Child Trauma Handbook

A Guide for Helping Trauma-Exposed Children and Adolescents

Ricky Greenwald

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317390831
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychotherapie

Originally published in 2005, the Child Trauma Handbook is a user-friendly manual that teaches a comprehensive, research-based, phase-model approach to trauma-informed treatment for children and adolescents. Both new and experienced clinicians will find clear explanations and tips for making the connection between child/adolescent behaviors and traumatic histories; they'll also learn practical skills for successful interventions. Each chapter and skillset is theory based and includes transcripts, case studies, exercises, and specific strategies for addressing problems.

Chapter 1 Understanding Trauma

DOI: 10.4324/9781315678320-1

Why Trauma Matters

If you are working with kids, chances are that you are trying to help them do better in some way: get in less trouble, do better at school, feel less angry or sad, not hurt people. So why not just focus on the problem? Why should we care about trauma?

Following is a partial listing of the kinds of problems kids might have that are potentially trauma related:

• Disruptive behaviors
• Poor frustration tolerance
• Depression
• Anxiety
• Poor concentration
• Loss of interest in activities/goals
• “Don’t care” attitude
• Anger
• Fighting
• School absences
• Substance abuse
• Criminal behaviors
• Noncompliance with medical treatment
• Suicidal behaviors

This is not to suggest that trauma is the only reason kids have problems. But trauma can find the child’s weak spot. Trauma is a powerful stressor that can either cause new problems or make existing problems worse. If we try to help kids but don’t take trauma into account, we risk ignoring a driving force behind the problems. We risk being less effective.

A Useful Definition of Trauma

Trauma was previously defined as a horrific event “beyond the scope of normal human experience” (American Psychiatric Association, 1980). To qualify as traumatic, an event should be subjectively perceived as threatening to a person’s life or physical integrity, and should include a sense of helplessness along with fear, horror, or disgust. Such events might include being in a car accident, house fire, or natural disaster; being raped; or being assaulted. Through research we have learned to identify a wider range of events as being possibly traumatic—for example, witnessing a parent or sibling being beaten; being diagnosed with a life-threatening illness.

The bad news is that traumatic events are not beyond the scope of normal human experience. Although not every child will be exposed to one or more traumatic events, most will. This is not just true for kids growing up in high-crime urban areas. Even our (presumably) best-protected kids experience trauma. For example, a study of second-year college students (modal age of nineteen) found that 84 percent had experienced at least one major trauma (Vrana & Lauterbach, 1994). Among disadvantaged urban populations, very few escape exposure to major trauma events (see Greenwald, 2002b). Trauma during childhood and adolescence is now so common as to be normative. When working with a child or adolescent with any kind of problem, we can’t afford to assume that trauma is not a factor.

Although the focus here is on trauma, it is important to note that other adverse life events can have a traumalike impact on kids. For example, a child’s response to a significant loss can be virtually identical to a posttraumatic response, except that following loss, hyperarousal may not be present (Pynoos, 1990). Indeed, the research on adjustment disorder shows that many children do not adjust to or recover from a range of adverse events (Newcorn & Strain, 1992) but maintain some symptoms indefinitely.

When working with a distressed child, we do not ask if the event qualifies as a trauma before offering help. We will offer essentially the same treatment regardless of whether the source of the distress is an earthquake, a sexual assault, or a death in the family. In this book, the term trauma is intended to apply to major trauma as well as loss and other adverse life events, as long as the event has had a traumalike impact on the child.

What Makes an Event Traumatic?

