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TRAINING MANUALDealing with traumatic responses in children
Psychological first aid for children II
Gen
na N
acca
che/
Save
the
Chi
ldre
n
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
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 5
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
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 6
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.)
12.55 - 13.00 Questions and answers 3.3 Comments and questions from participants about session 3 (5 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.)
14.25 - 14.30 Questions and answers 4.3 Comments and questions from participants about session 4 (5 min.)
Session 5
14.30 - 14.45 Wrap-up 5.1 Check-out exercise 5.2 Wrap-up
PFA 2 TRAINING SCHEDULE
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 7
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).
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 8
Jona
than
Hya
ms/
Save
the
Chi
ldre
n
Dan
Ald
er/S
ave
the
Chi
ldre
n
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 10
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 11
xxxxxxxx
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.
Gab
riel
le F
ranc
ois
Cas
ini/S
ave
the
Chi
ldre
n
Dav
id B
loo
mer
/Sav
e th
e C
hild
ren
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 13
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 14
Luca
Kle
ve-R
uud/
Save
the
Chi
ldre
n
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.
Loui
se D
yrin
g M
bae/
Save
the
Chi
ldre
n
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 16
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 17
Jens
en W
alke
r/G
etty
Imag
es fo
r Sa
ve t
he C
hild
ren
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 18
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 19
HAND
OUT
1 –
1/4
Tip
s fo
r st
aff
HO
W IS
TH
E C
HIL
D R
EAC
T-IN
G?
WH
AT D
OES
TH
IS L
OO
K
LIK
E?G
OO
D T
O K
NO
WH
OW
TO
RES
PON
D
Wit
hd
raw
al,
d
epre
ssio
n
an
d s
uic
ida
l th
ou
gh
ts/
A d
epre
ssed
chi
ld is
sad
, la
cks
ener
gy a
nd d
esir
e.
Slee
p di
stur
banc
es a
nd
diffi
cult
ies
in c
once
ntra
ting
are
com
mon
as
wel
l. W
hen
depr
esse
d, it
is
hard
to
imag
ine
that
th
ings
will
impr
ove,
and
fe
elin
gs o
f wor
thle
ssne
ss,
hope
less
ness
and
soc
ial
wit
hdra
wal
are
oft
en
asso
ciat
ed w
ith
depr
essi
on
and
suic
ide.
Som
etim
es,
depr
essi
on is
acc
ompa
nied
w
ith
suic
idal
tho
ught
s.A
chi
ld w
ith
suic
idal
th
ough
ts m
ay n
ot
dire
ctly
tal
k ab
out
his/
her
thou
ghts
. Ins
tead
, the
y m
ay m
anife
st t
hrou
gh
inte
rest
in s
uici
de o
r de
ath
– w
hich
can
be
diffi
cult
to
diffe
rent
iate
from
bei
ng
norm
ally
pre
occu
pied
wit
h th
e ov
eral
l em
erge
ncy
sett
ing.
Som
etim
es, t
he
child
will
spe
ak in
dire
ctly
ab
out
wan
ting
to “
mak
e it
all g
o aw
ay”
or “
the
wor
ld w
ould
be
a be
tter
pl
ace
wit
hout
me.
”
Som
etim
es, t
here
are
fe
w s
igns
of s
uici
dal
thou
ghts
and
thi
s m
ay b
e a
func
tion
of y
our
child
’s pe
rson
alit
y; a
shy
or
mor
e w
ithd
raw
n ch
ild m
ay h
ave
less
obv
ious
sig
ns t
han
an im
puls
ive
or m
ore
atte
ntio
n-se
ekin
g ch
ild
who
may
be
mor
e ov
ert
abou
t th
e fe
elin
gs.
Whi
le n
ot a
ll ch
ildre
n w
ho a
re d
epre
ssed
ha
ve s
uici
dal t
houg
hts,
de
pres
sion
is c
onsi
dere
d a
risk
fact
or fo
r su
icid
al
thou
ghts
and
att
empt
s.
Suic
idal
tho
ught
s do
not
al
way
s le
ad t
o su
icid
e at
tem
pts,
but
are
tho
ught
to
incr
ease
a c
hild
’s ri
sk.
Nev
er d
ism
iss
a ch
ild’s
suic
idal
tho
ught
s an
d ne
ver
prom
ise
to k
eep
a se
cret
for
them
. A r
efer
ral
to o
ther
ser
vice
s m
ay b
e ne
eded
.
Expl
ore
the
onse
t of
the
dep
ress
ion
wit
h th
e ch
ild a
nd p
aren
t. In
vest
igat
e if
the
depr
essi
on is
ca
used
by
a sp
ecifi
c ev
ent,
and
inve
stig
ate
the
suic
idal
tho
ught
s.
List
en a
ctiv
ely
to t
he c
hild
in a
n em
phat
ic w
ay.1
Let
the
child
ach
ieve
a fe
elin
g of
suc
cess
by
enga
ging
him
or
her
in a
ctiv
itie
s it
can
influ
ence
and
co
ntro
l. Su
ppor
t th
e ch
ild in
the
feel
ing
of b
eing
a v
alua
ble
and
impo
rtan
t pe
rson
. Do
not
give
th
e ch
ild t
he fe
elin
g of
bei
ng w
rong
or
diffi
cult
beca
use
of t
he d
epre
ssio
n.
1 Se
e th
e PF
A M
anua
l, pa
ge 9
7
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 20
HAND
OUT
1 –
2/4
An
xiet
yPh
ysic
al r
eact
ions
incl
ude
head
ache
, nau
sea,
di
zzin
ess,
dia
rrhe
a,
num
bnes
s, s
hort
ness
of
brea
th, r
apid
hea
rtbe
at,
feel
ing
fain
t, s
wea
ty o
r sh
aky
hand
s an
d fe
et.
Emot
iona
l rea
ctio
ns
incl
ude
feel
ings
of
ange
r, fe
ar, h
elpl
essn
ess,
di
sapp
oint
men
t an
d ex
cess
ive
wor
ryin
g.
Beh
avio
ral r
eact
ions
can
in
volv
e la
ck o
f eye
con
tact
(if
cul
tura
lly a
ppro
pria
te)
and
low
voi
ce v
olum
e.
Anx
iety
is a
nat
ural
hu
man
rea
ctio
n, a
nd it
se
rves
as
an a
larm
sys
tem
th
at is
act
ivat
ed w
hene
ver
we
perc
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 21
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 22
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
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HAND
OUT
1 –
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Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 23
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).
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 24
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
HANDOUT 2 – 2/2
Tips for parents and caregivers
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 25
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.
Psychological First Aid for Children 2 – Dealing with Traumatic Responses in Children 26
Save
the
Chi
ldre
n
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.