July 2022: Talking to Your Child About Trauma

Brad Schlaggar (BS): Welcome to Your Child's Brain, a podcast series produced by Kennedy Krieger Institute with assistance from WYPR. I'm Dr. Brad Schlaggar, pediatric neurologist, the president and CEO of Kennedy Krieger Institute. In today's episode, we will be discussing trauma in children. Trauma can be narrowly defined as a physical event like an assault or a physical injury like traumatic brain injury. But more broadly, trauma refers to the impact that an incident or condition has on an individual or perhaps a few people. Collective trauma refers to traumatic experiences that impact entire groups of people, communities or societies. Traumatic events, periods, conditions including school and other mass shootings, natural disasters, wars, pandemic, and other large-scale tragedies like September 11th are of course, highly disturbing to adults. But today, we will address their impact on children and how parents can speak with their child when these catastrophic events occur. Each of today's guests on this podcast are experts on this topic. My great colleagues at Kennedy Krieger Institute, they are Dr. Lindsay Cirincione, a pediatric psychologist who is the director of outpatient operations for the pediatric psychology consultation program at Kennedy Krieger, and is an assistant professor of psychiatry at Johns Hopkins Medicine. Dr. Gabrielle Blackman, a child and adolescent psychiatrist, is the medical director for the Kennedy Krieger School programs and is also an assistant professor of psychiatry at Johns Hopkins Medicine. Patricia Shepley is a licensed clinical social worker, the director of social work, and the clinical director of the Psychiatric Mental Health Program at Kennedy Krieger. Welcome Lindsay, Gabrielle, and Trish. Trish, let's start with you, and some definitions. Can you explain the term ACEs, Adverse childhood experiences, so we can get started with this discussion today.

Patricia Shepley (PS): Thank you, Brad. ACEs range from experiences that happen directly to a person, such as all types of child abuse, physical or emotional neglect, witnessing household violence, loss of a parent, accidents, medical traumas, being a victim in a disaster, or having family members who have mental illness, who are addicted to alcohol or other substances, or are incarcerated. ACEs along with increasing collective traumas, as you described, can lead to toxic stress. Toxic stress is an over activation of the stress response, like rubbing a car engine continuously. That will result in wear and tear on the body. Accumulated ACEs place children at greater risk of developing chronic illnesses, mental health conditions, and substance abuse in adulthood.

BS: You brought up toxic stress as you state the ever present toxicity that comes from ongoing stress. Maybe traumatic stress is in the setting of a specific event. The two certainly are present and important, especially after a traumatic event. Gabrielle, maybe we can take it from there. After a traumatic event, what are the first steps a parent or guardian should take to help mitigate the potential for the impact of repeated trauma?

Gabrielle Blackman (GB): A parent should also help their child to communicate about the event. They should make sure that child has a correct understanding of what happens so they aren't responding to misinformation, and help them express their feelings if they are experiencing any feelings at this time. This can be done for various modalities. It can be done through a discussion, but also through journaling music or art if these are better modalities for that particular child.

BS: You're really getting at the things that are adaptive approaches to stress or trauma. What would you say would be some of the maladaptive responses that we see kids have in response to traumatic events?

GB: Maladaptive responses would include behaviors such as self-harm behaviors, which would include substance abuse, cutting on yourself, or binge eating. They also include intrusive thoughts or ruminations when you have negative thoughts cycle that you just can't break and are stuck there, emotional numbing where you really feel almost nothing at all, which isn't healthy or on the other extreme, emotional outbursts. Also, procrastination and avoidance can be unhealthy, and maladaptive coping mechanisms when they prevent you from getting on with your regular functioning.

BS: I want to get at the issue of how those responses can look at different developmental stages. But before we do, Gabby, maybe what do we know or maybe touch on what we know about how this toxic or traumatic stress affects the developing brain. It's a big topic I know. But maybe address some of what we know these days.

GB: Yeah. As you said, Brad, we do know that repeat trauma can affect the brain. Chronically high levels of stress hormones cause decreased immune function, and this can lead to an overactive amygdala, which is the alarm center of the brain. It can also lead to a shrunken hippocampus, which is the area that stores memory of what happened, and can cause a less active prefrontal cortex, resulting in difficulty managing emotions with either increased or decreased expression of emotions. Poor impulse control, and difficulty solving problems and learning new information. However these changes can be reversible.

