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Title: RESPONSE TO TRAUMA: KIDS IN CRISIS DEENA MCMAHON 6512100335 dmcmahonmcmahonccs.net


1
RESPONSE TO TRAUMAKIDS IN CRISISDEENA
MCMAHON651-210-0335dmcmahon_at_mcmahonccs.net
  • FLORIDA 2009

2
AN ORDEAL
  • Trauma knocks the child down
  • Breaks down their defenses
  • Leaves the child helpless
  • Comes from outside the child

3
HELPLESSNESS
  • When a child feels helpless too long, they become
    despairing
  • Desperation often turns into extreme behaviors
  • Desperation often turns into depression
  • Desperation often turns into violence
  • It implies total loss of control

4
HEALING
  • Healing is all about mastery and control which is
    the opposite of helplessness and despair.
  • THIS IS A PARALLEL PROCESS FOR US

5
FIGHT/FLIGHT RESPONSE
  • The flight/fight response becomes over developed
    at the expense of the other areas of the brain.
    Children become socialized to hurt and kill, they
    anticipate the worst so they respond to this
    inner fear, and are reactive, treating the adult
    as if the adult were thinking of hurting the
    child
  • Executive functions decrease

6
FLOODED - PTSD
  • It all rushes back
  • The gates are open and the feelings pour in
  • The child is overwhelmed and seems to be over
    reacting to some small thing
  • Their reaction is way out of proportion to the
    event in front of them
  • They cant regulate

7
FLIGHT
  • Numb
  • Flat affect, I dont care
  • It does not matter
  • Disengagement
  • Dissociative behaviors
  • Dont touch me
  • Non responsive this could look like ADD

8
FIGHT
  • This is usually called oppositional,
    disrespectful behavior
  • The child will argue and fight and oppose those
    who ask for compliance
  • They think they are fighting for survival, not
    for or about respect and compliance
  • A child in a tantrum is often in a state of
    terror
  • Looks like ODD but it is PTSD

9
ON GUARD
  • The child anticipates hurt and trauma (triggers)
  • They respond to this inner fear (reactive)
  • They are limited in their choices(problem
    solving)
  • They are charming, defensive or withdrawn

10
CHRONIC STRESS
  • Chronic stress prevents the brain from returning
    to a relaxed state
  • Trauma activates the stress-response in the brain
  • Children will normalize this activated state
  • They will become intolerant of peace and quiet
  • ADHD/PTSD

11
INTERVENTION
  • Take relaxation in small doses
  • Give the parents very realistic expectations
  • This is where sensory stimulation, or lack of,
    makes a huge difference
  • Pay attention to the home environment of the
    child, does it promote quiet time
  • Practice and time the child when they begin to
    learn about peace
  • Use the concept of voice in their head

12
WHY THIS HAPPENS
  • The more threatened the child the more
    primitive (regressive) their style of thinking
    and behaving
  • When they are triggered (when they are thinking
    about the trauma) they are less capable of
    concentrating, more anxious and pay more
    attention to non verbal cues, face, tone, body

13
WHAT MAKES IT TRAUMA?
  • When the adult cant /wont be there
  • If the toxic state is prolonged, trauma is
    multiplied
  • When it is the adult who causes the harm

14
THE WORST OF THE WORST
  • Caregiver induced trauma is the most traumatic
    possibility for the child
  • The relationship the child had with the person
    who hurt them will be a factor
  • Who failed to protect them will be a question
  • They believe that normal families do not have
    this happen (shame)
  • They believe that good kids dont have this
    experience (guilt)

15
AGE MATTERS
  • The younger the child the worse it is
  • The more often it happens, the worse
  • The more moves, the worse
  • The closer the child was to the perpetrator, the
    worse it is

16
CHANGES IN THE BRAIN
  • They stay focused in the lower part of their
    brain and in a constant fear state
  • They pay attention to non-verbal cues much more
    than verbal messages
  • Teachers rely on students being good listeners
  • Hypervigilence takes a long time to extinguish
  • Short term memory is impaired

17
INTERVENTION
  • Keep interventions about connection, not talk
  • Conversations will not be remembered
  • The adult must be aware of the expression on
    their face and the tone of their voice
  • Place people where you want them to be,
    (structural family therapy strategies)
  • They do not need to look at us to be focused

18
THE RIGHT BRAIN
  • An event is remembered by the body and central
    nervous system as an implicit memory (van der
    Kolk, et. al 1996).
  • The experience is stored implicitly through
    images, sensation, affective and behavioral
    states.
  • Children respond to what they SENSE!!!

