Steele, Raider Article

A program of
Children's Home of Detroit

ARTICLE

Structured Sensory Intervention
for Traumatized Children, Adolescents, and Parents
William Steele, MSW and Melvyn Raider, PhD

This article is reprinted from TLC's Journal,
TRAUMA AND LOSS: Research and Interventions, Volume 1, Number 2, 2001

William Steele, MSW, PsyD is the founder and director of The National Institute for Trauma and Loss in Children, as well as consultant to schools and agencies across the country and a frequently requested presenter in the area of children and trauma. He is currently completing his Doctorate in Psychology.

Melvyn Raider, PhD is Associate Professor at Wayne State University School of Social Work and serves as Chair of the Post-Masters Certificate Program for Social Work with couples and families and is Chair of Research.

Abstract: This article reviews eleven years of field-testing, focused feedback sessions, anecdotal information and research of intervention programs designed to assist children, adolescents and parents exposed to trauma-inducing incidents. These efforts were conducted by the National Institute for Trauma and Loss in Children in schools and agencies across the country and resulted in a series of intervention programs which made up the Institutes Structured Sensory Interventions for Traumatized Children, Adolescents and Parents (SITCAP) Model. The use of drawing as a primary sensorimotor activity to facilitate the safe reexperiencing of the incident, the use of structured, trauma-focused questions addressing the major themes of trauma to facilitate the development of the trauma narrative (telling the story), and cognitive reframing statements designed to shift from victim thinking to survivor thinking were the primary intervention strategies used in each program. The SITCAP model has been instrumental in assisting victims seen in schools and agency settings find relief and resolutions of reactions to their trauma.

Introduction

Structured Sensory Intervention for Traumatized Children, Adolescents, and Parents (SITCAP) is the result of eleven years of development, field testing in school and agency settings, and research by the National Institute for Trauma and Loss in Children (TLC). SITCAP includes trauma specific intervention programs for pre-school children three to six years (What Color Is Your Hurt? Steele, Kordas, 1998); children six through twelve years (I Feel Better Now! Steele, 1995); children six through twelve years and thirteen through eighteen years (Trauma Intervention for Children and Adolescents, Steele, 1997; formerly the Trauma Response Kit); (Parents in Trauma: Learning to Survive, Steele, 2001), and (Debriefing for Schools and Agencies, Steele, 1999).

A combination of formal research, case studies, focused feedback sessions, and anecdotal accounts have been used since 1990 to develop these programs. They are now being used across the country in over 1,500 school and agency settings with children and families exposed to such incidents as murder, suicide, sexual/physical assault, domestic violence and other forms of violent acts; car fatalities, house fires, drownings, critical injuries, terminal illness, divorce, and separation from parents.

The SITCAP programs address ten major trauma reactions: fear, terror, worry, hurt, anger, revenge, accountability, powerlessness, absence of safety, and victim thinking versus survivor thinking. Primary intervention strategies include exposure, trauma narrative, and cognitive reframing. Drawing is a major component of exposure. The trauma narrative is facilitated with the use of trauma-specific questions, and educational materials facilitate cognitive reframing. Each intervention is structured for the purpose of creating a sense of safety for the child, adolescent, or parent while re-experiencing, re-telling, and re-framing of major trauma reactions. The restoration of a sense of safety and power is of primary concern in each program. The activities are primarily sensory activities, as trauma is experienced at a sensory level not a cognitive level. The structure of the intervention, however, directs those sensory experiences into a cognitive framework, which can then be reordered in a way that is manageable and empowering.

