in grades three to eight who witnessed someone being hit, slapped, or punched found that 12 percent of these children reported levels of anxiety that could require treatment.

Similarly, six months after the September 11, 2001 terrorist attacks, a survey of over 8,000 New York City students in grades four through 12 showed that nearly 30 percent of children reported symptoms of anxiety or depression.

Exposure to violence could have other long-term impacts as well: children could get desensitized to violence and its effects. Studies have shown how children can get desensitized to violence: that is, children can come to believe that violence is an acceptable way to solve problems and that it is without consequence. They could also come to believe that violence could happen anywhere and to anyone at any time.

Further, such children are also at a risk of perpetrating violence against others.

Our studies have shown that children who witness or are victimized by violence are more aggressive toward others. These children also show problematic levels of post-traumatic stress symptoms.

We have consistently found relationships between violence exposure and trauma symptoms, whether we surveyed children in schools, youth in the community or juveniles who were receiving treatment as a result of diversion from the prison system.

Adolescents exposed to high levels of violence reported higher levels of anger and depression. They also reported higher rates of wanting to hurt or kill themselves compared to adolescents in lower violence exposure groups.

Media exposure

More recent studies have confirmed that high exposure to television violence for children and adolescents is also associated with higher levels of aggression and violent behavior. Exposure to violence shown through media is consistently associated with problem behaviors, such as increases in aggression and anxiety. Children could also end up with lower empathy and compassion for others.

Some children exposed to various forms of media violence (not just television violence but violence on the Internet, in movies and in video games) can come to view the world as a mean, scary place where they are not safe and they can do little to protect themselves from harm. This is a particular problem for very young children such as those under the age of six who have difficulty distinguishing reality from fantasy.

Exposure to violence could harm the emotional and mental development of young children and adolescents. Children at that age aren't able to effectively process what they are seeing and hearing. This may be due in part to the fact that chronic exposure to violence can affect parts of their brain.

For adolescents, the front part of their brains is the last to develop and mature. This part of the brain is called the prefrontal cortex, and it is responsible for processing information, impulse control and reasoning. Adolescents exposed to violent video games experience a decrease in activity in their prefrontal cortex, leaving them more vulnerable to having difficulty with problem-solving and controlling their emotions.

What can parents do?

Parents have an important role to play. Knowing where their children are, what they are doing and with whom are some of the best ways to help support children. That improves their ability to cope with what is going on in the world around them.

The same is true for adolescents as well. It is sometimes assumed that as children reach adolescence, they need less support and monitoring as they spend more time with their peers and make increased demands to be more independent.

That is not the case.

Adolescents have more access to social media, to drugs and alcohol, and to transportation. Coupled with this is the growing evidence that the problem-solving and impulse control parts of their brains are not yet fully developed.

Parents are often the first to recognize their children are struggling with mental health and behavioral issues. And they could be the best providers of mental health first aid whenever and however their children need them.

The immediacy, intensity and imagery of the coverage of the concert bombing in Manchester may be very disturbing to both youth and adults. It is important that we continue to discuss this with our children and help them express their emotions and viewpoints, while assuring them that these extreme acts of violence, while deeply disturbing, are the exception and not the rule.
Editor's note: The above was written in response to children in the United States witnessing coverage of school shootings. It has been updated to reflect the May 22 attack in Manchester.

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Here's how witnessing violence harms children's mental health

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Caroline was having a hard time getting her daughter to go to school. The night before, her daughter saw the news about a terrorist bombing that had occurred that day where several children and adults were killed and schools were immediately closed. Her daughter had a difficult time sleeping and was refusing to eat her breakfast.

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What teacher can do for Traumatic Stress 

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What teacher can do for Traumatic Stress 

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Traumatic stress can have a significant impact on children's emotional well-being and academic performance. As a teacher, there are several things you can do to help your elementary school students cope with traumatic stress:

1. Create a Safe and Supportive Learning Environment: Children who have experienced trauma may feel anxious, fearful, and mistrustful of others. Therefore, it is essential to create a safe and supportive learning environment. Make sure to establish clear rules and routines and provide a warm and caring atmosphere in the classroom.

2. Be Attentive and Understanding: Teachers need to be attentive to their students' behavior, particularly when it comes to trauma. If you notice any changes in their behavior, such as withdrawal or acting out, try to understand their situation and provide emotional support.

3. Encourage Communication: Encourage children to express their feelings and thoughts, even if it's challenging for them. Provide a safe space where they can talk about their experiences without fear of being judged or criticized.

4. Use Trauma-Informed Teaching Strategies: Trauma-informed teaching strategies involve recognizing the impact of trauma on learning and behavior and adjusting your teaching approach accordingly. For example, you can use calming techniques like deep breathing or mindfulness exercises to help children regulate their emotions.

5. Involve Parents and Guardians: It's essential to involve parents and guardians in the process of addressing traumatic stress. Share resources and strategies with them, and encourage them to seek additional support if needed.

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10 Things About Childhood Trauma Every Teacher Needs To Know

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With grief, sadness is obvious. With trauma, the symptoms can go largely unrecognized because they mimic other problems: frustration; acting out; or difficulty concentrating, following directions, or working in a group. Students are often misdiagnosed with anxiety, behavior disorders, or attention disorders rather than understood to have trauma that drives those symptoms and reactions.

