As my 12-year-old client whirled through my office, his tantrum had the feel of the Tasmanian Devil.
“I wanna call my mom now!” he yelled.
I’d told him that making a call at that moment was not an option—that he needed to calm down first so that we could solve whatever nuance of unmet expectation or perceived social slight was afflicting him.
Samuel lunged for my desk, leapt atop it, grabbed the phone, and began to dial frantically. My embarrassment-prone mind was thankful that I was alone in the group practice that evening. No colleagues to witness my incompetent management of my bipolar disorder and PTSD-diagnosed client.
“Come on buddy,” I said. “Let’s talk this out. There’s no need—”
“Shut up, a$&^%$!” he yelled.
I stepped forward and puffed myself up in an attempt to create a human bubble around him—a bubble that seemed about to pop at any second.
I said that he was “making the person who cared for him very nervous.”
Why I felt the urge to speak of myself in the third person was almost as notable as my desperate offer to give him some of my sandwich if he’d please simply calm down.
“F&%& you!” he screamed. “I’m calling her now!”
And then I did it—I reached and unplugged the phone from the jack on the wall behind my desk.
Samuel’s fury ignited into desk shoving and a flung chair. I called 911 from an adjoining office and had the paramedics take him to be screened for admission to a psychiatric inpatient unit.
Samuel laid on the gurney inside the ambulance the entire short ride over to the hospital.
In stark contrast to his swearing and yelling during his tantrum in my office, he lay like a discarded mannequin on the gurney. The paramedic who sat with us in the back tried to get Samuel to answer a few simple questions during the ride: “What’s your birthday? What seems to be the problem today? What medication do you take?”
But Samuel did not respond.
I looked away and out the back window. I wanted to watch anything but this boy’s face. It was reddened and tight from the malicious mix of sadness, fear, and anger squatting behind it. I’m not sure if I remember accurately that Samuel’s eyes were welling with tears during the ride to the hospital. It may very well be my own crying that my memory has pasted onto his face.
I do remember how he wouldn’t look at me as we rode to the hospital, the adrenaline-strangled silence inside the ambulance in stark contrast to the siren’s wail. The only question he responded to was, “What seems to be the problem today?”
“Ask him,” he said, flat and raw as a cancer diagnosis. “He’s the one that called you.”
Photo: MShep2 / iStock
Samuel had indeed crossed a threshold, and he certainly needed to go to the hospital. He trashed my office and made me feel as trapped and powerless as he did. Samuel had known far too much trauma and loss in his twelve years.
I felt I had far too few years of experience to know how to best help him.
Across the years of my professional work in residential, inpatient, outpatient, and therapeutic day-school programs, I have stubbed my toes enough in working with youth who have experienced trauma to have learned a few things that might benefit staff members who face the challenge of working with these children.
I will defer to others more expert than me regarding the specifics of the psychotherapeutic treatment of trauma in children (Judith Cohen at the Center for Traumatic Stress in Children and Adolescents in Pittsburgh, Pennsylvania; Bessel Van der Kolk at the Trauma Center at Justice Resource Institute in Brookline, Massachusetts).
The bottom line to treatment
The bottom line across approaches to treatment is to ground traumatized children in consistency and predictability of support in order to create a healing context of safety, as well as to slowly take the charge out of their learned traumatic reactions through skills training in understanding and modulating anxiety and behavior.
It’s also important to help kids author a new “narrative” of themselves, as opposed to whatever scripts were laid down in the midst of trauma, and the disruption to development that often occurs in its wake.
Why they react the way they react
Children who have experienced trauma (particularly over periods of time and at the hands of family members or caregivers) often react in an understandable, though maladaptive way. Their nervous systems respond to extreme sensory experience (trauma) by shutting/walling off and going into hyper-alert. These responses minimize the psychic and perhaps physical damage to their systems at the time of the trauma.
The problem is that this coping response may no longer match the environment.
How you can help
You, the professional caregiver, are not their abuser. You are there to help them, but these kids often seem to miss that fact. They are disconnected from the realities of their current sensory settings. Their bodies are over- and perhaps underreacting to their senses. They need help in reconnecting—with feeling safe with what their senses are telling them, and in trusting their ability to tolerate and navigate sensory and emotional experience.
Photo: Juanmonino / iStock
Here, we focus on pointers that staff members in various settings might find useful in working with this population. Recommendations fall into three categories:
- Preventing trauma behavior cycles in care settings
- Staff behavioral responses to trauma-reactive behavior
- Follow-up staff responses after difficult interactions with clients
Attention to all three areas helps ensure that staff members provide the essential context these children need to heal and get back on the appropriate developmental path. The more you learn to move beyond all that’s hard in working with traumatized children, and the more you loosen and think beyond the moment, the more you’ll actually help.
