Mastering emotional challenges

Emotionale Herausforderungen meistern

Mastering emotional challenges

How can professionals better understand behavioral problems in children with refugee experiences? Here you will find knowledgeable and helpful tips for practice.

In this module, you have the opportunity to learn more about psychologically conspicuous and inconspicuous behavior in children with refugee experience. Different types of behavioral problems are described and suggestions for dealing with them are given. The module is supplemented by comments from child and adolescent psychotherapists Karen Krause and Sören Friedrich. Ms. Krause is head and Mr. Friedrich is managing director of the outpatient clinic for children and adolescents at the Bochum Centre for Psychotherapy.

A scientific study (Buchmüller, Lembcke, Bihler, Kumsta & Leyendecker, 2018) on behavioural problems of children with refugee experiences in bridge projects shows that pedagogical staff are more often aware of externalizing problems (including aggression and concentration problems). From the parents' perspective, on the other hand, internalizing abnormalities (e.g. sadness, anxiety) predominate in the children. In addition, parents perceive more behavioral problems than the pedagogical staff.

Psychological traumatization

Psychological (also known as psychological or mental) traumatization refers to an impairment caused by a strongly negative biographical experience. In the context of flight, this includes in particular war experiences (including witnessing acts of war resulting in injury or death), kidnappings, terrorist attacks, torture or arrests before and during flight. Such experiences can (but do not necessarily have to) trigger extreme stress in people and create feelings of helplessness or horror. People are particularly at risk if the experiences exceed their ability to mentally process and cope with them. If this increased stress remains over a long period of time and there is no way to adequately process the experiences, this can lead to the development of sometimes persistent psychological symptoms (see post-traumatic stress disorder). The experiences of war and torture in the countries of origin as well as the dramatic flight to Europe, which often lasts for months, also place a heavy burden on children and young people.

Children in particular can be psychologically traumatized if their parents or close relatives are involved. Their positive image of people and society is destroyed. In addition, sequential traumatization makes it more difficult to recover from the trauma. Children who have experienced flight can also be exposed to several traumatic situations before, during and after their flight to the country of asylum. They often experience traumatic experiences before and during the flight, a high level of stress in the present (after the flight) and thoughts about the future are also fraught with fear.

In principle, children with refugee experiences may or may not necessarily exhibit behavioral problems. It can be assumed that certain risk factors lead to a specific pattern of behavioral problems. Accordingly, it is possible that children with refugee experiences who have been exposed to war, deprivation or migration will develop a specific symptom pattern corresponding to these risk factors. This pattern is dominated by anxiety, social withdrawal and attention problems. The educational staff in the bridge projects surveyed estimate that around 25% of the children in the bridge projects have had a traumatic experience (experience of violence, loss of a parent, fear of death, etc.) and 31% have experienced deprivation (hunger, emotional neglect, lack of protection, etc.). In comparison, 11% of the parents reported imprisonment before the flight and 20% during the flight, 9% injuries before and 20% during the flight, and 34% deprivation/hunger/deprivation before and 40% during the flight. 10% of the children show age-related symptoms of post-traumatic stress disorder (PTSD) or their behavior is dominated by the three symptom areas of anxiety, social withdrawal and attention problems. Depending on the study, 26-37%, or around a third, also show PTSD in infancy.

If a child behaves conspicuously, this does not necessarily have to be due to past "traumatization", but can be attributed to various (also situation-specific) influences, or possibly also a developmental delay. In addition, the spectrum of reactions of children and adolescents to traumatic events is broader than that of adults. How children react to traumatic events basically depends on their stage of development. Some children are unexpectedly cheerful, carefree and well-adjusted. Others show behavioral abnormalities that indicate a mental disorder. They withdraw, are restless, have problems concentrating or are aggressive. In addition, symptoms of PTSD can occur individually or in combination.

PTSD is diagnosed when the affected child...

(A) has been exposed to a threat causing fear of death one or more times or has witnessed such a threat to a primary caregiver.

(B) is plagued by recurring haunting memories (intrusions, flashbacks and/or nightmares)

(C) avoids or attempts to avoid anything reminiscent of the traumatic event and persistent changes in affect and cognition (memory problems, anxiety, guilt, lack of interest, etc.) manifest.

