Upcoming Trauma Webinar Highlights Childhood Anxiety and How We Can Help

Children who have been traumatized exhibit anxious behaviors and often have a lot of “worries.” On June 22, 2011, Dr. William Steele, founder of the National Institute for Trauma and Loss in Children, will present a webinar, “What do parents/guardians really need to know about childhood trauma?” and will address some of the ways to help children and adolescents with trauma symptoms. According to Steele, today’s children and teens are steadily becoming more anxious; recent catastrophic events such as war, economic down turns, violence and natural disasters have possibly contributed to this increase in worried responses.

There may be other more subtle reasons for the persistence of anxiety in this generation of young people. For example, anxiety and depression correlate to our sense of control or lack of control over events in our lives. It is widely accepted that individuals who perceive that they are in charge of their lives are less likely to become worried or sad than those who feel victimized by similar experiences. If you remember your Psychology 101 course, you might recall the standard measure of a sense of control by Julien Rotter in the late 1950s—the Internal-External Locus of Control Scale. Internal control represents the beliefs about control that come from the individual and external control represents the beliefs about circumstances outside of the individual’s control. In brief, studies based on this measure have consistently shown that people who score higher in areas of internal control fare better [less anxiety and depression] than those who score higher in external control areas.

So is there evidence that there has been a decline in children’s and adolescents’ sense of internal control in recent years? From what researchers have learned over several decades, yes there has been a decline and at the same time, an increase in anxiety and depression. For example, Jean Twenge and colleagues (2004) studied young people ages 9 through 14 and college students from 1960 to 2002 and discovered that by 2002 the average young person was more externally-oriented when compared to individuals in 1960. This trend paralleled a rise in depression and anxiety during the same time period.

How do you know when anxiety is more than just passing “worry?” Here is a short list of some indicators found in children and adolescents:

• When children and adolescents can no longer perform or enjoy activities enjoyed by their peers;
• When anxiety is persistent, lasting more than a month;
• When anxiety distresses the entire family system [tension and anxiety during activities that normally are enjoyable];
• When young people avoid activities that normally require independence or become overly dependent on parents and caretakers;
• When there is avoidance of social activities [fears of social scrutiny and criticism];
• When there is constant need for reassurance and/or perfection-oriented behaviors;
• When there are unexplained physical symptoms like headaches and stomachaches.

Family histories of anxiety may contribute to an increased risk for anxiety disorders in children as do temperament and personality. Of course traumatic events, particularly repeated incidents, may contribute to that risk. Children and adolescents experiencing extreme levels of parental or family stress [divorce, domestic violence, homelessness, etc] are at higher risk for anxiety and depression. In working with families with anxious children, I often initially ask parents the following questions:

• On a scale of 1 to 10, 10 being the highest, how bad do you think your child’s problem is?
• On the same scale, how hard is the problem to manage? Are there days when the problem is worse? Give me an example of one or two of those days.
• Are there days when the problem is not so bad? Give me an example of one or two of those days if you can.
• What do you feel contributes to your child’s anxiety?

Because these questions may not be easily answered, I often ask parents to show me on a visual scale how “big” the problem is and draw images of “good” and “bad” days. Depending on the parent, I might even ask, “what does your anxiety look like when your child is anxious? Can you draw me a picture of that or pick out some magazine photos from these collage materials to show me?”

How is it that some children and adolescents with anxiety do better than others when faced with the same traumatic events? What can parents do to ease their child’s fears while building their resilience in a world that is frightening for adults as well? Dr. Steele will be addressing these and a number of topics related to anxiety in young people along with a variety of practical tips about how to help traumatized youth move from victims to survivors to thrivers. To register, see this webpage and read more about future webinars, too.

Be well,

Cathy Malchiodi, PhD, LPAT, LPCC

Reference

Twenge, J. M., Zhang, L., & Im, C. (2004). It’s beyond my control: A cross-temporal meta-analysis of increasing externality in locus of control, 1960-2002. Personality and Social Psychology Review, 8, 308-319.

Animal-Assisted Therapy and Children: Calling in the Furry Therapist

Increasing numbers of helping professionals are including animal-assisted therapy – sometimes called pet therapy– in their work with clients of all ages. In particular, this approach is being used with children who have been traumatized by abuse or neglect. Consider 10-year-old Robbie who has lived in foster care for the last two years after previously being physically abused by his father and brother for more than seven years. Many of Robbie trauma reactions were helped by art and play therapy and family intervention, but he still had some problems with self-regulation and nightmares.

