Chapter 5
Trauma and Traumatic Loss
W'hen forming attachments, parents and I are often struck by how a child's fear forms a barricade to attachment. Even after attachment is formed, trauma seems to have left its imprint on many layers of children's developing identity—and even on their physiology! Sometimes children's trauma can feel like toxic waste in family life. Understanding trauma, calming traumatized children, reducing trauma's toxicity in children, and moving beyond a trauma-impacted worldview are among the considerable challenges for parents and affected children. Techniques and attitudes that assist in these tasks are described in the rest of this chapter and will be continued in Chapter 9.
What Is Trauma?
Kimberly and Allen did not know a definition for trauma when they met Ginny. But both parents were focused on trauma after six months of placement. They researched to find answers
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to questions like, "How can she keep going without sleep?" Ginny, at age four, took two hours to go to sleep. She woke up in the night. She was also awake in her bed when parents got up in the morning. She gazed and smiled at strangers. She also smiled as she grabbed toys from her little brother. A sudden noise made Ginny jump and tremble. She either screamed or laughed when someone got hurt.
When they called their caseworker for a referral for help, the caseworker agreed with the parents' assessment, "Our daughter is the poster child for trauma." They added, "We were told that since Ginny was nonverbal, she wouldhave little memory. That is clearly not true. Maybe she can't tell us what happened, but some part of her remembers. Dying is the biggest theme in her play. And what typical four-year-old sneaks a steak knife to bed to protect herself?" These parents identified related symptoms, putting them into a cluster that was telling. It helped them to go get appropriate help.
The following paragraphs give some technical information about trauma, giving parents access to the same information that professionals
are using.
Parents find the terms trauma or traumatic event used precisely by mental health professionals. The American Psychological Association describes a traumatic event as "an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone." (APA, 2000, p.468). In the entire lifetime of people in our culture, about 50 percent of women and about 25 percent of men are traumatized. (The rates are higher in high-crime areas. Women have higher exposure because of their higher rate of sexual assault.) Trauma is followed by specific, high-stress symptoms that have lasting effects on key areas of functioning. Those symptoms are called posttraumatic stress symptoms. When mental health professionals use the term trauma, it is not used lightly. If parents hear the term, they should catch the implicit information carried with it—that the event has left its indelible mark on their child.
Competent parents in safe communities reduce their children's exposure to traumatic events. However the cocaine and methamphetamine epidemics in North America have dramatically compromised parental
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competence and community safety. Children today enter care with more exposure to violence, higher rates of abuse, and traumatic levels of neglect. An enormous change in the foster care and adoption field has occurred as these traumatized children enter families.
Children who are adopted internationally are also a changing population. According to statistics from the Immigration and Naturalization Service, the rate of international adoption has increased at least 10 percent for each year since 1992. A decade ago, two thirds of the children adopted internationally came from Korea, a country where children tended to be cared for in foster homes and where they tended to have access to good medical care. Now, more than two thirds of children arrive from institutional care settings in countries with poor nutritional and health care resources. According to Dana Johnson, M.D., a pediatrician with many years of experience working with children adopted internationally, of the children adopted to North America from Eastern Europe, the rate of traumatic exposure is high. In a sample studied by Dr. Johnson, of the 30 percent of children who have several serious problems, trauma was a common denominator (Johnson, 1997).
People who have been traumatized show its impact in four areas: lowered control over regulation of their moods; exaggerated startle response (evidence of overdeveloped "fight or flight" response); emotional numbness; and physical symptoms such as stomach aches or unexplained pain that tie back to trauma. Children demonstrate changed patterns of thinking and specific behaviors associated with trauma—they organize their world as if it were hostile.
•  They are hyper-alert.
•  They show helplessness in problem-solving.
•  They have trouble organizing information.
•  They move from hyper-arousal into fighting or aggression; or they move from hyper-arousal into dissociation; or they move from hyper-arousal to panicked recoil.
•  They are oversensitive to stressful stimulation. When in a shocked state, they may actually look insensitive.
•  They are ashamed of their helplessness, and try to cover it in some way.
■ They experience emotional numbing. It is unpleasant, like feeling "dead."
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•  They have physical pains, with a questionable basis.
•  They show a decrease in auditory processing—the ability to understand what is being said—when exposed to reminders of trauma.
When children are first coming into a home, some of the behaviors above can be evident without any trauma. It is normally stressful to adjust to a new family, culture, or language. Within months, parents are able to detect the presence of trauma, even when adopting children for whom they have no history. Over-arousal, dissociation, or both, remain high. Children often begin sharing their fears with parents, especially after a frightening reminder of trauma or nightmare.
Parents of adopted children have a more complicated parenting course today than they used to have, by far. As children come into new families with more complicated trauma histories, parents are contacting their agencies more frequently for referrals to services. Parents regularly describe the surprised reactions of experienced adoption workers to traumas reported by children.
In response to changing populations, foster care and adoption agencies have had to move into high gear, providing post-placement services to deal with more serious mental health needs. Some agencies complain that since their international programs are self-described as independent adoptions in-country, the agency only functions to facilitate. They resist taking on ethical and legal liability. Other agencies do provide post-placement help when asked, but worry about frightening prospective adoptive parents and international connections if they discuss potential problems openly with prospective parents.
Indeed, some prospective parents find that the stories they report of their children's suffering are unwelcome, that connection with parents with similar problems is not provided, and that parents are not supported through their agencies. Other agencies are stepping forward to meet the extra challenges of foster and adoptive children and families by requesting training, learning resources, and providing post-placement help.
Diagnosing Post-Traumatic Stress Disorder
About 30 percent of people exposed to traumatic stress go on to develop a chronic condition known as posttraumatic stress disorder, PTSD.
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Since the most important protective factor for children in preventing the development of PTSD is the quality of continuing attachment from the caregiver at the time of trauma, parents reading this book are likely to see their children affected (Perry, 1999, p.5) (Zeanah, 2000, p. 202). The diagnosis of traumatic stress is found in the Diagnostic and Statistical Manual, DSM-IV-TR. You will find this diagnostic criteria on page 364-66 in the Appendix, and parents who believe that their children may be suffering from PTSD are encouraged to read that formal definition. A parent-oriented checklist is as follows:
1.    Children have been in an extraordinarily frightening situation that filled them with fear and dread—to the extent that they may not have been able to move or talk.
