-Factors influencing this response-

The complexity of trauma in children requires consideration of multiple factors when analysing the individual response to a traumatic event.

According to Webb’s model, three interacting categories of factors influence a child’s particular response to a traumatic event or series of events:

• Nature of the traumatic event
• Individual factors
• Environmental factors

Nature of the traumatic event (after Webb, 2007)

• Anticipated versus unexpected event

Predictability of the stressful event makes it easier to understand and assimilate. Of course, some traumatic events (natural disasters, sudden death of a parent) are by their very nature unpredictable. However, there are also cases where life situations become progressively critical (terminal illness of a family member, one parent leaving home following divorce), offering the possibility of gradual understanding and acceptance of future loss.

• Single or recurrent event: Type 1 (acute) versus Type 2 (chronic)

In the case of stress accumulated over a longer period of time (e.g. repeated physical abuse), a state of vulnerability is created, causing an otherwise minor event (a bad note) to trigger the child’s crisis. Terr (1991) proposed the distinction between type 1 trauma, due to a single event/shock versus type 2 trauma, precipitated by a series of traumatic events.

Sometimes the two types of trauma coexist. Although both types can lead to the development of pathology, type 2 trauma usually results in more severe symptoms and longer duration of therapeutic intervention.

• Traumatic experience alone or shared with others

Although any traumatic event is experienced personally, sharing such an experience with others leads to a reduction in the stigma of victimisation. Even for those who have experienced trauma individually (for example, as victims of incest), participating in support groups made up of children with similar life experiences can be extremely beneficial. Sometimes, however, victims avoid those who have co-experienced trauma in order to protect themselves from the negative impact of memories of trauma. This factor is age-dependent, as the importance and influence of friends begins at school age.

• Proximity of the traumatic event

The physical proximity of the traumatic event increases the likelihood of developing PTSD, amplifying the number and severity of symptoms; in particular, intense sensory responses and feelings of the threat of death contribute to this symptom exacerbation. In addition, exacerbation of posttraumatic reactions by media exposure is also found in children (Pine, Costello & Masten, 2005).

• Measure of exposure to violence/injury/pain (witness/victim)

The risk of developing PTSD symptoms increases when children are victims of violence compared to when they are only witnesses of such acts. Witnessing can lead to experiencing helplessness and confusion, especially if it is about human acts of violence from those close to them. The age of the child is also critical in this regard.

• Nature of loss/death/destruction

Death/separation from family, attachment person are experiences of psychological loss that are traumatic by their very nature. But physical illness, imposing temporary or permanent restrictions on the child’s life, can also precipitate the development of psychopathology. Likewise, loss of predictability of environment can be equally stressful. The response to a current traumatic event is complicated if previous experiences of loss and psychological grief are activated.

• Attribution of causality: random act/divine will versus deliberate/human act

When traumatic events are the consequences of deliberately caused human acts, their negative impact is stronger. The more so as older children understand the complexity of human behaviour and motivation, including the malevolent nature of such actions, they may experience loss of trust in people and increased anxiety. This is where intervention is critical, to reassure children that their current experiences are not typical of all people and that good is stronger than the evil in the world.

Individual factors (after Webb, 2007, Patt-Horenczyk, Rabinowitz, Rice & Tucker-Levin, 2009)

• Age/developmental/cognitive level of the child

Although the manifestations of PTSD differ according to the chronological age and developmental level of the child, no age of maximum vulnerability has been demonstrated. In general, age interacts with other factors such as family variables and type of trauma.

Higher level general intelligence is a resilience factor and verbal intelligence seems to be the strongest protective factor against the development of PTSD symptoms (Silva et al., 2000).

• Gender

Some studies have shown that, following natural disasters or physical/sexual abuse, girls are more affected than boys; in fact, it seems that more internalising symptoms, including those specific to post-traumatic stress, are manifested in girls than in boys, who are more likely to show externalising symptoms (ADHD, aggression) and relationship problems.

• Temperamental characteristics

Difficult, irritable temperament, a precursor to neuroticism as a personality dimension, appears to be a risk factor for the development of trauma-related psychopathology.

According to multidimensional temperamental models such as Rothbart’s, not only hyperreactivity to negative stimuli but the presence of concurrent difficulties in self-regulation determine an individual’s increased vulnerability to stressors, including traumatic ones. Hyperreactivity to stress is supported at the neurobiological level by hyperactivation of the HPA (hypothalamic-pituitary-adrenal) axis, which may be genetically determined.

