Post-Traumatic Stress Disorder (PTSD)
Post-Traumatic Stress Disorder (PTSD) can develop after experiencing or witnessing a traumatic event, in which children were exposed to actual or threatened death, serious injury or sexual violence.
Some examples of traumatic events include being involved in a car accident, house fires, being assaulted, spending time in hospital, witnessing domestic violence, being victim to torture or war crimes, and even being involved in natural disasters such as earthquakes.
Common symptoms of PTSD in children include experiencing unwanted intrusive memories, thoughts or images of the traumatic event, nightmares, avoiding reminders of what happened such as people, places, situations, or even avoiding talking or thinking about what happened. Children also commonly seem more on edge and jumpy, can be more easily irritated or angered, and struggle to concentrate.
Younger children might repeatedly re-enact aspects of their trauma through play or draw it out, they can become more clingy, develop more general fears of perceived dangers (e.g. the dark, animals, and being alone) and can appear more oppositional – exerting more control over their environments.
Be aware and notice
Keep informed of who in your class has been exposed to traumatic events. Be aware of and look out for common symptoms of PTSD. As avoidance is one of the main symptoms of PTSD, it can be very difficult to spot. Be aware of the differences in symptoms across younger children and adolescents. Bear in mind that some symptoms of PTSD (e.g. increased irritability) can look like something else (e.g. being naughty).
Respond to triggers in the moment
Children who have experienced traumatic events can be easily ‘triggered’ and distressed by reminders of those events. Have an awareness of reminders that might act as triggers so that you can prepare ways to support children to cope, in the moment. Triggers will be different for each child and will often directly relate to the event they experienced, but at other times they could be more discrete. For example, a loud door slam or a specific date.
Grounding techniques can be used to connect children to the here and now. They commonly require children to pay attention to their five senses. A really simple one, for example, is ‘5,4’,3,2,1’, where you can encourage children to say five things they can see, four things they can feel, three things they can hear, two things they can smell and one thing they can taste. Practise grounding activities as a whole class to avoid singling out children who have experienced a trauma. Other grounding techniques include practicing calm breathing, muscle relaxation, listening to music and colouring in. It’s important to practice these techniques even when they are not needed, so that they can be called upon more quickly when they are needed. Lots of nice grounding videos can be found online, for example Belly Breathing with Elmo from Sesame Street on YouTube.
Calming Corner and Coping Box
If possible, find a spot in your classroom that children can go to when they start to feel triggered. Fill it with sensory items such as blankets, cushions, and lights. Add a coping box filled with sensory play items such as play dough, fidget toys and lavender bags. Ensure children know how and when they can use the calming corner. Having a signal or code which they can use to let you know that they need to use the coping corner can be helpful. For example, a ‘time-out’ card that they can give you. For some children, they will need your help to identify when they could use the calming corner.
Then vs Now
Another valuable way to respond to children’s distress can be to help them to notice differences between ‘then’, the day of their trauma, and ‘now’, today, when they are faced with triggers. For example, you could say ‘then the loud noise was a gun-shot, today it was a door slamming, and you are safe’. Encourage children to practice this themselves too, they might find it helpful to write down the differences between then and now.
It is often thought that discussing traumatic events can make PTSD symptoms worse, however evidence suggests the opposite is true; talking can help children to overcome distress, even if it is hard at first. Unless children are asked about traumatic events, PTSD symptoms are also likely to be missed. Children also have active imaginations, and without discussing traumatic events, might be assuming the worst. Offer children the opportunity to speak about what is distressing them, when they are calm. Be sure to show that you welcome conversation when they would like, as children with symptoms of PTSD will often avoid talking about their difficulties because they do not want to upset others (especially those who might also have been affected by the trauma too). Let them know a named person that they can go to. Keep in mind that it is normal for children to find it very difficult to speak about traumatic events, and do not force them. Be patient during discussions. Show that you have listened to them, check your understanding of what they are saying, and validate their emotions. Remain calm yourself when having these discussions. Reinforce what is known now; that the traumatic event has come to an end, and that the child is safe.
If children are experiencing unhelpful thoughts such as that they were to blame for the traumatic event, that they did something wrong or shameful during, or that the event (if rare) is likely to happen again, it can be helpful to challenge their thoughts with what is known. For example, tell them that they were not to blame, that they did all they could at the time and their reactions are normal and understandable, and that the event is unlikely to happen again. Only challenge misunderstandings. It is important to remain honest with children about what did happen so that misunderstandings can be reduced.
Limit reassurance giving
Monitor and limit how much reassurance you are giving children about their concerns. Although it is natural to want to give reassurance, it can maintain difficulties in the long-term. Instead, ask children what they know now that they did not know at the time of their trauma, and what they can do to feel better.
Manage challenging behaviour
Traumatised children can often behave in a way that’s disruptive and considered ‘naughty’ by adults. It’s important to remember, especially for younger children, higher levels of irritability, anger and aggression are some of the most common symptoms of post-traumatic stress. Set clear and consistent expectations of behaviour as well as consequences for not following them. The emphasis of the expectations should be on what you want to see, for example ‘kind hands’, rather than what you do not want to see, for example, ‘hitting others’. Consequences should also be logical and fair, not punitive.
Establish and adhere to daily routines
Following a daily routine makes children’s days more predictable and thus enhances their sense of safety. Support children to follow visual timetables and offer them the opportunity to make more choices about their day in order to give them more of a sense of control.
These children are likely to struggle to concentrate on tasks, especially in the busy classroom. Support them to stay focused by presenting information in multiple formats, break task instructions down into smaller, more manageable, steps and seat children in spaces with less distractions.
Encourage ‘reclaiming life’
Low mood and a lack of motivation to engage in previously enjoyed activities is also common following a trauma. Look out for this at break times and with extra-curricular activities. Encourage children to continue to engage in previously enjoyed activities, even if they don’t feel like it.
Promote strengths through giving praise and rewards
It can be easy to focus on the negatives with these children, but it is important to focus more on the child’s strengths. Acknowledging, praising and rewarding them for following class rules and using coping strategies can be a simple, but highly effective strategy for teachers to use.
Foster a whole class approach to enhancing safety
Teach general tips on how to keep safe, as part of the curriculum. For example, teach children basic self-care (e.g. sleep hygiene and body ownership rules), to identify trusted adults that they can turn to when feeling unsettled and who to contact in an emergency. Remind children that their parents and carers are responsible for ensuring their safety too, and that if they are unsure what to do in an uncertain situation, a trusted adult should be able to help.
Communicate with others
Remember to liaise with parents and carers about how their children are doing. Inform them of difficulties you notice, as children may be more avoidant of showing their carers that they are struggling. Ask parents and carers about known triggers and techniques that they are using to manage symptoms at home. Consistency is key – so share these top-tips with them too! Bear in mind that depending on the traumatic event, parents could be traumatised themselves. It is also possible that the threat is ongoing and so it will be important to liaise with relevant professionals to consider safeguarding.
Monitor symptoms and refer on
Remember that you are not expected to be a therapist. Monitor how long symptoms persist for. If they continue for more than one month beyond the traumatic event occurring, professional support is advised, and we recommend that children visit their GP. PTSD very rarely resolves itself on its own without specialist help.
Further support and information
For more information on how to support children who have experienced trauma, visit:
Dr Sarah Miles, Clinical Psychologist) and Dr Zoe Maiden, Senior Clinical Psychologist
National and Specialist CAMHS Trauma, Anxiety and Depression Clinic