Aggression As an Outcome Of Trauma
NYIPT Workshop at ACS
Gloria Malter, L.C.S.W. and Tracy Simon, Psy.D.
On July 12, 2006 NYIPT conducted a training workshop with mental health workers at the Administration for Children’s Services (ACS). These workers see children who have been taken from their homes and are awaiting foster care placement.
Donna Smith, Director at ACS and NYIPT Candidate, oriented us to the activities, needs and problems at the agency. She explained that many of the children seen at ACS have been victims of trauma and appear to be very angry or aggressive. Our workshop on how to understand and manage children’s aggression was greatly needed.
As part of the training we broke into small groups and some of our candidates, graduates and faculty served as facilitators, helping the workers speak about their own personal worries, angers and concerns so that they could better relate to the children on the job. We even added an exercise on stress management at the end of the session to help the workers take care of themselves!
In reaction to the small groups NYIPT Graduate Nneka Njedeka said:
“Initially I expected the staff to speak at length about the children they worked with on a daily basis and the various traumas they have been exposed to. However the ACS group I volunteered with spoke in detail about the traumas they experienced during their childhood and it turned into a support group for ACS staff. During the group I realized the extreme importance for ACS staff to have ongoing support and therapeutic training.”
Providing support to the staff of ACS staff has left a lasting impression on me.
This workshop was so well-received that NYIPT was asked to return and conduct a series of training workshops on working with adolescents! We’ll report on these meetings in the next edition of NYIPT TODAY.
Clinical Interventions
Gloria Malter, L.C.S.W.
Although I have had many years of experience in a school setting and then in a mental health clinic in East New York, not even during the height of the crack epidemic did my colleagues and I live with the pressures that you are experiencing here.
All of you at ACS live with trauma on a daily basis through your contact with traumatized children. In order for us to have a common language, I will begin with a definition of “trauma” and its consequences. Trauma can be a sudden event or it can occur over time. Dr. Nancy McWilliams writes “[Trauma is] a catastrophe that overwhelms our capacity to cope, especially if it involves unbearable pain and/or terror. Experiencing trauma can diminish a person’s ability to think, or act in the face of overwhelming emotion.
Traumatized people may confuse ordinary stress with life-threatening circumstances … [and therefore tend to overreact. The experience of] trauma causes structural [change and] injury to the brain [and]… it causes emotional disturbances which are prolonged for some time. [Childhood] trauma is a situation where the child’s psyche is bombarded by stimulation of such intensity that it cannot be mastered or discharged. Anxiety develops automatically.”
At ACS you are dealing with experiences of trauma that children suffer which can be broadly divided into abuse, neglect and abandonment. The ongoing experience of abuse, be it emotional, verbal, physical, or sexual, will profoundly alter a child. The American Academy of Pediatrics states, “Abused and neglected children (in or out of foster care) are at peak risk for not forming healthy attachments to anyone… To develop into a psychologically healthy human being, a child must have a relationship with an adult who is nurturing, protective, and fosters trust and security. Attachment to a primary caregiver is essential to the development of emotional security and social conscience.”
Many of the children you see have been subjected to intense emotional stress during critical periods of early brain development and personality formation. The age of the child dictates the developmental response and manifestation of stress, and, as was noted before, will become traumatic, with lasting effects, if the stress persists. When an infant is under chronic stress, the response may be apathy, poor feeding, withdrawal and failure to thrive. These we can call “flight” responses. When the infant is under acute stress, the typical “flight” response to stress may change to a “fight” response in reaction to an impending threat. The child may give up on crying because crying did not elicit a response and may begin having temper tantrums, aggressive behaviors or inattention. Repeatedly traumatized older children often experience PTSD and when feeling anxious may automatically freeze. Those of us who are interacting with these children can easily view them as oppositional or defiant when they do not answer or respond to our requests.
I’m going to list a number of major responses to trauma that both adults and children may exhibit. As I do so, please think about whether you have experienced any of these symptoms yourself as you have worked with these children. The symptoms of trauma are: disorientation in time or place, difficulty in concentrating or remembering things, feelings of helplessness or being overwhelmed, agitation or anger, trouble sleeping, sadness, and/or apathy. Do any of these symptoms sound familiar? If they sound familiar to you, you may have experienced transmitted trauma. Children experience these reactions in response to trauma in addition to the specific reactions of childhood including: bedwetting, fear of the dark, thumb-sucking or other regressive behaviors, withdrawal and isolation, refusal to cooperate, stubbornness, sadness and anxiety, resistance to school, recklessness, repetitive play, fighting and irritability.
