MENTAL HEALTH CHALLENGES TO KNOW

What might the children in your care be experiencing?

Children react to stressful experiences in different ways, but common reactions include:

• Physical problems like headaches, stomach aches, and changes to appetite.
• Being scared and worried.
• Difficulty sleeping, nightmares, night terrors, shouting or screaming.
• Difficulty concentrating.
• Children may go back to ways they used to behave when they were younger, for example, bedwetting, clinging to their parents, frequent crying, thumb-sucking, being afraid to be left alone.

Coping with specific issues

➤ Fear, Anxiety and Worry
➤ Panic Attacks
➤ Aggression
➤ Grief
➤ Sleep Problems
➤ Fear of Separation or Crying when Caregivers Leave
➤ Excessive Crying
➤ Withdrawal and Lack of Interest in Playing
➤ Risky Behaviors

FEAR, ANXIETY AND WORRY

Anxiety, worry, and fear are natural reactions when we sense danger. These emotions serve as an «alarm system» that is activated whenever we feel threatened. Both adults and children can experience these emotions in response to scary thoughts and memories, as well as when there is a real threat.

• Children often become more fearful when they have experienced an emergency situation. Try to remain as calm as possible when interacting with children and assure them that you will do everything you can to keep them safe.
• Physical reactions can include headache, nausea, dizziness, diarrhea, numbness, shortness of breath, rapid heartbeat, feeling faint, sweaty, or shaky hands and feet, and others.
• Emotional reactions can include feelings of anger, fear, helplessness, disappointment, and excessive worrying.
• Behavioral reactions can vary widely. Some children may panic and make a lot of noise, others may withdraw, become quiet, and avoid eye contact.
• As much as possible, try to protect your child against situations that might trigger high levels of anxiety and provide a safe, predictable, and peaceful environment. Try to stay close to your child to comfort and calm them.
• Often, distressed children are preoccupied with issues that they cannot control, or by questions with no clear answer, such as, «Why did this happen to me?». Try to help your child to focus on things in their immediate environment that they can control, rather than focus on big, overwhelming questions. For example, by asking them «What are we going to have for dinner tonight?», «What game would you like to play now?» or «What story would you like to hear?»
• If your child has an irrational fear, do not judge, or belittle them. Acknowledge how they are feeling and provide reassurance. Encourage your child to share their fears with you. For example, you could say «If you start feeling scared, take my hand. Then I’ll know you need to tell me something.»
• Give your child strategies to use when they are feeling scared. For example, you can try some relaxation exercises with your child. [See messages on «Relaxation exercises for children»]
• Avoid forcing your child to experience things they are afraid of. For example, if a child is afraid of the darkness, do not force them to stay alone in a dark place. This may make them more afraid and harm their trust in you. Children who feel confident and safe in the care of a trusted adult are less likely to have irrational fears.
• Encourage physical exercise and socializing with other children, as these activities can help reduce anxiety.

PANIC ATTACKS

• Panic attacks are brief periods of overwhelming fear or anxiety. Panic attacks can include physical reactions like shaking, a very fast heartbeat, sweating, chest pain or discomfort, nausea, and dizziness.
• Panic attacks can happen during stressful experiences, but they can also seem to occur randomly.
• Panic attacks can be a scary experience. You might think you are losing control, having a heart attack, or even dying. You may feel like you are somehow disconnected from your mind, body, or surroundings. However, panic attacks don’t actually cause physical harm.

If you are having a panic attack, it can help to:

• Remind yourself that this feeling is temporary – try to remember that panic attacks always pass and that you are not in physical danger. Remember that the physical sensations are caused by a release of adrenaline and try to be patient as you wait for the adrenaline to decrease.
• Focus on breathing slowly and gently – try to count to five as you slowly breathe in and again as you slowly breathe out. It can help to place one hand on your stomach as you do this and notice how your hand rises and falls as you breathe deeply.
• Use your senses – try to use your senses to notice details about the world around you, for example, noticing what sounds you can hear, how the ground feels as you move your feet, what you can see and what you can smell. The 54321 Technique may help: try to name 5 things you can see, 4 things you can feel, 3 things you can hear, two things you can smell, and 1 thing you can taste.
• If your panic attacks get worse or more frequent, or if they interfere with your ability to carry out your usual activities, seek help from a professional health or social care provider. They can help you to understand what triggers your attacks and support you to develop more techniques to manage your anxiety.

