Did you know that just learning to relax is key to trauma-informed intervention, resiliency and recovery from a variety of disorders? Dr. Roger Klein, expert on the impact of relaxation training with children and adolescents, presented a workshop “Helping Children and Teens Self-Regulate Using Imagery and Relaxation” at a recent trauma conference. In this presentation, Klein underscores that that there are many ways children and teens can learn to regulate their responses to stress and traumatic events. Additionally, using imagination along with relaxation activities and resilience-focused thinking, young people can learn to minimize their responses to every day stress and traumatic experiences.
Relaxation is a state of being in which there is an absence of tension and hyperarousal, two common reactions to stress or traumatic events. Roger Klein and other experts on trauma propose that practicing relaxation skills over time is a highly effective way to mediate and reduce the effects of stress on the body and mind. Without the ability to relax, we may stay locked in a “fight or flight” response; the latter leads to chronic feelings of anger, depression, panic, and burnout and even stress-related medical conditions. In other words, there are many benefits to practicing relaxation including reduced susceptibility to disease, improved concentration and most of all, increased happiness and life satisfaction.
Meditation is one form of relaxation and is often defined as a form of mindfulness, the bringing of one’s complete attention to the present experience on a moment-to-moment basis. Mindfulness meditation has been studied for several decades and has proven to be effective in the treatment of pain, anxiety, stress and even addictions. Many trauma specialists now regularly apply some form of mindfulness practice in work with clients of all ages, including children, because of the outstanding evidence indicating that meditation actually “changes” our brains in positive ways. Mindfulness expert Jon Kabat-Zinn developed a now widely used protocol called Mindfulness-Based Stress Reduction (MBSR) to treat chronic stress and the illnesses that repeated exposure to psychological trauma causes, including high blood pressure, heart disease and weakened immune system functioning.
Just recently researchers at University of California at Los Angeles (UCLA) found that certain areas in the brains of individuals who meditated for many years were larger than those individuals who did not engage in regular meditation. They also found that those people who meditate have more gray matter and show less age-related brain atrophy (weakening), suggesting that meditation may be good for everyone because our brains naturally shrink in size over our lifespan. In follow-up studies, these researchers found that the benefits of meditation are not isolated to one part of the brain, but involve many parts including the cortex, limbic system and brain stem.
When it comes to children, some readers may ask, “Well, how do we successfully adapt what is known about meditation, mindfulness and relaxation to young people?” One popular technique I have used with children for many years is called “Lion’s Breath” and uses an imaginative metaphor (the lion’s roar) to help young people learn the same relaxation skills that teens and adults may learn through traditional methods and yoga breathing:
“I am going to teach you about a way to let go of worries or thoughts that might be bothering you. It’s called the Lion’s Breath and I want you to imagine you are a lion. Remember, a lion has a really, really big roar—can you roar? Now I want you to sit up with your legs crossed; if you feel more comfortable sitting up against a wall with your legs crossed, go ahead and do that (some children feel safer with their backs against a wall). Now, get ready to make your roar! Let’s try one all together as a group (we all roar in unison).
Before we roar again, let’s all think of a worry that we would like to let go off. For a minute I want you to watch me and see how I roar. First, I am going to take in a really, really deep breath through my nose and then let my roar out through my mouth, sticking my tongue out at the same time and stretching out my arms out as far as I can in front of me. Let’s all try it together, okay?” (Leader and children perform the breathing and roaring together, sticking out their tongues and stretching out arms) (Malchiodi, 2000, p. 14).
Repeat this activity several times; inevitably the deep breathing, roaring and stretching lead to a child-friendly (and fun) form of relaxation. For more information on relaxation with children and teens, visit Roger Klein’s website.
Be well,
Cathy Malchiodi, PhD, LPAT, LPCC
References
Malchiodi, C. (2000). Creative activities manual for children from violent homes. Salt Lake City, UT: WIJ Publications.
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.
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.
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.
If you are a Super Bowl fan, I hope you had the chance to enjoy both the game and some of the entertaining commercials. There was one in particular has captured people’s imaginations. It’s all about a little boy in a Darth Vader costume who tries in vain to use his super powers around his home and finally gets his wish. If you missed it, take a minute to watch it before reading the rest of this post:
While you might have found the ending of this commercial funny or unexpected or charming, to me it is also a good example of how we give children the experience of empowerment. To make the pint-sized Darth Vader’s wish to become “empowered” come true, his father intervenes to give his son an actual experience of what that is like.
Personal empowerment can be affirmed by through what we say to children, but it is most effectively communicated through actively experiencing it. Role models are important, but doing is just as effective. The pint-sized Darth Vader in the commercial was given the opportunity to play act and to explore and to dream; while he would probably eventually find out that he did not start the car by magic, he was given a priceless moment of empowerment by his father.