So just a few words here about transmitted trauma: how does the trauma you are in contact with on a daily basis affect you?. When we travel by plane we are told about emergency procedures, we always hear, “If you are traveling with a small child, first put the oxygen mask on yourself and then help your child.” When dealing with traumatized children we must protect ourselves in this stressful environment before we can help them.
Ms. Smith told me that the children housed in this center come in with a variety of diagnoses, including autism, conduct disorders, schizophrenia, ODD, etc. Aggression is one possible outcome of trauma, and I understand the most troubling if not overwhelming consequence you are faced with at ACS. Given the time constraints, I shall focus on those children who behave so aggressively so fast as to take your breath away and threaten your professionalism.
A child who has experienced a loving and consistent home can be focused, organized and able to learn most of the time under stress.
I mention this to remind ourselves of how far from the norm are children who have been hit, burned, starved, misused, abandoned, or children who have watched their mother being beaten, which, in effect, means they have also been beaten.
In the book Children Who Hate, the authors Fritz Redl and David Wineman write, “There is a great difference between a child whose basic personality is still in good enough shape to be approached by psychiatric treatment or through the design of a benevolent institutional program and the child in whom some of the normal behavioral controls have already been destroyed by those who hated him (or her) so much when he was dependent and weak and who by now is but a helpless bundle of aggressive drives.” These are the children we are talking about – they are often an angry “bundle of aggressive” energy.
Ms. Smith told me of a 15-year-old girl who recently became so wild and out of control with rage and hate that it took several police officers to restrain her and tie her down. While this particular situation may have been unavoidable, sometimes it may be possible to short-circuit or avoid the explosive event by being tuned-in to cues from the child that may indicate that his or her rage may be building. For example, if you notice signs of agitation in the child, such as leg-shaking or other compulsive discharging of energy, you might say to the client, “Maybe, I’m talking too much. I’ll stop talking for a while. Is that alright?” This offers the child an opportunity to cool down in his or her own time. After allowing “sufficient” time, you might then ask, “Are you okay to continue our conversation now or do you need to wait a little longer?"
When writing about Children Who Hate the authors say that these children “very soon become the children nobody wants.” Even when we know how they got to be who they are and that they are not ‘at fault’, by the time we meet them, (given how sick they are), it is sometimes impossible to tolerate these children, even for those of us who really care about children.
We would not be so presumptuous as to come here and say, “Here, this will solve your problem tonight.” What we can hope to accomplish tonight is to present a mind-set which you may have already put into practice on some level, that just as a building that is threatening to fall can be shored up with supports, so, too, a boy or girl who has an ego that can’t perform can be shored up.
In research described in the book Children Who Hate, there are three principles of working with a population similar to the one you work with. We would like to present these three principles, or values, as a mindset that can be productive in searching for ways to manage and help these difficult children.
THREE BASIC PRINCIPLES FOR DEALING WITH AGGRESSIVE CHILDREN WHO HAVE BEEN TRAUMATIZED:
1. We must offer them complete protection from traumatic handling by any personnel associated with the facility. This must be guaranteed. No one in the facility can afford to duplicate traumatic handling that has occurred in previous life situations, handling that has contributed to the creation of the child’s disturbance pattern.
2. We must provide age-appropriate activities in a caring manner. In addition, all offerings must be absolutely divorced from any consideration as to whether the child deserves them or not from the point of view of his behavior. From the point of view of psychology, to withhold such gratifications because a child was "bad" or could not receive what we offer would, in the cases of the children who hate, be as unsound as taking away cough syrup from a child with bronchitis because he refused to stop coughing.
And last, the third principle is:
3. We must develop tolerance for the child’s symptoms and give leeway for regression. This must be an intrinsic part of the environment. Techniques must be developed for purposes of protective interference on the part of the staff in moments when the overflow of excitement and stimulation involved in some behavior will force the child into overwhelming guilt, anxiety, fear, depression, or rage, unless checked.
Adapted from Children Who Hate by Fritz Redl and David Wineman
Discussion of malter’s paper
Tracy Simon, Psy.D.
