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https://www.healthline.com/health-news/the-world-is-experiencing-mass-trauma-from-covid-19-what-you-can-do#How-to-recognize-signs-of-trauma

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Increased Mental Health Issues for Children

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Increased Mental Health Issues for Children

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Therapy and learning how to maintain social interaction will be essential for these children.

Keeping an eye on depression and other mental or emotional illness for timely intervention is also key to ensure that these children are safe.

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For many people, the pandemic resulted in an epidemic of loneliness and social isolation.The impacts have been particularly pronounced for older adults, who were already more likely to experience isolation as well as other issues like financial insecurity. In Laura Shannonhouse’s lab (the H.O.P.E. lab, or Helping Others Provide Empathy) researchers are developing programs to help people, especially older adults, who are struggling with depression and thoughts of suicide.

# data[].attributes.body
Perhaps the greatest psychological burden, however, has been borne by those in what’s known as the “helping professions.” Caregivers, including social workers and healthcare professionals, can be traumatized by their work through what’s known as “secondary traumatic stress.” The pandemic has dramatically increased the trauma exposure for these individuals, putting them under extraordinary levels of strain.

# data[].attributes.attachment_link.readable_text
Written by Noelle Toumey Reetz

The COVID-19 pandemic has been the most traumatic collective event of our lifetime. And after two excruciating years and more than a million deaths in the U.S. alone, it is still unclear when, or if, the pandemic will end. That uncertainty is one of many stressors, along with worries about health, family, work and finances, that have taken a significant toll on mental health.

In a recent survey, the American Psychological Association found that nearly two-thirds of respondents said their lives have been permanently changed by the pandemic. The report also showed that a large proportion of the country has been living in "sustained survival mode" with significant consequences for mental health. The World Health Organization says the pandemic has sparked a 25 percent increase in anxiety and depression worldwide.

"I think the mental health issue is percolating, just like a virus incubating," says Laura Shannonhouse, associate professor of counseling and psychological services in the College of Education & Human Development. "We're seeing little pieces now, but it's like an iceberg. Most of it is still below the surface."

Shannonhouse is one of several researchers at Georgia State University who have been studying how individuals are dealing with the stress of the pandemic. While they agree the mental health crisis is just beginning, they're also seeing signs of hope and resilience.

For most people who have survived the pandemic, this time will leave a mark. There may always be a line of delineation - before and after. However, says Jeff Ashby, co-director of Georgia State's Ken Matheny Center for the Study of Stress, Trauma and Resilience, we still haven't reached the "after" - and for many, the anxiety of the unknown can be harmful in and of itself.

"When we first began our research, we thought, 'We must hurry, because of course, this will be over soon...' and two years later we still don't know what's going to happen," says Ashby, a professor in the Department of Counseling and Psychological Services. "I think that's the hard part. It's still a moving target."

Ashby and his colleagues, including center co-director Ken Rice, recently surveyed 745 people to examine whether the strain of the pandemic could lead to stress disorders, and if so, which groups are most at risk. The results, which were published in published the Journal of Community Psychology, showed the pandemic is an independent source of traumatic stress and, for a subset of people, that stress can predict the development of post-traumatic stress disorder (PTSD).

The research determined the association between COVID traumatic stress and PTSD is stronger among individuals who have cumulative trauma. In other words, if you've already dealt with loss and trauma in the past, there's an increased risk that the pandemic was harder for you.

"People have what's known as a 'trauma load,' and part of what you're doing is reactivating traumatic experiences from previous situations," says Ashby. "So that would suggest that in higher-risk populations, the experience of fresh trauma would be more acute."

Ashby and Rice also looked at how the pandemic affected individuals' mental health based on race/ethnicity. They were surprised by what they found.

"We know that certain minority groups were hit harder, both in terms of infections and deaths," Ashby says. "We expected to see similar impacts on mental health, yet we did not find it."

Instead, researchers found an association between increased PTSD symptoms and high levels of cumulative trauma for all groups, except for Asian Americans. For this group, the relationship between COVID, traumatic stress and PTSD symptoms did not appear to be affected by previous trauma.

Why were the results conspicuously different for Asian Americans? The researchers note that previous surveys have found Asian Americans are less likely to report psychological distress compared to other groups. Additionally, the research was conducted amid a backdrop of increased discrimination and violence against Asian Americans during the pandemic. Asian Americans who have a greater history of previous trauma may be more affected by being scapegoated as the source of COVID‐19 in the U.S., and as a result, COVID‐19 specific trauma (for example, a personal fear of infection) may have a comparatively diminished effect on PTSD symptoms.

Ashby says the results emphasize the importance of examining subgroups for potential exacerbating - or protective - effects of COVID stress on mental health outcomes. He adds that future research should examine other factors, such as how socioeconomic status has affected how people coped during the pandemic.

"We know that resources help buffer traumatic or stressful experiences," he says. "There are those of us for whom the largest imposition was a kind of social isolation, while others were riding public transit to get to work that was mandatory for their livelihood."

Because the pandemic has affected millions - even billions - of people around the world, Ashby predicts a skyrocketing need for mental health services in the coming years.

"Given the widespread effect of COVID-19 related stress and its far-reaching impact, there will likely be an increased need for mental health services that exceeds our current capacity to meet those needs," says Ashby."

For Front-Line Workers, Emotional Exhaustion

It's been approximately 750 days since life ground to a standstill in the U.S. Those who had the option to work from home left their offices in March 2020 - with their plants healthy and their coffee cups half-full - and many didn't return for months or more. Millions of others lost jobs or kept commuting as essential workers.

Perhaps the greatest psychological burden, however, has been borne by those in what's known as the "helping professions." Caregivers, including social workers and healthcare professionals, can be traumatized by their work through what's known as "secondary traumatic stress." The pandemic has dramatically increased the trauma exposure for these individuals, putting them under extraordinary levels of strain.

Brian Bride is a Distinguished University Professor and former director of the School of Social Work in the Andrew Young School of Policy Studies. In 1995, he developed the internationally recognized Secondary Traumatic Stress Scale, designed to measure these reactions of helping professionals who have experienced traumatic stress through their work.

"Medical personnel have had to respond to a large number of patients, many of whom have died. At the same time, they've been worried about getting sick themselves," he says. "Many of them have also had to deal with moral distress about rationing PPE or even rationing care. Even if they haven't had to make those hard choices, they've likely had to worry about it. That causes people to second-guess who they are morally in the work that they're doing."

In addition to secondary traumatic stress, says Bride, there's the issue of shared trauma, which occurs when a professional has directly experienced the same collective trauma as their patients. There were many reports of shared trauma after the attacks of September 11, 2001, and it can trigger nightmares, depression, hyperarousal and even PTSD in extreme cases.

"When the notion of PTSD first emerged, it was thought to occur only if the person directly witnessed the trauma. But our research shows that's not necessarily the case," says Bride. "This notion of shared trauma primarily comes out of social work and psychology and therapy, but it certainly could apply to healthcare professionals and even teachers.

"We know that the professions at the highest are those in which people work with children who've been traumatized, such as child welfare professionals or social workers," he adds.

Bride is currently working to update the scale to include pandemics as a traumatic event and clarify the impacts to those who have been on the front lines.

"One of the things that's important to me is setting both individual and organizational guidelines," says Bride. "For a long time with secondary traumatic stress, the onus has really been on the individual to take care of themselves. We need to recognize that secondary trauma occurs within work settings and organizations have a responsibility to create a culture where the staff and professionals can admit to that and seek help."

Grieving the Loss of Connection

For many people, the pandemic resulted in an epidemic of loneliness and social isolation. The impacts have been particularly pronounced for older adults, who were already more likely to experience isolation as well as other issues like financial insecurity. In Laura Shannonhouse's lab (the H.O.P.E. lab, or Helping Others Provide Empathy) researchers are developing programs to help people, especially older adults, who are struggling with depression and thoughts of suicide.

During the pandemic, their work with older home-bound adults has led to the expansion of a suicide-intervention project. Known as "BE WITH" (Belonging and Empathy, With Intentional Targeted Helping), the project is designed to reduce social isolation, loneliness and elevated suicide risk in racially diverse, older adults - the demographic hardest hit by COVID-19. In 2018, Shannonhouse's team began training home delivery meal providers (think Meals on Wheels) in suicide prevention techniques.

Mary Chase Mize, postdoctoral research associate and assistant director of the H.O.P.E. lab, recently published a study from her dissertation (under the direction of Shannonhouse) in the journal of Educational Gerontology, which found that trained volunteers repeatedly used their new suicide intervention skills. That response is important since these volunteers are often the only social connections for the older adults they serve. When the pandemic made in-person meal delivery a challenge, Shannonhouse and her team used $1.3 million from the Department Health and Human Services to train 160 new suicide interventionists to make warm calls instead. They have cataloged more than 4,000 life-affirming calls and are working to extend this programming beyond the pandemic.

"We know 19 million people, or six percent of the U.S. population, have thoughts of suicide. That's a huge issue, and yet anyone can do a suicide intervention, anyone can get these skills," says Shannonhouse.

Her team is halfway through a project designed to code and analyze recorded files, some which include suicide interventions, to identify the types of volunteer behaviors that occurred and which ones made a difference. She notes that their model can also be applied in other crisis situations, such as to prevent self-injury among students.

In honor of this work, Shannonhouse was recently awarded the Garry R. Walz Trailblazer Award from the American Counseling Association, which recognizes individuals whose vision, passion and leadership skills help advance the counseling profession. She says even though her work is centered on suicide first aid, it's chiefly about fostering hope.

"People want connection; they're craving it. So much so that the people who are the loneliest and are hurting the most will put suicide on hold at just the hope of getting connection," she says.

Pey-Shan Wen is an assistant professor of occupational therapy in the Byrdine F. Lewis College of Nursing and Health Professions. When the pandemic hit, she began studying how the pandemic influenced people's participation in normal activities (like going to church, shopping and attending school or work), and how that in turn impacted their mental health. In her study, which is still ongoing, she surveyed more than 300 adults ages 18 to 89 to compare the participation levels of different age groups and explore factors that could contribute to depression and anxiety.

Wen found that after the initial pandemic lockdown, most young respondents did not change their participation levels, while participation decreased for the majority of older respondents. Yet even though older adults reported the lowest participation during the pandemic, they also reported lower levels of stress and depression compared to middle-aged and young adults. The subjects who fared the best were those aged 45 or older who were married or living with someone.

"That may be because compared to single parents, they had less to juggle," says Wen. "Yet even among those without children who were over 45, marriage or companionship was protective against depression or anxiety."

The survey also found that women tended to be more depressed than their male counterparts, and younger people reported higher levels of stress and depression compared to the oldest group. In addition, Wen found higher levels of depression among young people living at home with family members, like parents or grandparents. She plans to present the research this summer at the World Federation of Occupational Therapists Congress meeting in Paris, and the team is continuing to dig into the data to look at how gender and education level shape respondents' mental health.

"Already our findings have important implications for the rehab profession," says Wen, "because when you are treating younger participants, it will be important to be mindful of whether they might also need mental health treatment."

The Consequences for Children

For kids and adolescents, the pandemic, and the disruptions it has produced, have driven a mental health crisis. Suicide attempts have risen among young people under 18, according to the Centers for Disease Control and Prevention, and a study of pediatric insurance claims has revealed a spike in mental health issues in children. In November 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children's Hospital Association went so far as to declare a national state of emergency for child and adolescent mental health.

Psychologist and associate professor Erin Tully is director of the FEELINGS Lab, which seeks to learn why some children become depressed and anxious while others seem protected even in the face of considerable risks. During the pandemic, Tully knew that children may have become especially attuned to their parents' emotions as they spent more time together at home, and that parents play a critical role in shaping their children's response to stress. She wanted to learn how children's feelings of self-blame about causing their parents to worry during the pandemic could affect kids' own mental health. The resulting research survey, which was presented at the 2021 meeting of the Society for Research in Child Development, found a strong correlation between children's self-blame for their parents' worry about illness and children's mental health problems. But it also found a link between children's feelings of responsibility for their parents' happiness and protective factors, like hopefulness.

"Children spending a lot of time with their families may have produced some negatives in terms of increased parenting stress, but also provided an opportunity for parents to spend more quality time with their children, which may have benefits for kids," says Tully.

The magnitude of the pandemic's negative and positive effects on children's mental health may continue to unfold as time goes on, she predicts.

"Especially for younger kids, we may see the effects a bit later. A child who is now three or four experienced important developmental shifts with respect to learning to respond to others during the pandemic," she says. "Children likely missed a lot of opportunities for interacting with peers. It will be interesting to see what the research reveals as these kids develop."

Still, the researchers agree that it's important to consider our amazing human capacity for hope and resilience as we come to terms with the great toll of this destabilizing event.

"These are very serious concerns. But the distress caused by the pandemic is not necessarily a life sentence," says Ashby. "For many, it will abate. You're probably familiar with the saying, 'It's okay to not be okay.' I would add that you probably will be okay again soon."

Filed Under: Tagged With: Georgia State Research Magazine, COVID-19, Research magazine, Research-Experts Health & Wellness, Science & Technology

# data[].attributes.attachment_link.description
The pandemic has produced a mental health crisis with effects that may reverberate for years - even decades - to come. At Georgia State, researchers are working to gain insights into the emotional toll and identify how people are finding hope even as the threats persist.

# data[].attributes.body
The research determined the association between COVID traumatic stress and PTSD is stronger among individuals who have cumulative trauma. In other words, if you’ve already dealt with loss and trauma in the past, there’s an increased risk that the pandemic was harder for you.

# data[].attributes.attachment_link.readable_text
Written by Noelle Toumey Reetz

The COVID-19 pandemic has been the most traumatic collective event of our lifetime. And after two excruciating years and more than a million deaths in the U.S. alone, it is still unclear when, or if, the pandemic will end. That uncertainty is one of many stressors, along with worries about health, family, work and finances, that have taken a significant toll on mental health.

In a recent survey, the American Psychological Association found that nearly two-thirds of respondents said their lives have been permanently changed by the pandemic. The report also showed that a large proportion of the country has been living in "sustained survival mode" with significant consequences for mental health. The World Health Organization says the pandemic has sparked a 25 percent increase in anxiety and depression worldwide.

"I think the mental health issue is percolating, just like a virus incubating," says Laura Shannonhouse, associate professor of counseling and psychological services in the College of Education & Human Development. "We're seeing little pieces now, but it's like an iceberg. Most of it is still below the surface."

Shannonhouse is one of several researchers at Georgia State University who have been studying how individuals are dealing with the stress of the pandemic. While they agree the mental health crisis is just beginning, they're also seeing signs of hope and resilience.

For most people who have survived the pandemic, this time will leave a mark. There may always be a line of delineation - before and after. However, says Jeff Ashby, co-director of Georgia State's Ken Matheny Center for the Study of Stress, Trauma and Resilience, we still haven't reached the "after" - and for many, the anxiety of the unknown can be harmful in and of itself.