Robbie’s counselor decided to try animal-assisted therapy with him, believing that positive interaction with an animal might make a difference. She introduced Robbie to Scout, a trained therapy dog; at first Robbie was a little afraid because he had never had the opportunity to play with a dog before in his life. She worked with Robbie to help him feel comfortable, modeling how to pet and play with Scout over the course of several meetings. In brief, through regular animal-assisted play therapy sessions with Scout and his counselor, Robbie’s relationships with others began to noticeably change. His behavior became less erratic and more predictable and his nightmares ceased; Robbie developed more healthy attachments and relationships with his foster family members and other children and a newly-found confidence in himself.

According to well-known play therapist Rise VanFleet (2007) animal-assisted play therapy is “the use of animals in the context of play therapy, in which appropriately-trained therapists and animals engage with children and families primarily through systematic play interventions, with the goal of improving children’s developmental and psychosocial health as well as the animal’s well-being. Play and playfulness are essential ingredients of the interactions and the relationship.” This form of intervention most often involves dogs, but other types of animals [cats, birds, rabbits, horses, and dolphins, among others] can be part of treatment, too.

There are many studies on how and why animal-assisted therapy can help children like Robbie. Some of the benefits of animal-assisted therapy include:

1)     reducing resistance and increasing attachment;

2)    enhancing empathy;

3)    teaching appropriate communication skills;

4)    building confidence;

5)    enhancing the ability to self-soothe;

6)    prevention of animal abuse [sometimes seen in children who have been abused or neglected].

If you are not familiar with animal-assisted therapy, what are your options to include this form of intervention in your work with children? One, of course, is to train your own therapy dog; many of my colleagues have done this with their own pets, but be prepared for a lot of commitment to training and follow-up. Some therapists who have their own therapy dogs keep their animals present at all times in their sessions [barring situations that preclude having animals present]. Others may include dogs in play therapy sessions periodically or for a short portion of the session depending on goals for treatment and the personalities and temperaments of the animal and the child.

The other option is to engage the services of a professional in the field of animal-assisted therapy. In this case, you may want to visit the American Humane Society website (see link below) for more information or your local metropolitan or state organizations for a referral to a qualified and experienced individual in your area. Like many helping professionals who work with children, you might just become interested in learning more about introducing your own “furry therapist” to your work, too!

Be well,

Cathy Malchiodi, PhD, LPAT, LPCC

References

American Humane Society. (2011). About animal-assisted therapy. See http://www.americanhumane.org/interaction/programs/animal-assisted-therapy/about/.

VanFleet, R. (2007). Pet play therapy: A workshop manual. Boiling Springs, PA: Play Therapy Press.

TLC's Children and Trauma Annual Conference: Trauma-Informed, Resiliency-Focused

A little sandtray therapy at the Assembly

It’s time to make your plans to attend the 2011 TLC’s Childhood Trauma Practitioner’s Assembly from July 12 to 16th! The Assembly will be held at the Macomb County Intermediate School District’s (MISD) new Educational Service Center. MISD is located at 44001 Garfield Road, Clinton Township, Michigan 48038-1100. This year’s program is about practices that are both trauma-informed and resilience-focused; some are evidence-based, others evidence-supported, as not all evidence-based interventions are appropriate for all traumatized children. Here are some of the leading edge presentations this year:

Relationship & Neurobiological Integration Part 1 Many children of trauma experience changes in brain structure and brain chemistry. This workshop is focused on providing strategies through the caregiver’s relationship to create new pathways for the healing of a child’s body and mind system. We will look at how behavioral approaches discriminate against children with neurodiversity issues. A relational paradigm will then be introduced, and you will be provided with several strategies including: co-regulation, time in, the three A’s (attunement, affection and attention), self exploration, playfulness and humor, acceptance, presence, containment, being a sensory detective, physical affection, entering pain pathways, limbic resonance, the neurophysiological feedback loop, transitional time in, multi-sensory feedback, rupture and repair, collaborative communication, non-verbal communication and many more. Here are just a few of the offerings at this summer’s Assembly:

Group Strategies and Interventions with Youth Exposed to Domestic Violence Participants will learn practical tools and important themes to consider when working with youth exposed to domestic violence. In addition, content presented will help participants gain a trauma-informed understanding about how these strategies and interventions promote safety, emotional expression, coping, validation, and normalizing related to working with youth from violent homes. Participants will also engage in activities and experientials to enhance their awareness and insight about the benefits of using hands-on and creative interventions in group work with traumatized youth.

What Really Gets Worked Out in the Sandtray? Sand, images and the sandtray help create a “safe and protected space” for the builder. This psychodynamic process can be part of a nondirective or directive experience. Participants will see video clips including “Sandtray Storytelling” and a clip of how sandtray was utilized in schools with children whose parents worked in the Twin Towers as shown on the New York cable show, Frontiers in Psychotherapy.

