Trauma Treatment for Children

I am working on training and materials to adapt the Restorative Approach for foster parents. As one piece of it, I am developing Behavior Management guidelines for foster families. The guideline will be meaningless unless embedded in a training program that teaches how to understand trauma, how to help children heal, understanding symptoms as adaptations, the use of the relationship, and taking care of ourselves. However, I do think it will be useful to give parents specific ideas about what we expect them to do. Here is what I have so far, and I would greatly appreciate feed back. Just click the word "comment" below. Thank you.

1. This approach to behavior management is based on the understanding that problem behaviors are the child’s attempt to manage intolerable emotions such as fear, despair and hopelessness. Because the child does not trust relationships and thus has trouble asking for and accepting help; because he or she has an overly activated nervous system; and because he or she has not learned emotion management skills, the child reacts to set backs with behaviors that help in the moment but have long term negative consequences.

2. The most powerful way to change behavior will be through forming strong relationships, creating attuned communication, creating a sense of self worth, and modeling and teaching emotion management skills.

3. Interactions with the children should be consistent with the Restorative Approach. They should display the qualities of playfulness, love, acceptance, curiosity, and empathy. (Daniel Hughes)

4. As the child begins to feel safe, her need for problem behaviors will decrease.

5. Behavioral difficulty should be handled through re-direction and persuasion. Consequences should not be threatened or imposed except as a last resort.

6. Children can be kept closer in (i.e. kept to house, in sight of parents) when they have acted out, but should constantly be re-evaluated as to whether this is still necessary.

7. Points Levels and behavior charts are not used.

8. As soon as the child is back on track after any incident, they should resume normal activities.

9. Children who are having difficulty should be kept closer to parents. They should not go on trips or off on their own.

10. When a child is agitated, escalated or out of control, all parent efforts should be directed towards helping them calm down. This can be done through listening, validating, taking a walk, quiet, adult closeness and calmness. There should be no discussion at this time of consequences or better ways to handle things. These can be discussed later when the child is calm.

11. If a child has a major problem, they should be given a restorative task consistent with the problem they had. The task should include the elements of learning, making amends and reconnecting. In other words, they should be given opportunities to repair damage done, make amends to people hurt, restore damaged relationships, and do something nice for the family.

12. Until the child has completed their restorative tasks, they should not participate in extra or just-for-fun activities. They should be part of all regular activities. This means all regular therapy and school unless parents determine it’s unsafe for the child to be in these activities. They could go to bed earlier to get energy for their restorative work.

13. When the child has completed their restorative task, they should return to all normal activity.

14. Isolation to any room should not be used. Children become regulated in the presence of regulated adults.

15. Restrictions can be used (car, pool, etc). These are used when a child abuses the rules around activities to the point where safety is compromised. They should be for short times such as a day or two and constantly reevaluated.

16. Children can be asked to leave the family area to calm down or re focus, and then return in a short time (5-15 minutes), but this should be done only rarely- children are most likely to calm down when close to calm adults, not when sent off by themselves.

17. Structure is extremely important and the children need a highly structured day with planned activities, and they are helped by knowing what will happen next. Families maintain order throughout the day by such mechanisms as plans, describing what will happen next, taking turns, quiet time, and game playing. Alternating quiet activities with more energetic activities helps the kids contain their emotions. When kids are unsafe, keeping them to a small circle of activities and people is helpful; taking them to events like large family picnics may be a set up for difficult behavior. Choices should be limited. Free time, alone time, and going to bed are particularly difficult and should be supported by the adult. Events in which there is a lot of noise, confusion and stimulation (such as shopping) can also be difficult for some children. The adults should try to structure the child’s day so he experiences success, not put him in situations for which he is not prepared. Routines, rituals and ceremonies are very helpful in establishing a safe structure in the home.

18. Bedtime and hygiene are particularly sensitive times for children who have experienced trauma. Problems in these areas should not be addressed through punishments or rewards. The children should be supported through parent closeness and creative interventions such as music, night lights, bubble baths, etc.

19. When a child’s behavior begins to deteriorate, the first question to ask is: is she feeling safe? The second question is: is she over stimulated?