"When we first began our research, we thought, 'We must hurry, because of course, this will be over soon...' and two years later we still don't know what's going to happen," says Ashby, a professor in the Department of Counseling and Psychological Services. "I think that's the hard part. It's still a moving target."

Ashby and his colleagues, including center co-director Ken Rice, recently surveyed 745 people to examine whether the strain of the pandemic could lead to stress disorders, and if so, which groups are most at risk. The results, which were published in published the Journal of Community Psychology, showed the pandemic is an independent source of traumatic stress and, for a subset of people, that stress can predict the development of post-traumatic stress disorder (PTSD).

The research determined the association between COVID traumatic stress and PTSD is stronger among individuals who have cumulative trauma. In other words, if you've already dealt with loss and trauma in the past, there's an increased risk that the pandemic was harder for you.

"People have what's known as a 'trauma load,' and part of what you're doing is reactivating traumatic experiences from previous situations," says Ashby. "So that would suggest that in higher-risk populations, the experience of fresh trauma would be more acute."

Ashby and Rice also looked at how the pandemic affected individuals' mental health based on race/ethnicity. They were surprised by what they found.

"We know that certain minority groups were hit harder, both in terms of infections and deaths," Ashby says. "We expected to see similar impacts on mental health, yet we did not find it."

Instead, researchers found an association between increased PTSD symptoms and high levels of cumulative trauma for all groups, except for Asian Americans. For this group, the relationship between COVID, traumatic stress and PTSD symptoms did not appear to be affected by previous trauma.

Why were the results conspicuously different for Asian Americans? The researchers note that previous surveys have found Asian Americans are less likely to report psychological distress compared to other groups. Additionally, the research was conducted amid a backdrop of increased discrimination and violence against Asian Americans during the pandemic. Asian Americans who have a greater history of previous trauma may be more affected by being scapegoated as the source of COVID‐19 in the U.S., and as a result, COVID‐19 specific trauma (for example, a personal fear of infection) may have a comparatively diminished effect on PTSD symptoms.

Ashby says the results emphasize the importance of examining subgroups for potential exacerbating - or protective - effects of COVID stress on mental health outcomes. He adds that future research should examine other factors, such as how socioeconomic status has affected how people coped during the pandemic.

"We know that resources help buffer traumatic or stressful experiences," he says. "There are those of us for whom the largest imposition was a kind of social isolation, while others were riding public transit to get to work that was mandatory for their livelihood."

Because the pandemic has affected millions - even billions - of people around the world, Ashby predicts a skyrocketing need for mental health services in the coming years.

"Given the widespread effect of COVID-19 related stress and its far-reaching impact, there will likely be an increased need for mental health services that exceeds our current capacity to meet those needs," says Ashby."

For Front-Line Workers, Emotional Exhaustion

It's been approximately 750 days since life ground to a standstill in the U.S. Those who had the option to work from home left their offices in March 2020 - with their plants healthy and their coffee cups half-full - and many didn't return for months or more. Millions of others lost jobs or kept commuting as essential workers.

Perhaps the greatest psychological burden, however, has been borne by those in what's known as the "helping professions." Caregivers, including social workers and healthcare professionals, can be traumatized by their work through what's known as "secondary traumatic stress." The pandemic has dramatically increased the trauma exposure for these individuals, putting them under extraordinary levels of strain.

Brian Bride is a Distinguished University Professor and former director of the School of Social Work in the Andrew Young School of Policy Studies. In 1995, he developed the internationally recognized Secondary Traumatic Stress Scale, designed to measure these reactions of helping professionals who have experienced traumatic stress through their work.

"Medical personnel have had to respond to a large number of patients, many of whom have died. At the same time, they've been worried about getting sick themselves," he says. "Many of them have also had to deal with moral distress about rationing PPE or even rationing care. Even if they haven't had to make those hard choices, they've likely had to worry about it. That causes people to second-guess who they are morally in the work that they're doing."

In addition to secondary traumatic stress, says Bride, there's the issue of shared trauma, which occurs when a professional has directly experienced the same collective trauma as their patients. There were many reports of shared trauma after the attacks of September 11, 2001, and it can trigger nightmares, depression, hyperarousal and even PTSD in extreme cases.

"When the notion of PTSD first emerged, it was thought to occur only if the person directly witnessed the trauma. But our research shows that's not necessarily the case," says Bride. "This notion of shared trauma primarily comes out of social work and psychology and therapy, but it certainly could apply to healthcare professionals and even teachers.

"We know that the professions at the highest are those in which people work with children who've been traumatized, such as child welfare professionals or social workers," he adds.

Bride is currently working to update the scale to include pandemics as a traumatic event and clarify the impacts to those who have been on the front lines.

"One of the things that's important to me is setting both individual and organizational guidelines," says Bride. "For a long time with secondary traumatic stress, the onus has really been on the individual to take care of themselves. We need to recognize that secondary trauma occurs within work settings and organizations have a responsibility to create a culture where the staff and professionals can admit to that and seek help."

Grieving the Loss of Connection

For many people, the pandemic resulted in an epidemic of loneliness and social isolation. The impacts have been particularly pronounced for older adults, who were already more likely to experience isolation as well as other issues like financial insecurity. In Laura Shannonhouse's lab (the H.O.P.E. lab, or Helping Others Provide Empathy) researchers are developing programs to help people, especially older adults, who are struggling with depression and thoughts of suicide.

During the pandemic, their work with older home-bound adults has led to the expansion of a suicide-intervention project. Known as "BE WITH" (Belonging and Empathy, With Intentional Targeted Helping), the project is designed to reduce social isolation, loneliness and elevated suicide risk in racially diverse, older adults - the demographic hardest hit by COVID-19. In 2018, Shannonhouse's team began training home delivery meal providers (think Meals on Wheels) in suicide prevention techniques.

Mary Chase Mize, postdoctoral research associate and assistant director of the H.O.P.E. lab, recently published a study from her dissertation (under the direction of Shannonhouse) in the journal of Educational Gerontology, which found that trained volunteers repeatedly used their new suicide intervention skills. That response is important since these volunteers are often the only social connections for the older adults they serve. When the pandemic made in-person meal delivery a challenge, Shannonhouse and her team used $1.3 million from the Department Health and Human Services to train 160 new suicide interventionists to make warm calls instead. They have cataloged more than 4,000 life-affirming calls and are working to extend this programming beyond the pandemic.

"We know 19 million people, or six percent of the U.S. population, have thoughts of suicide. That's a huge issue, and yet anyone can do a suicide intervention, anyone can get these skills," says Shannonhouse.

Her team is halfway through a project designed to code and analyze recorded files, some which include suicide interventions, to identify the types of volunteer behaviors that occurred and which ones made a difference. She notes that their model can also be applied in other crisis situations, such as to prevent self-injury among students.

In honor of this work, Shannonhouse was recently awarded the Garry R. Walz Trailblazer Award from the American Counseling Association, which recognizes individuals whose vision, passion and leadership skills help advance the counseling profession. She says even though her work is centered on suicide first aid, it's chiefly about fostering hope.

"People want connection; they're craving it. So much so that the people who are the loneliest and are hurting the most will put suicide on hold at just the hope of getting connection," she says.

Pey-Shan Wen is an assistant professor of occupational therapy in the Byrdine F. Lewis College of Nursing and Health Professions. When the pandemic hit, she began studying how the pandemic influenced people's participation in normal activities (like going to church, shopping and attending school or work), and how that in turn impacted their mental health. In her study, which is still ongoing, she surveyed more than 300 adults ages 18 to 89 to compare the participation levels of different age groups and explore factors that could contribute to depression and anxiety.

Wen found that after the initial pandemic lockdown, most young respondents did not change their participation levels, while participation decreased for the majority of older respondents. Yet even though older adults reported the lowest participation during the pandemic, they also reported lower levels of stress and depression compared to middle-aged and young adults. The subjects who fared the best were those aged 45 or older who were married or living with someone.

"That may be because compared to single parents, they had less to juggle," says Wen. "Yet even among those without children who were over 45, marriage or companionship was protective against depression or anxiety."

The survey also found that women tended to be more depressed than their male counterparts, and younger people reported higher levels of stress and depression compared to the oldest group. In addition, Wen found higher levels of depression among young people living at home with family members, like parents or grandparents. She plans to present the research this summer at the World Federation of Occupational Therapists Congress meeting in Paris, and the team is continuing to dig into the data to look at how gender and education level shape respondents' mental health.

"Already our findings have important implications for the rehab profession," says Wen, "because when you are treating younger participants, it will be important to be mindful of whether they might also need mental health treatment."

The Consequences for Children

For kids and adolescents, the pandemic, and the disruptions it has produced, have driven a mental health crisis. Suicide attempts have risen among young people under 18, according to the Centers for Disease Control and Prevention, and a study of pediatric insurance claims has revealed a spike in mental health issues in children. In November 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children's Hospital Association went so far as to declare a national state of emergency for child and adolescent mental health.

Psychologist and associate professor Erin Tully is director of the FEELINGS Lab, which seeks to learn why some children become depressed and anxious while others seem protected even in the face of considerable risks. During the pandemic, Tully knew that children may have become especially attuned to their parents' emotions as they spent more time together at home, and that parents play a critical role in shaping their children's response to stress. She wanted to learn how children's feelings of self-blame about causing their parents to worry during the pandemic could affect kids' own mental health. The resulting research survey, which was presented at the 2021 meeting of the Society for Research in Child Development, found a strong correlation between children's self-blame for their parents' worry about illness and children's mental health problems. But it also found a link between children's feelings of responsibility for their parents' happiness and protective factors, like hopefulness.

"Children spending a lot of time with their families may have produced some negatives in terms of increased parenting stress, but also provided an opportunity for parents to spend more quality time with their children, which may have benefits for kids," says Tully.

The magnitude of the pandemic's negative and positive effects on children's mental health may continue to unfold as time goes on, she predicts.

"Especially for younger kids, we may see the effects a bit later. A child who is now three or four experienced important developmental shifts with respect to learning to respond to others during the pandemic," she says. "Children likely missed a lot of opportunities for interacting with peers. It will be interesting to see what the research reveals as these kids develop."

Still, the researchers agree that it's important to consider our amazing human capacity for hope and resilience as we come to terms with the great toll of this destabilizing event.

"These are very serious concerns. But the distress caused by the pandemic is not necessarily a life sentence," says Ashby. "For many, it will abate. You're probably familiar with the saying, 'It's okay to not be okay.' I would add that you probably will be okay again soon."

Filed Under: Tagged With: Georgia State Research Magazine, COVID-19, Research magazine, Research-Experts Health & Wellness, Science & Technology

# data[].attributes.attachment_link.description
The pandemic has produced a mental health crisis with effects that may reverberate for years - even decades - to come. At Georgia State, researchers are working to gain insights into the emotional toll and identify how people are finding hope even as the threats persist.

# data[].attributes.body
While at first it may seem silly, the trauma and stress of Covid-19 is very real, especially in places where the response has continued to be strict and unending. In countries like China where lockdown can happen at any time without warning (meaning complete lock and cage if not separation from the home and family) the very real stress and trauma of isolation, lack of resources, and anxiety induced sudden and indefinite lockdown become even more serious.

# data[].attributes.attachment_link.readable_text
Looking after our mental health

As countries introduce measures to restrict movement as part of efforts to reduce the number of people infected with COVID-19, more and more of us are making huge changes to our daily routines.

The new realities of working from home, temporary unemployment, home-schooling of children, and lack of physical contact with other family members, friends and colleagues take time to get used to. Adapting to lifestyle changes such as these, and managing the fear of contracting the virus and worry about people close to us who are particularly vulnerable, are challenging for all of us. They can be particularly difficult for people with mental health conditions.

Fortunately, there are lots of things that we can do to look after our own mental health and to help others who may need some extra support and care.

Here are tips and advice that we hope you will find useful.

Keep informed. Listen to advice and recommendations from your national and local authorities. Follow trusted news channels, such as local and national TV and radio, and keep up-to-date with the latest news from @WHO on social media.

Have a routine. Keep up with daily routines as far as possible, or make new ones.

Get up and go to bed at similar times every day.

Keep up with personal hygiene.

Eat healthy meals at regular times.

Exercise regularly.

Allocate time for working and time for resting.

Make time for doing things you enjoy.

Minimize newsfeeds. Try to reduce how much you watch, read or listen to news that makes you feel anxious or distressed. Seek the latest information at specific times of the day, once or twice a day if needed.

Social contact is important. If your movements are restricted, keep in regular contact with people close to you by telephone and online channels.

Alcohol and drug use. Limit the amount of alcohol you drink or don't drink alcohol at all. Don't start drinking alcohol if you have not drunk alcohol before. Avoid using alcohol and drugs as a way of dealing with fear, anxiety, boredom and social isolation.
There is no evidence of any protective effect of drinking alcohol for viral or other infections. In fact, the opposite is true as the harmful use of alcohol is associated with increased risk of infections and worse treatment outcomes.

And be aware that alcohol anddrug use may prevent you from taking sufficient precautions to protect yourself again infection, such as compliance with hand hygiene.

Screen time. Be aware of how much time you spend in front of a screen every day. Make sure that you take regular breaks from on-screen activities.

Video games. While video games can be a way to relax, it can be tempting to spend much more time on them than usual when at home for long periods. Be sure to keep the right balance with off-line activities in your daily routine.

Social media. Use your social media accounts to promote positive and hopeful stories. Correct misinformation wherever you see it.

Help others. If you are able to, offer support to people in your community who may need it, such as helping them with food shopping.

Support health workers. Take opportunities online or through your community to thank your country's health-care workers and all those working to respond to COVID-19.

Don't discriminate
Fear is a normal reaction in situations of uncertainty. But sometimes fear is expressed in ways which are hurtful to other people. Remember:

Be kind. Don't discriminate against people because of your fears of the spread of COVID-19.

Don't discriminate against people who you think may have coronavirus.

Don't discriminate against health workers. Health workers deserve our respect and gratitude.

COVID-19 has affected people from many countries. Don't attribute it to any specific group.

If you are a parent

In times of stress, it is common for children to seek more of your attention.

What you can do:

Maintain familiar routines as much as possible, or create new ones, especially if you must stay at home.

Discuss the new coronavirus with your children in an honest way, using age-appropriate language.

Support your children with at-home learning and make sure time is set aside for play.

Help children find positive ways to express feelings such as fear and sadness. Sometimes engaging in a creative activity, such as playing or drawing, can help you with this process.

Help children stay in contact with friends and family members through telephone and online channels.

Make sure that your children have time away from screens every day and spend time doing off-line activities together. Do something creative: draw a picture, write a poem, build something. Bake a cake. Sing or dance, or play in your garden, if you have one.

Try and ensure that your children do not spend significantly more time than usual on video games.