Why SITCAP Programs Are Unique

They can be applied to either violence-induced trauma or non-perpetrated, non-assaultive trauma-inducing incidents.
They are brief interventions designed to meet the unique intervention parameters in school settings where children are most accessible, or to support more clinically focused interventions in agency settings.
The programs address both grief and trauma-specific reactions.
Each program is very structured in its directions, interventions, and activities to sequentially and systematically ensure the individual is given the opportunity to safely address each of the major themes of trauma.
Each program provides educational materials related to trauma and the interventions which are beneficial to the recovery process.
The model focuses on trauma reactions: fear, terror, worry, hurt, anger, revenge, accountability, powerlessness, absence of safety, and being a survivor versus a victim, rather than symptoms.
The model encourages parental involvement through specifically structured sessions designed to obtain necessary information and to allow parents to witness how the trauma has impacted their child.
A specific eight session program also helps those parents who themselves have been traumatized and need assistance to recover from their own trauma exposure.
Resource materials, in a structured booklet format, are provided for parents to ensure they receive information on the differences between grief and trauma as well as the course the intervention will take.
Exposure is accomplished through structured drawing activities, developing the trauma narrative through asking trauma specific questions, and cognitive reframing through use of the reflective statements.
The model is outcome driven. A Posttraumatic Stress Disorder (PTSD) Questionnaire identifies initial reactions and their severity levels and provides a baseline to compare final outcomes with initial assessment. It is clinically based, so it serves as a diagnostic tool to support third party insurance requirements for approved treatment and if needed, continuation beyond the short-term period.

Theoretical Foundations

Freud believed that the ego would actively attempt to rid itself of a traumatic experience by an effort of will and that trauma was not the result of an incident itself, but “an interaction between the patient’s intrapsychic organizing tendencies and the external event” (Piers,1996, p. 545). The trauma therefore was seen as a psychic one not an external one. Freud basically suggested that an incident became traumatic as a result of “psychology of unique sensitivities of the patient” (Piers, 1996, p.545).

McFarlane (1998) states that intrusive reliving rather than the traumatic incident itself is the cause for the complex, biobehavioral change referred to as PTSD. Repeated intrusive thoughts and images cause the individual to attempt to avoid the reexperiencing of trauma. Traumatized individuals have difficulty with such intense and overwhelming reactions and become unable to utilize emotions as guides for actions. Bessel van der Kolk, McFarlane and Weisaeth (1996) concurs, indicating that PTSD causes people to “experience their internal world as a danger zone that is filled with trauma-related thoughts and feelings. They seem to spend their energy on non-thinking and planning. This avoidance of emotional triggers, further diminishes the importance of current reality and paradoxically increases their attachment to the past.” (1996, p. 419)

Piers (1996) describes the constant “recalling” of trauma as being “triggered by similar auditory, visual, affective and relational cues” (p. 545). He also suggests that the trauma is dissociated from the rest of the mind “through concrete, structured partitioning. Trauma theorists theorize that the trauma incident is remembered in an unmodified form, not in symbolic representation as suggested by Freud. Despite the differences that exist between modern trauma theorists and Freud, there are critical areas of agreement. Piers (1996) writes,

“They agree that human actions can be influenced by non-conscious mental content (repressed trauma memories can alter behavior and personality...that the mind can preserve impressions from childhood long into adulthood (trauma remains active in its influence on behaviors, personality)...and that (most critically) the trauma experience needs to be integrated into consciousness (or the) patient’s larger experience of self.” (p. 545)

Motivated by the theoretical belief that trauma needed to be integrated into consciousness, Freud, Breys and other analysts worked at bringing the trauma experience into consciousness and helping the patient provide a detailed account of the experience (Piers, 1996, Emery, 1996). Saigh (1999) and others have conducted numerous case studies with children that strongly supported the use of exposure, cognitive based interventions with children.

Exposure-Based Intervention

Re-exposing the trauma victim to his experience has remained a core component of trauma intervention. Malleson (1959) used “in vitro” exposure as a way to reduce severe anxiety. Stampfl (1961) combined Malleson’s exposure techniques with that of Freud’s approaches to develop “implosive therapy.” This process of identifying cues triggering the trauma memories and reactions and then exposing the client to these cues repeatedly resulted in the extinction of trauma reactions.

