Helping children heal after a traumatic event
The Yale Child Study Center’s short-term treatment has become a national model for treating symptoms such as feelings of helplessness and giving young patients back a sense of control.
Steven Marans, a national expert on childhood trauma, has a treatment approach that has become a national model.
(January 2012) Michael was 9 when he watched his friend John shot at close range by another boy in a basketball dispute. Soon after, he began starting fights and having nightmares. Charisse was 15 when she was robbed of her leather coat at gunpoint and beaten. For several weeks, she was unable to sleep at night or go into the rooms in her house alone.
Clinicians in the Childhood Violent Trauma Clinic at the Yale Child Study Center have many more cases where those came from. They treat children who have witnessed or experienced murders, kidnappings, house fires, and even hostage and barricade situations. Abuse by family members is especially common.
The center provides a range of treatments for up to 1,000 children and adolescents a year for what comes later: the symptoms.
These can include a racing heart, insomnia, sweaty palms, nightmares, and generalized anxiety and immobility. There may be long-term post-traumatic stress disorder (PTSD) and a range of psychiatric disorders.
Changing the feeling of helplessness
Marans (center) discusses a case with Hilary Hahn, MPH, EdM, associate research scientist, and Steven Jay Berkowitz, MD, medical director of the Intensive In-home Child and Adolescent Psychiatric Service.
“I’m a great believer in increasing order and understanding to alleviate suffering and injustice. In traumatic events, loss of control and subjective meaning are the greatest sources of terror, “says Steven Marans, MSW, PhD, director of the clinic, Harris Professor of Child Psychiatry and professor of Psychiatry at the Yale School of Medicine, and a member of a National Task Force on Children Exposed to Violence.
Marans and his colleagues use an approach that has become a national model that is helping families in New Haven as well as at sites in New York City and other parts of the country. Their Child and Family Traumatic Stress Intervention (CFTSI) is a brief 4-to-6 session treatment for children ages 7-18 and their families, administered in the clinic or in the family’s home. Clinicians talk to children and parents separately, asking specific questions to help them access feelings and put symptoms into words.
“Then we bring parents and children together and compare notes. Sometimes parents literally didn’t realize their kids were suffering—or parents notice symptoms that the kids don’t realize they are having,” Marans says.
“There is a reality in which the victim could not control what happened to them, in which they feel alone and isolated. But then the traumatic experience is compounded in another loss of control over feelings and symptoms, and their isolation continues. So we teach skills that can alter the experience of helplessness, and increase communication with caregivers,” Marans says.
Referrals from various sources
Families are referred to the center by the Yale Child Sexual Abuse Clinic, the Connecticut Department of Children and Families, the Yale-New Haven Hospital Emergency Department and private pediatricians.
Many patients are treated as the result of a collaboration established in 1991 with the New Haven Police Department that provides cross training for city police, and mental health and other professionals, along with an opportunity for Yale clinicians to join police in responding to calls involving children.
“It’s extremely helpful for us to go on these calls,” says Kristen Hammel, LCSW, clinical coordinator of the program. “We know more about child development and symptoms, so it’s a good collaboration. If it’s domestic violence, we can talk to the family about the legal process and protective orders, and things like that.”
Andrea Asnes, MD, medical examiner for Yale’s Child Sexual Abuse Clinic, which refers 25 to 30 percent of the cases treated in the Violent Trauma Center, praises the center for providing families with strategies tailored to specific symptoms, and taking extra steps to work with schools and other partners. “It’s a very practical form of therapy,” she says.
Providing help right away
Hahn and Dr. Berkowitz discuss the CFTSI treatment. Toys can help young children feel comfortable.
The sooner a clinician sees a new family, the better. The Trauma Center doesn’t keep a waiting list. When a child is referred, clinicians bring in the family as soon as possible or meet them at the forensic interview.
“We want to see them while the trauma is still so present,” says Hammel. “Then we can provide them with tools such as stress management techniques, including focused breathing, progressive muscle relaxation and guided imagery. We want to calm the body down so that we can determine what is triggering intrusive thoughts.”
Initial studies show children who receive CFTSI treatment are 63 percent less likely to be diagnosed with PTSD three months after the incident than children who receive high quality standard care. The percentage is higher for partial PTSD. Research also shows that outcomes improve when adults recognize the child’s distress and when the child is well supported.
“We don’t think it’s a cure-all, although the results have been very exciting,” Marans says. The problem is that in addition to symptom relief, many families need help with a range of issues involving the stressors of social adversity as well as preexisting, often unidentified psychiatric problems.”
“We do what we can. If what we can do is offer a treatment for the most immediate traumatic insult or injury, then that’s a home run right there. What we’ve been seeing, anecdotally, with families who receive CFTSI is that when recommendations are made for the treatment they are more likely to stay engaged. It becomes a wonderful window of opportunity to identify those kids who need further evaluation, who may need other treatments that they may never have had before. “
Photos by Robert Lisak
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How to talk to kids about disasters
Steven Marans, MSW, PhD, has played a national role in helping children in the wake of such mass tragedies as Hurricane Katrina and September 11. He is the author of a book called “Listening to Fear: Helping Kids Cope, from Nightmares to the Nightly News,” and was recently invited by Attorney General Eric H Holder, Jr., to serve on a National Task Force on Children Exposed to Violence.
Marans counsels giving children ample opportunity to describe their worries rather than dismissing fear with immediate reassurance.
“It’s so hard to think like a child, but we forget that and make assumptions about what our kids need to hear from us. We’re so much more effective at reassuring them when we first take the time to listen,” he says.
Marans provides these tips for talking to children about traumas, including earthquakes, hurricanes, wars and other major traumatic events that can be as accessible as the TV news.
- If you’re a parent, look at your own fears first, as they may inadvertently affect your children.
- Listen and observe. Don’t just assume you know what is going on in your child’s mind.
- Sometimes it is easier to begin discussions about horrific events by asking your children what their friends and classmates are thinking, feeling and saying. In most cases, it is not a good idea to force your children to talk with you.
- Don’t be surprised if the child shows no interest in the event. They may visit concerns briefly, then return to play or involve themselves in schoolwork or other activities rather than letting themselves feel overwhelmed.
- When we remain calm and limit our expectations about the length of the discussions, our kids are much more likely to engage in further talk down the road.
- Don’t worry about knowing exactly the right thing to say, because there is no one answer that will make everything okay. On the other hand, your silence will only prevent them from understanding and coping with the situation.
- Don’t be surprised if your children get upset when talking about disturbing things. Remind them that talking about it does not make it come true, and they will probably feel better if they don’t hide their feelings.
- Reassure them that you are there for them and can support them in times of distress.
- If your child seems unusually upset for several days—especially if they are upset or worried about many things, or are having trouble in school, at home or with their friends, speak with someone outside the family for advice.
