Tag Archives: trauma

Day 2 of Joy Osofsky at IPMH

kidsatschoolDBT

The following day Joy Osofsky talked about trauma. She outlined ways in which children can be traumatized by adverse childhood experiences as noted in the “ACE” study, in the 1990’s, . She talked about how trauma affects children’s cognition, behaviors, emotions, and brain architecture. Finally, she described several ways traumatic sequelae can be healed. I would like to think of these issues in terms of a spectrum from normative stress, which can be positive, to trauma, with “tolerable” and “toxic stress” in the middle. I will explain more about this spectrum later on, but I want to introduce the idea of a spectrum of stress at this point, because I believe that much of what Joy was talking about in terms of trauma can also be true in situations of high stress – especially when it is prolonged – that do not reach the level of actual trauma.

Children are traumatized by child maltreatment; exposure to community violence in their neighborhoods and in their schools; exposure to domestic violence in their homes; exposure to or hearing about unusual traumatic events such as accidents, terrorist attacks, or hurricanes; military children when their parents are deployed; and exposure to violence in media (usually the effects of an earlier trauma will be exacerbated by subsequent exposure to media).

Joy and her husband were leaders in the psychological response to Katrina in New Orleans. She notes that the psychosocial impact of natural disasters can be similar to that of trauma. The impact is related to the disruption of family structures, changes in the ways people and communities relate to each other, and the taxing effect on the individual, family, school, and community infrastructure. The psychological referral rate for students was very high after Katrina and then declined, but subsequent smaller spikes seem to reflect retraumatization from other hurricanes, oil spills, etc. A child in my hospital clinic began waking up with nightmares after hearing Donald Trump on television saying that all Mexican immigrants should be deported, because she feared that she would lose her parents.

Interestingly, in New Orleans, the children who were integrated into East Baton Rouge schools had higher depression rates than the children who were able to return to their New Orleans schools. This seems to relate to the importance of a “sense of place”. Another window into trauma is the child welfare system, where children have experienced family violence, substance abuse, sexual abuse, removal from primary caregiver, subsequent placement in foster care, and physical abuse.

Trauma alters the developmental trajectory of the child. Joy referred to the children’s book, The Little Engine That Could. She said that trauma pushes the train off the track, and our job as mental health professionals is to help put the little train back on the track. Joy noted the continuum from stress to trauma, starting with normative, developmentally appropriate stress, then emotionally costly stress, sometimes called “toxic stress”, and finally trauma. Positive stress is necessary to healthy development. It occurs in the context of stable, supportive relationships and results in brief increases in heart rate and mild changes in stress hormone levels. Tolerable stress includes stress responses that could disrupt brain architecture but are buffered by supportive relationships that make it possible for the brain to heal. Toxic stress involves a strong, prolonged activation of the body’s stress response system in the absence of the buffering protection of adult support. Toxic stress can damage the developing brain architecture and create a short fuse for the body’s stress response systems, leading to lifelong problems in learning, behavior, and both physical and mental health.

Helping a Child Manage Violent Events

img_5564-scaled10001

As promised, I have given more thought to the question of what to tell children about the recent tragic events in Boston. I have talked to teachers and other clinicians and listened to children and read information on the Internet and in published material. One of the good things I read was the American Academy of Child and Adolescent Psychiatry guidelines on talking to children about terrorism and war. http://www.aacap.org/cs/root/facts_for_families/talking_to_children_about_terrorism_and_war. Another is an excellent link provided by Dr. Heidi Ellis from Boston Children’s Hospital –
http://www.nctsn.org/content/pfa-mobile

In general, sensible guidelines for helping children through these troubled times include talking to children about the events, communicating comfort with emotions about the events (both child’s emotions and parents’ emotions), and emphasizing safety.

