Community Crisis Response Team Training Manual:  Second Edition

Chapter Seven:  Crisis and the Continuum of Age 

I. The Continuum 

Age may play a large part in the survivors' ability to cope with crisis. Much has been written about the reactions of children to trauma, and yet, paradoxically, they remain an underserved part of a traumatized community. The elderly are similarly underserved. This chapter addresses both the young and the old through a framework that looks at the effects of development on trauma reactions. It may be useful for the crisis responder to use the chart in Appemdix A of this chapter as an aid to understanding the following description of this continuum. 

How far you go in life depends on your being tender with the young, compassionate with the aged, sympathetic with the striving, and tolerant of the weak and the strong - because someday you will have been all of these. 
- George Washington Carver 

A. Age and human needs 

The effects of trauma on different age groups vary due to the biological, environmental, and psychological changes that people go through at different developmental stages. In some respects the continuum may be perceived as a circle, since many of the developmental issues facing children are similar to those faced by aging adults in reverse. 

The primary needs of a healthy, functioning adult are outlined in Maslow's Hierarchy of Human Needs (see Chart, next page). It is significant that from infancy to adulthood, each developmental stage focuses on issues related to the growth of new capacities towards self-actualization. The chart on the next page shows the parallel of Maslow's "Hierarchy" with developmental stages of children and the elderly. 

					Maslow's "Basic Hierarchy of Human Needs"
Child Development										Adult Adaptation
14-Adult (Structure/Stability            Self actualization					60-70
10-14 (Self-Esteem)               Intellectual and spiritual growth				70-75
6-10 (Relationships)		         Love and belongingness					75-85
2-6 (Care/Trust)     	Cognitive functioning (activities of daily living)			85-90
0-2(Contact/Care)			          Safety and security				90-100+
				    	       Basic human/survival needs	

The developmental stages of children and the study of how they create cognitive structures in interaction with their enviornment achieved important prominence with the work of Jean Piaget. Early emotional development and its affect upon the nature and character of personality functioning was explored in the impressive work of Erik Erikson, Anna Freud and others. This manual focuses on the translation of their understandings and new research on the impact of trauma on both emotional and cognitive development in children. The intent to summarize clearly selected developmental factors that affect the internalization of trauma. 
In infancy, the primary need is for contact with humans and the sustenance of physiological needs. Infants crave and need care and nurturing as the basis for their secure sense of safety. In preschool children, the primary need is to grow successfully into physical independence in support of the activities of daily living. As they become independent, they also begin to learn to trust others and develop extended relationships. This ability to invest in such relationships is a major function of growth for school-age children. As children move into pre-adolescence, they begin to develop a sense of personal identity and the process of building self- esteem. Healthy teenagers use the foundation of self-esteem to begin to transcend their environmental influences and move into creating themselves through music, words, dance, the generation of beliefs - a process of self-actualization. The need for them at this stage is one of structure and stability in their lives so that they have the opportunity of creation. 
While much attention has been focused on the developmental stages of children, there has been far less research on the developmental stages of the elderly. As people age, they often descend through the hierarchy of needs. Retirement from jobs or careers, decreased income, loss of relationships with friends and family due to death or immobility, and increasing health problems may affect the stability of their lives. 
While many people continue to grow and create themselves, some may find that the impact of aging constricts this self-actualizing process. There is an initial need to establish new structure and routines in order to maintain involvement with life. As they become older and face changes in their physical or mental capabilities, they suffer a loss of self-esteem. As their self-image changes, there is an increased need for finding meaning in their lives and a sense of satisfaction with what they have done and who they are. Often older people become reliant on their friends, children or others to assist them, and they need, more than ever since childhood, trusted relationships. Some older people lose all physical independence and must rely upon others for activities of daily living. There is a special need for care, nurturing, and human contact among some of the very old. 
Shakespeare famously captured this circular progression in his lampoon of the lives of the elite males of his age: 

All the world's a stage, 
And all the men and women merely players; 
They have their exits and entrances; 
And one man in his time plays many parts, 
His acts being seven ages. At first the infant, 
Mewling and puking in the nurse's arms; 
Then, the whiling school-boy with his satchel 
And shining morning face, creeping like snail 
Unwillingly to school. And then the lover, 
Sighing like furnace, with a woeful ballad 
Made to his mistress' eyebrow. Then a soldier, 
Full of strange oaths, and bearded like the pard, 
Jealous in honour, sudden and quick in quarrel, 
Seeking the bubble reputation 
Even in the cannon's mouth. And then, the justice 
In fair round belly, with good capon lin'd, 
With eyes severe, and beard of formal cut, 
Full of wise saws and modern instances; 
And so he plays his part. The sixth age shifts 
Into the lean and slipper'd pantaloon, 
With spectacles on nose, and pouch on side; 
His youthful hose, well sav'd, a world too wide 
For his shrunk shank; and his big manly voice, 
Turning again towards childish treble, pipes 
And whistles in his sound. Last scene of all, 
That ends this strange eventful history, 
Is second childishness and mere oblivion; 
Sans teeth, sans eyes, sans taste, sans everything, 
- William Shakespeare, As You Like It, Act II, Scene VII 

At either side of the age spectrum, key developmental issues are associated with the growth or decline of functioning. These issues include: physical and mental change, cognitive and emotional information processing, attitudes toward change, communication styles, primary relationships, and perceived status or power in the social environment. 

B. Developmental issues affecting the continuum of age 

1. Physical and mental transformations 

a. The physical and mental changes in children and adolescents can be characterized as substantive growth. 

All children grow and change physically. They grow taller and heavier; reach pubescence; and see their faces and bodies take on unique shapes. Their sensorial perceptions also grow. Infants and children learn to focus their eyes; distinguish sounds, smells and tastes; and recognize different kinds of touch. Their brain structure and chemistry is changing as they develop neuronal patterns to record information, and their experiences begin to define for them what information is relevant to their lives and what is not. Their emotions become more refined and they develop the capacity to speak and interpret the world around them. 

b. In adults, physical and mental changes relate to their abilities to build on the foundation of growth during childhood. They have the capacity to enhance their brain functioning through education and experience. They may not use this capacity, but it is available. 

c. For the elderly, physical and mental changes often are characterized by a decline in abilities. Their bodies may compact, causing them to lose some of their adult height. Their senses become less acute. Eyesight dims; hearing losses make sounds confusing; smells and tastes are muted; and the sense of touch may be altered by pain or numbness. Their brain structure and chemistry may also change. While degeneration of the brain is not inevitable, and many people are mentally alert throughout long lifetimes, about a third of all people age 60 and older have recall problems. 

There was a time when meadow, grove, and stream, 
The earth, and every common sight, 
To me did seem 
Apparelled in celestial light, 
The glory and the freshness of a dream. 
It is not now as it hath been of yore;
Turn wheresoe'er I may, 
By night or day, 
The things which I have seen I now can see no more. 
- William Wordsworth, "Ode on Intimations of Mortality." 
  
a. Children and youth are in a constant state of absorbing information. Since their senses are newly acute and their brain patterns are in the process of being established, their ability to take in new information is often better than people who are older. They may be more receptive to learning languages or music or acquiring physical skills. However, they do not have the cognitive foundation of knowledge to analyze the information they are acquiring. Therefore, they tend to make decisions or solve problems through trial and error. They tend to remember things well only for a short time. 

It may be that long-term memory depends on the ability to form narratives of perceived information, and that traumatic events sometimes leave only emotional and physical impressions, while ordinary events leave memory traces that, with repetition, become solidified over time. 

Children also have limited concentration spans for processing information. They do not yet have the discipline or the capacity to focus their attention for long time periods. This may be the reason that time itself is experienced as a slow process. The lack of memory of the past, and the lack of understanding of future possibilities, contribute to the fact that children are centered on present-day activities and events. 

b. Adult cognitive and emotional processing of information expands as they make associations and connections between thoughts, experiences and previous knowledge. Information becomes translated into protocols, frameworks, and perceptions. Nothing may be new under the sun, but there may be new ways of understanding. Information is no longer simply random - it becomes knowledge. With knowledge comes the ability to make decisions based on choices and the prioritization of values and options. For most people, their sense of identity and personality tends to solidify with age. Some may talk of a "new awareness" of themselves, but often the new perspectives are a revisitation of comfortable ways of living. It is in the middle years that most people have the most conscious ability to access both long-term and short-term memories. They can concentrate longer and put life in perspective. Since they now understand the concept of the future, future plans, rather than the present, often become the dominant force in adult life. The sense of time is demarcated by its routine passage in hours, the movement of the sun, the passing of days, the transitions of the seasons, all of which are based upon previously-experienced information and have been recorded in a temporal rhythm. 

c. The elderly tend to take what they have learned and know and merge it with an understanding of a meaning in life. Many cultures look to the elderly for wisdom. Even in the United States, where there is discrimination based on age, young people often turn to the elderly for advice on life and its meaning. Because of their experience, the elderly often rely upon routine, habit and tradition in problem-solving. New things are not always understandable. It is not unusual for the elderly to have limited, short-term memories. For many, a memory of what happened yesterday is not as much use or of as much comfort as a memory of what happened years ago. Concentration spans for the elderly may be as limited as those of a child. The elderly generally focus on life in the past and they experience life in the present as going faster and faster. 

3. Attitudes toward change 

A third developmental issue is people's attitude toward change. These age-related distinctions are very simple. 

a. A child or young adult experiences constant change and generally responds with an attitude of exploration and discovery. They do not have an established equilibrium in their lives. 

b. Most individuals in their middle years have acquired an equilibrium that is marked by daily, monthly and yearly routines. Even those who work in crisis situations on a regular basis learn to accommodate those crises in a routine manner. Change may be viewed as disruptive although adults often have learned coping skills that assist them in handling change. 

c. The elderly usually respond to change in one of two ways. They may cope well because they have developed coping strategies over time, or they may cope badly because change has caused so many painful losses. However, once again, they tend to rely upon a review of past behaviors as a compass for dealing with the present. 

4. Methods of communication 

The primary way individuals express themselves is also age-related. 

a. Children and youth initially rely on physical expression for communication, and gradually absorb language, and then become verbal. Infants communicate through noise and physical action. Throughout early childhood and into adolescence, forms of play remain the primary methods of ventilation. Games, dance, exercise, or athletics may all serve as modes of expression. As children become adults, there is a social value placed on how well they can communicate through reading, writing, or speaking. There is also evidence that linguistic ability contributes to brain development and mental functioning. Sometimes illiteracy, or the inability to speak the primary language of the country, interferes with the development of communication skills. For some, barriers to development of communication skills can also be barriers to development of adult learning skills. 

b. Adults in their middle years focus on verbal communication skills. Translating thoughts and reactions into narratives is central to the process of understanding those thoughts and reactions. 

c. The elderly may find that their communication skills decline in tandem with their physical decline. A person suffering from poor eyesight may not be able to see in order to read or write. A person who has poor hearing may find it difficult to hear what is being said. Small strokes, lack of concentration, dementia or Alzheimer's disease may make it difficult for older people to convey their thoughts to others. For this reason, many older people find comfort in a return to expression through physical means. Singing, dancing or swaying to music may be an achievable form of communication. While they may not be able to describe what happened to them on a particular day, if sights or sounds are recreated, they may be able to identify them. 

5. Primary relationships 

Human beings are social animals and through much of their life this is demonstrated by the relationships in which they invest most time and care. These relationships are affected by developmental stages. 

a. Children and youth begin their lives with their primary relationships based on their parents and their immediate family members. However, as they grow up, their focus changes to their peers. 

b. For those in their middle-years, the primary relationships remain with peers, whether those be friends, fellow employees, siblings, or partners. While parents often love and care for their children with great intensity, mental and emotional support is sought within their own age group. 

c. As people grow old, they retain their focus on their own age group, but gradually, the emphasis shifts to people in the younger generation. Those relationships may be with their own children or simply with young adults. It is not unusual for the relationships to "skip" a generation such that some elderly have closer relationships with people in their grandchildren's generation than people in their children's generation. 