19
THE BRAIN SHIFTS
  • If the early environment is abusive, the brain
    creates memories of these experiences, they shape
    the child's world view (internal working model)
  • Neuronal pathways develop under negative
    conditions
  • The child learns to cope in a negative environment

20
ADAPTATIONS
  • The brain adapts to an unpredictable and
    dangerous world.
  • The child does not know how to deal with nurture
    and kindness, intimacy, trust

21
INTERVENTION
  • Child may learn to cope with discomfort
  • Child does not always get to be in control of
    receiving affection
  • Disregulated and fearful children need touch
  • Parents teach the child that touch is safe and
    pleasant
  • Small doses are good, especially when the child
    is doing trauma work

22
REPETITIVE BEHAVIORS
  • The child has a sensation and they redo it, play
    or act it out over and over to make sense of it
  • Acting it out is an attempt to make cognitive
    sense of the experience
  • As they can think about how they feel, it moves
    the process up the brain stem into a region of
    the brain they have more control over

23
HOW TO INTERVENE
  • Sometimes, re-enacting is exactly what the child
    needs to do
  • Must learn when to do it
  • How to do it safely
  • How to set some limits around it and have some
    control over it
  • This is about mastery and control!!!

24
HORMONAL CHANGES
  • The brain starts major hormonal changes in
    puberty
  • Some of these changes can begin early in children
    who are sexually abused
  • Hormones help the brain deal with danger and
    stress so the brain talks to the body and has it
    respond in a certain way.
  • A return to normal behavior is hard even when
    the danger is past.

25
PUBERTY
  • Puberty is disorganizing for any child
  • This is when trauma kids can look crazy
  • Feelings make a person feel in danger
  • Trauma kids do not know how to hire mentors that
    are good for them, so they get retraumatized

26
ADOLESCENTS
  • When trauma kids become adolescents their
    cognitive skills are in a retarded state.
  • The state of arousal becomes a personality trait
    (when states becomes traits!)
  • The ability to dissociate does not work well any
    more as they can no longer pretend their trauma
    was not so bad.

27
LEARNING IS IMPAIRED
  • Children who experience trauma often spend so
    much time in the limbic region of their brain
    (the fear/survival part) that they consistently
    overlook or ignore verbal communication and over
    focus on non-verbal.
  • Stress induces the release of glucocorticoids,
    such as cortisol, that can damage the left
    hippocampal area of the brain and cause memory
    deficit.

28
THE AROUSED CHILD
  • The child may be frozen in a highly activated
    state
  • The left-brain becomes less able to remember
    (hippocampus) which impairs cognition
  • The child has trouble following directions,
    remembering was what said, focusing, retaining
    and comprehending verbal information
  • Poor problem solving abilities

29
AUDITORY DISTORTIONS
  • Perception problem, trouble taking in information
    by hearing it
  • Discrimination problem, hears a critical or angry
    tone instead of a joking or serious tone
  • Differentiation problems, cant hear one sound
    over another, if one person is talking, they
    cant hear anything else, if the TV is on, they
    cant hear someone talking, the phone ring

30
INTERVENTION
  • The adult MUST set the tone
  • The adult must be very Body Aware
  • The adult must stay regulated
  • Tone of voice is critical
  • The child will be hyper critical of the adult
  • The adult may fall into despair and feel hopeless
    that they will ever be helpful-need tons of
    encouragement

31
PRACTICE LISTENING
  • Did you hear that?
  • What do you hear?
  • What did I just say?
  • What do you think that means?
  • Can you say that back to me

32
TROUBLE WITH TOUCH
  • Tactile defensiveness does not like touch,
    finds it uncomfortable and avoids
  • Likes hard, almost hurtful touch hurts others
    without meaning to
  • Touches all the time, with no limits
  • Has trouble interpreting what touch means

33
PRACTICE TOUCHING
  • Draw a body on big paper
  • Tell stories about children who are afraid or who
    touch too much
  • Use third person examples
  • Give examples throughout the day
  • Emphasize what they do well and use what they are
    good at

34
YOU WILL GET MORE CALLS
  • They will visit the nurse more often
  • They will say they do not feel well often
  • They will have many complaints
  • They will have compromised immune systems
  • Their grades will decline
  • They may become truant

