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

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RESPONSE TO TRAUMAKIDS IN CRISISDEENA
MCMAHON651-210-0335dmcmahon_at_mcmahonccs.net

• FLORIDA 2009

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AN ORDEAL

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

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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

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HEALING

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

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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

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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

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FLIGHT

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

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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

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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• They are charming, defensive or withdrawn

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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

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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

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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

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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

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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)

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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

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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

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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

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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!!!

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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

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ADAPTATIONS

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

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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

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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

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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!!!

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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.

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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

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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.

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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NO HOMEWORK IEP

• Relieve the parents
• Collaborate with the teachers
• Figure out what real learning is going on

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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

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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.

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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

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IMPACT OF TRAUMA ON RELATIONSHIP DYNAMICS

• Betrayal
• Powerlessness and helplessness
• Blame and guilt
• Trust and responsibility

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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

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SELF BLAME

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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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,

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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?...

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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

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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

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ADULT APPROVAL

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

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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

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BE NORMAL AND BORING

• No surprises
• Same is good
• Slower is better

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DONT MAKE PROMISES

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

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USE PRETEND

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

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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

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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.

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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

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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.

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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

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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!

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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

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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

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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

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CELEBRATE

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