First, the talking: Talking can be very helpful, but only in the child’s own “language” and time frame. Too much talking can be at best confusing to children and at worst can be alarming. It is of course essential to speak in words the child can understand. Discussing frightening events is best done at the initiation of the child, usually in response to his questions. The rule of thumb I usually use is to answer the child’s question briefly and without elaboration, then stop. If the child wants to know more, she will ask. Moving back and forth in this turn taking rhythm gives the child the chance to feel adaptively in control of the information gathering, to find the answers he or she needs and to avoid unnecessarily alarming or confusing information. A 9-year old boy, hunched over a video game told me in response to my simple question about his experience of the attack, “When bad things happen, I just don’t pay attention and wait for them to go away.” When I did not challenge him, he later told me about how some kids in his class were scared and talked a lot about the attack and its aftermath.

It is also important to remember that you do not have to answer all your child’s questions. Repetitive questions can often indicate the child’s wish for reassurance about safety more than his desire for specific answers. Instead of responding concretely to a question about the type of weapon used, for example, the parent may instead say something like, “What I do know is that the policemen are working hard to find out the information they need to protect us.” (Now some parents will insist that their child will “not let them get away with” an indirect answer like that. What I would say about this is that the child is trying to find reassurance in what seems like an out of control world through controlling the parent with his questioning, and in the long run a calm parent who declines to answer the questions he thinks inappropriate will make the child feel safer.)

Children also give other cues besides questions to communicate their concerns. For example, a young child may tell a parent that he had a scary dream, or an older child may say that she feels like staying home from school that day. In these cases, the parent may choose to ask about the dream or the child’s wish to stay home from school without bringing up the event specifically. Or, the parent may say something about the dream or the wish to stay home reminding them of the scary event. “Your scary dream reminded me of the scary things that happened in Boston yesterday,” or “Your not wanting to go to school reminds me of how I don’t want to go to work today after all the frightening things that have been going on!” In both cases, the parent isn’t pressuring the child to “take on” the frightening thoughts but joining the child in her concerns. It is important to hang around, to be available to talk. Tell the truth because child will know if you are being dishonest. Be prepared to answer questions multiple times in different ways, since children put together information in bits and pieces depending on the context and on their mood and state of concentration. This is different from the perseverative questioning I mentioned before.

Second, communicating comfort about emotions: All children – young and older –respond not only to the frightening event but also to the emotions of the people around them. Remember that a picture is worth a thousand words, so that the image of a parent’s anguished face will tell a child more than her reassuring words. It is important for parents to take care of their own emotions first in order to prepare themselves to be available to their child, just as the flight crew tells you to put the oxygen mask on your own face first and then on the child’s, in case of an emergency on an airplane. When your own feelings are under control, acknowledge them – fear, anger, sadness.

Children may tend to revert to earlier behaviors in response to frightening events, just as they do after other stresses. For example, when I went into a classroom yesterday morning, one 3-year old boy that I know well greeted me with baby talk. Of course, his affectation may not have been directly related to the crisis. Still, given the context of current events, it occurred to me that his baby talk might have been a response to fears about those events, and that awareness alerted me to the state of his mind on that day. In another classroom, two 5-year old boys at the lunch leaned in towards me when a third boy brought up the subject of the bombings. All children need and deserve extra tolerance and comfort in times of crisis.

Children will respond differently to frightening events, depending on their unique circumstances and personalities. Kids whose parents are separating, children who have had a recent move or other transition, or children who have lost a relative or friend, would be expected to react more strongly to danger in their environment.

Finally, emphasizing safety. Parents can stress safety by containing the stimulation of television, radio, and adult conversations. Remember that when children are anxious they listen more carefully to communication that is intended to be for adults alone. Limit the amount of television in the home at these times, and if you turn on the t.v., watch it with your children so that you can help them make sense of what is being broadcast.

They can support a feeling of security by maintaining comforting routines at home and in school. After Katrina, one of the first acts taken by Joy and Howard Osofsky in their rescue efforts was to create a school for the displaced children (Joy Osofsky, Personal Communication, 2010).