35
PRACTICE BOUNDARIES
  • Discuss with the child who will know
  • Prepare them for the next school day and how to
    answer questions
  • What to tell other kids, the teacher,
  • Allow them to call you anytime, if needed
  • Give them a plan if the day or night seems too
    hard to manage

36
PREPARE AND PRACTICE
  • Changes in schools are painful and VERY anxiety
    producing
  • Prepare and discuss the school
  • Let them visit
  • Let them stay home
  • Help them find a buddy
  • Give them a plan to cope

37
HOMEWORK AND SCHOOL
  • Keep in mind this may be a place of skill and
    comfort or a place of shame and distress
  • Kids may find it a soothing part of a normal day
    or a highly unmanageable part of their day during
    which they are constantly reminded of how much of
    a freak they are
  • They may not be able to learn by sitting still
    and listening

38
NO HOMEWORK IEP
  • Relieve the parents
  • Collaborate with the teachers
  • Figure out what real learning is going on

39
BE TRAUMA INFORMED
  • As responders to children in crisis, we need to
    get it right.
  • Well-meaning is not enough
  • Bad help can be worse than no help at all
  • Positive, early interventions are a predictive
    factor for coping long term
  • If you dont know, ask

40
HONOR THE SYMPTOMS
  • Response to trauma must be seen as an effort to
    adapt and survie or escape
  • Symptoms such as defiance, control, manipulation,
    lies, false charm, rage dissociation need to be
    admired before they can be changed.

41
USE REFRAME
  • Wow, you sure know how to have big emotions
  • I like the way you can let your feelings out
  • I think you are beginning to know that you can
    trust me with your feelings
  • I like that you were not pretending to be ok with
    how you felt
  • That felt very real, it takes courage to be honest

42
IMPACT OF TRAUMA ON RELATIONSHIP DYNAMICS
  • Betrayal
  • Powerlessness and helplessness
  • Blame and guilt
  • Trust and responsibility

43
FEAR AND SHAME
  • Children may not be able to admit what they saw
    or may not talk about it as they are ashamed
  • They feel like a freak or weirdo
  • Let them know other children feel the same way
  • Normalize or generalize if possible

44
SELF BLAME
  • I think I am crazy
  • I will do the same thing some day
  • I must be icky, my family did icky things

45
IN GENERAL
  • Negative self attribution, I deserved it, it was
    my fault
  • Loss of protective caretaker, they let it happen
  • Loss of protection of others, no one kept ME safe
  • Loss of trust in helpers, no one cared
  • Expectations of future, it will happen again

46
WHOSE FAULT IS IT?
  • Attribution of guilt is essential
  • The child needs to know they were not in control
    of the event, even if they were involved
  • They need to know they could not have stopped it
  • They will internalize some guilt
  • They will be ashamed by the event

47
PERCEPTION IS EVERYTHING
  • Trauma becomes a part of the child
  • The perception of the trauma is much more
    important than the facts
  • The adult response is a critical feature

48
TAKE CARE OF MOM/DAD
  • As stories emerge, the parent is horrified
  • The horror stays with them for a long time
  • They need to express some of this to the child
  • They need to express this to you
  • They need to know who they can tell

49
SOME SHIFTS IN THINKING
  • I am here to help VS How can I help?
  • Looks like you might need help VS, You need to
    get that done, we talked about it already, why
    didnt you ask?
  • You seem sad/scared VS what it the matter?
  • My job is to take care of you and keep you safe
    VS that is the rule in our house.

50
JUST ASK IF YOU NEED SOMETHING?
  • These children are afraid to ask
  • They do not know how to ask
  • It is not safe to ask
  • They cant explain what they need
  • They do not have the language or words
  • If they knew what they needed, your job would be
    easy

51
SEND THE RIGHT MESSAGE
  • I can be bigger than your pain
  • I am stronger that your rage
  • I can withstand your chaos
  • I can help you find meaning
  • I can take care of you

52
ANTICIPATE AND GIVE FREELY
  • Know what hurt kids need
  • Give them the words and the feelings
  • Hug them when you feel the urge, and dont wait
    to be invited
  • Express your feelings about them and their hurt
    and horror
  • Dont be afraid to get it wrong or look stupid

53
GET INFORMATION
  • Know as much as possible about what happened
  • Let the child know that you know
  • Let them know what to expect
  • Let them know you can call people and find out
    more
  • Find out if there is something they want to ask
    and who you can ask

54
PREDICT, EXPLAIN AND REPEAT
  • Let the child know the process
  • Explain your job
  • Tell them the truth about what happened
  • Let them know what is likely to happen next
  • If they will be moving soon, tell them this.
  • Explain what foster care is

