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TRAINING MANUALDealing with traumatic responses in children

Psychological first aid for children II

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Published by Save the Children 2017. Permission to use, copy and distribute this document partly or entirely is granted, provided that the source of references appears in all copies.

Author: Rosa Øllgaard

Should be used as addendum to Psychological First Aid Training Manual for Child Practitioners: Two-day programme by Pernille Terlonge

Editor: Anne-Sophie Dybdal

Proofreading: Wendy Ager

Contributors:, Miyuki Akasaka, Angie Bamgbose, Sita Michael Bormann, Arij Boureslan, Marcia Brophy, Alessia Chiocchetti, Marie Dahl, Karen Flanagan, Mazen Haber Sarah Hildrew, Shirley Lo, Mie Melin, Norbert Munck, Ruth O’ Connell, Minja Peuschel, Bimal Rawal, Karin Tengnäs, Kai Yamaguchi-Fasting, Jumanah Zabaneh, Louise Lykke Østergaard.

Front cover: Chris Stowers/ Panos for Save the Children

Design : Westring kbhPrint : Toptryk Grafisk ApSISBN : 978-87-91682-70-4Printed : 200 ex.

The manual is available online from Save the Children’s Resource Centre at http ://resourcecentre.savethechildren.se/

We would like to thank Danida for their financial contribution to this publication. The material was developed with the participation of Save the Children staff and partners across the world. We are very grateful for the support we have received in developing this training manual from everyone involved in the drafting, testing and reviews.

The photos used here do not portray people affected by the specific circumstances relat-ed to programmes presented in the training module.

Save the Children DenmarkRosenørns Allé 12DK-1634 Copenhagen VPhone : +45 35 36 55 55Mail : [email protected] : www.savethechildren.dk

Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 4

ContentsBackground . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

The scope of the training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Session 1Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Session 2Responding to children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Session 3Responding to parents and caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Session 4When to worry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Session 5Wrap-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Handout 1Tips for staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Handout 2Tips for parents and caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Handout 3When to worry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26


BackgroundTHE SCOPE OF THE TRAININGThis training provides guidance for staff working with children who are severely affected psy-chologically by acute crisis. It is not a clinical tool and does not in itself qualify staff to engage in clinical interventions.

It provides advice to staff dealing directly with children who are showing concerning behaviors (beyond what is perceived as common reactions to traumatic events). These include flashbacks and suicidal thoughts. The training has been developed as a response to the need for guidance expressed by field staff involved in the Syria response, but it can be used in all contexts where children are displaying behaviors that require extra attention. The advice applies to children of all age groups unless otherwise indicated.

Save the Children’s Psychological First Aid Training for Child Practitioners, which is currently being rolled out in several regions lays the foundation for providing PFA as a basic psychological support. However, in some situations, it appears that methods such as comfort and stabiliza-tion are not sufficient. PFA 2 is supplementary to the basic PFA training. It provides advice for non-psychologists, based on field experience, research and the latest theories on child trauma, resilience and recovery.

It is recommended that staff complete PFA training before doing the PFA 2 training. In certain circumstances, it may be appropriate to integrate PFA 2 training with the main PFA training.

PROMOTING LEARNING From the beginning of the training, encourage participants to ask questions, when needed. After each session allow for a question and answers session. If you cannot answer the question, do not feel embarrassed or shy to admit this. Use the group as a resource by asking if anyone else like to comment. No one is expected to know everything. With delicate matters like mental health, do not try to guess the answer, but instead tell the participants you will try to find an answer for the next day or the next time you meet. After each session, summarize the key points on a flipchart to consolidate learning.

RESPECTING CHILDREN Distressed children and families are survivors rather than victims, whatever the concerning behaviors that may be evident. It is helpful to focus on the resources that children and families have, rather than on the problems and the hopelessness. It is important to always treat children as unique individuals and to show them respect. Sometimes, we find ourselves talking to parents without the children understanding what is being said. However, it is important to talk to the child as a person too. Explain that you are going to talk to his/her parents to find out how they are experiencing things. Address the child directly, saying, “Do you ….” and. look at the child as you talk. Don’t ignore the child just because he or she seems disconnected.

NOTES ABOUT THE FACILITATORThe facilitator should have a solid background in mental health and psychosocial support in humanitarian action. The facilitator should be familiar with the technical terms and have expe-rience in clinical work with children and families. This is crucial for the ability to make the dis-tinctions between clinical work and the relevant first aid intervention


Materials needed for the training: PowerPoint slides, handout 1-3, ball, post-its, flipchart paper, flipchart markers, pens, information on local referral mechanisms for session 4, objects for session 5, and certificates if relevant

Session 1

9.00 - 9.20 Introduction Welcome

Session 2

9.20 - 9.30 Responding to children 2.1 Check-in exercise (10 min.)

9.30 - 10.55 2.2 Role-play on children’s reactions (85 min. total)Preparation for role-play (15 min.)Group work (20 min.)Role-play presentations (50 min.)

10.55 - 11.00 Questions and answers 2.3 Comments and questions from participants about session 2 (5 min.)

