Interventions for Children Who Suffered Trauma

Dave Zidar, LISWZidar, Training and ConsultingZidar, Training and Consultingdavezidar@mac.com

The Shift

• In the 1980’s there was a move from internal forces (neurosis) to the concept of psychological injury.

• Trauma influenced practice asks, “what happened to this person?” not, “why is this person being problematic?”

• How can we create an environment to heal the these trauma.

The Cup metaphorThe Cup metaphor

Fill or Flush

Rerecording memories

• With Milieu; the goal is to over power negative memories (in allpower negative memories (in all it’s forms) and fill it with new, more adaptive memories.

Types of trauma:• Abuse• Neglect• Accidents• Placement• War• Witness to a crimeWitness to a crime • Fire or natural disaster• Medical Treatment• Untreated Mental illness of the parentUntreated Mental illness of the parent• Drug abuse and addiction of the parents• What else?

The topography of the trauma

• What is the nature of the trauma?• What is the trajectory of the trauma?• What developmental factors are in play?• Age of the child• What idiosyncratic factors of the trauma are

manifesting themselves,e.g., strange pairing?• Any cultural factors?• Any cultural factors?• It is important to note these factors in

development of the milieudevelopment of the milieu.

Two models of traumaTwo models of trauma

Terr and NCTSN

Type 1 and Type 2 TraumaType 1 and Type 2 TraumaLenore Terr (1990)

Type 1• Short Term

Unexpected

Type 2• Chronic, long standing

Usually of intentional• Unexpected• Single blow, isolated• Sudden, surprising

• Usually of intentional human design

• May lead to altered , p g• Likely to Lead to PTSD

symptoms• More likely for quicker

view of self and world with feelings of guilt, shame and

• More likely for quicker recovery

worthlessness• Complex PTSD

symptomsy p• Longer recovery time

NCTSN

• Acute

• Chronic

• Complex

Trauma and ongoing stress:Trauma and ongoing stress:A moving target!

• Physical• PsychologicalPsychological• Reality

D l t l• Developmental

Milieu: The old Definition

• Bettleheim called this new environment a “milieu,” which was defined as “A ,medium, environment and surrounding or an enveloping matrix in which one p glives”

Milieu It’s is not just forMilieu, It s is not just for Residential Treatment!

• A milieu is an environment rich in therapeutic exchanges.It i t ifi t id ti l t t t• It is not specific to residential treatment programs.

• Our job is to look at their environment as part• Our job is to look at their environment as part of the healing process and make the necessary changes to promote wellness after the trauma.

• Creating a new schema of success and safety after the eventsafety after the event.

• Milieu: Creating a needs satisfying environment

Trauma Risk Factors:

• Co-morbidity with other pathology Including /MR/DD

• Low self esteemP i T• Previous Trauma

• Low or poor mother-child bondingPoor or strained famil relationships• Poor or strained family relationships

• Lack of consistent adult role models• Drug or alcohol use• Drug or alcohol use• Pre-trauma training

Post- incident Trauma RiskPost incident Trauma Risk Factors:

• Low emotional support• Weak safety interventionsy• Failure to provide debriefing• Lack of bio-chemical supportpp• Lack of consistent role models• Poor or strained family relationshipsPoor or strained family relationships• Drug or alcohol use• Post-trauma training and care• Post-trauma training and care

QuickTime™ and a decompressor

are needed to see this picture.

Bruce Perry’s Model ofBruce Perry s Model of Trauma Memory

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Questions to ask based inQuestions to ask based in Perry

• What is their overt affect saying?• What part of their “brain” is speakingWhat part of their brain is speaking

and behaving at the time?• Are we seeing regression in service of• Are we seeing regression in service of

the ego? H i th ili i t h l b i• How is the milieu going to help bring them back to balance?

Learning styles and MemoryLearning styles and MemoryAuditory:Auditory: Visual:Kinesthetic:

Thoughts + Feelings= BehaviorMilieu Levels:

Learning styles and MemoryAuditory:

Visual:Kinesthetic:

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Four areas of the milieuFour areas of the milieuWorking

Learning

Playing

Forming Relationshipsg p

W kiWorking: Developing a sense of what we can do.

Adding value to our lives and the people around us.

LearningRelearning positi eRelearning positive memories and learning how to apply them inour post trauma lives.

Playing:Playing:

Developing new pleasurable memories inDeveloping new, pleasurable memories in relations to Movement, Hearing and Visual

iexperiences.

Forming Relationships:Forming Relationships: •Developing new Relationships.Developing new Relationships. •Strengthen relationships that improve the overall wellnessoverall wellness.

WorkingW kiWorking:

Developing a sense of what we can do.Adding value to our lives and the people

around us.

Assessment of Activity forAssessment of Activity for therapeutic value

Work:Small detail work (Fine Motor)Large muscle work(Gross Motor)g ( )Do they enjoy the work they do?

Play:Play:Are they using play to grow, or as an ongoing distraction?Is it providing an opportunity to grow?

Assessment of Activity forAssessment of Activity for therapeutic value 2

Forming relationships:Forming relationships:Is the environment conducive to forming relationships?Are people “struggling” toward a common good?A l t lki b t l ti hi ?Are people talking about relationships?Are relationships growing over time?Has the pre-trauma relationships changed in light of the p p g gRevelation of the trauma?Learning:Are they learning “new” ways to self sooth?Are they learning new ways to self sooth?Are they aware of the effect of the trauma on their currentbehavioral choices?

