Traumatic stress
Wei
Ciara
Karla
Allison
Craig
iuliia
Tanja
Cohort11
Homelessness
Cause
Military family-related stressors (deployment)
Divorce
Death of a family member
Moving to a new country
Cyberbullying
Cyberbullying - abuse of students using digital recourses. It includes sending, posting, or sharing negative, harmful, false, or mean content about someone else. It can include sharing personal or private information about someone else causing embarrassment or humiliation. Some cyberbullying crosses the line into unlawful or criminal behavior.
73% of students report that they have been cyberbullied in their lifespan, and 44% say it happens in the last 30 days.
Symptoms of Domestic Violence
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School Aged Children
Aggressive / bullying
Anxiety
Stomach aches
Poor grades / failure of one or more grades
Low self-esteem / poor social skills
Fear of abandonment
Teenagers
Withdrawn
Poor grades / fails or quits schools
Immunity / irresponsible
Violent outbursts
Property destruction
Unable to express feelings
Low self-esteem
Feels responsible for taking care of home and adult victim
Domestic Violence can be verbal, physical, sexual, and psychological
The US Department of Justice defines domestic violence as "a pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner."
Symptoms
Uneasy, shy, nervous, moody or scared about going to school or outside.
Skip school or protest about going to school.
Nervous or jumpy when texting or using social media.
Upset or frustrated after going online or gaming.
Unwilling to discuss or share information about their online accounts and activity.
Unexplained weight loss or weight gain, headaches, stomachaches, or trouble eating.
Trouble sleeping at night or sleepy during the day.
Loss of interest in favorite hobbies or activities.
Child suddenly seems depressed or anti-social.
Withdrawn from close friends and family.
Change a usual circle of friends.
Making passing statements about suicide or making a suicide attempt.
Response:1. Trusted adult - The top first solution here is to create a class norm and grow its implementation around the whole school community. Homeroom teacher, technology teacher, school counselors, school administration and other related specialists that work with students need to reinforce the idea of a “trusted adult”. This is a strategy where a student have a clear understanding who his/her trusted adult is (or a range of them) and whom he/she needs to talk to at any uncomfortable situations. The school/ homeroom teacher needs really emphasize the importance of reporting cyberbullying cases immediately.
Response 2: Make it visual and easy to approach – each class should have visual poster/ display that explains the steps to follow if experiencing cyberbullying right away:
a) Stop – do not respond
b) Report – tell a trusted adult about the situation that made you uncomfortable
c) Save evidence – younger children might need an adult support here
d) Ignore the meaning of messages – do let cyberbullying hurt your feelings
Response 3: Teacher action – it is important for a teacher to note changes in a student behavior and immediately take actions. Usually as an individual teacher the following steps should be taken:
a) Talk to a student or report to a homeroom teacher about your observations, who then should talk to a student
b) Report the situation to administration/ counselors
c) Help the student to save evidence
d) Inform parents
e) Counselor/ homeroom teacher hold meetings with the victim and help him/her to respond to the situation
Resources:
Adams, C. (n.d.). Cyberbullying: What teachers and schools can
do. Retrieved April 02, 2021, from
https://www.scholastic.com/teachers/articles/teaching-
content/cyberbullying-what-teachers-and-schools-can-do/
Assistant Secretary for Public Affairs (ASPA). (2020, September
15). What is cyberbullying. Retrieved April 02, 2021, from
https://www.stopbullying.gov/cyberbullying/what-is-it
Hartung, E. (2021, March 30). The 10 warning signs of
cyberbullying. Retrieved April 01, 2021, from
https://www.netnanny.com/blog/the-10-warning-signs-of-
cyberbullying/
Broadband. (2021). All the latest cyber BULLYING statistics and
what they mean in 2021. Retrieved April 01, 2021, from
https://www.broadbandsearch.net/blog/cyber-bullying-
statistics
Stress is an unavoidable psychological and emotional factor that affect students who move to a new country. It increases if the change of a location is every several years.
It is quite common for international students, especially of an older age, to experience stress of adaptation to a new environment. There are several affects: language barrier, culture shock, homesick, high expectations, loneliness, departing from friends and favorite places.
Response 1: Clear instructions – make sure that your class norms/ expectations/rules are clear and easy to understand. Use variety of techniques to help ELL students – help to eliminate language barrier.
