The statistics on homelessness in the United States are astounding. According to the National Child Traumatic Stress Network (NCTSN) (2011), more than 1.3 million children are homeless at some time each year and on the average day, at least 800,000 Americans, including 200,000 children are without a home. These individuals have also encountered trauma before becoming homeless and homelessness itself can exacerbate or re-traumatize children and adults. Ultimately, it is an experience that has powerful effects not only on individuals and families, but also on our neighborhoods and communities.
Homelessness affects individuals of all ages and in all areas of the US; it disproportionately affects people of color and single parent families, but it also impacts people of all ethnicities. For children, the loss of a stable home environment may include loss of pets and possessions, previous routines, school changes, and lack of privacy, compounding the stress related to homelessness. There can be additional stresses too, including abrupt separation, interpersonal or domestic violence, or illness that add to emotional challenges and risk for increased trauma reactions. Children may experience higher incidence of ear infections, asthma attacks and stomach problems; may develop learning and cognitive difficulties; and may have emotional problems that require professional intervention, but frequently go without recognition or treatment. According to NCTSN, by the time homeless children are 8 years old, one in three has a major emotional disorder. Additionally, trauma-related symptoms make recovery more difficult for these youngsters.
A recent episode of CBS’s 60 Minutes addresses how children are impacted by sudden homelessness in the U.S. and highlights the unique challenges children and families face when displaced from home and familiar routines. If you missed this compelling episode, take a few minutes to watch it and hear firsthand accounts from children who are confronting the realities of homelessness in their daily lives:
So what can we do to help homeless children and families? Here are just a few evidence-based, trauma-informed, and resilience-focused practices:
Work to ensure that children and families are not re-traumatized after entering a shelter or program;
Respond in trauma-informed ways to support resilience and empower individuals;
Provide safe and non-threatening environments that maximize choice and control for individuals;
Model positive behavior, maintain clear boundaries, allow participants to make decisions and share power, and respond with cultural sensitivity;
Help children and adults learn skills to self-regulate and reduce trauma reactions;
Provide support for both emotional and physical health, adaptive coping, and culturally appropriate services that address trauma and the experience of homelessness;
Above all, help children and families become survivors and eventual “thrivers” who are capable and empowered to overcome challenges and move forward with hope and dignity.
Be well,
Cathy Malchiodi, PhD, LPCC, LPAT
Reference
National Child Traumatic Stress Network. (2011). FactsonHomelessandChildren. Retrieved on June 28, 2011 at http://www.nctsn.org.
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.
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.
Today, National Institute for Trauma and Loss in Children (TLC) training programs are in place in more than 3,000 schools, community-based programs, treatment centers and childcare facilities across North America and internationally. More importantly, they are giving parents, teachers and childcare professionals the early intervention tools and techniques it takes to change trauma-related behaviors and to help traumatized children survive and thrive.
If you haven’t attended a TLC Training and Certification in awhile or you are new to the trauma field, why not join TLC Certified Trainers for a special weekend of learning from February 18 through 20, 2011 in San Antonio, TX. For your convenience, courses begin on Friday morning and end early on Sunday and are a short complimentary hotel shuttle ride from San Antonio International Airport. Whether you want to work on your trauma certification [for more information, click here] or would just like to improve your skills in working with children, this weekend will provide you with practical knowledge and activities that you can apply immediately. There is a school track and a clinical track, plus courses that meet Association for Play Therapy (APT) continuing education requirements; the following courses are scheduled:
Structured Sensory Interventions: From Sensory Memories to Play Therapy— William Steele. This is a practice day. Participants will be engaged in the evidence-based, grief and trauma psycho-educational and play therapy intervention processes used in schools and community settings across the country. Cases, including the mother of a 7-year-old who died of cancer at home, a 12-year-old exposed to repeated domestic violence, a 15-year-old, raped multiple times at a drug house, a spouse’s husband tortured and killed, will be presented along with the remarkable evidence-based reduction of their PTSD and other mental health and cognitive related reactions. Participants in schools or agency settings will feel comfortable using any of TLC’s structured manualized psycho-educational and play therapy trauma intervention programs and tools at the end of this practice-directed training.