As Ms. Malter illustrated in her wonderful paper entitled, Aggression as an Outcome of Trauma, children removed from the home due to parental neglect or abuse experience trauma at multiple levels and often transmit their trauma onto others. These children, harmed by those who are supposed to protect them, come to ACS with fear, anger, uncertainty, self blame, and isolation. Aggression is one response to trauma that often creates anger and frustration in others, thus repelling caregivers and repeating the trauma of feeling unloved.
I my discussion, I will review the definitions of trauma and discuss reactions to trauma by age groups. Following this review, I will offer clinical techniques specific for interviewing traumatized children at ACS.
Trauma is an acute or chronic exposure to an extreme stressor, including a direct personal experience of an event that causes actual or threatened self-injury, witnessing death or injury of another person or learning of an unexpected or violent death or injury of another person. Experiences of trauma overwhelm the system and can be disorganizing, terrifying, and confusing.
Common reactions to trauma include re-experiencing, avoidance and increased arousal. Re-experiencing reactions include nightmares, flashbacks, feelings of guilt, and intrusive thoughts. Avoidance reactions include avoidance of feelings, people, places associated with trauma, diminished interest in activities, detachment, numbing, dissociation, restricted affect, and sense of foreshortened future. Increased arousal reactions may include intense anxiety, helplessness, sadness, difficulty falling or staying asleep, irritability and anger, difficulty concentrating or making decisions, hypervigilance and exaggerated startle response, as well as somatic complaints such as headache, stomachache rapid breathing, pounding heart, sweating, exhaustion, and/or worsening of chronic conditions.
Reactions to trauma differ by age group. Preschoolers lack the verbal and conceptual skills to cope with stress and often react to feelings of helplessness and fears of abandonment with regressed behavior such as clinging, bedwetting, thumb sucking, and night terrors. School age children can understand the separation from home and often become fearful of permanent loss. They tend to respond with regressed behaviors, aggressive behaviors, such as competition with siblings and classmates, as well as avoidance behaviors such as school refusal, not wanting to be separated from parent, and physical complaints. Adolescents often exhibit a combination of childlike and adult reactions. They may respond with physical complaints, depression, such as isolation, withdrawal, sleep or eating disturbance, agitation or decreased energy, as well as risk taking behaviors such as rebelliousness, aggression, and delinquency. Children admitted to ACS have often experienced chronic, intergenerational stress and trauma. These kids are more vulnerable than others and may respond with numbing and dissociation or may have exaggerated reactions that exacerbate previous symptoms.
As Ms. Malter described and our small group discussions highlighted, children’s trauma is often transmitted to care providers. As providers, we can both identify with these children based on our own experience of trauma or through the child transmitting their feelings onto us. As service providers, it is our job to receive, hold onto, and name these feelings for the child.
Traumatized children often use projection and, as care providers, we are constantly the receptacle for children’s projections and intolerable emotions. We can come to know and empathize with a child’s experience by becoming aware of our own thoughts and feelings while sitting with a child. Via countertransference reactions, we become aware of the child’s experience, which most often includes feeling sad, hopeless, scared, hated, abandoned, alone or unloved.
As Ms. Malter discussed, when a child is feeling vulnerable, threatened or pushed by you in the interview, we can assume they have been pushed before, whether physically or emotionally, and it is your job to slow it down, name the feeling, and adjust the pace, tone and questioning of the interview accordingly. In therapy we have the privilege of getting to know the patient over time, but at ACS, service providers have only a few hours in the middle of a crisis, so there will be heightened emotions for everyone. However, it is our job as the adults and the safe providers to hold onto the feelings the child cannot, without attacking back or repeating the abuse the child already experienced, no matter how much the child provokes you.
Some useful clinical techniques for interviewing traumatized children include talking about events in a factual, open and honest, but structured way. Find out what the child thinks and feels. Many children have distorted information and make false assumptions, such as self blame for being removed from the home. Take the child’s lead; let the child ask questions, which may need to be repeated many times in different contexts without feeling as if you must know all answers to all questions.
Continually reassure children about their safety and decrease traumatic stimuli by attempting to create a calm, soothing environment. Anticipate increased emotional and behavioral problems, including regression and aggression, which often resolve with reassurance, patience, and nurturing.
Additionally, caregiver’s reactions influence the child and children respond to the emotional intensity around them. Therefore, it is important to monitor your own hate, rage, and frustration. Additionally, it is important for care providers to recognize their own mental health and physical needs and to address these appropriately.
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