Who creates the Milieu?•Parents•Teachers •CoachesCoaches •Therapist•Grandparents•Most importantly :•Most importantly :THE CHILD

Factors to Milieu Development

• Interest of the child(ren)• Temperament of the childp• Nature of the family• Willingness to try new thingsg y g• Amount of money to spend • Willingness of NOP in support of the childWillingness of NOP in support of the child• Past history of trauma

Predictability

• Survivors of trauma will benefit from clear structured routines

• After the trauma, the child will desire to get back to their routine

• If foster care is a factor, we have to develop a new routine

• This provides the child with anticipatory guidance

Activities to promote wellnessActivities to promote wellness 1

• Pets• Water

Music• Music • Sports• Gardeningg• Private time• Limit alone time

S i l di• Social readiness

Activities after the trauma• Structure, routine and predictability• Rituals and awareness of high risk situations• Anticipatory guidance• Anticipatory guidance• Soft questions• Create safe places• Use of faith• Sleeping areas: nightlights, teddy bears (Transactional objects)• Re-direction• Focus on the activities• Develop an awareness of the child’s reaction to consequences• Functional analysis of behaviorFunctional analysis of behavior

Safety Rituals and Activities

• Trust walls• What things make you safe activitiesg y• What if games• Prayer time• Study carolStudy carol• Environmental changes• Self-control and self discipline• Overheard conversationsOverheard conversations• Use of role models• Validate feelings

Over Training

• Training the child and the family with the understanding that theyunderstanding that they may regress by up to 50%

• How does the family view the post trauma training?

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

training?

Informing the family aboutInforming the family about post trauma care

• How open is the family system to new information.

• Seek and discover the families frame of reference in relation to trauma and creation of a milieu. (translated: do they get it!)

• Parents are going to have to be willing to change how they parent.

Two Major Goals!

• Help the parents and other care givers reduce states of arousalgivers reduce states of arousal of the child?

• Look at trauma as a manageable conditionmanageable condition.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

The written safety plan

• Parents, children and the therapist need to develop a cooperative plan to create the milieu.

• Every family member will need to have an d t di f h thi l kunderstanding of how this plan works.

• There needs to be a default plan.• There needs to be some psychological child

proofing.

Aspects of the plan 1

• Bedrooms: Night lights, door alarms on inside.T h Wh t t f

• What are the relatives to know?

• Touch: What type of boundaries are needed.

• TV: What’s OK?

• Who are the family supports? TV: What s OK?

• What to do during a flashback? It is better to thi k b t it b f it

• What about the school, how are they

i t h l iththink about it before it happens.

going to help with the safety plan.

Aspects of the plan 2

• Routines for non-readers: Create a picture board of their

• 1. Body tensing• 2. Deep breathing

picture board of their routine.

• Development of body

• 3. Belly breathing• 4. Foot breathingp y

awareness.• Teaching parents and

children relaxation

• 5. Teeth clicking• 6. Developing body

awarenesschildren relaxation methods, such as:

awareness• 7.Thinking+Feeling=

BehavingBehaving

What if the trauma happened in the home you are trying to create

a milieu?• Work with the child

to see how much • Work with the family

in relation to what “control” the environment has on the child

things they can change to limit the problems thethe child.

• What things can be done to change the

problems the environment create.

done to change the environment? • Move! ?

High risk situations that may “tapHigh risk situations that may tap into” traumatic event Long, N., Wood, M. & Fecser,(2005)

• Bath time• Bedtime• 3:00-5:00 AM

• TV (News or shows that have the theme of their abuse)

• Going to social services• 3:00-5:00 AM• Driving through the

home areaHome visits

• Going to social services office

• Funerals • Being on the presents of

• Home visits• Accidentally contact

with predator

guns , ropes or knives• Smells, sounds or other

sensory experience that reminds the child of• Fire and police trucks reminds the child of traumatic event.

• Sadly, you can’t prevent every reminder every possible cue!possible cue!

Bibliography for Children Who Suffered Trauma

Abramowitz, R. & Bloom, S. (2003) Creating Sanctuary in Residential Treatment for Youth: Well ordered Asylum to a living Learning Environment.” Psychiatric Quarterly. Vol 74, No. 2 summer 2003.

Edited by J. Goodwin and R. Attias (1999).”Splintered Reflections:” Images of the Body in Trauma Basic Books

Gunderson, J.G.(1978) Defining the therapeutic processes in psychiatric milieus. Psychiatry, 41,327-335.

Claude MONET (1890) Meules, milieu du jour [Haystacks, midday]

Long, N., Wood, M. & Fecser,(2005) F.Life Space Crisis Intervention: Talking With Students in Conflict: Second g, , , ,( ) p gEdition.

Perry, Bruce, D. (2007) Adapted in part from: "Maltreated Children: Experience, Brain Development and the Next Generation" (W.W. Norton & Company, New York, in preparation)

T bi Ul i h C (1994) Th W Th L T d l H P b C l S IllTobias, Ulrich C. (1994) The Way They Learn. Tyndale House Pub. Carol Stream, Ill.

Terr, Lenore (1990) Too Scared to Cry. Basic Books. New York

Zidar, David. (2006) “The Four Areas of the Therapeutic Milieu”. Frontline, Ohio Association of Child and Youth Care ProfessionalsProfessionals.