2.    They are having dreams that cause them to wake up in terror. They seem to be recalling parts of a real experience.
3.    They have tantrums or shut down in fear over incidents that remind them of the traumatic event.
4.    Children complain of someone trying to harm them, and may seem to see that person's face through the window, in a crowd, etc. The "someone" is related to the trauma.
5.    They act blank at times, and seem to lose their place in time. They are frightened rather than daydreaming.
6.    They rage after being exposed to something that reminds them of the frightening situation—hitting, punching, and seeming to fight for their lives.
7.    They have symptoms of being on high alert—not getting asleep easily or sleeping through the night, jumping at sudden noises, watching for clues of danger, concentrating poorly.
It is obvious by looking at this criteria that traumatized children will be demonstrating, rather than discussing, their traumatic exposure. Children who have been traumatized may not be able to recall events in a descriptive fashion. Often, however, the memories are stored in what is called behavioral memory (Brown, Scheflin, Hammond, 1998, p.21). That means that they will act out relevant events, with Utile understanding of what they are doing, or why.
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A little boy, age four-and-a-half, who had been moved at eighteen months of age after he wandered for a time on a busy highway and had experienced several near misses with cars, played out the event three years later. He put a boy doll on the road, brought a policeman, and showed himself being taken away to a new home. He played this repeatedly, but could not "remember" this as part of his placement story. He said that he did not know why this "picture" kept coming into his head. "I hate the picture and the feeling," he said.
Children who are traumatized after having a background of deprivation and neglect are particularly vulnerable to developing posttraumatic stress disorder (PTSD). Rather than "being used to it," in a way that would show resilience or coping, children and adults are over-sensitized. They become even more stressed by additional stressors and traumatic reminders. An exaggerated startle response in children is one example of this over-sensitization of the body to new stress after previous trauma. It is important to note that extreme deprivation and neglect are earlier traumas. (Briere, 1992; Friedman, 1997).
Children's emotional states are disregulated and poorly moderated. In children who had early trauma, those memories tend to be stored in the part of the brain that was developing at the time. When they recall the memory, they recall the memory in the same way a child would, which is in the same overwhelmed way that they stored it, and with little cognitive input. When very small children are hungry, they are all the way hungry. Their brains have not decentralized as an adult's brain or older child's brain is capable of doing. Adults can get a little hungry and de-centralize that feeling successfully. Children who have reminders of the traumatic event often have a difficult time due to this overwhelming way of remembering. Children remember traumatic events in much the same centralized way that they were stored, (van der Kolk, 1994). They often respond to day-to-day events in this same overwhelmed and poorly modulated way.
Children may suddenly lose their place in time and space, responding to some reminder of trauma as if the trauma is happening in the moment. This is a result of physiological changes to the body post-trauma. "For
some individuals with PTSD the sympathetic nervous system appears to over respond to a variety of stimuli even many years after having experienced an overwhelming trauma. The individual continues to act psychologically and biologically as if the danger is still present even through the event may have occurred in the distant past." (Southwick, Yehuda, 1997). Children are at particular risk if they do not get help in de-sensitization from the reminders of trauma, or if they are not buffered from high stress situations.
How Trauma Impedes Attachment
In order to guard against more negative, traumatic events, children organize their world as if it were hostile. One of the ways that they defend themselves is through friendliness to strangers. Rather than believing in the safety provided by their parents, they feel at the mercy of any adult around. Children know that it goes better for them if adults are favorably disposed to them. Children control the total strangers by acting overly friendly and charming. Their mcUscriminate friendliness can fool parents during pre-placement visits. Parents think that they are seeing a child who is open to a family. Instead, after placement, parents find that the charming smile masks fear.
Trauma causes a child to be certain that more bad things will happen in the future, and that adults will be ineffective in preventing these insults. Children who are thinking about life in this way are not likely to trust new parents. When they do relax and begin to depend on parents, they are afraid to risk trust for very long at a time.
Trauma causes numbing of emotions, as well as rapid shifts in emotions. Children are either not feeling much, or they are feeling far too much. This makes it difficult for children to receive the signals of love, appreciation, and care that their parents are conveying. If they are having night terrors, they become stiff, cool, or explosive, literally overnight. In order to avoid these unpleasant extremes, children may try to use dissociation. Or, they try to control much of their environment—parents are part of their landscape. When children are putting all of their energies into control, they are not working on trusting or attachment.
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Even though children are not as responsive after having been traumatized, attachment work still comes before trauma work. There is some evidence that attachment helps to calm some of the over-aroused parts of children's brains, which in turn helps them with trauma. Eight-year-old Melody's story follows a typical order: work on attachment, then on trauma, and finally on grief.
Melanie came in with her mother to see me. Her life included having witnessed a lethal assault, having been sexually assaulted, and having functioned as the scapegoat in her biologic family. She had had a failed adoption, as well. She did not have the cognitive resources to work on trauma, yet was having flashbacks. At home, her mother had learned many ways to control Melanie's frequent, oppositional acts. However, Melanie stayed dissociative, cool, and remote, unless she was screaming. In our first sessions, I told her that before working on trauma, it seemed best to make her a happier, more comfortable girl. Melanie liked the notion that we should help her to be happier.
I told Melanie that her job was to get close to Mom. I compared her to a gecko in the room, who got too chilly to be able to move. I told her that she needed to bask in her mother's love, Mice the gecko would bask on a warm rock. Looking at a thermometer, Melanie decided that she would like to feel nice and warm inside instead of still and cold. Her mother hugged her, snuggled her, tickled her, and j oked with her until Melanie felt nice and warm— about 82 degrees, she decided. When Melanie got chilly, still, and distant at home, Mom used their common language. "You look about 55 degrees, Melanie," she would say. "Come warm up!" Her mother began to rock Melanie twice daily. They dropped all outside activities in order to slow life down. Mom rubbed Chapstick on Melanie's Ups, which she loved. It helped Melanie's motivation that she had to call my voice mail to report her progress on a nightly basis.