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Several behaviors that teachers should pay attention 

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Several behaviors that teachers should pay attention 

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There are several behaviors that teachers should pay attention to when it comes to traumatic stress in elementary school students. These include:

1. Withdrawal or Isolation: Students who have experienced trauma may withdraw or isolate themselves from others. They may avoid social interactions, have difficulty making friends, or prefer to spend time alone.

2. Emotional Outbursts: Children who have experienced trauma may have difficulty regulating their emotions. They may become easily upset, angry, or frustrated, and may have frequent emotional outbursts.

3. Physical Symptoms: Trauma can also manifest in physical symptoms such as headaches, stomach aches, or fatigue. These symptoms may be related to stress or anxiety and can impact a child's ability to focus and learn.

4. Hypervigilance: Students who have experienced trauma may be hypervigilant or constantly on high alert. They may have difficulty relaxing or concentrating and may be easily startled or frightened.

5. Regression: Traumatic stress can also cause children to regress in their behavior. For example, they may start wetting the bed or sucking their thumb again, behaviors that they had previously outgrown.

6. Academic Difficulties: Traumatic stress can also impact a child's academic performance. They may have difficulty concentrating, completing assignments, or retaining information.

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APA Mental Health Primers

This information is designed to help teachers respond to students who may need support. It is not intended to be used as a diagnostic tool or to replace the use of formal assessments employed by mental health professionals. Additionally, it is important to consider the context of the situation, individual differences, and cultural and linguistic factors.

Teachers play an important role in establishing and maintaining healthy environments for students to learn and grow. For students who have been exposed to traumatic experiences, the first step is to ensure that classrooms feel safe for the child. Only after a student feels safe, can teachers work toward building supportive relationships and academic gains.

Unfortunately, trauma exposure is common. When students require additional support, teachers play a critical role in guiding students suffering from trauma to professionals in the building who can be of assistance.

What is Trauma?

A traumatic event is a frightening, dangerous, or violent event that poses bodily or psychological harm or is a threat to a student's life or a loved one. Students may or may not experience a situation as traumatic. The manifestation of trauma may differ based on cultural perspectives. For example, in some cultures people express their experiences of trauma more publicly and with their community whereas in others the expression is more individualistic and private.

Some traumatic events could be, but are not limited to:

Gun violence

Sexual abuse

Domestic abuse

Addiction

Suicide/death

Familial illness

Car accidents

Natural disasters/catastrophic events

Traumatic experiences often initiate strong emotions and physical reactions that can persist long after the event. Notably, a student does not need to have experienced a traumatic event directly.

A child may witness a traumatic event or see it through the media.

A child may be told about a trauma, often with gruesome details.

Traumatic events during one's childhood can impact a student's development throughout the rest of their life.

How Might Trauma Be Expressed by Students in School?

Left unaddressed, the negative impacts of stress and trauma can disrupt a student's behavior, and emotional wellbeing, academic success and health. Witnesses and bystanders of traumatic events might be disruptive or inattentive in school, or demonstrate unacceptable or defiant behavior. They might also demonstrate more fear-based behaviors (e.g., not wanting a door closed; being disturbed by a normal occurrence, like a bell ringing).

Students who have been exposed to trauma might also show a disruption in cognitive skills (e.g., memory, attention). This might result in decreased academic performance and school engagement. In the virtual learning environment (VLE), students who have experienced or witnessed trauma might withdraw from video or text/chat engagement or appear to have difficulty focusing.

In both learning environments, students exposed to trauma may also exhibit truancy, repeated tardiness, decreased attention to personal hygiene and grooming, and behaviors they have not demonstrated before, such as unreasonable fears or repetitive speech and behavior patterns.

Refer Students to Further Help if Needed

Review your school policy for seeking student supports.

Contact your school counselor, psychologist, social worker, and other personnel.

Empirical Research

Berson, I. R., & Baggerly, J. (2009). Building resilience to trauma: Creating a safe and supportive early childhood classroom. Childhood Education, 85(6), 375-379.

Blitz, L. V., Anderson, E. M., & Saastamoinen, M. (2016). Assessing perceptions of culture and trauma in an elementary school: Informing a model for culturally responsive trauma-informed schools. The Urban Review, 48(4), 520-542.

Dods, J. (2013). Enhancing understanding of the nature of supportive school-based relationships for youth who have experienced trauma. Canadian Journal of Education/Revue canadienne de l'éducation, 36(1), 71-95.

Hudson, C. C., Adams, S., & Lauderdale, J. (2016). Cultural expressions of intergenerational trauma and mental health nursing implications for US health care delivery following refugee resettlement: An integrative review of the literature. Journal of Transcultural Nursing, 27(3), 286-301. https://doi.org/10.1177/1043659615587591

Figge, C. J., Martinez-Torteya, C., Taing, S., Chhim, S., & Hinton, D. E. (2020). Key expressions of trauma-related distress in Cambodian children: a step toward culturally sensitive trauma assessment and intervention. Transcultural psychiatry, 1363461520906008. https://doi.org/10.1177/1363461520906008

Terrasi, S., & De Galarce, P. C. (2017). Trauma and learning in America's classrooms. Phi Delta Kappan, 98(6), 35-41.

The Mental Health Primers are developed by the Coalition for Psychology in Schools and Education. This resource was updated in October 2021 with support from cooperative agreement NU87PS004366 funded by the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views or endorsement of the CDC or the Department of Health and Human Services.

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Teachers play a critical role in guiding students suffering from trauma which if left unaddressed can disrupt a student's behavior, and emotional wellbeing, academic success and health. Part of the APA Mental Health Primers for teachers responding to students who may need support.