The COVID-19 pandemic (CP) exposes preschool children to illness, separation from and death of significant family members. In this reality, we must be aware of trauma produced by significant losses and changes in their social interaction system, consider its effects on preschool children and their parents, and how they can be helped in coping with this challenge. Children suffering from child traumatic stress are those who have been exposed to one or more traumas and develop persisting reactions that affect their daily lives after the events have ended. This theoretical article is based on a scientific analysis of the current literature, containing many and varied perspectives and worldviews on the subject. Research shows that trauma affects both physical and mental health, permanent changes in brain structure and function having long-term adverse effects on memory, learning, and behaviour throughout life. Post-traumatic adults experience difficulties raising children calmly and confidently, and struggle in helping their children process traumatic experiences. Trauma thus impairs parents' ability to serve as safe grounds for their children. In recent years, evidence-based treatments (EBT) have been widely used to help preschool children and their parents cope with the effects of trauma The common ground of Trauma Informed Care (TIC) intervention with preschool children and their parents should include elements of attachment, parenting, safety, self-regulation, and competency of children. Studies conducted on TIC intervention in child, parent, educational, community, and municipal systems have proved its efficiency.
Dr. Alicia Lieberman was on a tele-therapy call with a mother and her four-year old son. The mother reported that the child often lay on the floor, playing “dead”, and the mother had lost her patience with him. Dr. Lieberman asked whether she had told him about coronavirus. The mother replied she had not wanted to frighten him. The therapist responded that he had obviously noticed that his mother was wearing a mask and therefore it was clear that the four-year old already knew something about the virus. When the tele-therapy call ended, the mother spoke to her son, explained what she knew about coronavirus and admitted that the virus was indeed frightening. Later she shared with her son what they did to protect him and all family members during the pandemic. He asked many questions and after the mother had given him age-appropriate answers, he appeared to be calmer and stopped games in which he pretended to be dead. “Trauma,” explains Dr. Lieberman, “will be transmitted from generation to generation unless it is addressed and processed. We have to be willing to speak the unspeakable. We have to be authentic. Children need us to take them seriously” (Swarttz, 2020, para. 5). Writing about trauma in early childhood, we will open with the title of Bowlby's book (1979), “On knowing what you are not supposed to know and feeling what you are not supposed to feel”. The intention is to clarify that naturally we want to prevent young children in any way from being exposed to traumatic events and protecting them from the dire consequences of their lives. Despite the desire to protect children from trauma, it is known that early childhood is the age of risk (Chu & Lieberman, 2010). They lack understanding of risks and do not know how to protect themselves sufficiently. They constitute a more vulnerable population in traumatic situations because their development is accelerated and they have not yet developed sufficient tools and skills to cope (De Young et al., 2011; Lieberman, 2004; Zero to Six Collaborative Group, 2010).
How is Early Childhood Trauma Unique?
Preschool children lack the understanding of the relationship between cause and effect. Children of this age think that thoughts, desires, and fears can affect reality. In addition, they tend to blame themselves and their parents for not preventing a traumatic event or circumstances of trauma (Zero to Six Collaborative Group, 2010). Even a single traumatic event can produce biological and behavior reactions to trauma reminders and could develop as coping strategies chronic avoidance with effects on the brain in the HPA axis and on development (Lieberman & Van Horn, 2011).
Trauma in the COVID-19 Pandemic (CP) and Pre School Children (PSC)
Young children are likely to undergo a variety of experiences classified to trauma (Cook et al., 2005; DC:0–5™ 2016, p. 114). Since most children only experienced the CP with mild symptoms or asymptomatically, we will address trauma following loss of a close family member such as a parent or grandparent who took ill and died as a result of the illness. These cases were characterized by the speed and suddenness of deteriorating.