Only after Melanie learned to relax and depend on her mother, was she able to talk about the horrible events that were on her
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mind. She needed a person of refuge to walk through the trauma with her. She also had to be certain that she would not feel stuck in the endless remembering of trauma. She felt that her mother could be trusted to help her calm down, move through, and endure her trauma work. As Melanie worked on trauma, she reached for her mother automatically, knowing from experience that her mother was there for her. She grieved for the lack of protection that she had gotten from her birthparents. After the trauma work was largely finished, Melanie showed an expansion in her attachment and in her outside interests. The screaming absolutely stopped.
Melanie's mother developed competence in helping her daughter to overcome trauma. She learned techniques and timing in the sessions. After all, the mother, not the therapist, was available at 2:00 A. M. when Melanie had nightmares. Melanie's mother learned to note a particular look as Melanie was getting frightened. She intervened quickly, pulling Melanie close. As they sat together, initially she could not feel much or talk much. Within about ten minutes of closeness and comfort, her feelings would begin to return, as well as her speech. She described in a halting way what triggered a memory for her. She hid her face in her mother's shoulder and listened to reassurances until she felt better.
After six months, Melanie found that she was able to reassure herself most of the time. She breathed deeply, as if sitting with her mother, and used the same words. When she discovered this, she asked to go on her first overnight at her girlfriend's house.
Meeting basic needs for comfort is always a good place both to begin and to come back to when helping children through trauma. Slowing down the pace of life is key. Traumatized children already have more than they can deal with. Reducing outside exposure helps them. Some children are so accustomed to a high level of arousal that they crave constant, excessive stimulation. This is not conducive to healing from trauma. More on this is covered in Chapter 9.
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When Trauma Is Part of the Child's Identity
Some people think that something about them keeps drawing trauma to them. They confuse the life event with their own identities. This is easy to do, since trauma is so insidious in the way in which it distorts beliefs. An example is Ahmed's case. He looks successful on the surface, but is a miserable teen due to his belief that trauma comes to people he loves:
Ahmed was working hard cleaning the home. A 4.0 student in the seventh grade, Ahmed had finished his homework. He avoided his parents after cleaning. His sister, whom he loved dearly, had left for a school program at a boarding school. Her learning differences had resulted in school problems. In the year before she left, the two of them had engaged in ugly verbal battles.
Amhed came into therapy trying to understand the meaning of his birthparents' traumatic deaths. The losses intersected with a new loss. He was afraid to grieve the loss that his sister's school placement represented, and the older losses that it brought up. He could not bring himself to lean on his parents. "I'm afraid that the stress will be too much for my parents," He said. "I've been having dreams that I will lose them too. Everyone just sees the outward person, the son of respected parents. No one else is like me." As we talked, he described how stress had lolled his aunt, who was his caregiver after his birthparents' deaths. "I'm the kind of person that these things happen to. Doesn't it seem like more than a coincidence that every parent figure has died? I don't want to die, but I probably will, too."
When his mother came into the therapy session, she assured him that she was strong, physically and emotionally. Ahmed gave lip service, but was a long way from accepting this as a new truth. As he left, he talked about his plans for the afternoon—he planned to work around the house. "Well, Ahmed," I said, "orphans have to work." At that, Ahmed stopped, and said through tears, "I don't
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like that.. .1 don't like hearing that!" His mother said, "Then just be our son. You do not need to earn your keep! We want to take care of you." She pulled him close to her as he broke into sobs. "This has been hard on you, too," she said, referring to his sister's leaving.
"Ahmed wonders if it should have been he who left," I mentioned.
"Just because he was adopted and she was born to us?" His mother said. "Of course not. I love you both. You are my son— always. Just like she is my daughter—always."
"Didn't Ahmed go to boarding school?" I asked.
"Yes, Ahmed, you went to boarding school after your aunt got cancer. In that country, children whose families had money often sent their children to learn languages, like English. You only came home occasionally until we adopted you."
"I am so mixed up," he said sadly. "I keep thinking that because of me you will die, or that I am the one who goes to boarding school, not her. I think that I was somehow to blame for my parents' and aunt's deaths."
In the vignette above, Ahmed's identity includes trauma's contamination. His beliefs include the following...
•  He believes that the traumatic event occurred because of something about him. "I am the kind of person that things like this happen to."
•  He connects cause and effect between events that are unrelated, except in his history. His boarding school placement and his sister's were for different reasons. He has exaggerated the impact of the latter, expecting disaster.
•  He has guilt and shame about the traumatic events, in part because he sees himself as causative.
•  He is looking for omens, attempting to control the out-of-control events in his life.
•  He experiences a "nothing feeling." It is a feeling that makes him feel empty and awful.
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Because Ahmed's trauma happened later in his childhood, and because he had good nurturing after his losses and his adoption, and because he had had a course of therapy during primary school, his brain had been reasonably calmed and well-organized until the recent trauma triggers. Trauma triggers are reminders of the trauma that cause an emotional response similar to the one at the time of the trauma. In his case, his impression that he is beginning to resemble his deceased father turned out to be a trigger, as did his sister's departure for boarding school.
In identifying with his biological relatives, Ahmed was identifyingwith their tragically foreshortened lives. He believed that the same fate awaited him. He needed help in being able to identify with parts of his parents' identities, but to form distance from traumatic parts. Sweet words to him began with this phrase, "You are different from your birthparents in these ways." They came via another biologic relative. As Ahmed was able to express his feelings, he felt grief. He said that this felt better than the "nothing feeling."
Children who have lost parents traumatically process ways in which they feel vulnerable by identifying with birthparents. These must be balanced byways to hold onto their birthparents.
A child who finished her work completed an exquisite dance with lyrics to describe her relationship and life with her birthrnother. This dance was shown in therapy, and to her father and mother exclusively. It allowed her to accept both her birthrnother's death as well as her continuing approval and influence on her life. In her therapy, she was permitted to work through which parts of her birthmother's story she needed to embrace, and from which parts she needed to distance herself. The result allowed her a peace that gave her more authentic emotionality. She described herself as being able to get rid of the "nothing feeling," most of the time. She believed that she would live, carrying an intact image of her birthrnother in her mind. She was free to attach, develop, and relax.
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When Your Child's Trauma Triggers Your Own
When parents have themselves been traumatized, they usually think that their experience will assist them in understanding a child's trauma. Parents do not usually anticipate the re-emergence of their own issues. In a confusing twist, extended high stress can renew traumatic stress symptoms. Sometimes issues are not similar, but prolonged high stress brings out symptoms from issues that had been carefully processed years before.