Symptoms
Absence at school – skipping school or a being actually sick more than usual
Fatigue and headaches – impaired concentration
Lost of patience/ Irritability
Pessimistic attitude
Trouble coping with school/classmates
Unusual desire for social isolation
Change in schoolwork performance
Frequent lying
Response 2: Offer off-class meetings – this is a time where international students can talk to you about different concerns, to clarify class routines, ask for suggestions and advices.
Response 3:Join Groups – offer afterschool activities for international students to join. This will help them to get into a new social group, avoid isolation and to do something that they like.
Response 4: Allow more of a group/peer collaborative projects
Response 5:Trusted adult - this is a strategy where a student have a clear understanding who his/her trusted adult is (or a range of them) and whom he/she needs to talk to at any uncomfortable situations.
Resources:
Elturki, E. (2018, June 14). Teaching international students: Six ways to smooth the transition. Retrieved April 02, 2021, from https://www.facultyfocus.com/articles/effective-classroom-management/teaching-international-students-six-ways-to-smooth-the-transition/
Miriam. (2019, June 09). Signs and symptoms of stress on international students. Retrieved April 02, 2021, from https://www.scholarshubafrica.com/39649/signs-symptoms-stress-international-students/
PlanBook. (2019, November 25). Self-regulation: Helping students cope with school stress and anxiety. Retrieved April 02, 2021, from https://blog.planbook.com/school-stress/
Symptoms
Symptoms of Middle/High School Aged Children
Symptoms
Symptoms of Middle/High School Aged Children
Covid 19
*Earthquake
Age1-5 Nervousness, Anxiety about being away from parents or other primary caregivers, Irritability and disobedience
Symptoms
Responses
According to American paediatricians
Signs of stress and mental health challenges are not the same for every child or teen, but there are some common symptoms.
Teenagers
Reference List
American Academy of Pediatrics (March 12,2021) Signs your teen may need more support
Retrieved April 2nd from https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Signs-your-Teen-May-Need-More-Support.aspx
Wegman, J.Finding happiness in a socially distanced World. 23.march 2021, podcast
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:
- problems with memory, thinking, or concentration.
- less interest in schoolwork and drop in academic effort.
- changes in appearance, such as lack of basic personal hygiene (within reason, since many are doing slightly less grooming during this time at home).
- an increase in risky or reckless behaviors, such as using drugs or alcohol.
- thoughts about death or suicide, or talking about it
Toddlers and Preschoolers
Toddlers & Preschoolers, Help keep the routines, Be patient, understanding and kind. Contact parents and paediatrician if needed
Elementary Students and adolescents
Be a role model for sustaining healthy habits,
Integrate mindfulness, relaxation, yoga, Fun Fridays into the weekly lesson plan.
Start lessons asking the question, how are you feeling today? Perhaps introduce the ‘Rose and thorn’ exercise , the muppetmeter, but first, decode the mimics of your students, take a minute to feel the temperature, discuss how it is normal to feel differently in abnormal situations like a pandemic
Group Work to practice trust in a fun way(https://www.bookwidgets.com/blog/2019/10/15-fun-team-building-activities-and-trust-games-for-the-classroom)
Generally,
Be more patient, understanding and kind. If a student is experiencing severe anxiety and depression, contact the parents and mention the possibility of a professional therapist. Suggest online sources like Parenting in a pandemic, tips to keep a calm and caring home, a win win for students and parents. https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Parenting-in-a-Pandemic.aspx
Wildfire & Displacement
Symptoms
Responses
School might be a evacuation center
Routines are very important to give students feelings of safety and stability
Allow students time and opportunity to talk about their experience, stress, and fears.
Writing and art can provide a therapeutic exploration of the student's experience.
Learning about wildfires - why they happen, how it is fought, what happens afterward - can help students understand and come to terms with the event.
Highlight examples of resilience and strength of human spirit.
