Mending Meaning
Intervention Strategies, Collaboration, and the Importance of Taking Care
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Traumatized children can be challenging. Their behaviors can seem erratic, uncaring, deceitful, and confusing. Inconsistencies can make it difficult to ascer- tain their abilities and skills (Ford & Courtois 2013, Heineman 1998, Heller &
Lapierre 2012, Kagan 2004, Pearce & Pezzot-Pearce 1997, Putnam 1997, Silberg 1998, 2013, Smith et al 1998, Waters 2005, Wieland 2011, Yehuda 2005, 2011).
Parents, teachers, caretakers, educators, pediatricians, nurses, coaches, dentists, and other child professionals can benefit from recognizing and understanding children’s reactions, and need practical tools for effective response. Children with developmental, relational, educational, and emotional difficulties are at high risk for trauma and overwhelm (Benedict et al 1990, Crosse et al 1993, Goldson 1998, Knutson & Sullivan 1993, Sullivan & Knutson 1998, 2000, Sullivan et al 1987, 2009). Realizing why children present a certain way, what triggers them, and how to minimize distress can improve communication and connection for everyone involved.
Advocating for Trauma-Sensitive Assessment and Therapy
Children end up at clinics and offices for all manner of reasons. Those who fall behind, forget directions, or do not express themselves well often get sent to speech-language pathologists. Those with misbehaviors, school refusal, or anxieties are taken to psychologists. Children who seem unable to tolerate stim- uli may see an occupational therapist; children in pain, physicians and physi- cal therapists, etc. Awareness to trauma and communication is important in all cases. Speech-language pathologists should watch for risk factors and clues in history and clinical presentation that may indicate need for trauma assessment by a psychotherapist. Psychotherapists need to keep aware of the prevalence and manifestation of language and communication issues in children with trauma histories and whether assessment by a speech-language pathologist is indicated.
All clinicians can guide caregivers in minimizing and attending to overwhelm.
In a perfect world, every child will have access to sensitive care that minimizes overwhelm, and receive informed care if trauma does happen. We are not there
Psychoeducation and Everyday Tools for Reducing Overwhelm
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yet. Limited awareness of traumatic impact on children’s communication and learning means that many children who struggle do not get assessed for trauma (Waters 2005). Cuts to funding often prioritize trauma referrals to blatant abuse cases or short-term advice after a tragedy or disaster. There remains a troubling tendency to minimize the prevalence and impact of trauma on children (Silberg 2013, Waters 2005, Wieland 2011), due to misinformation, politics, denial, taboos, and conflicts of interest (Freyd & Birrell 2013).
Nonetheless many professionals and caregivers are increasingly aware of the ramifications of trauma, the long-term impact of untreated overwhelm, and the availability of effective remedies (Gomez 2012, Kluft 1985, Levine & Kline 2007, Perry & Szalavitz 2006, Silberg 1998, 2013, Waters 2005, Wieland 2011, Yehuda 2005, 2011). Multidisciplinary research into developmental trauma is already serving to inform professionals and the public (Cozolino 2006, 2014, Gaens- bauer 2011, Scaer 2014, Schore 2012, Siegel 2012, van der Kolk 2014). Together we can help increase the numbers of trauma-informed lawmakers, educators, and clinicians who understand the implications of trauma and can offer children much needed support.
Reframing Problem Behaviors
Most people accept that bad things happen to children. However, knowing about children’s difficult beginnings does not always translate into understanding why they don’t listen in school, behave inappropriately, or ‘act oppositional’ (Silberg 2013, Smith et al 1998, Waters 2005, Wieland 2011, Yehuda 2005, 2011). Many of the coping behaviors of traumatized children can be disruptive, problematic, and unacceptable. Spitting, pushing, cursing, giving lip, throwing tantrums (or chairs . . .), ignoring, denying, and lying are rarely endearing. Teachers and care- givers can find “challenging kids” difficult to connect with, and because post- traumatic reactions can be out of awareness and/or control, misunderstandings and additional acting out often follow. By placing a difficult child’s behavior in the context of traumatic overwhelm, adults are more likely to hold a caring and rewarding connection. For both child and adult, understanding fosters better attachment and regulation.