Thanks again for any ideas or suggestions you may have.

On the second day of the conference, the general speakers were:
Glenn Saxe speaking on Complexity Theory
Dan Hughes speaking about the use of the body in therapy
And
Bessel van der Kolk on Developmental Trauma Disorder

Glenn Saxe is one of my favorite theorists and writers. His book, Saxe, Glenn; Ellis, B. Heidi; and Kaplow, Julie B. Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach (2006, The Guilford Pres)s does the best job of any I have read to conceptualize a model for working both with the child themselves and with the system around the child.

At this presentation Dr. Saxe was talking about his latest fascination, complexity theory, which is the science that investigates how schools of fish or flocks of birds maintain their complex, moving patterns with out a leader or a plan. Dr. Saxe is using this theory to look at the complex patter of a traumatized child in his or her social systems, and stated that the theories will help us understand which changes will be most powerful, and where we could intervene to gain the most effect.

Daniel Hughes has long been an inspiration of mine, and was part of our beginning down the journey towards trauma informed care. His book: Hughes, Daniel. (1998). Building the bonds of attachment: Awakening love in deeply troubled children. Jason Aronson served as our guide book as we invented this new model. More recently, I have appreciated his newest books: Attachment Focused Family Therapy, (W.W. Norton & Co.; 1 edition May, 2007) and Attachment-Focused Parenting: Effective Strategies to Care for Children (Norton Professional Books, March 2009). At the conference Dr. Hughes was emphasizing the role of non-verbal communication within therapy. In fact he wondered why we call it "non-verbal" communication- 80% of our communication is what he would term "body communication". Since trauma is held in the body, it is essential that the therapist deliberately use all body communication to facilitate and deepen the therapeutic process. This includes:
Matching vitality and affect of client
Congruent with verbal communication
Awareness of other’s nonverbal meaning
Clear, nonambiguous expressions
Flowing- gradual, regulated, changes
Gaze- direct, warm, open, interested, responsive
Voice- variable, responsive, relaxed, open, animated
thoughtful, alive, empathic.
Gestures- animated, expansive, dramatic, responsive
Posture- open, moving/leaning forward

Dr. Hughes showed some wonderful videos to illustrate his points. However, he was especially prod of the picture with which he began his slide show- a lovely picture of his daughter and her daughter in attuned communication.

Bessel van der Kolk then presented on his work on establishing a new diagnostic category for the upcoming DSM V- that of Developmental Trauma Disorder. Dr. van der Kolk started by relating the history of the trauma diagnosis- noting that there is a new phrase for the effect of war on soldiers in each war, and it reflects the weapon predominated in that war (such as "shell shock"). The PTSD diagnosis was created in the aftermath of the Vietnam war, in an attempt to get funding and medical care for the veterans, and has proved effective for adults who experience trauma in adulthood.
However, there has been recognition of the profound difference between adult onset PTSD and the clinical effects of interpersonal violence on children, as well as the need to develop effective treatments for these children. It has become evident that the current diagnostic classification system is inadequate for the tens of thousands of traumatized children receiving psychiatric care for trauma-related difficulties.
PTSD is a frequent consequence of single traumatic events. Research supports that PTSD, with minor modifications, also is an adequate diagnosis to capture the effects of single incident trauma in children who live in safe and predictable caregiving systems. Even as many children with complex trauma histories exhibit some symptoms of PTSD, research shows that the diagnosis of PTSD does not adequately capture the symptoms of children who are victims of interpersonal violence in the context of inadequate caregiving systems. In fact, multiple studies show that the majority meet criteria for multiple other DSM diagnoses.