Resources
PTSD, depression, anxiety
Physical injuries or health effects
Difficulty with hygiene and apparel due to evacuation or house loss
Physical exercise
Mindfulness exercises
Support through school counselor
Nightmares
Grief
Students may be tired, stressed, anxious
Other considerations
Teachers and staff may be victims, too
The school building may have been damaged
Emotional response might be delayed for months
Suicidal ideation
Acting out in class, disruptive behavior
Numbness, lack of affect, withdrawn
Involves multiple traumas - terror, loss, death, displacement
Be patient and flexible
References
Jones, C. (2020, September 29). Even when the smoke clears, schools find student trauma can linger. EdSource. Retrieved April 3, 2021, from https://edsource.org/2020/even-when-the-smoke-clears-schools-find-student-trauma-can-linger/640713
Pang, V. O., Madueno, M., Atlas, M., Stratton, T., Oliger, J., & Page, C. (2008). Addressing student trauma in the wake of the California wildfires. Social Education, 72(1), 18-23. https://www.socialstudies.org/system/files/publications/articles/se_720118.pdf
Reinberg, S. (2021, February 16). Mental health trauma plagues wildfire survivors. U.S. News. Retrieved April 3, 2021, from https://www.usnews.com/news/health-news/articles/2021-02-16/mental-health-trauma-plagues-wildfire-survivors
Bullying
Symptoms of the victim
Responses
Physical injury
Lost or destroyed possessions
Frequent stomach/head aches
Nightmares, lack of sleep
Reluctance to come to school, increased absences
Declining academic performance
Changes in socialization, isolation
Lowered self-esteem
Symptoms of the bully
Pattern of aggression, increasing aggression
Part of a pack of aggressive children
Self-harm or suicidal ideation
Frequently being disciplined
Blames others, does not accept responsibility
Intervene immediately when you witness bullying
Report the bullying incident to the Child Protection Officer
Separate the children directly involved
Address any medical needs
Make sure everyone is safe
Document the incident in detail in the appropriate school recording interface.
Call police/medical if serious injury or weapons were involved
If you have not witnessed direct bullying, but suspect something is happening based on vicitm's symptoms, report to the Child Protection Officer
If a student tells you they are being bullied, reassure them that it will be addressed and report it to the Child Protection Officer.
References
U.S. Department of Health and Human Services. (2017, September 28). Respond to bullying. StopBullying.com. Retrieved April 3, 2021, from https://www.stopbullying.gov/bullying/warning-signs
U.S. Department of Health and Human Services. (2020, July 21). Warning signs for bullying. StopBullying.com. Retrieved April 3, 2021, from https://www.stopbullying.gov/bullying/warning-signs
Age 5-11
**Symptoms
Age 14-18
Wonder by R.J. Palacio
Wildfire by Rodman Philbrick
Wildfire! by Ashley Wolff
Bibliotherapy - reading can help students process their trauma
Bibliotherapy - reading can help students process their trauma and learn better social skills
Despite being one of the wealthiest nations on the planet, the United States struggles with a high level of poverty and homelessness, especially among the younger population. In fact, 40% of the homeless population in the US are under the age of 18.
While the numbers are shocking, it’s even more disturbing to learn over 50% of young people living in shelters and on the streets report that their parents actually told them to leave, or at least knew they were leaving and didn’t care.
The main cause of teen homelessness is physical, sexual, and/or emotional abuse from parents or guardians. Here’s a closer look at the numbers:
• 46% reported being physically abused
• 38% reported being emotionally abused
• 17% reported being forced into unwanted sexual activity
Response Strategy
Cause
Response strategy
-Parental separation, family reunification, and reintegration.
-Disruption of relationships with friends and neighbors due to frequent moves
-Adaptation to new schools and new community resources.
-The trauma of a parent returning home from combat with injuries or illness; and also some others face their parent's death.
Traumatic stress reactions
Traumatic stress reactions
-Being easily angered Being physically or verbally aggression (e.g., yelling, name calling, hitting, biting, etc.)
-Experiencing sexual aggression towards peers
-Having troubles with their friends
-Fidgeting or difficulty sitting still
-Experiencing stomachaches, headaches, or other body pains
without having an underlying medical condition
-Struggling with new fears (i.e., social situations, separations, changes, etc.)