Jennifer’s teachers saw her as “promiscuous” and “disgusting.” The eight-year-old constantly had “her hands down her pants,” displayed “seductive” behaviors, and used “gutter language.” She was almost universally disliked and often in detention for “misbehavior” (and her discomfiting presence). The gym teacher was especially uncomfortable and worried the child could get him in trouble if people misinter- preted her behaviors as his fault. He preferred to exclude Jennifer from his class for
“bad influence” and “inappropriateness.” Already struggling academically, Jennifer kept missing instruction. She was also frustrated, lonely, and locked in impossible binds of hunger for connection, inability to verbalize her needs, and punishment when she attempted to get them met.
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Staff knew that Jennifer had been molested as a preschooler and was in foster- care because of parental maltreatment. Both parents had addictions. The father admitted to “fooling around” with Jennifer and the mother reportedly let her drug dealer “spend time” with the small girl. Teachers rationally understood where Jen- nifer “learned this stuff ” but they still judged her ongoing sexualized behaviors as somehow complicit. “She seems so into it,” the classroom teacher grumbled. “Like this is what she wants.”
I met with the teachers to discuss the realities of entrapment and the desper- ate need of young children to make meaning and adapt to whatever circumstances maltreating adults place them in. Jennifer’s undesirable behaviors were the product of the reality she had lived. She communicated with adults the way adults showed her to—sexually. Like many sexually abused children, Jennifer may have learned to initiate sexual contact to control anxiety about when she might be abused. It was also possible that sexual contact was the only way Jennifer received warmth or contact. She might have learned to associate attention with sexual advances and receiving comfort with sexual stimulation. Jennifer was ‘telling’ her reality through her behavior and it was up to us to understand and reframe her needs in healthier ways, not to push her away for internalizing realities she endured.
Reframing helped. “I knew Jennifer had sexual abuse,” the gym teacher admitted,
“but I didn’t really think what it had to be like. Makes me mad—a small child stuck with adults doing these things.” Another teacher nodded: “Maybe that’s how she knows to get through life. Breaks your heart, it does.” With the child’s behaviors in context, the teachers found more compassion toward her and became less shaming.
They were also more open to noticing and reinforcing instances of good behavior, something Jennifer was hungry for and responded very favorably to. With increased positive attention for nonsexualized things, Jennifer seemed to have ‘less need’ for inappropriate behavior. Her teachers also became protective of her. When a para- professional commented, “This girl behaves like a ho’,” the classroom teacher jumped in with “This is what her lousy-excuse-for-parents taught her! Not her fault. The shame’s on them that did not protect her!”
Clarifying Boundaries and Expectations
Understanding and reframing children’s behaviors certainly helps increase compassion and empathy and lowers frustration. However, understanding and reframing are not enough. It is also important to have safe boundaries and real- istic expectations that are clearly stated and that the child understands and can succeed in keeping. For traumatized children, this is no easy feat. Children learn about boundaries and how they are kept (or breached) through experiences with implicit and explicit modeling of boundaries with them. Traumatized children often had boundaries (of their bodies, safety, and tolerance) violated or ignored (Diseth 2006, Gaensbauer 2011, Silberg 2013, Wieland 2011, van der Kolk 2014).
They may not know how to recognize, keep, or request boundaries. They can
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stand too close, ignore cues for avoiding or stopping touch, miss signs of dis- comfort, and misinterpret approval or denial. They may hit, grab, push, pull, lean into, rub against, take, hide, deny. They often do not know how to explain why.
“You would think he’d know how it feels to be hit,” Jimmy’s foster-mother com- plained, “after all the fists he got at his bio home, he should be the last person to hit others . . .”
“Or,” I offered, “he is hitting because it is how he saw frustration expressed and power displayed. It may even be the only way he knows to show he cares.”
“A very strange show of care—knocking someone’s teeth out,” Jimmy’s foster- mother muttered, politely dismissing my interpretation. She was speaking literally:
She’d rushed another foster-child to the dentist after Jimmy (age nine) boxed him in the teeth, loosening a brand new incisor.
“Yes,” I repeated meaningfully, “strange way indeed to show care . . .”
She paused and took a breath. “I forgot.”