6. Attributes of status and power 

Finally, social distinctions based on status and power change throughout the years. While these distinctions vary among different cultures, religions, and nations, the following tend to define the dominant approach to each age group in the United States.

a. Children are usually thought of as being very important. They are the next generation - a nation's greatest resource. However, because they have little access to true power, they may be ignored, neglected, or abused. 

b. Those in the middle years wield the highest levels of both status and power. They are old enough to have access to sources of power and they are young enough to still be considered a valuable resource. 

c. The elderly continue to be the most discardable segment of the population. As people age they are viewed as being less important because their contributions to society are assumed to have ended. They also have little access to power. Their financial power tends to diminish, and their physical abilities decline - they represent the past, not the future. 


II. Trauma in Children 

[Adapted from: Young, M.A., Working with Grieving Children After Violent Death: A Guidebook for Crime Victim Assistance Professionals, NOVA, 1996] 

A child is a person who is going to carry on what you have started. He is going to sit where you are sitting, and when you are gone, attend to those things which you think are important. You may adopt all the policies you please but how they are carried out depends on him. He will assume control of our cities, churches, schools, universities, and corporations... The fate of humanity is in his hands. 
- Abraham Lincoln 

Lincoln's observation should be a compelling argument for providing interventions to children who have suffered or witnessed traumatic events. 

Trauma overwhelms a person's sense of control, connection and meaning in life. It causes an individual to experience fear, helplessness and isolation. Traumatic events experienced by children have a particularly harmful effect. Trauma may directly affect the growth and development of responses in a child's brain. It interferes with a child's ability to develop a sense of functional equilibrium with the world. It compromises the child's sense of safety and security. It invades the construction of personal identity and integrity. It may disrupt the formation of relationships and appropriate social interactions. 

The experience of death can be traumatic for a child. The death of an elderly grandfather who was the source of nurturing, caregiving, and protection may be a traumatic source of grief for a grandchild while it may be an expected moment of sorrow in the child's parent's life. Violent death is experienced as a double trauma. There is the trauma of death and there is the violence that caused the death. 

It is important for crisis responders to understand the typical developmental stages of children and their reactions to trauma, and as well as how trauma reactions are related to grief reactions, in order to provide direct crisis intervention in schools and communities and for training parents, teachers, and other caregivers in how to better respond when children have been traumatized. 

One of the challenges for a field of developmental victimology is to document how victimization at different stages of development can have different kinds of effects (Trickett & Putnam, 1993). Such developmental specific effects can be related to three different aspects of development, according to a formulation Shirk (1988) made in regard to physical abuse:(a) differences in the developmental tasks children are facing at the time of victimization, (b) differences in the cognitive abilities that affect children's appraisal of the victimization, and (c) differences in the forms of symptom expression available to the child at that stage of development. Each of these processes is worthy of further study 
- Finkelhor & Kendall-Tackett, in press. Finkelhor, D., "The Victimization of Children and Youth: Developmental Victimology," in Victims of Crime, 2nd ed., eds. Davis, R.C., Lurigio, A.J., Skogan, W.G., Sage Publications, Inc., Thousand Oaks: CA, 1997 [References to Trickett, P.K., & Putnam, F.W., "Impact of child sexual abuse on females: Toward a developmental psychobiological integration. Psychological Science; Shirk, S.R., "The interpersonal legacy of physical abuse of children," in Abuse and Victimization across the Life Span, Straus, M.B. ed, Baltimore: Johns Hopkins University Press; and Finkelhor, D. & Kendall-Tackett, "A developmental perspective on the childhood impact of crime, abuse, and violent victimization," in The Effects of Trauma on the Developmental Process," Cichetti, D. & Toth, S., eds., Rochester, NY: University of Rochester] 

A. Development stages affect the trauma and grief 

1. Neurodevelopment may change. 

While much more research needs to be done, there is growing evidence that there may be changes in brain circuitry, brain chemistry and physiological reactivity in the brain as a result of trauma in children. Since the brain is still constructing its pathways of information processing from the time an infant is born until late adolescence, these types of changes seem reasonable. 

... brutality and cruelty to children can leave a clear mark on the chemistry of the brain. And those changes in brain chemistry may be the route by which a brutalized child becomes a violent adult. 
- Goleman, D., "Early Violence Leaves Its Mark on the Brain," The New York Times, October 3, 1995. 

First, neurophysical alterations in traumatized children may disrupt normal biological maturation (Perry, in press). Second these alterations, along with their effects over time, may have a significant impact on a variety of other aspects of child development. 
- Pynoos, R.S., Steinberg, A.M., & Goenjian, A., "Traumatic Stress in Childhood and Adolescence: Recent Developments and Current Controversies," in Traumatic Stress, van der Kolk, McFarlane and Weisaeth, eds. New York, NY, 1996. 

The recording, processing, and analyzing of sensory information may vary developmentally according to the specific sensory input, as well as the relative importance of sensory, kinesthetic, and somatic registration. For example, the smell of gunfire during a violent event may be registered with very little process; this is perhaps related to the underlying neuroanatomy of olfaction. Visual information ...requires more mature ability to discriminate. 
- Pynoos, Steinberg & Goenjian, "Traumatic Stress," van der Kolk & McFarlane and Weisaeth, eds. New York, NY. Guilford Press, 1996. 

2. "Traumatic memory" in a developmental perspective might better be understood through the concept of "traumatic expectation." 

a. Young children may have only physical memories of an event, without words to put to the memory. Even if verbal, they may not be able to integrate sensory perceptions into a narrative understanding of what happened. Hence, often a memory may focus on one specific impression associated with the threat or harm. 

...before about age twenty-eight months, a child seemed not to possess the mental capacity to take in, retain, or retrieve full traumatic images in words.... [however] behavioral memory (fears, play, reenactment, dreams) is almost universal. No matter what the age of the child when he experienced a terrible event ... the child repeatedly behaved in a fashion consonant with that event. In most instances, the children indulged in more than one kind of behavioral "memory." ...These behaviors turned out to be the truest, most accurate indicators of what traces of memory still existed in the mind of a child exposed very early in life to a traumatic event or a series of events. 
- Terr, L. Too Scared to Cry, NewYork, NY:Harper & Rowe, 1990. 

b. A child's memory of trauma often includes reinterpretations that integrate misrepresentations of the threat, incorporate intervention fantasies, and co-constructions of parents or peers. 

In general, childhood traumatic experiences contribute to a schematization of the world, especially of security, safety, risk, injury, loss, protection, and intervention. The importance of traumatic memories lies in their role in shaping expectations of the recurrence of threat, of failure of protective intervention, and/or of helplessness, which govern the child's life and behavior. "Traumatic expectation provides a more powerful explanatory concept for understanding the long-term consequences of trauma on the child's emerging personality. 
- Pynoos, Steinberg & Goenjian, Traumatic Stress. 
  
3. Reactions tend to mirror growth stages. 

There is a need to focus on the level and nature of the primary needs of a child and the developmental tasks that may be particularly vulnerable to disruption at the time of the trauma as well as the child's ability to absorb, respond to, and remember information. Children need to process their traumas through each developmental stage. If the trauma and grief inhibit, delay, or cause a child to "skip" a developmental stage, there will be a need to revisit that stage in light of the traumatic grief. 

Whatever the stage at which a child may have been victimized or whatever appraisals a child may make, the subjective distress from that victimization will usually be expressed within a vocabulary of behaviors or symptoms specific to the current stage of development. Thus distress expressed by preschool-age children in the form of disruptive behavior in preschool may take the form of self-blame or depression at a later stage. 
- Finkelhor, D., "A Developmental Perspective on the Childhood Impact of Crime, Abuse, and Violent Victimization," The Effects of Trauma on the Developmental Process, Cichetti, D. and Toth, S. eds., Rochester, NY, University of Rochester, 

4. Children process traumatic reactions and grief more slowly than adults because of their developmental processes. 

Children do not fully grasp the impact of trauma or the permanence of death. Children are unable to sustain conscious anxiety or sadness for long periods of time. Children do not usually deny the reality of what happened, but since they do not have an alternative reality, it may be emotionally more harmful and the cognitive impact may take years to sort out. 

The childhood tendency not to deny the reality of a traumatic event makes a striking contrast to the denial one sometimes sees in an adult. The adult may be unable to accept or to remember parts of an incident to which a child responds with vivid, detailed remembrance. 
- Terr, L., Too Scared to Cry. 

B. Childhood developmental stages and trauma 

1. Infants and toddlers (ages 0-2) 

a. Infants have limited verbal capacity to express their needs or emotions. However, they exhibit significant physical distress if daily needs are not met. They also retain physical memories of traumatic events even though they may never be able to articulate these memories or retrieve clear images of the events. A physical memory (or "imprint") occurs when the body recalls sensory perceptions of traumatic events. Much later, unexplained physical pains can occur that are related to these physical memories. 
  
Psychic trauma appears to leave an indelible mark in a child's mind, no matter how young he is when the trauma strikes. Perhaps traumatic occurrences are first recorded as visualizations, or even, by the youngest infants, as feeling sensations. These perceptual registrations occur long before any remembrances can be recorded in words ... perhaps [there are] two different kinds of memory - one a primitive kind operational from the earliest moments of conscious life (perceptual-behavioral memory), and the other, a more developed form that does not become fully operational until some time around twenty-eight to thirty-six months (verbal memory). 
- Terr, L., Too Scared to Cry. 

b. Infants initially experience their mothers as extensions of themselves with no clear distinction between self and other. As they grow older, they may become more aware of differentiation but they still see their primary caretakers as existing solely to meet their needs. They are dependent upon their caretakers for safety, security and daily functioning. 

An infant's awareness of the world is very narrow. First, the child is aware of mother. Next, the infant is conscious of his or her own physical being, and finally, of existing as a separate being ... The infant's needs are for physical contact, warmth, and consistency. The child's fears during the infancy are only those which pose a threat to his or her survival, such as the fear of separation from the nurturer, the fear of being left alone, or the fear that comes from seeing an unfamiliar face. Up to the age of two, there is no concept of death. 
- Staudacher, C., Beyond Grief, New Harbinger Publications: Oakland, CA, 1987. 

c. Infants lack a sense of object permanence until around one year of age. When people leave the immediate presence of infants, infants fear that they are gone forever, experiencing each such "leaving" as abandonment. When infants lose a caregiver through trauma or death, they may retain a sense of abandonment into adulthood even though they have no cognitive memories of the person who died. As infants grow to two years old they begin to explore their own independence and autonomy. However, they need constant reassurance that their adult caregivers will be available when needed. 

Sigmund Freud ... in discussing the responses of young children to their mothers' absences, referred to their crying and facial expressions as evidence of both anxiety and pain. Freud stated, with regard to the distressed child, "it cannot as yet distinguish between temporary absence and permanent loss. As soon as it loses sight of its mother, it behaves as if it were never going to see her again." 
- Webb, N.B., "The Child and Death," in Helping Bereaved Children: A Handbook for Practitioners, Webb, N.B., ed., New York: The Guilford Press, 1993. 

d. Death of a parent is experienced as a critical loss and leaves an infant fearful and anxious. It may also be experienced as absence - the death is defined not by the existence of a parent who is now gone but by the nonexistence of a parent who should be there. Trauma is also experienced as loss for it impedes the initial growth of autonomy and independent functioning. If the infant or toddler is exposed to a traumatic event, the exposure may leave the child numb and muted.  

