Working with Grieving and Traumatized Children and Adolescents

Discovering What Matters Most Through Evidence-Based, Sensory Interventions

William Steele, Caelan Kuban

• Publisher: Wiley
• Year: 2013
• ISBN:
  9781118645079
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

A structured, sequential, and evidence-based approach for the treatment of children and adolescents experiencing trauma or grief

Working With Grieving and Traumatized Children and Adolescents features the Structured Sensory Interventions for Traumatized Children, Adolescents and Parents (SITCAP) intervention model, proven in successfully addressing violent situations such as murder, domestic violence, and physical abuse, as well as non-violent grief- and trauma-inducing situations including divorce, critical injuries, car fatalities, terminal illness, and environmental disasters.

Filled with practical and proven activities for use with children and adolescents experiencing trauma and grief, this resource is based on the authors' experience working with all types of traumatic events in school-, agency-, and community-based programs across the country.

Chapter One

How Structured, Sensory Interventions Help Grieving and Traumatized Children

This first chapter begins with a brief history of what we learned at the National Institute for Trauma and Loss in Children (TLC) while working with grieving and traumatized children who had been exposed to a variety of violent and nonviolent experiences. Established in 1990, TLC is a program of the Starr Global Learning Network of Starr Commonwealth, which has been helping children and adolescents flourish for the past 100 years. The children taught us what mattered most in their efforts to overcome their painful and overwhelming experiences, which lead to the development of the evidence-based Structured Sensory Interventions for Children, Adolescents and Parents (SITCAP) programs presented in detail in this text. The SITCAP model meets the criteria validating it as a practice-based and an evidence-based intervention model. This criteria and how it is supported by SITCAP is reviewed, as funding sources are more frequently requesting that today’s interventions meet these requirements.

In addition, a distinction is made between nonviolent and violent situations to illustrate that the subjective experiences of children, not the nature of the situation, determine whether the experiences are grief or trauma inducing. This is followed by a very simple yet profound mandate by children and a brief discussion regarding its implications for treatment. This introduction becomes essential to understanding the Core Principle and Key Concepts of SITCAP presented in subsequent chapters. These concepts describe how children’s subjective experiences are revealed and utilized to help diminish the painful, overwhelming, and terrifying reactions they can experience. Similar to Lenore Terr’s (2008) descriptions of magical moments in psychotherapy, we also introduce Magical Moments, those turning points in children’s lives that practitioners using SITCAP shared with us over the years. Magical Moments are featured in each chapter, in addition to Points of Interest, which briefly discuss a variety of subjects pertinent to helping grieving and traumatized children and adolescents. The chapter concludes with a review of two cases and their evidence-based outcomes, supporting the overall benefits experienced by those who have participated in SITCAP over the years.

Was It Grief or Trauma: What Matters Most?

Examining our experiences in the 1970s and 1980s with children, teens, and families who sought help while in crisis—or created a crisis to draw attention to their need for help—revealed what mattered most in our efforts to help. Grief was a common response to their crisis experiences resulting from the losses precipitating their crises—loss involving a loved one to sudden or accidental death, suicide, homicide, domestic violence, sexual and physical abuse, or terminal illness, or loss due to divorce, betrayal of trust in relationships, abandonment, homelessness, or exposure to catastrophic events. In the early 1980s, suicide became an epidemic claiming the lives of youth. At the core of the suicide experience is the loss of value for oneself, the loss of connectedness to any significant person, and the loss created for the family members and friends who are left behind. In the later 1980s, suicide rates remained high; however, violence claimed this unfortunate title of epidemic, reflecting the disturbing ways our children were now experiencing their worlds.