Rachman (1966), Marks (1972), Saigh (1987, 1999), and others have utilized exposure as a core process in helping trauma victims integrate their experience into consciousness. Bessel van der Kolk, McFarlane and Weisaeth (1996) stated:

“Traumatic memories need to become like memories of everyday experience, that is, they need to be modified and transformed by being placed in their proper content and restructured into a meaningful narrative. The purpose of full exposure is to make the fragments of the traumatic event lose their power to act as conditioned stimuli that reactivate affects and behaviors relevant to the trauma, but irrelevant to current experience. Thus, in therapy, memory paradoxically becomes an act of creation rather than the static (fixation) recording of events that is characteristic of trauma-based memories.” (p. 420)

Exposure Techniques

Exposure techniques are derived from learning theory. Mower’s two-factor theory was at the core of the variety of exposure techniques that have been developed. Mower suggested that fear is “acquired via classical conditioning, when a neutral stimulus is paired with an aversive stimulus or unconditioned stimulus. The neutral stimulus, now a conditioned stimulus, came to illicit a fear response (Saigh, 1999, p. 376).” Fear is maintained through operant conditioning (re-experiencing of aspects of event) and the efforts to avoid or escape these responses.

In trauma, even when the unconditioned stimulus is removed (the incident itself), the continued attempts to avoid the fear prevent the realization that the conditional stimulus no longer leads to negative consequences. In other words, the avoidance efforts support the fear. When traumatic memories are not integrated into consciousness via activating exposure to them and then modifying them into an integrated memory, the memories then continue to trigger the traumatic state or conditioned responses.

Exposure techniques are designed to help the trauma victim realize that the conditioned responses are no longer dangerous and avoidance no longer necessary. The ability to learn to tolerate the intense fear and emotional reactions experienced by a traumatic event is a critical part of recovery. From here the experience can be modified or reordered into a form that is acceptable and manageable by the victim -- a cognitive restructuring into a meaningful, integrative narrative.

Foa and Kozah (1985) stated that two conditions were required for the treatment of PTSD and the reduction of fear:

The traumatic memories must be reactivated in order to be modified. The ability to decrease fear or anxiety is dependent upon the controlled reliving of that fear in a safe environment so as to be able to diminish the response to it;
Corrective information must be provided so that the victim can form a new narrative or meaning that places the traumatic memory to the place and time it occurred as opposed to generalizing that experience to everyday life.
Thompson et al (1995) and others have shown significant results in the reduction of trauma reactions when using exposure techniques with a variety of traumatic experiences. Blake (1993) conducted a variety of single case studies with children and other traumatized populations with similar results. Taken collectively, these studies provide “consistent evidence for the efficacy of imaginal and in vivo exposure in the treatment of PTSD” (Saigh, 1999, p. 379).

Cognitive Therapy

Aaron Beck (1972, 1976) pioneered cognitive therapy, which was then further developed by Marks (1992), and others. The basic premise of cognitive theory is that thought drives emotion. Similar situations may lead to different emotional states based upon the way that situation is interpreted (e.g. thought about) by the different individuals. Disturbing, anxiety ridden, pathological emotional states are driven by dysfunctional thoughts. Cognitive therapy suggests that by changing the thoughts, the emotional states change.

Cognitive therapy helps the individual first identify the thoughts (traumatic memories), evaluate their validity, challenge erroneous or defeating and destructive thoughts, and then replace these with thoughts supportive of health or manageable emotional states (Saigh, 1999). This process is referred to as cognitive restructuring.

The studies on the effectiveness of cognitive therapy with PTSD are few, but those that do exist strongly suggest its value and efficacy. Cognitive therapy becomes beneficial in the integration of trauma memories into conscious memories. In other words, the thoughts associated with that experience are altered to reflect the current life space. They are reordered in a way that these memories now become manageable. An example might be, “I survived this experience. I will survive other experiences because it has prepared me, made me stronger, etc.” This is referred to as “survivor thinking” versus “victim thinking.”

Cognitive restructuring studies are also limited, but their outcome certainly supports their efficacy with PTSD and especially as an adjunct to exposure therapy. Cognitive therapy has become a component of Stress Inoculation Training (Meichenbaum, 1974), one of the anxiety management treatments for PTSD which studies support as an effective treatment of PTSD. Cognitive therapy is used to provide a rationale for the victims to expose themselves to the pain of their experience. It is also used to reframe their perception of that experience and as a means of stopping dysfunctional thinking.