But what happens when a child who already has achieved some autonomy is suddenly robbed of it?... The same autonomic releases for fight or flight come about - adrenaline is released, nutrients flow quickly to the muscles, and oxygen supply is augmented. But motoric discharge is blocked. The child's body - all ready for taking risks - cannot move. There is no hope of success. The child's mind, thinking overtime and totally on the alert, cannot fashion a plan because the shock of the ambush feels too overwhelming, the attack, too devastating, the attackers, too powerful. A child, in such circumstances, is totally helpless, and he knows that he is. He has temporarily lost a very human attribute and an early accomplishment, the ability to exert autonomy. 
- Terr, L., Too Scared to Cry. 

2. Pre-School (ages 2 to 6) 

a. Children usually become verbal between two and four. Preschool children often talk well. They can tell about what they eat and toys they play with, but do not understand less tangible concepts. Death may be thought of as a different state but not permanent. Children often believe in and experience "visitations" from the dead person through ghosts or reincarnations. 

I remember seeing my mother standing at the foot of the bed. She died when I was three years old. But, she would come back to me - at first every night after I knew she was dead. Then, as I got older, until I was about 12 years old, she would only visit me when I was troubled. When I was in my teens, I lost her. I used to have nightmares in which I was looking for her and never found her. When I had my first child, she visited me again for the last time. But I always remember those first nights when I was three. 
- A survivor of a murdered mother, a statement in a group crisis intervention, NOVA Crisis Response Team Report, December, 15, 1987. 

b. They may not be able to discuss events in terms of time because their understanding of concepts is related only to concrete or personal concerns. If children are asked when something happened - in terms of a month, day, or year - they may not be able to answer. But if they are asked whether an event happened before or after their birthdays, holidays, the beginning of school, or other significant events, or whether an event happened when the leaves were brown or when it was snowing, they are likely to provide a reasonable response. They may also be confused about where something happened because they may fail to identify distinguishing features in the environment around them. However, they may be very aware of their specific physical position at the time and where they might have been in relation to others. 

During our early years, we do not think of ourselves as a certain age - just as a certain size, or as in a certain grade in school, or as living in a certain house. Physical placement, on the other hand, is very exact in memory, especially in memories formed under terrifying circumstances. To defend yourself to the death, you do not need to know exactly how old you are - just your approximate size relative to the threat - but you do need to know your own position. Your position helps you to plot defensive action or a retreat. Your position can save your life. 
- Terr, L., Unchained Memories, New York, NY:Basic Books, 1996. 

c. The focus for children of this age is on their immediate life. Nonessential details, for them, are often forgotten or perhaps integrated with their own perception of important events. They think in terms of what is happening now, not what happened yesterday or what will happen tomorrow. 

Children from 3 to 6 understand their world in terms of day-to-day events that happen in their lives. Children consider time in terms of personally meaningful occurrences such as holidays, nap times, when "daddy" comes home, and "supper time."... "Future" is an abstraction that children only gradually comprehend as they move from the ability to remember past events of significance (i.e., their last birthday) to projection ahead to "next" Christmas. 
- N.B. Webb, personal communication, November 19, 1992, in Le Vieux, J., "Terminal Illness and Death of Father," Helping Bereaved Children, Webb, N.B., New York, NY, The Guilford Press, 1993. 

d. Children at this age are actively engaged in discovering a larger world than the home or the immediate family. This role of discoverer is needed to achieve greater independence in physical abilities, but it is quite challenging. Children must learn that they can trust their environment to stay somewhat stable if they are going to venture into new worlds. Trauma and loss that affects where or how they live, who their caretaker is, or what their surroundings look like interfere with the development of an understanding of trust and security. Sometimes they create their own environments of security. Cynthia Monahan relates the following case history in her book. 

Jenny [three years old] had become extremely distressed immediately following her grandmother's sudden disappearance from her life. The grandmother had left with no warning to get urgent treatment for a tumor at a hospital in a distant city. This grandmother had taken care of Jenny daily during the mother's work hours since birth and was clearly a most important person to this little girl. The suddenness of this major loss was immediately evident in Jenny's behavior. In addition to becoming very clingy and demanding over a month's period, Jenny began making little nests out of towels and blankets all over the house. She would curl up in these nests and cuddle with her favorite bunny several times a day during the first month of her grandma's absence...No one in the family could recall exactly when the nest building had stopped, but her mother thought that the nests had disappeared....Jenny's mother had actually forgotten about the nest building until Jenny was to begin kindergarten, which involved a new and challenging separation. Jenny's fears and anxieties regarding kindergarten brought up the earlier situation of loss and anxiety with her grandmother and she returned to her nesting solution to cope with it. 
- Monaham, C., Children and Trauma, New York, NY, Lexington Books, 1993. 

e. The most common communication device for the preschool child is play. Playing remains a key form of communication for older children as well. It is a nonthreatening language which can mask direct confrontation with nonthreatening issues. But while playing is an important mode of communication for all children, it is extraordinarily important in pre-schoolers. Their verbal ability can be good, but their security remains more intact through "acting-out" than through language. 

The children rarely spoke spontaneously of their experiences. Three children played games of "burying" in the sand. 

- [After the Aberfan disaster in Wales, October 21, 1966] Yule, W., "Technology-Related Disasters," in Children and Disasters, ed. Saylor, C.F.; New York, NY:Plenum Press, 1993. 

f. Fantasy is an integral part of play. It serves a useful purpose in providing children with an outlet for their fears, hopes and dreams. Fantasy involves magical thinking and vivid imaginings but such thoughts are grounded in observed reality. Lack of conceptual development means that young children are unable to extrapolate well from concrete to abstract thought. Hence, many of their fantasies involve mimicry, anthropomorphisms, and variations on perceived reality. 

Magical thinking and self-centered interpretation frequently combine to create some highly unlikely private explanations and meanings. Commonly these explanations involve the child's idea of just punishment for misdeeds. The child's attempts to make sense of a trauma too often end in self-blame. 
- Monahan, C., Children and Trauma, New York, NY:Lexington Books, 1993 

g. They may also believe that what they think about something can cause it to happen. Such egocentric thoughts may cause young children to believe that something they did or said caused the death of a love one. Children may use magical thinking to construct alternative realities when the world around them is painful. Most can distinguish concrete fact from fantasy but may have more difficulty understanding real versus imaginary causes for events. In today's world, sometimes they may become confused with what is "real" on television and what is real life. 
   
Mom frowns. Ben thinks. "I must have done something wrong to make her so angry. It's my fault. I've been such a bad kid lately!" He didn't understand Mom had just heard bad news on the telephone. Children can't separate themselves from the experience. They take in an adult message, "swallow it," and "stuff it," sometimes carrying it all of their lives. 
- Goldman, L., Life & Loss: A Guide to Help Grieving Children, Accelerated Development, Inc.: Muncie, IN, 1994. 

3. School-age children (ages 6-10) 

a. School-age is marked by rapid cognitive and competency development. Children tend to be able to formulate and articulate concepts and understand multidimensional ideas, even though they may not be able to independently identify such dimensions. Thus, they usually have been exposed to death and have thoughts about it, but may still think of it as reversible. Death may be externalized in concrete fears and images of monsters, scary animals or people, or inanimate objects. Memories of trauma may be replayed in day- and night-dreams. But their impressions of these events may be shaped by misperceptions and myths overheard from others or seen in the media. 

One of the major perceptions that occurs within (or near) this age range is that death ... is a bogeyman, a monster, a ghost, a skeleton, or an angel who comes to take people away. It comes from the outside, and in that sense it is not a person. Children think that by being clever and trying hard, they can escape personified death as they could escape an assailant. 
- Staudacher, C., Beyond Grief: A Guide to Recovery from the Death of a Loved One, Oakland, CA: New Harbor Publications, 1987. 

b. Children become less egocentric and develop an ability to see things from another person's perspective. However, this ability may increase conflicted feelings about another person's death or a traumatic event. The death of a sibling may cause a child to fear his or her own mortality, feel bad because the sibling is gone, feel angry with parents for their preoccupation with grieving to the exclusion of the surviving child, or feel guilty about wishing the sibling dead at some time. 

If your child is in this age range, he has had more years to experience sibling rivalry, more memories of fights with his brother or sister, and more death wishes. 
Even more than when he was younger, he may feel that he was responsible for the killing of his brother or sister. He is not intellectually mature enough to persuade himself of his innocence. 
- Lord, J.H., No Time for Goodbyes, Pathfinder Publishing: Ventura, CA, 1987. 

c. School-age children relate much better to time and space. In part this occurs because they begin to develop relationships with other people and things outside of their own home. The fact that they must be at school at certain times and days gives them a more precise frame of reference. Weekdays now become distinguishable from weekends. However, the growing independence of children from the home means they must increasingly trust and invest in new attachments. Traumatic events may shatter that security and impede the capacity to make new relationships and attachments. They interfere with children's ability to trust others and their environment, especially when a child's routine, home, school or family life is destroyed. While children who have not suffered trauma may begin to develop a sense of identity, routine and equilibrium, children who have been traumatized learn that instability and disruption are reality. 

With my mother's death all settled happiness, all that was tranquil and reliable, disappeared from my life. There was to be much fun, many pleasures, many stabs at Joy; but no more of the old security. It was sea and islands now; the great continent had sunk like Atlantis. [C.S. Lewis's mother died when he was nine.] 
- Lewis, C.S., Surprised by Joy, Harcourt Brace: San Diego, CA, 1956. 

d. Children become increasingly able to respond with emotional affect but may find it difficult to tolerate the pain of grief for any length of time. They lack the ability to concentrate on any particular activity or issue for long periods of time. This inability to concentrate characterizes both their cognitive and emotional responses. Ad-ults may view children's natural need to sporadically distance themselves from sadness as an absence of grief. Children rarely forget their sorrow but visit and revisit it in short, intense periods of time, punctuated by a determination to distract themselves with other things. 

My friend kept saying, "Don't you care that your father died? Aren't you sad?" I said, "Yeah, I'm sad, but I can't cry all day." It was like she thought I didn't care, but I couldn't cry at school. [Ten-year-old girl whose father died in an auto accident] 
- Staudacher, C., Beyond Grief. 

e. As children grow older they often become more conscious of right and wrong. Things seem to be black or white. There is little room in their thoughts for the grays. If they think that they did something wrong, guilt may be overwhelming. If they think that others have done something wrong, anger and blame characterize their attitudes toward those persons. They do not have the ability to begin to comprehend choices that adults make or to understand when certain choices are not available. Children may be angry at their parents for not protecting them or angry at them for dying and abandoning them. There is a poignant and chilling description of such anger in an biography of James Dean whose mother died when he was eight and whose father then delegated his care to an aunt and uncle. According to that account, Dean was asked why he became an actor and he replied with the following words. 

Because I hate my mother and father ... I'll tell you what made me want to become an actor, what gave me the drive to want to be the best. My mother died when I was almost nine. I used to sneak out of my uncle's house at night and go to her grave, and I used to cry and cry on her grave - "Mother, why did you leave me? Why did you leave me? I need you ... I want you ... I'll show you for leaving me ... fuck you, I'm going to be so fuckin' great without you!" 
- Dalton, D., James Dean: The Mutant King, New York, NY:St. Martin's Press, 1974. 

f. Play is an important part of communication for school-age children; however, they need to be able to explain the purpose of their play as they become more verbal. School-age children often create "savior" endings when they retell stories of trauma in an effort to reestablish a sense of safety and mastery over an event. As they grow older, they may become more interested in games or play that is governed by rules and conventions. This is a part of their developmental efforts to internalize control and become increasingly independent from adults. 