With these losses, we were observing reactions not only associated with grief but also with the posttraumatic stress disorder (PTSD) described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) (APA, 1980). Unfortunately, these criteria, as defined by the DSM-III-R, were specific to adults. The challenge we faced was helping others acknowledge that children could, in fact, experience the reactions attributed to adults at the time. This would not occur until the mid-1990s. Practitioners in the 1980s, for example, observed adult PTSD criteria in adolescent survivors of suicide as well as those who discovered the bodies of those who took their own lives. However, it wasn’t until 1993 and subsequent years that the literature began to acknowledge that discovering the body of a loved one, friend, or peer who had taken their life was traumatic (Brent et al., 1993). The term trauma was not formally assigned to children by the American Psychological Association until 1994, when they were included in the adult-designed PTSD diagnostic category in the DSM-IV (APA, 1994). This inclusion was certainly encouraged by the research that emerged in the 1980s regarding the association of PTSD with suicide and violence among children and adolescents (Pynoos & Eth, 1986; Pynoos et al., 1987).

Despite the various situations that brought children and families to our attention, so many victims showed us that grief and trauma were not necessarily separate entities; they often coexisted. Symptoms could be attributed to both grief and trauma, as we understood them at that time, but also to other disorders, making it difficult to assign treatment based on symptoms alone. What we discovered really mattered the most to those who were grieving and traumatized was not their symptoms, but how they experienced themselves, others, and life following exposure to traumatic events in their lives. TLC was founded in 1990 to develop an intervention process that would be helpful to both grieving and traumatized children and that could be initiated in clinical and community settings and also in schools, where children are the most accessible.

It Is Not the Situation

An Internet search for trauma-informed care yields more than 7 million references. It is safe to say that a great deal of information exists about the prevalence of trauma experienced by children and what constitutes trauma-informed care. The majority of articles regarding trauma consistently cite violence as the primary cause of trauma. There is no doubt that violence does induce severe trauma in children. Most would agree that at least 50% of the children in child welfare and 60% to 70% of youth in the juvenile justice system experience trauma (Hodas, 2006; Kerig & Becker, 2010). However, research began to emerge as early as the 1990s indicating that trauma can also be induced by disasters such as fires (McFarlane, Policansky, & Irwin, 1987), hurricanes (Lonigan, Shannon, Finch, Daugherty, & Taylor, 1991), boating accidents (Yule, 1992), burns, and medical procedures such as bone marrow transplants (Stubner, Nader, Yasuda, Pynoos, & Cohen, 1991). Three million people yearly are involved in car accidents; up to 45% of those injured suffer PTSD (Goodin & Abernathy, 2011). In fact, divorce can also induce trauma when the conditions of that experience leave children vulnerable (Divorce and PTSD, 2012).

We have two reasons for making this distinction between violent and nonviolent situations, which are not the result of direct intent to do harm. First, in comparison to the volumes written about the relationship between violence and trauma, we rarely read about the daily nonviolent trauma-inducing situations in children, such as homelessness. Often, trauma is not screened for in children who are exposed to situations such as a depressed parent, house fires, car fatalities, critical injuries, terminal illnesses, divorce, or victims of bullying and cyber bullying. Second, we must conclude that if both violent and nonviolent situations can induce trauma, then perhaps it is not the situation that induces trauma but how that situation is being experienced that leaves children and youth vulnerable to trauma. If this is true, then it follows that we must first know how children are experiencing what they are exposed to if we want to determine what might be the most helpful and appropriate trauma-informed response.

Children’s Mandate

If you don’t think what I think, feel what I feel, experience what I experience, and see what I see when I look at myself, others, and the world around me, how can you possibly know what is best for me?

This is a simple yet profoundly wise mandate. When we can appreciate how traumatized children are experiencing themselves, others, and their lives as a result of their experiences, we can assign timely, useful, and appropriate interventions. Resilience research, for example, clearly documents that not everyone exposed to what we might consider to be a trauma-inducing incident is necessarily traumatized by that incident (Bonanno et al., 2002). Assigning an appropriate intervention dictates that we first determine how children are experiencing what they are exposed to if we are to provide an intervention that is not itself traumatizing. In fact, the primary dictate of trauma-informed care is to avoid re-traumatizing, “to do no harm” (Hodas, 2006), by not making assumptions that children must be traumatized by what they have been exposed to or, if traumatized, that all children need the same intervention (Steele & Raider, 2001).