11.00 - 11.20 Refreshment break

Session 3

11.20 - 11.30 Responding to parents and caregivers

3.1 Check-in exercise (10 min.)

11.30 - 12.55 3.2 Role-play on how to talk to parents (85 min total)Preparation for role-play (15 min.)Group work (20 min.)Role-play presentations (50 min.)


13.00 - 14.00 Lunch break

Session 4

14.00 - 14.25 When to worry 4.1 Which reactions are the most worrying? (20 min.)4.2 Referral mechanisms (5 min.)


Session 5

14.30 - 14.45 Wrap-up 5.1 Check-out exercise 5.2 Wrap-up

PFA 2 TRAINING SCHEDULE


Session 1. Introduction

AIM

To welcome participants and orient them to the training

MATERIALS

slides 1-2.

Note to facilitator : If this training is part of the main PFA training, do not do this introduction.

1.1. Welcome

AIM

To welcome participants and orient them to the training.

MATERIALS

Slides 1-2.

Welcome the participants and thank them for joining this training on dealing with traumatic responses in children.

Invite the participants to stand with you in a circle where everyone can see each other. Step into the circle and introduce yourself, say your name and the organization you work for. Step back out and ask everyone to do the same, one at a time.

Now introduce a game called ‘The sun always shines on those who …’ Explain that when partici-pants hear a statement that is true for them, they step into the middle of the circle. If the next thing someone says is also true for him or her, they stay in the middle of the circle. If not, they step back out again.

Start the game with:

• The sun always shines on those who work directly with children.• The sun always shines on those who have more than three years working experience.• The sun always shines on those who have met a distressed child.

Invite the participants to take turns. When everyone has had a turn, ask the participants to sit down again.

End the session by going through slide 2 (The training schedule).


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Session 2. Responding to children

AIM

To practice responding to children in distress.

MATERIALS

Handout 1 ( Tips for staff) slides 3-8, flipchart, markers, ball.

2.1. Check-in exercise

AIM

To identify the range of reactions that participants see in children in the course of their work.

MATERIALS

Ball.

Invite participants to stand in a circle where everyone can see each other.

Ask participants to reflect on what they see in their work and what kind of reactions they see in the children they meet.

Now take the ball and say one or two words on what reactions you might see in children in the field. Now throw the ball to a participant and ask them to say one or two words, and then to throw the ball to another participant.


Participants are free to share or to repeat what the previous participants have shared. Continue until everyone has had a turn.

2.2 Role-play on children’s reactions

AIM

To consolidate learning through role-play.

MATERIALS

Handout 1 (Tips for staff), slides 3-8, flipchart, markers.

Preparation for the role-playSay: “Let us look at the different reactions you might see in children.” Explain how reactions differ in different contexts and underline how important it is for the participants to identify chil-dren’s reactions in the context of their own work.

Give out handout 1 (Tips for staff) on children’s reactions and how to respond.

Show slide 3 with the different reactions listed (withdrawal/depression, anxiety, flashbacks, sleep disturbances, anger/aggressive behavior,).

Show slide 4 detailing withdrawal/depression and ask participants to read the section on the handout, ‘What does it look like?’ Refer to examples of withdrawal/depression that participants shared (if any) during the check-in exercise.

Continue working through the other reactions, one at a time (slides 5-8) and ask participants to read the handout and share examples form their own experience.

Group workDivide the participants into seven groups. Give each group a reaction from the list:

• withdrawal/depression• anxiety • flashbacks• sleep disturbances• anger/aggressive behavior.

Give two groups ‘withdrawal/depression’ and two groups ‘anxiety,’ because they are dense in content and need extra attention.

Explain the steps for the group work:1. Ask the participants to read the ‘good to know’ section on handout 1 for the reaction they

have been given.

2. Ask the groups to create a short role-play about a staff member dealing with a child who is reacting in a certain way (depending on the reaction the group has been asked to address). Ask them to think about how the staff member would respond and what he/she would need to be aware of.

3. Explain that the role-play should be five minutes maximum. It should present a specific situation. All group members should participate – playing the child who is reacting in a concerning way, the staff member, other children, parents or caregivers, etc.


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4. Give the group 15 minutes to discuss, prepare and rehearse the role-play.

5. Before they begin, explain that each group will present their role-play in plenary followed by discussion.

Role-play presentations

Note to facilitator : Try to establish a positive, supportive learning environment for all the participants to encourage an open discussion.

Invite each group in turn to present their role-play in plenary. After each role-play, ask the other participants for their comments. What were the most important aspects of the role-play? What did they learn about responding to children in distress from the role-play? Invite the group doing the role-play to add their own thoughts.

Make sure each role-play addresses the key points on handout 1. If certain aspects are missed out, then bring them into the discussion.

When all groups have completed their role-play, thank them for participating.

2.3 Questions and answersAsk participants for comments on this session and address as any questions. Write key points on the flipchart.

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Session 3. Responding to parents and caregivers

AIM

To practice responding to parents and caregivers.

MATERIALS

Handout 2 (Tips for parents and caregivers), slide 9, flipchart, ball.

3.1 Check-in exercise

AIM

To identify the range of reactions that participants see in parents and caregivers in the course of their work.

MATERIALS

Ball.

Explain: “We are now going to do a check-in exercise which is the same format as before, except this time we’re going to focus on reactions and questions by parents and caregivers.”