Previously traumatized parents wonder later whether they were re-enacting by adopting. In re-enactment, people find a similar experience, attempting to master the situation in the present tense. It is a high-risk way in which to work out a psychological problem. These situations often unravel, ending in disruption, or in highly dysfunctional families.
How do parents know if their trauma has been triggered? Since most parents are adjusting after a placement, some symptoms of difficulty are normal, especially with international travel. Confusion and disorientation should be on the wane after the first six weeks of placement. Signs that are classic red flags of resurfacing trauma reactions are night terrors, intrusive thoughts of doom, and hyper-vigilance. If parents are becoming numb, distant, angry, harsh, and insensitive, the damage is mounting.
Parents with traumatic stress symptoms cause confusion and alarm in their children. Children will tend to develop a disorganized attachment style with this type of parent figure. If parents are having symptoms and a child is already in their care, an immediate course of therapy is necessary. The outcome does not have to be disruption or dysfunction. Often simultaneous treatment helps get the parent back on track, able to meet the needs of their child.
Sometimes parents find that certain aspects of a child's history trigger their issues, but that those aspects can be avoided. One child found that she could disorient and iinmobilize her parent by screaming. Her mother gave her anything that she wanted to stop the screaming. Her parent stopped the manipulation by putting on airplane mechanic ear protection when her child started up. The screaming did not affect her mother, so
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the girl gave up the behavior. Before she gave up the behavior, the little girl tried harder and louder for two weeks.
Another child's sexual abuse issues triggered a parent's memory. "While she supported the child's therapy, she was not present during the disclosures. The toxicity of those descriptions would have rendered her ineffective for comfort and support.
Parents who have been traumatized have to watch their own stress levels carefully. Regular hours, sufficient sleep, processing time, and pleasurable activities all help parents to keep their own internal regulation. Limiting the demand for emotional support from outside the family is necessary. After trauma, children and adults have a threshold to stress that is lowered. Participation in parent support groups should be selective. Having a small group, with loiown stories, is preferable to having new stories at every meeting. Avoiding traumatic stories, which play off the parent's own, helps keep the parent's boundaries intact. Sometimes parents do much better with an adoptive or foster mentoring partner than with a group. They can get support in this manner, but minimize their risk of exposure to toxic information.
Some parents find that it helps to have the same therapist as their child's therapist, asking for time for both of them. A careful therapist can help arrange attachment-oriented techniques and behavior shaping with the parent's vulnerabilities and strengths in mind.
For example, a parent who could not endure her newly adopted child in her lap did a lovely job using attachment techniques while sitting next to her daughter. They worked in front of a mirror, which the child watched, receiving positive facial expressions from her mother. This child also was sung to, read to, and snuggled. After a four-year follow-up, this nine-year-old girl has never complained about lack of lapsitting. Her anxiety level is only slightly elevated. But previously, as a five-year-old, she had complained that her mother did not like her. The mother had been avoiding her daughter's frantic hands and insistence on full body contact, which triggered traumatic memory. When freed to do things differently, she warmed to her daughter and formed an attachment.
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Trauma's Influence on Normal Learning
The stress hormones that ready the brain for quick response actually damage the brain's capacity for normal learning over time (Perry, 1993). The brain prunes away structures that it is not using, as it builds connections that it does use for survival. When curiosity, achievement, and positive relationship building are ignored, children do not develop them. The brain structures that support these capacities actually get reduced. Research studies show that very extreme deprivation and other forms of trauma result in abnormal brain scans.
Traumatized children are hard to teach. They are hyper-vigilant and hyper-aroused. Often, they are misdiagnosed with attention deficit disorder. If they do have attention deficit disorder, they can also be hyper-aroused. It is tough to treat both successfully. There is a need to both stimulate the brain, and to calm it, in different areas.
These children lack concentration. They tend to be inflexible in learning. Often they are not sleeping well, so appear as grouchy students. If a trauma trigger is hit during class, the child might dissociate for the next couple of hours, completely missing the lesson's main point.
A child traumatized by sexual abuse could not get past the letter "m" in the alphabet. Every time she came to the letter, she dissociated. After a visit to the class, her mother noticed that the key word for "m" was "man." The alphabet pictures circled the classroom walls and appeared on a poster. The "man" bore an uncanny resemblance to her daughter's abuser. The teacher was an excellent and no-nonsense educator. She had a "moon" pasted over the "man" within a half-hour. The child resumed her progress through the alphabet by the end of the day. Successful education takes such adaptations and teamwork.
When children flood with anxiety, their ability to tell about what is happening inside of them is diminished. Sometimes they become aggressive, responding to all of the flight and fight energy that anxiety
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brings. They are the children who need the most structure given in the most nurturing manner. Instead, they often get the least nurture, with school systems using a tough, harsh approach. Traumatized children need a calm, consistent, and nurturing approach in order to learn best. They do much better with a teacher who knows them well and can see when they start to get anxious. The teacher can often intervene with support before the child becomes aggressive.
Traumatized children have more trouble with sequencing when they are especially upset. They also have difficulty with memory. Verbal instructions just do not stick in their brains. If teachers know this, they can repeat directions without shaming children. Or, better yet, they can write directions on the board for all to see.
Traumatized children do best when school visits to the police, fire department, and other disaster drills are minimized. Some children may need to stay home those days. Other children will do better having a parent accompany them on a field trip. Some accommodations in procedures are important and work well. For example, officials who overstate safety issues to make a point can reduce a child's feeling of competence.
A second grader, who had heard that another child's life might hinge on her response during a disaster, was terrified that she would freeze up when she had to pull the emergency release on the back door of the bus. Since her traumatic incident, she had had several instances of freezing. She had nightmares about the bus driver, the lever, and wrecks. Assigning her an older "lever partner" was the solution reached in five minutes by the transportation director and therapist. Unlike their non-traumatized peers who bhssfully live in denial, children with exposure to disaster need to believe that they are reasonably insulated from danger.
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How Does Trauma Impair Social Skills?
Children who have been physically and sexually abused are the children s research population with the highest aggression scores (Mash, Barkley, 1998, pp.563-573). Such children tend to have fewer friends, simply because potential friends are afraid of getting hurt. Within eighteen months after sexual abuse, girls show a decrease in their social acceptance by other girls (Putnam, 1999).