No Bullies-No Victims: Trauma-Informed Bullying Prevention for K-12 This presentation will explore the bullying happening in schools and on the internet and explore specific, effective strategies at the organizational and student levels. Participants will be provided with a workbook outlining those strategies that can then be transferred to their organization or counseling practice. Emphasis will be on building students’ strengths by giving them the skills and strategies they need to prevent the bullying from happening and to deal with it when it does. Participants will also be given strategies for managing the environment and working with school staff and parents in order to help this transformation.

And of course, we hope you will join us for the keynote and full-day courses [to be described in a future post] to become certified in the use of TLC’s school and agency-based SITCAP® programs or, if already certified, to learn additional strategies presented by practitioners in a variety of 3-hour workshops.

Be well,

Cathy Malchiodi, PhD, LPCC, LPAT

Sensory-Based, Trauma Informed Assessment

In a previous post in September 2010, I discussed some concepts pertaining to “trauma informed art therapy.” Over the past few months, Dr. William Steele and I have been working on a new book called Trauma Informed Practices with Children and Adolescents. How we apply trauma informed principles to assessment and evaluation of children and teens is an important part of this book. Trauma informed practices do not only apply to interventions, relationships, and environments inherent to our work with traumatized young people; we also can apply these principles to how we evaluate individuals, especially those who have experienced chronic abuse, neglect, interpersonal violence, and other challenges during their lives.

There are several excellent trauma informed assessments that evaluate multiple dimensions, including physical and medical status, cognition, psychosocial issues, and the impact of trauma itself. However, how do we capture additional information that may be missed through standardized, paper and pencil assessments or parental, caretaker, or professional observations? Trauma informed assessment also includes evaluation of the sensory experiences of children—in other words, how the mind and body respond to traumatic events and the flight, fight, or freeze responses of the individual. It also includes the recognition that these responses are adaptive coping strategies rather than pathological reactions.

I also believe that trauma informed assessment includes an evaluation of how traumatic events may have impacted neurodevelopment. Neurodevelopment is a term used to describe how the brain develops over the first 20 years or so of the lifespan, from infancy through adolescence into young adulthood. Bruce Perry (2006) and others have presented comprehensive theories about what neurodevelopment and specifically, neurosequential development entail.

In order to fully understand and evaluate sensory responses in young clients, sensory-based methods of assessment are necessary. These can include many types of action-oriented activities, but the most widely applied involve art and play-based protocols, many of which are found in the fields of art therapy and play therapy. Why art and play? Because for children and adolescents who may not be comfortable with standardized, more cognitively-based assessments, they have an opportunity to use materials, media, toys, and props to give us a series of snapshots about their experiences, trauma reactions, and worldview. Because there are identifiable developmental sequences for play and art expression over the first decade of life, applying this knowledge to child clients provides another way to use the senses to engage individuals in treatment. And, as most of you already know, art and play are child-appropriate forms of communication that allow for a wide-range of expression and for many, a way to tell us about their terrors when words are not available.

Finally, in using sensory means to conduct assessments (especially in a trauma informed, culturally sensitive way), isn’t it nice that many children will find a degree of self-soothing in using toys, paint, or props to communicate their perceptions, feelings, and experiences to you? This is one of the core principles of trauma informed work—to create a sense of safety through all interactions and to capitalize on positive relational aspects between helping professionals and young clients as much as possible. Look forward to reading more about this topic as Bill Steele and I finish up the book!

Until next time, be well,

Cathy Malchiodi, PhD, LPAT, LPCC

Reference

Perry, B.D. (2006) The Neurosequential Model of Therapeutics: Applying principles of neuroscience to clinical work with traumatized and maltreated children In: Working with Traumatized Youth in Child Welfare (Ed. Nancy Boyd Webb), The Guilford Press, New York, NY, pp. 27‐52.

Using Art Therapy to Address Bullying: Part Two

"Authority Figure" by a 16 year old adolescent in juvenile detention

Back in 1993, I taught a university course on developmental approaches to art therapy that included a section on the impact of bullying on children and teenagers. Surprisingly, at that time bullying was not discussed as a serious mental health issue and it certainly was not included as a possible cause of trauma reactions or posttraumatic stress disorder in young clients. While we still have a long way to go to eliminate bullying from our schools, workplace, and culture, helping professionals are now more acutely aware of the affects of bullying and how to recognize and address its affects on young people.

One of the activities I used as an example for the course and as a way to address bullying with adolescents was called “The Authority Figure” (Malchiodi, 1993). I based it on the Erikson principle that teenagers struggle developmentally both with identity and authority [parents, teachers, adults in general] during adolescence. Since that time I have used this activity not only with teens, but also adults, adults in the workplace, and even couples. The concept of “authority” is metaphor that evokes both positive and negative feelings, including admiration, respect, leadership, rule-making, protection, power, and control, among others.

