Middle Childhood

Middle childhood is considered to cover the years of 6 to 12 and is a key transition stage between early childhood and adolescence. In this stage of development children begin and complete primary education. It is also a period critical for the development of important psychosocial functions such as cognitive skill acquisition, social relationship formation and self-concept consolidation.  It is a time when children gain the building blocks of education, social skills and motivation to become productive adults, and failure to gain these building blocks can lead to long-term negative consequences in the future (Penela et al., 2015).  Cognitively, in middle childhood, the ability to problem solve, reason and think logically is developed.  Additionally, the building blocks of literacy, numeracy and scientific learning are gained. These building blocks have an impact on future academic success.  It is also a time of social development. Peers become more important, and children have greater contact with adults external to their family (Eccles,1999).  It is during this time that social and emotional regulation is learnt, communication skills developed, and a sense of self and confidence is gained (Bishop, 1995).   It can be a time when comparison to peers causes inferiority and self-doubt however, protective factors like a close relationship with a teacher and a supportive family can mitigate these risks.  Children become able to identify differences in social functioning and compare and contrast this functioning between social situations.  Children in this stage of develop a sense of self pride as they expand their social and peer groups, they strive for achievement (Cherry, 2020).  Emotional adjustment and development is a key area for change in middle childhood, they forge a personal identity, a self-concept, and an orientation toward achievement that will play a significant role in shaping their success in school, work, and life.

 Post Traumatic Stress Disorder

Post Traumatic Stress Disorder (PTSD) can result from a singular trauma or as a result of prolonged, repeated or multiple traumas.  The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013b) sets specific criteria for the diagnosis of PTSD as exposure to an event or situation (either short- or long-lasting) of an extremely threatening or horrific nature. Examples include child abuse and neglect, disasters, serious accidents, violence, a sudden death of a loved one or a life-threatening illness.  Following the traumatic event the experience of the following 3 core elements lasting for several weeks:

1. Re-experiencing the traumatic event in the present, in which the event(s) is not just remembered but is experienced as occurring again in the here and now, typically in the form of vivid intrusive memories or flashbacks or repetitive dreams and nightmares (Carr,  2004).
2. Avoiding, reminders of the event in a deliberate way to reduce re-experiencing the traumatic event, avoidance can be active internal avoidance of thoughts and memories related to the event(s), or external avoidance of people, conversations, activities, or situations reminiscent of the event(s) (Carr, 2004).
3. Persistent perceptions of heightened current threat, for example hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises (Carr, 2004).

Further to the above 3 elements, consideration is given to the disturbance or significant impairment in personal, family, social, educational, occupational or other important areas of functioning (Carr, 2004).

Evidence of Symptoms 

In Middle childhood, PTSD often manifests behaviourally, for example in trauma-specific re-enactments during play, in drawings, frightening dreams or impulsivity not previously a characteristic of the child behaviour (Kenardy et al., 2011).  There may be no distress evident when children are talking about the trauma or acting it out in play despite the traumata actually having impact on functional development.  There may be changes in behaviour such as hypervigilance that occurs in the form of temper tantrums with increased frequency and intensity.  A child may regress in their behaviour and experience separation anxiety, age-appropriate fears may be overexaggerated, or they may cry excessively (Kenard et al., 2011).   A child’s behaviour may also become disinhibited or more inhibited when compared to past behaviour.  Avoidance of thinking about or talking about the trauma may be evident through the observation of new acting out behaviours, protective strategies not seen before, reluctance to engage in new activities and require excessive reassurance from trusted caregivers (Kenardy et al., 2011).  Some children may engage in self soothing behaviour in a routine way and can include includes rocking, self-stimulation, sleeping, playing computer games, listening to music and eating.   These behaviours can be helpful for the child to focus their attention and move into a relaxed state. However, if a child becomes pre-occupied with these behaviours their benefit is decreased (Kenardy et al., 2011).  Once a child reaches 8 to 10 years old their reactions to trauma become more similar to those of an adult as cognitively the child can understand more about the situation and see more of the long-term consequences of the trauma as well as being more able to reflect on their own role in the traumatic events.

