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Traumatic Events in the School:
An Educator’s Guide to Childhood Posttraumatic Stress
Written and Compiled By:
Matthew D. Kliethermes, M.S.
The Greater St. Louis Child Traumatic Stress Program
M.D. Kliethermes
Traumatic Events in the School
Warning and Disclaimer
This booklet is designed for use by educators in attending to their normal school duties in
unusual situations. It is in no way intended to train individuals to be therapists, but rather
to fulfill their jobs as educators in a more effective manner when working with children
who have experienced trauma. Further, it is in no way meant to replace professional
mental health services (e.g., consultation, assessment and/or psychotherapy), when such
services are needed or recommended. Readers are advised to make use of any mental
health services available in your community when dealing with trauma in schools.
Further, this booklet makes no attempt to address legal issues of responsibility or liability
for educators.
***Please do not reproduce or distribute this booklet outside of your organization without
the express written consent of the author. Thank you for your consideration.
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Table of Contents
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
Types of Traumatic Events……………………………………………………4
A. Traumatic or Not Traumatic? That is the Question..…………………….4
B. What Makes a Trauma a Trauma?………………………………………..5
Crisis Response and Postvention……………………………………………..6
A. Crisis Response Plans…………………………………………………….6
B. General Crisis Response Procedures……………………………………..7
C. Postvention……………………………………………………………….7
Posttraumatic Stress Disorder (PTSD) and Related Issues….………………..9
A. What is PTSD?…...………………………………………………………9
B. PTSD: How Often? How Long? How Come?…...……………………13
C. Can a Person Have PTSD and Another Disorder at the Same Time?……16
Developmental Differences in Responses to Trauma……….……………….17
A. Preschool…………………………………………………………………17
B. Elementary………………………………………………………………..18
C. Adolescence………………………………………………………………19
What Can a Teacher Do to Help?……….……………………………………20
A. Helping Traumatized Students…………………………………………...20
B. How to Talk (and Listen) to Traumatized Children……………………...22
C. Assisting Parents of Traumatized Students………………………………24
D. Identifying Students Who May Need Professional Help………………...25
E. Taking Care of Yourself…………………………………………………26
Trauma and Students with Disabilities………………………………………28
A. Are Students with Disabilities More Vulnerable to Trauma?……………28
B. How Does Trauma Impact Children with Disabilities?………………….29
C. How Can Teachers Help Traumatized Children with Disabilities? ..……30
Traumatic Loss and Grief……………………………………………………33
A. “Normal” Loss and Grieving…………………………………………….33
B. Traumatic Loss and Grieving……………………………………………35
C. What Can Teachers Do to Aid Grieving Students?………………………36
Suggested Readings………………………………………………………….38
References……………………………………………………………………39
I. Types of Traumatic Events
A. Traumatic or Not Traumatic? That is the Question.
What is a traumatic event? According to the American Psychiatric Association (1994), it
is an event or events that involves actual or threatened death or serious injury, or a threat
to a person’s physical integrity. Also, the event must result in a response of intense fear,
helplessness or horror (Children may show disorganized or agitated behavior instead).
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As you may have noticed, this definition is not very specific. There are a wide variety of
events that could be considered traumatic in nature. From car accidents to acts of war,
many situations can meet the criteria described above. Some traumatic events could
impact large numbers of children in school settings. Examples of such events that could
impact children in your school include:
 Natural Disasters
 Kidnapping/Disappearance
 School Violence
 Community Violence
 Acts of Terrorism
 Traumatic Injury/Death of a Student or School Employee
Considerable research has been conducted examining how such events impact the lives of
the children who experience them. This research has indicated that children who
experience these events often develop significant emotional and behavioral difficulties
that represent childhood Posttraumatic Stress Disorder (PTSD) (Fletcher, 1996) (See
Chapter III for a description of PTSD).
However, it is also important to remember that symptoms of posttraumatic stress can also
be seen in response to events that only impact a single child or family. These events,
though more limited in nature, can impact the emotional well-being of a child in a way
that is similar to the impact caused by the events listed above. Traumatic events that
might only impact one child or family include:
 Physical and Sexual Abuse
 Witnessing Domestic Violence
 Medical Procedures
 Victim of Crime
 Accidents (e.g., car accidents, house fires)
 Surviving Homicide/Suicide
Furthermore, different people may have different experiences regarding traumatic events.
No two individuals experience the same event the same way. Events perceived as
traumatic by one person may not be seen that way by another person. Children, in
particular, may perceive some situations as life threatening and traumatic (e.g., losing
sight of their mother in a crowd) while most adults would not. The opposite may also be
true. A child may not have the awareness to recognize the danger in a situation that an
adult might view as being highly traumatic (e.g., walking alone in a dangerous
neighborhood) (Sheeringa & Gaensbauer, 2000). This suggests that the way a person
“thinks” about an event is very important in determining how they are affected by the
event. If they think there is a serious threat to themselves or someone else, symptoms of
posttraumatic stress may develop.
B. What Makes A Trauma a Trauma?
This may have you believing that just about any event could be traumatic. Fortunately,
there are some general guidelines that may help you determine if an event will be
perceived as traumatic and result in symptoms of posttraumatic stress. Research has
indicated that three factors related to the nature of the traumatic event are predictive of
the development of posttraumatic stress in children (Cohen, Berliner & March, 2000).
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First, the more severe the traumatic exposure, the more likely the child is to develop
symptoms of posttraumatic stress. Therefore, a child is much more likely to experience
emotional difficulties after witnessing the death of a family member, than they are after
being in a minor car accident. In particular, interpersonal violence places children at a
significant risk for developing PTSD, and tends to result in more chronic difficulties than
non-interpersonal traumas. Secondly, the more distressed the child’s parents are by the
event, the more likely it is the child will develop symptoms of posttraumatic stress. If the
child’s parents are able to remain calm and are able to provide a supportive environment,
the child is less likely to develop significant symptoms. Finally, the closer the child is to
the traumatic event the more likely they are to experience emotional distress. Therefore,
a child who was walking next to someone who was struck by a car is much more likely to
develop posttraumatic stress than a child who was several hundred feet distant when it
occurred.
In addition to these three factors, other studies have also indicated that children exposed
to traumatic events may be at greater risk for developing posttraumatic stress if any of the
following are true. Children may be more at risk if they have an emotional attachment to
someone who was injured or killed, if they have experienced previous traumatic events, if
they have a history of emotional difficulties or if their family has a lack of material and/or
social resources (Sandoval & Brock; 2001).
II.
Crisis Response and Postvention
With regard to crises, it has been said that there are two types of schools: schools that
have experienced a crisis in the past, and schools that will in the future. By their very
nature, crises are typically unpredictable and uncontrollable. However, that does not
mean that preparations can not be made in hopes of reducing the impact of a crisis.
A. Crisis Response Plans (CRP)
CRPs are predetermined plans designed to address crisis situations in schools. These
plans will vary depending on the type of crisis (e.g., school shooting, bomb threat).
Crisis plans may also be developed for events that occur off campus (e.g., student
suicide), as such events may also impact students and personnel.
Only a brief summary of the components of a CRP is provided in this booklet. Most
school districts have already implemented CRPs in their member schools. If you are
uncertain of the CRPs in place in your school, it is recommended that you contact your
school administration and/or school district administration for further information. The
information provided in this section was taken from Jane’s School Safety Handbook
(Wong, Kelley, & Stephens, 2001). This would be an excellent resource for anyone
interested in further information regarding the topic of crisis response plans in schools.
Roles of School Personnel During Crisis Events
1. Principal/Administrator
 Coordinates implementation of school crisis response plan.
 Liaison to police, fire and other decision-makers and responders.
 Makes decisions regarding continuing the school day.
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 Activates and oversees the school crisis response team.
2. Crisis Response Team (CRT): The CRT is made up of trusted, responsible
administration and staff that are trained in responding to a variety of crises and
emergency situations. The CRT is an integral part of the crisis response plan. The
members of the CRT regulate such issues as:
 Liaison to responders (e.g., police, fire)
 Student evacuation
 Media contact
 Student pick-up
 Securing the campus perimeter
 Student transportation (e.g., busing)
 Staff mobilization.
3. Teachers/Staff
 Responsible for the safety of their classroom and/or children in their care and control.
 They are not expected to personally resolve the crisis situation (e.g., face down a
gunman).
 Teachers and staff should work to either safely secure or evacuate students in their
care and other employees.
B. General Crisis Response Procedures
1.
2.