Last year she [my seven-year-old] became interested in the Titanic. She poured over several of my Titanic books, and at her request we went to see an IMAX movie that shows the actual wreck lying on the ocean floor. At first I found her interest unsettling ... Then one night I came in to check on her while she was taking her bath. A wooden boat lay overturned in the water; around it floated three Barbie dolls and a dozen other plastic figurines. Susannah was pushing her inflatable teddy-bear soap dish through the water, picking up the characters and loading them on board. When I asked her what she was doing, she gave an embarrassed smile. "I'm playing Titanic," she said. "But the way I play it, there are enough lifeboats and everybody gets rescued." 
- Colt, G.H., "The Strange Allure of Disasters," Life, June, 1997. 

4. Early adolescence (10-13 for girls, 12-15 for boys) 

a. This stage may well be one of the most awkward and difficult for most children. The abruptness of physical changes, along with the related emotional upheavals that accompany increasing needs for independence and greater feelings of insecurity, are major sources of stress for these children. Since they are already dealing with physiological changes and identity development, a trauma that changes their lives and sometimes their physical well-being may have lasting effects. Children in this age group often talk about physical stress-related symptoms: nausea, headaches, sleep disturbances, frequent crying spells, and so on. 

...almost universally puberty is a time of inner turmoil as a result of psychological factors and internal sensations derived from bodily changes. 
- Sarnoff, C.A., Psychotherapeutic Strategies in Late Latency through Early Adolescence. Jason Aronson: Northvale, NJ, 1987. 

b. Preadolescence and adolescence brings with it a solid concept of death. But sudden trauma may undermine an emerging sense of an autonomy of identity at the same time as it may propel children into early adulthood. Traumatic events are readily acknowledged as natural, accidental or cruel events. Death is not equated with imaginary monsters or incarnations but rather is perceived as a biological process. Fears about death may focus on the dying process and the consequences of the death for the living. Pre-adolescents rarely think about their own death but rather consider it as an aspect of the aging process, something that may occur in their lives - but at such a distant future it is inconceivable. Hence, if a peer is killed, the impact is intense activity, depression, and upheaval. 

...children from nine to twelve years old seem capable not only of perceiving death as biological, universal, and inevitable, but of coming to an appreciation of the abstract nature of death, and of describing the feelings generated by this quality. This complex recognition pattern associated with death is joined by an emerging belief in the mortality of the self, but for these children death is far off in the future and remains in the domain of the aged. 
- Lonetto, R., Children's Conceptions of Death, New York, NY:Springer, 1980. 

c. The emotional roller-coaster that a child deals with at this age is manifested in wide mood swings. Their own identity is not clearly established and their self-esteem is shaky. Bravado and aggressive behaviors may be used to disguise their vulnerabilities. Traumatic events have a direct impact on the psychological construction of self-esteem and identity. While some young people may feel exhilarated as a result of trauma because they survived, in the aftermath, most acutely feel loss of control and autonomy, many times manifested in the inability to move or to feel. Thoughts of suicide, survival guilt, existential anomie, preoccupation with mortality, and loneliness are often complications for traumatized preadolescents on the emotional roller-coaster. Robert Lifton has the mindset of survivors of the Hiroshima bombing as one that contains "a legacy of lethal impairment." (The Broken Connection: On Death and the Continuity of Life, Basic Books: New York, 1983) And, for many traumatized preadolescents and adolescents that legacy also holds true. 

The "Aarvy Aardvark" story, while addressed to "people of all ages" connects to that impairment.

The next day the clouds hung low, like heavy grey curtains drawn over the sun. Aarvy lay in their shadow all day long.  
He was tired. So tired that he barely moved. So tired that he didn't even open his eyes. But he couldn't sleep either. He didn't even daydream.  
But several times he said to himself, "I just wish that I was dead." 
- O'Toole, D., Aarvy Aardvark Finds Hope, Burnsville, NC: Mountain Rainbow Publications, 1988. 
  
d. In early adolescence, children become more preoccupied with peer relationships and begin to distrust or challenge adult interpretations of the world. This is particularly true when they perceive that adults failed to protect them from a traumatic event or sudden death of a loved one. They yearn to remain a young child sheltered from harm, but, when there is no shelter to be found, they may lash out at those who might have tried to help them. 

My father killed Scott. He pulled me out of the car and I could've gotten out by myself. Scott couldn't have because he was unconscious. Now my father thinks I should be grateful to be alive and thankful to him. But it was his fault that Scott died and I don't care if I live or die without Scott. He was my best friend. It was my father's fault. If he helped Scott, we would all be alive today. Every time I look at my father, I think about what he should have done. 
- An eleven year old boy after a car crash in which two people were killed, NOVA Crisis Response Notes, July, 1988. 

e. There is a tendency for children to become very emotional in response to events at this age. The emotional interpretation of events without a pre-defined cognitive structure causes young adolescents to perceive things symbolically. They use their brains to translate their emotions into powerful symbols for protection and security. Increased abilities to understand abstractions may result in introspective searches for the meaning of life and death. As cognitive powers increase, so does the drive to connect consciously or unconsciously the emotional truth of an event with the cognitive understanding of it. Preadolescents are prone to active dreaming and the sense of telepathic powers, particularly in the aftermath of trauma. 

There is considerable psychological truth to the idea of dream prediction, but it is an internal truth, not an external one. Our deep inner drives impel us to action - certainly to future action. By giving our drives expression in dreams, Freud tells us, we do reveal something of our personal futures. But these futures are internally derived destinies, not prefixed fates awaiting outside of ourselves... 
In childhood trauma, paranormal "powers" develop after, not before, the overwhelming events. By virtue of time-skew and repetitive dreaming, traumatized children come to think that they are psychic. 
- Terr, L., Too Scared to Cry. 

f. Ideals and commitments are viewed as a sacred trust. Betrayal of promises, vows, or relationships is rarely tolerated, even when being faithful to them may be harmful to the children who rely upon them or when the person making such vows is incapable of honoring them. In the same way, children often feel extraordinary commitment to fulfill any request made to them by people who are dying in the aftermath of disaster or to live the lives that their loved ones would have wanted for them. Joseph Lash wrote about Eleanor Roosevelt's life after the early deaths of her mother and father.  

Because of her overwhelming attachment to him [her father], she would strive to be the noble, studious, brave, loyal girl he had wanted her to be. He had chosen her in a secret compact, and this sense of being chosen never left her. When he died she took upon herself the burden of his vindication. 
- Lash, J. Eleanor and Franklin, W.W. Norton: NY, 1971. 

g. Words and symbols mean a great deal to the preadolescent and the adolescent child. Stories, plays, poetry, and music lyrics often serve as a basis for expression - those written by others and particularly those created by the child. 

You told me to write in my diary about Joshua's death. When I did, he seemed to come alive. I described his dark brown hair, his wonderful eyes and I cried. I would never see them again. But, then the words took on a life of their own. He was alive on the paper. I used paper I had bought specially for him with lilacs in the corner because he loved the smell of lilacs. 
- A twelve year old girl whose boyfriend had been killed, NOVA Crisis Response Report, June, 1988. 

5. Adolescence (13-18) 

a. Normally, adolescence tends to increase the emotional upheaval of preadolescence. This adjustment period seems designed biologically to help us move to adulthood; however, the world is so complex that such growth still may seem to come too fast. Children often want independence but are unable to work within such independence and hence may simultaneously want more guidance and structure in their lives. This may be particularly true if the child has been abused and feels out of control. 

There weren't any rules; the rules just kind of dissolved after awhile. I used to dread going home. I never knew what was going to happen. The threat of a beating was terrifying because we saw what my father did to my mother. There's a saying in the army: "shit rolls downhill." He would do it to her and she would do it to us. One time she hit me with a poker. After awhile I got used to it. I would roll up in a ball. 
- Interview quoted in Herman, J.L., Trauma and Recovery, Basic Books, NY, 1992. 

b. At this age, adolescent behavior becomes inconsistent. Adolescents often love and hate the same person at the same moment. Anger may manifest itself as rage, and sorrow may become suicidal. As a corollary to their need for independence, they often have a great need for privacy and hence become very secretive. Confidences may be offered sporadically and may be peppered with untruthfulness when shared with adults. Secrecy may also become a coping mechanism when young persons are afraid that their emotions will not be tolerated by others. 
  
Jesse [age thirteen] said it was only when she was alone at night, lying in bed, that she could let herself think about her mother and their old apartment. Then she would realize that she would never go back there, and that her mother would never come back. Sadness and anger would flood through her. But she felt she had to be careful during the daytime. Otherwise, she and her brother and sister might get kicked out of this new home. 
- Fry, V.L., Part of Me Died, Too, New York, NY:Dutton Children's Books, 1995. 

c. The immediacy of death when it affects teenagers is in stark contrast to their desire to see death as a part of a far distant future and their inherent sense of immortality. Sometimes their activities center around proving themselves more powerful than death. Involvement in risk-taking activities may be exacerbated by the loss of risk-inhibitions due to traumatization. They often express themselves by acting out and through experimenting with new behaviors. Violence may be used as an expression of manhood by some young males. The suicide of a peer - a friend - may be particularly traumatic because news of a suicide is usually accompanied by disbelief, hurt, guilt, betrayal and fear. The fear for adolescents may be that they have considered suicide themselves at one time or another and they now realize that this option is a real possibility. 

The threat of personal mortality or the loss of loved ones may be so great that denial becomes a major defense. Adolescents' omnipotence may be viewed as counterphobic to the fear of the reality of death. Faced with a loss (whether death or another loss, such as the breakup of a relationship), the adolescent's grief may be expressed in death-defying, risk-taking behaviors such as substance abuse. 
- Gudas, L.J., "Concepts of Death and Loss in Childhood and Adolescence," in Saylor, C.F., ed., Children and Disasters. 

d. Most adolescents are creative and energetic. Their creativity is manifested through the creation of their own symbols, activities, and words. Slang, fashion fads, and alternative music styles are all examples of this need for creative expression. It is also illustrative of teenagers' need for control over their own worlds. They are likely to question and resent adult authority and decision-making in which they are not active participants. This is why it is so important to involve adolescents in the reconstruction of communities or the plans for a new life after a tragedy. It gives them a sense of ownership of their lives as well as a way to physically and mentally express their emotions. Facilitation of peer support groups, or organization of peer crisis response teams in planning for catastrophe, provides a way for adolescents to take leadership in the aftermath of trauma. Many young people create symbolic activities to memorialize their losses and to maintain a living connection to loved ones who have died or been injured in a catastrophe. 

A young teenager whose father, who was also his Little League coach, had died began to play every game for his father. 

"My father has been my baseball coach for six years, that is six GREAT YEARS. It was great having him for my baseball coach. He would always warm up the pitcher before the game started. Every time I was up to bat he gave me hand signals from third base on what I should do. 
"Now when I look down at third base and see he is not there to give me hand signals, I say to myself before the pitch, `This one's for you Dad.' " 
...Making something from his memories of his father helped Barry feel closer to his dad, stronger in his love for him. In the same way, it helped him feel better to dedicate each one of his hits to his father. 
- Fry, V.L., Part of Me Died Too, New York, NY, Washington Square Press, 1959. 

C. Children's reactions to trauma at any stage are affected by the impact of "parent loss" 

1. Actual loss of parent(s) 

A violent, traumatic event may cause the death of a parent. Children then must cope with the shock of the event but also with the sudden loss of one of the most important people in the world to them. Parents are normally the source of nurturing, care, and stability. They are the focus of a child's sense of security and protect their children from harm. If a parent suddenly dies, the child is left feeling scared and vulnerable. Infants and toddlers may only remember fleeting images or feelings associated with the parent, but they may experience the absence of a father or mother as a loss through adulthood. Some older children may regress to infant behaviors in an effort to recapture the time when they felt safe. However, many older children seem to accelerate their maturation process, taking on adult roles and behaviors. 