It is difficult for children who are frightened to learn games, to share, and to involve themselves in the flexible give and take that friendships require. Children who are emotionally numb often wear the matching look on their faces. Other children veer away from that face because it looks unfriendly. When traumatized children play, their play themes can be fascinating, but unnerving, to other children. Children may give them attention, but not acceptance. This only accents their perception that they are different and inferior to other children.
Their mood regulation necessaiy for keeping friends is poor. Children who act out their feelings aggressively may lack friends. Children who hold their intense feelings inside may do better with friends. However, they pay a price for holding in feelings with increased anxiety and depression. Recall Ahmed, from the first section. Ahmed was popular, but complained that no one really knew him. He thought of suicide. His biggest restraint in considering suicide was concern for his parents.
Some children have had such little empathy shown to them during abuse and neglect, that they internalize brutality and lack of empathy. While this is not typical of all traumatized children, it is common.
One boy, who went on to develop a loyal, protective and kind character, pulled a cover off a heating vent and tried to stuff his toddler brother's legs into the duct work during a family session. Through the tangle of six adult arms, the brother's howling and both parent's directions, I could hear the boy laughing at his brother's distress. "You are so funny," he chortled. His speech mimicked a drunken person. The incident had happened within a few seconds. Like other traumatized children before treatment, he
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moved instanüy from the idea to the action phase. He did not inhibit bis impulse. His hyper-vigilance gave him information that the screws on the vent cover had not been replaced, a detail that most children would have missed.
Lack of empathy combined with impulsivity make adult supervision worth battle pay. It is no wonder that play dates are made warily. Parents find that "going outside to play," is not safe for some traumatized children. Left without structure, they will play out themes of victimization and dominance.
Some traumatized children do well with initial friendships, but they are so intense in their friendship styles that they wear other children out. They are acting with high levels of stress hormone in their bodies. Visiting children ask for some breaks and calm down periods. Until traumatized children improve in their level of arousal, they have a hard time feeling the same need for a balance of quieter activities. Often they hound the visitor for more intense play. The guest gives in, but avoids future invitations.
In an interesting twist, these children routinely express the belief that someone can tell by looking at them that they have been abused. Since adults know details about them, they assume this to be true. They do not know, nor have they been told, that these adults have read their histories. So a surprising number of children thinlc that personal information must be discernable. It has been quite reassuring to children to realize that there is nothing transparent that shows this information to other children or
adults.
As girls move into the third and fourth grades, they are expected to match the body language and voice tones of other girls. If girls are not able to do this, they risk being ostracized by cliques. While good schools work to interrupt cliques, it is helpful for traumatized girls, especially, to learn to match the facial and body language of others. It helps them with social acceptance. It is more difficult for children to do this matching after trauma, since the body is not in regulation. Many children can learn to do matching, even if they have not healed from trauma or remain hyper-aroused after treatment. The skill set is a learned one. After children have learned the skills, they can use them when motivated. There is more on this topic in Chapter 12.
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Coaching children on friendship skills helps to ensure the development of these skills. Working with specific strategies helps children to key into situations in which they are likely to miss signals, or misread signals.
One boy, who constantly kicked others accidentally, realized that he did this when he was uncomfortable after other boys bumped him. Instead of an automatic kick, he learned to give a friendly push on the shoulder. The push was typical of boys his age. It was rehearsed until it came naturally.
A girl who wanted to talk about spooks, hauntings, death, and decomposition agreed to interview several slightly older teens, who advised that these were topics that would label her as "messed up." She saved these topics for therapy and for her mother—an accepting soul who visualized little.
Helping children to develop empathy works much better than a punitive system for aggressive behavior. As children feel sensitivity shown to their needs, they are more likely to show sensitivity to others. Often children can work backwards. As they describe the injustice to another, they can remember how they felt when someone did something similar to them. After finding their feelings of disappointment, parents can ask them if they want to pass that feeling along. Sometimes, provocatively, I say, "Nowyou are acting just like the person who stole your stuffed bunny when you were little. Are you feeling good?" The child usually adds with a long face, "No, not very. I didn't know that was what I was doing." They identify with the child they wronged by remembering their own losses. Then, they can move to restitution more easily. Restitution is a necessary part of caring for a friendship. In the long term, aggression towards friends is reduced by the improvement of empathy towards themselves, and empathy towards then- friends.
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How Parents Can Intervene to Help Their Children
When children have been traumatized, they are afraid almost all the time. This is an important concept to grasp. Fear is the reason that parents need to go back to the basics when dealing with their traumatized children. Forming attachment and strengthening attachment come first in working with frightened children. Children learn through attachment work that parents are connected, that they will protect, and that they will comfort.
If parents imagine turning off the sound in their homes and trying to imagine the ways that their children would be reassured, they have the amount of reassurance that children receive reliably. Traumatized children have reduced auditory processing ability when very frightened. Words must always be accompanied by pictures, smells, touches, or role-plays in order to help. Which works better? The father who calls, "You are fine," as the child goes into his dark room, or the father who walks into the room ahead of his child, turns on the light, and says with a smile and reassuring touch on the shoulder, "You are fine." Little is conveyed about parent protection through words alone. Verbal discussions work only after children begin recovering from trauma.
I must emphasize that parents' first job is fostering closer attachments in their traumatized children. Techniques for attachment are described in Chapter 8. Teaching children the protective value of a family and parents overlaps the formation of attachment. Parents can describe their jobs, interpreting their behaviors to children as they do their daily tasks. For example, parents ask children to walk with them around the house before leaving for a trip. As the parent closes and locks windows and doors, the parent describes how seriously he takes his job to keep the home secure. Parents can show children their checkbook, and describe how they budget for cartloads of groceries. Without giving detailed financial information for the benefit of the entire fourth grade, parents can still share their careful plans to feed their children. These types of practical plans are reassuring to children who have been traumatically neglected or abused. These children worry about very basic needs getting met.
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The nightmare most common and the worry most prevalent in traumatized children is that they will be taken from their parents. This theme is recurrent. Parents must demonstrate ways that this can be prevented. Rather than a global reassurance, parents should describe the systems that are in place to prevent this. Sign-out procedures at school, block watch programs, patrol patterns of neighborhood police, immigration procedures that prevent unwelcome visitors, security systems in the home, are all topics that help children.