Jimmy was removed to foster-care at five years old, after his mother’s boyfriend
‘disciplined’ him by punching him in the face and knocking out two teeth. Jimmy’s mature teeth have grown in since, along with his use of violence on others . . .
Understanding Jimmy’s behavior did not mean he could continue smashing people’s teeth out when he got frustrated or felt the need to ‘discipline’ someone.
Like other children whose bodies were exploited, intruded upon, disrespected, or neglected, he needed opportunities to learn and practice boundaries. He needed to be able to make mistakes, get gentle correction, and be praised when he suc- ceeded. We cannot assume traumatized children know how to keep body bound- aries or other boundaries. In fact, we should assume they don’t.
Body Boundaries
Body boundaries are often taught to children in reference to “good touch, bad touch” as part of sexual abuse prevention. More generally these include people’s right to their bodies and the right to say “no” to what is unacceptable—sexual or not—without apology or guilt. Under normal conditions, children should have the power to stop any contact they find uncomfortable or unwelcome. They should be able to have it stopped first and explain why later, or even not explain at all beyond “I don’t like this” or “I don’t want to.”
Things get tricky when conditions are not normal, such as if a child needs to be restrained for his safety or get medical treatment he does not approve of. It can be even more confusing when treatment involves intimate parts that children were taught were “no touch” areas or when their demand to “not touch there” or “let me go” cannot be followed. Because stress reduces language pro- cessing (van der Kolk 2014), children may find it difficult to process explanations for why rules are breached, and their confusion can increase. Even in the context of overall respect, boundaries can become untrustworthy after a breach, let alone
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for children whose boundaries were not kept and who have no blueprint of hav- ing power over their bodies.
Anytime a child’s boundaries have been violated—even for reasons adults believe were justified—it is important to repair them afterward. To explain what happened, validate the ‘rules’ and how and why this deviated from them, acknowledge the child’s rage and fear, apologize for breaking promises, and reaf- firm how boundaries are still real and important. Depending on the child’s dis- tress, distrust, and confusion, it might mean repeating the repair several times and providing opportunities for the child to ‘test’ that the rules indeed matter.
Without repair, children may worry not only about the rule that broke but that all rules are unreliable.
Careful teaching and explanation is even more essential to children who suffered ongoing trauma and disrespect of their boundaries (Silberg 2013).
Children cannot be expected to ‘maintain good boundaries’ without having had a way to internalize and establish what those are or why to keep them. We cannot assume that children understand boundaries by watching how they treat others, either. Some children learned to respect other people’s boundaries (or risk serious harm, abandonment, rejection, etc.) but do not extend these to themselves. Their needs remain unmet by people mistaking their lack of limiting for ‘not minding,’ and it leaves the children vulnerable for continued victimization.
It goes without saying that anyone working with traumatized children should be acutely aware of boundaries and of the children’s possible difficulty with understanding or verbalizing them. If a caregiver must restrain a child to pre- vent her from harming herself or others, these interventions must be followed with verbalizing the breach of boundary, apologizing for it, and ensuring that everyday boundaries and their limits are explained. The same goes for the child’s behavior toward others: We cannot assume children know or understand.
Using Touch with Traumatized Children
The daily care and protection of young (or disabled) children often requires physical contact: donning and doffing coats and mittens, zipping zippers, cross- ing safely, wiping noses, washing up. There are also therapeutic needs like work- ing hand-over-hand, correcting posture, and offering comfort and support.
Maintaining good boundaries around children should not mean refraining from affectionate or supportive touch. Touch itself is not the problem but how and why it is provided. Touching should always be done with care and respect, never in anger, and with the child’s level of comfort or discomfort in mind. Children may not verbalize their comfort with proximity but they communicate it in their bodies. They may express dilemmas by simultaneously leaning into and away, getting close and retreating.
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In my practice, unless I need to keep a child safe (e.g. from falling), I usu- ally wait for the child to initiate contact. How and when he or she does so tells me a lot. Some high-risk kids watch my interaction with others before they attempt proximity. Others reach out to me right away, though this does not necessarily indicate comfort with closeness—a child may be testing to see what I would do.
