Friday, December 14, 2012

How to talk to your kids about tragedies like the Sandy Hook Elementary School shootings

My heart is breaking for the children, families, community members and professionals affected by the tragic shooting today at Sandy Hook Elementary School in Newtown Connecticut.  Why horrific events like this occur is a complicated issue for another day.  Right now, many parents, teachers and loved ones are faced with explaining what happened today to the youngsters who trust them.  Here are some suggestions.

First of all, turn off the news when your kids are around.  Young children are not equipped to make sense of the ongoing news coverage of tragedies like this one.  In fact, if YOU are having trouble coping with something you see on the news, you can be sure your children will have trouble with it too.  Little kids often can’t tell the difference between what is real and what isn’t on television.  Also, because a child’s sense of time and reality is different from adults, a child watching ongoing news coverage may fail to understand that the terrifying event has ended.  The child may think the shootings are continuing and may be confused and upset about why adults and police are doing nothing to stop it.

Toddlers and preschoolers will rarely comprehend what has happened so it’s usually best to only discuss traumatic events if your child spontaneously brings them up.  Very young children’s ability to tell fact from fiction on television is very limited and even very tragic events that don’t directly touch their lives are unlikely to effect them very much.  However, their emotional radar is very sensitive so they may pick up on your sadness, grief and horror.  If you are feeling emotional don’t just brush it off.  You might explain to your child that something sad has happened and you are feeling sad about it but you will be OK.  Accept a comforting hug, the loan of a favorite stuffed toy or cup of water offered by your child and let them know they are helping you to feel better.

When discussing traumatic events with school aged children it’s important to consider your child’s developmental level.  Your child will usually give you clues about how much they can handle.  Children do need to understand that there are bad people in the world and sometimes those bad people do bad things that hurt people.  If your child doesn’t bring the topic up on his own, you might start out with a general statement, such as, “A bad thing happened at a school in Connecticut today. Have you heard about it?” It’s important to listen carefully to your child’s answer.  Don’t hurry the conversation.  Maintain good eye contact and use hugs and other kinds of touch for comfort.  Answer any questions they have as gently as you can. Don’t lecture or provide excessive detail but strive to be as honest and direct as you can.

Allow your child to talk out their worries and concerns and provide responses that will help your child feel safe, secure and taken care of. Avoid making promises that you can’t keep but be as reassuring as you can.  The conversation might go something like this: Child: “Why would someone go into a school and shoot up a bunch of little kids? Schools are supposed to be safe!  Why didn’t the police and teachers keep him from hurting those kids?” Your responses might be “Most people are good and most people would never harm a child or shoot anybody.  There are bad people who sometimes do bad things.  Often there is something wrong with these bad people but sometimes nobody knows what’s wrong with them until it’s too late. Most of the time, adults keep children safe and nothing bad happens to them.  Schools are usually very safe and it’s very rare for any child to be harmed in a school.  Teachers and principals do everything they can to take care of school children and keep them safe.  Policemen usually keep bad people from hurting other people. The bad things that happened today are very unlikely to happen here.  I will do everything I can to keep you safe and prevent bad things from happening to you. It’s also important to think about all the good people today who did great things to help.  Most of the children and teachers were not hurt.  The police came and did a good job today. Do you have any worries about your own school or your teachers or friends?” Listen to the child’s answer.  Then ask if there is anything they would like to do to help the children families and people in the community where the shootings occurred.  You and your child can draw and mail condolence cards, send money or toys, or light a candle and say a prayer. With the holidays upon us, you also might discuss if there is anything you and your child want to do to contribute to the victim’s families for the holidays. Children have very generous hearts and helping them help others can be a particularly beautiful way for them to cope with tragedy and help themselves as well.

Your child may regress. Children may start wetting the bed or having nightmares.  Handle these occurrences calmly and provide support and comfort.  Encourage the use of “transitional” objects such as blankets or stuffed toys if they help the child feel safe and secure.  If your child starts having angry outbursts or tantrums, be as patient as you can and help the child understand their feelings and talk them out. Violence or aggression is not acceptable and should be discouraged and appropriately consequenced in a way that is consistent with your values and family rules.

Older kids and teens may raise some very difficult questions.  If you don’t know how to answer a question it’s OK to admit it.  Moral, spiritual and faith-based discussions and prayers can be very helpful and comforting. If you are unsure how to handle a situation have the child talk to a counselor or religious leader about their concerns. You can still be a loving caring parent without having all the answers! You aren’t required to know how to handle all situations but you are responsible for finding the resources your child needs when you aren’t sure what to do.

It’s always a good idea to discuss safety issues with your children.  To effectively address your child’s fears and worries, have a discussion about how they can respond if something bad happens or if they find themselves in a dangerous situation.  Be practical and realistic. While you don’t want your child’s response to trauma to be a life ruled by fear and worry, you do want a child who knows how to keep him or herself as safe as possible in a world where bad things sometimes do happen. We all want to raise children who make good decisions and know how to stay calm and handle adversity well.   