Invite participants to stand in a circle where everyone can see each other.

Ask participants to reflect on what they see in their work and what kind of concerns parents and caregivers have about their children.


Now take the ball and say a question a parent or caregiver has asked in the field in relation to a child who is causing them concern. Now throw the ball to a participant and ask them to say a question they might have been asked by a parent or caregiver, and then to throw the ball to another participant, etc.

Participants are free to share or to repeat what the previous participants have shared. Continue until everyone has had the ball.

3.2. Role-play on how to talk to parents

AIM

To consolidate learning through role-play.

MATERIALS

Handout 2 (Tips for parents and caregivers), slide 9, flipchart, markers.

Preparation for the role-playKeep the same seven groups from the group work in the previous session.

Show slide 9 and read through the range of children’s reactions that may cause concern to parents and caregivers.

Give out handout 2 (Tips for parents and caregivers).

Group workGive each group a different reaction from the list as follows:

• sleep problems• lack of appetite• crying when parents or caregivers leave• excessive crying• risk-taking behavior• withdrawal and lack of interest in playing• fear of everything ( general fear)

Explain the steps for the group work:1. Ask the participants to read the ‘how to respond’ section on handout 2 for the reaction they

have been given.

2. Ask the groups to create a short role-play about a staff member dealing with a parent or caregiver who is concerned about their child (because the child is distressed and is react-ing by having sleep problems/lack of appetite, etc.). Ask them to think about how the staff member would respond and what he/she would need to be aware of.

3. Explain that the role-play should be five minutes maximum. It should present a specific situation. All group members should participate – playing the parent or caregiver, the staff member, the child causing concern, other children, etc.

4. Give the group 15 minutes to discuss, prepare and rehearse the role-play.

5. Before they begin, explain that each group will present their role-play in plenary followed by discussion.


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Role-play presentationsInvite each group in turn to present their role-plays in plenary.

After each role-play, ask the other participants what they thought were the important messag-es conveyed. Invite the group doing the role-play to add their own thoughts to the discussion.

After each role-play, ask the other participants for their comments. What were the most impor-tant aspects of the role-play? What did they learn about responding to children in distress from the role-play? Invite the group doing the role-play to add their own thoughts.

Make sure each role-play addresses the key points on handout 2. If certain aspects are missed out, then bring them into the discussion.

When all groups have completed their role-plays, thank them for participating.

3.3. Questions and answersAsk participants for comments on this session and address as any questions. Write key points on the flipchart.

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Session 4. When to worry

AIM

To identify very serious reactions in children which may need referral to specialized services and/or child protection services.

MATERIALS

Handout 3 (When to worry), slide 10, flipchart, post-its, pens, markers, information on local referral mechanisms.

4.1. Which reactions are the most worrying?

AIM

To identify very serious reactions in children which might need referral

MATERIALS

Handout 3 (When to worry), slide 10, a piece of flipchart with a child drawn on it, markers, post-its, pens.

Invite participants to go back into their groups. Give each group post-it notes and pens.

Ask each participant to write down what they consider to be the three most worrying/trou-bling/disturbing reactions in children – one reaction per post-it note. Give them 5 -10 minutes to do this.

Now ask participants to stand in a circle. Put the drawing of the child somewhere so that every-one can see it.


Invite each participant in turn to read their post-its aloud and then put them on the drawing of the child.If the same reaction is mentioned more than once, ask participants to stick the post-its on top of each other on the flipchart. Encourage participants to share examples.

Ask the participants to sit down again. Give them handout 3 (When to worry)

If some signs of distress from the list on the handout have not been mentioned by any of the groups already, show slide 10 and explain what they are.

This is the list from the handout:

• If the child is at risk of harm to himself/herself and/or others • If a child expresses suicidal thoughts• If the child shows extreme, persistent withdrawal i.e. no emotional response, and the

child’s expression seems flat with no negative or positive expressions.• If the child is persistently whining/whimpering/uncontrolled crying over time

(different from a grieving, liberating sob).• If the child is dissociating i.e. if the child is detached from surroundings and fails to

engage emotionally like the child used to do.• If the child is experiencing hallucinations i.e. the child is hearing voices that are not real

(auditory hallucinations) or seeing things/people that are not real (visual hallucinations) in ways that do not seem playful or joking.

• If the child is experiencing persistent anxiety attacks • If the child is showing signs of mental disability such as permanent difficulties

understanding language and social interaction

4.2 Referral mechanisms

AIM

To ensure that participants are aware of local referral mechanisms.

MATERIALS

Information on local referral mechanisms.

Note to facilitator : It is very important that participants know how and where to make referrals in responding to children in acute distress. There is not much time for this part of the training, so it is crucial that you prepare in advance for it. Make sure you have updat-ed information on local referral mechanisms that you can share with the training group.

Give out the information on local referral mechanisms to the participants. Give participants time to read it and ask if they have any additional information to add.

If there is time, invite two or three participants to describe their experience of making a referral.

4.3. Questions and answersAsk participants for comments on this session and address as any questions. Write key points on the flipchart.


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Session 5. Wrap-up

AIM

To bring the training to a positive close.

MATERIALS

Objects for the room, certificates.