Overall, the use of exposure and cognitive-based therapies have shown to be effective and essential components of successful PTSD therapy.

Drawing

Cognitive psychology has demonstrated “that memories determine the interpretation of the present even when they are not conscious” (Mihaescu & Baettig, 1996, p. 239). Children experience trauma at a sensorimotor level then shift to a “perceptual (ionic) representation to a symbolic level”(Mihaescu & Baettig, 1996, p. 239). Later in adult life these memories are ordered linguistically. When a terrifying incident such as trauma is experienced and does not fit into a contextual memory, a new memory or dissociation is established (van der Kolk, McFarlane and Weisaeth, 1996). When that memory cannot be linked linguistically in a contextual framework, it remains at a symbolic level for which there are no words to describe it. In order to retrieve that memory so it can be encoded, given a language, and then integrated into consciousness it must be retrieved and externalized in its symbolic perceptual (iconic) form.

Drawing is a form of exposure therapy used to assist in constructing the traumatic narrative while at the same time reliving that memory. SITCAP interventions provide the individual an opportunity to create a visual (symbolic) representation of what the experience was like and to share it with the interventionist. Trauma-specific questions are used to help the individual develop his or her story; in other words, to give it a language. At this point cognitive reframing helps to reorder it cognitively, in a way that is now manageable.

Pynoos (1986) observes that drawing was used as early as the First World War to access repressed memories of traumatic scenes. Malchiodi (1998) states that drawing provides children an impetus to tell their story. It provides the child the ability to translate his traumatic experience into a narrative. Riley (1997) indicates that the act (drawing) is a form of externalization, a visible projection of self, ones thoughts and feelings. Drawing provides a link between dissociated memories and retrieval into consciousness after which the experience can be translated into narrative form and then reordered by the child’s effort to integrate the experience into his life experiences.

Pynoos (1986) relies heavily on drawing as his primary intervention with children traumatized by violence. He indicates (1986) that drawing “invariably signifies the child’s unconscious preoccupation with the traumatic memory” (p. 316). The motor (drawing) and verbal (giving the narrative) actions of drawing helps move the individual from a passive (internal) powerless involvement with the trauma to an active (external) control of that experience.

Byers (1996) described the use of drawing with children and families with PTSD as a result of exposure to military conflict in the West Bank and Gaza. She cited numerous studies of the use of nonverbal media (drawing) to assist PTSD children with access to trauma memories, the integration of the split-off parts induced by the trauma and the successful reintegration of these into the child’s current understanding of his world. Magwaza et al (1993) formed similar results with South African children exposed to violence. Saigh (1999), in discussing exposure by “flooding,” indicates that children may not be able to imagine trauma scenes or tolerate prolonged “in-vivo” experiences. Instead, he suggests that an “effective adjunct to the more orthodox form of flooding is for traumatized children to prepare sketches of their stressful experience and verbally repeat (narrate) the content of their experience” (p. 370). A number of therapists have reported on the value of using drawings with victims of violence, such as rape, war, terrorism, as well as with natural disasters (Abbernante, 1982; Golub, 1985; Herl, 1992; Johnson, 1987; Roje, 1995; Webb, 1991). Johnson (1987) states that art has a unique role in the early stages of treatment in accessing traumatic memories; individuals who have experienced trauma may encode such images via a photographic process.

Drawing activities used within SITCAP assist with this process in the following ways:

Initiating focused psychomotor activity to assist in triggering traumatic memories stored at the sensory level;
Moving the victim from a passive to an active involvement in the healing process;
Providing a vehicle to safely communicate what children and even adults often do not have the words to adequately describe;
Providing for the externalization for the trauma into a “container” (8 x 11 sheet of paper) that has boundaries, is concrete and tangible and assists in bringing about a renewed sense of power over that experience;
Creating a focal or impetus to tell the story;
Giving the intervenor a visual representation of the way the trauma was experienced so the intervenor, as a witness, can see what the victim sees as he now looks at himself and the world around him following his trauma;
Allowing trauma sensations to be replaced with positive sensations;
Re-establishing a connectedness to the adult world which leads to a greater sense of safety and hope as a survivor.