Assess the situation.
Determine course of action;
Lockdown-get all students and staff into locked rooms.
Evacuate-this may involve evacuating all or a portion of the campus; evacuation
could involve an on campus (e.g., gymnasium) or off campus (e.g., local park)
location.
3. Implement all or a portion of your school crisis plan.
4. Alert the fire or police department (call 911 if available)
5. Gather as much information as possible regarding the incident.
6. Assist the injured.
7. Secure the perimeter of the campus.
8. Isolate the crime scene (if applicable).
9. Account for students in classrooms and/or evacuation site.
10. Return student workers to their classrooms.
11. Notify district of transportation needs.
12. Notify superintendent.
13. Alert school/district counselors.
14. Prepare written statement for office staff to use when answering phones.
15. Notify media regarding:
 parent pick-up area
 time and location of press conference regarding the incident
 media staging area
16. Keep students and staff advised of facts regarding the crisis.
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C. Postvention
Postvention refers to efforts made to reduce the impact of a crisis immediately after it has
occurred. The primary focus of most postvention activities is to have survivors describe
their experience factually and realistically and express their current thoughts and
emotions about the incident (Deaton & Berkan, 1995).
One common postvention strategy is known as critical incident debriefing. Debriefing is
designed to be a single-session, semi-structured crisis intervention. It is meant to
alleviate the impact of trauma by promoting the emotional processing of the traumatic
experience. This is done by helping the individual to express their thoughts and emotions
about the event, normalizing their reactions to trauma and preparing them for future
experiences. The main purpose of the procedure is to review the impressions and
reactions of survivors shortly after the incident and to assure them that they are normal
people who were exposed to an abnormal event (Bisson, McFarlane, & Rose, 2000).
It is important to note that the intense reexposure to trauma involved in debriefing may be
traumatizing in and of itself, and could result in increased distress. Therefore, if
debriefing is used, it should be provided by an experienced mental health professional,
and trauma survivors should not be forced to participate if they are not willing.
Furthermore, potential participants should be assessed prior to being exposed to
debriefing (Bisson et al, 2000). Specifically, it should be determined that the person
actually is in need of debriefing. If the person is not experiencing distress related to the
incident they may be needlessly traumatized by being exposed to the distress of others. It
may be most useful to focus debriefing efforts on individuals who were in the closest
proximity to the event, or those who had close ties to people injured or killed.
III. Posttraumatic Stress Disorder (PTSD) and Related Issues
A. What is PTSD?
Before starting an in depth description of what PTSD is, it is important to consider one
thing that PTSD is not. PTSD is not a sign that someone is crazy. Many children with
PTSD are afraid that they are going crazy, but in reality PTSD is a NORMAL response
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to an ABNORMAL situation. Anyone could develop PTSD in response to a traumatic
event. If someone does develop PTSD it does not mean that they are weak, fragile or
“messed up.” It means that they were placed in a situation that could be too extreme for
any normal human being to cope with emotionally. It is very important for children to
know that many other people have had similar difficulties, even adults. Now let’s
consider what these difficulties look like.
Symptoms of PTSD
According to the American Psychiatric Association (1994) there are three clusters of
symptoms that must be present, after a child experiences a traumatic event, for PTSD to
be diagnosed. These clusters are Re-experiencing symptoms, Avoidance/Numbing
symptoms and Hyperarousal symptoms.
1. Re-experiencing Symptoms:
In general, re-experiencing symptoms indicate that the child is in some way “re-living”
the sights, sounds, smells, tastes, emotions, thoughts or other sensations associated with
the traumatic event. For PTSD to be diagnosed, at least one of these symptoms must be
present in the child. The specific re-experiencing symptoms are:
a. Repeated and intrusive distressing recollections of the event:
These recollections include images, thoughts or perceptions that the child associates with
the traumatic event (e.g., a child repeatedly remembers the face of a mugger even when
he/she doesn’t want to). In children this symptom may also show up in the child’s play,
with the child repetitively expressing aspects of the event in their play (e.g., a child
repeatedly reenacting a car accident using toy cars).
b. Repeated nightmares:
In children, these nightmares could be related to the traumatic event, but they also could
be nightmares that are not specific to the trauma (e.g., a child in a house fire having
dreams about being chased by a monster instead of specific dreams about the fire).
c. Acting or feeling like the traumatic event is happening all over again:
This may include hallucinations or flashbacks that are related to the traumatic event. In
children, this symptom may involve actual behavioral reenactment of the trauma (e.g., a
sexually abused child may reenact the abuse with a doll).
d. Strong emotional distress when exposed to reminders of the traumatic event:
The child may demonstrate strong emotions when they come into contact with any sort of
reminder of the traumatic event (e.g., a child who experienced a tornado becomes
extremely upset whenever there is a thunderstorm).
e. Strong physical response when exposed to reminders of the traumatic event:
The child may show changes in the way their body functions when they encounter a
reminder of the traumatic event (e.g., a child who survived a school shooting begins to
sweat and has an increased heart rate when they enter the school in which the shooting
occurred).
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2. Avoidance/ Numbing Symptoms:
In general, these symptoms involve the child’s tendency to avoid all reminders of the
traumatic event and a general lack of responsiveness to his/her environment. For PTSD
to be diagnosed, three or more of these symptoms must be present in the child. The
specific symptoms in this category are:
a. Efforts to avoid thoughts, feelings, or conversations related to the trauma:
A child with PTSD may be very resistant to being asked to describe the traumatic event
or to discussing their thoughts and feelings about the event (e.g., a child who witnessed a
homicide runs out of the room every time someone begins to talk about it).
b. Efforts to avoid activities, places, or people related to the trauma:
A child with PTSD will often avoid being around physical reminders of the traumatic
event as well (e.g., an adolescent refuses to walk by the locker of a friend who committed
suicide).
c. Memory difficulties related to the traumatic event:
The child may have an inability to remember an important part of the traumatic event that
cannot be explained by drug/alcohol usage or physical injury to the brain (e.g., an
adolescent rape victim can not remember her assailant removing her clothing).
d. Withdrawal from important activities:
A child with PTSD may show significantly decreased interest or participation in
important activities (e.g., after being in a car accident in which his brother died, a child is
unable to complete his coursework, even in his favorite classes).
e. Feeling withdrawn from other people:
A child with PTSD may appear detached or distant from other people in their life (e.g., an
adolescent girl who survived rape no longer enjoys spending time with her friends).
f. Restricted range of emotions:
This symptom suggests that the child experiences a decrease in the variety and intensity
of emotions that they feel in response to invents in their environment (e.g., a physically
abused child remains “flat” and emotionless during a birthday party at the zoo).
g. Sense of a foreshortened future:
People experiencing this symptom tend to feel a great deal of uncertainty that they will
live a full lifetime (e.g., a traumatized child states that he doesn’t have to study because
he probably won’t live long enough to go to college).
3. Hyperarousal Symptoms:
These symptoms indicate a significant increase in the child’s physical arousal that was
not evident before the traumatic event. Two or more of these symptoms must be present
for PTSD to be diagnosed. The specific symptoms in this cluster are:
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a. Sleep difficulties:
A child with PTSD may experience significant difficulty with both falling asleep and
staying asleep throughout the night (e.g., a sexually abused child is unable to fall asleep
unless her mother is in her bedroom with her).
b. Increased irritability/aggressive behavior:
A child with PTSD may become more easily irritable or more likely to lash out
aggressively than he/she was prior to the traumatic event (e.g., following a car accident, a
previously non-aggressive child slaps his younger brother for coming into his room).
c. Concentration difficulties:
Children that have experienced a traumatic event frequently demonstrate difficulties with
concentration and attention that may appear very similar to AD/HD (e.g., following the
unexpected death of a classmate, children in a classroom are unable to focus on what