Before I start this activity with any group, I always begin with a discussion of “what is authority” to see what participants understand about the concept. “Authority” is an abstract term and depending on the cognitive abilities of your client or group, it may not be well understood by some teens and even adults. Through inviting discussion, I also want to see if the group or individual is ready to engage with this theme; the concept of authority can be very confrontational under some circumstances. Imagine, for example, a person who has experienced interpersonal violence or abuse; the authority figure can quickly become the “perpetrator” in this case.  Bullies can fall into the same category because of the emotional and physical violence they inflict on others. On the other hand, there may be a point in intervention when inevitably the need to confront an authority becomes appropriate and of course, with the helping professional’s guidance, support and sensitivity to any trauma reactions.

With individuals, you can use large white paper [18 x 24 inches] and colored drawing materials [felt markers or oil pastels] and invite the person to “make an image of what you think an authority figure looks like.” In working with groups and if there is sufficient time, I prefer to offer a larger piece of paper [such as Kraft paper that comes on a roll] and collage materials [magazine images and text, colored papers] so that several participants can work together, discuss and create an image. If you are working with an adolescent group that focuses on issues of bullying, you can facilitate and support participants’ exploration and decision-making about how to portray positive and negative aspects of authority through this activity.

With this and any other sensory-based activity, always remember that teens who have experienced bullying feel intimidated, overwhelmed, and even threatened. They need you to validate what are often very powerful and sometimes frightening emotions and experiences. While an activity can address some of their feelings, we also have to remember that all survivors of bullying need careful monitoring and that their fears and worries are being taken seriously. Most of all, as helping professionals our goal is to assist them in realizing that being bullied is not their fault and to help them begin the process of strengthening a positive self-image and enhancing personal resilience [think about how you can use your art and play trauma intervention skills!].

Be well,

Cathy Malchiodi, PhD, LPCC, LPAT

Reference

Malchiodi, C. (1993). Developmental art therapy. Syllabus for California State University Sacramento, graduate art therapy program.

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Using Art Therapy to Address Bullying

Safran and Safran (2008) note that victims of bullying can benefit from opportunities to express themselves in a safe, creative way. In particular, art expression offers opportunities to communicate and explore more deep-seated feelings about being bullied, emotions that may not be addressed in school-based anti-bullying programs. Fear, worry, confusion, and rage toward the perpetrator and some well-meaning teachers and counselors who fail to protect the victim may emerge in a drawing or collage before articulated with words.

Safran and Safran recommend individual and/or group art therapy for bullying victims; they emphasize that drawing can be one way to eventually explore self-image, perceptions of bullies, and a trauma narrative. The latter is particularly important with those children who can benefit from telling their stories and sharing their images with either the helping professional (Malchiodi, 2001) or with peers who may be able to empathize with the victim.

Collage is another medium I frequently use with older children and adolescents. To begin any collage activity, do some preparation work by collecting colored paper and many magazines; pre-cut a variety of images from the magazines to put into a “picture collage” box (Malchiodi, 2006). Be sure to include a wide range of images of people, environments, objects, and phrases/text and of course, remember to ensure that cultural diversity in present in these magazine photos. Avoid just handing out magazines to your client or group; pre-cutting the images will prevent your young clients from wasting time flipping through magazines rather than engaging in the activity of creating a collage.

At this point, many helping professionals often say, “create a collage that represents bullying and/or the victims of bullying.” That’s a relevant directive, but try to think about the topic of bullying more globally and create and use themes strategically. When working with adolescents, I like to use this directive—“create a collage that represents what the feelings of powerful and powerless mean to you.” If I am working with a group, I might initiate a short discussion about these two feelings and give them some options for how to construct the collages. I sometime suggest that, “you can fold your paper in half and put the images of powerful on one side and images of powerless on the other. Or, if you want to, you can mix them up in any way that you like.” For this activity, I generally supply 12 by 18 inch colored construction paper or poster board, glue sticks or white, non-toxic school glue, and scissors if appropriate.

After everyone finishes creating the collages, let each present their pictures to the group. Have each participant talk about at least one image in his or her collage that represents “powerful” and one that was chosen to show “powerless.” Depending on how the discussion unfolds, participants may want to share their own experiences with bullies, including whether they have been the targets of bullying (powerless) or been a bully (powerful). Encourage further exploration of how one can be powerful when confronted with bullying and other aspects of powerful-powerless dynamics.

There are many, many variations to this activity; what is important is that you consider your group’s needs and adapt this activity to meet those needs. If you missed the two previous blogs on bullying, see Bullying 101 and What is Relational Bullying for more information; remember TLC has an excellent online course on bullying and cyber-bullying, too. Next up: More creative interventions to help children and adolescents address bullying.