Be sure to bring the focus back to the positive aspects of family, community, comfort, caring and faith. Draw the child’s attention to all the heroes of the day. Help your child do something positive and constructive to help the victims.  Teens in particular may also be interested in participating in political or community action to help prevent future re-occurrences of similar events. Artistic or written self-expression and music can help your child process the experience and the deep feelings it may have evoked. Religious services, vigils, memorials and community ceremonies can be very comforting so participation should be encouraged if the child wishes.        

Sadly, coping with your child’s reaction to traumatic events can be a long-term process.  If your child has been directly affected by tragedy, expect ongoing conversations.  Your child will be unable to process everything you tell them the first time they hear it.  Be open to your child’s feelings and reactions.  Validate their feelings. Listen, give lots of hugs, provide comfort and have confidence that things will get better.  Most children are resilient so with love and the right kind of support, they will be fine. 

Sunday, November 18, 2012

Helping the Injured Athlete Return to Play

The Injured Athlete: Getting Back: in the Saddle, on the Slopes, on the Field, on the Track (You Get The Idea!): A talk presented at the Vail Summit Orthopedics CATA conference, Edwards Colorado, November 17, 2012

Take a moment to imagine the following: You've been playing your sport as far back as you can remember. You’ve built strength, and endurance and you’ve perfected your technique. Your entire life revolves around practice, performance and competition. You love your sport. It’s who you are! It’s the most important part of your life and your identity.  Its how you spend your time and what you’ve built your plans and dreams around. 

Then the unimaginable happens. Suddenly you're injured and you can’t play.

For a serious athlete the physical pain of an injury is only one VERY small part of the suffering experienced as a result of that injury. The severity and impact of the emotional pain and the temporary or permanent loss of your sport can far exceed any physical discomfort from the physical injury. Emotional suffering must be addressed for rehabilitation to be successful. Coaches, trainers and rehab professionals who are sensitive to these issues facilitate the rehab process. Professionals and loved ones who don’t recognize the importance of emotional issues in recovery can further traumatize the injured athlete and may compromise the healing process.

To better understand what happens psychologically when an athlete is kept out of action because of an injury, it's important to consider three major roles that sports play in the life of a serious athlete.
       Sports fulfill multiple needs for athletes
       The injured athlete experiences multiple losses:
       Sense of identity / role / teammate
       Loss of physical health / invincibility
       Loss of Independence
       Sense of alienation and isolation
       Loss of recognition / esteem
       Loss of major way they spend time
       Loss of constructive outlet for stress
       Sports fulfill multiple needs for athletes

Identity – For serious athletes the sport is their life. They’ve invested years of time, energy and pain. It's how they see themselves and how others see them.

Self-esteem - For most dedicated athletes, sports provide ongoing positive reinforcement and feedback. The enjoyment and self-satisfaction that come from mastering new skills, overcoming new challenges and progressively growing stronger and better is a central source of self-esteem. The recognition of your accomplishments by friends, family and members of the community feed the athlete’s sense of joy and accomplishment. A well-played game, race or match feels fantastic and provides tangible evidence that the athlete’s hard work has paid off.

Stress-managment - Physical exertion is a great stress reliever. When people have no physical outlets they tend to internalize their stress, often leading to headaches, GI complaints or other physical symptoms. Many athletes find that their involvement in sports also provides an escape from family, school or relationship problems. Participation in sports is also a healthy way for athletes to manage frustration and anger.

Normal Reactions to Injury may include: Initial denial / minimizing  - Grief and mourning - Sadness - Anger - Questioning - Frustration- Loneliness- Helplessness - Disillusionment - Boredom - Anxiety - Fear

Worrisome Reactions to Injury
       Prolonged denial of the injury itself, injury severity and / or response to recovery or limitations
       Obsession with return to play
       Extreme guilt
       Impatience and Irritability
       Rapid mood swings
       Suicidal Ideation
       Panic Attacks
       Aggression and Raging

Depression: What to Watch For: Low self-esteem - Sadness - Irritability - Hopelessness -Tearfulness - Indecisiveness - Difficulty Concentrating - Guilt - Lack of Motivation - Agitation/anxiety - Loss of sex-drive - Suicidal thoughts - Loss of interest - Lack of Energy - Unexplained Aches and Pains - Disturbed sleep or appetite - slowed speech or movement - Social withdrawal - impaired school or work performance

Negative thoughts often accompany depression: Why me? -  It’s not fair - Why now? - If only… - But now I can’t / won't - I’ve worked too hard for this to happen to me! - I’ve let everybody down - Nobody cares - Nobody understands - Nobody can help me - I can’t handle this -  It will never get better - I’m being punished for my sins -  I’m a loser - It’s hopeless - I can’t take it anymore - Everyone would be better off without me - I’m a burden -The future holds nothing. - What now?