Exposure, by drawing about the specific sensations of the trauma itself, telling the story, or developing a trauma narrative through trauma-specific questions, and cognitive reframing to move from victim thinking to survivor thinking are the major intervention components of SITCAP.

Research and Field-Testing History
Seven County Trauma Referral Network

In 1990, TLC initiated exploratory research involving one hundred and fifty professionals from seven diverse Michigan counties. Professionals were trained to conduct a trauma-focused consultation interview adapted from the trauma consultation model initiated by Eth and Pynoos (1986). This one session used drawing to enable children and adolescents six through eighteen years of age to tell their story. The first drawing depicted what happened; the second drawing depicted the victim. Trauma-specific questions were structured by the Institute for the professional to pursue with the child. Questions related to the drawings and their details, but also to the children’s reactions at the time of, and following exposure. The questions reflected the focus Pynoos and Eth considered critical--the story’s details, the victimization, anger, revenge, guilt, and powerlessness. Participants completed the Pynoos PTSD Child Reaction Index to assist in identifying the presence of trauma reactions and level of severity.

One hundred and fifty children and adolescents were selected by the professionals. Each had a known history of exposure to a potentially trauma-inducing incident. Some of the children were existing clients, others were new referrals. The incidents had been experienced as recently as six weeks before this interview, and as long as fourteen years prior to this session. The incidents covered a wide range of violent and non-assaultive experiences such as drowning, terminal illness, accidental death, house fire, divorce and separation, physical and/or sexual abuse, murder, domestic violence, suicide, and pit bull attacks.

This study’s outcome demonstrated that:

Trauma can be induced by either violent or non-assaultive incidents;
Compared to assaultive incidents, levels of severity can be as high or higher with non-assaultive incidents;
Duration from the time of trauma to the intervention indicated greater levels of severity the longer the duration from the trauma to the intervention;
Children were eager to draw about the details of their experience and thereafter tell their story.

Intervenors reported that this format provided them the direction and tools needed to better understand what the experience was like for the child. Many intervenors, working with children who were already existing clients, reported that this process allowed them to learn things about the child previous sessions had never revealed.

This study supported the need to teach the helping profession the differences between grief and trauma reactions, and how they manifest themselves in children, how to help children tell their story and, most importantly, what to do once trauma has been identified. It also raised the major questions of what type of intervention must follow the first session and what focus that intervention should take. From 1990 through 1994, TLC initiated efforts to meet those needs.

I Feel Better Now!

During the three years following the 1990 study, TLC worked with a number of survivor groups. There were several “grass roots” survivor groups in the Detroit area that developed as a result of the high incidence of murders of youth in the city. TLC also worked with the Michigan Chapter of Parents of Murdered Children. Consultation and training was being provided to school social workers and counselors as well as agency clinicians. The Institute’s director also spent time in Kuwait following the Gulf War. This exposure and the Institute’s ongoing consultation with front line clinicians in schools and agencies led to the development of I Feel Better Now! (Steele, 1995), a group program for traumatized children six through twelve years of age. The program was field tested in 1994 in thirteen school districts and several agencies (a YWCA, community mental health children’s center, and a foster care counseling center).

This eight-session group program identified the major reactions to trauma as the focus of intervention. Drawing, telling the story of the trauma, and cognitive reframing were the primary strategies used in each session. Fear, terror, worry, hurt, anger, revenge, accountability, and survivor thinking versus victim thinking were the major reactions (sensations) that sessions were designed to address. Each session was very structured, worksheets were included, and their directions detailed. Field testers were masters level social workers, counselors, psychologists, and mental health workers. Each had one full day of training in the use of the program. Participants had a known exposure to potential trauma inducing-incident(s) and were selected by the field testers because of difficulties observed and believed to be associated with their trauma history.