Other individual factors that seem to modulate the impact of the traumatic event would be: ethnicity/race/minority status; pre-trauma adjustment, presence of previous traumatic experiences/psychological loss – whereas exposure to trauma does not “harden” the person, but increases the chances of later development of post-traumatic stress symptoms (Silva, 2004); coping style: avoidance versus confrontation; specific meaning attributed to the trauma; presence of post-traumatic stress symptoms or other disorders of clinical intensity.

Environmental factors (after Webb, 2007)

• Culture

In cultures that do not encourage the open expression of emotions – for example, Eastern cultures – there may be more somatisation and fewer psychological symptoms. Religious beliefs and practices in turn influence the impact of the traumatic event, which may be received as part of the cycle of life, and accepted as such – Buddhist karma – or seen as punishment from God.

Even adults’ reaction to children’s symptoms is filtered through their cultural and religious beliefs: for example, Fang & Chen (2004) drew attention to the ignorance of some Chinese parents in New York of their children’s post-traumatic symptoms (nightmares, poor school performance) developed after 9/11. It is therefore essential to consider cultural background in diagnosing and intervening on trauma in children.

• Family and attachment relationships

The nuclear family – the parents – is often the primary source of a child’s resilience. But when they are themselves traumatised or overwhelmed, or are the ones who have caused the child’s trauma, the extended family is called upon to identify those who can provide support to the child in crisis. To do this, it is useful to draw up a genogram, marking those people who are most important to the child and can assume the status of reference persons/attachment figures.

The demographic characteristics of family members (age, socio-economic status, level of education) affect the particular response to crisis or trauma: for example, in poor families, the environment is often far from supportive and secure for the child.

A particular category of people who can become attachment figures are those “first responders”, the “rescuing angels”, the first adults the child meets and who rescue him or her from a critical situation. Perhaps their impact is so great because they instil security in the child, conveying the idea of an adult you can rely on in difficult times.

• School/friends/community support

Beyond the family circle, school/friends can be a refuge or a source of threat for the child, depending on how comfortable the child feels among his/her peers and on the prevalence of positive or negative relationships with them. In turn,

the community can itself be a source of insecurity and threat for the child, or it can be a source of alternative values, especially through extracurricular programmes, run under the supervision of adults who are both protectors and positive role models.

Unfortunately, such extracurricular programmes are rare, especially in disadvantaged environments.

Both individual and environmental factors can be risk or resilience factors.

It is therefore important to be aware of and exploit them in an individualised therapeutic approach.

℘ Developmentally dependent characteristics of children’s response to traumatic events (Pynoos & Nader, 1993), DeWolfe, 2001)

Early childhood (0-3 years) and pre-school age (3-6 years)

– helplessness, passivity, lack of responsiveness

– generalised fear

– high arousal, confusion – including cognitive

– difficulty talking about the event; lack of verbalizations

– difficulty identifying emotions

– sleep disturbances, nightmares

– separation anxiety, ‘clinging’ behaviours in relation to adult references

– regression (enuresis, loss of motor or language skills)

– inability to understand the permanence of death

– anxiety about death

– psychological grief/bereavement related to abandonment of the child by the adult reference person

– somatic complaints (stomach ache, headache)

– flinching at loud/unfamiliar sounds

– “freezing”, sudden immobility of the whole body

– restlessness, excessive, unusual crying

– avoidance reaction, alarm responses to visual stimuli or physical sensations related to the trauma

School age (6-11 years)

– responsibility, guilt

– repetitive traumatic play

– negative emotions to stimuli reminiscent of trauma

– sleep disturbances, nightmares

– worry about safety of self/others, concerns about potential dangers

– aggressive behaviour, angry outbursts

– fear of trauma-related emotions

– attention to parental anxieties

– school refusal

– excessive worry or concern for others

– changes in behaviour, emotional mood, personality

– somatic symptoms (pain)

– overt anxiety, generalised fear

– behavioural regression

– separation anxiety

– loss of interest in activities

– confusion, inadequate understanding of traumatic events – most evident in play

– magical explanations to “fill in the gaps” in understanding events

– inability to concentrate, distractibility, decreased school performance

Pre-adolescence and adolescence (12-18 years)

– exacerbated self-consciousness

– life-threatening acts

– rebellion, rebellion at home or school

– sudden changes in relationships with others

– depression, social isolation

– decline in school performance

– trauma-induced acting-out behaviour: sexual acting-out, risk-taking behaviour

– effort to distance oneself from feelings of shame, guilt, humiliation

– engaging in activities, compulsively or distancing oneself from others to manage emotional tension

– vulnerability to accidents

– desire for revenge, action-oriented responses to trauma

– heightened self-focus

– sleep disturbances, eating disorders, nightmares

Source: „1,2,3 Pași în reabilitarea copilului care a suferit o trauma, Asociația Salvați Copiii Iași, 2009”