Therefore, the goal of introducing the diagnosis of Developmental Trauma Disorder is to capture the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma and thereby guide clinicians to develop and utilize effective interventions and for researchers to study the neurobiology and transmission of chronic interpersonal violence. Whether or not they exhibit symptoms of PTSD, children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems are ill-served by the current diagnostic system, as it frequently leads to no diagnosis, multiple unrelated diagnoses, an emphasis on behavioral control without recognition of interpersonal trauma and lack of safety in the etiology of symptoms, and a lack of attention to ameliorating the developmental disruptions that underlie the symptoms. Most children exhibited posttraumatic sequelae not captured by PTSD: at least 50% had significant disturbances in affect regulation; attention & concentration; negative self-image; impulse control; aggression & risk taking. These findings are in line with the voluminous epidemiological, biological and psychological research on the impact of childhood interpersonal trauma of the past two decades that has studied its effects on tens of thousands of children. Because no other diagnostic options are currently available, these symptoms currently would need to be relegated to a variety of seemingly unrelated co-morbidities, such as bipolar disorder, ADHD, PTSD, conduct disorder, phobic anxiety, reactive attachment disorder and separation anxiety.

Suggesting that an alternative diagnosis was necessary to capture the spectrum of coherent symptoms of children exposed to interpersonal violence and disruptions in caregiving, van der Kolk (2005) proposed the creation of a Developmental Trauma Disorder diagnosis and described the broad domains of impairment and distress that characterize these children and adolescents.

PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER

A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse

B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following:
B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization
B. 2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions)
B. 3. Diminished awareness/dissociation of sensations, emotions and bodily states
B. 4. Impaired capacity to describe emotions or bodily states

C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following:
C. 1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues
C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking
C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation)
C. 4. Habitual (intentional or automatic) or reactive self-harm
C. 5. Inability to initiate or sustain goal-directed behavior

D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following:
D. 1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation
D. 2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness
D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers
D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other adults
D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance
D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others

E. Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D.

F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months.

G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at two of the following areas of functioning:
· Scholastic: under-performance, non-attendance, disciplinary problems, drop-out, failure to complete degree/credential(s), conflict with school personnel, learning disabilities or intellectual impairment that cannot be accounted for by neurological or other factors.
· Familial: conflict, avoidance/passivity, running away, detachment and surrogate replacements, attempts to physically or emotionally hurt family members, non-fulfillment of responsibilities within the family.
· Peer Group: isolation, deviant affiliations, persistent physical or emotional conflict, avoidance/passivity, involvement in violence or unsafe acts, age-inappropriate affiliations or style of interaction.
· Legal: arrests/recidivism, detention, convictions, incarceration, violation of probation or other court orders, increasingly severe offenses, crimes against other persons, disregard or contempt for the law or for conventional moral standards.
· Health: physical illness or problems that cannot be fully accounted for physical injury or degeneration, involving the digestive, neurological (including conversion symptoms and analgesia), sexual, immune, cardiopulmonary, proprioceptive, or sensory systems, or severe headaches (including migraine) or chronic pain or fatigue.
· Vocational (for youth involved in, seeking or referred for employment, volunteer work or job training): disinterest in work/vocation, inability to get or keep jobs, persistent conflict with co-workers or supervisors, under-employment in relation to abilities, failure to achieve expectable advancements.

(Material adapted from:
Proposal To Include A Developmental Trauma Disorder Diagnosis For Children And Adolescents In Dsm-V, Bessel A. van der Kolk, MD, Robert S. Pynoos, MD, 2009)

At the conference Dr. van der Kolk discussed the complex political process that is involved in changing the DSM. The proposed new diagnosis would create sweeping changes, in that it postulates that early childhood trauma is actually at the root of other diagnosis, such as Borderline Personality Disorder. Many grants, insurance payments, and other funding streams are shaped by the DSM, and such a profound change might threaten many established programs. This change has at the time of the conference been rejected by the DSM committee. It will be fascinating to watch the process and the evolution of our understanding.

I highly recommend this trauma conference, which is held every year in Boston. It is the only conference of the many I attend which so effectively combines science, social issues, advocacy and clinical practice, and brings us the most current thinking in our field.