If you are an older adult

Keep in regular contact with loved ones, for example by telephone, e-mail, social media or video conference.

Keep regular routines and schedules as much as possible for eating, sleeping, and activities you enjoy.

Learn simple daily physical exercises to do at home when in quarantine so you can maintain mobility.

Find out how to get practical help if needed, like calling a taxi, having food delivered or asking for medical care. Make sure you have a one-month supply or longer of your regular medicines. Ask family members, friends or neighbours for support, if needed.

If you have a mental health condition

If you are being treated for a mental health condition, make sure that you continue to take medication as prescribed, and that you have a way of re-stocking your medication. If you are see a mental health specialist, find out how to continue with that support during the outbreak.

Keep in touch with people who care for you and know who you can contact for support if your mental health declines.

If you are being treated for an alcohol or drug use disorder, be aware that the COVID-19 outbreak may lead to increased feelings of fear, anxiety and isolation that can increase the risk of relapse, substance use, disengagement from treatment or non-compliance with treatment regimens. Make sure that you continue to take medication as prescribed, particularly if you receive treatment with opioid medicines such as methadone or buprenorphine, and that you have a way of obtaining a regular supply of your medication. If you are receiving support through a psychologist or support group, find out how to continue that support during the outbreak.

If you are being treated for gaming or gambling disorder, continue with your treatment if possible. Check with your therapist or health-care provider about the best way of continuing with therapy during confinement at home.

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Looking after our mental health As countries introduce measures to restrict movement as part of efforts to reduce the number of people infected with COVID-19, more and more of us are making huge changes to our daily routines.

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PTSD 101 – TIPS FOR TEACHERS, SCHOOL STAFF, & COUNSELORS

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PTSD 101 – TIPS FOR TEACHERS, SCHOOL STAFF, & COUNSELORS

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Step 1: Listen
Teachers or staff provide students with an opportunity to share their experiences. Adults should avoid making judgements.

Step 2: Protect
Teachers should help re-establish student's feelings of physical and emotional safety.

Step 4: Connect
Teachers should help students reestablish their normal social relationships and stay connected to others in order to experience social support

Step 4: Model Calm and Optimistic Behavior
Maintain level emotions
Take constructive actions to assure student safety
Express positive thoughts for the future
Help students cope with day to day challenges

Step 5: Teach
"To support and facilitate the coping process, it is important to help students understand the range of normal stress reactions. School counselors, nurses, psychologists or social workers can take on this task. They can help students become familiar with the range of normal reactions that can occur immediately after a traumatic event or disaster and teach relevant coping and problem-solving skills."

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How common is PTSD in Children and teens?

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How common is PTSD in Children and teens?

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"Studies show that about 15% to 43% of girls and 14% to 43% of boys go through at least one trauma. Of those children and teens who have had a trauma, 3% to 15% of girls and 1% to 6% of boys develop PTSD. Rates of PTSD are higher for certain types of trauma survivors."

Risk factors for PTSD

How severe the trauma is

How the parents react to the trauma

How close or far away the child is from the trauma

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How Common is PTSD in Children and Teens?

Studies show that about 15% to 43% of girls and 14% to 43% of boys go through at least one trauma. Of those children and teens who have had a trauma, 3% to 15% of girls and 1% to 6% of boys develop PTSD. Rates of PTSD are higher for certain types of trauma survivors.

What Events Cause PTSD in Children?

Children and teens could have PTSD if they have lived through an event that could have caused them or someone else to be killed or badly hurt. Such events include sexual or physical abuse or other violent crimes. Disasters such as floods, school shootings, car crashes, or fires might also cause PTSD. Other events that can cause PTSD are war, a friend's suicide, or seeing violence in the area they live.

Child protection services in the U.S. get around three million reports each year. This involves 5.5 million children. Of the reported cases, there is proof of abuse in about 30%. From these cases, we have an idea how often different types of abuse occur:

65% neglect

18% physical abuse

10% sexual abuse

7% psychological (mental) abuse

Also, three to ten million children witness family violence each year. Around 40% to 60% of those cases involve child physical abuse. (Note: It is thought that two-thirds of child abuse cases are not reported.)

What Are the Risk Factors for PTSD?

Three factors have been shown to raise the chances that children will get PTSD. These factors are:

How severe the trauma is

How the parents react to the trauma

How close or far away the child is from the trauma

Children and teens that go through the most severe traumas tend to have the highest levels of PTSD symptoms. The PTSD symptoms may be less severe if the child has more family support and if the parents are less upset by the trauma. Lastly, children and teens who are farther away from the event report less distress.

Other factors can also affect PTSD. Events that involve people hurting other people, such as rape and assault, are more likely to result in PTSD than other types of traumas. Also, the more traumas a child goes through, the higher the risk of getting PTSD. Girls are more likely than boys to get PTSD. It is not clear whether a child's ethnic group may affect PTSD. Some research shows that minorities have higher levels of PTSD symptoms. Other research suggests this may be because minorities may go through more traumas.

Another question is whether a child's age at the time of the trauma has an effect on PTSD. Researchers think it may not be that the effects of trauma differ according to the child's age. Rather, it may be that PTSD looks different in children of different ages.

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Studies show that about 15% to 43% of girls and 14% to 43% of boys go through at least one trauma. Of those children and teens who have had a trauma, 3% to 15% of girls and 1% to 6% of boys develop PTSD. Rates of PTSD are higher for certain types of trauma survivors.

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Tips for school-age children who exposed to domestic violence

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Tips for school-age children who exposed to domestic violence

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Here is some info from the government of Victoria, Australia:

Follow the Four Critical Actions when responding to an incident, disclosure or suspicion of child abuse:

Action 1: Respond to an emergency

Actions you must take if a child has just been abused, or is at immediate risk of harm.

Action 2: Report to authorities

You must report all incidents, suspicions and disclosures of child abuse. Failure to report physical and sexual child abuse may amount to a criminal offence.

Action 3: Contact parents or carers

When to notify parents and carers if it is suspected their child is a victim of abuse, and which relevant authorities need to be notified.

Action 4: Provide ongoing support

Actions that schools must take, where deemed appropriate, to support students who are impacted by child abuse.

You must act

As a school staff member, you must act as soon as you witness an incident or form a reasonable belief that a child has been or is at risk of being abused, including exposure to family violence.

You must act if you form a suspicion or reasonable belief that abuse has occurred or is at risk of occurring, even if you are unsure and have not directly observed child abuse (for example, if the victim or another person tells you about the abuse).

You should make sufficient enquiries to form a reasonable belief and to determine a child’s immediate needs. However, once a reasonable belief has been formed, it is not your role to investigate. This is the role of the Department of Families, Fairness and Housing (DFFH) Child Protection or Victoria Police.

Child abuse includes any instance of physical or sexual abuse (including grooming), emotional or psychological harm, serious or significant neglect and family violence involving a child.

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Talk to students about what happened in a way they can understand. Keep it simple and appropriate for each child’s age. (Learn more about common reactions by age range)

Provide students with opportunities to talk about what they went through or what they think about it. Encourage them to share concerns and ask questions.

Children react, in part, to what they see from the adults around them. When teachers deal with a disaster calmly and confidently, they can provide the best support for their students.

Children who were directly exposed to a disaster can become upset again; behavior changes resulting from the event may be long lasting and can worsen or return if these children see or hear reminders of what happened. Be aware that that this could happen and know what resources are available at your school for children and families, should you need to report concerns to the appropriate people at your school.

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Centers for Disease Control and Prevention

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Teachers have an important role to play in helping children both prepare for and recover after a public health emergency.
Public health emergencies and disasters affect millions of children worldwide each year. These emergencies and disasters include natural events (such as severe weather, earthquakes, fires, floods, and tsunamis) and man-made events (such as acts of terrorism). An emergency or disaster can be destructive to a child's physical environment, as well as affect their mental health. As a teacher, you are committed to keeping schools safe and supporting children and their families. If your students experience an emergency or disaster, there are steps you can take to help your students cope and recover.

How can I help my students cope and continue to support their recovery from a disaster?

Talk to students about what happened in a way they can understand. Keep it simple and appropriate for each child's age. (Learn more about common reactions by age range)

Provide students with opportunities to talk about what they went through or what they think about it. Encourage them to share concerns and ask questions.

Children react, in part, to what they see from the adults around them. When teachers deal with a disaster calmly and confidently, they can provide the best support for their students.

Children who were directly exposed to a disaster can become upset again; behavior changes resulting from the event may be long lasting and can worsen or return if these children see or hear reminders of what happened. Be aware that that this could happen and know what resources are available at your school for children and families, should you need to report concerns to the appropriate people at your school.

It is difficult to predict how some children will respond to disasters and traumatic events. Because parents, teachers, and other adults see children in different situations, it is important for them to work together to share information about how each child is coping after a traumatic event.

After a disaster, teachers may also be struggling with severe posttraumatic symptoms and personal losses. This might prevent them from getting involved in any kind of post-disaster intervention with their students. In this case, it is important that teachers take care of themselves first and seek help from a professional. CALL or TEXT Substance Abuse and Mental Health Services Administration's (SAMHSA's) Disaster Distress Hotline: 1-800-985-5990; People with deafness or hearing loss can use their preferred relay service to call 1-800-985-5990.

What are some resources that I can use in my classroom to help children cope?

Additional Resources
For more information about how to help children cope after a disaster: For resources about being prepared for an emergency in your classroom:

Page last reviewed:

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centers for disease control and prevention

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Returning to School After an Emergency or Disaster | CDC

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Teachers have an important role to play in helping children both prepare for and recover after a public health emergency.

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Being frequently absent from school

Inappropriate clothing (e.g. shoes too small, clothes are ill-fitted or unsuitable for the weather conditions)

Clothes are consistently dirty or smelly

Being hungry

Hands are cold, red and swollen

Unkempt appearance and poor hygiene; hair quality is poor or is messy, teeth are dirty, skin dirty

Lacking necessary medical or dental care, including immunisations or glasses

Missing medical appointments

Health problems, including anaemia, body issues, poor muscle tone or prominent joints, regular illness of infections, repeated accidental injuries (often cause by lack of supervision), skin issues (e.g. sores, rashes, flea bites, scabies, ringworm), thin or swollen tummy, weight or growth issues, untreated injuries

Developmental problems, including poor language or social skills

Frequent and untreated nappy rash in infants

Being constantly underweight or considerably losing weight

The parent or carer has failed to keep the child protected from physical harm or danger

Begging or stealing things like money or food

Living in an unsuitable environment (e.g. no heating, messy)

Being left home alone for long periods of time

Taking on the role of a carer for other family members

Changes in behaviour, such as becoming clingy, aggressive, withdrawn, depressed or anxious, displaying obsessive behaviour

Changes in eating habits

Using drugs or alcohol

Self-harm or attempts at suicide

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Beyond the immediate trauma and harm caused by natural disaster exposure, children also may suffer longer-term physical, psychological, and educational deficits. Children who have experienced a disaster are much more likely to have:

Physical health problems - Young children who experienced a natural disaster within the past month showed a 9 to 18% increase in acute illnesses (e.g., diarrhea, fever, respiratory illness) and heightened somatic symptoms (e.g., headaches, nausea, and lethargy).

Mental health symptoms - As many as 50% of children report post-traumatic stress symptoms after experiencing a disaster, such as recurring thoughts about the disaster, hypervigilance, or difficulty sleeping or concentrating. Children exposed to natural disasters also often experience depression symptoms, such as feeling sad or losing interest in activities, and symptoms of anxiety, such as fears and worries about safety. Chronic mental health symptoms have been observed among children even four years after a disaster event.

Lower school attendance and trouble learning - Children’s learning is often disrupted by natural disasters because many schools close and children’s attendance is interrupted. Trauma exposure can alter brain anatomy and functioning, inhibiting learning and memory processes. For example, children exposed to disasters report trouble concentrating (a common symptom of post-traumatic stress), which can interfere with learning at school.

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Understanding the Impacts of Natural Disasters on Children | Society for Research in Child Development SRCD

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Natural disasters present a significant threat to children's health and well-being. Actions are needed now to mitigate this threat. Greater investments in infrastructure, remediation efforts, and more effective, evidence-based responses will help promote healthy development among children exposed to natural disasters.

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Natural disasters such as floods, bushfires and storms can be particularly traumatic for many children as they typically affect entire communities, involve significant destruction, loss of property and even loss of life. Further, the effects of such natural disasters are often long-term, creating adverse financial, social and emotional living circumstances for many families for extended periods of time.

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Treatment options for children with PTSD

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Treatment options for children with PTSD

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Children, Violence, and Trauma—Treatments That Work

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An explanation of "Trauma-informed schools"

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An explanation of "Trauma-informed schools"

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What Teachers Should Know

Posttraumatic stress disorder (PTSD) is a mental health condition brought on by the overwhelming stress of a trauma. Someone can develop PTSD after a traumatic or terrifying event in which physical or emotional harm was experienced, threatened, or witnessed.

Traumas that can lead to PTSD include:

violent assaults

physical, emotional, or sexual abuse

fires or natural disasters

automobile accidents

senseless acts of violence, such as school or neighborhood shootings

arrests, overdoses, evictions

serious physical injuries or life-threatening medical illnesses

witnessing another person go through these kinds of traumatic events

PTSD also can happen after the unexpected or violent death of a family member or close friend, or following serious harm or threat of death or injury to a loved one. Survivor guilt (feeling guilty after surviving an event in which someone died) also might lead to PTSD.

People of any age can have PTSD. PTSD-like symptoms can begin right after a trauma, or not until weeks or months after it. In some cases, PTSD develops long after a trauma has happened.

Students with PTSD may:

seem irritable, anxious, cranky, or angry

seem detached or depressed

have problems paying attention or concentrating

have trouble eating or sleeping

may startle easily or be overly sensitive to noises, sights, or smells that remind them of the traumatic event

avoid people, places, things, or activities that remind them of the event

Students with PTSD might not recognize the link between their symptoms and the trauma.

Not every student who has been through trauma will develop PTSD. Most won't. But they may show trauma-related (PTSD-like) symptoms for a short while, and need support. When symptoms are present in the first days and weeks after a trauma, a student may be diagnosed with acute stress disorder. With help and support, most students who have been through trauma do find ways to cope and recover.

Symptoms must last longer than a month to be diagnosed as PTSD. PTSD usually needs help from a mental health professional with experience in treating it. Therapy helps students with PTSD recover.

Students with PTSD or acute stress disorder might need to:

take medicine to treat anxiety

miss class time to talk with school counselors or mental health specialists

have extra time to do class work

What Teachers Can Do

Teachers or school counselors can offer:

referrals to qualified therapists, if needed

accommodations tailored to the student's needs

listening, support, encouragement, and understanding

extra help with schoolwork

Trauma makes it harder to focus and learn. Avoid overloading students with homework or things that can add to their stress. Allow students to practice relaxation skills at school when appropriate. Encourage them to talk with a school counselor when symptoms arise.