Creative Play Therapy Crisis Intervention: Promoting Posttraumatic Growth— Lennis Echterling and Anne Stewart. Traditional crisis intervention has focused on distress, deficits and traumatic wounds of survivors. However, recent research on the inherent resilience of people and the importance of play and their attachment relationships has exciting implications to child, family and play therapists responding to traumatic events. The psycho-educational and play therapy techniques presented emphasize personal strengths, enriching personal relationships; feelings of resolve and helping survivors try new coping strategies. The play therapy interventions presented require minimal materials, are developmentally appropriate, culturally sensitive and can be implemented in any setting. Out of Ashes, A Coping Heart, Eggactly: Supporting One Another, Colors From Your Emotional World, and Reaching our with LUV will be presented as way to help those in crisis play, make meaning, regulate their emotions and move forward.
Advanced Sensory-Based Interventions: From Sensory Memories to Play Therapy—William Steele and Caelan Kuban. This presentation will engage participants in a variety of advanced psycho-educational, sensory activities to allow for the use of these interventions beyond the core TLC program or for use in those situations where it is not possible to use the full program. Play therapy activities will cover early childhood through adulthood and address the sensory experiences associated with trauma or grief. This is a practice session so participants experience the full value and application of these play therapy activities. Rap It Write, Strike A Pose, Ready…Set…R.E.L.A.X., My Play Island and This Reminds Me Of… are just a few of the sensory activities presented. TLC activities are used in school and agency settings.
After the School Crisis— Glenn Carlton, Jennifer Haddow and Michael Markowitz. Participants will be introduced to the Traumatic Event Crisis Intervention Plan (TECIP) that provides the tools necessary to initiate protocols that offer crisis team members a proven structure to stabilize all involved in recovering from the crisis, mobilize resources, accelerate normalization of routine, and minimize the adverse impact on students and staff by restoring adaptive functioning. The Rapid Assessment Guide Traumatic Event Briefing Process, TECIP, 4×5 Development Flow Chart, the what, when, where, who and how to initiate and navigate through the Roadmap to Recovery will be presented. Lecture, demonstrations, small and large group discussion, and practice make this a “must attend” for school crisis response members. The TECIP Manual will be given to every attendee.
And did you know you can take Children of Trauma with William Steele as an online course from the convenience of your home or office? It’s the prerequisite course for all certification levels and now it’s even easier to get the benefit of this excellent presentation.
Don’t miss out of these opportunities to improve your skills in working with traumatized children, adolescents and families! For more information about the upcoming San Antonio, visit this page to learn more and register.
According to the American Academy of Child and Adolescent Psychiatry, as many as half of all children are bullied at some time during their school years, and at least 10% are bullied on a regular basis. Most helping professionals know that bullying can include physical intimidation and verbal threats or gossip, including cyber-bullying via online social networks and e-mail.
You probably also know that children who are bullied experience tremendous suffering, anxiety or depression, may have cognitive problems that interfere with schoolwork, and may be challenged socially and developmentally. But have you ever considered the dynamics involved in bullying? Caelan Kuban, LMSW, Program Director and Certified Trainer for the National Institute for Trauma and Loss in Children, explains the role of not only the bully, but also the bully’s impact on the victim and the witness:
The Victim
Terror – scared for one’s safety/one’s life;
Powerlessness – unable to do or say anything to stop the current situation;
Hurt – physical and emotional hurts from being bullied physically/verbally;
Fear – never knowing if/when bullying is going to happen next;
Anger – anger at the bully, anger at self for not being able to do anything to stop it, at witnesses for not helping put a stop to the bullying behavior and anger at adults for not doing anything to stop the bullying behavior;
Revenge – wanting to “get back” at the person who bullied;
Victim Thinking – “I am the target of bullying, I am no good, Nobody likes me.”
The Witness
Terror – scared for the victim’s safety/life;
Powerlessness – “If I can’t protect others, how can I protect myself?”
Hurt – viewing physical and emotional abuse and sometimes becoming desensitized to hurtful behavior;
Guilt – “I should have stopped it.”
Survivor Grief – “I’m okay but he/she is not.”
Fear – “Is it going to happen again? Could it happen to me? If I help will I be an outcast too?”
Anger – mad that the victim “takes it”. Angry that the bully’s “bullies.”
Revenge – wanting to “get back” at the person who bullied;
Victim Thinking – “I could be next. I’m no good for not jumping in or stopping the bullying.”
The Bully
Terror – “I’m out of control, I even scare myself. If I can hurt someone else like this, I could hurt myself too.”
Powerlessness – “I can’t stop what I am doing.”