Parents can also help their child feel secure by scaffolding the child’s own efforts to create a feeling of safety. Some children will want to play firefighters or choose rescue vehicles instead of the usual racing cars or trucks. In a 3-year old classroom today, the children were playing with rescue vehicles, making them so strong and magical that they could fly through the air to rescue people. No explicit mention was made of the bombing, but the children could in their play experience an enhanced sense of their own strength and master that will protect them against some of the adverse effects of traumatic events. Older children may want to make some kind of restitutive action such as writing letters or giving gifts to the first responders. Regardless of how unrealistic the child’s ideas might be, parents should treat them with respect. One 5-year old boy told me Monday that he had a plan to throw blueberries at the bad guys, and I just nodded with interest.

 

 

 

.

 

 

 

 

 

Childhood Sexual Abuse

img_0678-scaled1000

Dealing with Sexual Abuse in Children

Sexual abuse is most common in dysfunctional families, but it occurs in all socio-economic groups. It is common in institutions for children. Why? One reason is because children in institutions come from families that could not nurture or protect them, for whatever reason. Sometimes these reasons include abuse and neglect in the home. Another reason is because institutionalized children may be vulnerable and easily exploited. Why do caregivers sometimes sexually abuse the children in their care? In families, this is called incest. One reason is because sometimes they carry childhood histories of abuse by their own caregivers into their adult lives. Often, child abusers have two sides to their minds – one “the rescuer” and one “the abuser”. “The abuser” exploits the child for the adult’s own needs. Often the adult convinces himself that he is acting for the good of the child (“She wants it.”) or normalizes it (“It is natural.”). In addition, the adult often has unhappiness in his present life that tips the balance from “the rescuer” to “the abuser”. Why is the abuse so destructive? Because it is exploitative, because it involves a crucial breach of trust, because it can be transmitted from one person to the next, and finally, because it can affect the developing brain of the abused child.

In relation to that last important point, let’s look at some of the major features of childhood sexual abuse, provided by the expert in child trauma, child psychiatrist, Maria Sauzier, (Maria Sauzier, Personal Communication, 2013).

Major Things to Know about Sexual Abuse

  1. Children must learn to cope with their own aggressive and sexual urges; that is part of normal development.
  2. The vicarious expression of this part of mental and physical life can be found in fairy tales and stories throughout history and across all cultures.
  3. Contact with the “cruelty of nature” is part of everyday life, especially in traditional and rural societies (animal slaughter, etc.).
  4. Most children witness adults arguing, are punished, and see others punished. This punishment is physical in some cultures.
  5. Some children live in unsafe neighborhoods where they have early contact with the cruelty of human beings.
  6. Children may witness violence in their own homes – towards a parent or a sibling.
  7. Children may be treated with violence, in their home or their school, as punishment.
  8. Some children’s bodies are treated with violent or sexual acts for the sadistic or sexual gratification of adults.

It is important to realize that the ascending curve of these various levels of contact with aggression and sex has no matching curve of distress, or of internal (depression, anxiety) or external (acting out behaviors) response. Instead, the reactions of children to violence and sexuality or sexual stimulation do not follow any predictable pattern.

The whole of the child’s brain does not grow uniformly; various parts of the child’s brain grow at a faster pace at any given time. Stress reactions will influence the part of the brain that happens to be in a fast-growth mode the most severely.

Children are also born with a variety of levels of reactivity to being stressed. Some babies startle in response to benign new experiences, while others will take even unpleasant experiences in stride. Their brains are wired differently, and the level of stress that will provoke the neurochemical cascade of stress reactivity varies widely.

Once the cascade of neurochemical hormones is activated, it follows the same pattern in humans as in animals in the response to perceived danger: the production of adrenaline prepares the body to react to the danger either with fight or with flight. These are normal reactions that have ensured the survival of the species. A third reaction is not helpful: freezing, going blank, without a coherent strategy is maladaptive in all cases.

Once the danger is over, the high adrenaline and cortisol levels circulating through the body and the brain need to be metabolized, deactivated, because the effects of high levels are not healthy. If this does not happen, the consequences may be high blood pressure, rapid respiration or heart rate, the diversion of blood supply from the gut and other internal organs to the muscles, or mental alertness to the point of oversensitivity to any sign of threat.