It takes time for students with PTSD to begin to feel better. In therapy, they learn coping skills to manage their anxiety. They learn to safely face things they avoided because of trauma. Gradually, as they learn to process the trauma they went through, their symptoms decrease.

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Posttraumatic Stress Disorder Factsheet (for Schools)

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Posttraumatic stress disorder (PTSD) is a mental health condition brought on by the overwhelming stress of a trauma. Someone can develop PTSD after a traumatic or terrifying event in which physical or emotional harm was experienced, threatened, or witnessed.

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1. Arrange an evaluation with a medical professional(preferably one skilled in talking to children).
2. Once a child is diagnosed, a student should be made comfortable and safe by their friends, family and school.
3.Minimize the chances of another traumatic event occuring

A child may need to attend psychotherapy in order to help them deal with the stressful event and reduce their fear and worry. A child may also be given medicine to reduce symptoms.

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Centers for Disease Control and Prevention

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All children may experience very stressful events that affect how they think and feel. Most of the time, children recover quickly and well. However, sometimes children who experience severe stress, such as from an injury, from the death or threatened death of a close family member or friend, or from violence, will be affected long-term. The child could experience this trauma directly or could witness it happening to someone else. When children develop long term symptoms (longer than one month) from such stress, which are upsetting or interfere with their relationships and activities, they may be diagnosed with post-traumatic stress disorder (PTSD).

Examples of PTSD symptoms include

Reliving the event over and over in thought or in play

Nightmares and sleep problems

Becoming very upset when something causes memories of the event

Lack of positive emotions

Intense ongoing fear or sadness

Irritability and angry outbursts

Constantly looking for possible threats, being easily startled

Acting helpless, hopeless or withdrawn

Denying that the event happened or feeling numb

Avoiding places or people associated with the event

Because children who have experienced traumatic stress may seem restless, fidgety, or have trouble paying attention and staying organized, the symptoms of traumatic stress can be confused with symptoms of attention-deficit/hyperactivity disorder (ADHD). Read a guide for clinicians on deciding if it is ADHD or child traumatic stress.

Examples of events that could cause PTSD include

Physical, sexual, or emotional maltreatment

Being a victim or witness to violence or crime

Serious illness or death of a close family member or friend

Natural or manmade disasters

Severe car accidents

Learn more about PTSD
Treatment for PTSD

Learn about the guidelines for diagnosing and treating PTSD

The first step to treatment is to talk with a healthcare provider to arrange an evaluation. For a PTSD diagnosis, a specific event must have triggered the symptoms. Because the event was distressing, children may not want to talk about the event, so a health provider who is highly skilled in talking with children and families may be needed. Once the diagnosis is made, the first step is to make the child feel safe by getting support from parents, friends, and school, and by minimizing the chance of another traumatic event to the extent possible. Psychotherapy in which the child can speak, draw, play, or write about the stressful event can be done with the child, the family, or a group. Behavior therapy, specifically cognitive-behavioral therapy, helps children learn to change thoughts and feelings by first changing behavior in order to reduce the fear or worry. Medication may also be used to decrease symptoms.

Get help finding treatment

Here are tools to find a healthcare provider familiar with treatment options:

Prevention of PTSD

It is not known exactly why some children develop PTSD after experiencing stressful and traumatic events, and others do not. Many factors may play a role, including biology and temperament. But preventing risks for trauma, like maltreatment, violence, or injuries, or lessening the impact of unavoidable disasters on children, can help protect a child from PTSD.

Learn about public health approaches to prevent these risks:

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Post-traumatic Stress Disorder in Children | CDC

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Children may experience very stressful events that affect how they think and feel. Learn about Post-traumatic Stress Disorder in children.

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"Before a PTSD diagnosis can be considered, an individual must have these “cluster” symptoms for over one month: recreating the traumatic event over and over; avoiding triggering people, places, or activities; and hyper-vigilance for danger. These symptoms should cause significant problems in everyday life."

It may take months or decades for the symptoms of PTSD to show. Furthermore, every person is different and so their symptoms are likely to differ as are their reactions to trauma.

After experiencing these symptoms, a person should visit a doctor in order to be diagnosed.

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A medical professional will take a complete medical and personal history and take into account many different criteria when identifying a posttraumatic stress disorder diagnosis. They will look for the following signs:

The traumatic event that an individual witnessed, experienced, or learned about, and the person's response to that trauma (in adults: horror, fear, helplessness; in children: behavior problems.)

How the trauma is being re-experienced in an individual's daily life: nightmares, intrusive thoughts, reliving the event, flashbacks, distress when triggered, in children: reenacting the trauma through play.

How the individual has coped with the traumatic memories: avoidance, detaching from relationships, blocked memories, etc.

Heightened arousal, including insomnia, anger, hyper-vigilance, easily startled.

How long an individual has suffered from these symptoms

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Diagnosing PTSD or Posttraumatic Stress Disorder Diagnosis

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A medical professional will take a complete medical and personal history and take into account many different criteria when identifying a posttraumatic stress disorder diagnosis.

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"Currently, for a diagnosis of PTSD, the student must experience a traumatic event in which he/she perceives a threat to either self or others, and must experience distress (horror, fear, helplessness)” (Kataoka et al. 2012)."

PTSD can be caused by
Bullying
Robbery (or other crime)
Natural disasters
Animal attacks
Medical trauma

Three main clusters of symptoms
Reexperiencing trauma
Numbing and avoidance of the trauma(or things the person previously enjoyed)
Hyperarousal (e.g irritability and difficulty sleeping)

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Susanne Babbel, Ph.D., M.F.T., is a psychologist specializing in trauma and depression.

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Understand how PTSD can affect students. Find support by knowing the resources.

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10 Things about Childhood Trauma Every Teacher Needs to Know

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10 Things about Childhood Trauma Every Teacher Needs to Know

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Learning can be more difficult for students who have experienced trauma, and trauma-informed teaching can help such students. Trauma symptoms go largely unrecognized because they mimic frustration, misbehavior, difficulty concentrating or following directions, or working in a group. Students are often misdiagnosed with anxiety, behavioral disorders, or attention disorders rather than understood to have trauma that drives those symptoms and reactions (2021).

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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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China Development Brief details extent of child sexual abuse

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China Development Brief details extent of child sexual abuse

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––70% of victims are under the age of 14.
––80% of assaults are committed by acquaintances.
––Nearly 50% of cases involve repeat offenders, particularly in rural areas.

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"In the long term, people who have been sexually abused are more likely to suffer with depression, anxiety, eating disorders and post-traumatic stress disorder (PTSD). They're also more likely to self-harm, become involved in criminal behaviour, misuse drugs and alcohol, and to die by suicide as young adults" (What are the effects, 2019).

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1 in 20 children in the UK will experience child sexual abuse. Here are the signs to be aware of and what to do if you suspect a child is being sexually abused.

What is child sexual abuse?

Child sexual abuse covers a range of illegal sexual activities, including:

possessing images of child sexual abuse

forcing a child to strip or masturbate

engaging in any kind of sexual activity in front of a child, including watching pornography

taking, downloading, viewing or distributing sexual images of children

encouraging a child to perform sexual acts in front of a webcam

not taking measures to protect a child from witnessing sexual activity or images

inappropriate sexual touching of a child, whether clothed or unclothed

penetrative sex

Both boys and girls can be victims of sexual abuse, but girls are more likely to be abused.

What are the signs that a child is being sexually abused?

Children often do not talk about sexual abuse because they think it is their fault or they have been convinced by their abuser that it is normal or a "special secret".

Children may also be bribed or threatened by their abuser, or told they will not be believed.

A child who is being sexually abused may care for their abuser and worry about getting them into trouble.

Here are some of the signs you may notice:

Changes in behaviour - a child may start being aggressive, withdrawn, clingy, have difficulties sleeping, have regular nightmares or start wetting the bed.

Avoiding the abuser - the child may dislike or seem afraid of a particular person and try to avoid spending time alone with them.

Sexually inappropriate behaviour - children who have been abused may behave in sexually inappropriate ways or use sexually explicit language.

Physical problems - the child may develop health problems, including soreness in the genital and anal areas or sexually transmitted infections, or they may become pregnant.

Problems at school - an abused child may have difficulty concentrating and learning, and their grades may start to drop.

Giving clues - children may also drop hints and clues that the abuse is happening without revealing it outright.

How do I report child sexual abuse?

It's best not to delay if you suspect a child is being sexually abused.

You can talk directly to the police or your local children's social services and this can be anonymous. You can also get advice or report your concerns anonymously to the NSPCC by phoning its free helpline on 0808 800 5000. Or you can report sexual abuse to the NSPCC via email or online.

If you are a health professional and suspect a child you're caring for is experiencing abuse or is at risk of abuse, you can seek advice from the "named nurse" or "named doctor" in your hospital or care setting.

The NSPCC has more information and advice about child sexual abuse.

If you're concerned about your own thoughts or behaviour towards children, you can phone Stop It Now! in confidence on 0808 1000 900 or contact Stop It Now! securely by email.

If you're a child and someone is sexually abusing you, you can get help and advice from ChildLine - call 0800 1111, calls are free and confidential.

Who commits child sexual abuse?

People who sexually abuse children can be adult, adolescent or a child themselves.

Most abusers are male, but females sometimes abuse children too.

Around a third of child sexual abuse is carried out by other, usually older, children or young people.

9 out of 10 children know or are related to their abuser. Child sexual abuse often happens either in the child's home or the abuser's home.

Sexual abuse can sometimes happen outside the home, for example, at leisure and sports clubs.

You may notice that an abuser gives a child special treatment, offering them gifts, treats and outings. They may seek out opportunities to be alone with the child.

Which children are at risk of child sexual abuse?

Children are more vulnerable to sexual abuse if they've already experienced abuse of some kind. Children who live in families where there is child neglect, for example, are more at risk.

Disabled children are more likely to be victims of sexual abuse, especially if they have difficulties with speech or language.

Children can also be at risk when using the internet. Social media, chat rooms and web forums are all used by child sex abusers to groom potential victims.
Find out more about how to talk to your child about their feelings

What are the effects of child sexual abuse?

Sexual abuse can cause serious physical and emotional harm to children both in the short term and the long term.

In the short term, children may suffer health issues, such as sexually transmitted infections, physical injuries and unwanted pregnancies.

In the long term, people who have been sexually abused are more likely to suffer with depression, anxiety, eating disorders and post-traumatic stress disorder (PTSD). They're also more likely to self-harm, become involved in criminal behaviour, misuse drugs and alcohol, and to die by suicide as young adults.

Child sexual exploitation

Children who've been sexually abused are also at risk of sexual exploitation, in which children are sometimes passed around a network of abusers for sexual purposes.
Find out more about how to spot child sexual exploitation

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How to identify signs that a child is being sexually abused, why it's important to act if you suspect a child is being abused and how to report your concerns.

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Over the years, a handful of my high school students have revealed that they had been sexually abused when they were younger, and others certainly have been traumatized by incidents such as groping, flashing, or other forms of sexual harassment. This padlet is about possible signs to look for, and responses teachers can take.

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Recognizing extreme emotional reactions or moods

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Recognizing extreme emotional reactions or moods

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Observation:

Emotional responses in students experiencing domestic violence vary by age. Preschool-aged children could cry uncontrollably, startle easily, or have trouble with nightmares. Elementary-aged children can be physically aggressive with other children or become overly-attached to an educator. Teenagers usually rebel, participate in risky behavior, and have a hard time with authority.

When you notice a student is displaying any of the above behaviors, battling heightened anxiety and depression, or disproportionately responding to specific situations, ensure that you’re taking it upon yourself to find out more about why these things are happening.

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Paying attention to physical signs of abuse

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Paying attention to physical signs of abuse

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If you see consistent physical signs of abuse, initiate a conversation with your student to identify the source of those signs. Gauge how willing they are to share the story of what happened and if it makes sense. If physical abuse is confirmed or you’re highly suspicious this is the case, you’re required to report it to authorities.

As a teacher, you’re classified as a mandatory reporter because of your frequent involvement with children. Mandatory reporters are required to report the facts and circumstances that led them to suspect that a child has been abused or neglected. Be sure you’re following your institution’s internal guidelines for suspected child abuse and your state’s guidelines for reporting with the help of the next level of leadership.

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Strategies for behavioral signs of domestic abuse

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Strategies for behavioral signs of domestic abuse

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Keeping a close eye on school performance.
Schedule some one-on-one time with them to explore potential challenges.
Ask questions surrounding their home life and see if you can identify any potentially abusive situations. Reach out to colleagues such as the school counselor for some questions you can ask that will glean more information. Also, be sure to ask them how you can further support them.

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In keeping with our Professional Development theme, I'd like to share the following.

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Abstract

Situations of war and military conflict have been linked to the development of Post-Traumatic Stress Disorder (PTSD). To our knowledge, there are no studies that have examined, within the same conflict and the same culture, exposure to different traumatic events or traumatic events of different intensity. The aim of this study was to evaluate the symptoms of PTSD among Palestinian schoolchildren in two different areas of Hebron. A total of 381 schoolchildren from different parts of Hebron participated in the study. To evaluate the symptoms of PTSD, the children were asked to complete the Child Post Traumatic Stress Reaction Index. To evaluate the traumatic events experienced, they completed the Gaza Traumatic Event Checklist. Results indicate that 77.4% of the children living in Hebron show symptoms of moderate-to-severe PTSD, and 20.5% of them meet the DSM-IV diagnostic criteria for chronic PTSD. There were no significant differences in total symptoms between the two areas of Hebron, but there were differences within the specific types of symptoms. It is clear that the traumatic events of the war lead to the development of post-traumatic stress in children and that psychological intervention is necessary.

Literature suggests that exposure to the traumatic events of war is related to high levels of PTSD among the victims of military conflicts. However, there are important differences between the stressors and prevalence of PTSD in each conflict due to cultural differences, type of conflict, and PTSD instruments administrated. Therefore, this study will compare Palestinian children from the same city, subjugated to the same conflict, and raised in the same culture; however the sample draws from two different types of stressful contexts.

In this regard, studies conducted in war zones indicate that exposure to the traumatic event leads to the development of PTSD in childhood and adulthood (Attari, Dashty, & Mahmoodi, 2006; Elbert et al., 2009; Carlson & Rosser-Hogan, 1994; Nader, Pynoos, Fairbanks, Al-Ajeel, & Al-Asfour, 1993; Qouta, Punamaki, & El Sarraj, 2003; Thabet & Vostanis, 2000). Different studies have been performed to determine the incidence of PTSD resulting from exposure to traumatic events. Studies from different conflicts have produced results that range from a high incidence to low incidence of children with PTSD who had been exposed to war and conflicts. A study carried out on Kuwaiti children who had lived through the Gulf war found that 70% of children showed symptoms of PTSD ranging from moderate to severe (Nader et al., 1993). A later study involving a sample of Iranian children who had witnessed a public hanging next to their school in Isfahan found that 75% reported a tendency for moderate-to-severe symptoms of PTSD (Attari et al., 2006).