Hurt – physical hurts from bullying behaviors/violence;
Fear – “I have to stick up for myself – nobody else will.”
Anger – “I am angry at the victim for making me do it.”
Revenge – “I want to get back at my Dad for beating me but he’d kill me, instead I’ll take it out on this little kid.”
Victim Thinking – “I’ll always be a bully. I’m too stupid not to fight.”
In upcoming posts, you’ll read more about some strategies for addressing bullying with children and adolescents, including the dynamics of bully, victim, and witness. If you want to learn more about bullying and cyber-bullying, why not register for TLC’s excellent online course with Caelan Kuban? The Bullying and Cyber-bullying course provides the foundation for working with youth involved in bullying regardless of their place within the bullying circle – victim, perpetrator, or witness. Upon successful completion of assignments, tests and evaluation you can download a CE Certificate of Completion. This course provides 6 continuing education contact hours.
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.
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.
Steele, W. & Rader, M. (2002). Structured sensory intervention for traumatized children, adolescents and parents: Strategies to alleviate trauma (SITCAP). Lewiston, NY: Edwin Mellon Press.
In a recent summary published in Cerebrum from the Dana Foundation, Regina Sullivan offers intriguing research data on how early negative experiences cause developmental changes in the brain, biochemistry, and psychosocial responses. Like many researchers in the area of child abuse and early intervention, she notes that there is wide agreement that providing nurturance, positive interactions, and experiences of safety have a long-lasting impact on children’s brain development.
When abuse goes undetected or is allowed to continue to impact children’s development, Sullivan cites that approximately 80 percent of abused individuals are diagnosed with a major psychiatric disorder by adolescence. Additionally, brain scans brains of individuals who have experienced abuse during childhood show abnormalities in areas of cognition and emotion. But something even more intriguing is also detectable in the brain function of children who are abused and maltreated. Changes in neurodevelopmental areas go even deeper than just brain function; abuse literally can change one’s genes.
Simply put, the influence by environmental and social factors on our genes is a field of study known as epigenetics. In brief, when an epigenetic change occurs, the biochemistry of how the gene is expressed is altered. In the case of child abuse, how gene expression is changed by abuse may tell us why many of the effects of child abuse do not appear until adolescence and why many maltreated individuals eventually become abusers themselves. Sullivan cites an intriguing study of the brains of individuals who committed suicide to underscore the profound influence of abuse and just how it may alter genetic expression. Of the individuals who committed suicide and who were the subjects of this particular study, some had been abused early in life and others had not. The brains of those who were abused showed significant genetic changes in the hippocampus function that could predispose them to life-long stress responses; those who were not abused, but had died from suicide, did not show similar changes. Individuals who died of natural causes also did not show changes to the hippocampus.
This finding may imply that abuse causes severe alterations in the hippocampus in those who have experienced abuse in childhood; these alteration are not found in others, even those individuals who may have conditions such as depression or anxiety that predispose them to suicide. And while these changes occur early in life, their presence may not be observed behaviorally until later in life, making early detection and intervention for abuse all that much more critical. Because of the nature of epigenetic changes, Sullivan speculates that these alterations may be present for at least two generations, a possible partial explanation for the intergenerational cycle of abuse that trauma specialists see in their work with abuse and domestic violence.
Despite the profound impact of child abuse, we know that we can counter the effects through early intervention and identification of maltreatment and provision of caregiving and conditions that provide positive social interaction and stimulation. As trauma specialists, it is undeniable that we face difficult challenges in our work with abused children and the impact of maltreatment over the lifespan. Fortunately, emerging research is continues to inform us on how to better meet these challenges on behalf of children and how to improve our efforts as trauma informed practitioners.
P. O. McGowan, A. Sasaki, A. C. D’Alessio, S. Dymov, B. Labonté, M. Szyf, G. Turecki, and M. J. Meaney, “Epigenetic Regulation of the Glucocorticoid Receptor in Human Brain Associates with Childhood Abuse. Nature Neuroscience 12, no. 3 (2009): 342–348.
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 5th 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.
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 penetratinghead 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.
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.
And remember on July 13th, 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!
Most professionals who work with family violence or child protective services know that April is Child Abuse Prevention Month. While identification and intervention for child maltreatment has improved, an average of one million children are identified as being abused each year.