their teacher is saying and begin to perform poorly on school work).
d. Hypervigilance:
Traumatized children often show a significantly heightened awareness of what is
happening around them, causing the child to be constantly “on the alert” (e.g., a child
who witnessed a homicide notices and investigates every noise they hear to make sure
that no one is breaking into their house).
e. Exaggerated startle response:
Children who experience this symptom may present as being very “jumpy” or “on edge”
(e.g., a child who witnessed his father die in a hunting accident jumps and screams in fear
when someone behind him drops a book).
PTSD Symptoms in Infants and Toddlers
Unfortunately, for those of you who work with preschool age children the diagnostic
criteria we just discussed may not be too helpful. It has been suggested that these criteria
(which were developed based on full-grown adults) have significant shortcomings when
applied to preschoolers. One study found that using these criteria, even severely
traumatized children very frequently did not meet enough of the criteria to be given a full
diagnosis of PTSD, even though they were obviously experiencing an emotional reaction
to the event (Scheeringa, Zeanah, Drell & Larrieu, 1995). This finding was largely due to
these children not possessing the cognitive or verbal skills necessary to discuss their
internal emotional state. Also, many traumatized preschoolers show emotional and
behavioral symptoms that make sense developmentally (i.e., new separation anxiety,
regressive behaviors), but are not considered because the diagnostic criteria for PTSD
were based on adults. Fortunately, alternative criteria have been developed that appear to
be more sensitive to the presentation of traumatized infants and toddlers (Zero to Three,
1994). The adapted criteria are as follows:
1. Re-experiencing (1 required):
a. posttraumatic play (i.e., compulsive, repetitive play representative of trauma that
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does not appear to relieve anxiety).
b. play reenactment (i.e., trauma related themes in play, but less repetitive and more
similar to pre-trauma play behavior).
c. non-play recollections of the trauma (i.e., verbally telling their experience; may
not be distressing to the child).
2. Avoidance/Numbing (1 required):
a. constriction of play (i.e., a decrease in the frequency and/or intensity of play; with
or without posttraumatic play).
b. social withdrawal (e.g., decrease in peer interactions).
c. restricted range of affect (e.g., not expressing feelings of happiness, sadness, etc.).
d. loss of acquired developmental skills (e.g., potty training).
3. Arousal (1 required):
a. sleep difficulties (e.g., difficulty falling asleep and/or staying asleep).
b. increased crying/irritability
c. easily startled
Typical symptoms of PTSD that are seen at different age levels will be discussed in
greater detail in Chapter III.
Other Behavioral and Emotional Responses to Trauma:
In addition to (or instead of) the symptoms of PTSD described above, children exposed to
traumatic events may experience a wide variety of other behavioral and emotional
symptoms (La Greca, Perez, & Glickman, 2002). These include:
 Fears and worries (e.g., afraid of something bad happening, fear of separation from
family, fear of the dark or of being alone)
 Depressive symptoms (e.g., crying or sadness, withdrawal, changes in appetite)
 School difficulties (e.g., refusal to attend school, decline in academic performance)
 Physical symptoms (e.g., stomachaches, headaches, nausea)
 Regressive behavior (e.g., whining, clinging, bedwetting, thumb-sucking)
 Behavioral difficulties (e.g., aggressive behavior, angry outbursts, hyperactivity)
B. PTSD: How Often? How Long? How Come?
PTSD can be a very difficult phenomenon to get a handle on. A lot has been learned
about PTSD, but a lot still remains uncertain. The occurrence and presentation of PTSD
can be very hard to predict because a great deal depends on the child and the situation
he/she is in. However, now that you have an idea of what PTSD looks like, this section
will provide you with some guidelines regarding how common PTSD is, the course it
takes, and why traumatic events cause these symptoms in some people.
Prevalence:
Prevalence refers to how common something is in a group of people. With regard to
PTSD, two aspects of prevalence are of importance. The first relates to how frequently
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people experience traumatic events. If traumatic events are not common, then by
definition, PTSD is not going to be common either. Unfortunately that isn’t the case.
Survey studies have indicated that 69% of the general population in the United States
have been exposed to one or more life-threatening traumatic events (Resnick, Kilpatrick,
Dansky & Saunders; 1993). That information was based on adults; however, traumatic
events are a relatively frequent occurrence in the lives of children as well. Research has
suggested that approximately 14-43% of children have experienced at least one traumatic
event in their lives (Hamblen, 2002). That means, in a classroom of 20 students
anywhere from 3 to 9 children may have experienced a traumatic event.
Fortunately not everyone who experiences a traumatic event develops PTSD. Otherwise,
you couldn’t turn around without bumping into someone with PTSD. On average, 24%
of adults exposed to a traumatic event develop PTSD. Of children and adolescents
exposed to trauma, 3 to 15% of girls and 1 to 6% of boys could be diagnosed with PTSD
(Hamblen, 2002). Therefore, in that same class of 20 students, even though 3 to 9 of
them may have experienced a traumatic event, probably only one or two would qualify
for a full diagnosis of PTSD. However, this percentage can vary depending on the
severity of the traumatic event. A common rule of thumb states that the more severe the
traumatic event, the more likely it is that the person will develop PTSD. This rule has
been clearly demonstrated in children. In children who have witnessed the murder or
sexual assault of a parent, some studies have found up to 100% of these children
qualifying for PTSD. High rates of PTSD have also been found in children who have
been sexually abused (up to 90%), in children who have witnessed a school shooting
(77%) and in children who have witnessed community violence (35%) (Hamblen, 2002).
Furthermore, even though a child exposed to trauma may not meet full criteria for PTSD,
they may demonstrate some of the symptoms and may still be in need of treatment.
Taken as a whole, among children in the United States, approximately 6-8% of children
will develop PTSD at some point during their childhood (Giaconia, Reinherz, Silverman,
Pakiz, Frost & Cohen, 1995; Kilpatrick & Saunders, 2002). Therefore, returning to that
same classroom of 20 students, 1 or 2 students will develop PTSD prior to age 18. This
may not seem like a lot, but if depression is the “common cold” of mental illnesses, then
PTSD may be the flu.
Course:
According to the American Psychiatric Association (1994) the onset of symptoms of
PTSD usually begins in the first 3 months after a traumatic event, but may be delayed by
months or years in some cases. The type of predominant PTSD symptoms and their
severity typically vary over the course of time; however, the symptoms may be
unremittingly severe for some individuals with the disorder.
The duration of PTSD symptoms varies a great deal from person to person. The greatest
amount of recovery typically occurs in the first 3 months, with complete recovery
occurring in about 50% of all cases (Resick & Schnicke; 1996, APA; 1994). However,
33-47% of PTSD patients in one study reported experiencing symptoms more than one
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year after the event (Davidson, Hughes, & Blazer; 1991). This suggests that for a
sizeable portion of individuals with PTSD, it can be a very chronic disorder. Chronic
PTSD appears to be especially common in response to repeated, multiple or abusive
stressors or in response to instances of interpersonal violence (e.g., repetitive sexual
abuse, witnessing a homicide). On the other hand, PTSD symptoms developed in
response to acute or “one time” events (e.g., a motor vehicle accident) tend to
consistently and gradually drop off over the course of time (Fletcher, 1996).
What Causes PTSD?
When people are exposed to traumatic events it results in the activation of the body’s
“survival systems” (e.g., fight or flight response, dissociation, numbing of pain). This
results in the person being much more likely to survive the situation. Unfortunately,
these body responses can result in enduring chemical imbalances and structural changes
in the brain. These changes seem to be especially significant when an individual is
exposed to repeated, chronic trauma. These changes in brain function in turn, are the
underlying causes of the symptoms seen in PTSD (Bremner, 2002).
This also tends to place individuals who have more “vulnerable” brains at greater risk of
developing PTSD in the aftermath of a traumatic event. Smyth (1999) indicated that
some populations that would be considered “vulnerable” in this sense include:
 Young children
 Persons with pre-existing mental disorders
 Individuals with low intellectual ability
 Individuals with a genetic predisposition to developing PTSD
 Persons with previous exposure to traumatic events
C. Can a Person Have PTSD and Another Disorder at the Same Time?
Yes! That is known as comorbidity. Comorbidity occurs when a person has two or more