5.1 Check-out exercise

AIM

To relax participants before they take their leave.

MATERIALS

Objects for the room

Note to facilitator : Place some objects in the training room before this exercise begins. Choose objects that you can refer to during the exercise, e.g. something blue, something made of wood, something round, etc.

Explain that this is a simple check-out exercise which aims to relax everyone before they get ready to leave.

Ask participants to sit as comfortably as possible.


Say: “In a couple of minutes I will ask you to find certain things in the room (without moving from your chair) and then to look at them, such as ‘Find something blue,’ or ‘Find something made of wood,’ or ‘Find something round,’ etc. In between instructions, you can choose to look down at the floor in front of you or to close your eyes – whatever feels more comfortable.”

Now begin the exercise. Use a calm tone of voice and take time in naming different types of objects and give time to rest between objects.

Tell participants when you are about to name the last object so that they know the exercise is coming to an end.

5.2 Wrap-up session

AIM

To wrap-up the training

MATERIALS

Flipcharts with key points from each session, training certificates

Read out the key points from each session of the training (or ask a participant to read them). Ask the participants if they have any further comments or questions and address them. Provide time for reflection and feedback.

Thank the participants for their participation and explain that they have now completed the training in Psychological First Aid for Children 2 – Dealing with Traumatic Responses. Arrange a farewell ceremony and present certificates of attendance.

Thank each participant and say goodbye.


HAND

OUT

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Tip

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fact

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icid

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and

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pts,

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are

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ease

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to k

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ay b

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eded

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Expl

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vest

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stig

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in a

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the

child

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by

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feel

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1 Se

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7


HAND

OUT

1 –

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An

xiet

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eact

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incl

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, nau

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num

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di

sapp

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d ex

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wor

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Beh

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(if

cul

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and

low

voi

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as

an a

larm

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th

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act

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eive

dan

ger

or a

thr

eat.

Anx

iety

is

prov

oked

by

real

thr

eats

as

wel

l as

scar

y th

ough

ts

and

imag

inat

ions

. D

istr

esse

d ch

ildre

n m

ay

also

exp

erie

nce

anxi

ety

whe

n th

ey e

xper

ienc

e ev

ents

sim

ilar

to t

hose

ca

usin

g th

e di

stre

ss.

It is

com

mon

for

child

ren

to a

void

tal

king

abo

ut h

ow

they

feel

, bec

ause

the

y ar

e w

orri

ed t

hat

othe

rs

(esp

ecia

lly t

heir

par

ents

) m

ight

not

und

erst

and.

The

ch

ild m

ight

als

o fe

ar b

eing

ju

dged

, con

side

red

wea

k or

to

be a

bur

den

to t

heir

pa

rent

s. T

his

lead

s m

any

child

ren

to fe

el a

lone

or

mis

unde

rsto

od.

Kee

p in

min

d th

at y

our

child

’s an

xiet

y is

not

a s

ign

of p

oor

pare

ntin

g. It

may

ad

d st

ress

to

an a

lrea

dy

stre

ssfu

l sit

uatio

n, b

ecau

se

you

need

to

adap

t yo

ur

life

arou

nd it

, but

you

r ch

ild is

not

rea

ctin

g w

ith

anxi

ety

on p

urpo

se.

If th

e th

reat

is r

eal,

the

child

has

to

be p

rote

cted

as

far

as p

ossi

ble,

and

the

car

egiv

er s

houl

d st

ay

with

the

chi

ld in

ord

er t

o co

mfo

rt a

nd c

alm

the

chi

ld.

Expl

ore

the

anxi

ety

prov

okin

g th

ough

ts w

ith t

he c

hild

and

do

not

judg

e. E

xplo

re w

ith t

he c

hild

if

the

thre

at is

rea

l; he

lp t

he c

hild

dis

tingu

ish

betw

een

thou

ght

and

real

ity b

y as

king

, “W

hat

is it

th

at m

akes

the

dan

ger

is r

eal?

” an

d ”W

hat

is it

tha

t it

mak

es it

not

rea

l?”

Red

uce

expo

sure

to

iden

tifiab

le a

nxie

ty t

rigg

ers

by p

rote

ctin

g th

e ch

ild a

gain

st a

nxie

ty t

rigg

ers.

Pr

ovid

e sa

fe, p

redi

ctab

le, p

eace

ful e

nvir

onm

ents

, eve

n if

it m

ight

be

diffi

cult

duri

ng a

n em

erge

ncy.

Oft

en, d

istr

esse

d ch

ildre

n ar

e pr

eocc

upie

d w

ith is

sues

tha

t ca

nnot

influ

ence

, or

by q

uest

ions

with

no

ans

wer

, suc

h as

, ”W

hy d

id t

his

happ

en t

o m

e?”

Hel

p th

e ch

ild fo

cus

on is

sues

to

influ

ence

suc

h as

”W

hat

are

we

goin

g to

hav

e fo

r di

nner

ton

ight

? W

hat

gam

e do

you

wan

t to

pla

y no

w?”

Hel

p th

e ch

ild b

y re

mov

ing

the

focu

s fr

om b

ig, o

verw

helm

ing

ques

tions

to

issu

es t

hat

may

be

deal

t w

ith

here

and

now

. Tal

k ab

out

the

thin

gs t

he c

hild

can

con

trol

tod

ay a

nd t

omor

row

.