Be well,

Cathy Malchiodi, PhD, LPAT, LPCC

References

Malchiodi, C. (2001). Using drawing as intervention with traumatized children. Trauma and Loss: Research and Intervention, 1(1), 21-28. See National Institute for Trauma and Loss in Children website for a copy of this article.

Malchiodi, C. (2006). The art therapy sourcebook. New York: McGraw-Hill.

Safran, D., & Safran, E. (2008). Creative approaches to minimize the traumatic impact of bullying behavior. In C. Malchiodi (Ed.), Creative interventions with traumatized children (pp. 132-166). New York: Guilford Press.

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Trauma Informed Art Therapy

According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2010), trauma informed interventions specifically address the consequences of trauma in the individual and recognize the interrelation between trauma and symptoms of trauma. A comprehensive view of neurological, biological, psychological and social effects of trauma and violence ultimately informs intervention. Here is what SAMHSA specifically has to say about trauma informed practice:

Trauma-informed programs and services represent the “new generation” of transformed mental health and allied human services organizations and programs who serve people with histories of violence and trauma.

Trauma survivors and consumers in these programs and services are likely to have histories of physical and sexual abuse and other types of trauma-inducing experiences, and this often leads to mental health and other types of co-occurring disorders such as health problems, substance abuse problems, eating disorders, HIV/AIDS issues, and contact with the criminal justice system. When a human service program takes the step to become trauma-informed, every part of its organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma impacts the life of an individual seeking services. Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization (Retrieved from SAMHSA at http://mentalhealth.samhsa.gov/nctic/trauma.asp)

In truth, I could be writing about trauma informed play therapy, bibliotherapy, narrative therapy, or any number of approaches that can be applied to trauma intervention. But I am talking about art therapy today because it is a central framework in my practice with traumatized individuals. It also is a particularly effective approach for trauma informed care with all individuals, especially children, because it is sensory, hands-on, and experiential in nature. As physician and neurodevelopment pioneer Bruce Perry has noted, it also can be a normalizing experience for children, one which children in all cultures recognize.

Art therapy, like other creative and expressive arts therapies, has a unique role as an intervention with traumatized children. In fact, the International Society for Traumatic Stress Studies (ISTSS) (Foa et al, 2009) provides a comprehensive summary of the role of the creative art therapies, including art therapy, in the treatment of posttraumatic stress disorder (PTSD). The ISTSS statement underscores the growing interest the relationship between the creative arts therapies and the brain, including how the brain processes traumatic events and the possibilities for reparation through art, music, movement, play, and drama interventions.

In my practice as an art therapist and mental health counselor, most children I have worked with over the years have been chronically abused and neglected. As a result, these children generally have a variety of severe trauma reactions (hyperarousal, avoidance, dissociation, and intrusive memories), learning and psychosocial challenges, and attachment difficulties. In many cases, psychodynamic and cognitive behavioral strategies alone cannot address the reactions of children whose cognitive, developmental, and interpersonal skills are compromised by multiple traumatic experiences of sexual abuse, physical abuse, emotional abuse, domestic violence, and neglect.

Trauma informed art therapy integrates neurodevelopmental knowledge and the sensory qualities of art making in trauma intervention (Malchiodi, in press).  In general, a trauma informed approach must take into consideration, but is not limited to, the following 1) how the mind and body respond to traumatic events; 2) recognition that symptoms are adaptive coping strategies rather than pathology; 3) emphasis on cultural sensitivity and empowerment; and 4) helping to move individuals from being not only survivors, but ultimately to becoming “thrivers” through skill building, support networks, and resilience enhancement (Malchiodi, in press).

Because young survivors of trauma may also be without the means to place memories in historical context through language, art therapy combined with neurobiological, somatic, and cognitive-behavioral approaches can assist children in bridging sensory memories and narrative. Trauma informed art therapy is based on the idea that art expression is helpful in reconnecting implicit (sensory) and explicit (declarative) memories of trauma and in the treatment of PTSD (Malchiodi, 2003). In particular, it is an approach that assists children’s capacity to self-regulate affect and modulate the body’s reactions to traumatic experiences in the earliest stages to set the stage for eventual trauma integration and recovery.

Trauma informed care not only involves how we practice, but also relationships between our clients and therapists, parents, family members, caregivers, case workers, teachers, and others; it is important to assessment and evaluation and the environments in which we see children and families, too. Dr. William Steele and I are currently working on providing more detailed information on trauma informed approaches to work with children and adolescents. And in future posts, I’ll be sharing some practical strategies on how to infuse trauma informed art and play interventions into our work as trauma specialists.

Be well,

Cathy Malchiodi, PhD, LPAT, LPCC

Be sure to check the TLC website for many resources, online learning opportunities, and future symposia that will help you to develop a trauma informed approach to work with children and families.