BS: That's the impact on the brain. Of course, there's also the impact on other organs in addition to the brain. It by itself is an important and expansive topic. But Lindsay, let's turn to this question of developmental aspects of how children are responding to stress and trauma. How do kids look different across development and how do they differ from adults in this respect?

Lindsay Cirincione (LC): Thanks Brad. I think this is a really important question to ask. The first thing I would say is that it's really important for us to remember that trauma itself is relative. Two people, adults or children, can experience the same traumatic event and have very different responses. One event might be perceived as one individual as very traumatic and distressing, while to the other individual witnessing the same event, it can appear mildly upsetting, but there are no lasting effects. When it comes to the differences that we see in traumatic responses in kids and adults, the mechanisms can be similar, but the outcomes can look vastly different. For example, in young kids, we might see more irritability, separation anxiety, temper tantrums, hyper-vigilance, always being on alert for something bad to happen, and a lot of sleep disturbances in young kids. In older kids or school-age children we might see some school avoidance. We might see complaints of stomach aches or headaches. They can also be really reluctant to leave people who they perceive as safe to go into new circumstances. Kids with developmental disabilities are kids who have limited verbal expression. May display regressions and adaptive behaviors. Things like toilet training or feeding themselves and dressing themselves, they may exhibit more difficulty doing those particular skills. You may see increases in problematic behaviors that had previously resolved.

BS: I can imagine that parents listening to this are automatically going to be thinking about topics like social media and the news. Lindsay, maybe we can address what roles social media and the news play in the process of dealing with a traumatic stress as well as the way that they are involved in contributing perhaps to the trauma as it plays out.

LC: Absolutely. I think media and social media such a hot topic these days anyway. Particularly in regard to traumatic events that may have happened in another location. One of the things that we need to remember is that when we're talking to kids about trauma, we need to do that at a developmentally appropriate level. Understanding what your child's ability to understand these events is really critical. Also remembering that most news outlets are geared toward adults. They're naturally going to be talking at a level that typically isn't appropriate for children and kids with developmental disabilities. Allowing your kids free access to media after a trauma can actually increase their fear about what happened and also decrease their sense of safety in their own immediate surroundings. There are lots of news and media outlets that are geared specifically toward kids. For example, Sesame Street often has really lovely packages, and principles, and resources that parents can use to talk to kids about trauma at a developmentally appropriate level. When it comes to social media, remember, there's no guarantee that things that are posted are true or even helpful. If you have a kid who accesses social media regularly, it can be a really great time to talk to them about how to differentiate fact from opinion, and also how to step away when social media becomes distressing. Finally, one thing I really want to highlight is that at Kennedy Krieger, we serve a lot of kids with developmental disabilities and also kids who are nonverbal for a number of reasons. It's really incumbent upon us as adults to remember that even if kids are nonverbal, they're still picking up on what's in their surroundings. Again, just being mindful and maybe not leaving the news on in the background when your kids are present because there's still taking that information and processing it in the best way that they possibly can.

BS: Such an important point. I'm really glad you brought up the issue of keeping in mind developmentally appropriate exposures, but also recognizing that individuals with developmental disabilities and nonverbal individuals are also going to be processing this information, of course. Gabrielle, maybe take it from there as we think about what can parents do to help a child respond to trauma, keeping in mind that for some, the incorporation of the fact that some children have developmental or intellectual disability has to be part of the consideration. What do you advise there?