In one study conducted in Palestine, 41% of the children of Gaza revealed a tendency to show moderate-to-severe PTSD symptoms (Thabet & Vostanis, 2000). A different study showed that the incidence of post-traumatic stress in 121 Palestinian children exposed to bombings was twice as high as results found in the previous study; 87% exhibited moderate to severe PTSD (Qouta et al., 2003). All of these studies found a high incidence of PTSD in children exposed to situations of war and conflict. However, other studies have found lower incidence rates. For example, a study conducted in Lebanon found that only 20% of Lebanese children who had been exposed to bombings and terrorist attacks met the diagnostic criteria for PTSD (Saigh, 1991). In addition, a study conducted in Sri Lanka following two decades of war and unrest found that 25% of the country's children met the diagnostic criteria for PTSD.

With regard to gender differences in the development of PTSD after living through situations of conflict or war, most studies find that girls show more symptoms of the disorder than boys (Durakovic-Belko, Kulenovic, & Dapic, 2003; Macksoud & Aber, 1996; Miller El-Masri, Allodi, & Qouta, 1999). However, Khamis (2005) conducted a study in Palestine and found that boys displayed more PTSD symptoms than girls. Contrary to both, a study performed in Palestine by Elbedour, Onwuegbuzie, Ghannamc, Whitcome, and Abu Hein (2007) found no significant differences between the two sexes.

These studies, however, did not give consideration to important variables that could explain their differing findings. For example, some studies evaluated PTSD after the conflict had ended (Awadah, Vance, El-Beblawi, & Pumariega, 1998), or they compared very different conflicts (De Jong et al., 2001). For these reasons, we decided to study PTSD in children who are subject to stress situations of the same conflict and in the same cultural and socio-demographic context.

The conflict in Palestine is still underway. For over six decades, the Palestinian population has lived through different types of traumatic events (e.g., killings, arrests, and destruction of homes and agricultural land). The city of Hebron is recognized in Palestine for its atypical circumstances: it is the largest city in the West Bank (a Palestinian territory) and a group of Israeli settlers currently live in the historic center of the city (Palestinian Central Bureau of Statistics, 2009). After the signing of the 1997 Hebron Agreement by the Israeli government and the Palestinian National Authority, the city was divided into two areas. The area called H1 (80% of the city) is under Palestinian control and is inhabited by over 115,000 Palestinians. The area called H2 has a population of over 35,000 Palestinians and about 500 Israeli settlers. This part of the city, according to the Hebron Agreement, is to be under Israeli military control, although its administration is the responsibility of the Palestinian authority. During the Second Intifada (2000) the Israeli army took control of H1 for several months (B'tselem, 2003). At the time of this study, H1 was under Palestinian control, although the Israeli army made incursions into the area.

Children, as part of the Palestinian population of Hebron, are an especially vulnerable group. They experience a variety of violent attacks in their daily lives. It is therefore necessary that studies be conducted to illustrate the traumas that boys and girls living in the city may experience, as well as the post-traumatic symptoms they may display as a result. Thus far, few studies have focused on PTSD among the Palestinian children of this region. One of the most important studies focused on Palestinian schoolchildren of the West Bank and found that 34.1% of them suffered from PTSD. Most of these children were older, employed male refugees (Khamis, 2005). Other studies revealed high rates of PTSD in primary school-aged children who had experienced the war firsthand. Of the sample, 39% showed symptoms ranging from moderate to severe (Thabet & Vostanis, 1999).

To our knowledge, no previous studies have considered differences in type of stressor or symptoms in different Palestinian territories. The aim of this study is to evaluate the impact of different traumatic events and the psychological consequences of their aftermath for children living in conflict zones, such as Hebron. It is important to note that this study allows variables such as culture and type of conflict to be controlled, as it compares two situations of exposure to traumatic events (H1 and H2) in the same city and with the same population. Also, as secondary objectives, (1) the prevalence of the PTSD will be studied, (2) if differences between girls and boys in the type of stressors and symptoms exist, and, finally, (3) if a positive relation between the number of stressors and symptoms exist. We hypothesized that type of stressor and symptoms will be different for H1 and H2, that the prevalence of PTSD will be similar to previously reported, that girls will experience more PTSD symptoms and, finally, that the more traumatic events children experience, the more symptoms children suffer.

Methods

Target Population

According to the Ministry of Education in the city of Hebron, there are 4,241 13-year-olds attending 59 schools. In H1, under Palestinian authority, there are 34 schools (16 for boys and 18 for girls) which have 2,732 (1,463 boys and 1,269 girls) 7th grade students. In H1, under Israeli control (with the presence of some Israeli settlers in addition to the Palestinian population), there are 25 schools (12 for boys and 13 for girls) which have 1,509 (671 boys and 838 girls) 7th grade students.

Participants

A total of 381 thirteen-year-old students (190 boys and 191 girls) participated in this study. This sample was divided into two groups, depending on where the students live in the city. The first group has 232 students (121 boys and 111 girls) who attend four schools located in H1. The second group has 149 students (69 boys and 80 girls) who attend five schools located in H2. In this study, the two different groups are equal in father's employment status (10% of the children's fathers (n=15) in H2 area were unemployed, while in H1 area 7% of children's fathers (n=16) were unemployed). This data was collected in a questionnaire that included questions about socioeconomic status.

After the research project was planned, we requested permission from the Palestinian Ministry of Education to conduct the study. The Ministry provided information regarding the number of schools and their geographical distribution. The next step was to select the sample randomly, using the SPSS program. Then we went to the schools where the random sample of students attended to obtain the directors' permission to begin assessing the participants.

In most cases, the tests were administered early in the morning and in classrooms with teachers who facilitated the activity. All of the subjects participated in the study on a voluntary basis. Classroom presentations about objectives and process of this study were given to children by researcher. Then they invite children to participate in this study. However, children were chosen randomly using the SPSS program.

Variables and statistical analyses

Results

As a result of not completing the two main tests of this study, data for 8 children were missing in the Gaza traumatic events, while data for other 14 children were missing in the CPTSD-IR. In our study the mean number of traumatic events experienced by children in Hebron is 6.03. The intensity of these traumatic events occurred varies: 9.4% of the children have seen their homes destroyed and 94.8% of the children have seen images of dead and injured people on television.

A descriptive analysis was conducted to study how many participants showed symptoms of PTSD, in accordance with the cut-off points proposed by the author. Of the total, 1.8% (n=7) showed no symptoms, 16.5 % (n=63) displayed mild PTSD, 47% (n= 179) displayed moderate PTSD, 30.4% (n= 116) displayed severe PTSD and 0.5% (n= 2) suffered from very severe PTSD. The mean total of symptoms shown was 34.18 (DT= 11.24). According to the three scales of the CPTSD-RI, 20.5% of the sample meets the DSM-IV diagnostic criteria for PTSD (APA, 1994).

Gender

First, we studied the differences between boys and girls in the amount and type of traumatic events. We found statistically significant differences between boys and girls [t (1,360) = 5.286; p < 0.000], with the boys' total (M= 7.10; SD=4.22) being higher than the girls' total of traumatic events (M=. 4.96; SD: 3.57).

Also, we found differences in the type of traumatic event experienced by children using a cross-tab analysis (gender x items). The results indicate that there are seven items of traumatic events that boys have suffered most frequently. The most important ones are: seeing a friend get hit by a bullet (item 7) [χ 2 = 27.0; p < 0.000]; being hit (item 8) [χ 2 = 22.3; p < 0.000]; seeing friend be arrested by soldiers (item 13) [χ 2 = 14.3; p < 0.000]; or seeing soldiers burst into your home at night (item 12) [χ 2 = 13; p < 0.000] (see Table 1).

With regard to the symptoms of PTSD, no significant differences in the total were found, but it is more frequent for the girls to relive the images repeatedly (almost always > 42.9%) [χ 2 = 13.8; p < 0.001], and to be upset by reminders (almost always > 52.4%) [χ 2 =12.0; p < 0.002].

Place (H1 vs. H2)

Considering the place variable, no significant differences were found between the two areas in the total of traumatic events. There were differences, however, within the type of traumatic event experienced. The results show that it is more frequent for the people of H1 to find about the death of a friend at the hands of the Israeli army (item 3) and to witness the attack of nearby houses with bombs, artillery, or heavy weaponry (item 16) than for the people of H2. On the other hand, it is more frequent for the people of H2 to have to wait for many hours at checkpoints (item 4), to see friends being hit (item 8) or arrested (item 13), to be hit themselves (item 10), and to see soldiers break into their homes during the day (item 11) or at night (item 12; see Table 2).

While there were no significant differences between the two areas in the total of symptoms, there were significant results within the types of symptoms. Children of H2 showed more frequency in being easily startled (almost always > 36.9) [χ 2 = 17.4; p < 0.000], and to have a higher likelihood of memory problems (almost always > 40.9) [χ 2 = 11.19; p < 0.004]. On the other hand, the people of H1 demonstrated a stronger sense of foreshadowing (almost always > 29.8) [χ 2 = 9.32; p < 0.009].

Relationship between traumatic events and symptoms

It was found that the number of traumatic events is related to the number of PTSD symptoms displayed. The results demonstrated that people who have experienced more traumatic events display more post-traumatic stress symptoms (F (3,357) = 11.53; p < 0.000). (See figure 1). Back analyses showed that there were statistically significant differences in the post-traumatic stress symptoms displayed by boys of quartile 1, 2, and 3, and between quartile 2 and 4. This data appeared with a clear linear tendency (F (1,357) = 34.41; p < 0.000).

Discussion

The aim of this study was to compare two groups of Palestinian children, subjected to the same situation of decades-long conflict and who belong to the same cultural and socioeconomic context. Another goal was to compare these two groups based on different stressor contexts, areas H1 and H2 of Hebron. The findings reveal that the mean number of traumatic events experienced by the children of Hebron is 6.03. In addition, 77.4% of the children living in the city of Hebron who participated in this study showed symptoms of moderate or severe PTSD, and 20.5% of them meet the DSM-IV diagnostic criteria for PTSD (APA, 1994). Results also showed different types of PTSD stressors and symptoms depending on the area of Hebron where the children were living, and a positive direct relationship between the number of stressors and symptoms.

More specifically, no significant differences were found in the mean number of traumatic events experienced by the people living in the two areas (H1 and H2). However, the type of traumatic events experienced did, in fact, differ. We found that events in H1 were more related to dangerous acts and death while events in H2 were more related to daily life. This may be due to the fact that the Second Intifada involved young Palestinians living in H1 and Israeli soldiers at the border of H2. Moreover, more infrastructures were bombed by Israeli troops in H1 during this Intifada. It is also important to note that the people of H2 must often wait for many hours at checkpoints because they are so plentiful in this area: two of the four schools included in the study (the Al-Ibrahimeyah Primary School for boys, and the Córdoba Primary School for girls) have electronic checkpoints on both sides of the building, and the other two (the Al-Hajereyeh Primary School for girls, and the Jawhar Primary School for boys) have regular checkpoints. Also, differences in the type of symptoms between H1 and H2 were found. Children under Israeli control experience more concrete and physiological symptoms such as being easily startled or memory problems. This could be explained because H2 children are exposed to more chronic stressors (such as crossing checkpoints several times a day). Chronic events have been shown to cause memory problems due to neural injury in the hippocampus (Astur et al., 2006)

Examining the development of PTSD by area, we found that H1 girls display more post-traumatic stress than H1 boys. In H2, however, girls did not experience more PTSD than boys. The results of H2 concur with studies carried out previously (Elbedour et al., 2007; Saigh, 1991; Thabet & Vostanis, 1999). This could be explained by the typology of the traumatic events, since we find that when the events are chronic and frequent, no differences are detected between boys and girls. Specifically, in the case of H2, the stressors occur frequently (almost daily) and there are no discernible gender differences. In H1, on the other hand, the traumatic events are not as frequent and gender differences are more noticeable. These results could perhaps also be explained by the fact that at the time of the study, no Israeli military incursions into H1 had occurred, although the military remained present in H2.

It is likely that one of the factors contributing to differences in percentages in the development of post-traumatic stress is the duration of the stressor, since in stressful situations that continue over a long period of time, as in Palestine, studies tend to show high percentages of post-traumatic stress (Buydens-Branchey, Noumair, & Branchey, 1990; Kang, Natelson, Mahan, Lee, & Murphy, 2003). However, in situations in which the stressful events are shorter-lived, the percentages fall. Another factor that must be taken into account is when the study took place, whether during a war or afterwards (Allwood, Bell-Dolan, & Husain, 2002)

Studies that have looked into stressful events in conflict-ridden populations have continuously found varying percentages for the development of post-traumatic stress. In our case, the percentage is 77%, one of the highest percentages. It coincides with the study by Thabet, Abed, and Vostanis (2004) involving Palestinian refugee children, and the study by Attari and colleagues (2006) involving Iranian children who had witnessed a public hanging. Other studies, however, have found lower percentages (Elbedour et al., 2007; Khamis, 2005; Saigh, 1991; Nader et al., 1993; Smith, Perrin, Yule, Hacam, & Stuvland, 2002; Thabet & Vostanis, 2000). It is likely that one of the factors contributing to differences in percentages in the development of post-traumatic stress is the duration of the stressor. Studies tend to show high percentages of post-traumatic stress in stressful situations that continue over a long period of time, as in Palestine. However, in situations where the stressful events are short-lived, the percentages tend to fall. Another factor that must be taken into account is when the study took place (e.g. during or after the war).

Among the most interesting results of this study is the finding that boys suffer more traumatic events than girls, which is similar to the findings of many previous studies (Husain et al., 1998; Khamis, 2005; Kuterovac, Dyregrov, & Stuvland, 1994; Thabet & Vostanis, 1999; Thabet, Abu Tawahina, El Sarraj, & Vostanis, 2008). However, it contrasts with another study that found that boys and girls in Palestine experience the same number of traumatic events (Miller et al., 1999). In our study, girls do not experience traumatic events in greater proportion than boys, and they are equal to boys only in the situation of "seeing images of dead and injured people on TV". This difference between boys and girls in the number of experienced traumatic events could be a result of the socio-cultural factors. For example, girls in Hebron normally stay and play at home more than boys, who spend a portion of their time outside their home. Other reasons could be political; soldiers that are responsible for these events may focus their aggression towards boys more than girls. In fact, Children at this specific stage (13 years old) are entering the adolescence, and boys may be more likely than girls to participate in risky behavior, putting them at a higher risk of experiencing traumatic events.