If this cascade is triggered frequently in the course of a child’s growing up, the child may stay on constant alert. The child’s brain is bathed in neurochemicals that will change his or her growth pattern and may lead to subtle or not so subtle changes that may take one of three major paths:

(1) Fast and indiscriminate reactivity; expecting danger where there is none and fleeing from it; feeling that you are on your own without support; no capacity to trust, being less capable of using higher levels of brain functioning that allow planning and flexibility, an inability to have a quiet, receptive brain in order to learn or even listen, need for constant stimulation expressed in risk-taking behavior. (2) Fast and indiscriminate reactivity; expecting danger where there is none and fleeing from it; feeling that you are on your own without support; no capacity to trust, being less capable of using higher levels of brain functioning that allow planning and flexibility, an inability to have a quiet, receptive brain in order to learn or even listen, risk-averse behaviors, sometimes to the point of paralysis. (3) Generalized helplessness, no mechanism for self-protection, no self-care, emotional and mental paralysis, giving up.

The children in the first group have serious behavior problems, as they are easily triggered and overreact to adult demands, to any change in plans, to anything they perceive as leading to a lack of control, losing face, to any “dissing” by a peer. They may invite danger with risky behaviors, provoke adults to punish and abuse them, get stimulated by repeating their abuse at the expense of others. I will continue with my Dr. Sauzier and my thoughts about child sexual abuse in the next posting.

 

Read this blog in Spanish.

 

“A Healing Place”: Part II

IMG_5672 2

I continued with the workshop, referring to Bruce Perry (as I so often do) as I addressed what Rachel had described to me as the caregivers’ discouragement. I told them that the parts of the brain that influence this problem behavior “have been shaped over many years with hundreds and thousands of repetitions”, and that traditional therapies that typically take place in 45 or 50 minute sessions at a frequency of once a week cannot be expected to reverse years and years of traumatizing experiences (Perry & Hambrick, 2008, p. 39). I wanted to talk about changing the brain in healthy directions and how that improves behavior, but mindful of the role of consultant and the necessity of staying close to the caregivers’ stated concerns, I addressed the need to respond to problem behavior “right now”.

Changing Behavior Right Now: Think Ahead

(1) Know the child. (2) Make realistic expectations. (3) Anticipate problems. (4) Prepare for transitions. (5) Be predictable, but not too predictable. (6) If something is not working, stop and try something else. (7) Resolve conflict. (8) Give rewards and consequences.

I will go into detail in the first point in this posting and continue with the subsequent ones in the following postings.

Know the child:

It is important to keep in mind the child’s strengths and weaknesses, and also to remember the child’s story of pain. The role of the child’s traumatic background is easy to forget when you are dealing with his problem behavior, but it is important to bring it to mind now and then, because it can help you with how to respond. First of all, remembering the child’s story of pain can refresh your empathy for the child. Second, it can help you identify “triggers” or special challenges for this individual child. For example, a child who has been sexually abused will often be triggered (have a traumatic reaction) to certain kinds of touch or to intrusive behavior (someone putting his or her face too close to the child’s face, or looming over him or her). Remember what I said about children on the autistic spectrum. Often these children will also react violently to someone coming in too close.

Again, channeling Bruce Perry, I emphasized the importance of special relationships – For traumatized children, “The relational environment of the child is the mediator of therapeutic experiences.” (Perry & Hambrick, 2008, p. 43) In fact, in the fortunate case that there are multiple good caregivers available, such as is true at Love and Hope, the child may choose one person who can help him feel calm, another whom the child can rely on to be firm, and another who can help him have active, rough housing kind of fun. This is not so different from what happens in families, especially big families.

We know that it is also important for the relationships that partners make with each other – such as adult partners or even close friends at any time in life – to include a mix of these functions. That is, we would not choose a partner or close friend for whom we could not rely on both for fun and also for comfort. Yet these children may require time to put it altogether, and a “family” environment in which these relationship functions are offered by different people is often a first step.

Reclaiming children and youth www.reclaiming.com

Read this blog in Spanish.