Ada

pt e

xpec

tatio

ns. W

hen

ever

ythi

ng s

eem

s ch

aotic

, it

is im

port

ant

to t

ake

thin

gs in

sm

all s

teps

. C

hang

es w

ill c

ome

little

by

little

.

Enco

urag

e ph

ysic

al e

xerc

ise,

whi

ch w

ill in

fluen

ce a

nxie

ty p

ositi

vely

. Enc

oura

ge s

ocia

lizin

g w

ith

othe

r ch

ildre

n.

Plan

for

tran

sitio

ns. F

or e

xam

ple,

allo

w e

xtra

tim

e be

fore

and

aft

er t

rans

ition

s fo

r th

e ch

ild t

o ad

just

.

Hel

p th

e ch

ild r

egai

n co

ntro

l ove

r th

e bo

dy b

y br

eath

ing

calm

ly a

ll th

e w

ay in

to t

he s

tom

ach,

ask

th

e ch

ild t

o fe

el h

is/h

er fe

et o

n th

e gr

ound

. Go

thro

ugh

neck

, bac

k, a

rms,

han

ds, l

egs

and

feet

and

as

k th

e ch

ild t

o re

leas

e te

nsio

n an

d co

ntin

ue b

reat

hing

into

the

sto

mac

h. If

you

wan

t, fo

llow

the

ex

erci

se y

ours

elf t

oget

her

with

the

chi

ld.

Use

rel

axat

ion

tech

niqu

es s

uch

as a

skin

g th

e ch

ild t

o si

t in

a c

omfo

rtab

le r

elax

ed p

ositi

on a

nd

brea

the

slow

ly in

and

out

. The

n as

k th

e ch

ild t

o na

me

five

non-

dist

ress

ing

obje

cts

that

the

y se

e.,

for

exam

ple,

”I c

an s

ee a

cha

ir/m

y sh

oe/t

he fl

oor.”

Rem

ind

the

child

to

brea

the

slow

ly in

and

out

. A

fter

thi

s, a

sk t

he c

hild

to

nam

e fiv

e no

n-di

stre

ssin

g th

ings

the

y he

ar, f

or e

xam

ple,

”I c

an h

ear

som

e ch

ildre

n pl

ayin

g/so

meo

ne w

alki

ng in

the

nex

t ro

om.”

Rem

ind

the

child

to

brea

the

slow

ly in

an

d ou

t. N

ow a

sk t

he c

hild

to

nam

e fiv

e no

n-di

stre

ssin

g th

ings

the

y ca

n fe

el, f

or e

xam

ple,

”I c

an

feel

the

pla

stic

cha

ir w

ith m

y le

gs/m

y fe

et p

ress

ing

agai

nst

the

floor

.” R

emin

d th

e ch

ild t

o br

eath

e sl

owly

in a

nd o

ut. Y

ou c

an a

lso

ask

the

child

to

nam

e di

ffere

nt c

olor

s th

ey s

ee a

roun

d.


Fla

shb

ack

sFl

ashb

acks

are

intr

usiv

e th

ough

ts p

rovo

ked

by

imag

es, s

mel

ls, s

ound

s,

tast

es a

nd s

itua

tions

re

min

ding

the

chi

ld o

f a

stre

ssfu

l or

trau

mat

ic

situ

atio

n. F

lash

back

s so

met

imes

feel

like

the

tr

aum

atic

exp

erie

nce

is

happ

enin

g al

l ove

r ag

ain

here

and

now

. For

som

e,

a fla

shba

ck e

ven

feel

s lik

e a

thre

at t

o lif

e, a

nd it

m

ight

tri

gger

anx

iety

(se

e se

ctio

n on

anx

iety

).

A fl

ashb

ack

may

be

tem

pora

ry a

nd t

he c

hild

m

ay b

e ab

le t

o m

aint

ain

som

e co

nnec

tion

wit

h th

e pr

esen

t m

omen

t.

How

ever

, som

e m

ight

al

so lo

se a

ll aw

aren

ess

of

wha

t is

goi

ng o

n ar

ound

hi

m/h

er a

nd b

e ta

ken

com

plet

ely

back

to

the

trau

mat

ic e

vent

, and

the

ch

ild m

ight

scr

eam

and

ac

t ou

t.

From

the

out

side

, it

mig

ht

look

inte

nse

and

be s

cary

to

wit

ness

, whe

n th

e ch

ild

lose

s co

nnec

tion

to t

he

pres

ent

mom

ent,

as

they

m

ight

see

m fa

raw

ay a

nd

out

of r

each

.

Kno

w t

hat

the

flash

back

s ar

e ou

t th

e co

nsci

ous

cont

rol o

f the

chi

ld

and

that

the

y ap

pear

sp

onta

neou

sly,

so

it m

akes

no

sen

se t

ryin

g to

ask

the

ch

ild t

o ca

lm d

own

or t

o fo

rget

the

pas

t.

Spec

ific

feel

ings

, lou

d no

ises

, tir

edne

ss a

nd

stre

ssfu

l sit

uatio

ns c

an

stim

ulat

e fla

shba

cks.