As in any horror movie, the worst fright is the one after the trauma, just when the person feels safe again and has let down defenses. Since "getting taken" is a common fear of children, it helps to find out what children thought happened to them. In child welfare cases their removal from the home was usually frightening, and it happened more than once. Often children are unaware that the Child Protective Services person was a "good guy," authorized to help. Or, they think that the police were mad at them during a visit that resulted in their leaving home. Many children are waiting for the same events to occur again. Learning why caseworkers or police officers came to the home in the first place sets the stage for why they would not come back again. This can be described in a sequence of pictures. Adopted children who have spent years in the system are surprised to learn that they no longer have a caseworker. Parents now make their decisions. This tends to be an "ah-ha" moment for children who expect people outside of the family to make decisions about them.
As children try to let down defenses and relax, they wonder whether it is safe to do so. Reassurances based on practical facts are helpful. Some parents are reluctant to make strong, predictive statements of safety. If children ask if the house is safe at night, their parents respond with, "Probably, but you never know in this day and age." This is not helpful. Instead, say, "Yes!" If parents are perceived as weak, then children have to remain hyper-vigilant. Part of the meaning of a family is that the family commits to keeping their children safe. This fundamental quality is accented in parents who are intervening on behalf of their children.
Since traumatized children are not well-regulated in their moods, parents should set the tempo in the home. They can help children slow down when they are becoming emotionally overwhelmed, racing faster and faster. They can provide structure and reassurance when children are slipping away into dissociation. It takes enormous reserve for parents, since
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they are using their own bodies' breathing rate, their touch, their voice tones, and their verbal content to re-regulate children throughout the day. If parents are moving too fast, they cannot help their children. Effective parents sit down, without television or the telephone, making themselves available to their children for calm down. They can invite their children to join them, since the time has already been cleared.
Some children use frantic over-activity as awayto express their terror, or to try to block out information. In the vignette that follows, brothers use this together. Often siblings have used frantic over-activity as a way to endure ovewhelrning events like domestic violence, physical abuse, and physical fights in drug houses.
James was grinning and poking at his brother. Timmy, ten months older, resisted briefly—he really did want to please Dad at this picnic. He took a sidelong look at James's tight body. Timmy's body became a mirror of James's.. .and they were off. Their pulses were high; their bodies revved up. They had evolved their own way of dealing with too much danger and tension. They became so wound up in their play that they could block out the people around them. Even though this "Welcome to Kindergarten" family potluck picnic contained no dangerous people, the boys stayed wired for danger. James felt scared and out-of-con-trol. He could not control or scan this many people. Besides, that one guy had a full beard and a ponytail like.. James could not stand the sudden memory that began to emerge. With a heart rate of 150 beats per minute and a plastered smile, he poked Timmy into their old "block out domestic violence" routine. The kindergarten teacher made a note to talk to the parents about screening for attention deficit disorder with hyperactivity. After an early exit, the parents went home to make a plan for the upcoming year that did not continue the pattern of frantic overactivity as a means of coping.
When kids whose brains have been wired for survival and danger enter safe homes, they continue looking for the dangerous elements. Their
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triggers, or reminders of danger, are essential for parents to know. Parents who do some detective work note that, like the children in the vignette above, their children may be afraid of men in flannel shirts, or who have beards, or who wear glasses. If parents know the reminders, they can desensitize their children, help them form a strategy of avoidance, promise to stay between the frightening person and their child, or take other reasonable approaches.
After the first two months of school, James' and Timmy's dad bought a beard, flannel shirt, and put a pillow under his shirt. The children had to approach him ten times, until they felt better. This was done with a lot of giggling. Then, they made "the bad guy." They stuffed the shirt and some jeans with some newspapers, and made a head out of a stuffed paper sack—complete with a beard. Masking tape held him together. The kids jumped on him, lacked him, remade him, controlled him, mimicked remembered insults, and eventually ignored him. By the next school event attended by parents, the boys were sure that they would not be confused by their classmate's father. "It is your choice." Their dad said. "We can either make the stuffed man again, or use the time to kick the soccer ball."
Kids with severe symptoms of traumatic stress usually need crowds and day trips limited. Some children feel better wearing a hat and sunglasses when outside of the home. They feel more protected and hidden.
It is uncommon to make much progress against stress reactions like dissociation, fighting, or frantic over-activity until the child has some alternative tools to use. Parents can take their child's pulse and feel their shoulders, both of which serve as barometers for escalating tension. If children are filling with the extra energy for fight or flight, parents can give the child an outlet for the energy, as well as help her to calm down. Children can do 150 jumping jacks, run in place for five minutes, or run up and down a hill. If the child is not already too overexcited, parents can ask their children to do some deep breathing; name collections of things; smell a good smell; get a drink of water; or have the child cozy his head
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into the parent's lap, arm, or shirt for a while. Frantic over-activity is a sign to me that a child is preparing for the flight that comes with hyper-arousaľs fight or flight. Children are simply working too hard in life when they have to use this as a defense.
Children who have begun a behavior due to stress are not above using it for control purposes at home or school. If children choose not to use the techniques that can help them, parents can make them pay for the privilege of using the old way.
For example, James and Timmy began giving evening baby sitters a horrible time because they were scared. When they were only a little scared, they continued the behavior. The solution was that they had to pay the sitter an additional fee when they acted out. The sitter got extreme duress pay. Soon the boys were trying harder to use their calm-down techniques.
Since it is wearing on adults to deal with certain behaviors, fining children either with money, extra jobs, or earlier bedtimes helps to curb outrageous behavior. After parents have permitted adjustment in the home, and after therapy is well under way, parents can put in these disincentives for acting out. Parents can say, "You can do 50 jumping jacks to help that feeling and come get a snuggle, or you can go to bed ten minutes early for each minute you play that way. It's your choice."
Practice preferred alternatives to acting out when children are not stressed. That makes it much easier for them to use the preferred behavior when they need to, since they have practiced when they were feeling good.