different disorders at the same time. This is a very important topic with regard to PTSD
because comorbidity is very common in individuals with PTSD. Research has shown
that 80% of people with a lifetime diagnosis of PTSD met criteria for another mental
disorder as well (Foa, Keane, & Friedman; 2000). This suggests that comorbidity is the
rule and not the exception.
Children with PTSD are also prone to comorbidity (Shah & Mudholkar, 2000). In
children comorbidity often occurs in one of two ways. Some disorders cause children
and adolescents to be more prone to exposure to traumatic events and, therefore, more
susceptible to developing PTSD (e.g., ADHD, oppositional defiant disorder, conduct
disorder, substance abuse). However, other disorders may develop after the trauma.
Disorders that are often seen with PTSD following a traumatic event include; depression,
generalized anxiety, separation anxiety, attachment disorders, and substance abuse
(primarily in adolescents).
NOTE: Often, following a traumatic event, children are mistakenly diagnosed as having
ADHD along with PTSD. However, it is common for children with PTSD (with or
without ADHD) to have difficulties with attention and concentration. Therefore, ADHD
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should only be diagnosed comorbid with PTSD if the difficulties with attention were
present before the traumatic event. This is an important consideration because the
medicines used for ADHD (e.g., Ritalin) may not be as effective for treating the attention
difficulties associated with PTSD (De Bellis, Lefter, Trickett, & Putnam, 1994).
IV. Developmental Differences in Responses to Trauma
It was mentioned earlier that everyone responds differently to traumatic events. This is
also true of different age groups of children. The response of a toddler to an event will be
much different than that of an 8-year-old child, the response of an 8-year-old different
than an adolescent, and the response of an adolescent will be different than both (and
probably irritating to any adults around). Different age groups may show similar
reactions to traumatic events, but they also demonstrate a variety of unique responses as
well. Next we will consider three different age groups (preschool, elementary, and
adolescence) and discuss the most common reactions to traumatic events seen in each
group. These behaviors may be related to the symptoms of PTSD that were discussed
previously, or they may be behaviors that occur above and beyond those symptoms (this
primarily occurs because the diagnostic criteria discussed earlier were based on adults
and did not consider the typical reactions of children).
A. Preschool Children
Preschool children often have a particularly difficult time adjusting to change and loss.
They often feel helpless, powerless and unable to protect themselves (American Red
Cross, 2002). They have not developed the skills necessary to cope with stressful
situations yet, and so they are dependent on the protection and support of care-giving
adults (SAMHSA, 2002). That being the case, preschool children tend to be strongly
affected by the reactions of their parents to the traumatic event. The more their parents
are disrupted by the event, the more likely they are to show difficulties related to
traumatic stress (NIMH, 2002). It is common for traumatized preschool children to show
“regressive” behaviors. This means that they might “lose” skills or behaviors that they
had previously mastered (e.g., loss of bladder control) or that they might “fall back” to
behaviors they had grown out of (e.g., thumb sucking). Similarly, traumatized preschool
children often become “clingy” and may be unwilling to separate from familiar adults
(including teachers). They may also resist leaving places where they feel safe (e.g., their
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home or classroom). Furthermore, they may show significant changes in their eating and
sleeping habits (e.g., refusing to eat, waking up repeatedly during the night). It is also
common for young children who have experienced traumatic events to report physical
aches and pains (e.g., stomachaches, headaches) that have no medical basis (SAMHSA,
2002). It is believed that this is one way that young children express emotions, as they
often do not have the necessary verbal skills to explain them.
A quick list of behaviors that traumatized preschool children may show includes:
 fear of separation from parents
 crying, whimpering or screaming
 appearing to be “frozen” or moving aimlessly
 trembling and/or frightened facial expressions
 thumb-sucking, bedwetting, loss of bladder control
 speech difficulties
 appetite change
 fear of the dark
B. Elementary Children
Elementary children may show some of the same behaviors as those mentioned for
preschool children; however, they also show a variety of different responses as well.
Elementary children may exhibit “younger” behaviors (e.g., asking adults to feed or dress
them) after exposure to trauma (SAMHSA, 2002). They may also report unexplainable
physical symptoms similar to those reported by traumatized preschool children.
However, these children also present symptoms that are not typical of younger children.
Elementary children have a better understanding of the full meaning of the traumatic
event. This means that they may experience feelings of depression, fear and anxiety,
emotional “flatness,” anger, or even feelings of failure and/or guilt for not helping others
more (NIMH, 2002). These feelings are often evident in the child’s behavior (e.g.,
withdrawal from friends, increased competition for attention, refusal to go to school,
aggressive behavior, inability to concentrate and a decrease in school performance)
(SAMHSA, 2002). Even though these children understand what occurred more fully
than younger children, that does not mean that they (or most adults) are able to
understand why it happened. Therefore, elementary children may be preoccupied with
the details of the event and want to talk about it continually (American Red Cross, 2002).
This can be very frustrating to adults, but it is one way children attempt to “come to
terms” with what they experienced.
A quick list of behaviors that traumatized elementary children may exhibit include:
 sadness and crying
 school avoidance
 physical complaints
 poor concentration
 irritability and/or aggressive behavior
 regressive behavior
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fear of personal harm, or other anxieties and fears (e.g., fear of the dark)
nightmares and/or sleep disruption
bedwetting
eating difficulties
withdrawal
attention seeking behaviors
C. Adolescents
Once again, traumatized adolescents may show some changes in behavior that are similar
to those that are common in younger children. For example, adolescents may report
vague physical complaints, seek attention from parents and teachers, withdraw from
others, experience sleep difficulties, avoid school, show a decrease in school
performance, and even show regressive behaviors (e.g., inability to handle tasks and
chores that they used to be able to handle) (SAMHSA, 2002). However, traumatized
adolescents may also exhibit behaviors and symptoms that are very different from those
typical of younger children. These adolescents may isolate themselves from others, resist
authority and become highly disruptive. Also, adolescents sometimes have feelings of
immortality, and may experiment with high-risk behaviors such as substance use,
promiscuous sexual behavior or other “risky” behaviors (e.g., driving at high speeds,
picking fights) (SAMHSA, 2002). They may also feel extreme guilt related to not
preventing injury or loss to loved ones and they may fantasize about revenge against
those they feel caused the trauma. Adolescents typically feel a very strong need to “fit
in” with their peers. This may result in their being very reluctant to discuss their feelings,
and they may even deny experiencing any emotional reactions. Finally, due to their
increased intellectual maturity, adolescents may show traumatic responses similar to
those seen in adults. These responses could include flashbacks, nightmares, emotional
numbing, avoidance of reminders of the trauma, depression, suicidal thoughts, difficulties
with peer relationships and anti-social behavior (e.g., criminal acts) (NIMH, 2002).
A quick list of behaviors that traumatized adolescents may show includes:
 detachment, denial, and/or guilt
 shame about their fear and vulnerability
 new or increased risk-taking or life-threatening behavior
 abrupt changes in or abandonment of friendships
 “pseudomature” actions such as getting pregnant, leaving school, and getting married
V. What Can a Teacher Do to Help?
A. Helping Traumatized Students
Clearly, teachers play a significant role in the lives of school-aged children. Teachers
spend a great deal of time with children, and therefore, can have a large impact on them.
This is true in the aftermath of a traumatic event as well. Fortunately, there are some
relatively straightforward actions that teachers can take to help traumatized children. The
American Psychological Association (2002) provides the following suggestions.
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
Reinforce ideas of safety and security. Students may have to be reassured of this
many times, especially in response to reminders of the trauma (e.g., a loud noise, a
toy gun, a thunderstorm, etc.). Anytime there is a discussion of the traumatic event,
end the discussion by focusing on how the children are currently safe and by doing a
calming activity (e.g., taking deep breaths, doing a quiet art project).

