“Where Do We Go From Here?”

Life after trauma

An article for She Inspired Her
Written by Dr Eleanor Akaho, MBChB MRCPsych

There are moments in life that are simply indescribable. Moments that make the word “trauma” seem so minuscule and inadequate. Words don’t do it. Silence doesn’t do it. Nothing can do it justice because it is exactly the opposite of that: an injustice.
The recent attacks in London for example are a prime example. So many words have been written and reported about what went on in these major cities in the United Kingdom and now, as we seek to find a way to move forward, we are facing the age-old question: “Where do we go from here?”

For many young people, this may be the first time that they are having to deal with loss and existential questions. This means that many families may be experiencing their children or teenagers go through the grieving process for the very first time. It can be an extremely confusing period for all involved. There are so few clear-cut answers when it comes to life after trauma but as someone who works with children and adolescents who have emotional, perceptual and behavioural difficulties, I endeavour to offer some information and advice to help you to support your young people.

“Where do we go from here?” Many other questions stem from this: What is normal grieving and when does it become pathological? What is a normal stress reaction and when does it become post-traumatic stress disorder? What signs should we be looking out for in our young people? What can we do to help? And where can we seek professional help when the support of family and friends simply isn’t enough?

Let's look at the normal grief process, delayed grief, prolonged grief and depression:

The first thing to bear in mind is that the “normal” response to trauma or tragedy exists on a large spectrum; what works for one person will not necessarily work for others. One of the greatest ways that we can support one another in the aftermath of tragedy is to respect these differences. It is helpful to recognise that grief has been identified as having five main stages: anger, denial, bargaining, depression and acceptance. These stages can occur in any order and it can take several weeks or months for individuals to work their way through each one.

It is common for sleep patterns, appetite, interest in socialising and many other aspects of everyday life to be disrupted during periods of grief. Some children may show evidence of regressive behaviours such as bed-wetting or thumb-sucking whilst grieving. Teenagers may face existential questions and if they feel they have no platform to discuss their observations and concerns, this can further compound the depressive stage of grief. Some may adopt negative coping strategies such as deliberate self-harm, excessive use of alcohol or drug use, and this can cause complications that delay the grieving period.

Usually, most people begin grieving straight away following a loss. The initial shock is often said to wear off within a month, although completing the grief process is known to take several more months. Most young people will be able to resume school within the first month after experiencing a trauma, unless there are physical limitations. However, grief is sometimes delayed, meaning that a young person may not begin to pass through the stages of grief until several weeks or months after the loss. This is sometimes due to having an ambivalent relationship with the person they have lost, but can also be due to lack of social support, issues with addiction or experiencing a life crisis immediately before the loss (such as serious illness or another major loss).

As young people represent a cross-section of the general population, it is inevitable that a proportion of them will go on to develop depression. It can be difficult to differentiate between prolonged grief and depression as there is a big overlap in symptoms. In both cases, the young person may appear low most of the time, their concentration may be impaired and they may not be eating or sleeping normally. In these situations, it may be best to involve your GP if this goes on longer than a month in order to aid early diagnosis of depression.

Acute stress reaction and post-traumatic stress disorder

Unexpected trauma may give rise to heightened uncertainty and anxiety in the context of feeling unsafe. On average, most people undergo a one-month period in which they describe symptoms of what is sometimes known as an “acute stress reaction”. This involves similar symptoms to grief and depression but tends to last less than a month. If it goes on for longer than this, the young person may be experiencing post-traumatic stress disorder (PTSD).

PTSD falls into the category of an anxiety disorder. It often develops within six months of witnessing or being involved in a significantly traumatic incident. As with other anxiety disorders, a young person may experience physical symptoms as well as psychological and social ones. These include headaches, upset stomach, pounding of the heart, nausea, the feeling of a lump in the throat and mild breathing difficulties. These are caused by an increased level of stress hormones in the bloodstream.

If you are the parent or carer of a child or teenager who has been significantly affected by trauma or tragedy, here are some indicators of post-traumatic stress disorder to look out for:

Difficulty remembering some parts of the trauma

Emotional numbness

Difficulty concentrating due to preoccupation with the trauma

Re-enacting the trauma through play

Impulsive behaviours (in young people who were not previously impulsive)

Aggressive behaviours (in young people who were not previously aggressive)

Hyper-vigilance – they may be extra-sensitive to noises and seem suspicious of people

Nightmares or difficulty sleeping

Flashbacks (often preceded by triggers)

Avoidant behaviours – they may not want to go out and will especially avoid anything that reminds them of the trauma

Clingy behaviours – they may worry about being left alone

Regressive behaviours they may resume behaviours such as bedwetting or thumb-sucking

In more complex cases, the young person may report or be seen responding to images or sounds that others cannot see or hear

What can parents or carers do to support children and teenagers?

Do not force them to talk about the trauma in detail; this may actually re-traumatise them.

Listen to them when they are ready to talk and do not judge or try to dictate their feelings.

Discuss happy memories of the person they are grieving for. Also, consider holding a memorial service for the person where they can express themselves and fellowship with others who are grieving the same person.

Acknowledge that a bad thing that no one could control has happened and they are likely feeling scared, confused and maybe even resentful as a result of no one being able to prevent it. Be open and truthful; you may want to express your own sadness regarding your inability to protect them or make things better.

Reassure them that in the same way bad things happen in the world, good things also happen. Perhaps you can help to re-adjust their worldview by looking up real-life stories about people pulling together to help others in the community.

Be aware of special dates such as birthdays of those they’ve lost or anniversaries and try to do something special on those dates.

It is important to emphasise that the child or teenager’s age, gender, personality and previous encounters with adversity may all play a role in how they are affected and how they respond to support.

Seeking extra help

If you are worried that a loved one is experiencing abnormal grief or post-traumatic stress disorder, the first advisable step would be to sensitively express your concerns to them. In some situations, this may be enough to pave the way for honest conversation and you may realise that the situation is not as severe as you had imagined. If, however, further help is indicated, it is advisable to encourage the person to visit their GP. Older children can see the GP without their parent being present if they prefer. The GP will be able to assess whether referral to a counselling organisation will suffice or whether secondary mental health services are required. This may sound alarming to some but it is important to bear in mind that only a very small proportion of people will end up requiring such services and the vast majority of cases will be managed on an outpatient basis.

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