Children whose trauma has thrown off their emotional, social, and cognitive development need professionals to give extra attention to creating a supportive, trauma-sensitive treatment milieu.
If you are not exceedingly proactive with your interventions, you end up like the young me in the example above—chasing your own knee-jerk reactions instead of shaping responses that coach and lead kids toward more adaptive functioning.
Here are some prevention tips:
- Crisis training. Children who have experienced trauma have the potential to lash out when “triggered” and may not provide significant warning. Your crisis management training is crucial for helping you develop skills that are automatic and consistent. The more your responses are “overlearned,” the less you will tend toward reactions that inadvertently feed the trauma cycle. Keep these skills current and revisit them often.
- Feedback/communication training with staff. Trauma-reactive youth can make your program setting the “canvas” on which they paint their inner turmoil. They push and pull at those with whom they’re connected, and overreact to minor stressors. They irritate, frustrate, and intimidate. Your patterns of staff-to-staff communication will be strained in working with such clients. You will step on each other’s toes, undo each other’s limits, make promises you shouldn’t, and any of an infinite number of other communication snafus. Emotions can run high among staff in such situations. Proactive attention to training each other in how to give authentic, constructive (though at times awkward) feedback, and how to manage the morass of difficult communication, will be time and money well spent.
- Taking inpidualized “trigger” inventories with kids. Spend the time with kids to learn their unique patterns. Through observation and interaction, find out what buttons they carry that, when hit, spark trauma reactivity. The more you learn to recognize their patterns, the more you can intervene early to shift the cycle. Here’s where it can also be crucial to involve parents and family members. Their collaboration is key to forming a strong therapeutic alliance, and for learning about the child.
- Training in conceptualizing trauma. It is tempting to get stuck in viewing these children as “intentionally” acting out and being disruptive. Doing so sparks your own negative reactivity, and decreases your effectiveness. Learn all you can about the “big picture” and the process of trauma, its manifestation for kids, and how relationships (such as with you) can become a primary battleground for them as they struggle toward healing.
- Training in sensory strategies for self-regulation. Occupational therapy techniques have been shown to be extremely beneficial for children whose nervous systems work in overdrive due to traumatic disruption. Make sensory strategies universally and readily available to kids, and make them interactive and engaging. Used early in the cycle, such interventions can make the difference between meaningful learning and meltdowns.
- Community development. A treatment milieu that puts the premium on quality of connection as opposed to compliance will have fewer trauma-reactive crises to manage. Kids will feel supported and contained, and you (by the way) will feel more engaged and supported as well. Go out of your way to note and build up the strengths in these children. Champion them and watch them look to you for support when their strengths are less evident.
Photo: Juanmonino / iStock
Staff Behavioral Response
Let’s assume you’ve attended to all of the above and yet, a particular client manages to dump his reactive mess at your feet anyway. You need to manage the behavior, but it’s important that you do so with less the attitude of a “bouncer,” and more that of a coach.
- Prompting in the use of self-regulation strategies. Without shoving strategies down kids’ throats, make it a habit to nudge them toward more adaptive ways of soothing their bodies and channeling their energy. Don’t wait for the behavior to erode. Instead, lead the child into an activity that engages and teaches simultaneously. It’s common to get “stuck in the headlights” when young clients escalate. What if you lead them Pied-Piper-style into some yoga poses, or a sensory strategy? At the very least, you’ll burn a few calories.
- Limit setting. YES, you need to set limits with these children. YES, you must be consistent despite the traumatic genesis of their issues. And YES, you must be highly attuned to the child, letting her know that you know there are understandable bad feelings behind her not-so-nice actions.
Follow-Up Staff Response
You’re doing great. Your approach is preventive; you’re prompt to react, and now you’re following up after an episode. “Staff Member O’ the Month” gold sticker for you!
Here’s what I hope you and your agency already do in the wake of trauma-reactive episodes. If this isn’t a part of your process, begin with a conversation as to why it isn’t—and how it could be.
- Debriefing meetings. Everyone involved in a significant episode with a student should get together (for at least 15 minutes) as soon after the episode as possible to debrief their reactions, as well as to conduct a “chain analysis” (a timeline rundown) of the episode. These meetings are not about pointing fingers, but are instead about uncovering the missed aspects of the trauma pattern. Make such meetings an iron-clad part of your agency’s culture and you will see results. Trauma-reactive children have a way of unintentionally stirring up provider teams. You need to get together and learn from each other. What could we do differently next time? Here’s where authentic, constructive staff member communication comes in again.