-Experiencing sudden changes in mood
Book reading about empathy to allow frequent move military kids to have a better transition. ()
Reference:
Reference
PTSD & Trauma. (n.d.). Retrieved April 4, 2021, from https://www.bratswithoutborders.org/ptsd-trauma
Griffin, D. (2020, October 19). Understanding Child Trauma and Resilience: For Military Parents and Caregivers. Retrieved April 4, 2021, from https://www.nctsn.org/resources/understanding-child-trauma-and-resilience-for-military-parents-and-caregivers
MilitaryChild. (2017, August 24). Retrieved April 05, 2021, from https://www.youtube.com
Peterson, S. (2018, May 25). Retrieved April 05, 2021, from https://www.nctsn.org/what-is-child-trauma/populations-at-risk
Peterson, S. (2018, May 25). Retrieved April 05, 2021, from https://www.nctsn.org/what-child-trauma-populations-risk/homeless-youth
Facts on Trauma and Homeless Children [PDF]. (2005). National Child Traumatic Stress Network
- Teacher and school both understand "The McKinneyVento Act."
It requires liaisons to ensure that “homeless children and youths are identified by school personnel through outreach and coordination with other entities and agencies
[McKinney Vento Homeless Act] for video ()
- The initial step in dealing with families exposed to trauma is for providers to become trauma-informed. An effective teacher would create safe, supportive, nonthreatening environments by the followings:
• Maximizing choice and control for students
• Avoiding provocation and power assertion
• Modeling prosocial behavior and skills
• maintaining clear and consistent boundaries,
• Sharing power in the running of shelter activities
• delivering services in a nonjudgmental and respectful manner
3.Establish safety and trust in the classroom. Encourage students—as they are ready—to share information and their personal history. (ex. during lunch date with teacher, during recess, or after school. )Youth need to know that no services will be withheld if they don’t answer specific questions.
- Assess the need and readiness for therapeutic interventions, and make appropriate referrals.
Many face barriers when it comes to -
- completing homework assignments
- finding reliable transportation so they can be in school on time.
- finishing a full grade at one school. The National Network 4 Youth found that 20 percent of homeless students repeat at least one grade while in school.
Sleep Deprivation - Without access to a permanent bed of their own, many homeless students sleep wherever they can find shelter – including storage units, vehicles, shared motel rooms with other people, or even on the street. Because they seldom get a restful night’s sleep, many of these students struggle to stay focused while at school.
High Stress - Aside from the normal stressors related to growing up, homeless K-12 students also must face much larger questions: When will I get my next meal? Will I be taken away from my parents?
-Maintain a predictable and consistent routine. Predictable routines help students feel safe, especially after a trauma. These routines can include, but are not limited to, a clear classroom norm and transition from class to class.
Involve parents
Let parents know that their child's support sources. School liaisons are available at most military installations to support military families. Their role is to help families coordinate access to resources in the community as well as on installation. School liaisons also help military children get set up at school.
Teacher provides continuous positive interactions with students following a traumatic experience. This helps our students balance their emotional experiences. Some positive interactions (dependent upon grade) might include:
- talking about their day during recess or “lunch date with teacher”
- playing interactive activities in class
-reading trauma-related book to help students recognize their feelings and emotions.
Incorporate drawing in class. Young graders are unable to put their big feelings into words, ask them to draw how they feel or what makes them feel angry, sad, scared, and worried.
Child abuse - Symptoms and causes. (2018, October 5). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/child-abuse/symptoms-causes/syc-20370864Effects. (2019, April 25).
The National Child Traumatic Stress Network. https://www.nctsn.org/what-is-child-trauma/trauma-types/intimate-partner-violence/effects
National Center on Domestic and Sexual Violence. (n.d.). Domestic Violence and Children. Retrieved March 31, 2021, from http://www.ncdsv.org/
Symptoms of Elementary Aged Children
Headaches or stomach problems
Frequent crying and emotional distress
Increased separation anxiety
Difficulty concentrating on schoolwork
Extreme negativity or criticism
Risky sexual behavior and/or substance abuse
Headaches or stomach problems
Poor academic performance
Increased conflict with peers
Aversion to activities that were once enjoyed
Symptoms of Elementary Aged Children
Thoughts about their own death
Regressive behaviors
Acting out
Withdrawal from friends
Feeling of denial or anger
Acting out
Regressive behavior
Risky behaviors
Suicidal thoughts
Response Strategies
Response Strategies
Changes in eating and sleeping habits
Lack of interest in fun activities
References
Child Mind Institute. (2020, March 27). Helping children cope with grief. Retrieved April 05, 2021, from https://childmind.org/guide/helping-children-cope-grief/
Shaunak, P. (2021, February 18). The impact of divorce ON School-Aged CHILDREN: COUNSELING@NYU. Retrieved April 05, 2021, from https://counseling.steinhardt.nyu.edu/blog/impact-of-divorce-on-students/
- Create a safe space for the child so they are comfortable expressing their emotions.