In general terms, while the boys of our study experienced more traumatic events, it was the girls who exhibited more frequently to relive the images and to be upset by reminders. These findings coincide with other studies (Breslau, Davis, Andreski, & Peterson, 1991; Kessler, 2000; Macksoud & Aber, 1996; Qouta et al., 2003; Smith et al., 2002). Some studies, however, do not agree with this statement, finding instead that men display more symptoms of PTSD in conflict situations (Khamis, 2005). Gender differences in developing PTSD symptoms could be due to how males and females percept and interpret traumatic events. Girls may internalize the same traumatic event more deeply than boys, so their fear and reactions to such events might occur at a higher rate (Greenberg & Schneider, 1995; Holbrook, Hoyt, Stein, & Sieber, 2002). Another reason could be the difference in cognitive processes between boys and girls (Simmons & Granvold, 2005).

Our study has certain limitations. The uniform 13-year-old age of the sample limits the generalizability of our research. Given our results, it would perhaps have been interesting to take into consideration other psychological consequences of living through traumatic events, such as depression and behavior problems. Along these lines, it would have been interesting to examine the cognitive consequences and academic impact of PTSD symptoms. This topic should be addressed in future studies.

In short, it is clear that war and political violence has an effect on children at the psychological level. Our study has shown that boys and girls in H1 and H2 differ from each other in the type of stressors they experience and that both show a high rate of post-traumatic stress symptoms.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, DSM-IV, (4th ed., pp. 427-429). Washington DC, American Psychiatric Association.

Attari, A., Dashty, S., & Mahmoodi, M. (2006). Post-traumatic stress disorder in children witnessing a public hanging in the Islamic Republic of Iran. Eastern Mediterranean Health Journal, 12, 72-80.

B'tselem, the Israeli Information Centre for Human Rights in the Occupied Territories. (Status Report August 2003). Hebron, Area H-2: Settlements Cause Mass Departure of Palestinians. Jerusalem.

Frederick, C. J. (1985). Selected foci in the spectrum of post-traumatic stress disorders. In J. Laube & S. A. Murphy (Eds.), Perspectives on disaster recovery (pp. 110-131). East Norwalk, CT: Appleton-Century-Crofts.

Husain, S. A., Nair, J., Holcomb, W., Reid, J. C., Vargas, V., & Nair, S. S. (1998). Stress reactions of children and adolescents in war and siege conditions. American Journal of Psychiatry, 155, 1718-1719.

Kessler, R. C. (2000). Posttraumatic stress disorder: The burden to the individual and to society. Journal of Clinical Psychiatry, 61(5), 4-14.

Palestinian Central Bureau of Statistics. (2009). Population, Housing, and Establishment Census 2007: Main Indicators by Locality Type. Palestine: Ramallah.

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Symptoms of PTSD among Children Living in War Zones in Same Cultural Context and Different Situations

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Situations of war and military conflict have been linked to the development of Post-Traumatic Stress Disorder (PTSD). To our knowledge, there are no studies that have examined, within the same conflict and the same culture, exposure to different traumatic events or traumatic events of different intensity.

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Background and introduction

"Children are both our reason to eliminate the worst aspects of armed conflict and our best hope of succeeding in that charge."-Dame Graça Machel, human rights activist, former first lady of Mozambique and South Africa (1996).

The "United Nations Convention on the Rights of the Child" (UNCRC), ratified by almost all nations of the world, states the fundamental rights of children and especially the right to life, health, and development, bans discrimination, and calls for mandates the protection of children's interests [ 1, 2]. In a later resolution, the UN Security Council, adopted the UNCRC with an Optional Protocol to the UNCRC about the "Rights of the Child on the Involvement of Children in Armed Conflicts", and determined that violence against children in armed conflicts poses a threat to durable peace, security, and development [ 3, 4]. The infliction of war and military aggression upon children can thus be considered a violation of children's basic human rights. From a developmental and psychopathological perspective, it can result in persistent impairment in health, well-being, and developmental potential.

Exposure to war, living in conflict zones, flight, and forced migration may create or increase the risk for broad sequalae of direct and indirect risks for physical and mental health, more so for children and their caregivers, and deprives children from developmental opportunities and basic resources. Effects on children's health result from actual violence against themselves and their families and from inadequate health care, malnutrition, infectious diseases, and distress caused to their families [ 5, 6, 7, 8]. Regarding maternal and child health, studies show a trend towards worse pregnancy-related outcomes, such as a higher rate of preterm births among refugee mothers, higher rates of stillbirths, children with low-birth weight, and increases and prenatal and postnatal mortality [ 5, 9, 10]. The global burden of mental health consequences of war and migration are enormous with high prevalence rates of depression and post-traumatic stress disorder (PTSD) in war affected countries [ 11, 12, 13]. Flight and forced migration are further risk factors for children's mental health, even more so for unaccompanied minors separated from their parents [ 10]. Next to consequences for physical and mental health, armed conflicts inflict high broad costs as basic social services deteriorate, existing communal divisions enlarge, local economies collapse, and schooling is disrupted, and educational opportunities decrease [ 14, 15]. Taken together, the risks inflicted by war, living in conflict zones, flight, and forced migration upon children are many fold and might have lifelong impacts on physical, mental, social well-being, and development.

Within UNICEF's recent report on "The State of the World's Children 2021", the current COVID-pandemic is considered the tip of the mental health iceberg-which has been ignored for too long [ 16]. The mental health burden being inflicted on Europe's children by the recent war in Ukraine is the part of the iceberg with the potential to sink the ship. Besides the children directly hit by the war, all other children across Europe might also be indirectly affected as the media carry the war into every family home. This adds another layer of insecurity and anxiety on children who are already burdened from the COVID-pandemic that has been accompanied by higher levels of anxiety and a reduced quality of life [ 17, 18].

Thus, the current crisis calls for political action and collective engagement to prevent and reduce the harm to children while supporting all those involved in their care. The aim of this scoping policy editorial is help guide mental health support for young victims of war through an overview of the direct and indirect burden of war on child mental health and of multilevel, need-oriented, and trauma-informed approaches to regaining and sustaining outer and inner security after exposure to the trauma of war.

Methods

Due to the complexity and urgency of the research objective and the aim to highlight timely guidance for caregivers and first responders considering the recent war-outbreak in Ukraine, we searched for studies that assessed and addressed the impact of war and flight on children's mental health in major conflict and war zones. A selective review of the literature was performed using multiple search strategies. A literature search of relevant publications through the 1st of March 2022 was conducted using the PubMed and Google Scholar databases. The following key words were used in varying combinations: 'children', 'war', 'flight', 'trauma', 'trauma-informed', and 'mental health'. For this review, childhood was defined as being under the age of 18 according to the UNCRC [ 2] and "children" refers to this age range if not otherwise explicitly specified. Reference lists from relevant reviews were examined for possible additional studies. Studies were assessed qualitatively.

Impact of war and forced displacement on children's mental health

Immediate psychological distress and stress reactions in children

"It does not take much imagination to think of the experiences children may have had in fleeing from their homes under threat, witnessing fighting and destruction, seeing violent acts directed at their loved ones, leaving their friends and possessions behind, marching or being transported in crowded vehicles, spending months in transit camps, and eventually finding temporary respite in a country at peace while the authorities decide whether the family can be granted permission to remain legally and indefinitely."-Yule [ 8, p. 696].

Children exposed to war and flight show a broad range of possible distress and stress reactions e.g. specific fears, dependent behavior, prolonged crying, lack of interest in the environment, and psychosomatic symptoms, as well as aggressive behaviors [ 19, 20, 21, 22, 23]. Children's play can also be affected, for instance with the emergence of morbid themes, restriction in fantasy play, and social withdrawal [ 23, 24, 25]. It is important to appreciate that it is not merely the 'objective' nature of the specific experience that is important, but how each child subjectively perceives, appraises, and interprets that experience [ 8]. Thus, there can be huge differences in children's stress reactions to what may seem from the outside to be similar experiences [ 8]. Also, it is important to consider that children respond differently to the stress of violent exposures depending on their developmental level, and that it is necessary to understand such stress reactions within the context of their social-emotional and cognitive development [ 26]. Taken together, the stress reactions of children comprise a broad array of potential emotional and behavioral reactions to different distressing experiences that depend not only on the objective nature of the experience but on the subjective perception by the child.

Post-traumatic stress, anxiety, and depressive disorders

Next to immediate stress reactions in children, studies show a higher prevalence of certain mental disorders among children during and post-conflict as compared with the general population [ 27]. Most studies have focused mainly on PTSD as the primary outcome, whereas others also assessed depression and anxiety disorders [ 27]. In general, multiple meta-analyses document a high burden of mental disorders and psychopathology on conflict-affected, internally displaced, and refugee populations [ 28, 29, 30, 31, 32, 33]. A meta-analysis of eight studies of child and adolescent refugees and asylum seekers reported a 22.7% prevalence of PTSD, 13.8% of depression, and 15.8% of anxiety disorders [ 29, 30]. These data raise concern, as studies estimate the absolute number of war-exposed children between 1989 and 2015 to be around 400 million [ 11, 12].

The high psychological burden on refugees underscores the need for continuous mental health care over and beyond the initial period of resettlement [ 29, 30]. Some studies show the prevalence for mental disorders in the first years of resettlement, only clearly to be increased for PTSD, however 5 years after resettlement the rates for depressive and anxiety disorders are also found to be increased [ 34]. A meta-analysis on risk factors for PTSD in children shows pre-trauma factors and objective measures associated with the event itself to only generate small to medium effects, whereas medium to large effect sizes were found for many factors associated-with subjective experience of the event and post-trauma variables, such as low social support, perceived life threat, social withdrawal, poor family functioning, and thought suppression [ 35]. These findings indicate that peri-traumatic factors and post-event factors have an important role in the development of PTSD in children [ 35]. Taken together, these reports point to the urgent need for support during and after war-related exposures, as well as for long-term mental health care for young people and families fleeing war and seeking refuge.

Broad sequalae: separation from parents, loss of outer and inner safety

During war children often become separated from one or both parents as seen in recent pictures of children fleeing with their mothers at the Ukrainian border and leaving their fathers behind. Research on attachment has shown the damaging consequences of deprivation and separation from parents in a variety of contexts and circumstances [ 36, 37]. Overall, research has found that parent-child separation has consistently negative effects on children's social-emotional development, well-being, and mental health [ 38]. Another major problem during flight from danger is the loss of safe places where to live with consequent high levels of prolonged stress. Within social safety theory, cognitive schemas of social safety are thought to develop during childhood and adolescence in relation to a child's appraisal of themself, the social world, and the projected future [ 39]. Such perceptions are shaped by the actual situations that the child encounters (for instance, exposure abuse and violence) and by the meaning and narratives that people in general, and their parents in particular, attribute to such events [ 39]. Thus, children exposed to war are ripped of their safety at multiple levels, from the individual feeling of being safe during separation and loss of family life, to being away from friends, their homes, cities, and at times even their countries.

Taken together the impact of war on children is tremendous, ranging from immediate stress-responses and increased risk for specific mental disorders-PTSD, depression, and anxiety-to the broad consequences of separation from parents and the loss of safety. Thus, children's experiences during and directly after war are in marked contrast with need and right to develop in a safe, secure, and predictable environment [ 8].

Multilevel, needs-oriented, and trauma-informed approaches aiming to reduce the impact of war on children's mental health

Interventions supporting war-affected children should be comprehensive, sustainable, and devoid of harm [ 40]. Support should be multilevel, resilience-oriented, multidisciplinary, and tailored to the needs of subgroups and individuals [ 40, 41]. The multilevel intervention pyramid for mental health and psychosocial support in emergencies proposed by the Inter-Agency Standing Committee (IASC) [ 42] includes four levels of intervention: provision of basic services and security, community and family support, focused non-specialized support, and specialized supports (see Fig. 1, right). In such a multilevel understanding of intervention, all layers of the pyramid are important and should ideally be implemented concurrently according to the need of the individual. Such a multilevel understanding of intervention is closely linked to a socioecological and multisystemic understanding of resilience, where resilience is linked to an individual's ability to harness resources, but also to the resources being provided to be harnessed [ 43, 44]. Thus, multisystemic and multilevel approaches are required.

Experiences that children in war and those searching for refuge face are in utter contrast to what can be consider to be the basic needs of every child: basic physiological and safety needs, including the need for shelter and food; the need for safety and security; the need for continuity of care by a loved one; and the need for good schooling and opportunities to develop and thrive [ 8, 46]. Basic human needs were described by Maslow [ 45] in his hierarchy of basic needs visualized as a pyramid (see Fig. 1, left) and discussed in the context of child development [ 46, 47]. These and other basic needs represents also recognized rights, including the right to be protected during war and the right to receive help if affected by war to regain health and dignity (Article 38 & 39, [ 1, 2]). Whether living in a warzone, being on the flight, or staying in a new country that offers refuge, children's needs should be properly assessed and accordingly met, from the more basic physiological needs and moving up along the pyramid.

Multilevel help efforts and interventions should be trauma-informed and, as such, "grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control, self-efficacy and empowerment" [ 48, p. 82]. Trauma informed care is built around three important pillars: safety, connections, and managing emotions [ 49]. It, thus, tries to translate trauma research into practice to inform and improve care efforts, practically address trauma, and promote resilience thus improving outcomes [ 50].

Taken together, mental health and psychosocial support and intervention for war affected children should be multilevel, targeted towards the child's needs, from basic physical needs upwards, and should be trauma-informed and thus strength- and resilience-oriented.

Multilevel interventions for children exposed to war and forced migration

(a) Provide immediate aid and intervention

Immediate humanitarian aid needs to be targeted towards addressing children's basic physiological and outer safety needs and must ensure children's access to basic services and safety from direct harm (lower levels of needs and intervention pyramids in Fig. 1). These basic services include the provision of food, shelter, water, and basic health care, established in participatory, safe, and socially appropriate ways [ 42]. Examining interventions for war affected children underlines "the importance of providing children with safety and a sense of security, as well as addressing basic needs and establishing trust with the child" [ 51]. Such non-specific interventions have the goal to reduce stress, to provide safe areas and shelters; to restore or reactivate protective factors [ 52]. Building up and adding to basic services, psychological first aid should aim at reducing initial post-trauma distress and supporting adaptive functioning [ 53]. Psychological first aid consists of eight core actions that address: contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connection with social supports, information on coping support, and linkage with collaborative services [ 53, 54]. From a trauma-informed perspective, it is important to build back some normal in the abnormal. This might include to rebuild daily structures and routines, to provide safe places for children to play and interact with others, to provide relationship offers to children and thus the opportunity to talk about emotions, to be aware of oneself and others, and to have the opportunity to regulate one's own emotions with a caregiver.