55
INTERVENTIONS MUST BE COLLABORATIVE
  • Know what you can tell the childs school
  • Know what relatives the child can receive calls
    from or whom they can contact
  • Know how much you are able to disclose
  • Have the case managers emergency number
  • Have a mental health provider emergency number
  • Know what to tell other children in their home

56
MASTERY AND CONTROL
  • Interventions are about helping the child to have
    some control over the experience
  • It is shared work, and at each step the child is
    told they are doing great work
  • The adult provides the leadership but the child
    is by their side
  • The parallel process is CO-REGULATION

57
KNOW ABOUT CULTURE
  • Food preferences/needs
  • Language barriers
  • Gender roles and expectations
  • Religious and spiritual beliefs
  • Parent/child roles and expectations
  • Know whom they expect to be in charge and explain
    the power base in the family

58
3 THINGS
  • Be consistent - transitions and change will be
    hard, scary and may trigger the child
  • Be sensitive - overly firm, frustrated, or
    impatient caregivers may frighten the child as
    the child will not correctly interpret the
    message or emotion
  • Be respectful - honor refusals when possible and
    be flexible as much as possible

59
KNOW WHAT TRAUMA WORK IS
  • Know when to intervene
  • Know that sometimes waiting is good
  • Know that you must stay with the child
  • Know that it will cost the child
  • Know that they should be in a secure setting
  • Know if they are ready
  • Do not remove their defenses

60
TALK TALK TALK
  • The child may talk about the incident
  • They may need to do this almost compulsively
  • Document what they say
  • Take the time to sit with them and touch them, if
    they let you
  • Coach them on who they can/cant talk to about
    their story

61
MOVE MOVE MOVE
  • Physical movement and exercise is essential to
    expel the cortisol/adrenaline that they have
    stored up
  • Regular, participatory, supervised
  • Encourage at least 30 minutes two or three times
    a day, work up to this if needed
  • Have other children join

62
PLAY PLAY PLAY
  • Children will many times play their story out
  • They need supervision
  • They need someone asking the questions
  • They need permission to reenact the story in play
  • They need appropriate toys

63
LET THEM BE LITTLE
  • Under socialized children do better with learning
    their skills with younger children who are
    learning them for the first time than with older
    children of their own age who are normal. The
    traumatized child needs to redo their early work.
  • Have some baby toys around

64
STIMULATE THEIR SENSE
  • Give them snacks and drinks often
  • Touch them whenever you can in a relaxed,
    nurturing way
  • Catch their eyes and watch what they pay
    attention to
  • Try to interpret what they are thinking and
    feeling, read their mind and wonder out loud

65
TURN THE TV OFF
  • Videos and TV are not multisensory
  • Things on TV will provide more triggers and
    stimulation than they can manage
  • Videos ramp them up instead of calms them
  • Video and TV are not interactive

66
COPING
  • We teach pre-living and pre-teaching by asking
  • What will you do next time?
  • What else can you do your options
  • That was then, timeline- this is now, a long time
    ago, distance themselves from the time of the
    event.

67
STRIKE WHEN THE IRON IS COLD
  • Dont intervene when the child is over reactive
    or activated
  • Label the feelings
  • Address what the child was feeling
  • Connect the memory to the here and now
  • What are you going to do next time
  • What are your options
  • Make the child think instead of feel

68
RULES VS STRUCTURE
  • Rethink how you feel about following house rules
  • Structure may be about how much you can nurture
    and be compassionate in one day
  • The child may be incapable of following simple
    instructions, may not hear, understand, remember,
    or care about your stupid rules
  • They may care but still cant follow them

69
ALL THE RULES ARE BROKEN
  • When the worst possible thing happens, then
    anything is up for grabs.
  • The child expects the worst
  • Worries and obsesses about the worst
  • Has nightmares about the seemingly impossible
  • Does not care what your rules are, rules do not
    keep kids safe

70
NEGATIVE CONSEQUENCES
  • Punishment and consequences wont be kind
  • They will teach nothing of value
  • They will reinforce negative messages about
    adults who have power
  • They will not motivate a child, and if they do,
    it will be from a place of fear, not a desire to
    please

71
USEFUL ALTERNATIVES
  • Mistakes are met with encouragement
  • Bad choices are met with sympathy
  • Frustrations are met with affirmations
  • Hurtful behaviors are followed with act of
    kindness and then making of amends