References

Foa, E., Keane, T., Friedman, M., & Cohen, J. (2009). Effective treatment for PTSD: Practice guidelines from the International Society for Trauma Stress Studies. New York: Guilford Press.

Malchiodi, C. (2003). Handbook of art therapy. New York: Guilford Press.

Malchiodi, C. (2008). Creative interventions with traumatized children. New York: Guilford Press.

Malchiodi, C. (in press). Trauma informed art therapy with sexually abused children. In Paris Goodyear-Brown (Ed.), Handbook of Child Sexual Abuse: Prevention, Assessment, and Treatment. New York: Wiley.

Substance Abuse and Mental Health Services Administration (2010). Trauma informed care. Retrieved September 12, 2010 from http://mentalhealth.samhsa.gov/nctic/trauma.asp.

Steele, W. & Rader, M. (2002). Structured sensory intervention for traumatized children, adolescents and parents: Strategies to alleviate trauma (SITCAP). Lewiston, NY: Edwin Mellon Press.

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What a Rubber Duck and Empathy Have in Common

In a recent commentary “What Makes Sense?” in the June 2010 TLC Practitioner, Bill Steele remarks, “the full utilization of one’s capacity to learn is predicated upon being in an environment where one feels above all safe and valued.” He goes on to say that feeling safe includes the following: being connected to adults who believe in us and who take the time to become our mentors and guides; exposure to multiple opportunities to engage in meaningful activities; and experiencing environments that encourage our potential to learn and grow.

Feeling personally responsible for our homes, schools, neighborhoods, and communities and those who live in them is another important experience– one that fosters empathy. Not surprisingly, many children who are traumatized by abuse, neglect, loss, or separation from a parent feel disconnected from those around them and often lose their capacity for empathy or concern for both people and their environment. As Steele observes, dignity comes from learning to care about others and how one’s actions impact everyone – and everything – around us.

The capacity to develop empathy is thought to be innate and is commonly seen in children who grow up with strong attachment to an adult and in healthy, safe homes and neighborhoods. We see examples of empathic behavior early in a child’s life when he or she brings a toy or blanket to another child who is in distress or cries in response to the discomfort of another person. Not surprisingly, the environment in which one is raised makes a difference in whether or not empathy develops.

So how do we help children develop empathy and concern for others and for their environments? First, early intervention is key; as most helping professionals know, it is essential that young children have a secure attachment to another person and exposure to empathy from others. Young children who are abused or neglected are particularly vulnerable because in place of positive attachment, these individuals experience misery, abandonment, and punishment that create distrust for others and the environment. Understandably, they also rarely experience empathy.

As children get older, they also need experiences that teach them how to go beyond themselves and learn to care for and about others. In brief, anything that helps children learn to respond effectively to the emotions and circumstances of others can enhance and strengthen empathy. If you attended the opening session of the recent 5^th Annual National Institute for Trauma and Loss in Children Assembly of Practitioners in July 2010, you learned at least one intervention to help begin the process of developing empathy with children. Participants were given small rubber ducks and asked to use some simple art materials [colored tissue paper, feathers, chenille stems, paper plates, scissors, and glue] to “create a safe place for your duck” [some photos of this intervention are included with this blog]. This is an activity I have used many times with children to not only explore what a safe environment is, but also to help them learn how to take care of someone needs outside their own.

Caretaking the rubber duck [or similar toy animal] is a way for a child to explore personal needs for safety, love, and respect and capitalizes on art therapy and play therapy as sensory methods to provide the child with an experience of empathy for another entity. For children who have experienced chronic trauma, it’s not enough to just talk about empathy; children must practice what empathy is through activities that teach self-care and care for others.

When children (and adults) lack empathy, the consequences are serious not only for the individual, but also for family, schools, neighborhoods, and communities. Children without the ability to feel empathy not only suffer isolation, frustration, and anger, they may be anti-social or become capable of violence, even murder. More often, they act without regard for the health, well-being, and feelings of peers, parents, siblings, and everyone they encounter. As helping professionals, we have the unique opportunity to help traumatized children replace worry with calm, fear with safety, and punishment with nurturing—and by doing so, introduce the experience of empathy and the sensory experience of just why helping others matters.