Tolerate retellings of the event. It is important that you be patient and allow the
child to communicate their experiences to you. This may occur in the form of
talking, but may also occur through the child “playing out” the event. Do not allow
scary or hurtful talk (e.g., graphic talk of revenge) or violent/aggressive play.

Encourage students to talk about their traumatic experience. This includes
talking about confusing feelings, worries, daydreams, or breaks in concentration.
This can be encouraged by being accepting of their feelings (even anger), listening
carefully, and reminding them that it is normal to have these kinds of reactions to
scary events. However, don’t force any children to talk about the event. Some
children need more time to get to that point, or may never need to. Just let your
students know that you are available if they would like to talk about their experience.

When answering questions about the traumatic event, try to respond in a calm
manner using simple and direct terms. Children often think about traumatic events
at very unpredictable times during the day. As they try to make sense of what
happened they may ask adults relatively shocking questions, including questions that
focus on gory or gruesome details. It’s okay to tell them that you don’t know the
answer to one of their questions. Don’t get flustered. Just knowing that you are
willing to take them seriously and listen means a lot to children.

Don’t try to “soften” the information you give to children. For example, use the
term “died” rather than “went away” or “went to sleep.” These types of phrases just
needlessly confuse children, and make it more difficult for them to come to terms
with what actually happened. However, don’t provide children with every gory
detail (e.g., discussing the injuries of a car accident victim in detail). That sort of
information doesn’t aid understanding, and is just likely to further frighten the child.
Keep it simple and to the point.

Help children develop a realistic understanding of what happened. Children
often misunderstand aspects of a traumatic event. They may believe that they could
have stopped the event, or may believe that the event happened because they had
been bad and were being punished. These ideas may seem ridiculous to adults, but
may be very powerful to children nonetheless. Gently correct any misperceptions
such as these that you become aware of.

Be willing to repeat yourself. Children may ask the same questions over and over
again, which can be very confusing or frustrating for adults. Try to understand that
children may need to hear the same information many times before they are able to
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understand it (Just like when they learn the multiplication tables). Give them the time
they need to cope with their fears.

Expect angry outbursts. Outbursts of anger and aggression are often seen in
traumatized children. Plan ahead. Try to catch the child before they “act out” by
taking them aside and giving them time to calm down. Don’t be overly punitive.

Normalize “bad” feelings. Reassure children that uncomfortable feelings (e.g.,
anger, sadness, fear) are normal and will get smaller and easier to handle over time.

Avoid exposing children to reminders of the trauma. This includes exposure to
news or other television programs. Television programs are designed to increase
ratings, not to help children cope with trauma. Children do not need to see hours of
footage of the event. If they do happen to see media coverage of the event, spend
time asking what they think or feel about what they have seen and correct any
misconceptions they might have.

Maintain normal school routines as much as possible. In a world “gone crazy” it
can be very comforting to a child to know, that no matter what, they always have
recess right after lunch and go to P.E. every Tuesday. However, it may be a good
idea to avoid or postpone large tests or projects that require extensive energy and
concentration for a while.

Address acting out behaviors involving aggression or self-destructive activities
quickly and firmly. Just as you always would, do not allow children to engage in
behaviors that could hurt others or themselves. Address these behaviors using your
school’s typical policies.