Physical and sexual assault often first come to mind when we hear of the term child abuse. However, emotional abuse is also part of the overall spectrum of child maltreatment and occurs concurrently with physical or sexual abuse. According to the American Humane Association [AHA], emotional abuse [also called psychological maltreatment] is a pattern of behavior by parents or caregivers that can seriously interfere in a child’s cognitive, emotional, psychological or social development. It is not an isolated or singular incident between parent and child, but a series of interactions that “erode and corrode” psychological well-being [Garbarino & Gabarino, 1994]. Types of emotional abuse [summarized from AHA guidelines] include:
Ignoring. Parent or caregiver is not present physically or psychologically to respond to the child. For example, a parent may not call the child by name or may be unresponsive to the child’s cries for assistance.
Rejecting. Parent or caregiver actively declines to respond to a child’s needs, including refusing to touch the child.
Isolating. Parent or caregiver consistently prevents the child from having normal social interactions with peers, family members and adults, confines the child, or limits physical movement.
Exploiting or corrupting. Parent or caregiver forces or coerces the child to participate in stealing, prostitution, or other illegal activities.
Verbally assaulting. Parent or caregiver belittles, shames, or threatens the child.
Terrorizing. Parent or caregiver bullies the child, reinforcing an environment of fear. For example, the parent may threaten danger or harm to the child’s pet or sibling if the child does not act or behave in a certain way.
Neglecting. Parent or caretaker does not provide access to education or to treatment for medical or psychological problems, among other necessities.
Unlike physical abuse that may leave visible scars, broken bones, or bruises, emotional abuse is often a “hidden hurt.” However, it is just as serious as battering or assault and is thought by some to be more predictive of developmental delays than severe physical abuse [Glaser, 2002]. We already know thatinfants who are deprived of emotional contact may become anxious children with delayed motor and cognitive abilities, may fail to thrive, or may even die from lack of appropriate human touch. When asked “which hurts more, being hit or being told you are bad,” you might be surprised that many children will say, “being told I am bad hurts more than being hit.” While physical abuse is traumatizing, children who are emotionally rejected, isolated, or terrorized feel verbal assault is worse than being beaten. A broken bone is undeniably serious, but a broken heart silently and painfully robs a child of his or her life.
While emotional abuse is difficult to detect, children affected by it do exhibit noticeable trauma reactions. Some of the signs and manifestations include destructive behavior [fire setting or animal cruelty], poor self-esteem, insecurity and anxiety, developmental delays, drug abuse, emotional withdrawal, inability to form relationships, and even suicidal thoughts. In brief, psychologically maltreated children grow up believing they are deficient and defective in some way. It is easy to understand that without intervention, these children eventually may become parents who continue the cycle of emotional abuse with their own children years later.
So what can we do to reduce the incidence of emotional abuse and its impact on children? Identifying that a child has suffered emotional maltreatment is the first step in intervention. As helping professionals, we can do this by asking appropriate questions about a family’s history and current behaviors, assessing parent-child interactions, and evaluating deficits, challenges, and resources within the family system. Most importantly, early trauma-informed intervention is key to the reduction of the affects of psychological maltreatment on children. This not only includes intensive resilience-building with a child at risk, but also addressing parents and caretakers who may need to learn relevant parenting skills and may require help in overcoming their own emotional abuse experienced during childhood.
For more information from the AHA, go to their webpage. For actual interventions and resource materials, please visit the National Institute for Trauma and Loss in Children Bookstore; Handbook of Trauma Interventions: Zero to Three, A Time for Resilience, and Raising Resilient Children in a Traumatic World are a few of the helpful resources you will find on that site.
Be well,
Cathy Malchiodi, PhD, LPCC, LPAT
References
Garbarino, J., & Garbarino, A. (1994). Emotional maltreatment of children. Chicago: National Committee to Prevent Child Abuse.
Glaser, D. (2002, June). Emotional abuse and neglect (psychological maltreatment): A conceptual framework. Child Abuse & Neglect, 26, 697-714.
The statistics on homelessness in the United States are astounding. According to the National Child Traumatic Stress Network (NCTSN) (2011), more than 1.3 million children are homeless at some time each year and on the average day, at least 800,000 Americans, including 200,000 children are without a home. These individuals have also encountered trauma before becoming homeless and homelessness itself can exacerbate or re-traumatize children and adults. Ultimately, it is an experience that has powerful effects not only on individuals and families, but also on our neighborhoods and communities.
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