- Listen (and do not dismiss) the child's feelings and emotions, even if they sound irrational.
- Set up a 1-on-1 meeting with the student and counselor where they can learn to develop and use coping skills, redirect their focus to taking care of themselves and expressing their emotions and possibly involve the parents to open the communication within the family.
- Develop a plan to improve academic performance by arranging homework help, study groups, or tutoring services.
- Modify classwork/homework around the funeral/memorial service to relieve unnecessary stress towards the student.
- Encourage expression of feelings through physical outlets and symbolic play (ex. drawing and stories).
- Encourage the student to talk to the teacher and/or counselor and do not dismiss their grief (allow the student to mourn).
- Work with the family and/or counselor to return to a normal routine as soon as possible, even if this means modifying the work during the grieving period.
- The teacher, counselor and family should stay in touch following the service to continue the discussion on the best way to help the student.
Common symptoms
- headache
- sleep problems
- digestive problems
- isolation
- irritability
- substance abuse
Age 11-14
- Loss of interest in activities
- Poorer school performance
- Disruptive behaviour,
- Resistance of authority
Responses from teachers
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Knowing and watching for signs of possible exposure to violence
No single behavior proves that a child has been exposed to violence, but teachers can watch for:
Physical signs such as bruises
Unexplained changes in behavior
Emotional signs such as depression, mood swings,
and fearful or anxious behavior
Responding appropriately to children's discolsures
express to the teacher that they were the parent
apprehensive about going home
A teacher's willingness to listen to a child's story can lay the foundations of getting the appropriate help.
The teacher’s first responsibility is to follow school policies and procedures and refer the child to specialized professionals such as the school social worker or psychologist
Supporting the healing process
It's important that students have a caring adult with whom they can share with and help to build resilience with.
Teachers can create an emotionally safe place for all children to learn.
These safe spaces will enable children who have been exposed to violence to begin their healing journey.
Get more help if needed
Children might need specialized care that a teacher cannot provide
If that is the case, teachers should refer children to other professionals within or outside the school system.
Interventions provided by schools
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a number of interventions provided in schools have shown effectiveness in working with children exposed to violence. Information about the following interventions is available at the National Child Traumatic Stress Network Web site (http://www.nctsn.org):
Cognitive Behavioral Interventions for Trauma in Schools (CBITS)
UCLA Trauma/Grief Curriculum
School Intervention Project (SIP) of the Southwest Michigan Children’s Trauma Assessment Center
Trauma Center Community Services Program
Neglect
Is frequently absent from school
Begs or steals food or money
Lacks needed medical or dental care, immunizations, or glasses
Is consistently dirty and has severe body odor
Lacks sufficient clothing for the weather
Abuses alcohol or other drugs
States that there is no one at home to provide care
Neglect is defined as the failure to provide for the development of the child in all spheres: health, education, emotional development, nutrition, shelter, and safe living conditions.
Types
Medical
Failure/delay in seeking medical care
Noncompliance with plan of care
Supervision/safety
Car seats/seat belts
Ingestions
Guns/other weapons
Intimate partner violence
Education
Truancy
Noncompliance
Failure to seek care
excessive damage
Failure to thrive
Obesity
Noncompliance to prescribed diet
Prenatal drug exposure
Homelessness
Clean
Hygiene/clothing
Nurturance and affection/love
Abandonment
Ignoring/apathetic care
Dental
Nutrition
Home/Shelter
Safe
Responses
Resources
Hornor, G. (2014). Child Neglect: Assessment and Intervention. Journal of Pediatric Health Care, 28(2), 186–192. https://www.jpedhc.org/article/S0891-5245(13)00349-0/pdf
Recognizing Child Abuse and Neglect: Signs and Symptoms. (2007, June). Childwelfare.Gov. https://www.childwelfare.gov/pubPDFs/signs.pdf
Neglectful families often appear to be multi-problem families, although families with numerous problems are not always neglectful.