Not every upsetting event is so intense and overwhelming that it is experienced as traumatic. The biggest factor pushing an event into the traumatic range is, not surprisingly, how bad it is. Several factors determine the severity of the exposure to trauma:

• The nature of the event itself
• Direct experience versus witnessing versus hearing about it or seeing it on TV
• Personal impact versus impact on a known person versus impact on a stranger
• After-event impact (e.g., lifestyle disruption)

Severity of the Event

Some events are clearly worse than others. For example, an open-hand spanking is not as bad as being whipped with a belt, which is not as bad as being beaten to the point of broken bones. In most cases, once the event has been described, its severity is readily apparent. However, children with special vulnerabilities may experience certain insults especially severely. For example, being punched in the arm will hurt a child who has hemophilia more than it will hurt a child who does not have this condition. Also, how the event is perceived contributes to its severity. For example, a child who does not understand the danger she was in may not experience a nearly fatal near-miss event as traumatic.

Proximity of the Experience

The more directly the child is involved in the event, the higher the risk of posttraumatic stress symptoms. For example, in a school shooting, children witnessing the event had the most severe symptoms, followed by children nearby who heard the shots but did not see the event, followed by children farther away who neither saw nor heard (Pynoos et al., 1987). However, even distant exposure can have impact, especially when children can personally relate or feel directly affected in some way. For example, younger children who saw the World Trade Center towers collapse on television, and who saw this multiple times, were exposed repeatedly to this event because they did not understand that it was only the same event being replayed. They thought that many buildings had been hit and were coming down, and they felt more vulnerable.

Personal Impact

Something that happens to the child or to someone he cares about is likely to have a greater impact than something that happens to a stranger. Children take it very personally when a parent or sibling is victimized or hurt. On the other hand, it is important not to underestimate the impact that an apparently distant event can have on a child.

• A ten-year-old boy’s classmate drowned during a school outing. He did not even like the drowned girl, but felt guilty that he had not been friendlier toward her and irrationally blamed himself for her death.
• A five-year-old boy looked out the window and saw a neighborhood man getting beaten up. After that he was afraid to go outside; he feared someone might beat him up too.
• A nine-year-old girl’s best friend’s father died of cancer. She became obsessed with the fear that her own parents might have cancer.

After-Event Impact

This is a critical element of severity of exposure that is often overlooked. Imagine that two identical bombs are dropped. One explodes and makes a crater in the ground. The other explodes somewhere else and also makes a similar crater in the ground, but then some nearby buildings collapse into the second crater. Although both bombs had the same strength, the second bomb has had more impact and thus can be considered more severe. Life experiences can be like this too. A traumatic event is more than just the single terrible moment.

• A fourteen-year-old girl was in a car accident. After the crash, she did not know for a few minutes whether her aunt (the driver) was dead or alive. In the hospital, she had to wait by herself in a small room for almost an hour. The attendants cut off and discarded the bloody jacket she had been wearing in order to tend to her wounds; her boyfriend had given her this jacket and she treasured it. She was left with a scar on her lower arm and felt that she could no longer wear short-sleeved shirts or bathing suits.
• A four-year-old boy’s father died in a work-related accident. His mother became depressed and withdrawn. Spring came around and the boy’s father was not there to teach him how to catch a baseball. He’d already received a baseball glove for Christmas. Father’s Day came. His birthday. His first day of school. (This could go on indefinitely, as major losses can have fresh impact at every developmental milestone.)
• An eleven-year-old girl lost an uncle in the World Trade Center disaster. Even a month later, her parents were upset all the time and couldn’t seem to talk about anything else. Also, her school wasn’t any good anymore; everyone there was angry now because hundreds of kids from some other school were all crammed in there too, until they could go back to their own school again.

In other words, it’s not just the event itself but the circumstances surrounding and following the event that may make it traumatic rather than merely upsetting. Personality, social support, and other factors (discussed later in this chapter) also help to determine whether a child can handle an event or will be overwhelmed.

The “Trauma Wall”

A popular saying is that “What doesn’t kill you makes you stronger,” or, less colloquially, that we grow from adversity. Although this certainly can be true, it is not always the case. Sometimes what doesn’t kill you may still hurt you or cause damage. So how does this work—why does it go one way rather than the other?