Very importantly, be patient with your students and yourself. Find ways to let
your students know you care about them.
B. How to Talk (and Listen) to Traumatized Children
Many of the suggestions provided above involve teachers having discussions with
children about traumatic events. However, this is often easier said than done. It can be
very intimidating for adults to talk to children about trauma. Even people who are great
communicators can become “tongue-tied” when having to discuss horrible events with
children. Specifically, many adults are afraid of causing children to get upset. Therefore,
adults often avoid talking about it altogether, or distort the information they give the child
to “make it easier on them” (e.g., telling a child that his recently deceased grandfather
went “on vacation”). This sort of approach is not very helpful. Faber and Mazlish (1980)
provide many valuable suggestions on the most effective ways for adults to talk to
children regarding their feelings and experiences.
Helping Children Deal With Their Feelings
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Children need to have their feelings accepted and respected. They need responses from
you that suggest that you are listening and trying to tune into what they are feeling. Ways
that you can convey that you are doing this include:
 listening quietly and attentively (e.g., make eye contact, nod your head)
 acknowledge their feelings with a word or two (e.g., “Oh… Mmmm… I see…”)
 give their feelings a name (e.g., “That sounds frustrating”)
 give them their wishes in fantasy (e.g., “I wish your dad could be here with you”)
 give statements that let the child know that you have a sense of what they are feeling
(e.g., “Wow, you sound angry!” “That must have been disappointing.” “How
scary!” “It can be really hard to be away from someone when they die.” “He really
hurt your feelings, didn’t he?”).
All feelings can be accepted, but certain behaviors can and should be limited (e.g., “It’s
okay to be angry at your brother, but tell him with your words, not your fists”).
Ways of Responding to Children’s Feelings that Are Not So Helpful
 Denial of feelings: “There’s no reason to be so upset. It’s foolish to feel that way.
You’re probably just blowing the whole thing out of proportion. It can’t be as bad as
you make it out to be. Come on, smile…You look so nice when you smile.”
 Philosophical response: “Look, life is like that. Things don’t always turn out the
way we want. You have to learn to take things in stride. Nothing is perfect.”
 Advice: “You know what I think you should do? Tomorrow morning go straight to
your teacher and say, “Look, I was wrong.” Then sit down and finish that
homework you didn’t do. And if you’re smart and want a good grade, you’ll make
sure nothing like that every happens again.”
 Too many questions: “Didn’t you realize he’d be angry if you were late to practice?
What were you thinking? Why didn’t you follow him when he left the room and try
to explain again?”
 Defense of the other person: “I can understand Billy’s reaction. He’s probably
embarrassed that he’s a slow runner. You’re lucky that he doesn’t get mad at you
more often when you beat him.”
 Pity: “Oh you poor thing. That is terrible! I feel so sorry for you, I could just cry.”
 Amateur Psychoanalysis: “Has it ever occurred to you that the real reason you’re
upset it because your father wasn’t there to see you play? You’re probably starved
for your father’s approval, and you feel abandoned when he doesn’t show up for
those important moments.”
Gently Correcting a Child’s Distorted Beliefs
There are five main steps to pointing out and adjusting a child’s distorted beliefs.
1. Point out the child’s distorted belief by briefly summing it up.
2. Label how you think they might feel because of this belief.
3. Validate their feeling. Show empathy.
4. Let them know how it makes you feel to hear the distorted belief.
5. Suggest a healthier belief. Keep it brief.
Example: The child says, “I should have done something to keep my brother from
being hit by that car. Now he’s gone and everyone’s really sad.”
1. “Wow, you think you didn’t do enough to protect him, and it’s your fault he died.”
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2. “You must feel really sad and guilty. I can tell you really miss your brother too.”
3. “I wish I could bring your brother back, but I can’t.”
4. “It makes me feel sad to hear you blaming yourself.”
5. “No one could have predicted a car was going to run off the road and hit your brother.
You did everything you could to help him by running and calling 911. I think it was
very brave that you did that, and shows how much you love your brother.”
C. Assisting Parents of Traumatized Students
Obviously, parents can be very important in helping children and adolescents to recover
from traumatic experiences. In fact, research has shown that parental support and open
communication within the family appear to be the most important factors related to the
recovery of traumatized children (Duncan, 1996).
Furthermore, many of the traumatic events that children are exposed to (e.g., car
accidents, homicide, domestic violence) are also experienced by adults. Therefore, these
parents may also be experiencing symptoms of posttraumatic stress. Not only is this
important for these parents, but it is also very important for their children. Research has
clearly shown that the severity of PTSD in parents and their level of daily functioning are
very strongly related to the severity of symptoms seen in their children (reviewed in
Scheeringa & Gaensbauer, 2000). Simply put, the more difficulty a parent is
experiencing, the more likely it is that their children will be experiencing significant
difficulties as well.
Teachers may be able to help these parents (and thereby their children) in several ways:
 Be sure to communicate with parents. Traumatized children may act differently at
home than at school. They may “cover up” their symptoms at home to avoid
distressing their parents. Provide parents with clear descriptions of their children’s
behavior if they are experiencing difficulties.
 Encourage parents to listen to their children closely about the traumatic event.
This includes allowing the child to talk about their experience and their thoughts and
feelings related to it. Encourage parents to attempt to provide their children with
understanding without being dismissive or critical.
 Encourage parents to set aside special time for their children. This should be
time when the parent and child engage in enjoyable, calming activities (e.g., reading a
book, playing a board game).
 Recommend that the parents maintain normal family routines. As much as
possible, they should follow their regular schedule of daily events. However, they
should not be totally inflexible. Routine is comforting for traumatized children, but
being forced to do something that isn’t absolutely necessary (e.g., cleaning their
room, visiting distant relatives) shortly after a traumatic event may not be.
 Encourage parents to remain as calm as possible around their children.
Emphasize that you understand their distress, but remind them that children can
become very scared when exposed to strong emotions displayed by their parents.
Encourage them to find other adults (e.g., spouses, friends, therapist) who they can
discuss their feelings with when their children are not present.
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Remind parents that many adults and children experience emotional and
behavior difficulties following trauma. It is normal for people to have these
difficulties and is not a sign of weakness or “craziness.” Also let them know that
professional counseling is often very effective in resolving these difficulties.
D. Identifying Students Who May Need Professional Help
All traumatized students will benefit to a degree from the strategies that have been
discussed in this booklet. However, for some children these strategies, though helpful,
will not be enough. A volunteer firefighter would not be expected to extinguish a fouralarm fire without help from professional firefighters. Similarly, teachers should not be
expected to solve severe emotional difficulties in a child. It is at those times that a
referral to a mental health professional should be considered. Listed below are a
variety of indicators that suggest a student may be in need of professional help (Lerner,
Volpe & Lindell, 2002).
 Poor educational performance. The child is unable to adequately participate in
classroom assignments and activities (compared to their pre-trauma functioning) after
3 months or after a majority of similarly traumatized peers are able to do so. This
may include signs of continued inability to concentrate on schoolwork.
 Continued high levels of emotional responses. The child continues to show
significant difficulty regulating their emotions (e.g., repeated episodes of crying or
fits of rage) after 3 months or after a majority of their peers have shown
improvement.
 Signs that the student is depressed, withdrawn and non-communicative. These
may include signs of lethargy, negative mood, disruptions in appetite, significant
changes in weight, and decreased interaction with peers and/or adults.
 Students who express thoughts of suicide or homicide, or students who are
intentionally hurting themselves (e.g., cutting themselves). These behaviors
should be taken seriously and reported to the child’s parents and appropriate school
personnel immediately.
 Students who show signs of apparent increased use of drugs or alcohol. This is
fairly common, especially among traumatized adolescents, and may put them at
further risk for harm.
 Students who show significant changes in behavior (e.g., violent behavior). A
child should return to their normal pre-trauma level of functioning within 3 months
following the traumatic event. Significant or disturbing changes in behavior that
persist longer than 3 months are indicative of a need for professional help.
 Students who no longer attend to personal hygiene.
 Students who show chronic (longer than 3 months) symptoms of PTSD (e.g.,
nightmares, intrusive memories, avoidance, hyperarousal).
If you feel a student is in need of professional counseling, it is strongly recommended
that you discuss your concern with the school counselor, school psychologist or