(D) shows conspicuous excitability (sleep disturbances, irritability, outbursts of anger, lack of concentration, startle, increased alertness)

Children often re-enact traumatizing events in games. If the behavioral abnormalities occur within six months of the traumatic event and last for at least one month, we speak of PTSD.

Peculiarity in children under 6 years of age: Memories, dissociations, etc. can be expressed in reenactments of trauma-like situations and nightmares can occur without any memorable content. Parents report a wide range of emotional and behavioral changes. Due to children's lack of ability to express their thoughts and name emotions, negative changes in mood and cognition primarily lead to a negative change in emotions. Avoidant behavior can refer to restricted play or exploratory behavior in young children and decreased participation in new games at school age.

Once a child is in a traumatic situation, the brain switches into an emergency program. Due to the high level of stress during the traumatic situation, the stress hormone cortisol is released in unusually high levels and leads to information processing being disrupted. As a result, the traumatic events are not adequately stored in the autobiographical memory. Instead, fragmented scraps of memory are created that cannot be stored and retrieved in chronological order. As a result, smells, sounds or images that are similar to those in the traumatic event can activate the memories of the event. As a result, the child cannot come to terms with the traumatic events and is virtually "haunted" right up to the present day. The peculiarities of this trauma memory give rise to the typical PTSD symptoms such as intrusions, flashbacks, dissociations or overexcitation.

In this context, we also asked Ms. Krause and Mr. Friedrich from the ZPT why PTSD can actually be considered a normal reaction to stress.

Audio file - Emotional challenges (PTSD)

It is particularly important to differentiate between trauma, traumatization and post-traumatic stress disorder. Not everyone who has had traumatic experiences develops symptoms of PTSD. Whether mental disorders develop after experiencing a traumatic event depends on the child, their psychosocial protective factors and their environmental conditions. For this reason, children should not be assigned victim roles, as they can develop unproblematically and even emerge stronger and more resilient from these experiences despite having had bad experiences. Important determinants for this are how the event was personally perceived and the context in which it is embedded, as well as internal resources such as psychological resilience, intelligence or social contacts.

Audio file - Emotional challenges (trauma)

In the interview, Ms. Krause from ZPT Bochum also points out that it is important to make a clear distinction between the terms used in the context of trauma - not every child develops PTSD. Caution is also required when categorizing children according to their "clinical picture", as not all behavioural abnormalities are indicative of traumatization or PTSD. In addition, it is often not clear to which symptom a behavioral disorder is attributable.

This shows that differentiating and categorizing child behavioural problems should not be done lightly. Nevertheless, it is worth paying attention to behavioral problems and, if necessary, initiating support measures, as early intervention has the most effective and lasting effect. However, in many cases you do not have to and cannot offer the child exactly what they need to alleviate their symptoms on their own. If you notice that you cannot work appropriately with a child or that their psychological symptoms are only getting worse (and you may also suspect PTSD), tell the parents immediately that the child needs medical or psychotherapeutic help. If necessary, provide support with the referral, as only doctors or child and adolescent psychotherapists have the resources and means to treat PTSD or other mental health problems professionally. To this end, parents should take their child to a socio-pediatric center (SPZ) or psychosocial counseling centers so that a clear diagnosis can be made and the appropriate treatment can be initiated. You can find a supporting network list in the Networking module.

In this regard, we asked Ms. Kraus when exactly a child should be sent to a child and adolescent psychotherapist.

Audio file - Emotional challenges (therapy)

Childhood behavioural problems are divided into "externalizing" and "internalizing". Externalizing behavioural problems can be observed from the outside. These include, for example, restlessness or aggressive behaviour. Internalizing behavioural problems, on the other hand, cannot usually be observed from the outside. These are abnormalities that are dealt with internally, such as self-doubt, depression or anxiety. Children then behave very quietly, appear sad or introverted. Externalizing behaviour is more often attributed to boys, whereas girls more often show internalizing abnormalities. However, both types can occur in both sexes.

Externalizing and internalizing behaviours can occur both in the context of PTSD and in isolation. Although there are overlaps between the behavioral abnormalities, it is important to refrain from jumping to conclusions about a disorder. Children can develop conspicuous behavior for various reasons that are not related to experiences of flight. For example, a child may behave aggressively because it has a very quick temper and little self-regulation. It does not necessarily have to have had violent experiences. In addition, the respective personality traits of the children and possibly also the parenting methods of the parents must be taken into account.