Here a food analogy is helpful. Usually, we chew food, swallow it, and digest it. It becomes part of our nutrition, something we can grow from. Ideally, we do something similar with an upsetting experience. Kübler-Ross (1969) described a similar process in the stages of processing grief.

For example, let’s say your dog dies. Maybe you don’t think about it or process it every minute of the day, but now and then you do think about it, remember different aspects: how frisky she was when you first got her, how she liked to have her belly scratched, how badly you feel about having let her out the day she got hit by a car. You remember, you talk to others, you take a walk, you write, you cry, you laugh. Little by little—or bite by bite—the hurt becomes smaller as more gets processed, integrated, “digested.” When an upsetting experience is digested, it becomes your nutrition, something you grow from. Then it becomes part of long-term memory, part of the past. It is not as fresh or upsetting anymore. Along with the emotional processing, we have organized the elements of the experience into a coherent story, including a perspective that allows us to move on. For example, you might say to yourself, “Well, she loved to play outside. I guess there was always the risk of an accident, but she would have been miserable tied up,” and “She was a great dog. I’ll always love her.”

However, sometimes upsetting experiences do not get processed in this ideal way. Sometimes it’s just too much to face, to take bites out of. Maybe the event was too upsetting and overwhelming; maybe you try to talk about it and are punished for that (perhaps by parents getting upset or peers teasing); maybe just when you are ready to take a bite out of this upsetting memory, another one comes along. It can be so difficult to face this upsetting memory, to tolerate it, that many people try to push it aside, push it behind a wall. That brings quick relief, so the strategy is experienced as helpful. Unfortunately, it provides only a temporary solution.

Back to the food metaphor: Imagine that you have eaten some food that is bad for you or poisonous. Ideally you will be able to get rid of it somehow. Maybe you’ll be shaky or sick for a little while, but it’ll be gone from your system. Unfortunately, with an upsetting experience, you can’t just reject it and flush it down the toilet. The only way out is to go through—through the memory processing system into long-term memory. Until the memory is processed, or digested, it stays behind the wall.

Although the wall may provide some relief, this system has problems. First, the memory stays fresh and keeps its power indefinitely, until it is digested. I have worked with people months, years, and even decades after the trauma, and the quality of the undigested memory is the same. When asked to concentrate on the memory, they say things like, “It’s so vivid it’s like it just happened yesterday,” or, even more telling, “I’m there.”

Also, although the memory retains its freshness and power, it is still behind the wall, so we can’t get at it with the rest of our psychological resources the way we can with processed memories. This means that the memory, or parts of the memory, can negatively influence us and we may feel helpless to stop it. For example, many rape victims will say, “I know in my head that it wasn’t my fault, that I didn’t do anything wrong, that I didn’t deserve that. But I can’t help feeling ashamed, dirty, to blame.” In other words, the healthy part that knows better can’t manage to influence the powerful beliefs and feelings that are shielded behind the wall.

Furthermore, the memories stored behind the wall are not content to stay there. They are always waiting for a chance to come out, go through the system to be digested, and become part of the past. It is as if the memory is seeing its chance and saying, “Me too! Can I finally be treated like a normal memory and get processed already?” When this happens, we say that the memory was “triggered” or activated by a reminder, something thematically related. Another way of explaining this is that the stuff piled up behind the wall is like a “sore spot,” and when some kind of reminder hits that sore spot, the reaction is stronger than others might expect. This is because the person is not just reacting to what’s happening right now; the old stuff is kicking in, too.

• Most of us who drive are at least a little nervous about driving. This is reasonable and inspires us to put on our seat belts and watch out for bad drivers. However, we are still able to enjoy conversations with our passengers, listen to the radio, and think about where we are going. Now think about the woman who experienced a car accident because she couldn’t stop on a snowy road. Afterward, whenever she got into the driver’s seat, she had the usual amount of nervousness, plus all the extra fear from behind the wall. You’ve probably seen people like her on the road, clutching the wheel and gritting their tee...