Parents were seen individually to obtain pre-trauma and post-trauma details, and to be informed of the major differences between grief and trauma and what their children would be doing in the program in order to give informed consent. The parent was also asked to agree to attend the seventh session of the program which was designed to give the child the opportunity to tell his story to his parent using his drawings and the support of the intervenor.

Following the completion of the program, parents completed a Parent Satisfaction Questionnaire and identified changes in the child’s behavior and mood from the first to the last session. The children also completed activities that identified the way they felt at the beginning of the program and at its conclusion.

Field-Test Outcomes

One hundred and fifty children completed the eight sessions. Of the twenty groups, all but three groups expressed the wish to continue meeting beyond the final session. All 150 parents indicated they would recommend the program to others, and that the information about trauma was very helpful. All saw positive changes in the majority of trauma related behaviors. Fifteen indicated that although most troublesome behaviors had improved, some areas saw no change.
All field testers indicated their surprise that the children were so eager to draw and tell their stories in the first session. Except for physically and/or sexually abused children who were in their own groups, other group memberships included children exposed to both violent and non-assaultive incidents. Field testers indicated that incident type made no difference in the way children related to one another. The children related to the common reactions they shared versus the type of incident experienced. Field testers recommended that all activities and the sequence of sessions should remain the same.

Anecdotal feedback reflected that children felt better, were less afraid, and less agitated. This was also confirmed by parent’s observations. Teachers reported positive changes in children’s attentiveness in class and diminished disruptive behavior from those whose behavior was problematic. All children completed the program.

The children’s response to sessions indicated that they were eager and quite capable of telling the details of their experience, that addressing different reactions such as fear, worry, and anger allowed them to reveal their “hidden secrets” and major concerns since the trauma. They indicated they felt better when they heard others say they had the “same feelings.” Children liked that they “did different things to help themselves feel better.”

The I Feel Better Now! program is now used in schools and agencies across the country. Field testing insured the program was adaptable to both school and agency settings. It met the needs of agency clinicians, school counselors, and social workers in their settings. The absence of formal research precluded generalizations of outcome. the feedback provided from parents, the field tester’s, and the children via the field testers testimonies and children’s worksheets was significant enough to make the program available to others given the absence of any other, structured, trauma-specific group program for traumatized children.

The successful outcome of this program’s field-test set the direction of the Institute’s commitment to develop a structured, trauma-specific intervention strategy that could benefit children three through eighteen years of age, as well as, the parents of these children. The primary focus of the Institute’s future effort is to also conduct formal research with the intent of being able to present statistical documentation about 1) the use of drawing with trauma-specific tasks and questions directed at the major sensations commonly experienced in response to trauma, 2) the telling of the story through structured, sequential activities, 3) the use of structured statements directed at reframing victim thinking into survivor thinking, and 4) the value of responding to the major sensations/themes of trauma as a way of reducing the severity of trauma-specific reactions. This research was initiated in 1997.

The Short-Term Intervention Model Research

An eight-session trauma-specific, individual intervention protocol for children 6-12 years of age and a second protocol for adolescents up to 18 years of age were developed with the assistance of six trauma experts. At the time the program was referred to as the Trauma Response Kit (Steele, 1997); it is now called Trauma Intervention for Children and Adolescents. Seven of the eight children’s sessions in the protocol were individual; one involved both children/adolescent and parents in a joint session. Parents were seen separately at intake whenever possible.
Each 50 minute session was designed for use in either school or agency settings. All sessions were formatted with session objectives followed by structured activities designed to achieve the session objectives. Step by step instructions were provided for each activity along with scripted survivor reflections to present to participants. There were notes to clinicians addressing possible cautions or suggestions related to responding to the participant.

Each session used drawing as the primary intervention with a focus on trauma-specific sensations or themes previously mentioned in this article. Activity worksheets corresponded with session activities and were included in a workbook format. One workbook was designed for children and another for adolescents. Trauma-specific questions related to trauma-specific themes and sensations were used to encourage participants to tell their stories in detail. This was followed by cognitive reflections designed to normalize or reframe those trauma-specific reactions and their associated sensations.