Stay

aw

ay fr

om t

rigg

ers.

Allo

w s

pace

for

com

mun

icat

ion

and

disc

ussi

on w

hen

an e

piso

de

happ

ens

to u

npac

k th

e co

mpl

exit

y fo

r th

e ch

ild.

Hel

p th

e ch

ild id

enti

fy e

lem

ents

of t

he fl

ashb

ack,

and

do

not

unde

rest

imat

e ho

w s

erio

us t

his

feel

s fo

r th

e ch

ild. T

hen

help

the

chi

ld id

enti

fy t

hat

the

flash

back

is n

ot r

eal,

but

a th

ough

t or

fe

elin

g on

ly e

xist

ing

insi

de t

he b

rain

. Thi

nkin

g of

the

flas

hbac

k as

a t

houg

ht o

r im

age

may

hel

p th

e ch

ild d

isso

ciat

e it

self

from

the

flas

hbac

k an

d gr

adua

lly c

ompr

ehen

d th

at t

houg

hts

are

not

dang

erou

s, a

nd t

hat

they

will

pas

s.

Whe

n fla

shba

cks

appe

ar, e

nsur

e ph

ysic

al s

afet

y an

d he

lp t

he c

hild

reg

ain

norm

al b

reat

hing

and

re

lax.

Iden

tify

the

cur

rent

tim

e an

d pl

ace.

Hel

p th

e ch

ild a

ccep

ting

that

tho

ught

s an

d fe

elin

gs

pop

up, a

nd t

hen

help

the

chi

ld le

t it

go b

y qu

ietl

y re

turn

ing

to w

hate

ver

acti

vity

the

chi

ld w

as

enga

ged

in p

rior

to

the

flash

back

.

Use

gro

undi

ng t

echn

ique

s2 whe

re y

ou in

volv

e al

l five

sen

ses.

Foc

us o

n sm

ells

, tas

tes,

sou

nds,

to

uch

and

sigh

ts t

hat

diffe

r fr

om w

hat

rese

mbl

es t

he t

raum

a to

div

ert

the

atte

ntio

n el

sew

here

.

HAND

OUT

1 –

3/4

2 G

roun

ding

is a

set

of s

impl

e st

rate

gies

to

deta

ch fr

om e

mot

iona

l pai

n. It

wor

ks t

hrou

gh d

istr

actio

n by

focu

sing

out

war

d on

the

ext

erna

l wor

ld a

nd t

o a

safe

pla

ce r

athe

r th

an in

war

ds. W

hen

over

whe

lmed

with

em

otio

nal p

ain,

it s

omet

imes

hel

ps t

o gr

ound

you

r th

ough

ts t

o th

e pr

esen

t he

re-a

nd-n

ow t

o ga

in a

sen

se o

f con

trol

of y

our

feel

ings

and

a s

ense

of s

tayi

ng s

afe.

A g

roun

ding

tec

hniq

ue c

ould

be

as s

impl

e as

ask

ing

the

child

to

focu

s on

the

col

ors

or

smel

ls in

the

ir s

urro

undi

ngs.


Sle

ep

dis

turb

an

ces

The

chi

ld h

as p

robl

ems

goin

g to

sle

ep, s

tayi

ng

asle

ep o

r ex

peri

ence

s ba

d dr

eam

s.

The

re t

ends

to

be a

link

be

twee

n an

xiet

y an

d sl

eep

diso

rder

s, s

o th

e se

ctio

n on

anx

iety

mig

ht b

e he

lpfu

l too

, whe

n de

alin

g w

ith

slee

p di

stur

banc

es.

Prom

ote

a sa

fe s

leep

env

iron

men

t. E

ncou

rage

abo

ut 9

hou

rs o

f sle

ep d

epen

ding

on

the

age

of

the

child

and

stic

k to

the

fam

ily’s

norm

al w

ake-

up t

ime.

Onl

y in

fant

s sh

ould

nap

at

dayt

ime.

Do

not

eat

or d

rink

too

muc

h ri

ght

befo

re b

edti

me.

Use

rel

axat

ion

and

brea

thin

g ex

erci

ses.

Enco

urag

e th

e fa

mily

to

stic

k to

nor

mal

bed

tim

e ro

utin

es e

.g. s

ingi

ng lu

llabi

es, t

ellin

g st

orie

s,

slee

ping

wit

h a

toy,

say

ing

pray

ers.

For

you

ng c

hild

ren,

enc

oura

ge c

o-s

leep

ing

wit

h si

blin

gs/

pare

nts

as m

uch

as p

ossi

ble.

If th

e ch

ild is

afr

aid

befo

re b

edti

me

do n

ot p

ersu

ade

the

child

tha

t th

ere

is n

othi

ng t

o be

afr

aid

of, b

ut r

athe

r he

lp t

he c

hild

dev

elop

mor

e re

alis

tic im

ages

for

the

situ

atio

n by

ask

ing

”Wha

t is

it t

hat

mak

es y

ou t

hink

it w

ill h

appe

n?”

and

“Wha

t is

it t

hat

mak

es y

ou t

hink

it w

ill n

ot

happ

en?”