Most children allow and even seek touch once they feel they have the right to refuse it, stop it, and move away from it. However, for children whose body boundaries have been compromised, even the gentlest touch may not be com- forting. Sexually abused children can find affection scary and triggering, not knowing ‘where it leads’ or what is expected. Oversensitive children can find even casual touch intolerable. Neglected children may be confused by affection, and physically abused children may not know how to interpret touch that is not aggressive. Children’s own behaviors often reinforce unpleasant contact. If restrained, grabbed, and tugged back, they may fight back, reinforcing cycles of aggression. They might shut down and ‘leave’ their bodies, reinforcing dissocia- tion. Touch communicates, and traumatized children may need to be taught a
‘vocabulary’ of tolerable and safe physical connection.
Teaching boundaries includes narrating what they can expect from others:
what will and will not happen. This can put in words what was left unspoken, and help form a baseline for verbalizing ‘body language,’ needs, and reactions.
Erring on the side of overexplaining, I tell children I will never do anything intentionally to hurt them. I ask that if by mistake I do anything uncomfortable, they let me know so I can stop and apologize. For some children this is novelty:
They never had control over adults’ actions in relation to their bodies, let alone permission to tell adults they did wrong and have adults apologize. I explain that unless it is an emergency where I must keep them safe, they can always stop me or move away.
Then we practice. They give me a hand and pull it out, get close and move away. If my work involves touching their face for oral-motor and articulation work, we practice my touching their cheek or lips and their saying “stop” or “no,”
where I immediately do so. For reciprocity and mirroring I often have children do on me the exercises I do with them. And so we practice my saying “no” and
“stop,” so they can get praise for good listening. It provides experience with being the one who stops an action and chooses to respect another’s body, and helps children regulate their touch, improving mastery over their bodies near other people. We discuss (and practice) how people differ in what feels okay and the body clues that show that someone is uncomfortable. We practice how to ask permission and how to apologize if a breach occurred.
When children are aggressive, I verbalize it and remind them of rules we have already established. I might say, “Please stop this hitting/pinching/poking. It hurts.” If they continue, I might hold them back gently and explain: “You are
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hurting me. Please stop. I am holding your arms so you won’t punch anymore.
Punching is not okay. It hurts. I don’t want you to hurt me and I don’t want you to get hurt. I see you’re upset. Let’s talk about what is making you upset.” When children stop hitting, I ask if I can let them go without their hitting, and then apologize for holding them and repeat why I had done so. We talk about what happened, what they felt, how they feel now. If they hit another child, I would ask them to apologize to the child so that both children can be assured that physical aggression demands an apology. However, I rarely if ever demand an apology for hitting me—children usually offer it themselves when I model my regret over having to restrain them.
When children touch me inappropriately—and some do—I adjust their position and calmly explain my own boundaries (e.g. “I am moving your hand because it is touching my breasts and my breasts are private parts of my body.
You can still sit next to me and you can hold my hand or touch my arm instead,”
or “This kind of touching is not comfortable for me, but you are welcome to lean into me/hug me this way instead . . .”). I use language the children understand and verbalize both the reason for the changed position and the fact that they are still welcome to maintain proximity. I stay matter-of-fact and non-shaming, and I never push children away or punish them for touching me that way: They are being as appropriate as they know to be according to the rules they understand.
It is up to me (and all adults) to recognize their underlying needs and provide them with alternative rules that work better.
I don’t necessarily touch every child I work with, but to me touch is an inte- gral part of communication and understanding of boundaries, especially with young children, those with developmental delays, and/or those who experienced distorted interrelating. Touch is in fact part of many therapeutic interactions and can be used well with care and awareness. That said, not everyone shares the same level of comfort with proximity. If you are uncomfortable with touch, you should probably not use it. Ambivalence about physical contact is always com- municated. Children—especially maltreated children—can be acutely percep- tive of such ambivalences and will likely interpret it as shaming.
More Boundaries
In the complex strata of interpersonal boundaries, children need modeling for acceptable words and actions that can allow them to express themselves without damaging property, people, or relationships. They need to learn how to express difficult feelings such as frustration, rejection, fear, rage, shame, worry, as well as exuberance, excitement, joy, and affection. Here, too, practice is essential. Chil- dren need direction and opportunities to practice acceptable behavior in neutral situations before they can be expected to use it when flooded with a feeling.
It takes more than “we don’t do that” or “hitting is not okay” to learn how to