GB: I wanted to start off just talking about for all children in general, parents should try to contain their own anxiety as much as they can because their child is going to feed off of this anxiety. As much as the parent can be a calming presence that will be helpful for the child. It's really important to maintain routines. If possible, the circumstances might make it so that the previous routines can't be maintained. In that case, establishing new routines is helpful because it's reassuring for kids to have this consistency. It helps minimize their anxiety about the situation. It's important to keep the same family rules, again, for having that consistency, but perhaps decrease the demands a bit if it's going to be helpful for the child. Distractions are a great thing, having some fun activities for the child, either with friends, or family, or alone if they prefer to help take their mind off of things. Choose a good time to talk to your child and listen well, be patient, go with the child's pace. Try to correct misinformation, if they have any misinformation. They may have picked up things that aren't correct and their anxiety is increased because of things that aren't even true. This can be helpful for them. Allow them to ask questions if they have questions, but some kids don't have questions about it and that's okay too. Don't dwell on some of the graphic details because that can be really traumatizing for the child. It's important to always answer honestly. It's okay to say, I don't know. This will help build trust with the child and help them to feel more secure. As Lindsay discussed, it's important to prevent or limit exposure to news coverage and social media. It's important also to understand that children cope in different ways. Some prefer to be with others, some prefer to be alone. They might cry in response, they might not. All of that is okay and can be normal. As I mentioned earlier in this segment, the parent can help the child find outlets to express their emotions. This might be through talking, but it might be through other modalities like journaling, art, or music. They may express various feelings like anger, guilt, or sadness. All of those can be normal. It's important to acknowledge those feelings and validate them. Finding ways to relax, like with breathing exercises can be helpful. It's important to let the child know that the situation wasn't their fault because a lot of children will take things on that parents don't even realize they might be thinking that, and it's important to give that kind of reassurance. Specifically for children with autism spectrum disorders, intellectual disability, we want to assess their understanding of the situation and recognize that they may require more time supporting guidance than others may need, you'll want to simplify the language so that it's appropriate for their level so they can follow along with the conversation and also with the pace of the discussion, and information may need to be repeated a bit more. Some kids, especially those with autism spectrum disorders, may be visual learners, and so having visual supports as part of the conversation may be helpful. Once again, it's important to have that normal routine and structure. I wanted to give an example from Kennedy Krieger School programs, where we have situations where a parent may call in and give us a heads up that a student may have had a traumatic event happened like the loss of a family member or a pet. Our staff will get this information, and if this is a student, especially who's on the autism spectrum who may really benefit from that structure and routine to help get them through the day and help manage their anxiety, we want to keep their day the same as much as possible. If they have a staff person get them off the bus every day, even if that's not their preferred staff person or their favorite person, if it's the person they expect to be there, that's the person we want to send to get them off the bus because then they have that reassurance that things are going to be the same here at school and they can get through their day. Just like that, we want to follow through the day as much as possible, keeping things the same. Final point I want to make is that kids overall, especially young kids, but also kids with developmental disabilities in particular, may follow a different timeline and may have a different sense of time and processing of an event. I worked with a student several years ago in our middle school program who had suffered the death of a parent and school staff and his mother were a little surprised that he seemed to have no reaction whatsoever. He seemed like his normal self at school and at home, but no changes in behavior or mood at all while the rest of the family was grieving. But two to three months later, seemingly out of the blue, he really started having a typical grief reaction, where he was crying at school and at home, talking about his father, giving nice anecdotes about things that he missed and really hadn't started processing until two to three months later. That's something to be aware of that may happen, and if your child isn't processing it immediately, it may come at a later date.

BS: It's such a great set of insights. Thank you for that, Gabrielle. I can also imagine that some parents might be listening and saying, how do I even get into this discussion? How do I approach the topic? Lindsay, what are your thoughts about the entry into the discussion, parents getting over the hump and finding their way into this really important content?

LC: Yeah, it's such a tough question, Brad, because we as adults and caregivers want to do the right thing. We're so afraid to do the wrong thing. But I think a really nice guiding principle is to let your child take a lead. Check in with them, but be neutral because remember, trauma's relative, so you may perceive something is really distressing while your child is coping with it really well. One of my favorite ways to approach these conversations is to just ask, would you like to talk about what happened? Is there anything in particular that you want to discuss? Then follow your child's lead in that conversation. If there are concerns about difficulty coping, one really nice question that parents can ask is, what can I do to help you feel safe? It may or may not be within your control as a parent to provide that, but that's a really nice talking point for understanding how your kid is processing this traumatic event.

BS: Tricia, of course, parents often are experiencing the trauma to the same events, the same environment that the child is. This by itself, a big topic, but how important is it for parents and other adults in that child's life to manage their own stress in at the observation of their child in this complex setting. What are your thoughts there?

PS: Thank you Brad. As Gabi mentioned, parents and other important adults need to set the tone for ongoing coping for our children. We need to also understand how to manage our level of calm and addressing their concerns. Initially there may be some authentic reaction that's experienced by just the surprise and the shock of the situation. I'd like to share an example of a colleague that the day after the Uvalde shootings chose to drive an older child in the family to school, she was aware that her older child was sensitive to the younger child in the house. It didn't really say much that night after hearing the news. She chose instead to drive her to school to create that opportunity so that they could have a chance to talk so that her older child could ask any questions that she had and to express, any feelings that needed to be expressed. This ended up helping both of them feel a lot calmer that day. For parents, it's most important for them to feel comfortable assessing their own needs and proactively learning how to cope with situations based upon how they're going to allow that information in the household to be discussed or watched on the news. Coordination between adults in the household is very important. Understanding what's going to be happening in terms of the information being discussed in the school situation and in your child's setting. It may be important for a parent who's feeling very overwhelmed by what's occurred to seek their own support and talking with friends or having a plan with household members to just step back when they're feeling overwhelmed. That can mean that they're going to develop their own coping routines and adults need to decide how they cope best. Some people really love to use the breathing exercises and visualizations and for others, it's to get out and to engage and just some exercise and that will help bring them calm. In any event, the go-to for them is important and they're modeling that as an example to their children will draw them into using regular coping skills when stress arises in their lives.