AGGRESSION

Sometimes children respond to stress by behaving in an aggressive way while playing and interacting. They may have difficulty controlling their tempers, may start arguments, and may be easily upset and annoyed by others. Experiencing or seeing violence can make this more likely. While this is a normal reaction, it can be worrying for caregivers, who need to protect their child and prevent them from harming themselves and others.

• It is important to have clear rules about what is allowed and what is not allowed. Try to give clear and specific instructions about what you want a child to do, not only what you do not want them to do. For example, Instead of saying "No shouting", you can ask the child to "please speak in a quiet voice".
• If children in your care are fighting, tell them firmly to stop immediately, and then tell them clearly what they should be doing instead.
• You can have a list of educational and play activities prepared to keep your child busy.
• It can be frightening for caregivers when a child is extremely angry, especially if you feel the anger is directed towards you. The best way to help the child cope with her or his anger is by remaining calm and supportive and avoid responding with resentment. Remember that no child wants to be angry or aggressive, but they are struggling to manage the emotions they are experiencing.
• Let the child express their feelings of anger in a safe environment. Limit aggressive behavior by helping them express their anger in words instead of aggression or by giving them an alternative way to express the anger (such as letting them punch a pillow or encouraging them to go for a run). For example, you can say something like«It seems like you are angry. It is ok to have those feelings, but it is not ok to hit me. You can stamp your feet or jump up and down. Let´s do it together.»
• When both you and the child are calm, you can explain why it's important for children to play and interact calmly and safely and discuss other ways they can react if they find themselves getting frustrated or angry (e.g. walk away from the situation, take some slow deep breaths, count to ten). Praise your child when they handle their emotions well.
• Remember that children learn by watching the adults around them. Try to demonstrate ways of communicating and interacting that you would like them to copy.

GRIEF

Grief is the name for the painful emotions we feel when someone we care about dies or when we are separated from things, people or places we love. We can also experience grief when things we had planned in our life no longer seem possible.

• The way children experience grief can vary greatly depending on their age, their previous experiences, their personality and the way life and death is understood within their families and broader culture. Children can respond in different ways: crying, shouting, not believing, feeling sick or going very quiet. All of these are normal reactions.
• When a loved one has died, it is important to provide a clear, honest explanation to children to help them understand and accept the reality of the loss. It is natural to want to protect children from distress, but even very young children will be aware that something unusual is happening.
• Not understanding what is happening causes more distress. What is imagined may be worse than reality and children may even blame themselves for events beyond their control.
• Before you tell your child about the loss, make yourself comfortable and think through what you are going to say. It is possible that children will ask difficult questions and that both they and you will feel distressed. Try to find a safe and quiet place to tell them. If you have very young and older children, you may want to tell them separately if that is possible.
• You may wish to begin by asking the children what they know already, or what they think has happened. Then explain what has actually happened in words appropriate to your child’s age. Explain in simple terms what happened and reassure them that they are not to blame. Ask the children directly if they have any other questions, or if there is anything else that is worrying or frightening them. Explain that sharing feelings, fears and worries can help, and that you are here to listen to them, answer any questions and to comfort them at any time.
• Use the word your family uses for death. Do not use phrases like "Grandpa has gone away", "... has gone to sleep" or "... is in the clouds" as this will confuse younger children who may think the person can come back.
• You will need to give children time to understand this information.Young children may react by seeming like they are not listening or continuing to play. Be patient and wait for their attention. Be prepared for younger children to ask the same questions again and again, both at this moment and in the days and weeks to come.
• It is helpful to allow children to be involved in the mourning processes in any way that they find comfortable, including attending funerals if they wish. Mourning allows children to accept that the death has happened and say goodbye. Support them in creating their own ways to remember their loved one, for example, planting flowers, writing letters, making drawings, making a box of memories that reminds them of the person, or thinking of them before they go to sleep.

SLEEP PROBLEMS

Sometimes, children begin to worry and have troubling thoughts at bedtime. Understand that the child is not being difficult on purpose.