Pre School Children (PSC) with Traumatic Loss and Bereavement
The view is that in early childhood, losing a parent is in itself is 'the trauma of loss' as Bowlby (1980, p. 15) called it. Bereavement is a situation in which a meaningful figure is lost as a result of death, mourning and grief describe the emotional state and pain accompanying the loss. Children mourn deeply. The process of mourning occurs at an immature developmental time and place because children do not yet have emotional systems and abilities to cope with neuropsychological regulation and internal abilities to process mourning. Somatic and emotional bereavement reactions are enhanced when children are dumbfounded by subjective senses. At this time, they express common traumatic reactions: reliving the trauma, withdrawal, senselessness, avoiding addressing the event or emotions linked to loss. Surviving parents’ and other adults’ reactions to loss add to children’s experiences of threat to their emotional world (Lieberman et al., 2003). Generally, reminders are linked to memories experienced in a sensory manner: picture, sound, smell, touch, taste etc. In this case trauma reminders are hints that remind children of traumatic death and it is unique to each child and his/her circumstance, according to something external characterizing that event, or something that happened in the event itself (Cohen & Mannarino, 2011). Identifying children’s reactions to trauma reminders is an important tool in understanding how and why children’s distress, behaviour, and functioning, often change over time (Mannarino & Cohen, 2011; NCTSN, 2012; Scheeringa et al., 2003, 2005). Death of a parent or another attachment figure has a negative effect on children’s sense of security when it is difficult in these circumstances to discern where mourning ends and trauma begins. Mourning and traumatic processes are interlinked and the question of which process is more dominant depends on intrinsic and extrinsic factors. The former includes mode of death, child’s previous knowledge of death, whether a child witnesses the death, how and what a child is told about death. The latter pertain to a child’s developmental stage, cognitive abilities, and emotional resources. In any case, one can say with certainty that child traumatic stress is common in parallel to ongoing mourning among PSC who lost a parent early in life (Lieberman et al., 2003). Features can resemble clinical depression in many ways, experiencing deep grief, crying, avoidance and withdrawal, loss of appetite, sleeping difficulty, lack of attention to learning and developmental withdrawal. Even shortly after a loss, children are likely to be seen playing or laughing, which can confuse and perhaps concern adults whose sorrow is likely to be more permanent. The volatile nature of children’s reactions to loss characterizes their behaviour generally, which often fluctuates in contract to typical adult behaviour (Mannarino & Cohen, 2011).
Treatment and Practices for preschool children (PSC) with history of trauma
Since young children have the potential to significantly improve their mental health and wellbeing, it is possible through therapy to minimize the implications of ongoing traumatic experiences on their emotional, behavioural, social, and neurophysiological development and hence build their future (De Young et al., 2011). For children of this age, clinical therapy including interventions aimed at making parent-child relationships more resilient, improve attachment and self-regulation attributed to functioning and developmental components are the necessary effective approaches for young children to recover from trauma (Chu & Lieberman, 2010). All interventions here are evidence based and established. Child-parent psychotherapy (CPP) (Van Horn & Lieberman, 2008), Trauma-focused Cognitive Behavioral Therapy (TF-CBT) (Cohen et al., 2004; Deblinger et al., 2011; Mannarino et al., 2012; Cohen & Mannarino, 2015)), Attachment, Self-Regulation and Competency (ARC) (Kinniburgh et al., 2005; NCTSN, 2012).
Interventions during the COVID-19 Pandemic (CP)
CP caused physical, economic, emotional distress to the entire population. Children and parents treated around early trauma also suffered due to detachment from a caregiver who had been a meaningful source of strength for them. Some PSCs and parents continued the therapeutic relationship online or on telephone. Remote therapy (tele-therapy, Psychotherapy via Video Telehealth Remote play therapy) was the only option to continue the therapeutic process while maintaining protecting participants' health. Relational treatments and especially Video Telehealth evidence-based interventions (EBT) are considered effective therapies (Gros et al., 2013; Wrape & McGinn, 2018). Nevertheless, change of setting is not a negligible issue, and it is important to understand that treatment does not continue exactly from where it was stopped when it was frontal. Parents testify that during this period of social distance and isolation with the children at home, the caregiver was a meaningful figure and an important source of support for coping (Ben-Shelomo, 2020).
Trauma-Informed Care (TIC) in Systems and Services
From what has been written so far, it is clear that trauma has a fundamental consequence on the lives of PSC and any intervention that helps must be through the lens of the trauma. Trauma-Informed Care(TIC) refers to programs, organizations or systems designed to support children and their families who have survived trauma (Bartlett et al., 2016; Hanson & Lang, 2016). Several common assumptions underpin TIC principles' conceptualization: (1) Signs or symptoms of trauma in children, families and staff must be identified; (2) Trauma's wide ranging effects; (3) Response is through EBT; (4) Reduce re-traumatization; (5) Trust; (6) Choice and control; (7) Compassion; (8) Cooperation; (9) Strengths-based approach. These assumptions are expressed practically in different and unique ways in various systems (Chadwick Trauma-Informed Systems Project, 2013; Abuse, 2014). TIC systems equip all members with knowledge about trauma. They understand the biological, emotional effects of trauma and recognize methods based on identification and evaluation of people after traumatic experiences. They have the ability to work cooperatively with surrounding systems. Staff emphasize preventing re-traumatization and have knowledge and qualifications to help prevent further damage to and heal survivors (Abuse, 2014; De Candia et al., 2014; Fredrickson, 2019). Especially at the height of the CP, it is possible to raise awareness of the consequences of trauma for children and their parents. Developing TIC in systems providing services to PSC and their parents is a way to cope with the "emotional damage wave" caused by the pandemic. How to identify and assist individually, organizationally, and community-wise PSC and their parents who have suffered from trauma and loss in their immediate family of environment during CP?