I attended a workshop entitled "Divided Mind, Divided Body: Interventions for Working with Dissociated Parts in Traumatized Individuals" by Kathy Steele, MN, CS and Pat Ogden, Ph.D. The workshop was about doing therapy with dissociative survivor clients integrating talk therapy and a body-oriented therapy called sensorimotor psychotherapy. While the workshop was about adult clients, there were a few themes relevant children. First, the workshop talked about an important factor worsening the impact of trauma, and often leading to dissociation, is the inability of the body to act -- being frozen during traumatic experiences. When unable to fight or flee, the body freezes -- but freeze mode is like having your foot full force on the gas and the brake at the same time. Therefore, in addition to emotional, cognitive manifestations of trauma, people have enduring somatic effects in their body from these childhood experiences -- patterns of how trauma shows itself and lives in the body. Part of the idea of sensorimotor psychotherapy (totally oversimplified) is that people are made aware of and asked to tune into their bodily sensations and take action with their body that was kind of action they would have wished to do at the time of the traumas.

Second, is the idea of every persons "window of tolerance." All of us have a "window of tolerance" of arousal or feelings we can tolerate or manage. Above this window of tolerance is is hyperarousal (often associated with body's danger response) and below the window is hypoarousal (numbness, deadness, etc). Traumatized children and adults have narrow windows of tolerance and quickly go out of the window, sometimes rollercoasting between hyper and hypoarousal. Our job is to help them and teach them to get back into the window. Much of the therapist job is to urge clients toward the "edge of the window" so they feel some affect, but not push them out of the window when they feel out-of-control. This is the true art of being a trauma therapist, walking this fine line. Body oriented therapies often talk about the "pendulation" of the the body's physiology. In normal development, infacts and children experience stress and are comforted by attachment figures -- the arousal up and comes down, up and down. Children learn to regulate their own stress over time. In unhealthy development, a child is stress and not soothed so the bodies smooth pendulation up and down never happens -- they get stuck in hyperarousal or hypoarousal mode -- and don't know how to return their body within window of tolerance. In our moment to moment attuned interactions with traumatized kids we are reteaching them and their bodies this pendulation.

20th Annual International Trauma Conference

June 4-6, 2009

Boston, Mass

I have just returned from the 20th Annual International Trauma Conference in Boston, Mass. This conference is put on by Bessel van der Kolk and the Trauma Center at Justice Resource Institute (http://www.traumacenter.org/). It is such an exciting and inspiring conference, because it blends science and clinical expertise is a way that is unique in my experience, as well as containing an advocacy, social and moral component.

I attended a day long pre-conference work shop entitled: Reorganizing the Disorganized Brain, with Ruth Lanius, MD, PhD, Eric Vermetten, MD, PhD., John Gruzelier, MD. , Rachel Yehuda, PhD., James Hopper, PhD., Laurence M. Hirshberg, PhD., Alexander McFarlane, MB BS, (Hons), MD, and Bessel A. van der Kolk, MD. This workshop examined how trauma affects brain regions that support intense emotions while decreasing (a) activation in the CNS regions involved in the integration of sensory input with motor output, (b) the inhibition of emotional expression, (c) the organization of self-experience, and (d) the translation of experience into communicable language.

The first speaker was Ruth Lanius. She uses fMRI to study the brains of trauma victims and discover the effects on various parts of the brain. In this presentation Dr. Lanius was focusing on the default state of the brain, which is how the brain looks when we are not doing anything in particular. She has discovered that the parts of the brain that are related to self reflection, creating a self narrative, and self awareness are almost non-functional in the default states of trauma survivors, while being very active in those of the control groups. Therefore, biologically trauma survivors are less able to be self aware and notice and name their emotions. They develop a post traumatic alexithymia. Alexithymia is a psychological construct that refers to difficulties identifying and labeling emotional states. Alexithymic individuals with PTSD may experience intense emotional-physiological states (e.g., fear, anger, and dysphoria) that are poorly integrated with, and modulated by, higher-order verbal cognitive processing. Therefore these individuals may report that they either do not know what they feel, or cannot feel anything at all.

This ability to self reflect, this part of the brain, is developed through attuned relationships with loving care givers. What cannot be communicated to another cannot be communicated to the self. In order to develop self reflection and self awareness, some one must reflect on the child and be aware of them- tell them their story. This is what our children either have not had or have had in fragments.