If your child is having sleep problems, it can help to:

• Try to keep the child's normal bedtime and amount of sleep. As much as possible, try to facilitate enough sleep time (depending on the age of the child) and stick to your family’s normal wake-up time.
• Try to maintain normal routines for going to sleep or create new ones, such as singing songs, telling stories, sleeping with a toy, end-of-day reflections (e.g. thinking of nice things that happened during the day), prayers, or cuddle time. A stable bedtime routine is helpful for children, adolescents and caregivers.
• If the child is feeling worried or scared about the emergency before bedtime, try to help them think of more hopeful but realistic scenarios. Do not make promises you cannot keep or tell the child that everything is going to be alright if you are not sure. Help the child to visualize a safe place, by imagining or remembering a specific situation in which the child felt safe and happy.
• Help the child relax at bedtime by doing relaxation exercises. This can help prevent negative, intrusive thoughts that might disrupt their sleep.
• Younger children may have a special toy or item with them. You can use it in a sleeping exercise with the child. Ask the child to lie down on the bed with the item on the child’s tummy. Create a game where the child pretends to rock the toy to sleep with the movements of their tummy, by breathing slowly and steadily. It might help to say, «breathe in, 2-3-4, breathe out 2-3-4.»

FEAR OF SEPARATION OR CRYING WHEN CAREGIVERS LEAVE

Goodbyes may remind children of separation from loved ones that happened due to the crisis. Understand that your child might be afraid of separating from you. When a young child sees somebody leaving, they may not understand the difference between a normal, short-term separation, and unplanned separations that may have happened during the emergency.

• For brief separations, (e.g., going to the bathroom) prepare your child by explaining where you will go and that you will be back shortly. If you are leaving your young child with someone else, it is important to show the child that you trust the temporary carer, so the child feels safe. It might be helpful to spend some time with the child and the other carer before you leave. If your child is feeling scared, you can say something like«I know you are feeling scared. Perhaps, you don’t want me to go, because last time we weren’t together you didn’t know where I was. This is different, I’m going to the market and I’ll be back after lunch.»
• For longer separations, have the child stay with familiar, trusted adults. Tell the child where you are going and when you will be back.
• When you talk about your return, provide specifics that your child understands. If you know you will be back by 3:00 pm, tell it to your child on their terms; for example, say, "I will be back after nap time and before afternoon snack." Explain time in ways they can understand. It can be helpful to talk about your return from a longer separation in terms of "sleeps." Instead of saying, "I’ll be home in 3 days," say, "I’ll be home after 3 sleeps."
• When separating, give your child full attention, be loving, and provide affection. However, keep the good-bye short and simple. Making it long or complicated may make it seem like something unusual is happening and may cause more anxiety.

EXCESSIVE CRYING

During and after emergencies, it is natural that children will feel sad. Allow them to express how they are feeling. Try to stay close to the child and acknowledge the emotions they are experiencing.

• Help them to find words to describe their emotions, and reassure them that it is normal for them to feel this way in the circumstances. This can help to comfort your child, even if they still feel sad.
• Support the child by sitting with him or her and giving them extra attention. Help them feel hopeful about the future by talking about how your lives will continue and any good things that will happen in the short or long term (e.g. playing games, going for a walk, telling a story, people being kind and offering support). Hugging and physical warmth can also help provide comfort.

WITHDRAWAL AND LACK OF INTEREST IN PLAYING

Your child may be feeling sad and overwhelmed. When children are stressed, some become unusually active or aggressive while others may become more shy, quiet and withdrawn. Some will have different reactions at different times.

• Let your child know that you care and that you are always there for them.
• Help your child to put their feelings into words. Let them know that it is ok to feel sad, angry or worried.
• Do not force your child to talk to you but let them know that you are always available to listen to them.
• Try to do activities that your child might like; such as reading a book, singing or playing together. A child who seems withdrawn might benefit from small activities such as helping you with tasks or small household chores.
• If your child is unusually active or aggressive, try to get them to do physical activities to burn some energy (e.g., running around; dancing; challenge your child to a jumping contest to see who can jump highest, longest, fastest, or slowest). Giving your child a focal point that is not the stressor will allow their brain and body to reset itself.

RISKY BEHAVIORS

When children feel unsafe, they sometimes behave in unsafe ways. It can be their way of telling you that they need your guidance and support. They need you to show them that they are important enough to be kept safe.

• If necessary, hold the child and explain that what they are doing is not safe. Let them know they are very important to you, and that you do not want anything bad to happen to them.
• With adolescents, it may help to establish activities that are beneficial to the community, to give the adolescents a sense of their value and ability to make a difference.

For in-country referrals, visit the Blue Dot Hub, select your current country of residence, and look for mental health services available under “Medical Care & Disability Support.”