For example, Mantze, age six, vomited and tantrumed when Mom left the home for a few hours, leaving Mantze with a kind, familial-, and long-suffering family friend. Her mother felt that Mantze was re-enacting her abandonment in a subway station at age two, over and over again. Verbal reasoning had not helped at all. Mantze practiced going to an agreed-upon calm-down spot, with a book and a nice-smelling pillow. Her mom went outside
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the door and came back in the house in a few minutes. As Mantze practiced sitting in her spot, she got praise. Mantze practiced this quite a few times, and received continued requests to practice, which she found inconvenient. Her mother said that she was not certain that Mantze was strong enough in the new behavior. Mantze insisted that she was certain that she did not have to practice further—her mother could leave! After many practices over two weeks, her mother went out while Mantze stayed with the plan. When she began to slide a few weeks later, Mom insisted on more practices, saying that she did not want Mantze suffering stress. She settled herself, rather than enduring interruptions in her days for boring practices.
In a final touch, the mother had also bought a tan, generic cereal for Mantze's breakfast, instead of the expensive brand with multicolored letters. Mom explained that her consulting work hours were reduced—from doing so many practices. She had to balance the budget.
Children often create reenactments or symptoms of traumatic events that are vivid and controlling. After de-sensitization practices give alternatives, and when children continue to use symptoms for control, parents should make the outcomes as dull as possible.
Some parents use their own extreme moods to signal their children to practice control. This rarely works for traumatized children, who get further out-of-control. Some children may dissociate when their parents get very angry with them, and will show worsening symptoms within a few hours or days. Parents who use the threat of expulsion from the family will only undermine their child's safety. The short-term improvement that parents see for a few days is at the expense of long-term progress. It is a signal to the child that the parents may not be strong enough to help their child. Parents who find themselves threatening their child in this manner should obtain professional support immediately.
Children removed from birthparents because of neglect and abuse often worry that they may parent like their birthparents. Using the concept of learning, parents can tell their children that they will learn parenting
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skills. That way, they will not lose custody of their children. Sometimes children will say to me," I wish that my birthmother had had a mother like mine. My mother could have taught her the right way." Or, "When my birthmother had trouble, my mother could have helped her, if she had been there." In figuring out the factual basis of events, children loosen the identification with the traumatic end to their birťhparenťs caregiving.
Maintaining Attachment after Trauma
But what if parents had their child in their home, and had an attachment, at the time of trauma? Parents have immediate steps that they can take to improve children's outcome. Immediately after an incident, physical closeness to their parents helps children to depend on their parents. Parents should provide for physical needs in a comfortable way that promotes dependence and prevents isolation. For the first few days after a traumatic incident, parents and children should be virtually inseparable.
A young teen, who had been molested at a sleepover, was interviewed by the police and sent home sometime around dawn. A few hours later, she told her mother to go on to work. Her mother started out, turned around, and came home. She later said, "She was in no condition to know how she was doing. I needed to be home." She was right. As she entered the house, she saw her daughter, sitting wide-eyed and in shock on the sofa, with the curtains drawn and the lights out. Proximity is essential in mamtaining attachment after trauma. Newly traumatized children need expressions of care and compassion that help them believe that they are not alone in their pain.
Unless children have empathy shown to them, they internalize the insensitivity that was shown to them or someone else during trauma (Pynoos, 1997). A new ending, with empathy, is put on the trauma story when parents hear their child's story, hold them close, and tell them how
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terribly sorry they are that it happened to their child. Often the parents and child cry together, which allows the child to internalize a sensitive, caring voice. It restores empathy for themselves, and allows them to feel empathy for others.
Children need to convey what happened to them. In working through the process of description, the first step is to find out what they wish had happened instead. For example "I wished that the tree would have fallen the other direction away from our home." Or, " I wish the car had not turned into us, but had stopped." Drawing the "wished for" event helps younger children to feel a little better. Children can also describe how they want things to go in the future. One child, working at the beginning of his trauma work said, "I would have a rule that no children could be separated from their mothers at the hospital. And only one doctor could feel the mass, not all of the student doctors." It gives children a sense of justice and control to talie, draw, and act out their wishes. Parents can encourage the statement of wishes.
Next, helping children to form a simple story line, with what happened first, second, and third, allows children to move from the beginning to the end of the event. This helps children not to get stuck in the middle of the event. They can describe where they were, where others were, and what they were thinking and feeling. This is work done best with pictures or role-play. It also helps to find out from children "the thing that they could have done without," in the words of Pynoos, an outstanding researcher in the area of children's trauma (1997). There is often some particularly painful detail that happens after a traumatic event.
One girl describes how her friend's notebook was tossed in the trash after emergency workers cleaned an accident scene. She felt that the notebook symbolized her friend; she was thrown in the trash.
Often children want to undo that symbol in some way. Finding out what reminders of the event are painful to children is another important task. Avoiding those reminders, and later having plans to de-sensitize, helps to bring down anxiety.
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Parents should get immediate professional help after a trauma. The opportunity to prevent posttraumatic stress disorder is best with prompt treatment. While the standard advice is to wait, the research does not support this at all. Immediate intervention for children is proactive.
A child who had been sexually abused by a female cousin came in for treatment because she was angry with her mother. At the end of two sessions, she looked fully into her mother's face and said, "The icky feeling is gone now. I have felt icky since it happened. It's gone!" Children are angry with parents when they have been hurt and their parents cannot help them with distressful feelings. Parents can help foster attachment by acting powerfully on behalf of their children by getting treatment.
Advice mentioned in earlier sections helps maintain attachment after a new trauma. Parents should maintain a slower pacing, increase comforting rituals, expect a regression in development, give more support for tasks that requiring concentration, show more protection, provide extra time for rest, and keep the home orderly.
Children need a sense of order and predictability in the home when things have become unpredictable. A quieter, uncluttered home and schedule help children to have the space and time to think things through.
Finally, children often feel powerless after a trauma. Give children choices and options after traumas, as long as they are not choosing re-enactments. Help them to see the many areas of their lives over which they still have control.
Preventing Toxic Reactions in Parents Dealing with Children's Trauma
Some parents are so attached to their children that they become deeply disturbed by the traumas their children are reporting. They begin to experience the horror of the incident, along with other symptoms of hyper-vigilance, lack of concentration, and intrusions into dreams and thoughts.
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While symptoms like this are normal for a few days as parents process what happened to their children, parents can develop the profile of a traumatized person themselves.