Eric Vermetten, MD, PhD is a military doctor from the Netherlands. He works primarily with veterans who return from deployments in Iraq and Afghanistan. He reported on the good results his team is finding from neurofeedback.

James Hopper, PhD is a delightful presenter. He spoke of the Buddhist concept of the mind, and how that integrates with what modern biological science is discovering. He described how trauma gets in the way of being able to experience (and enjoy) the present moment. This of course interferes with the experience of pleasure and the richness of life, but also with the development of a narrative and self awareness.

The rest of the day was given to explaining what neurofeedback is, and the amazing results that are happening in 20-30 half hour sessions. I would love to add neurofeedback to our treatment- is any one doing it? I know that Kevin Creeden does it at his place.

The actual conference began on Friday. The first speaker was Rachel Yehuda, PhD who spoke on Mothers, DNA and the Transmission of Trauma. She is my new heroine. She is a bio chemist, very smart and rigorous in her work. And she is funny, irreverent, caring and always questioning. She started by saying she has more questions than answers- but a later speaker said she was lying. Her specialty is the blood chemistry and genetics, and the effects of trauma.

Rachel taught us a lot about the complexity of blood chemistry. One point she made is that cortisol is the substance in the blood which is responsible for stopping the human danger response. People who suffer from trauma have low cortisol, so PTSD can be thought of as a failure to effectively end the danger response.

But the main point Dr. Yehunda was communicating was that the chemicals that are in our bodies can actually interact with our genes and change them, through a mechanism she explained. So in this way trauma can be transmitted through the generations.

The next speaker was Alexander McFarlane, MB, BS (Hons) MD, who spoke on Integrating Past and Present: PTSD as an Information Processing Disorder. Dr. McFarlane, who is from Australia, discussed the fact that although we often realize the presence of flashbacks and dissociation in traumatized individuals, in fact the damage to thought processing is much more profound. Through careful fMRI studies Dr.McFarlane showed a large difference in the amount of processing going on in the brains of trauma survivors. In short, it’s not just that these kids are having flashbacks and dissociating, even doing their math is much harder for them.

Harry Spence, JD was the Commissioner of the Child Welfare agency in Massachusetts, and is no longer. He said he could speak more eloquently about the system now that he was not in charge of it. One important point he made was that the system was strongly influenced by the high profile case- the child death that makes headlines in the paper. In such situations there is tremendous pressure to scapegoat a social worker. At times this has been done, and the social workers are very aware of this possibility. So, Dr. Spence made the comparison between the experience of the workers and the families they serve- both are demoralized, under-resourced, distrust authority, and are overwhelmed. Another excellent point was that trauma work demands work in teams- and child welfare workers do not have any access to a team. Furthermore, the system almost prohibits workers from examining their own reactions to the work- silence is demanded from the workers. There is no culture of self examination. Young people are making life altering decisions about children and families with little team support, little self awareness, and emotional distress.

Dr. Spence spoke of the moral endeavors that all our organizations are engaged in. He said that workers join organizations- child welfare, the military, education- with the goal of doing good. All too often, however, they feel betrayed by their leaders. The compromises that are made erode the purity of purpose. When the workers are blamed or treated badly they become less connected to their moral purpose. Their moral universe shrinks- not it is just their unit, or their best friend and themselves that are doing good. They adopt a "who cares, it’s not my job" attitude towards the larger organization.

Dr. Spence called on all leaders and administrators of organizations to keep and enhance the moral commitment of their workers, by highlighting the moral victories of the organization, the ways in which the organization does good and changes the world.

In the afternoon I attended a workshop by Jane Koomar, PhD, OTR/L, FAOTA; Elizabeth Warner, PsyD; and Anne Westcott, LICSW. They were describing a program in which they integrated sensory intervention techniques into the therapy room. They used large balls, weighted blankets, rhythmic activities, and other sensory techniques to help the child regulate their body. Both in individual and family therapy this resulted in the child being much more open and available for both connection and discussion. Their video tapes were moving. This is something we could all do in our treatment centers without too much difficulty.

I will write about the second day next time, plus Steve Brown has written up the workshop he went to on Dissociation, which I will also post here.