Sometimes traumatic events separate parents from their children or cause them to abandon a child. If children can't understand why or how the separation occurred, the loss of a parent under such circumstances harms children's abilities to trust others, and also their self-esteem. 

If a parent is the cause of the trauma, through accidental or criminal behavior, the loss of the parent may be complicated by feelings of alienation, betrayal, and even hate. Rage may become a dominant reaction toward the parent as well as others that the child views as conspirators with the parent. Children may blame themselves for their parent's actions and carry a burden of guilt into adulthood. 

2. Perceived loss of parent(s) 

Children tend to look to significant adult figures in their lives for reassurance about their own reactions and to learn how to grieve. Parents and teachers are natural models of behavior. However, often parents and other significant adults in a child's life are unavailable to the child after a traumatic event because parents are so involved with other concerns. They may also be perceived to be unavailable because they don't understand children's reactions, avoid or deny that such reactions are often intense and complex, or simply don't observe the reactions. 

Parent loss may be experienced when parents become consumed with their own losses or reactions to a trauma. It is often difficult to cope with the impact of violence and to offer comfort to children at the same time. Some parents may even fall into behaviors in which they assume a childlike role while their children take on adult roles in their relationships. 
  
3. Actual or perceived parent loss can be more traumatic than the trauma event itself 

Parent loss can affect how children later cope with adulthood. Since children tend to model their own behaviors on parent behaviors, parent loss may have an impact on a child's own parenting skills. It may have an impact on how the child deals with other adversities and how children cope with trauma when they are adults. 

D. Child and adult grief reactions are exacerbated by violent traumatic loss 

1. Intensity of emotion increases 

Since most grief reactions are similar to trauma reactions, trauma and grief have a multiplier effect on emotional responses. Anger at the traumatic event or the perpetrators of the event is made more complex by grieving protest over the loss. Fear or terror about the vulnerability of one's own life is complicated by the real knowledge of the death of others. Confusion about what happened, how it happened, or why it happened, mirrors confusion about the meaning of life and the meaning of death. There is also grief over the trauma, compounded by the grief over the consequent death. 

2. Duration of grief may be extended for years 

Grieving reactions following expected death may last for a year or two. Grief spasms - when people are reminded of the death of someone whom they loved - often are felt for a lifetime. Grieving reactions following an unexpected death may be unresolved for five or ten years. The trauma of the loss must be dealt with before normal grieving may begin. This means an individual endures the crisis reactions of shock, disbelief, anger, fear, frustration, shame, guilt or grief in response to the trauma and may suffer long-term stress reactions due to the impact of the trauma. Often, in the process of coping with the trauma, people have little ability to face the finality and impact of death. Their abilities may be impeded since trauma issues are forced to be reexperienced repeatedly because of involvement in the criminal justice system, civil litigation, or reflections by the media. Grief may also be confusing because of the extent of losses. Someone loved has died, but the traumatic event may also have caused the survivor to suffer a loss of faith or trust in the world, a loss of innocence or belief in certain values, a loss of a sense of identity or purpose, or a loss of meaning of life. Each of these losses need to be mourned and marked by conscious remembrance of what existed and now is gone. This grieving process is separate and different from the grief that will be experienced as one realizes the full impact of the loss of a loved one. 

E. Trauma and grief patterns of children are similar to adults but are manifested differently 

1. Length of grieving extends throughout the developmental stages 

As children mature, they should reprocess the impact of the trauma and loss in the context of their development. The loss of a father for a young toddler may be grieved over in terms of the loss of a loving caretaker. The loss of that father for the school-age child must be grieved over in terms of the absence of a teacher, an authority figure, as well as how the father would have been perceived by new friends and peers. The loss of the father for the preadolescent may take on new meaning in the absence of a model for sex roles or in the construction of the child's growing sense of identity. The loss of the father for the adolescent can affect his or her understanding of stability and the growth of independence. A young adult may grieve over the loss of the father in terms of a loving companion and source of friendship. The meaning of the traumatic event may also change throughout the sufferer's development. Memories of a sudden trauma are reprocessed in activities and attitudes. 

2. Traumatic events may be accompanied by ongoing crises and challenges in a child's life 

Children are constantly facing change and new situations. They are learning new lessons at school, changing classes, establishing new relationships, and taking on new responsibilities as they grow. Trauma may add significantly to their changing worlds. They may be sent to a new temporary or permanent home as the result of losing a parent and that may also mean they are in a new school and deprived of current friends or teachers who might have been supportive. They may be faced with a sudden change in their roles as a daughter or son, a sister or brother. They may have to go to work to help out with family finances. In addition, by nature, children must take time out from grieving to meet new challenges in life, cope with ongoing changes, establish new relationships, participate in school and to play. 

3. Children's communication styles differ from the communication styles of adults 

Children engage in activities to deal with trauma and grief. With young children, these activities involve spontaneous play, usually with objects or other children who are readily available. Older children and adolescents also engage in activities to express their reactions. These activities may include sports, drama, dance or song. Trauma- or grief-related activities may be sporadic and repetitive. 

4. Some adults have spiritual beliefs that help them to cope with trauma and grief 

Children may not have fully developed such beliefs, and trauma intrudes on their conceptions of life and death. On the other hand, for children who believe in God, they may become disillusioned in their beliefs. They may think God has betrayed them. The spiritual questions that may beset adults may also occur to children, but they may resolve them in ways that destroy their faith. 

F. Traumatic grief reactions 

1. Loss and death 

The experiences and concepts of loss and death are closely intertwined. Death is often expressed as the loss of life. Someone who has died has been "lost" to his or her survivors. The end of relationships or certain periods in life are often talked about through death imagery: divorce may be experienced as the death of a marriage; memories of the past may be thought of as old, faded, or dead. Grief reactions are normal when anything has been lost. When someone or something is gone forever, the grief may seem overpowering. The concept of death for children may be more difficult to understand when there is no tangible or physical evidence of finality. It is also difficult for children to comprehend or accept the permanence of death. 
  
2. Denial 

Adults often react to notification of traumatic death with denial. They can't believe that someone they love is dead or that they died due to violence or trauma. Denial occurs because the death does not fit into the adult's perspective of normal everyday life. Trauma may not be extraordinary - violence and death happen routinely in today's world - but traumatic death in a particular individual's life is extraordinary to that person. 

Children lack the ability to deny trauma and death because they don't have a fully-formed perspective of normal life. They live in a temporal world that is the present. What occurs today is reality, even if it is an awful reality. If they have had little experience with loss or death, they have little experience in dealing with the emotions that accompany loss or death. They don't deny it, but they may be unable to sustain the sadness or the fears that they face. 

Fantasy may be used to cope with those reactions and to escape from their intensity. Imaginary or magical thinking is a key source of emotional and mental processing. Children tend to replay the trauma or death through daydreams and nightdreams. They may not be as likely as adults to experience intrusive thoughts or flashbacks about the event. Rather, they let their minds wander into thoughts of the event and imagine ways to restore the past or recreate relationships that might now exist but for the event. Sometimes fantasies are scarier than reality. Images of a loved one buried alive in a coffin, confusion over the state of sleep with death, and concern over where the loved one is now are examples of sources of scary fantasies. On the other hand, younger children may create imaginary playmates or substitute parent figures in their dreams to help cope with their loneliness. Older children may idealize memories of the person who has died. Often dreams and fantasies focus on possible reunions. Some children may experience "visitations" by ghosts or spirits of the dead. Others may develop a belief in reincarnation of the deceased. Sometimes fantasy is used to explore alternative roles they might have played in responding to the trauma or in preventing a death. Fantasy may also be used to imagine different endings to the traumatic event that could have happened and would have had more positive consequences. 

3. Losses caused by death are concretely identified in a child's life; explanations about death and loss are often interpreted literally 

Someone has died. If a child sees the person who is dead, they notice the absence of activity. However, the difference between life and death may not be otherwise obvious. Their concern about the physical aspect of death may be manifested through questions about how someone eats, breathes, or goes to the bathroom when she is dead. Since they don't comprehend death's permanence, they may worry about what will happen to the person when they live again. Caregivers need to be alert to behaviors or casual comments that might indicate children have unspoken questions. Simple, straightforward answers, or acknowledgments that the caregiver has similar questions, are helpful to children. 

Because children's perspectives are tied to concrete, factual observations, it is particularly important to involve them in activities that acknowledge the mourning process and provide them with rituals and symbols that help to memorialize what has happened. Children sometimes think that adults don't care what happened to the deceased because adults do not involve children in funeral arrangements or memorials and may be uncomfortable demonstrating their own grief in front of children. Children often resent what they perceive as attempts to replace loved ones or to forget them. When the deceased's clothes or property are removed quickly, children may see that as a betrayal of the deceased. 

As children become more aware of the fact that the deceased will not return to their life, they also become more aware of the consequences of the death. They miss the behavior of the deceased - habits, routines, activities that they had learned to expect in their lives. They may miss physical reminders of the deceased, particularly if adults have removed clothes, personal property, or photographs from the child's home or school. They also miss the deceased when they are not a part of their life. If a child's father has died, dinner time may be particularly traumatic because the father doesn't sit in his usual place. Children may long for opportunities to discuss ongoing life events with a person who has died and who served as an advisor or counselor during their life. 

Loss may also be marked by increased expectations in a child's life, such as role changes or the need to become more mature. Sometimes these expectations are driven by children's own interpretation of the death and their need to behave differently in order to become safer or to substitute their own life for the one that has been lost. Sometimes the expectations are defined by family or social connections. A grieving mother may turn to her son after the death of her husband and want him to assume the role of the "man in the family." 

4. Trauma reactions are related to grief reactions 

Traumatic death compounds grief but reactions to the trauma often take precedence over grief. There is shock and disbelief about the nature of the traumatic event. Emotional reactions such as anger, fear, frustration, guilt, shame and grief over the traumatic event prolong efforts to begin life again. Grief may be postponed over and over again, but it is also a part of the traumatic reaction. While there are common elements of grief - just as there are comment elements of trauma reactions - every child is different. Some reactions may be illustrated in the following. 

a. Protest or anger over the loss or death 

Anger may be directed at the person who died - How could he do this to me? How could he leave me? It may be directed at parents or adult caretakers who failed to protect themselves or the child. It may be addressed to God or the supernatural - Why did he have to die and someone else is still alive? Sometimes it is directed internally by children themselves as they worry about what they might have done to cause the death. 

b. Sorrow and sadness about the loss or death 

Children need to know that crying is a normal way to express sadness. They need to know that feeling lethargic or uninterested in things around them is also a sign of their grief. Some children misbehave or withdraw from ordinary activities. It is often important to reassure children that it is okay to laugh and play, and that it doesn't mean they didn't love the person who died. 
  
c. Guilt or self-blame 

Children often believe that their thoughts or feelings can cause things to happen. If they wish that someone was dead and then that person dies, they may feel their thoughts made death happen. They may feel that if they had been better people, God wouldn't have let this happen to them. They may have deep regrets and guilt over times when they were angry or behaved badly towards the deceased. 

5. Children face additional risks which increase the traumatic grief reaction 

They may experience changes in the primary adult or adults who are responsible for their caretaking. They may be forced to relocate their home or to attend a different school because of the impact of the trauma. Sometimes they are sent away to homes of relatives or friends for a temporary time to give parents or significant adults a chance to organize their lives. Excluding children from transition activities and events adds to their sense of abandonment and isolation. Particular activities which children had enjoyed before the trauma may now cease because the person who died was the one responsible for promoting those activities or involving the children in those activities. 