Be well,

Cathy Malchiodi, PhD, LPAT, LPCC

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Traumatic Brain Injury: Signature Wound, Silent Epidemic in Returning Military

I have been working with Mark, an Army officer who has been diagnosed with posttraumatic stress disorder [PTSD], for almost six months now. In addition to medical intervention including medications for anxiety, Mark has been making good progress through a combination of somatic therapy, art therapy, mindfulness approaches, and stress reduction. However, Mark continued to have problems with language and cognition; in contrast, his ability to recognize the onset of stress reactions and reduce hyperarousal steadily improved. My concern led Mark and I to sit down with his doctor at our local clinic and revisit his symptoms and injuries sustained from his tour of duty in Iraq. After a number of tests, his doctor concluded that Mark had an undiagnosed mild traumatic brain injury [TBI], possibly due from a jolt to his head as a result of a bomb blast a week before his return to the US. In fact, Mark did not recall an injury since he had no visible head injury and only recently remembered that there he had been a block away from the bomb blast that likely caused some post-traumatic amnesia and a mild TBI.

We are now adjusting Mark’s psychosocial program to address TBI, in addition to PTSD and anxiety. For Mark, just having been identified has relieved the stress of his symptoms and his treatment can be redirected to focus on returning his cognitive functions to normalcy through rehabilitative efforts, including art therapy, occupational therapy, and other methods. Fortunately, much of the sensory intervention involved in treating his PTSD and anxiety issues were helpful in addressing TBI. Mark is lucky in that he is already in recovery from his TBI and is expected to have no long-term affects from his head injury;

As trauma specialists and mental health professionals, we generally focus on psychological symptoms our clients present and particularly stress reactions and posttraumatic stress in particular. However, when working with survivors of traumatic events who may have been exposed to head injuries, I learned from Mark that I have to take a broader perspective on what may be causing distressful reactions and lack of progress. We now know that returning military are not only susceptible to PTSD, but also TBI, a condition that often goes undiagnosed for days, weeks, or months.

A TBI is most often defined as a blow or shock to the head or a penetrating head injury that disrupts the function of the brain. TBI has been named one of war’s “signature wounds;” it can be caused by shock waves from bombs, a hit to the head, or a jolt that affects the brain. There may be no visible scars, but lasting cognitive and physical harm may be extensive. In contrast to a missing limb or spinal injury, TBIs are not visible, but still of great concern in the overall treatment of trauma to mind and body. Here are some facts about TBI:

• Not all blows to the head result in a TBI;
• Concussions are a type of TBI and are also known as closed head injuries.
• TBIs can be mild, moderate, or severe, depending on the impact on consciousness and duration of amnesia or other symptoms, post-trauma;
• TBI symptoms may occur immediately after an event or may appear days or weeks after an injury;
• TBIs may affect thinking, sensing, motor skills, and emotions; their psychosocial impact can appear similar to emotional disorders such as PTSD;
• In military, blast injuries are a significant cause of TBIs.

Hundreds of thousands of service members are believed to have suffered TBIs during their service in Afghanistan and Iraq, and many go undiagnosed, suffering the “invisible wounds” of war without explanation. The military is currently addressing TBI and the Pentagon recently opened a new 72,000 square foot facility for TBI research. The intent is to keep a comprehensive database that will follow US troops from the war zone through post-deployment, recording all personnel who are exposed to bomb blasts or similar trauma. Ideally, these individuals will be continuously monitored for developing symptoms weeks and months after exposure to injury.

As with PTSD, returning military with TBIs may have personality changes that impact family members, including their children. Imagine the stress a spouse and children experience when a husband, wife, “daddy” or “mommy” comes home with invisible scars that have altered behavior and interpersonal actions. According to my client Mark, his family might have been able adapt to broken leg or back injury more easily than to his personality changes. He feels fortunate that he and his family are getting the help they need in terms of his TBI and posttraumatic stress; he believes that his children are doing better than others under similar circumstances because they are receiving support and counseling at their schools and that he has benefited from medical and psychosocial care.

Finally, while the focus of this article is on TBI in returning military, let’s not forget that we may see undiagnosed brain injury in anyone, including children. Child and adolescent athletes often sustain a blow to the head, but may not be evaluated for TBI; meanwhile, these youngsters may show signs of cognitive and emotional problems for days and weeks after an incident. Their symptoms, too, may be identified as psychological when, in fact, an undiagnosed head injury is the main cause of behavioral changes and cognitive challenges.

There are a large number of great websites on the topic of TBI and the military; here is a short list of resources to get you started:

Traumatic Brain Injury in Theater: When Blasts Damage the Brain. This website provides a visual overview of various head injuries sustained in battle.

http://www.propublica.org/special/tbi-in-combat

National Public Radio on Traumatic Brain Injury. Listen to an interesting podcast and read extensive coverage of TBI in returning military.

http://www.npr.org/templates/story/story.php?storyId=127402993

In Their Boots: A Documentary on Soldiers with Traumatic Brain Injury. Watch first person film accounts highlighting the challenges of TBI.

http://www.intheirboots.com/itb/index.php?option=com_content&view=article&id=60&Itemid=85

Making Art After Trauma. Listen to a short podcast, see a slide shows, and read about art and art therapy in the recovery process of Bret Hart, with commentary from Dr. Kathleen Bell.

http://www.publicbroadcasting.net/kplu/news.newsmain/article/1/0/1670360/KPLU.Local.News/Artscape.Making.Art.After.Trauma

Be well,

Cathy Malchiodi, PhD, LPAT, LPCC

And remember on July 13^th, 2010, National Institute for Trauma and Loss in Children will welcome military personnel and their families to the Annual TLC Practitioners’ Assembly at Macomb ISD Education Center, Clinton Township, Michigan. For more information, click here. We hope to see you there!