In essence, a situation such as divorce may not be violent or traumatizing for many children. However, even in a nonviolent divorce—one void of physical abuse and threats of bodily harm—if the child’s experience of that divorce involves terror, worry, guilt, feeling powerless, and other subjective experiences associated with trauma, then that divorce may become traumatic. This is why interventions must match how children are experiencing their life events.

Implications for Treatment

The child-driven mandate presented earlier dictates that to be helpful we need to relate to grieving and traumatized children at a sensory level rather than primarily at a cognitive level. What does this mean? Today neuroscience has confirmed that trauma is experienced in the midbrain, the limbic region, sometimes referred to as the “feeling” brain or the “survival” brain, where there is no reason, logic, or language. Reason, logic, and the use of language, to make sense of what has happened, are upper brain cognitive functions that become difficult to access in trauma (Brendtro, Mitchell, & McCall, 2009; Levine & Kline, 2008; Perry, 2009; Schore, 2001; van der Kolk, McFarlane, & Weisaeth, 1996). Neuroscience also shows that “learning anything requires building new neural networks [by] being actively involved in what is being learned” (Fischer, 2012).

For these reasons, we must direct our efforts at helping children with how they are experiencing their worlds, with what they now see when they look at themselves and others as a result of their exposure to trauma. We must engage them in nonverbal, sensory-based experiences that allow them to rework their traumatic memories and their trauma-related sensations, images, and feelings in ways that also allow them to see themselves and their experience as survivors and thrivers, not victims. We must help them to see and experience others as helpful and supportive rather than threatening and unsafe, and to see and experience life as promising rather than continually painful. This goal is difficult to accomplish using cognitive-based interventions alone. If, for example, I experienced something terrifying months earlier and I am now physically safe, but elements in my environment are reminding me of that terrifying experience (my midbrain is being activated by the associated memories), then all of the verbal reassurance in the world will not calm me. I must do something that brings about a sense of safety and calms (deactivates) my midbrain responses to those past memories. Numerous examples and sensory-based activities that restore this sense of safety are presented throughout the book.

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A Magical Moment

My magical moment in using SITCAP is about a 7-year-old boy. He had lovely eyes with an eagerness and innocence that shone through. Much of his little life had been filled with turbulence and trauma. He had witnessed violence in his home and had experienced neglect and emotional abuse. In our work together, we had been using many interventions from SITCAP programs. In one session, Shawn (not his real name) was telling me how he would hear his mom and dad fight a lot. I asked if he could show me how that felt in his body when he thought about it now. He drew a picture of a person with a breaking heart and said he felt sad, scared, and worried. We talked about the meaning of each feeling for him and how he experienced it in his body. Then, spontaneously, he drew an image of a worry thermometer. He exclaimed that this thermometer goes from 0 to 100, and that his worries were so big that it was more than 100 degrees, and that the thermometer broke. “That’s how much I worry!” he said.

Shawn then asked me to make a string of paper dolls. He took the paper dolls, and he drew happy faces on all seven of them and asked me to draw hearts on their bodies. He called these dolls the “worry breakers.” He paid special attention to the doll on the far right, calling it “a soldier.” He said that this soldier is the leader, and the rest of the dolls follow to help fight and break worries. As he spoke about the power of these dolls, his eyes widened and his back straightened. I could feel his own power growing as he spoke with confidence about how he might use these dolls in his life when he starts to feel worried. We then noticed the paper that was left over from cutting out the paper dolls looked like a crown. Shawn invited me to assist with drawing hearts and stars on the crown. We then stapled the ends together and, putting it on his head, he reported, “This crown helps with sad feelings!”

We talked about how he and his mom could use his powerful new resources. We walked aro...