(b) Assess and screen for mental health burden and needs

When guiding help efforts, it is important to acknowledge that some children might 'only' require a sense of safety and support by family and close others, whereas others might be in need of more complex and focused psychosocial support that addresses the different stress reactions and emotional and behavioral problems that manifest [ 8]. Thus, a phased model of intervention with a stepped care approach is needed [ 42, 55, 56]. For such an approach the assessment of children's needs and thus a screening for their mental health burden is indicated [ 55]. The detection through proper assessment and the subsequent treatment of mental health issues among refugee children should be a priority to reduce war-associated morbidity [ 57]. Assessing the needs of younger children can be especially difficult [ 23, 57, 58]. Using validated instruments to assess the circumstances of refugee minors that can be easily and widely implementable, such as in online-based screening instruments, is of great importance (as for instance implemented within "PORTA") [ 59, 60, 61]. An adequate assessment and screening of children's mental health burden and needs, and their resources is a precondition for indicated and targeted intervention.

(c) Provide evidence-based interventions for groups and individuals

Based on an individual assessment of the burden and needs of children, appropriate, effective, and efficacious evidence-based treatments should be made available. Different forms of evidence-based programs and treatments exist, ranging from lower-threshold group-based interventions implemented by non-specialists to individual evidence-based trauma-focused psychotherapy by trained professionals [ 62, 63, 64, 65]. With a stepped care approach in mind, interventions with lower participation thresholds and fewer sessions can be implemented in group-based settings to reduce the mental health burden of minors-e.g., as implemented in the program "Mein Weg" (English "My Way") [ 20, 21, 66]. Another short-term low-threshold program is START (Stress-Trauma symptoms-Arousal-Regulation-Treatment), for which there is preliminary evidence of efficacy in improving emotion regulation in adolescents with traumatic exposures and which has been recently adapted and tested in adolescent refugees [ 67, 68, 69]. In a meta-analyses of 36 studies, different treatments were found to have overall large effect sizes, with evidence-based classroom-based interventions showing effect sizes of equal magnitude compared other individual therapies [ 62, 63]. In a review of 25 evidence-based interventions for children and youth affected by armed conflict, several practice elements were seen in more than 50% of the intervention protocols [ 62]. These elements included: access promotion, psychoeducation for children and parents, insight building, rapport building techniques, cognitive strategies, use of narratives, exposure techniques, and relapse prevention [ 62]. Taken together, a growing body of research demonstrates the efficacy and effectiveness of evidence-based interventions from low-threshold and short-term group-based interventions to long-term individualized and evidence-based psychotherapy. Such interventions, if indicated and accessible, should be made available.

(d) Provide appropriate post-migration infrastructures and social environments that foster mental health

For long-term help, it is important to consider providing appropriate physical infrastructures where people seeking refuge can regain and sustain their mental health. Worse mental health outcomes are seen in refugees living in institutional accommodation with restricted economic opportunities. Humanitarian aid that improves living conditions is likely to have a positive impact on mental health as well [ 33]. Also, factors after migration may moderate the ability of those seeking refuge to recover from pre-migration trauma, stressing the importance to address post-migration stressors to improve mental health [ 70]. With a trauma-informed perspective, infrastructures and social environments are needed that provide children with the opportunity to develop in a safe environment that is child appropriate regarding social interaction, education, and strength promotion. Taken together, post migration structures are needed that suit the 'higher' needs of children over and beyond providing initial safety. This includes social interaction and a sense of belonging, education, and a promotion of individual strengths.

(e) Support parents during and after war

Supporting children does also mean to support parents and enable them to care for their children. Studies have shown that more war-exposed parents show less warmth and more harshness toward their children, which partly explains child adjustment [ 71]. Overall, studies have consistently documented the protective nature of parental support on the mental health of children in armed conflict [ 72]. In preschool children, studies show the emotional sensitivity and regulation, attachment style, and PTSD symptoms of mothers as central moderators between traumatic exposures and mental health consequences of their children [ 73]. Such findings also emerged between parental and children's psychopathology [ 23]. Another moderator of the exposure-outcome association for children is the family environment and parental functioning [ 23]. In general, interventions in war zones should ensure the least disruption to communities and families and should wherever possible involve parents in preventive or treatment programmes for children [ 74]. Thus, promoting healthy development of war-affected children should also focus on supporting their parents. In particular, helping parents to maintain warm interactions despite war atrocities, thus limiting harshness as much as possible, might foster healthy child adjustment [ 71].

(f) Support indirectly affected children

War does not only affect those children directly exposed, but also those indirectly impacted through mass media bringing the pictures of war into their homes. Children cannot protect themselves against the themes addressed in the news and omnipresent pictures of war on television, in newspapers and on social media. Perceived anxiety of war in parents might lead to a loss of sense of security and enhanced anxiety in children. As discussed above, cognitive schemas of social safety are developed during childhood and adolescence in relation to a child's appraisal of themselves and the social world around and by the meaning and narratives that people in general and their parents in particular attribute to such events [ 39]. Children indirectly affected by war, gladly and mostly are not separated from their families, and do not have to leave their friends, home, and city behind, but they can experience this social threat on the collective level-hearing about missiles and nuclear deterrence. Considering the COVID-pandemic and its burden onto families with already high levels of anxiety and mental health problems and a reduced quality of life of children and their parents [ 17, 18, 75, 76, 77, 78, 79]-the current feeling of unsafety has the potential to create a double jeopardy. Vulnerable children and adolescents must thus cope with both war in Europe and the consequences of a two-year pandemic. This situation will likely create further challenges and struggles for already challenged child and adolescent psychiatric service providers dealing with the increased post-COVID mental health needs.

How can parents talk to their children? It is important to find a balance between telling the truth about the adversities of war and to still convey hope and signs of physical as well as emotional safety. It is important to protect children from constant inundation of overwhelming information about the current situation especially from disturbing images in the media and to at times turn off one's own devices. Providing relationship opportunities and encourage children to talk about their feelings and to share one's own feelings can be helpful. Much can also be done through simple, concrete acts to support children and families directly hit by the war, such as donations of money or clothes. When children see that parents do something for refugee children, this might help to connect their stress into an essential context of meaning and action.

Implications for European Child and Adolescent Psychiatry

Considering the direct or indirect impact of war on children's mental health: what can the European Child and Adolescent Psychiatric Services and in particular the European Society for Child and Adolescent Psychiatry (ESCAP) contribute?

The current war outbreak in Ukraine and the high mental health burden of children following the COVID pandemic underline the need to focus on mental health and adequate help and intervention for those in need. We should support our colleagues in Ukraine, Russia, and the countries where people are finding refuge, e.g., by providing help to colleagues and emergency personnel. We will continue to advocate for the increased mental health needs of children in the actual situation. With the hope that European nations provide new funds and resources to address the mental health crises of children and to launch large-scale programs to counteract these challenges. Longitudinal and developmentally oriented follow up is needed as early and chronic traumatic stress often does not heal naturally in those strongly affected [ 80, 81, 82]. Children's mental health has been challenged due to recent crises and adversities, as discussed, the COVID-pandemic and war in Ukraine creating a recent double jeopardy. These however can be seen as current episodes of a continuum of crises within Europe, at its borders, and worldwide, which constitute to a cumulative negative impact on children's mental health, well-being, and development-to mention two: the ongoing refugee crises around the Mediterranean and future implications of climate change on children's mental health [ 76]. The actual crisis also shows that children in our own European spheres are affected by war, but that we need be aware of the much larger number of war-affected families worldwide [ 13].To address this need, the European Union and other nations need to invest into the future of the world's children, as they are, in the words of Dame Graça Machel (1996), "both our reason to eliminate the worst aspects of armed conflict and our best hope of succeeding in that charge". Thus, it's time to come together and give our absolute best to protect and support our children!

Acknowledgements

Members of the Board and Policy Division of ESCAP: Dimitris Anagnostopoulos; Maeve Doyle; Stephan Eliez; Jörg Fegert; Joaquin Fuentes; Johannes Hebebrand; Manon Hillegers; Andreas Karwautz; Eniko Kiss; Konstantinos Kotsis; Milica Pejovic-Milovancevic; Anne Marie Räberg Christensen; Jean-Philippe Raynaud; Sofie Crommen; Füsun Çuhadaroğlu Çetin; Vlatka Marsanic Boricevic; Laura Kehoe; Maja Drobnič Radobuljac; Renate Schepker; Robert Vermeiren; Звepeвa Haтaлья.

Funding

Open Access funding enabled and organized by Projekt DEAL.

Author information

Authors and Affiliations

Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, University of Ulm, Steinhövelstrasse 5, 89073, Ulm, Germany

David Bürgin, Thorsten Sukale & Jörg M. Fegert

Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals, University of Basel, Basel, Switzerland

David Bürgin & Marc Schmid

National and Kapodistrian, University of Athens, Athens, Greece

Dimitris Anagnostopoulos

Division of Child Neurology and Psychiatry, Department of Public Health and Pediatric Sciences, Regina Margherita Pediatric Hospital, University of Turin, Turin, Italy

Benedetto Vitiello

Consortia

the Board and Policy Division of ESCAP

Dimitris Anagnostopoulos

, Maeve Doyle

, Stephan Eliez

, Jörg Fegert

, Joaquin Fuentes

, Johannes Hebebrand

, Manon Hillegers

, Andreas Karwautz

, Eniko Kiss

, Konstantinos Kotsis

, Milica Pejovic-Milovancevic

, Anne Marie Räberg Christensen

, Jean-Philippe Raynaud

, Sofie Crommen

, Füsun Çuhadaroğlu Çetin

, Vlatka Marsanic Boricevic

, Laura Kehoe

, Maja Drobnič Radobuljac

, Renate Schepker

, Robert Vermeiren

& Звepeвa Haтaлья

Corresponding author

Correspondence to Jörg M. Fegert.

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Conflict of interest

All authors declare to have no conflict of interest.

Additional information

Members of the Board and Policy Division of ESCAP are listed in acknowledgments.

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Bürgin, D., Anagnostopoulos, D., the Board and Policy Division of ESCAP. et al. Impact of war and forced displacement on children's mental health-multilevel, needs-oriented, and trauma-informed approaches. Eur Child Adolesc Psychiatry 31, 845-853 (2022). https://doi.org/10.1007/s00787-022-01974-z
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Keywords

Children

War

Refugee

Forced migration

Mental health

Burden

Human rights

Children's rights

Psychopathology

Post-traumatic stress disorder

Depression

Anxiety

Trauma

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Impact of war and forced displacement on children's mental health-multilevel, needs-oriented, and trauma-informed approaches - European Child & Adolescent Psychiatry

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The infliction of war and military aggression upon children must be considered a violation of their basic human rights and can have a persistent impact on their physical and mental health and well-being, with long-term consequences for their development.

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Keeping with the theme of Professional Learning Communities, I'd like to share the following.

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Abstract

This study investigated the long-term effects of the 2012 war on children's psychological distress in Gaza Strip. It was hypothesized that a) greater levels of exposure to war trauma would be associated with greater behavioral and emotional disorders, neuroticism, and PTSD symptoms; b) children who rely more on problem-focused coping will manifest less behavioral and emotional disorders, neuroticism, and PTSD symptoms whereas children who rely more on emotion-focused coping will manifest higher levels of behavioral and emotional disorders, neuroticism, and PTSD symptoms; and c) certain children's characteristics (i.e., age, gender, and family income) would be predictive of children's behavioral and emotional disorders, neuroticism, and PTSD. Participants were 205 males and females aged 9 to 16 years. Questionnaires were administered in an interview format with participants at schools. Results indicated that approximately 30 percent of the Palestinian children who were exposed to higher levels of war traumas have developed PTSD with excess risk for co-morbidity with other disorders such as emotional symptoms and neuroticism. The findings revealed that children with lower family income reported higher levels of emotion and behavioral disorders and neuroticism. While emotion-focused coping was positively associated with emotional and behavioral problems, neuroticism, and PTSD, problem-focused coping was negatively associated with neuroticism and PTSD. The clinical implications of these conclusions were discussed to formulate cognitive-behavioral coping interventions that can lead to positive outcomes in the posttrauma environment.

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labels that serve to define a youth's role in the school community and society.

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Principal Matters | William D. Parker & Friends

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This topic may be a little too recent to discuss with some perspective, but we recently lost a senior student in a car accident.

She was one of our dream students: cheerleader, great student, fun-loving, and loved by all.

You can imagine the grief and remorse that gripped our school and community during this time. As painful as the time was for our school, I also watched people pull together in some beautiful ways.

A good friend asked me how a school can prepare for something like this. I don't think anyone can ever prepare for the loss of a student, but here is some feedback I shared with him as he wanted some ideas to share with his school leadership:

1. Communicate, communicate, communicate.
Information is vital for people to cope with grief. As soon as we were able to establish a line of communication in this situation, we did. We had a staff person on site who was loved and trusted by the family.

Frequent messages were relayed back to us. One staff person at the school emailed out those updates so teachers/students could be kept up-to-date. Nothing is more difficult for people in grief than not knowing what is happening, so communicate frequently and factually.

I also took time to send an email to all of our parents attempting to sensitively inform them. I assured them them that we would have a team of counselors on hand, and encouraged them that we would patiently and compassionately carry on with as normal a school schedule as possible.

We also held an emergency faculty meeting so everyone was on the same page with understanding what happened and how we would respond.

2. Be present and visible.
As the principal, I felt it important to visit the family as well. So as soon as I could, I was present and available to the family. I kept my time brief, but I wanted to communicate on behalf of the school the sadness and love felt by all for the student and her loved ones.

I also attended a prayer vigil and the funeral and kept in constant communication with a family friend as well as my school and district leaders on what was happening.

We ended up hosting the funeral at the school, which also required some hands on preparations.

Needless to say, many of my other duties were postponed for this priority, but I tried to be as visible as possible throughout the school so teachers and students could sense we were still "doing school" while also responding to the crisis.

3. Maintain as much stability and routine as possible.
A healthy way to manage grief is staying the course. In the spirit of trying to maintain routines, we cancelled some professional development time we had scheduled that would have brought some substitutes in for some teachers.

Instead we encouraged all of our teachers to be in class so that our week could be "as normal as possible."

Even while we prepared for grief, I encouraged our teachers to teach. Not every student or teacher grieves the same. And some knew the student better than others. Keeping the routine as normal as possible helped school stay on track with a back-up plan for those needing more attention.

4. Allow creative and spontaneous responses.
While maintaining a good routine is important, likewise, you can never predict the kind of responses students will demonstrate or ask to initiate, so remain flexible.

For instance, some volunteers organized an evening prayer vigil. Teachers created signs where students could write love messages and prayers.

Students asked for a school-wide effort to wear a favorite color in memory. They requested a spontaneous group photo at the end of one day and over 300 students participated. We sent the photo as a love message to the family.

One teacher told me that the first day back, her students were unable to speak with the empty desk reminding them of their friend. Finally, one of them asked if they could sign the desk. With sharpies in hand, this began a time of guided and compassionate memory sharing.

Other teachers were able to carry on class as usual as individual students asked to visit or share with others in the counseling office.

Be prepared to play it by ear. Maintain as normal a routine as possible while also allowing room for expressions of sympathy.