72
POWER STRUGGLES
  • When a child grows up in a power based family
    where strong people hurt little people, every
    interaction becomes a win or lose and these kids
    struggle with reciprocity, because it is a
    contest.
  • It appears that they love to argue but they are
    driven by fear

73
AVOIDING THE STRUGGLE
  • Know what is worth the fight
  • Dont make rules or statements that are not
    enforceable i.e. you wont talk to me that way,
    you wont use that language, you need to eat
    that, you cant do that, we dont let kids do
    that etc..
  • Learning to rephrase is very important,

74
MORE REFRAME
  • It worries me that
  • I wonder if that is the only choice
  • I would prefer if you could find a different way
  • Sometimes you get stuck, but you dont have to
  • It would be easier for both of us if we could
  • What does the voice in your head say?...

75
YOU CANT SPOIL THESE KIDS
  • Dont buy or give a lot of stuff
  • Stuff does not matter
  • They may ask for a lot of stuff
  • They need so much stuff that it will never feel
    like enough

76
INDULGENCE?
  • Give all you can, it wont cost you
  • Prepare other family members
  • Misbehavior is met with sympathy
  • Fear is met with sturdy safety
  • Shame is met with emotion, not logic

77
ADULT APPROVAL
  • What they need is you
  • Your supervision
  • Your affirmation
  • Your patience
  • Your acceptance
  • Your warmth and friendliness
  • Your humor

78
HELP THEM FIND HOPE
  • My patience is stronger than your anger
  • My care is more lasting than your rejection
  • My consistency will last longer than your chaos
  • My love is bigger than your hate
  • I can take care of you, I am not leaving, neither
    are you

79
BE NORMAL AND BORING
  • No surprises
  • Same is good
  • Slower is better

80
DONT MAKE PROMISES
  • Dont offer false reassurance
  • If you dont know, admit it
  • Dont offer something you cant be sure to deliver

81
USE PRETEND
  • Pretend I am your little sister
  • Pretend I am your mom
  • Pretend you are Magic
  • Pretend I am the judge
  • Pretend.

82
HOW YOU HELP
  • Sometimes you think you are just the maid or
    keeping them company in a temporary fashion
  • What you are really doing is lending them your
    coping skills and validating and naming and
    taming their feelings that terrorize them, you
    help them make sense and order of the senseless.
  • You offer them a relationship

83
THEY GET BETTER
  • Trauma does not ever really go away
  • The child can retire the coping mechanism
    (symptoms) and experience mastery and competence.
  • They will be triggered and need to redo some of
    their early work.

84
WHAT ABOUT YOU?
  • Self care is essential
  • Respite may be essential
  • Good support will be necessary
  • A safe place to talk about how hard the work is
    will be very helpful
  • Someone to answer some of the hard questions will
    help

85
EILEEN MOON
  • THOSE WHO LABOR ON THE FRONT LINES OF HUMAN
    EXPERIENCE MAY BE HAUNTED BY IMAGES AND EMOTIONS
    THAT ARISE IN THE COURSE OF DAY'S WORK WITH
    VICTIMS OF TRAUMA.

86
PSYCHOLOGICAL TOXIC WASTE
  • Mental health professionals encounter the toxic
    waste of the world on a daily basis. This is
    especially true for those who are highly
    committed. Clients turn to professional helpers
    to tell the stories that they can tell to no one
    else.
  • Dr.
    Beth Stamm

87
WE SHARE THE HORROR
  • The second hand experiences we hear about have
    the power to change the way we think about our
    world and the way we live in it.
  • It affects our relationships, our sense of well
    being, our sense of competence and our sense of
    hopefulness
  • We are just like the children. We need help and
    care too!

88
SPTSD
  • It will catch up with you
  • It is just a matter of time
  • You will take on the same feelings the child has
  • You will make a connection that is so intimate it
    hurts when they hurt

89
SELF CARE ROUTINE
  • Sleep no less than 8 hours
  • Get some exercise or activity that helps you
    relax
  • Have a few moments just for you
  • Dont forget your other important relationships
  • Dont make too many sacrifices
  • Know what too many is for you

90
PASS IT FORWARD
  • Find the good in them
  • Be the mirror they want to look into
  • Believe that children are resilient
  • Good responses, early, can make a long term
    positive impact
  • Stay hopeful
  • Lend them your courage

91
CELEBRATE
  • Understand your usefulness and talents
  • Celebrate your gifts
  • Celebrate the children.
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