principal prior to discussing the issue with the student’s parents. These individuals will
have an understanding of how your particular school approaches mental health referrals
for students, as well as knowledge regarding mental health services available in your
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community. Do not “diagnose” a child for their parents. This often results in parents
becoming very defensive and is best left to mental health professionals.
E. Taking Care of Yourself
Just like parents, teachers are role models for children. In the event of trauma, teachers
serve as symbols of safety and care for students, but also often provide children with
their interpretation of what actually happened. Therefore, it is important for teachers to
remain calm and supportive. However, teachers may also experience, and be affected
by, the same traumatic events that students experience (e.g., school violence, terrorism,
disasters). It can be emotionally exhausting for a teacher to provide a calm, supportive
classroom while at the same time they themselves are feeling stressed, anxious or in
danger. Therefore, it is just as important that you take care of yourself as it is that you
take care of your students. The following list describes a variety of steps that you can
take to protect yourself from the emotional distress associated with trauma (Bernstein,
Franklin, Brimes, Lake, & Ramos, 2002).
 Alleviate additional stress. Limit how much you expose yourself to media coverage
of the traumatic event. Also decrease your exposure to other stressful events not
related to the trauma (e.g., driving in rush hour traffic) if possible.
 Request temporary relief from the classroom if needed. It may be helpful to take
a break from the classroom in order to talk to a mental health professional if you are
feeling overly emotional and fatigued.
 If applicable, take the time to make sure your own family is safe. It is impossible
to concentrate on the needs of your students if you are unsure of the wellbeing of your
own family.
 Participate in staff debriefing sessions. In the case of traumatic events in the
school, debriefing sessions are often made available by school psychological
personnel or by external mental health providers. These are often very helpful.
 Schedule time away from work to talk about your personal experiences and
feelings regarding the event. It is most helpful to discuss these issues with someone
that you can trust a great deal (e.g., a close friend, spouse, therapist).
 Be aware of your limitations. Identify stressful events you can control (e.g., how
you are going to comfort a crying child) and let go of those that you have no control
over (e.g., how the President of the United States will respond to a terrorist act).
 Pick your battles. Fight for things that are important to you (e.g., your family, your
students), but do not waste time on those that require more energy than you have at
that time and are less critical (e.g., mowing the lawn).
 Surround yourself with people who make you feel good and on whom you have
the same effect. Avoid putting yourself in situations or around people who make you
feel nervous or upset (e.g., your obnoxious neighbor whose dog is always digging up
your flower garden).
 Take care of yourself physically. Get the proper amount of rest, nutrition and
exercise.
 DON’T BE A SUPERHERO! Ask for help from your colleagues and loved ones, or
seek help from a mental health professional if you need to.
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VI. Trauma and Students with Disabilities
A. Are Students with Disabilities More Vulnerable to Trauma?
Unfortunately, the majority of research that has been conducted in this area has suggested
that children with disabilities are more frequently exposed to traumatic experiences than
are non-disabled children. This research has largely focused on the occurrence of child
abuse among these children. Children with disabilities tend to be greatly overrepresented in various samples of abused children. One study, conducted in a large
school district in the Midwest, found that nearly 45% of reported child abuse cases
involved children who were receiving special services (PACER Center, 1988). Another
study indicated that the prevalence of maltreatment in children with disabilities was
almost 2 times higher than in children without disabilities (Westat, Inc., 1993). Among
abused children, the most common types of disabilities found were behavior disorders,
speech and language disorders, mental retardation, learning disorders and hearing
impairments. However, children with mental retardation tended to experience the most
severe (and possibly most traumatizing) combinations of physical and sexual abuse
(Sullivan & Knutson, 1998). The same study indicated that children with disabilities
were most likely to be maltreated by members of their family, that a large proportion had
been maltreated most of their lives, and that the majority had been abused prior to age
five (Sullivan & Knutson, 1998).
Though rates of abuse do tend to be higher among children with disabilities, little
information is available regarding the frequency of their exposure to non-abuse traumas
(e.g., car accidents, community violence). However, one study did report that the
majority of a sample of 310 developmentally disabled adults had corroborated reports of
trauma exposure, and that 16.5% of them met criteria for PTSD. Some researchers have
suggested that there is insufficient evidence to prove that individuals with disabilities
experience higher rates of trauma. However, even they stress that people with disabilities
do experience trauma, and that PTSD is a relevant issue for them and for people who are
associated with them (Newman, Christopher, & Berry, 2000).
Why are Children with Disabilities at Greater Risk?
Researchers have developed many theories regarding why these children appear to be at
greater risk for experiencing trauma, especially in the form of child abuse (Tharinger,
Horton & Millea, 1989; Sobsey & Verhagen, 1989). Listed below are a few factors that
may put children with disabilities at increased risk of child abuse.
 Increased dependency on caregivers for basic needs.
 Lack of control and choice over their own lives
 Compliance and obedience are instilled as good behavior; children with disabilities
are encouraged to follow the instructions of all adults.
 Many lack knowledge about appropriate social behaviors, particularly with regard to
sexualized behaviors.
 Isolation and rejection by peers can increase their responsiveness to attention and
affection, as well as their desire to please others. This, combined with the possibility
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of limited cognitive abilities, may result in these children being more easily taken
advantage of.
Children with language disorders may have a difficult time disclosing the abuse and
may not be seen as credible, accurate reporters.
Stressors related to the disability (e.g., inability to care for self, extensive medical
costs) may result in high frustration in family environments.
The care and treatment of children with disabilities may result in their being placed in
potentially harmful situations (e.g., residential care facilities).
Note: As a side note it is important to remember that another potential reason PTSD and
disabilities are often seen together is because the disability may be the result of the
traumatic event (e.g., experiencing a brain injury as the result of being shot in the head
during a car-jacking). This may result in added difficulty in recovering from the event, as
the individual not only has to cope with the trauma, but also has to come to terms with
the loss of function associated with the disability.
B. How Does Trauma Impact Children with Disabilities?
Research has indicated that children with disabilities who experience trauma tend to show
many of the same symptoms and difficulties that non-disabled children experience.
There is no evidence to suggest that having a disability will in some way protect a person
from the impact of being exposed to a traumatic event. In fact, children with disabilities
may be at even greater risk because they often lack some of the protective features that
non-disabled children might possess (e.g., effective coping abilities, strong parental
support) (Mansell, Sobsey & Moskal, 1998). Some of the symptoms that children with
and without disabilities share in common include withdrawal, changes in eating and
sleeping habits, increased aggression, self-destructive behaviors, sexualized behavior (in
the case of sexual abuse), poor self-esteem, nightmares, and a sense of vulnerability
(Horton & Kochurka, 1995; Mansell, Sobsey & Moskal, 1998). Furthermore, work done
with developmentally disabled adults has indicated that, among those who have been
exposed to trauma, a sizeable portion experience symptoms of PTSD and roughly 16%
meet diagnostic criteria for the disorder (Ryan, 1994).
Unfortunately, behaviors that could signal trauma exposure may be misperceived as
being related to the child’s disability (e.g., an autistic child who is sexually abused
becomes even more withdrawn) (Horton & Kochurka, 1995). It is important that teachers
remain sensitive to significant changes in the behavior of children with disabilities.
Difficulties associated with most disabilities tend to be stable over time, unless impacted
by events that are external to the disability (e.g., medical difficulties, substance use,
exposure to trauma).
C. How Can Teachers Help Traumatized Children with Disabilities?
Just as children with disabilities often have many of the same difficulties as non-disabled
children following exposure to trauma, the strategies discussed in the previous chapter
can be as helpful for children with disabilities as they are for other children. Special
education teachers, or other teachers who have contact with children with disabilities,
should not hesitate to put these techniques into use. However, this section (adapted from
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Cobb & Warner, 1999) will highlight some considerations and suggestions that may be
particularly meaningful for children with disabilities.
Tips for Helping Traumatized Children with Disabilities