Parents can start to insist that the world revolves around their child's trauma. They want to focus friends and groups on events designed to right the injustice done to their child. While in itself this seems laudable, when this is a symbol of traumatic stress, nothing is ever good enough. The story of their child gets told over and over again. The efforts for change are subsumed in the need to tell of the overwhelming suffering. Such parents are clearly caught in the middle part of their child's story. They cannot permit themselves to move on to the present.
Parents in this position need to immediately back out of their child's trauma work. Interestingly, these are parents who are usually intrusive and somewhat harmful to the child's work. Parents having problems with toxic reactions bring up the child's trauma at home when the child is relaxed and happy. They may attempt to add to the scope of the child's story.
Parents who are very interested in the dramatic should be aware that they may become pathologically interested in their child's trauma issues. Other parents, who handle normal life changes with difficulty, may be overwhelmed by the child's trauma. In both of these situations, parents should be up front with the treating therapist. They will do best to sit out of the sessions. SmTOunding themselves with a positive, regulated, familiar, and healthy environment will help them to stay stable, which benefits their children.
Why Seek Help for Traumatized Children?
"Why do we have to talk about all that old stuff?" A parent posed an excellent question at a conference recently. He added, "Why open up a can of worms?" Before I could answer him, an experienced adoptive parent from a panel explained, "So the kids don't have to think about it all of the time. That's why we talk about it!"
Until children have worked through trauma, it keeps intruding upon everyday life. It is a silent shaper of eveiyday experiences. An example of this shaping of perception is in the example which follows:
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Cynthia was mad and snotty. It was the last week of school. She was finishing the first good school year of her life. The teacher liked her! Cynthia's mother called, confused and wanting to bring her daughter in to see me, because Cynthia was so difficult. As Cynthia and I talked, she mentioned that her mother had scheduled something so that she would miss the final two hours of school, the time children would just be saying, "Goodbye." Processing with Cynthia, I mentioned that this was, "Goodbye for now." She was going to see the teacher over the summer, and could stop into her classroom the next year.
"Yeah," Cynthia said, relaxing and looking cooperative for the first time. "It is not like my teacher is going swimming!" Cynthia's sister had drowned two years before, after Cynthia was moved to a foster home. Cynthia felt keenly that she had never had a chance to say "Goodbye" to her sister. She was superimposing some unfinished trauma and grief on a normal situation that had a related theme.
Professionals and parents work on trauma and loss so children can move on to think about other tilings, more typical of childhood.
Trauma therapy has three stages of treatment (Pynoos, 1997). In the first stage, the child is stabilized. Even though it feels like parents are going against the tide, they still work on attachment. Both parents and therapists are aware that until trauma is treated, attachment will be impeded. Children have extra security, comfort, and predictability in eveiyday life. Dependence on safe parents is encouraged.
The second stage is trauma-focused. In that stage two major tasks are undertaken: correcting distorted and destructive beliefs, and desensitiza-tion to trauma-related memories. Grief is a prominent theme in this stage.
In the last stage, children disconnect from trauma and grief and reconnect with the present (Pynoos, 1997). During this stage, major tasks are developing strategies to deal with trauma triggers and developing coping skills in life. Typically an additional increase in attachment occurs near the end of this stage. Children are less frightened and have much more energy to put into relationships, including ones with their parents.
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In the final stage, children show more independence, which is true independence based on trust.
The children who have not worked on trauma maintain trauma-contaminated core beliefs. These beliefs distort their developmental perspectives of themselves and others. Girls and boys who have been sexually abused regularly worry about whether their bodies were damaged, whether a foreign object remains inside of them, or whether others will feel compelled to similarly abuse them if the abuse is discovered. They believe that they are sexually irresistible, or that they should be treated like an older person because they have met the sexual needs of an older person. Commonly, they pair victimization and dominance with sexuality. They believe that something about them caused the abuse. Typically some disturbing beliefs are very specific, like, "He would not have abused me if I had not called him "stupid."' Global reassurances do little to dispel these specific beliefs.
In order to protect themselves from prosecution, abusers will sometimes say things like, "Your mother knows what I am doing. She does not care." Or they might say, "Your parents will be very angry with you if they find out." There is an interruption of the protection by the parent. Unless some specific work is done, children will believe what the abuser has told them. They then lose confidence in the protective function of adults in other areas of their lives. This occurs even after they change caregivers. Unless they can risk examining some of their beliefs, many of these beliefs remain fully operational and unexamined.
Without treatment, trauma's disturbing beliefs and images can gain momentum as the years pass, rather than recede. For example, researchers note a "sleeper effect" in damage from sexual abuse. As time goes on past the sexual abuse, children have more marked impairment with social relationships, show disruptive behavior, have concentration problems, and show poor frustration tolerance (Putnam, 1999). As the brain readies itself for quick response to a dangerous world, it loses its adaptability to function in a safe world.
Severely impacted children may need intermittent treatment for many years. They have a form of posttraumatic stress disorder that functions like a chronic illness, with flare-ups and better times (Marsh, Barkley, 1998). Other children maintain their gains, coming back in at particular developmental stages to consolidate gains and to get ready for the next
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developmental tasks. Typically, when children are about eleven, their brains begin to develop abstract tliinking, and children do well with a check-in. At thirteen or fourteen, before teens are entering romantic relationships, another check-in is good. Prior to leaving home, around seventeen, is another good check-in time. Many children become skillful at knowing when they should come in. They will tell their parents that it is time to make an appointment. This is typical of a successful working relationship with a therapist.
Researchers are showing decided improvements for children who receive therapy for trauma when compared to children who do not (Foa, Keane, Friedman, 2000). Because of the clarity and consistency of these studies, I recommend counseling for all traumatized children even if children do not remember trauma.
Chapter 6
The Impact of Cultural Change
How do parents communicate their love to children who are frightened of them and who cannot understand parents' soothing messages? How do children bridge the distance between the cultures of two families in open adoptions? How do parents and children ease the beginning stages of sharing their lives, becoming close families after coming from opposite sides of the world and speaking different languages? What steps should be planned to assist families in forging strong cultural identities when they come from culturally and racially dissimilar backgrounds? These good questions are addressed in this chapter on the impact of cultural change. Sensitive parents must assist the developmental progress of children not just through their transition into the family, but through their identity work as they enter the larger community. In open adoptions parents are assisting the identity work of then- children as they negotiate their ties to a different family system with different rules.
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