Impact on the individual and interactions

Exposure to different types of trauma and the resulting PTSD have been associated with complex and varying adverse outcomes, including adverse effects on cognitive functioning, attention, memory, academic performance, and school‐related behaviours (de Bellis et al., 2014). Exposure to traumatic events can disrupt brain development having immediate and lifelong negative effects on social, emotional, and physical wellbeing, including inadequacy in executive functioning, developmental delays, behavioural problems, impaired social-emotional regulation, academic performance and school behaviour problems (McClean, 2016).

Children with PTSD have suffered a traumatic event or events and these events often cause the body to react with its stress response system. When in stress the body’s biological functioning activates the brains amygdala to respond with fight, flight, freeze or fawn reactions.  A child with PTSD can often remain in this mode or state of heightened vigilance for long periods of time, and brain research has shown that the amygdala grows larger (Bryce et al., 2019).  Children have no sense of what to expect next so remain in this heightened state finding it difficult to know how to feel calm, how to feel safe and how to feel in control (Dalgleish et al., 2001).  As a consequence of trauma suffered, children lack adaptability and in varying situations and contexts have difficulty responding in different ways as the trauma has left them with limited coping strategies and limited strategies to guide their actions (Costello et al., 1998).  With limited coping strategies children with PTSD are likely to just react to situations rather than respond.  They are also reluctant to forming new relationships or connections with others, including their peers, due to the need to self-protect (Gearity, 2015).  It is often difficult for children with PTSD to separate the past from the present and often their reactions in the present are reactions from the past when triggered by a reminder from the traumatic event such as a smell, sound or sight as well as feelings of past fear and insecurity.  This difficulty impacts negatively on the child’s ability to develop a strong sense of who they are and where they belong and they find it difficult to find where they fit into the environment around them.  Given traumatised children often display challenging behaviour, they have difficulties functioning in classrooms and with peers (Peterson, 2018).  They may be severely withdrawn and therefore have few opportunities to develop peer relationships or relationships with significant adults.  These displays of adaptive survival were effective at the time of the trauma but are counterproductive if continued into the present where the trauma no longer exists.

Suggested Interventions

In a school setting the primary focus for students displaying PTSD would be trauma informed management of behaviours and making room in their working memory for learning.  In order to accomplish this, I would begin with the Australian Childhood Foundation (2022) developed Trauma and Connection assessment (TECA).  The TECA is an assessment process that enables understanding of trauma expressions a child may be displaying and assists to identify how their PTSD is impacting on their behavioural and relational presentations (Australian Childhood Foundation, 2022). Central to trauma responsive practice is safety and promotion of strong, safe and healthy relationships which can be used as a resource to support healing.   As an implementation tool the TECA supports co-regulation, decreasing a child’s trauma behaviours by recommending prescribed therapeutic responses that are matched to the individual child’s needs (Australian Childhood Foundation, 2022).  The TECA assessment is based on behaviours that are likely to be observed in a child with PTSD, the behaviours are organised neurologically into the categories of flight, fight, freeze and fawn.  The behaviours in each category are rated as often seen, sometimes seen, rarely seen, never seen and a simple check box for the appropriate observed behaviours is checked (Australian Childhood Foundation, 2022).  Observations could be completed by families, teachers, support staff at school or guidance officers.  Each category is then scored and given an intensity rating with the intensity ratings giving information about the trauma response area most experienced by the child (Australian Childhood Foundation, 2022).  Activities for fight, flight, freeze and fawn are then detailed; these activities are specifically designed to move the child out of the trauma response and open them up for learning, development and self-regulation.  Fight activities are designed to help the child make their own body a safe place to inhabit and flight activities are grounding activities to keep the child focused in the present.  Freeze activities are designed to move a child out of shut down and Fawn activities are designed to build confidence and decrease the need for the child to appease (Australian Childhood Foundation, 2022).  Once suitable activities are identified, the child could be included in choosing activities, an individual classroom plan could be developed and trialled. In any intervention there needs to be scheduled reviews and opportunities to modify or change activities for the child.