Not every conspicuous behavior of children with refugee experiences necessarily indicates a mental disorder. Due to cultural differences in the family system or refugee-related experiences, children with refugee experiences often exhibit behavior that can be interpreted as an adaptation reaction to their new environment. These are not serious and should diminish after a certain time. Have you ever noticed the following behaviors?

  • Observant obedience to adults: this may be due to pronounced hierarchies in families with refugee experiences; parents have unquestionable authority and orders and firm rules are also expected from educational staff
  • Disinterest/lack of advice when dealing with toys: in some countries of origin there are often other (or no comparable) toys, so that the children are initially overwhelmed; they explore how the toys are to be used
  • Hoarding toys or food: can be due to experiences of deprivation during the flight or in the refugee accommodation
  • often play on their own or do not want to be disturbed: often have no peace and quiet in cramped accommodation or very small apartments to play on their own
  • tend to get help from older children or only play with siblings: as siblings help raise younger children in some countries of origin, children with refugee experiences often have a close bond with them or are used to receiving instructions from older children

Recognize anomalies in behavior

Thirteen different behavioral problems in children are briefly described and explained how you can deal with them.

1 Intrusions/ flashbacks

  • Sudden and unexpected intrusions of uncontrollable memories and thoughts
  • Are difficult to recognize from the outside in children, as they are not always intrusions when a child appears absent (a child can also be absorbed in a game or a thought)
  • Note the difference between uncontrollable memories and controllable thoughts
    • Can take the form of images, tactile or auditory sensations or smells
    • Are overwhelming (fading out is not possible)
    • Are caused by trauma memory: memories of the trauma are not anchored in autobiographical memory and can therefore be triggered by similar stimuli
  • Memories are a form of intrusion:
    • When traumatic memories gain the upper hand over the present
    • Traumatic situation is experienced as if it were happening in the present moment
    • Can be caused by a trigger stimulus
    • Children behave very anxiously, show feelings & behaviors from the traumatic situation or repeatedly re-enact certain situations in play
    • Possible triggers can include smells (e.g. the smell of sweat, oil or smoke), noises (e.g. fire alarm, testing the siren signal or a loud bang) as well as looks, movements and touch
  • Attention: repetitive behaviors often occur as an expression of memories (see below)
  • Listen attentively to the child if they want to tell you something or talk about something
  • Try to reassure the child (although younger children often do not understand the content of reassuring words, the attention and tone of voice alone can cause children to calm down again)
  • Help the child to process the memories through play:
    • Only a good strategy if the child is emotionally available: Bring calming into the game by using distraction strategies (=fogging) that down-regulate the child.
    • Intervene in the game as early as possible, even before a child gets "into the game".
  • Example: "I can see that many events from your past are bothering you and scaring you, weighing you down, making you sad. All these bad things are over now and are just memories. Nothing bad will happen to you here and now, because you are safe with us. "

2 Dissociation

  • Mental absence/stagnation/lost in thought
  • Can range from mild daydreaming to a complete lack of responsiveness
  • Protective reaction to stressful events, whereby frequent and intense dissociations are not helpful for processing traumatizing experiences, as there is no integration into the autobiographical memory
  • The child subsequently has no memory of the moment in which the dissociation occurred
  • The child becomes rigid, the narrative style or behavior suddenly changes
  • Can be triggered by memory or external factors such as loud noises, smells or voices
  • Attention: repetitive behaviors are often an expression of dissociation (see below)!
  • Bring the child back to the present
  • Pay attention to the following points if possible
    • Stay calm
    • Establish and maintain eye contact with the child
    • speak in simple and clear sentences
    • address the child by name
    • announce touching
    • Orientation: Explain who you are and name the place, time of day and what has just happened (example: "It's lunchtime. We've just eaten together and we're in the play corner playing with the dolls. I am Mrs. X and you are X....")
    • reassure the child that they are safe
    • ask the child what their name is and where they are
    • ask the child to name things and perceptions in the environment (e.g. toys, names of children present, noises)
    • give the child an object that they associate with safety, e.g. a cuddly toy (a symbolic object in the hand can also help)
    • strong and clear sensory stimuli, e.g. placing a cold cloth on the arm, making high or shrill noises (whistling, clapping), or using strong-smelling substances (oils, herbs, etc.) in the room
  • Warm/soft/quiet speaking voice: convey security/child should feel comfortable