G. Common coping skills among children 

1. Coping through spasmodic crises 

Children naturally allow themselves to deal with crisis and trauma by confronting those issues incrementally. They tend to focus on their grief and distress in short time periods and then return to everyday activities. They are not prone to dwelling on events or concentrating and analyzing the aftermath. They may become overwhelmed with emotions relating to a tragedy for a while but other things often divert them. 

2. Seeking and relying upon help from others 

Resilient children develop strategies for finding older children or adults who might help them. They will gravitate towards people who seem to provide stability and comfort. A child whose parent has died may actively identify a surrogate parent in the neighborhood or become especially close to a teacher or religious group leader. 

3. A sense of a foreshortened future 

Many children after surviving trauma cannot conceptualize a longlasting life. This can be a positive coping skill when it helps them to focus on the present. It can be a negative coping skill when they believe that they may, can, or will die in the near future and contribute to that belief through their actions. 

4. Retreat into fantasy 

Children often use fantasy as an escape from reality. They may imagine "savior" endings to a traumatic event that resulted in death or destruction. At times their fantasies will involve seeing themselves as the savior to the event, at other times they may imagine a loved one appearing as a superhero. 

5. Education and aspiration 

Some children cope well because they view the traumatic event as something to overcome through their learning or physical activities. Literacy seems to help children because it provides them a method of learning about what happened and beginning to process and understand its dimensions. School can provide a welcome relief to a traumatized child because it is routinized and the child knows what is expected. Lessons that are targeted and have definite definable goals help children to concentrate and adapt. 

6. Spirituality 

Children may cope better if they have a belief in God or other spirits. Children may believe that they are communicating with a loved one who has died and that they see the ghost or spirit of the loved one. This is not a frightening thought to many children but a comfort as they continue to grow and develop. Some children rely upon a belief in a loving God to help them through times when they feel alone and afraid. 

H. Interventions for traumatized children 

1. Caregiver communication 

Initial efforts at intervention should focus on communication techniques that are age-appropriate. Children should be encouraged to express themselves in play, artwork, music, dance or drama. Verbal communication through which children explain their activities should also be sought. 

a. Attention should be paid to helping children develop a narrative or a story of the traumatic death. Key components of such a story include placing the death in the context of time, space, understanding clearly what they observed and clarifying any particular misperceptions, and assisting children as they seek to find a meaning or purpose in what happened. 

b. Caregivers should remember that children need to take the lead in defining the terms of discussion or expression. A child's questions should be answered factually and simply when possible. Caregivers should listen carefully to questions so that they don't make assumptions about what the child knows or wants to know. Often caregivers fall into the trap of providing too much information in response to a question. 

c. Behaviors should be non-judgmental with regard to the traumatic event, the traumatic grief reaction, and the child's age-related behaviors. 

2. Goals of assistance 

a. Establish safety and security 

* Respond to and provide opportunities for children to receive positive human physical contact to reaffirm needs for sensory comfort and care. 

* Help children get enough sleep. This may involve responding to a child's concern about the safety of his bedroom or home, ensuring that someone is readily available to provide assurance after nightmares or sleep disturbances, or providing a soothing and calming environment before bedtime. 

* Help children develop protective plans of action if another traumatic event were to occur. This may include educating them on what they might do if something happened again and providing them opportunities to practice their trauma response. 

* Provide them with physical symbols of nurturing, love or remembrance. Teddy bears or stuffed animals are often a source of great comfort to children of all ages. Establishing and reestablishing routines or habitual activities gives children reassurance that life has returned to a kind of order. Rituals such as prayers, a regular "memory time," or special ceremonies may also be a source of security. 
  
b. Allow children to tell what happened and to talk about death and loss 

* Encourage them to tell or develop stories that help them explore intense reactions such as anger or fear. It helps to give them materials to draw or paint with. Activity accompanies and inspires communication with children. 

* Ensure that children understand differences between life and death. 

* Reassure them that sadness and grief are a necessary part of surviving the death of someone they loved. Help them to describe and understand reactions to trauma and reactions to the death. 

* Talk with them about what they observed in the reactions of parents, peers, or other significant adults. 

* Don't minimize their losses after a trauma. The death of a pet or the loss of a teddy bear may be heartwrenching for a child. 

c. Predict what will happen and prepare children for the future 

* Encourage the establishment and reestablishment of comforting routines. 

* Provide them with tangible comfort items: a photograph of a loved one who died, a stuffed animal, or a favorite blanket. 

* Educate them about trauma, death, and loss. 

* Help them develop reasons for living. 

* Help them take time to think about their future. 

* Support adult caregivers in their efforts to react appropriately. 

* Work to help children solve problems they face because of the trauma. 

- Address what can and can't be done. 

- Help mitigate other changes in their lives. 

- Address estrangement or their removal from peers and friends. 

- Help children frame their loss in the context of all of their relationships and their life as a whole. 

- Help children focus on the future. 

* Give concrete aid and factual information. 

3. Methods of intervention 

Much of what caregivers do when intervening is to try to help children tell the story of what happened and how they feel about it. The following methods can help children feel comfortable telling about their thoughts, emotions and concerns. 

a. Oral storytelling 

Caregivers encourage children to tell a short story about the traumatic event, the person who died or about themselves. Caregivers can suggest the following types of introductory sentences or phrases: 

* "Once upon a time there was a little girl named Mary who was very sad because..."; 

* "A few days ago I woke up and it was bright and sunny and I was very happy, but then..."; 

* "I'd like to tell you a story about the bombing." 

  With younger children, caregivers may need to model telling a short story. It may be useful for caregivers to consider telling a story about their own life when someone they loved died. While this technique is not usually suggested for use with adults, children are often exceedingly curious about adults who have suffered traumas similar to their own. 
  
b. Guided free play 

Traumatized children will often automatically use toys to reenact their trauma and their concerns. If caregivers have a range of toys available in a special box, shelf, or a bag, children can pick and choose their favorite mode of expression. Young children will run to the toys or immediately ask what is in the bag so they can start to play as soon as possible. Caregivers can observe children begin to play without prompting while doing preparatory things such as putting out refreshments, or hanging up coats. They can join the children with neutral questions such as, "That looks interesting. What are you playing?" Toys that are often helpful story tellers are: building blocks, cars, trucks, airplanes, human figures, dolls, stuffed animals, simple puzzles of people or people's faces. 

c. Stimulating discussion 

For children who are articulate and verbal, discussions can have a healing effect similar to that experienced by many adults who "talk out" their concerns and reactions. Caregivers can help children begin to discuss the trauma by showing photographs of the deceased, showing a video story about death and trauma, reading a short story, poem or parable relating to death and trauma, or presenting a news story or media article about the event for critique. 

d. Creative writing 

School age children and adolescents often find it helpful to write about what concerns them. Outlets for creative writing include journals, letters to loved ones, prose, poetry, articles, or memory books. Caregivers can help suggest titles for pages in memory books that may help children express potent feelings. Some ideas are: 

* "Mary's Name" [the child spells Mary vertically down the page and attaches a word to each letter that reflects what Mary meant to the child]. 

* "The thing I loved most about Mary is..." 

* "My saddest memory of Mary is..." 

* "My happiest memory of Mary is..." 

* "My funniest memory of Mary is..." 

* "Mary's favorite hobby, color, bird, music, food, sport was..." 

* "If you had been able to say good bye to Mary, what would you have said?" 

e. Creative art 

Children love to draw, paint, play with clay, and do crafts. All can serve as useful media for expressing the message of grief and trauma. Finger painting and working with clay are both messy arts but can be particularly helpful because they seem to offer children a more interactive, visceral sense of expression. Clay is often soothing to the touch, although some children like to pound or stab it in anger. One imaginative caregiver offered children the opportunity to finger paint shower stalls in the school locker rooms. They had plenty of room and the finished product could be washed away easily. The negative side of using impermanent art is that some children want to keep their creations because the expression of their feelings is so meaningful to them. However, sometimes it is feasible to take a photograph of the artwork to preserve its memory. When working with groups, caregivers might suggest that the group create a community mural. 
  
f. Dramatic enactments 

Most children like to play-act, particularly if props, costumes or makeup are available to enable them to become totally involved in being another person. Puppets can also be used. Young children may simply use the opportunity to reenact funerals or portions of the trauma stories. Older children and adolescents may want to create their own "mini" plays. Adolescents may also find playing parts, or reading scripts from classic and modern tragedies, helpful in expressing their concerns over death. 

g. Music 

Listening to, playing or singing music can be a wonderful release for children. It provides a reconnection to the sense of rhythm as well as the fact that certain musical instruments may echo sounds of grief reactions: anger might be expressed through the sound of drums or a blaring trumpet; reed and string instruments might remind children of weeping or feelings of loneliness; drum rolls and cymbals may reflect tensions, anxieties and fears; harps, flutes, and piccolos often sound like spirits talking, and so forth. Death-related lyrics are found in music as diverse as country-western, rap, opera, or hymns. 

h. Prayer, repetitive meditations, and chants 

The power of prayer for many children rests in the affirmation of spiritual beliefs, but also in relaxation responses triggered by the repetition of familiar and comforting words. They add an air of solemnity and gravity to rituals and memorial activities. 


III. Trauma for the Elderly 

To know how to grow old is the masterwork of wisdom, and one of the most difficult chapters in the great art of living. 
- Henri Frederic Amiel. 

The fear, helplessness and isolation that trauma may evoke in an individual may become overwhelming in older people because it may complicate their increasing sense of vulnerability in life. 

Someone who is competent in dealing with everyday activities but who has experienced some decline in physical or mental functioning may suddenly feel that he or she is not capable of even simple tasks. A disaster may also cause the deaths of important loved ones or destroy a familiar environment. Elderly peo-ple may feel isolated for lack of supportive contact or sensory perceptions. Trauma may also shatter previously-held concepts of a safe world or beliefs in a secure future for children or grandchildren. 

Some older people who have experienced victimization in the past are at greater risk for current trauma because the aging process leaves most people less resilient physically, financially, emotionally, and mentally. While death or trauma for a child may be experienced as a "double trauma." Death or trauma for an elderly person may be experienced as the continuing consequence of a "season of losses." 

Stressful life events - not only retirement and the subsequent loss of status and activities and reduction in income, but also illness and disease; the deaths of spouses, siblings, and friends; and children leading their own lives away from the parental home - are to some extent inherent to the life cycle. In fact, such events are more or less age-related, since they are more likely to occur and/or to accumulate during the later decades of the lifespan ... Life events may well trigger a delayed onset or exacerbation of PTSD in trauma survivors, as has indeed been observed in many instances, but they are certainly not a sufficient cause in themselves. 
- Aarts, P.G.H. and Op Den Velde, W., "Prior Traumatization and the Process of Aging: Theory and Clinical Implications," van der Kolk, B.A., McFarlane, A.C. and Weisaeth, L., eds., Traumatic Stress. 

For many years, crisis intervenors have responded to elderly victims as a group - those over the age of 65 were treated alike. It is important for crisis responders to understand the typical developmental stages of aging and kinds of trauma reactions that may occur at different stages as well as how trauma reactions are related to grief reactions in order to provide direct crisis intervention in nursing homes and community centers and training for caregivers, children and grandchildren in how to better respond when their significant elders have been traumatized. 