5. Ask for help from outside the school.
We were intentional about calling in counselors from our other schools to be with us the first day after our student's death. In addition, ministers from area churches were allowed to be present for students comfortable in sharing with them.

Having additional, supportive adults in the building was also comforting to parents as they were concerned about their own children's ability to cope at school.

As we coordinated with the funeral home on arrangements, we also leaned on staff and volunteers to help with set-up, sound systems, etc. Our school photo vendor donated a large print of her senior portrait for the family. It was a time where lots of people wanted to lend a hand.

6. Enjoy and appreciate your students.
One of the best ways to soothe the hurt of loss is by paying special attention to the wonderful kiddos you still have in your care. Continue to give them kudos and don't forget to congratulate their successes.

For example, our football team had just made it to playoffs when our student tragedy took place. Even in the midst of grieving, we still celebrated their win. The team was treated to a special dinner. We made a big deal in announcements about their accomplishments. Their coach was our teacher of the month.

Losing someone reminds you to let individual students and teachers know how much they are appreciated.

7. Be prepared for media contact.
It wasn't long before the tragedy made it on the news. We were contacted by at least two different sources wanting details. Thanks to my yearbook teacher, I was prepared with a digital photo the family gave me permission to share. We highlighted the positive response of our students, teachers, and community.

It helped that we had already established good contact with these news sources in the past, so I could trust them to report and not exploit the situation. In fact, their reporting was another kind tribute to her memory.

8. Allow yourself time to grieve.
Times like these often bring back painful memories of former student losses or even personal losses. Don't forget to allow yourself time to grieve in the process of comforting others.

Even though I was not personally close to the student we lost, I still found myself appreciating the comfort and prayers of those closest to me.

Taking time to privately acknowledge your own struggle will help you compassionately respond to the struggles others are having.

Conclusion:
No one is ever really prepared for something as painful as a student death. But one way to show compassion during such a time is to be prepared to support your school community when they are grieving.

Whether that includes communicating, being there, bringing in help, keeping up routines, showing appreciation, managing media contacts, or allowing yourself time to grieve-these are just some of the ways you can positively contribute during a painful time for your school.

Now It's Your Turn
I know some of you have been through similar or perhaps more difficult situations. What are some other ways we could be better prepared to help during such times? Share your thoughts, ideas, or resources with the rest of us!

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8 Ways to Help Your School Manage Grief | Principal Matters

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This topic may be a little too recent to discuss with some perspective, but we recently lost a senior student in a car accident. She was one of our dream students: cheerleader, great student, fun-loving, and loved by all. You can imagine the grief and remorse that gripped our school and community during this time.

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These books and resources deal with symptoms of grief, such as feelings of loss, guilt about feeling joy, and disruption from routines.

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It can be extremely difficult when you lose someone you knew. Whether you've lost a family member, a friend, or a pet, you may feel a whole range of emotions.

Grief is an emotional response to this loss, and is a process rather than an event. It may affect how you feel physically, mentally and socially.

On this page, we have provided a few links to useful websites, to support parents and carers and books about grief which we hope will help your child come to terms with a loss.

Useful websites

Young Minds

https://youngminds.org.uk/find-help/feelings-and-symptoms/grief-and-loss/ - this is a great website for children, teenagers and adults. The video on this page is suitable for children in Year 3 upwards.

Winston's Wish

https://www.winstonswish.org/ - another excellent website which gives appropriate information for supporting children.

The Heart and the Bottle

'The Heart and the Bottle' is written by Oliver Jeffers and is about love and loss.

This explores how disorientating grief can be for a young mind. A little girl is shown the world by her father, or father figure, until one day he is no longer there. Unable to cope, she places her heart in a bottle and ties it around her neck. It is not until she has her own child that she is open to the joy and curiosity of the world again. A beautiful book that helps children to understand that in order to experience the joys of life, we must also allow ourselves to feel pain and loss.

The Goodbye Book by Todd Parr

Through the lens of a pet fish who has lost his companion, Todd Parr tells a moving and wholly accessible story about saying goodbye. Touching upon the host of emotions children experience, Todd reminds readers that it's okay not to know all the answers, and that someone will always be there to support them. An invaluable resource for life's toughest moments. Great for Reception and KS1 pupils.

Michael Rosen's Sad Book

An honest and open account of grief and the all-consuming feelings of sadness that accompany it, based on the author's own experiences. This beautifully written book shows us how someone copes with grief, and helps us to realise that grief will not disappear one day but will become a manageable part of life. Quentin Blake's illustrations, which capture the heartbreaking look of sadness and grief, allow children to go on that difficult journey with the author. This is more appropriate for KS2 children.

Badger's Parting Gifts read by Susan Varley

Badger is so old that he knows he must soon die, so he does his best to prepare his friends. When he finally passes away, they are grief-stricken, but one by one they remember the special things he taught them during his life. By sharing their memories, they realise that although Badger is no longer with them physically, he lives on through his friends.

The Memory Tree by Britta Teckentrup

Fox lies down in the snow and passes away. The other animals in the forest each recount happy memories of Fox. As they do, a beautiful orange plant starts to grow in the place where Fox died. This is an excellent book to help us reflect on what we love and miss about those who have died and a reminder that death is a natural part of life.

The books starts just after 1 minute so you may wish to start here.

Always and Forever by Alan Durant

When Fox dies, the rest of his family are distraught. How will Mole, Otter and Hare go on without their beloved friend? But months later, Squirrel reminds them all of how funny Fox used to be, and they all realize that Fox is still there in their hearts and memories.

The Invisible String By Patrice Karst | Children's Book Read Aloud | Lights Down Reading

A mother tells her two children that they're all connected by an invisible string. "That's impossible!" the children insist, but still they want to know more: "What kind of string?" The answer is the simple truth that binds us all: An Invisible String made of love. Even though you can't see it with your eyes, you can feel it deep in your heart, and know that you are always connected to the ones you love. Does everybody have an Invisible String? How far does it reach? Does it ever go away? This heartwarming picture book for all ages explores questions about the intangible yet unbreakable connections between us, and opens up deeper conversations about love.

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It can be extremely difficult when you lose someone you knew. Whether you've lost a family member, a friend, or a pet, you may feel a whole range of emotions. Grief is an emotional response to this loss, and is a process rather than an event.

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Modern Law Divorce and Family Law Attorneys

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Helping Children Deal With the Stress of Divorce | Kids | Teens | Stress | Divorce | Stress Remedies

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developing an understanding of children’s reactions to their parents and divorce by reflecting on their observations and conversations with children

developing an understanding of the type and effect of parents’ stress

having private conversations with children, asking if they are OK, being a good listener, letting children talk, and providing reassurance

arranging one-on-one time with a teacher aide to provide emotional support or to help them settle into the day

being available for children and parents to speak to

creating a safe, friendly environment where children feel free to talk

developing friendships with children and families so they can feel safe and secure to talk to them

communicating with parents about how their child is going emotionally, socially and academically at school

referring children to the student welfare coordinator when necessary for additional support

talking about catastrophic scales to help children put their problems into perspective on a scale from zero to ten where zero is no problem and ten is the worst problem ever

being consistent with school routines, rules and expectations

making sure the child is included in supportive friendship groups, both in the classroom and playground

making activities and communication inclusive – for example, not always saying “tell mum” but instead saying “tell the person who packs your lunch” or “does your homework with you”

having flexible expectations with the child’s schoolwork

arranging tutoring for the child with the teacher, other parents, peers, and teacher aides

getting financial support through the school welfare budget or community organizations for resources, food and to help pay for school excursions and camps

providing encouragement for children to make good decisions and to manage their own behavior

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Almost one in two marriages in Australia end in divorce. It's estimated that in Australia, one in five children under the age of 18 have a parent living elsewhere. This represents around one million Australian children.

For many children, their parents' separation and divorce is a stressful time. Children have different experiences and reactions and bring these into their classrooms. Children's social and emotional well-being, and learning can be affected for many years. At this time, it may be difficult for parents to provide the support their children need as they deal with their own stress.

Read more: How will my divorce affect my kids?

Teachers and schools can help children make positive adjustments. Teachers see these children the most each day apart from their parents. They're in an ideal position to provide support when needed. But they may not know how to help in these situations. Our study provides some helpful strategies that have proven to be successful for teachers.

Negative impacts of divorce

Much is known about the short-term and long-term effects of separation and divorce on children's social and emotional well-being and learning. But there is little known about these children's experiences at school. There is even less known about how their teachers work with them.

Related studies have shown having a support network that includes children's teachers can promote resilience.

Another study found children talked to their teacher so their teachers were aware of their situation. Teachers could then offer support if needed.

Other studies showed children felt secure when the daycare and school environment was friendly, structured and predictable. While these studies provide some awareness, little is known about teachers and their interactions with these children to promote well-being and learning. This provided the motivation for our study.

Our study

Grounded theory research design was applied in this study. Grounded theory is a useful methodology to use when little is known about the topic. It explores the perspective of participants - this could be through interview, focus groups, journalling or observation, although many researchers rely on interviews.

Read more: How to tell your child you're getting divorced

In our study, teachers from multiple government schools in regional Victoria were interviewed. During the interviews, teachers talked about their experiences with children in their class whose parents were separated or divorced.

Useful strategies for teachers

Our study showed teachers were firstly concerned with children's social and emotional well-being. They believed when children felt safe and secure they could learn. Importantly, the support teachers in our study provided varied depending on the different needs of children and their families, as it should.

Useful and effective actions teachers in our study took included:

developing an understanding of children's reactions to their parents and divorce by reflecting on their observations and conversations with children

developing an understanding of the type and effect of parents' stress

having private conversations with children, asking if they are OK, being a good listener, letting children talk, and providing reassurance

arranging one-on-one time with a teacher aide to provide emotional support or to help them settle into the day

being available for children and parents to speak to

creating a safe, friendly environment where children feel free to talk

developing friendships with children and families so they can feel safe and secure to talk to them

communicating with parents about how their child is going emotionally, socially and academically at school

referring children to the student welfare coordinator when necessary for additional support

talking about catastrophic scales to help children put their problems into perspective on a scale from zero to ten where zero is no problem and ten is the worst problem ever

being consistent with school routines, rules and expectations

making sure the child is included in supportive friendship groups, both in the classroom and playground

making activities and communication inclusive - for example, not always saying "tell mum" but instead saying "tell the person who packs your lunch" or "does your homework with you"

having flexible expectations with the child's school work

arranging tutoring for the child with the teacher, other parents, peers, and teacher aides

getting financial support through the school welfare budget or community organisations for resources, food and to help pay for school excursions and camps

providing encouragement for children to make good decisions and to manage their own behaviour.

Read more: How to co-parent after divorce

Teachers can buffer the stress of divorce or separation and help children adjust to their changed family arrangement. The strategies for teachers identified in this study can help teachers support children and families through these unsettled times.

The actions teachers take are important in increasing the bonding between children, families and teachers. Teachers must consider the uniqueness of children and their family situation as they promote resilience and coping skills, encourage a realistic and positive outlook, and decide which of these strategies to use.

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How teachers can help support children during their parents' divorce

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Almost one in two marriages in Australia end in divorce. It's estimated that in Australia, one in five children under the age of 18 have a parent living elsewhere. This represents around one million Australian children. For many children, their parents' separation and divorce is a stressful time.

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Mahony, L. (2018, September 27). How teachers can help support children during their parents’ divorce. The Conversation. Retrieved October 1, 2022, from https://theconversation.com/how-teachers-can-help-support-children-during-their-parents-divorce-102900
Schuller, W. (2017, August 23). 8 Signs of Stress Post-Divorce in Children. Divorced Moms. Retrieved October 1, 2022, from https://divorcedmoms.com/8-signs-of-stress-postdivorce-in-children#:%7E:text=8%20Signs%20of%20Stress%20Post-Divorce%20in%20Children%201,the%20brink%20of%20violence%2C%20is%20not.%20. . .%20%E6%9B%B4%E5%A4%9A%E9%A1%B9%E7%9B%AE
undefined [Modern Law Divorce and Family Law Attorneys]. (2021, December 3). Helping Children Deal With the Stress of Divorce | Kids | Teens | Stress | Divorce | Stress Remedies. YouTube. Retrieved October 1, 2022, from https://www.youtube.com/watch?v=I4CgaQVEEyU

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Signs of Stress Post-Divorce in Children

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Signs of Stress Post-Divorce in Children

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1.  routinely have stomach and headaches
2. develop behavioral or neurological issues
3. revert back to more infantile behavior such as bedwetting and become clingier
4. trouble controlling emotions/ mood swings
5. become quiet and withdrawn

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-Teachers should have conversations with guidance counselors and other school administrators about what the procedures and guidelines are for dealing with a bullying case.
-Engage in a private conversation with the student who is the bully.
-Teach about conflict resolution.

Source:
https://study.com/blog/what-to-do-when-you-have-a-bully-in-the-classroom.html

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What are the signs teachers should look for to determine if a child is being bullied?

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What are the signs teachers should look for to determine if a child is being bullied?

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-Refuse to talk about what is wrong
-Falling behind on school work.
-Appear insecure or frightened.
-Showing aggressive behavior.
-Having unexplained bruising or other injuries after recess/ lunch.
-Often seen alone, and excluded from friend groups.
-Be a frequent target for teasing.

Source:
https://www.education.vic.gov.au/about/programs/bullystoppers/Pages/signs.aspx

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Changes in mood, behaviour and physical appearance can all be warning signs of being bullied, however, some students may not display any warning signs at all.

Warning signs at school

If a student is being bullied at school they may:

become aggressive and unreasonable

start to get into fights

refuse to talk about what is wrong

have unexplained bruises, cuts, scratches, particularly those appearing after recess or lunch

have missing or damaged belongings or clothes

have falling school grades

be alone often or excluded from friendship groups at school

show a change in the their ability or willingness to speak up in class

appear insecure or frightened

be a frequent target for teasing, mimicking or ridicule.

Warning signs at home

A parent may observe changes in their child's behaviour at home which they can report to the school. Their child may:

have trouble getting out of bed

not want to go to school

change their method or route to school or become frightened of walking to school

change their sleeping or eating patterns

have frequent tears, anger, mood swings and anxiety

have unexplained bruises, cuts and scratches

have stomach aches or unexplained pain

have missing or damaged belongings or clothes

ask for extra pocket money or food

arrive home hungry

show an unwillingness to discuss, or secrecy about, their online communication.

It might not be bullying

Some changes in behaviour may also be a result of other student issues such as depression or substance abuse, which may require a different response.

Whether it involves bullying or other student issues, schools can help out for example by involving student wellbeing staff.

More information

If you are a student who is being bullied, see: I'm being bullied

If you are a parent whose child is being bullied, see: My child is being bullied​ ​​​​

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Changes in mood, behaviour and physical appearance can all be warning signs of being bullied, however, some students may not display any warning signs at all.