Create structures such as rituals (integrate predictable things into the daily routine to create a sense of security)

3 Repetitive behaviors

  • Constantly repeating, possibly thematically specific behaviors
  • Some aspects of sometimes traumatic experiences are re-enacted
  • Reenacting/painting situations (e.g. with puppets)
  • For frequent or compulsive repetition of these games: post-traumatic play
  • An attempt by the child to process the experience
  • Stop games that disrupt the get-together or violate general rules in everyday educational life
  • Naming the feelings that are perceived in the child
  • Try to calm the child down if he or she appears very upset as a result of replaying or painting.

4 Fears

  • Generalized fear
    • Fears that extend to everyday things (e.g. fear of being abandoned, going to bed, saying goodbye, fear of the dark or of strangers)
  • Specific fear
    • Tied to the original traumatic situation
    • E.g. fear of people or animals that were present during the traumatic situation, were involved in it or trigger a memory of the traumatic situation
  • Separation anxiety
    • Fear when the parents leave (crying, aggression) that they will not come back or that something will happen to them if the child is not with them
    • Frequent somatic complaints such as stomach ache or nausea
    • Can be caused by previous experiences of loss, but children without experiences of loss can also develop separation anxiety
  • Try to reassure the child
  • Explain where the child is and that they are safe
  • Explain what the child was frightened of and what this means
  • Give the child the opportunity to share their fears
  • Explain to the child exactly where the parents are going and when they will be back.
  • Do not reinforce the child's avoidance behavior by having the parents take the child back or not bring them to daycare or the bridge project at all.
  • Introduce and maintain regularity and structure

5 Hypervigilance

  • Increased arousal level: body is still in a state of alert
  • Can lead to sleep disturbances, increased alertness and jumpiness
  • Sensitive reaction to changes
  • Motor restlessness
  • Use relaxation exercises such as fantasy or dream journeys, as well as progressive muscle relaxation, so that the children can learn how to deal with restlessness/tension
  • Exercises can be carried out with the whole group

6 Attention/concentration problems

  • Diminished attention, concentration and memory
  • Difficulty listening to or following a story
  • Can also be accompanied by frequent or excessive fatigue (see sleep problems)
  • Limited ability to think or narrate chronologically
  • Fabulation or fantasizing is also common
  • Tell the child exactly what is meant: e.g. "Be quiet, look closely and listen carefully!" instead of "Now concentrate!"
  • Avoid "Don't" statements
  • Reduce expectations and don't overwhelm the child
  • Turn off restlessness and noise when the child needs to concentrate
  • Get the child used to focusing on one thing at a time as early as possible
  • Train your child to observe themselves better and regulate their behavior ("Stop, what are you doing right now? What did you actually want to do? What do you need to do?")
  • Listening to music, dancing, reading aloud regularly

7 Limitless / risky / aggressive behavior

  • Unconscious attempt to enforce boundaries and thus experience more support and security or to check whether support is being provided
  • In confrontations, "not giving in" can serve as an attempt to take on the active and controlling role again in comparison to the helplessness experienced in the traumatic situation
  • Oppositional behavior, e.g. refusal to participate in the sitting circle or similar
  • Check explanations that the child gives for not following the rules (e.g. understanding of rules, fears)
  • Allow the child a small amount of freedom within the scope of possibilities, in which they can satisfy their need for autonomy and control (e.g. choosing a game / song, determining a sequence), giving them time
  • Insist on adherence to rules that are important for cooperation and safety
  • Teach the child rules in a non-punitive way and show their own boundaries and the boundaries of other children
  • Giving the child an opportunity to let out their anger, for example by letting off steam through strenuous activities
  • Offer the child an anger box containing sour chewing gum, a very cold drink, a stress ball, etc. (help the child to concentrate on the various senses in an acute anger situation and deal with the intense emotions)
  • As a preventative measure, introduce a mood barometer and the stop rule so that children learn to recognize their boundaries and maintain them non-violently when others try to cross them. For the mood barometer, you can use a poster on which the children can indicate their mood (e.g. emoticons/thumbs up or thumps down). The mood barometer helps the children to reflect on and communicate their feelings. The child should learn not to react aggressively, but to communicate their anger so that the group can look for a solution. The stop rule is about a child shouting "stop" loudly when they feel overwhelmed and angry in a situation. This helps to avoid arguments and set boundaries for other children