Because neglect often is chronic rather than episodic, these children may grow up believing that this is a normal way life and will not seek assistance or confide this information to anyone.
Emotional Neglect
Symptoms
Response Strategies
Parental alcoholism
Symptoms
Response Strategies
Depression
Anxiety
Apathy
Hyperactivity
Low self Esteem
Aggression
Truancy
Confusion/lack of emotion
Withdrawal from Social activities
Poor Hygiene
Report symptoms to school Councilor/Therapist
Compare your observations with other professionals' observations who also regularly visit with the student
Conduct activities that encourage the student to express their feelings and emotions
References
Crosson-Tower, C. (2003). The Role of Educators in Preventing and Responding to Abuse & Neglect. Retrieved April 04, 2021, from https://www.childwelfare.gov/pubPDFs/educator.pdf
Holland, K. (2019, November 25). Childhood Emotional Neglect. Retrieved April 05, 2021, from https://www.healthline.com/health/mental-health/childhood-emotional-neglect
Keller, A. (2020, February 27). Children of alcoholics. Retrieved April 04, 2021, from https://www.drugrehab.com/addiction/alcohol/effects-of-alcoholism-on-families/children-of-alcoholic-parents/
Person. (2018, February 05). Making students feel safe. Retrieved April 05, 2021, from https://www.edutopia.org/video/making-students-feel-safe
Exaggerated self-guilt
Truancy
Loss of weight/eating disorders
Apathy
Withdrawal from social activities
Signs of physical abuse (Bruises, cuts, etc)
Depression
Thoughts of suicide
Give student choices in their learning journey. This helps the student develop preferences and take control of their experiences.
Offer choices in their learning journey. This empowers the student to take control of their learning experience.
Poor academic performance
Inability to express appropriate emotions
Emphasis on social engagement to strengthen social bonds
Report symptoms to school Councilor/Therapist
Plan activities that encourage the student to express their feelings and emotions
Assign a mentor to regularly meet with student about needs and being proactive
Assign a mentor to visit with student about setting goals and being proactive
Establish social and emotional safety in your classroom.
Classroom contracts
Explicit anti-bullying or community-building curricula
Timely interventions in conflicts and hurtful exchanges
Teaching and modeling of empathy and active listening skill
Increase your self-awareness and trauma competency.
Create a behavior-management plan that focuses on positive reinforcement.
Implement student-generated agreements and contracts
Adopt “zero indifference” (NOT zero-tolerance) policies
Seek out training in restorative justice techniques
Explore stress-management strategies to diffuse tense situations and help students process feelings in the moment
Give students opportunities to demonstrate their strengths
Responding to Trauma in Your Classroom. (2016). Learning for Justice. https://www.learningforjustice.org/magazine/spring-2016/responding-to-trauma-in-your-classroom
Create a safe environment for students
Build relationships
Meet students where they are
Be predictable
https:\/\/resilienteducator.com\/classroom-resources\/trauma-informed-strategies\/#author. (2020, June 13). Trauma-Informed Strategies to Use in Your Classroom | Resilient Educator. ResilientEducator.Com. https://resilienteducator.com/classroom-resources/trauma-informed-strategies/
Provide consistency and structure
Utilize social-emotional learning
Use restorative practices over zero-tolerance policies
A. (2021, April 6). Trauma-Informed Teaching Tips for Classroom & Online Educators | Resilient Educator. ResilientEducator.Com. https://resilienteducator.com/classroom-resources/trauma-informed-teaching-tips/
Response 6: Prepare in advance
Elementary and adolescents
mood changes,
changes from extroverted to more introverted,
little interest in chatting with friends on social media,
loss of interest in activities previously enjoyed changes in appetite,
weight or eating changes
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- backward progress in skills, crying more easily.
- waking up more during the night.
- feeding issues
- clingy, withdrawn, or hesitant to explore
- hitting, frustration, biting
- bedwetting
Books
Mommy’s Black Eye
By William George Bentrim
A Family That Fights
By Sharon Chesler Bernstein
Hear My Roar: A Story of Family Violence
By Gillian Watts
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Irritability
Disobedience
school phobia
Heartfulness relaxation exercise focusing on the heart,
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