As usual, all comments welcome. Did any one else attend the conference? Add your impressions by clicking on the word "comment" below.

I did a Risking Connection training in Louisville, Kentucky this past week. In one section we ask participants to share success stories, as a way of reaffirming the worth of the work we do and combating vicarious traumatization. One person shared a letter he had recently received from a client, expressing her gratitude for the program’s help and the changes she and her son had made. The letter started, as such letters often do, with the phrase: "most of all, you didn’t give up on me."

Perhaps the most important thing we do for clients is not to give up on them. Sticking with them- staying around- something many of our kids and families have not experienced. Our kids have been in so many placements, so many families, and so many treatment facilities. In addition to undermining healing relationships, all these moves underscore the basic message- you are such a terrible person that no one is able to stay around you for any length of time.

In order for any of our techniques to work, we have to keep the kid with us. And many times I have experienced situations in which we had completely given up on a kid, and we were sure we could not help him. However, the child welfare system being what it is, the child did not leave. And guess what- time passed, and he got better.

So maybe we should pay more attention to exactly what makes it possible for us to keep a child. And when we are struggling with a particular child, maybe we should have a meeting specifically focused on enhancing our ability to keep her.

And what could we do to increase our stamina? Some ideas are:

1. Increase staff stamina by dividing the responsibility for the child among several staff every night. If (as we do) you have a concept of a "primary" staff (we call them team mates) then maybe a certain child needs two or three team mates. Maybe we should plan that any one who deals with this child for a long period gets a break off the unit.
2. If there is a particular horrid task (such as cleaning the room of a child with hygiene issues) let’s do it in teams, not one staff alone.
3. Let’s keep a note book of any signs of hope we see.
4. We must articulate clearly that even if we do not (yet) see any change, our not kicking this child out is a victory in itself, and we should congratulate each other for that.
5. Let’s regularly review what happened to this child, and how we understand her symptoms- what problems are they solving for her? How are they adaptive- helpful in the short term, even if they have negative long term consequences?
6. Let’s make sure we have a treatment theme (such as: Jeff is learning to trust adults) that everyone on the team including the child and family knows, and that we use this theme to frame all events and interventions.
7. Let’s plan some ideas for restorative tasks before the child is in crisis, during our treatment team. Each task should be an opportunity for the child to practice one small skill that he would need to develop to give up his current symptoms.
8. We can make sure to compliment each other lavishly whenever anyone is particularly caring, giving or helpful to this child.
9. Administration can attend meetings and praise the treatment team for their stamina.
10. Is there anything we can do to make the child feel more safe and connected?
11. Can we deliberately do something fun together, to acknowledge the effort we are making- a pot luck lunch, little presents, chocolate?

12. The most important thing is to acknowledge both how difficult and how valuable what we are doing is. If we can stick with the child, his or her entire life may be different.

This is not to say that children should never leave our programs, or that children never need a different form of care. That happens- but not as often as we think. More often, we are frustrated by the pain the child is feeling, and by his ways of making sure we feel the same pain. We think, if only she were gone, the unit would go so well. But if we do succeed in ejecting a child, another one always steps into the role.

Let’s talk actively about our feelings about the child, how hard working with her is, how much chaos she creates for us and others, and how tempted we are to get rid of her. Let’s talk about our feelings of sadness, of inadequacy, anger and frustration. Let’s remember how she got this way, how we understand her, and let’s make sure we have a strong team plan.

And then let’s re-engage with the child and hang in there. Then after he gradually starts to get better, and finally achieves that positive discharge, and does fairly well, we will get one of those letters:

Dear staff,
I just wanted to let you know I am doing well at my new home. I really miss you guys! I want to thank you for not giving up on me...

Do any of you people reading this blog Twitter? Do you have a Facebook page? I am considering using these services to further connect us, the people trying to do trauma informed treatment of children. It is hard to work this way- it is hard to start doing it, and hard to keep doing it. It will help if we support each other. Would you be interested in Twitter and/or Facebook connections? Let me know by clicking "comment" at the bottom of this post. Thanks!