BS: These are excellent points, Trish, and it's the idea that the adult managing their own stress and their response probably contributes to reassurance for the child. Lindsay maybe return to the topic of what other ways can we work to help reassure a child in this context.

LC: Sure. There's a lot of scientific and empirical data out there about this subject, but one of my favorite statements comes from Fred Rogers, help your child look for the helpers. Helping kids identify trusted adults in their environment, particularly after a traumatic event, but even when a traumatic event hasn't happened, teach your kids to identify who they can go to for help. That might be a family member, a teacher or anyone else that they feel safe with. But giving them a plan for what to happen when they're scared can really increase their sense of control and safety. I would say one of the most critical pieces for adults to remember is that kids are excellent lie detectors and after a trauma, it can be really natural for us as caregivers to want to say, I promise everything's going to be okay. I promise this is not going to happen at your school or on your block or in your home. But if we can't guarantee that promise, it's really unwise to give it to a child. An alternative might be, I promise we're doing everything we can to keep you safe or I've talked with your teachers and I know they have a plan for keeping you safe. Those things are true and trustworthy and don't land you in a situation where you've told the child something that you can't guarantee. Just one more quick point. I think very often after a trauma, communities come together and they want to support kids and families. One thing that you might want to think about is giving your child permission to defer those conversations. Sometimes adults ask questions like what happened and are you okay? It's very well-meaning, but it might contribute to that child experiencing more distress about the trauma. Explicitly give your child permission to say I don't really want to talk about that now or can we talk about this later while my parents are with us. That can really just give them a way to relieve some of that pressure and decrease the stress that they're experiencing.

BS: Excellent points. Thank you for that, Trish. Sure the minds of parents will be. What is the trigger for seeking professional help? When is it time to take that stuff?

PS: Well, there's probably a trigger that happens both within the parents and in the observations of the child. First of all, if a parent is feeling like they're unable emotionally to give to their child what they need like the sense of calm that we've discussed, it's great to seek help because they're doing their first job, which is to assess themselves. Secondly, it's time to seek help if the child's symptoms don't go away after a reasonable period of time, they get worse instead of better or new symptoms emerge and continue. When the emotional experience is getting in the way of day-to-day functioning such as being able to sleep or continuing to need to sleep with parents, refusing to go to school, losing interests in activities they usually really enjoy or you see school performance drop-off in a way that just continues. It's time to seek help.

BS: Before we wrap up today, I know we all are aware of some really excellent resources out there that we've shared with each other. Trish maybe, describe some of those sources and we can put links to those sources on the website associated with this episode of the podcast.

PS: Yeah, so we've come up with links that may be helpful for anyone listening to this podcast. That are from SAMHSA, from Sesame Street, from the Harvard group, from the American Academy of Adolescent Psychiatry and the American Academy of Pediatrics.

BS: I'll just say that SAMHSA is the Substance Abuse, Mental Health Services Administration, a federal government administration. We'll have all of those links available. You've been listening to your child's brain. [MUSIC] This month, we're sharing information about talking to your child about traumas. I'm Dr. Brad Schlaggar pediatric neurologist and President and CEO of Kennedy Krieger Institute in Baltimore, Maryland. I'm joined by my colleagues Dr. Kennedy Krieger, Dr. Lindsay Cirincione, Dr. Gabrielle Blackman, and Patricia Shepley. Thank you to our guests for sharing your expertise today and thank you to our listeners for joining us. Please take a moment to rate this podcast and,  if you'd like, share it with your friends. Please check out our entire library of topics on your child's brain at WYPR.org, KennedyKrieger.org, WYPR.org/studios or wherever you get your podcasts. You've been listening to Your Child's Brain. Your Child's Brain is produced by Kennedy Krieger Institute with assistance from WYPR and producer Spencer Bryant. Please join us next time as we examine the mysteries of your child's brain.