Hel

p th

e ch

ild fi

nd a

saf

e pl

ace

- by

imag

inin

g a

spec

ific

situ

atio

n in

whi

ch t

he c

hild

felt

safe

and

hap

py. T

his

can

help

in k

eepi

ng n

egat

ive,

intr

usiv

e th

ough

ts a

way

bef

ore

bedt

ime.

An

ger

an

d

ag

gre

ssiv

e b

eha

vio

r

Chi

ldre

n w

ith

aggr

essi

ve

beha

vior

may

be

argu

men

-ta

tive

and

verb

ally

agg

res-

sive

. A

ggre

ssiv

e be

havi

or

child

ren

may

als

o ha

ve d

iffi-

cult

y co

ntro

lling

the

ir t

em-

per

and

are

easi

ly u

pset

and

an

noye

d by

ot

hers

. T

hey

are

ofte

n de

fiant

and

may

ap

pear

ang

ry a

nd r

esen

tful

.

Faci

ng

ange

r ca

n be

ve

ry

frig

hten

ing,

an

d yo

u m

ay

as a

hel

per

get

the

feel

ing

that

the

ang

er i

s di

rect

ed

tow

ards

you

, if

the

child

is

host

ile

tow

ards

yo

u.

The

be

st w

ay t

o he

lp t

he c

hild

co

pe w

ith

her/

his

ange

r is

by

rem

aini

ng c

alm

and

sup

-po

rtiv

e an

d av

oid

resp

ond-

ing

wit

h re

sent

men

t.

Und

erst

and

how

m

uch

desp

air

is b

uild

ing

up w

ith-

in

the

child

in

or

der

for

he/s

he t

o ac

t ag

gres

sive

ly.

Rem

embe

r th

at

no

child

w

ants

to

act

aggr

essi

vely

.

Mod

el a

ppro

pria

te e

mot

iona

l con

trol

and

man

agem

ent

of a

ngry

feel

ings

. Tea

ch y

our

child

ren

how

to

exp

ress

the

ir e

mot

ions

– g

ood

and

bad.

Mod

el t

hat

you

as t

he a

dult

can

hand

le w

hate

ver

the

child

thr

ows

at y

ou.

Agg

ress

ive

beha

vior

can

be

diffi

cult

to d

eal w

ith

com

ing

from

a c

hild

. It

is im

port

ant

to m

odel

cop

-in

g to

the

chi

ld b

y ha

ndlin

g th

e ag

gres

sive

beh

avio

r, bu

t it

is a

lso

impo

rtan

t th

at y

ou s

et p

erso

nal

boun

dari

es f

or w

hat

you

can

tole

rate

by

taki

ng m

omen

ts d

urin

g th

e da

y w

here

you

bre

athe

for

yo

urse

lf.

Allo

w t

he c

hild

to

feel

ang

ry, v

alid

ate

the

feel

ing

as a

nor

mal

rea

ctio

n to

a s

tres

sful

situ

atio

n –

a si

tuat

ion

that

is n

ot n

orm

al.

Let t

he c

hild

exp

ress

the

ang

ry fe

elin

gs, e

ven

if th

e an

ger

is d

irec

ted

at y

ou. L

imit

aggr

essi

ve b

ehav

-io

r by

tra

nsfo

rmin

g th

e ag

gres

sion

into

wor

ds o

r by

giv

ing

the

child

an

alte

rnat

e w

ay t

o ex

pres

s th

e an

ger

(suc

h as

lett

ing

them

pun

ch a

pill

ow o

r go

for

a ru

n). Y

ou c

an s

ay s

omet

hing

like

“M

aybe

yo

u ar

e an

gry

and

that

is o

k, b

ut it

is n

ot o

k to

pun

ch m

e. Y

ou c

an s

tam

p yo

ur fe

et o

r ju

mp

up a

nd

dow

n.”

Expl

ore

why

the

chi

ld is

ang

ry a

nd t

ry t

o un

ders

tand

the

roo

t ca

use

of t

he a

nger

in o

rder

to

solv

e th

e pr

oble

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HANDOUT 2 – 1/2

Tips for parents and caregiversREACTION HOW TO RESPOND

1. Sleep problems: Sometimes, children are more sensitive at bedtime and may worry and get troubling thoughts. Create a bedtime routine; a story, a prayer, cuddle time. Understand that the child is not being difficult on purpose. If you want, let your young child sleep next to you for a while to avoid fear of separation. A stable bedtime routine can be useful for adolescents and parents as well. Create quiet times before going to sleep by avoiding exercise and if possible exposure to disturbing noises right before bedtime. Focus on the good sounds that you hear and make sure that the child is with familiar people.

If your child has bad dreams, help them by distinguishing dream from reality by saying something like “Bad dreams come from our thoughts inside about being scared. You are in a bed, and we are safe now.” Explain that bad dreams are normal, and that they will go away.

Younger children often have a precious toy or item with them, and you can use this in a sleeping exercise with the child. Ask the child to lie down in the bed with the item on the child’s tummy. Now tell the child that the precious item needs to be rocked to sleep by the movements of the child’s tummy, so the child needs to breathe slowly and steadily. It might help to say “breathe in, 2-3-4, breathe out 2-3-4.”