- Feedback loops. Circle back to the child and to the child’s parents. Don’t merely report the facts of an episode, but connect with the child and his family. Talk about their emotions and the ripple effects of behaviors. Ask for their experience (and really hear it). Make them feel like crucial links in learning new patterns for the future.
- Repair work. Children who act out from a place of trauma reactivity are well aware that they’ve done so. They may not “move on” like other clients, and therefore benefit greatly from extra attention to repairing therapeutic relationship ruptures. Let the client know he matters to you, and that there’s nothing he could do to turn you away permanently. And yet, help him “repair the damage” caused by his extreme behavior. It’s a dual message: “I care about you and I care about you caring about others.”
- Address burnout and vicarious trauma. If you’ve worked with enough trauma-reactive children, you know a bit about this already. Hopefully, you’ve learned the crucial importance of addressing your own excessive (perhaps punitive) reactivity, the shutting down, avoidance, numbing, snappishness, etc. Talk to supervisors and each other. Pursue your own therapy. Bottom line: Don’t take others’ trauma deep into yourself.
As we end this discussion of how to go about doing the best work with this very challenging group of clients, let me summarize things with something written more from the perspective of children themselves. It’s important to wonder about the “voices” of these children. Research and clinical experience are crucial, but so is the experience of those we’re caring for.
Photo: jpmediainc / iStock
Things I Need You to Know . . .
I need lots of attention.
Even when I swear at you, I still need your attention.
I will talk endlessly about stuff like video games because that’s all I’m really good at.
I will do odd, quirky things that always seem to get weird looks from people.
And when I tell you I don’t care, it really means I just don’t know how to let myself care.
The four letter word that makes me the most uncomfortable is “SPED.”
I don’t want to be here because it means I failed in order to get here.
I’ve never belonged to things much in the past.
I learned a long time ago to reject you before you can reject me.
Did I mention that I want your attention?
I’ll be looking for ways to get control by hitting your buttons,
And by “splitting” you against one another,
And against my family as well,
And by sparking other kids to get in trouble,
Because control is something I’ve been without for quite awhile.
My file says I’m not retarded but I think I am.
My diagnosis crawls through my file like some sort of bug I want to squash.
You WILL misunderstand me.
You WILL assume I’m being “lazy” or “manipulative” or “nasty” on purpose.
I really just don’t know what else to do to not have to feel the way I feel.
Every day, my medication is a reminder of how I’m sick but you can’t see how.
Bald kids with cancer get cards and warm smiles.
I get blamed and punished because I’m bad.
And even if you tell me I’m not bad, I won’t believe you.
It’s your job to say nice things to me, so again, I won’t believe you.
But did I already say (because it’s hard for me to focus on things and I forget) . . .
I really want your attention?
I just want a chance to fit in; to do something right once in a while.
I just want to feel okay for a day.
I just want my family to be proud of me for once.
I just don’t want to have to remember all the bad stuff from before all the time.
I just want you to follow through on your promises to me (because others haven’t).
I just don’t want you to confuse my actions with who I really want to be in the future.
And yes, before I forget, the future means almost nothing to me.
I will try to embarrass you.
I will try to make you angry.
I will try to make you nervous.
I will try to make you hate me.
Because then I will know I’m not crazy for feeling these things myself.
Because then I will know who I can begin to trust.
And trust is five letters because it’s better even though it’s hard.
Four-letter words are just easy but if I can get to five letters then . . .
Maybe I can make it to six, and then . . .
Maybe I can start CARING. . .
And then maybe, just maybe, I’ll let myself believe I deserve your attention.
Download a copy of the poem[PDF].
About the Author
Dr. Mitch Abblett is a clinical psychologist and the Clinical Director of the Manville School, a Harvard-affiliated therapeutic day school program in Boston, serving children and adolescents with emotional, behavioral, and learning difficulties. He maintains a private therapy and consulting practice (Incite Consulting Group), and has written books on mindfulness, professional development, and family mental health, including The Heat of the Moment in Treatment: Mindful Management of Difficult Clients (W.W. Norton) for clinicians, and the upcoming workbook, Mindfulness for Teen Depression (New Harbinger). He has also co-authored the child/family-friendly practice aid Growing Mindful: A Deck of Practices for All Ages (PESI Publications). Dr. Abblett blogs on mindfulness and family life/parenting on Mindful.org, and conducts national and international trainings on mindfulness and its applications.
Editor's note: This article was originally published in the Journal of Safe Management of Disruptive and Assaultive Behavior, Spring 2013, © 2013 CPI. Certified Instructors, log in to read more JSM articles.