Depression in Athletes after Injury: Statistics
      Over half become depressed
      10-15% seriously depressed
      80 % experience symptoms of depression
      Suicide is rare
      Time frame determined by physical recovery time frame
      Highly treatable with psychotherapy

       Intense memories, dreams, nightmares
       Uncontrollable strong feelings
       Pushing people away
       Negative thoughts
       Hyper-arousal and agitation
       Concentration problems
       Sleep disturbance
       Fear of re-injury

Substance Abuse Issues in Athletes Recovering From Injury
Alcohol abuse
Illicit drug abuse
Prescription drug abuse: easy for professionals, coaches and trainers to be complicit in prescription drug abuse or even encourage it.  Must challenge the athlete about abuse

Psychotherapy can be highly effective in helping people cope with injuries, overcome depression or PTSD from their injuries and recover more quickly and completely from their injuries.  Of course, psychotherapy is very cost-effective too.  A course of psychotherapy to assist an athlete in recovering from injury will often cost less than a single MRI.

Psychotherapy techniques to assist athletes in recovery from injury
       Supportive listening
       Coping skills training
       Problem solving and planning
       Relaxation skills
       Communication skills
       Mood regulation
       Visualization and hypnosis to facilitate recovery and return to play

Advice for the Athlete Recovering From Injury
       Accept your feelings
       Learn about your injury
       Learn about your treatment
       Be an active participant in your care
       Take responsibility
       Set achievable goals
       Maintain a positive attitude
       Follow treatment recommendations
       Self monitor
       Work hard within guidelines
       Practice patience, with yourself and with your body
       Seek and accept social support

Social Support after Injury Can:
       Maintain a connection with the team during rehabilitation and recovery
       Help with treatment
       Help with daily tasks
       Make the athlete comfortable asking for help
       Provide education and answers
       Offer empathic listening and opportunity to vent
       Be encouraging
       Provide a positive opportunity for distraction / fun / pleasure

Suggestions For Recovering Athletes
       Bring a list of questions to your doctor’s appointment or therapy sessions
       Participate with your team in non-active ways
       Have friends / team mates / coaches check in with you
       Schedule activities with friends
       Plan ahead and ask for help if you will have mobility issues
       Get assistance with transportation needs

Set Appropriate Goals
       Injury can be another training challenge
      Focus on recovery rather than performance
       Maintain motivation
       Focus on small incremental improvement
       Work closely with therapist or doctor
       Obey doctor’s orders about pace of rehab
       Accept injury and know your limits
       Maintain fitness while injured
       Knowing what to expect can facilitate sense of control and agency

How can medical professionals facilitate recovery in injured athletes?
       Build trust and rapport with the injured athlete
       Listen to concerns and provide honest answers
       Assess and monitor the athlete’s emotional state
       Educate the athlete about the injury
       Identify misinformation
       Involve the athlete’s family, coach and trainer
       Prepare the athlete and coach for the recovery process
       Encourage the development and use of coping skills
       Recognize return to play issues
       Screen for depression and other mental health concerns
       Refer to a psychologist with expertise in sports psychology and / or rehabilitation psychology     if needed

How can Trainers and Coaches Facilitate Recovery?
       Be empathic and caring
       Build up the athlete’s self-esteem
       Discourage self pity
       Take an interest in the recovery process
       Encourage realistic goals
       Offer general encouragement and emotional support
       Listen to the athletes concerns and feelings
       Encourage optimistic ways of thinking and discourage pessimism
       Discourage maladaptive ways of thinking such as “no pain-no gain” or “suck it up”
       Monitor athlete for depression, substance abuse or other mental health problems
       Encourage acceptance of help from a psychologist if indicated
       Encourage patience and realistic expectations

How can Trainers and Coaches Facilitate Recovery?
 Reach out to the athlete, do not wait for him to reach out to you
      If the athlete is in the hospital, visit, bring greetings from the team
      Participate in family conference if invited
      Visit at home during recovery
      Accompany to physical therapy if appropriate
Keep the athlete involved with the team
      Keep athlete in touch with team activities and issues
      Give the inured athlete achievable team related tasks
      Have the injured athlete participate in team activities in non-injurious ways
      When appropriate expect the athlete to participate in practice (with modifications) 
Do not allow social isolation and withdrawal
      If necessary assign team mates to check up on or provide practical help
Make the athlete accountable for participation in rehab
Participate in return to play issues and decisions
Encourage athlete to maintain fitness during rehabilitation

How can Trainers and Coaches Facilitate Recovery?
Gently help the athlete get in touch with other areas of personal strength, creativity, interests and ways to participate in their sport in new ways if they are faced with a long-term recovery or permanent disability

I hope you help the athletes you work with fulfill their dreams.  I hope some of the information I’ve shared today will help you do that even better than you might have imagined. I will end with another quote from the same person who’s quote introduced this talk.

Wise words for recovering athletes:
 “Speak quietly to yourself and promise there will be better days. Whisper gently to yourself and provide assurance that you really are extending your best effort. Console your bruised and tender spirit with reminders of many other successes. Offer comfort in practical and tangible ways — as if you were encouraging your dearest friend. Recognize that on certain days, the greatest grace is that the day is over and you get to close your eyes. Tomorrow comes more brightly.”
 *** Mary Anne Radmacher:

I hope in your work you help athletes have tomorrows that come more brightly.
That is the most precious gift you have to give.  Thank you for your attention and may your tomorrow burn more brightly too.

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Text copyright 2012 by Jill Squyres, PhD.  All Rights Reserved