2. Lack of appetite: Stress affects your child in different ways, including the appetite. Healthy eating is important, but focusing too much on eating can cause more stress and tension. Sit together, and try to make meal times fun and relaxing, and never force your child to eat. Model healthy eating habits for your child. Make sure that there is no medical reason for loss of appetite. The primary concern is the child’s psychological wellbeing, but make sure to return to normal eating habits when possible. To help the child through the crisis, it is ok that these are not the ultimate meal, and it is important to provide energy in a way the child can receive.

3. Crying when you leave:

It is often difficult for children to say how they feel, so they may show their fear by clinging or crying. Goodbyes may remind your child of any separation that you had related to the disaster. Understand that your child is probably scared of separating from you and not just trying to control you. Try to stay with your child as much as possible. For brief separations (bathroom, store, etc.), prepare the child by putting its feelings into words and explain that you will be back shortly. If you are leaving your young child with someone else, it is important to show the child that the temporary carer is capable, so the child feels in safe hands. It might be useful to spend some time with the child and the other carer before you leave in order to normalize the situation. You can say something like “I think you are scared. Perhaps, you don’t want me to go, because last time we weren’t together you didn’t know where I was. This is different, I’m going to the bathroom and I’ll be right back.” For longer separations, have the child stay with familiar people, and tell the child where you are, and when you will be back.1 If possible, avoid leaving the child alone for longer periods of time (two hours is a long time for a young child).


4. Excessive crying: Your family may have experienced difficult changes because of the disaster, and it is natural that your child is sad. When you let your child feel sad and provide her with comfort, you help your child even if she remains sad. If you have strong feelings of sadness, it may be good for you to get support, but it is ok to cry with your child. Allow your child to express feelings of sadness. Help your child name her feelings and understand why she may feel that way. Support your child by sitting with her and giving her extra attention. Help your child feel hopeful about the future. It will be important to think and talk about how your lives will continue and the good things you will do, like go for a walk, to CFS, play games or tell stories within the family. Hugging and physical warmth often helps a lot as well.

5. Risk-taking behavior:

It may seem odd, but when children feel unsafe, they sometimes behave in unsafe ways. It can be their way of telling you that they need your guidance and support. They need you to show them that they are important enough to be kept safe. If necessary hold your child, let the child know that what it is doing is not safe, and that the child has great importance to you, and that you do not want something bad to happen. With adolescents, it may help to establish activities that are beneficial to the community at large to give the adolescents a sense of actually helping and being important in the recovery.

6. Withdrawal and lack of interest in playing:

So much has happened, and your child may be feeling sad and overwhelmed. When children are stressed, some shout and act out, others shut down. Both need their loves ones. Stay close to your child and keep them close. Let your child know that you care. Try to put your child’s feelings in words. Let her know that it is ok to feel sad, angry or worried. Take charge and show the child that you, as the adult, are in charge and you are capable of taking care of your child. Try to do activities that your child might like; reading a book, singing or playing together. A child who lacks interest might benefit from small activities such as small household chores or practical help. Do not force your child to talk to you, but let them know that you are always available.

7. Fear of everything:

Your child may become more fearful in stressed situations. Try to remain as calm as you can with your child. Do not force your child to overcome the fears; for example if your child is afraid of darkness, do not force the child to stay alone in a dark place. Avoid talking about your own fears in front of your child. Give your child ways to communicate their fears to you, such as saying ”if you start feeling more scared, take my hand. Then I’ll know you need to tell me something.”

1 Be aware of Save the Children’s Safeguarding Policy, PFA page 118

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Tips for parents and caregivers


HANDOUT 3

When to worryThe list below indicates signs that a child may be in extreme distress, and a referral to specialized services and/or child protection services may be needed:

• If the child is at risk of harm to himself/herself and/or others

• If a child expresses suicidal thoughts

• If the child shows extreme, persistent withdrawal i.e. no emotional response, and the child’s expression seems flat with no negative or positive expressions.

• If the child is persistently whining/whimpering/uncontrolled crying over time (different from a grieving, liberating sob).

• If the child is dissociating i.e. if the child is detached from surroundings and fails to engage emotionally like the child used to do.

• If the child is experiencing hallucinations i.e. the child is hearing voices that are not real (auditory hallucinations) or seeing things/people that are not real (visual hallucinations) in ways that do not seem playful or joking.

• If the child is experiencing persistent anxiety attacks

• If the child is showing signs of mental disability such as permanent difficulties understanding language and social interaction

Always seek the support from colleagues, line managers or mental health specialists when considering what a reaction might mean.

Do not label reactions as ‘symptoms,’ or speak in terms of ‘diagnoses,’ ‘conditions,’ ‘pathologies,’ or ‘disorders.’

Try to describe the behaviour and thoughts of the child as accurately as you can.

In some cases, it might be relevant to consult a medical doctor to make sure the behavior you are concerned about is not due to medical illnesses such as diabetes or epilepsy.


Save

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Save the Children works in 120 countries. We save children’s lives. We fight for their rights. We help them fulfil their potential.

Our vision is a world in which every child attains the right to survival, protection, development and participation.

Our mission is to inspire breakthroughs in the way the world treats children, and to achieve immediate and lasting change in their lives.

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