Some of the Research Suggestions
1. PSC experience and remember traumatic experiences through body and senses, leaving them frightened and helpless. Thus, their reactions to trauma reminders are in a sensory-behavioural manner rather than verbally. To understand trauma in early childhood, it is necessary to see it in a developmental context of age and attachment of the child and its parents. During the pandemic, PSC experienced trauma deriving from illness, loss and bereavement of parents or other meaningful figures such as grandparents.
2. Loss per se is not necessarily trauma as death is a natural part of life. However, losing a parent is always traumatic for a child. Looking through the developmental lens is a way to understand loss among PSC as their emotional and regulatory abilities are not yet ripe for processing mourning. Bereavement is unique to circumstances and narrative of loss and PSC response is influenced by that of adults and their behavior. Death is a cause of uncertainty and damage to the basic security children need. Upon losing a parent, a child experiences the bereavement of the surviving parent and feels harm to his protective shield.
3. Following trauma, PSC respond with anxiety, behavioral difficulties and dependencies related to the daily functions: eating, sleeping, separation, etc. Lacking sufficient emotional expression, they express difficulties in play recreating the trauma as cited in the introduction to this article. Trauma affects the brain and achievement of age-appropriate developmental milestones. Developmental gaps or regression of previously acquired skills may arise. Additionally, trauma affects their relationship with parents or attachment figures. The consequences are cyclic: a child response to trauma influences parent's response to the event. In parallel, a child is influenced by parents' coping, regulation, and skills of parental metallization as supporters who provide explanations and calm the child.
4. Early intervention at an age that has flexibility and the ability to change achieves better results in PSC and prevents consequences for childhood, adolescence, or adulthood. Recommended treatment methods for PSC after trauma are EBT methods that have been researched and proven to be effective. These interventions share components tailored to trauma consequences for PSC: harm to a child's attachment, development, and security in the world. At this age it is not possible to care for and help a child without a parent being a full partner in treatment. Dyadic or triadic treatment of child and parents are the more effective methods.
Despite closure and social distancing during the CP period, treatment of PSC and their parents continued remotely online or telephone. Without other significant support sources, the virtual therapeutic relationship in a state of ongoing stress is a major significant support factor for children and parents who are at home in quarantine, After 16 months of addressing CP, more research is being conducted on the effectiveness and complexity of remote treatment methods.
TIC is an approach to treating traumatized children, parents, and families, placing trauma at the center while recognizing that trauma continues to affect life even after the event is over. "Speak the unspeakable" is one of the approach's components, acknowledging trauma, the survivor's narrative, and all that it entails. Implementing TIC in education systems, human services and organizations directs teams in contact with children, parents, families, and communities to recognize that the consequences of trauma are broad and deep, and trauma paints survivors' life functions. The unique components required in TIC include EBT interventions, use of the "strengths approach" - restoring choice and control to a person, working with clients collaboratively and systemically, providing protection and awareness to prevent secondary traumatization in teams.
The world has changed during the CP period and feelings of uncertainty have increased, especially in children who have experienced trauma in the form of illness and loss parent or close family member. There are also effects upon the second circle, children in their vicinity that have seen human loss and were also affected by CP consequences.
Reduced morbidity following the vaccination of the adult population allows for a gradual return of PSC to frontal encounters in educational settings. It is my wish to raise the education, welfare and mental health systems awareness of traumatized children and parents during CP and cause them to develop new ways of helping individual trauma victims as well as families and communities through TIC.
TIC is the approach required to assist in coping with PSC and parents returning to function and rehabilitation, having witnessed, or survived trauma and loss. The education, health, mental health, and welfare services are required to assimilate TIC in their work and thus see children and their parents' difficulties through the lens of trauma and make necessary changes. If in the past, an unregulated child was asked "What are you doing?" In TIC approach we will ask "What happened to you?". Under these conditions, a child will feel sufficiently secure to talk about the traumatic experience. In this way he/she will receive the necessary care and support, and we will also be able to ensure the protection and safety of children and prevent re traumatization.CP Strengthened my desire and need to know more about early childhood trauma and indeed these days I have undertaken, in the framework of my doctoral studies, research of social services in Israel: "".
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23 March 2022
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Miller Itay, M. R. (2022). “When Will Grandma Come Back?" Healing From Trauma Preschoolers And Their Parents. In I. Albulescu, & C. Stan (Eds.), Education, Reflection, Development - ERD 2021, vol 2. European Proceedings of Educational Sciences (pp. 769-776). European Publisher. https://doi.org/10.15405/epes.22032.76