8 Regressive behavior

  • Falling back into earlier stages of development (e.g. repeated bedwetting, thumb sucking) or getting "stuck" in these (= developmental delays)
  • Greater need for attention/attachment
  • Avoid scolding, as the behavior is understandable in light of the experience
  • Ignore minor problem behavior as far as possible or accept it without comment
  • Praise the child for age-appropriate behavior
  • Make sure that the child is not teased or teased by the other children because of the behavior

9 Feelings of guilt Develop when you are safe but your family is still exposed to danger

  • Tell the child that they are not to blame for their current circumstances and explain why they are innocent
  • Explain to the child that feelings of guilt are completely normal and that many people suffer from them, but that this does not help anyone
  • Respond to possible emotional outbursts with understanding
  • Distract the child and engage them in positive interaction

10 Physical complaints

  • heart palpitations and dizziness, which may persist after the threatening situation has ended
  • Abdominal pain, nausea and loss of appetite (especially in younger (school) children)
  • Try to expose the child to as little stress as possible
  • Relaxation exercises are also a good way of teaching the child how to react to tension by relaxing, so that physical complaints can be prevented at an early stage
  • Heart palpitations and dizziness can be very unpleasant for the child if they become very involved in these sensations; However, panic attacks are rather rare in early childhood and tend to manifest themselves in young children through tantrums, screaming fits and the like
  • When tantrums etc. occur, try to distract the child. try to distract the child so that they don't get carried away with the physical symptoms and avoid possible triggers
  • If the child is constantly unwell, e.g. if they are in the bridge project and nothing helps, seek professional help

11 Emotional reactivity

  • Intensity or amount of behavior with which the child reacts to a stimulus/situation
  • Strength of reaction is individually dependent on the child's temperament
  • Strong reactivity = high sensitivity or low resilience
  • Recognizable as sudden changes in mood or emotions in the child, often ending in emotional outbursts
  • Child-friendly mindfulness training for children to cut through reactive emotional patterns
  • Integrating sport into everyday life
  • Telling your child relaxation stories
  • Emotional coaching: Recognizing how the child is feeling and supporting them in expressing these feelings verbally/making it clear to the child that their emotions are being taken seriously and that they are being helped to deal with the situation appropriately
    • If the child is old enough: look for a solution to the problem together
    • If the child cannot be calmed down quickly enough: postpone the search for a solution to the problem until a later date

12 Depressiveness

  • Expression of sadness or depression
  • Closedness / avoidance of contact with other children or adults
  • In infants or very young children, the manifestations can vary greatly
  • frequent physical symptoms (loss of appetite / sleep disturbances / inactivity / apathetic behavior)
  • Offer space for discussions
  • Show patience
  • Focus on listening instead of giving advice
  • Hold back with tips and comments such as: "Cheer up, you'll be fine" or "Pull yourself together"
  • Address all feelings openly and without reproach
  • Encourage the child to talk

13 Sleep problems

  • Frequent waking up
  • Problems falling asleep
  • Restless sleep
  • Insert bedtime rituals
  • Introduce fixed bedtimes (the child's body rhythm gets used to the rest phases)
  • Tell goodnight stories or sing lullabies
  • Do not flood your child with too many stimuli before bedtime
  • Give your child a cuddly toy or turn on a night light

Stress reduction and mindfulness for children Take care of the children - and yourself!

Here you will find an audio clip on the topic of stress reduction and mindfulness in children. Have fun listening!

FAQ - Guidance for educational professionals

The guide provides answers to frequently asked questions from educational professionals who have questions about children with refugee experiences in their facilities. The guide provides recommendations for dealing with children's behavior, for communicating with parents and for mental hygiene for educational professionals.

Trauma in children and adolescents - information brochure for educational professionals and teachers

Trauma can affect everyday life at nursery or school. Some children recover from traumatic experiences, but others develop problematic behavior or post-traumatic stress disorder. For this reason, the Institute for Quality and Efficiency in Health Care (IQWiG) has developed the following brochure. It is aimed at educational staff in nurseries and schools so that they can better understand and support traumatized children.