A. Developmental Stages of Aging Affect Trauma and Grief 

There are specific development issues to be addressed at every stage of life. For children there is ultimately the developmental issue of mastery over their environment and control over their daily lives. To achieve this, they must gradually obtain the capacities to meet the human needs diagramed in the Maslow Hierarchy. For elderly people, the tasks of ongoing development are complicated by the fact that their capacities for meeting their needs are compromised by the aging process. They must face the decline in their capacities even as they face the challenges of successful adaptation to aging which include: 

* Mourning for losses 

* Giving meaning to past and present experiences 

* Accepting one's past and present states 

* (Re)establishing self-coherence and self-continuity 

* Achieving ego integration" 

- Aarts and Op Den Velde, Traumatic Stress. 

This adaptation is dependent upon the integration of cognitive and emotional memory with present circumstances. If the memory is deficient or wholly or partially destroyed, the adaptation to aging and eventual death may never be accomplished. While adaptation is incremental and continuing until death, it is possible to construct a loose chronology of the interaction of developmental stages of aging with the tasks at hand. 
  
B. Elderly developmental stages and trauma 

1. The maturation of middle-age (ages 60-70) 

This is a reflective period for many older adults. It is a time to begin to assess what they have done in their lives and what has given them gratification or sorrow. It is also a time when they begin to realize that, while they have survived the vicissitudes of youth, they will not live forever and to consciously consider the imminence of their own death. Their potential deaths are usually put in prominence because they have already survived the deaths of some or many of their loved ones from the past. This developmental stage marks the beginning of conscious mourning for existing losses and anticipatory grieving for losses that are soon to come. This is also an age when there may be an assessment of the cumulation, so far, of physical and mental decline. Older persons may be incapable of running for three miles and have reduced their exercise routine to walking. They may have acquired glasses to compensate for vision deficiencies. Often they realize that they are suffering from aches and pains in their bodies from old injuries or simply the stress from daily living. It may also be a time when they realize they no longer look like they did when they were younger and that they have become an old person. 

It is this very awareness that one is no longer an attractive object that makes life so unbearable for so many elderly people. 
- Simone de Beauvoir. 

A traumatic event may interrupt the completion of age-related tasks by causing survivors to regress to earlier life stages that no longer apply in their present. It may injure them in a way that exacerbates their decline in physical functioning radically and abruptly such that they may no longer feel they have reason to live. It may invalidate their sense of purpose and meaning in the world and suddenly shake their faith in their own existence. It may cause them to believe there is no hope in their lives for happiness or contentment. It may also remind them of former traumas that they had "forgotten" or had sought not to remember. They then may face the conundrum of trying to integrate parts of their unwanted past with their current present in a consistent way. That conundrum may result in intrusive thoughts, nightmares, and pervasive physiological symptoms of emotional turmoil. 

After the hurricane, I began to dream, no, that is not the right word. I began to remember in the dark of night strange fantasies about my life when I was a child. I dreamed of human monsters and remembered strange places. They were places I never had been. But the dreams haven't stopped. They are always waiting when I go to sleep. Not dreams of hope but dreams of how to defend myself against the terror. I don't want to go on to defend myself. I'm 69 years old, successful in my family life and I continue to work. I don't want the dreams and memories of something I can't describe. I am sick during the day and sick during the night." 
- Survivor, after Hurricane Andrew, NOVA Crisis Response Notes, 1992. 
  
2. The young elderly (ages 70-75) 

Healthy elderly at this age tend to have completed the mourning process for their losses. They focus on developing an understanding of the meaning of their lives and perpetuating their self-actualization processes within the range of their competence. There is a reconciliation with the fact that they have suffered a decline in some abilities but a realization that they have other strengths. 

Because they continue to suffer a diminution of former physical abilities, they are often impressed with the need to consolidate their experiences and to attempt to make sense out of them. This means remembering their youth and past traumas as well as assessing what challenges exist in the present. The process of remembrance may be painful if they have endured traumatic events during their lives. It can also be a part of long-term healing as they begin to understand the nature of their life story. This is a particularly good age for encouraging autobiographical reminiscence. 

The impact of trauma at this age can be ambiguous. The elderly may draw upon former experiences and successes in overcoming them to dramatically reformulate their lives or to continue to survive in good health although grieving over the trauma itself. On the other hand, if they are already somewhat depressed and have constricted their emotional connections, the trauma may precipitate a sudden spiral into total dependency and incapacitation. 

To grow old is to pass from passion to compassion. 
- Albert Camus. 

3. The maturing elderly (75-85) 

Elderly people at this age may be faced with coping with decreased independence and the need to rely upon others for help with routine tasks such as driving, housekeeping, taking care of financial needs, or even some health care. This dependency state may frighten some maturing adults and they may need reassurance that those upon whom they rely will live up to the trust that is invested in them. Dependable relationships with others are critical to their sense of well-being. 

As the maturing elder copes with his or her present state there is a need to review the past, accept it, and accept his or her personality and character as it is now. What is left to be accomplished in life may need to be defined. What has been accomplished needs to be emphasized. Acknowledgment of the possibility of death, illness, and the process of dying may need to be revisited. Often, maturing elders find it comforting to know that not only their current loved ones are with them but their past loved ones are "waiting to be with them." It may be a time of revisiting spiritual issues and faith. 

The maturing elderly are often more judgmental of others than they were in the past. Their rigidity may be related to their need to re-establish their past identity which was rooted in values and perceptions from their youth. Acceptance of this rigidity by caregivers and loved ones is essential. This is not a time for changing attitudes of an elderly person but rather providing them with an affirmation of their life. 

Despite this tendency to rigidity, the maturing elderly often are in desperate need of companionship. Too many younger people think that an occasional visit, letter or telephone call suffices for this need for connection. In fact, maturing elderly often live for that moment of contact, which is so carelessly bestowed. In part, that is the reason that maturing elderly often bond so closely with pets, the comfort of feeding birds or squirrels in their window, or plants. Those living things are there every day and come back - seemingly grateful for the attention they receive. 

When trauma occurs at this age, it often is disorienting and serves as a final severing of connection to the world. Physical incapacities may deteriorate into physical incompetence. Mental flights of fancy or memories of the past may collapse into beliefs that memories of secure places and associations exist now or are altered to meet present needs. Caregivers should be aware that this reconstruction of old memories with present perceptions is not unusual. It is a coping strategy to continue to establish a sense of coherence. 

I want to pet my dog. [A demand to pet the dog with the crisis intervenor.] I remember my dog was there when the bombing happened. His name is Henri. He was there. He helped me escape. I'm glad I found him again ... this is not Henri, I don't know who this dog is, but I'm glad he is here. I was so afraid when I came downstairs and found everything in a mess. Its nice to have a dog ... It makes me feel okay. If the dog is not afraid, then I won't be afraid. But I don't know how I will put everything back. I don't know what to do ... I wish Henri could be here now. He would help me find things I want ... what's this dog's name?" 
- Interview with an 75 year old burglary victim conducted by Young (Rifai), M.A., Multnomah County Sheriff's Office: Portland, Oregon, 1975. 

4. The elderly (85-90) 

As people near the end of their eighth decade on earth they may be faced with the frightening prospect that they can no longer care for their daily physical needs. They may not care about eating and are incapable of controlling defecation or urination. This is particularly demeaning to those who still remain mentally alert. 

Even for people who are active, mobile and alert, the definition of those states may have changed. They used to jog around the park, and now they walk up the block and back. They used to be able to best their children at a card game and now they occasionally draw even. Life has gradually become less demanding for those who have resources and loved ones. But, life has also become more demanding as they continue the efforts to survive with dignity. Verbal and expressive communication with this age group is critical. Telling their life story is a process of not only remembering but establishing their internal narrative of their life's significance. 

If people at this age must be physically assisted in their care, they may confront discrimination. They may be ridiculed or become the subject for laughter and jokes. Even their loved ones may join in derisive comments - in part due to their own sense of powerlessness over the processes of age. There is a need for friends and family to help the elderly to focus on their own sense of competence and continuity as well as to provide them with the same care and nurturing that one would provide for a young child. 

This is also an age when the introduction or maintenance of pets or plants into their lives may be particularly useful. Cats or dogs with appropriate temperaments may become valuable companions. They can be warm, soft and loving. Raising plants, even on a small scale, can help elderly persons to connect with life. They have a reason to continue. They have a reason to wake up in the morning and ensure that life goes on. 

When trauma strikes older people, their first thoughts may focus on their own well-being, but just as likely their concern will be for the others in their lives who may need care. If the others do not survive, they may be desolate in the aftermath. Survivor guilt may predominate. The "others" here may be loved ones, children, pets, plants, or the community. Elderly people who are mentally alert may grieve for the rest of their lives over what was lost, unnecessarily, when they survived. Spiritual faith is critical for many elderly as they seek answers in their efforts to continue. Most people not only regress to childhood in their trauma reactions but also in their beliefs and coping strategies. For many elderly, those coping strategies rest on their spiritual beliefs. 

Twilight and evening bell, 
And after that the dark! 
And may there be no sadness of farewell, 
When I embark; 
For tho' from out our bourne of Time and Place 
The flood may bear me far, 
I hope to see my Pilot face to face 
When I have crost the bar. 
- Alfred, Lord Tennyson. 

5. The elderly survivors (90-100) 

Many people who survive over the age of 90 may face physical and mental debilitations that demand from caregivers only physical contact and care. They may be bedridden, incapable of movement and consideration of their own needs. Even if they have no friends or loved ones to provide such contact and care, there is a need for others to love, hold, and assure such elderly survivors. 

Disruptions and disasters that interfere with daily functioning can be fatal. Even if the disaster itself does not kill a person, in the immediate aftermath the person may not find the will to live or may be deprived of life-giving care. However, elderly survivors who continue to have strong connections to life and are engaged in positive cognitive and emotional relationships may serve as inspirations for younger people. Despite their infirmities and limitations, they may exhibit hope and dignity even after disaster. 

I am not afraid of tomorrow, for I have seen yesterday and I love today. 
- William Allen White 

Tomorrow is the most important thing in life. Comes into us at midnight very clean. It's perfect when it arrives and it puts itself in our hands. It hopes we've learned something from yesterday. 
- John Wayne 

C. Elder reactions to trauma are exacerbated by the season of losses 

An elderly person's life situation often dramatically changes as a result of the circumstances accompanying a traumatic event. 

1. Loss of peers, loved ones, and "descendants" 

In many cases, catastrophes result in the deaths of others who are closely related to elderly people. If the deaths of peers or loved ones represent the last remaining contact the elderly person had to their childhood or adult world, they will be devastating. If the deaths of others involve people whom they thought of as their children, their acolytes, their voice to the next generation, then that loss will also be catastrophic. While the elderly may have grown to accommodate "ordinary death" in their lives, the sudden random destruction of natural disasters or humanly caused violence may cause a blizzard to descend in their seasons of loss. 

2. Perceived loss of connection 

Children often suffer traumatic effects from the distraction of parents after a trauma. Elderly people also suffer from the sudden disconnection with loved ones who are still living but do not have time to visit or see them because of the demands of a catastrophe. They are abandoned by children who think that they are old enough to take care of themselves and who fail to realize the growing challenges of aging. 

3. Role changes 

Elderly survivors of a catastrophe may find themselves pushed into roles they used to assume in their middle years. They may be in the position of assuming parenthood of grandchildren, or even great-grandchildren, at an age when they themselves feel vulnerable. At times they may take on the care of multiple generations because they have financial assets that can help an extended family but at the sacrifice of their own security. At other times, they may be dismissed from family or loved ones they knew because they are disposable "extras." The sudden change of roles may be more threatening than the trauma they survived. 
  