Think about children who due to abuse or neglect, may have never experienced a feeling of empowerment on a sensory level. Or the bullied child who has lost a sense of self-worth or young person who has survived a significant loss now only to feel hopeless and unable to affect change in the world. We need to try harder with these individuals to give them as many positive opportunities as possible so they can “find out how that feels,” and “hear words of encouragement” that make a difference. Most of all, like the father of little Darth Vader, we have the responsibility to provide the safety, security, role modeling, support, and most of all, the “magic moments” in order to help all children “see how much you can do” and thereby give them a chance to discover their own personal power.
"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.
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.
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!
What do Sesame Street’s Elmo and friends have to do with military children and their families? It all about learning how to “talk, listen, and connect” with family members when dad or mom return home from deployment.
Sesame Street’s “Talk, Listen, Connect: Deployments, Homecomings, Changes” is a DVD series that was launched in 2008 by the Sesame Street Workshop and was designed for military families with young children. It came about in response to the challenges of multiple deployments, homecomings, and changes to family relationships as a result of injuries post-tour of duty. It is also in recognition of the selfless service of the US Armed Forces—Army, Navy, Marines, Air Force, Coast Guard, National Guard, and Reserves. “Talk, Listen, Connect” has helped countless military families to learn how to communicate more effectively with each other with greater understanding, sensitivity, and clarity, strengthening parent-child bonds and attachment.
In true Sesame Street style, these DVDs introduce children and families to the important challenges of reintegration and multiple deployments through the characters familiar to everyone. In one segment, Elmo’s dad has just returned home and Dad, Mom, and Elmo have to readjust to family life after their reunion; as a family, they have to reconfigure their roles as parents and child now that dad is back. In another segment, the viewer also meets Rosita whose father has been injured in the war and now is in a wheelchair. Rosita is understandably anxious, afraid, and confused by the changes in her father and the family’s life and does not want to talk to her mom and dad initially because, like many children, she thinks she might upset her parents. However she eventually learns that there are new ways to be with her father and that she can even play ball and dance with her dad despite his injuries. Overall, the DVDs also instill a sense of pride, honor, and resilience, underscoring both challenges and triumphs. To learn a little more about this program, please take a couple of minutes to watch this short film:
For those readers not yet familiar with the consequences of the current conflicts, over 12,000 children of military have lost a parent since the start of the Iraq and Afghanistan wars over eight years ago. In response, the Department of Defense has again partnered with Sesame Street to produce another military-themed episode called “When Families Grieve.” This particular installment addresses death and loss and how children experience grief when a parent in the military does not return home again. Sesame Street intends to make available approximately 800,000 new resource kits to military families to provide hope and reassurance that they need during the difficult experience of a death of a father or mother. You can find out more information about this latest project at the Sesame Street Workshop website.
And have you made plans to attend the National Institute for Trauma and Loss in Children 2010 Summer Practitioner Assembly? The first day of the conference [July 13th] is dedicated to how practitioners can help military children via a renowned panel of experts on families, US armed services, and reintegration, homecomings, and multiple deployments. The panel includes Retired Brigadier General Don Scott and Betty Scott, Retired Major Margaret Dellio Storey, and other notable experts on military issues and children and families. The remainder of the conference features special sessions focusing on children of the military as well as workshops and courses on intervention with children who have experienced violent trauma, disaster, domestic violence, abuse, deaths, or loss. You will also receive a free copy of Sesame Street’s “Talk, Listen, Connect: Deployments, Homecomings, Changes.” And military personnel and families are invited to attend the July 13th presentation free of charge.
So consider taking advantage of this unique opportunity! If you are in the military, you and your family can connect with other families and share your expertise and wisdom with practitioners in attendance. If you are a practitioner, you’ll be enhancing your trauma intervention skills via the National Institute for Trauma and Loss Certification courses; you can attend Level 1 and Level 2 courses in addition to other workshops on non-military trauma and loss subjects during the four-day conference. We look forward to seeing you there!
Did you know that just learning to relax is key to trauma-informed intervention, resiliency and recovery from a variety of disorders? Dr. Roger Klein, expert on the impact of relaxation training with children and adolescents, presented a workshop “Helping Children and Teens Self-Regulate Using Imagery and Relaxation” at a recent trauma conference. In this presentation, Klein underscores that that there are many ways children and teens can learn to regulate their responses to stress and traumatic events. Additionally, using imagination along with relaxation activities and resilience-focused thinking, young people can learn to minimize their responses to every day stress and traumatic experiences.
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