Principles of Clinical Work with Traumatized Children
Special Considerations for Parents, Caretakers, & Teachers by Bruce D. Perry, M.D., Ph.D.
DRAFT June 2, 1995 version 2.0
ChildTrauma Academy Programs
Department of Psychiatry and Behavioral Sciences
BAYLOR COLLEGE OF MEDICINE
One Baylor Plaza
Houston, Texas 7030
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Principles Of Clinical Work with Traumatized Children
1. DO NOT BE AFRAID TO TALK ABOUT THE TRAUMATIC EVENT
Children do not benefit from 'not thinking about it' or 'putting it out of their minds'. If a child senses that his/her caretakers are upset about the event, they will not bring it up. In the long run, this only makes the child's recovery more difficult. Don't bring it up on your own, but when the child brings it up, don't avoid discussion, listen to the child, answer questions, provide comfort and support. We often have no good verbal explanations, but listening and not avoiding or over-reacting to the subject and then comforting the child will have a critical and long-lasting positive effect.
2. PROVIDE A CONSISTENT, PREDICTABLE PATTERN FOR THE DAY
Make sure the child knows the pattern. When the day includes new or different activities, tell the child beforehand and explain why this day's pattern is different. Don't underestimate how important it is for children to know that their caretakers are 'in control'. It is frightening for traumatized children (who are sensitive to control) to sense that the people caring for them are, themselves, disorganized, confused and anxious. There is no expectation of perfection, however, when caretakers are overwhelmed, irritable or anxious; simply help the child understand why, and that these reactions are normal and will pass.
3. BE NURTURING, COMFORTING AND AFFECTIONATE, BUT BE SURE THAT THIS IS IN AN APPROPRIATE 'CONTEXT'
For children traumatized by physical or sexual abuse, intimacy is often associated with confusion, pain, fear and abandonment. Providing 'hugs', kisses and other physical comfort to younger children is very important. A good working principle for this is to provide this for the child when he/she seeks it. When the child walks over and touches, return in kind. The child will want to be held or rockedgo ahead. On the other hand, try not to interrupt the child's play or other free activities by grabbing them and holding them.
Do not tell or command them to 'give me a kiss' or 'give me a hug'. Abused children often take commands very seriously. It reinforces a very malignant association linking intimacy/physical comfort with power (which is inherent in a caretaking adult's command to 'hug me').
4. DISCUSS YOUR EXPECTATIONS FOR BEHAVIOR AND YOUR STYLE OF 'DISCIPLINE' WITH THE CHILD
Make sure that there are clear 'rules' and consequences for breaking the rules. Make sure that both you and the child understand beforehand the specific consequences for compliant and non-compliant behaviors. Be consistent when applying consequences. Use flexibility in consequences to illustrate reason and understanding.
Utilize positive reinforcement and rewards. Avoid physical discipline.
5. TALK WITH THE CHILD
Give them age appropriate information. The more the child knows about who, what, where, why and how the adult world works, the easier it is to 'make sense' of it. Unpredictability and the unknown are two things which will make a traumatized child more anxious, fearful, and therefore, more symptomatic. They will be more motorically active, impulsive, anxious, aggressive and have more sleep and mood problems. Without factual information, children (and adults) 'speculate' and fill in the empty spaces to make a complete story or explanation. In most cases, the child's fears and fantasies are much more frightening and disturbing that the truth. Tell the child the truth-- even when it is emotionally difficult. If you don't know the answer yourself, tell the child. Honesty and openness will help the child develop trust.
6. WATCH CLOSELY FOR SIGNS OF RE_ENACTMENT (e.g., in play, drawing, behaviors), AVOIDANCE (e.g., being withdrawn, daydreaming, avoiding other children) AND PHYSIOLOGICAL HYPER_REACTIVITY (e.g., anxiety, sleep problems, behavioral impulsivity)
All traumatized children exhibit some combination of these symptoms in the acute posttraumatic period. Many exhibit these symptoms for years after the traumatic event. When you see these symptoms, it is likely that the child has had some reminder of the event, either through thoughts or experiences. Try to comfort and be tolerant of the child's emotional and behavioral problems. These symptoms will wax and wane-sometimes for no apparent reason. The best thing you can do is to keep some record of the behaviors and emotions you observe (keep a diary) and try to obseNe patterns in the behavior.
7. PROTECT THE CHILD
Do not hesitate to cut short or stop activities which are upsetting or re-traumatizing for the child. If you obseNe increased symptoms in a child that occur in a certain situation or following exposure to certain movies, activities and so forth, avoid these activities. Try to restructure or limit activities that cause escalation of symptoms in the traumatized child.
8. GIVE THE CHILD 'CHOICES' AND SOME SENSE OF CONTROL
When a child, particularly a traumatized child, feels that they do not have control of a situation, they will predictably get more symptomatic. If a child is given some choice or some element of control in an activity or in an interaction with an adult, they will feel more safe, comfortable and will be able to feel, think and act in a more 'mature' fashion. When a child is having difficulty with compliance, frame the 'consequence' as a choice for them-- "You have a choice- you can choose to do what I have asked or you can choose thence, which you know is..." Again, this simple framing of the interaction with the child gives them some sense of control and can help defuse situations where the child feels out of control and therefore, anxious.
9. IF YOU HAVE QUESTIONS, ASK FOR HELP
These brief guidelines can only give you a broad framework for working with a traumatized child. Knowledge is power; the more informed you are, the more you understand the child, the better you can provide them with the support, nurturance and guidance they need.
The Threatened Child
When we are under threat, our minds and bodies will respond in an adaptive fashion, making changes in our state of arousal (mental state), our style of thinking (cognition) and in our body's physiology (e.g., increase heart rate, muscle tone, rate of respiration). To understand how we respond to threat it is important to appreciate that as we move along the arousal continuum -- from cairn to arousal to alarm, fear and terror -- different areas of our brain control and orchestrate our mental and physical functioning. The more threatened we become, the more 'primitive' (or regressed) our style of thinking and behaving becomes. When a traumatized child is in a state of alarm (because they are thinking about the trauma, for example) they will be less capable of concentrating, they will be more anxious and they will pay more attention to 'non- verbal' cues such as tone of voice, body posture and facial expressions. This has important implications for understanding the way the child is processing, learning and reacting in a given situation.
The key to understanding traumatized children is to remember that they will often, at baseline, be in a state of low-ievel fear -- responding by using either a hyperarousal or a dissociative adaptation -- and that their emotional, behavioral and cognitive functioning will reflect this (often regressed) state.