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Children and Trauma: What Will Proposed Revisions to the DSM Mean for Trauma Specialists?

A 5th revised edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) will be published in 2013. If you are a mental health professional who has used the current DSM-IV in your work, you may remember that the previous document was introduced in 1994, approximately 16 years ago. Since that time we have witnessed tremendous changes in how emotional disorders are viewed and evaluated. Everything from brain imaging technology, advancements in the understanding of genetic and environmental influences, and how data are collected and analyzed have increased our knowledge of psychiatric conditions, including those disorders resulting from traumatic events during the lifespan.

While there are many ongoing discussions about proposed revisions, there are two discussions in particular that are relevant to our work with traumatized children. The first is the proposed section involving posttraumatic stress disorder (PTSD) in preschool age children; the second is the debate about the proposed section on developmental trauma disorder (DTD).

Posttraumatic Stress Disorder in Preschool Children

Research tells us that the younger a child is at the time of the trauma, the more likely he or she is to develop PTSD. According to the latest information, 39% of preschoolers develop PTSD in response to trauma, while 33% of middle school children and 27% of teens do. Young children (ages 1 to 6 years) react with helplessness and passivity; generalized fear; heightened arousal; cognitive confusion; nightmares and sleep disturbances; anxieties about death; somatic symptoms; freeze responses; and “fussiness,” crying, or neediness. Understandably, these youngsters often have little comprehension of traumatic events because of age and other influences.

With regard to this proposed revision to the DSM, the intention is to create guidelines for identification of PTSD in young children inclusive of developmentally appropriate factors. While the criteria will be familiar to most helping professionals, there is still some disagreement about several items. Two symptoms still under discussion include: 1) negative alterations in cognitions and mood as evidenced by increased negative emotional states in young children exposed to trauma; and 2) reckless or self-destructive behavior. Those of you who work with young children may see these reactions manifest through children’s sensory responses such as play activities in contrast to older children who may express these reactions in other ways. In addition, there is some debate about whether or not children who are exposed to traumatic events that have occurred to close relative or close friend should be included in this category.

Recommendations for severity criteria for this disorder are forthcoming; you can check the APA website for updates here.

Developmental Trauma Disorder

Well-known trauma expert Bessel van der Kolk and colleagues propose Developmental Trauma Disorder (DTD) as a new DSM category intended to identify children who have a history of complex trauma. In brief, this category addresses the differences in the expression of PTSD in children, particularly those who have experienced a series of traumatic events throughout their lifespan. Like many trauma specialists who work with children with complex trauma histories including abuse and neglect, I was particularly excited about the possible inclusion of this category to help identify and address the unique constellation of symptoms in chronically traumatized young people.

As it turns out, this category has been controversial and is not currently included in the final revisions. A recent article by Mary Sikes Wylie called “The Long Shadow of Trauma” by Mary Sikes Wylie  (March/April 2010 Psychotherapy Networker), provides some insight as to why this category ended up on the “cutting room floor.” While DTD broadened the symptom range of children with PTSD-like reactions, epidemiologists and researchers generally revise the DSM, not clinicians who actually encounter clients face-to-face. Thus, revisions are based on data gathered through rating instruments, population studies, and other quantitative measures and less on clinical reports or qualitative studies. Others argue, including van der Kolk, that a category such as DTD challenges the structure of traditional research, funding initiatives, and accepted rating scales. In essence, DTD demands that we look at the children we see in treatment as individuals with needs best addressed by a combination of approaches not currently promoted by the status quo in the trauma field. These approaches include mind-body, somatic, sensorimotor, art therapy and other expressive arts therapies, play therapy, and neurofeedback, among others—approaches that promote the integration of mind and body. Bessel van der Kolk’s Trauma Center utilizes a number of these methods, implementing a blend of psychology, integrative approaches, and neuroscience as well as accepted evidence on how the body responds to repeated chronic trauma.

If you would like to read more about the DSM-V and send comments about these two categories and other proposed revisions, you can access the DSM-V website at: http://ow.ly/1oqfI.

Be well,

Cathy Malchiodi, PhD, LPCC, LPAT

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