4. Destruction or diminution of values 

Often elderly survivors have watched the values of their culture or society change over time and have resented or rejected such changes. This change in values may cause them to have less self-esteem and feel more isolated from others. That destruction of values may become even more difficult when a tragedy or catastrophe suddenly exaccerbates their perceptions of values. An elderly woman, a widow, who was raped felt that her marriage vows had been violated even though she had been assaulted. An elderly couple whose home was destroyed in a community-wide arson interpreted the event as a destruction of their family since all their sentimental remembrances and pictures had been destroyed as well as their home. 

5. Physical and mental ailments 

Due to the physical changes that aging brings, the elderly are more vulnerable to the consequences of disaster. Immobility, illness, and sensorial decline all may be exacerbated by catastrophe. Elderly persons who were not previously impaired may be jolted into disability. Caregivers need to be aware of the physical problems of older people in order to better communicate with them. Problems with memory loss may also be increased with tragedy. Since trauma interferes with ordinary memory processing, it can especially interfere with the memories of elders. They may confuse the current tragedy with tragedies of the past. They also can simply forget what happened but be aware of their emotional or physical distress and not know why they are distressed. 

D. Elder grief is different when it is occasioned by traumatic loss 

1. Lack of understanding of what happened 

The elderly often cope well with loss when it is incremental, if it is sudden, the surprise may overwhelm them. Confusion over why a disaster happened at this particular time may preoccupy them. They may have enough past experiences to recognize the reality of what happened but consciously or subconsciously choose to ignore it. 

2. Fear of additional traumatic loss 

The elderly may become increasingly afraid of what might happen to them or their loved ones. They may not want to watch television or read the news because it alarms them. They may be confused about where an event happened and worry that an earthquake in Mexico will occur in the near future in New Jersey. They may become fearful of doing new things or meeting new people because such new experiences will bring danger into their lives. 

3. Reliving previous losses 

For many elderly, a serious loss, death or traumatic event may cause them to relive other traumatic events or losses. They may need to process and reprocess memories that have long remained dormant. 

E. Natural coping skills of the elderly 

1. Spasmodic crises reactions 

The elderly often retreat in and out of a crisis when it happens. They do not concentrate on the crisis itself for certain periods of time and may focus on survival needs of food, sleep and shelter rather than the traumatic event. They may be unwilling to talk or discuss what happened, but, then intermittently, become overwhelmed with it. These reactions are helpful in many cases because it allows elderly people to take the event and cognitively process it slowly. 
  
2. A sense of a foreshortened future 

For some elderly, a disaster is the precursor to a recognition that they will die relatively soon. Their internalization of death's immenence can be frightening. However, for some, they cope with the recognition by preparing for death. They may begin to say good-byes to loved ones, distribute assets, and take more interest in the people they for whom they feel special love. There may be a need for them to tell stories from the past and remenisce about activities and relationships because they realize that these stories will pass with them at their deaths. They may also begin to prepare and plan for their funerals and other memorial activities. 

3. Retreat into fantasy 

The elderly often use fantasy as a method of coping. Their fantasies usually differ from children and young people. While youth focus on savior endings to current traumas, the elderly often retreat into fantasies of the past and how they survived. At times, these mental excusions are a review of coping skills that they used, but, at times they reflect revisionist personal histories. In either case, fantastical thinking can be a great aid in overcoming the emotional turmoil of trauma for older populations.  

F. Interventions for traumatized elders 

1. Caregiver communication 

The development of specialized communication skills for working with the elderly is critical. Caregivers need to be aware that for many elderly, it is difficult to listen to loud voices or to hear soft voices. While they may have a hearing impairment, yelling does not help them to hear. Distinction of phrases, enunciation of vowels, modulation of tone, and clear articulation are key to being heard. Elderly people with vision problems need to have written materials or other visual communication conveyed in large letters, bright or contrasting colors, and with distinct images. 

Just like children, the elderly should be encouraged to express themselves in play activities, artwork, music, dance or drama. Music seems to be a powerful tool for evoking emotional reactions and reassuring older people. Caregivers should know that the music that one learns, creates, or absorbs as a teenager or young adult is often the most memorable in later years. If an older person can articulate their reactions to various forms of expression, it assists in their construction of a narrative about what happened. 

a. Key components of a narrative for older people may be placing the trauma in the context of their past. Hence, when working with the elderly, caregivers may find themselves listening to a series of trauma stories from the past that relate to the current interpretation of this particular trauma. 

b. Questions from older adults should be answered factually and simply when possible. Caregivers should listen carefully to questions so that they can distinguish questions that relate to the older person's concern about care from questions that relate to a need to know pertinent information about what happened. 

c. Behaviors should be non-judgmental with regard to the traumatic event, the traumatic grief reaction, and the older person's behavior behaviors. 
  
2. Goals of assistance 

a. Establish safety and security 

* Respond to and provide opportunities for older people to receive positive human physical contact to reaffirm needs for sensory comfort and care. Often older people are "touch-deprived." While many caregivers will instinctively and spontaneously hug a child who looks forlorn, often they ignore the indications of the need for physical touch from older persons. 

* Help older people find a secure place to rest and relax. Older people may not need as much sleep as younger people but they need rest. Older people also tend to sleep in sporadic patterns so that opportunities for napping should be sought. 

* Help older people develop protective plans of action if another traumatic event were to occur. This may include informing them of who will take care of them, providing them with information on escape routes, ensuring that adequate food or blankets are available, and allowing them to decide what they would do if the event happened again. 

* Provide them with physical symbols of nurturing, love or remembrance. Teddy bears or stuffed animals are often a source of great comfort to all ages. As with children, older people rely upon routines to give them a sense of order in their lives. Daily meal functions at specific hours, "obligatory" social functions and specific tasks such as doing laundry, gardening, or walking a dog assist with the "return to normal." Rituals, prayers and ceremonies are also particularly important with older people. 

b. Allow elders to tell their stories 

* Encourage them to talk. It helps to give them something to do while they are talking. Many older people like to have coffee, tea, snacks, or meals while telling their stories. Throughout many cultures, food serves a function in setting the stage for social interaction. 

* Understand that older people may want to tell stories that have nothing to do with the current trauma. Reliving the past is a part of their way of integrating the present in their total life story. 

* Most older people have suffered grief and survived the death of loved ones in the past so encourage them to draw on their memories to find coping strategies for the present. 

* Let them tell you what is important to them. Their perspective may be dramatically different from the perspective of younger people. The destruction of an historical monument in a natural disaster may have more significance than the deaths of twenty community members because the monument was more intimately connected to the older person's life history. 

* Don't minimize their losses after a trauma. The death of a plant, the loss of a radio or television set, or the death of a pet may represent to them the loss of their connection to the world and to life. 

c. Predict and prepare older people for their future 

* Establish or reestablish comforting routines. These routines should be punctuated by reminders of the routine. Large calendars and clocks may be used to identify times of important functions, ceremonies or obligations. Repetitive statements of what is happening now and what will be happening next may be useful with some older people. 
  
* Provide new ideas or activities. While change may be resisted, older people are often encouraged when they have new opportunities. New positive possibilities stimulate and energize their cognitive and emotional abilities. 

* Encourage involvement with other people. 

* Identify items that may have sentimental value and put them where they can be easily seen or touched. 

* Review what older people have learned over the years about trauma, death, and loss. 

* Develop reasons for living. For some, this may be difficult. It is not unusual for elderly survivors to decide that it is time to die in the aftermath of tragedy. Caregivers should be aware that suicide is often prominent in the minds of older people who are in physical or emotional pain. They should also take care to avoid judgment on the ethics or morals of people in their eighties or nineties who might be already facing death if they decide death is preferable to life. However, many times, elderly survivors will choose to live if they have found a reason for continuing. 

* Support caregivers in their efforts to react appropriately. Most caregivers are younger than the elderly they serve. They have no experience with aging and may not have any education in working with older persons. Children are forgiven by caregivers for their behavioral transgressions and their lack of social skills in many situations while adults who commit similar errors are not. Adult caregivers need to be reminded and educated about the process of aging and what they can or cannot expect of the elderly. 

* Work to help older persons solve immediate problems. 

- Identify resources 

- Help mitigate life changes 

- Provide companionship 

- Help frame loss in the context of life 

- Encourage a vision of life as a continuum in which this disaster is another episode 

* Give concrete aid and factual information. 

3. Methods of intervention 

In order to accomplish the goals of intervention, crisis responders should experiment with the following tools. 

a. Oral history making 

Caregivers encourage older people to relate their life history as they remember it after the immediate tragedy. Caregivers can suggest the following types of introductory sentences or phrases: 

* "When I was little, I remember..." 

* "This flood scared me because of what happened before..." 

* "Let me tell you a story about the flood..." 

While it may be useful for caregivers to stimulate story-telling by telling their own story with children, with the elderly, this method is counterproductive. Older people may be interested in someone else's story, but is rarely as compelled by that story as by their own stories. Allowing older people to tell their stories, and tape recording them, is often an inspiration for the elderly. 
  
b. Pet intervention 

Pet animals often open up the hearts, minds, and thoughts of the elderly. Pets tend to give love and affection as well as respond to and crave touch from humans. The healing power of the human-animal bond can be extraordinary. Crisis responders who use pets should be appropriately trained, but if they use pets as co-counselors they will find that many elderly people will become more alert and more attentive to life. 

Eyes sparkle and hands reach out when PAL [PeopleAnimalsLove] pets come visiting. Mrs. Knight, a resident of Mariner Nursing Home, says "Wednesday are my best days, because `my girls' (PAL volunteer Linden Tucker and her basset hound Summer) come to visit. I love to feel her velvet ears, see her roll over and feel her head on my foot when she snoozes! It makes me forget all my aches and pains." 
- Strimple, E.O., PAL, Washington, D.C. 

c. Creative art 

Many older adults appreciate the opportunity to draw, paint or sculpt. Even if they cannot do detail work, they may thrill in the blending of colors or the feel of clay beneath their fingers. Each medium can be a useful tool for expressing immediate grief or trauma or long-term anxieties. Caregivers should be alert to the concern that many older people have that they may not be able to create anything worthwhile. Older people may need extra reassurance that their efforts are appreciated and valuable. 

d. Dramatic enactments 

Older people may love the opportunity to participate in enactments, particularly if they are in the position of "mimicking" others. Acting also provides them with an audience. Even if they have no audience, the fact that they are "acting out" what happened or what may occur means that they are their own audience. 

e. Music 

Listening to music, singing or playing music, or dancing/moving to music may open up communications with older people. Music can provide an almost magical connection between feelings and thoughts. It can soothe or invigorate. It may facilitate laughter or tears as a release from stress. It may stimulate memories of hope or memories of sadness. Many times music may be the key to helping elders find ways to integrate their life story if the narrative has been lost due to trauma. 

f. Prayer 

The nature of aging involves the necessity of putting one's life and the lives of others into perspective. This is why most elderly believe in some kind of spiritual connection to the world or to God. The power of prayer and the hope or solace it may offer can be a critical refuge for the elderly in the aftermath of tragedy. It is no wonder that for many older people who believe in the Bible that the Psalms of David strike such a resonant chord. 
 
The Lord is my shepherd; I shall not want. 
He maketh me to lie down in green pastures: 
He leadeth me beside the still waters. 
He restoreth my soul: He leadeth me in the paths of righteousness for his name's sake. 

Yea, though I walk through the valley of the shadow of death, I will fear no evil: for thou art with me; 
Thy rod and thy staff they comfort me. 
Thou preparest a table before me in the presence of mine enemies: thou anoinest my head with oil; my cup runneth over. 
Surely goodness and mercy shall follow me all the days of my life: and I will dwell in the house of the Lord for ever. 
-The Holy Bible, King James Version, "Psalm 23" Nashville, Tennessee, Regency Publishing House, 1976.

Copyright -  1987, 1994, 1998 by the National Organization for Victim Assistance, Washington, D.C.