Pre-existing symptoms may get worse. Many of the difficulties associated with
PTSD are also difficulties associated with a variety of disabilities (e.g., poor
concentration, poor academic performance, social withdrawal, poor self-esteem, etc.).
Therefore, in essence these students can receive a “double whammy” resulting in
even greater difficulties than were seen before the trauma. This may be very
frustrating for the teacher. Be patient.
Consider “mental age” rather than chronological age. Depending on their
disability, these children may be significantly less mature than other children their
age. Any information given to them, or activities they participate in, should be
designed to meet their developmental level. Otherwise, they may become
unnecessarily confused and/or frightened. Provide information to them in a simple,
concrete fashion (e.g., give a direct factual account of what happened, avoiding
discussion of theories about why the event happened or what may or may not happen
in the future).
Consider communication deficits and abilities. Many children with disabilities
experience difficulties with regard to communication. In particular, their ability to
express themselves verbally may be underdeveloped. Therefore, when encouraging
these students to express their thoughts and feelings related to the traumatic event, it
is very important to provide nonverbal means for them to do so. Some options
include having them draw a picture about their experience or “play out” their
experience using dolls and other toys. However, it is also important to remember that
the receptive language skills of these students is often largely intact, meaning they
can understand what they are hearing much better than they can express their own
thoughts and feelings. Therefore, it is still very important to spend time explaining
the circumstances of the event to these children.
Try to alleviate social isolation. Children with disabilities are often stigmatized by
peers and may have inadequate social support at home as well. This is compounded
by the fact that children with disabilities may also have difficulties with socially
inappropriate behavior (e.g., aggressive behavior, inappropriate comments). The
experience of trauma can also result in feelings of social isolation among survivors.
Therefore, it is important for children with disabilities to be included in the school
community during the process of recovery from the traumatic event. This may help
to alleviate feelings of isolation, as well as providing students with disabilities the
opportunity to learn appropriate ways to communicate about and cope with the effects
of trauma experience.
Maintaining structure and routine is very important. Structure and routine are
very important to children with disabilities regardless of their trauma history. When
the experience of trauma is thrown into the equation they become even more vital.
Children with disabilities often have little control over their environment, frequently
relying on the support of various caregivers. Therefore, trauma can be very upsetting
to these students as it frequently results in the disruption of the care they receive.
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This often leaves these children feeling very vulnerable. Maintaining their regular
routine as much as possible can greatly help to alleviate these difficulties.
Children with disabilities are often misinformed. Children with disabilities may
have significant difficulty understanding events that occur around them due to various
cognitive limitations. Furthermore, adults often overlook these children, or decide
not to provide them with information because they feel the child “just wouldn’t
understand.” These factors result in children with disabilities possibly being at
increased risk for developing misconceptions about what actually happened (e.g.,
blaming themselves for not stopping the event from happening, feeling something
they did caused the event). Gently correct these misconceptions when apparent.
Be patient. In general, children with disabilities often need frequent repetition in
order to learn. This holds true for traumatic situations as well. Be prepared to answer
the same questions and provide the same information many times in a consistent
manner. This is soothing for the children and helps them learn as well. These
children may also recover from trauma at a slower rate than their non-disabled peers.
Many of their personal resources are already being used to cope with their disability,
making it difficult to cope with other stressors, such as trauma. Students with
disabilities often show an inconsistent, “up and down” pattern of recovery.
Make referrals for mental health services if needed. Mental health services can be
helpful for children with disabilities when modified to meet their level of functioning.
Unfortunately, children with disabilities often have limited access to mental health
services. Your referral may help make the difference.
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VII. Traumatic Loss and Grief
A. “Normal” Loss and Grieving
Grief is a very normal and healthy response to the loss of a loved one. However,
everyone handles grieving in a different manner and has different symptoms of grief.
Typical symptoms of grief include great sadness and longing, feelings of anger, sleep
problems, loss of appetite and weight, preoccupation with death and difficulty
concentrating on normal activities (note some of the similarities to PTSD symptoms)
(Cohen, Mannarino, Greenberg, Padlo, & Shipley, 2002). Grieving individuals may also
have “unusual sensory experiences.” During the first six months after the loss, children
(and adults) often experience unusual visual, auditory, or tactile sensations (e.g., a child
may think she hears her dead mother’s voice in the next room). These misperceptions are
more common at bedtime and upon waking. These experiences are not hallucinations
(Perry & Rubenstein, 2002). Typically, these symptoms should be significantly reduced
(i.e., no longer interfering with daily activities) within 6 months of the loss, but may be
present in some form for years.
Of course, children at different age levels will show different characteristics of the
grieving process.
Infants and Toddlers:
 Experience a sense of “goneness” or absence of the loved one
 Typically react to the loss of an attachment figure with sleep disturbance, change in
eating patterns, fussiness, bowel and bladder disturbances, and difficulty being
comforted.
 May have difficulty reattaching to remaining or new caregivers and may develop
reactive attachment disorder (a disorder involving significant difficulties forming
appropriate relationships with others) (Cohen et al., 2002).
Preschoolers:
 Often believe death is reversible. May engage in “magical thinking” in which they
believe they are powerful enough to reverse death.
 May exhibit regressive behaviors such as thumb sucking, baby talk, and loss of toilet
training.
 They may reenact the death in play and use this to express their feelings.
 May express wanting to die or to go to heaven to be with the deceased. This should
not be automatically seen as suicidal ideation, but that possibility should be
considered.
 Symptoms of grief may be intermittent. Children this age are often unable to sustain
emotions for long periods of time and may go back and forth between active grieving
and periods of “normalcy.”
Young School Children (6-9 years):
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Tend to see death as something physical that can be touched. They may also
personify death, so that death is something that chases you, and can be escaped if you
are fast and strong enough.
These children begin to understand the permanency of death, but may still express
feelings, through play, that the deceased is still alive.
Children this age may show aggression and other behavioral problems due to an
inability to cope with the strong emotions they are experiencing.
May be very anxious about the safety and survival of other family members, though
they tend to not worry about themselves dying (Cohen et al, 2002).
Older School Children (10-12 years):
 Become more realistic about the inescapability of death and the concept of a soul and,
therefore, life after death.
 However, they may still show signs of “magical thinking” as they may feel their
behavior in some way contributed to the death of their loved one (Cohen et al, 2002).
Adolescents:
 Understand death cognitively, but struggle with the “why” of death (e.g., “Why did
my mother have to die?”).
 Are often fascinated by death, but view themselves as being invincible. They may
show inappropriate risk-taking behavior or emotional withdrawal.
 Teenagers may often feel they have been cheated and display considerable anger as
they try to find meaning for the death.
 Since teenagers have a more adult understanding of the implications of their loss, they
may show more typical adult symptoms of grief including profound sadness, sleep
and appetite problems, and difficulty concentrating (Cohen et al, 2002).
Tasks of Mourning
The resolution of grief is a difficult process. There are several tasks that are involved in
the process of childhood mourning (Wolfelt, 1996). These tasks are as follows:
a. accept the reality of the loss;
b. experience fully the pain of the loss;
c. adjust to an environment and self-identity without the deceased (which usually
involves integrating positive aspects of the deceased into one’s own self-concept
(e.g., a child becomes interested in watching football on television after his father
dies));
d. convert the relationship from one of live interactions to one of memory;
e. find meaning in the deceased’s death;
f. experience a continued supportive adult presence in future years.
Clearly, this is a fairly involved process and requires the child to utilize a lot of their
personal resources. Specifically, the child has to be able to tolerate extended thoughts
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about the deceased; and to face and withstand the emotional pain associated with the loss
(Cohen et al, 2002).
Unfortunately, these tasks of mourning can be disrupted by the presence of symptoms of
PTSD. This results in what is knows as traumatic bereavement.
B. Traumatic Loss and Grieving
Many children have experienced both loss and trauma at the same time (e.g., being in a
car accident in which a parent died). For these children the process of mourning is often
more difficult. Traumatic bereavement occurs when the traumatic nature of memories
associated with the loved one’s death interfere with the positive remembering and
reminiscing of the deceased that is a critical component of the mourning process. In
essence, all memories of the deceased, including good ones, become reminders of the
traumatic event and then trigger physical arousal and intense emotional distress. This
results in the child avoiding all memories of the deceased because they are afraid of
experiencing the PTSD symptoms. This frequently results in the child being unable to
resolve the mourning process (Cohen et al, 2002).
Fortunately, this response to traumatic loss is not a common one. The large majority of
children who have experienced the traumatic death of a loved one do not develop chronic
PTSD symptoms that interfere with mourning. Therefore, this response to traumatic loss
should not be considered normal (Cohen et al, 2002).
Note: The strategies discussed in the next section for helping grieving children can be
useful for helping children experiencing traumatic bereavement as well. However, these
children should also be referred to a mental health professional for assistance.
C. What Can Teachers Do to Help Grieving Students?
Here are some basic guidelines that may be helpful in assisting children coping with grief
due to the loss of a loved one (Perry & Rubenstein, 2002). You’ll notice that many of
these guidelines are very similar to those given for working with children who have
experienced trauma. This makes a great deal of sense given that grief and trauma are
often linked together:
1. Don’t be afraid to talk about the death or loss. Children do not benefit from “not
thinking about it.” Be honest, open and clear. Do not try to “cover up” the important
details of the death or “make it easier to swallow.” The imagination of the child will
fill in the details if they are not provided. Frequently, these imagined details are not
accurate, and are often more frightening than what actually happened. When adults
refuse to talk about the death it further suggests to the child that it must have been too
horrible even for an adult to talk about. However, do not force a child to talk about
the event. Let them know you are open to talk about it and then wait for them to
come to you. They will talk when they are ready. So…
2. Do not avoid the topic of death when the child brings it up. Make yourself
available to talk to, but avoid probing the child. Making yourself available to talk
may mean answering some very difficult questions (e.g., “Why did God take my
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3.
4.
5.
6.
Traumatic Events in the School
daddy away?”). Again, it is very important to be clear and honest with the child. It is
okay to say that you don’t know the answer, and that sometimes no one knows why
something happened. Also, it is okay to let the child know how you feel about the
death. Children are reassured by knowing that they are not alone in being
emotionally upset. However, you should do your best to remain calm during the
discussion. This provides a good model of coping for the child, showing them how to
express emotions in a healthy way.
Be prepared to discuss the same details over and over again. Expect the child to
act as though they didn’t “hear” you the first time you explained an aspect of the
death. This situation is very overwhelming to children and they may need to hear the
same information repeatedly. This is reassuring for the child and also helps them
come to their own conclusions about the death. Once again, stay patient!
Be available, nurturing, reassuring and predictable:. This makes the child feel
safe and cared for, and makes the work they have to do in adapting to the loss much
easier. Maintaining routine is very important. The life of the child has been thrown
into chaos. Being able to predict some aspects of their lives is essential.
Help other children in the class learn how to respond. Help them understand how
devastated their classmate feels. Explain that the grieving child may be more tired
than usual, more irritable and less interested in playing. Advise them that their
classmate may be interested in talking about the loss, and encourage them to listen.
Inform the other children that this is a totally out-of-bounds topic for teasing.
Consider modifying your lesson plan. For a while, plan for shorter lessons, go at a
slower pace and assign similar, but less homework than usual (Wong et al, 2001).
However, don’t remove all expectations from the student. The “school routine” can
be comforting for the student and should not be altered too much.
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VIII.
Traumatic Events in the School
Recommended Readings and Web Sites
A. Readings:





Childhood Traumatic Grief: Concepts and Controversies (Cohen et al, 2002)
[Available in: Trauma, Violence and Abuse, Vol. 3, pp. 307-327]
Handbook of Crisis Counseling, Intervention, and Prevention in the Schools
(Sandoval, 2001)
How to Talk So Kids Will Listen and Listen So Kids Will Talk (Faber & Mazlish,
1980)
Jane’s School Safety Handbook (Wong, Kelly & Stephens, 2001)
Keeping Children Safe: A Program to Help Children Cope with Community
Violence (La Greca, Perez & Glickman, 2002)
B. Web Sites:
 American Psychological Association:





IX.
www.helping.apa.org/therapy/traumaticstress.html
American Red Cross:
www.redcross.org/services/disaster/keepsafe/childtrauma.html
National Center for Posttraumatic Stress Disorder:
www.ncptsd.org
National Child Traumatic Stress Network:
www.NCTSNet.org
National Institute of Mental Health:
www.nimh.gov/publicat/violence.cfm
The Child’s Loss: Death, Grief and Mourning:
http://teacher.scholastic.com/professional/bruceperry/child_loss.htm
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