The intervention process utilized the following techniques:

Normalization through education;
Understanding through cognitive restructuring;
Anxiety management through psychomotor activities;
Empowerment through discovery and reframing of responses; and
Relief through telling and showing, restructuring, and replacement.

The goals of this trauma-specific intervention model were:

Stabilization (return to previous level of functioning or prevention of further dysfunction);
Identification of PTSD reactions;
Reduction of level of severity of trauma reaction identified in the three subcategories of the DSM-IV (APA, 1994);
The opportunity to revisit the trauma in the supportive, reassuring presence of an adult (professional) who understood the value of providing this opportunity;
An opportunity to find relief from the terror of the experience;
An opportunity to re-establish a positive "connectiveness" to an adult;
Normalization of current and future reactions;
Support of the child's heroic efforts to become a survivor rather than a victim of the experience;
Replacement of the child's traumatic sensory experience with positive sensory experiences;
Identification of additional needs and involvement of the parent to help meet these needs.

Dependent Variables

Based on posttraumatic stress symptoms specified in the DSM IV, (APA 1994), symptoms were operationalized with the use of two instruments developed by the researchers for this evaluation. The Child and Adolescent Questionnaire (CAQ) a self-report instrument, was a modification of the Child PTSD Reaction Index used by Frederick, Pynoos and Nader (1986). In the CAQ ambiguous and double-barreled questions were eliminated and language and vocabulary appropriate for children 6 to 12 years of age as well as adolescents was substituted.

The CAQ consists of 35 Likert-type questions comprising three sub-scales. Subscale I is re-experiencing traumatic event, subscale II is avoidance of stimuli associated with traumatic event, and subscale III is symptoms of increased arousal due to traumatic event. The Parent Questionnaire (PQ) was developed to capture parent-observed perceptions of their child's symptomatic behaviors. It consists of 22 Likert-type questions with no subscales.

Reliability and Validity of Dependent Variable Measures

Both the CAQ and the PQ were judged to have content validity by a panel of six trauma clinicians. The panel reviewed each item for its age appropriateness, clarity and relationship to DMS-IV PTSD diagnostic criteria. The panel also offered suggestions as to the wording of specific questions in the CAQ to be appropriate to the cognitive level of the subjects. Following revisions, a second review was completed. One hundred percent agreement by all clinicians of the appropriateness of each item was mandatory before inclusion of each item. Internal reliability was assessed at intake, termination and three-month follow-up, utilizing Cronbach's alpha. Reliability of the re-experiencing traumatic event subscale of the CAQ was r = .82 at intake, r = .86 upon completion of intervention and r = .87 at three-month follow-up. Reliability of the avoidance subscale of the CAQ was r = .78 at intake, r = .80 upon completion of the intervention, and r = .82 at three-month follow-up. Reliability of the arousal subscale of the CAQ was r = .73 at intake, r =.75 upon completion of the intervention, and r = .76 at three-month follow-up. The reliability of the Parent Questionnaire was r = .89 at intake, r = .90 upon completion of the intervention, and r = .89 at three-month follow-up.

Finally, items from the CAQ which corresponded to the PTSD subscale from Briere's Trauma Symptom Checklist were assessed in terms of their reliability as a measure of PTSD. Reliability results were .80 or above for each time period, suggesting that the CAQ scale items were comparable to the Briere subscale.

Methodology

Ethical concerns to provide help to children and adolescents who were experiencing painful symptoms of PTSD as soon as possible made the use of a random selection, assignment, and control group unacceptable. Although a control group would have enhanced the strength of the findings, the time-series design utilized in this study is more suggestive of causality than a simple pretest/post test design. Independent time series assessment of parent’s observation of changes in reactions from the first to the final session and again three months following the final session strengthened outcome findings.

Clinicians who participated in the field testing of the short-term intervention model were social workers, psychologists, school counselors, mental health counselors, bereavement specialists, child care specialists, art therapists, and pastoral counselors. Clinicians were recruited from social agencies, mental health clinics and schools to participate in the field testing of the model.

Forty-one (41) clinicians participated in the field trial. Ten (10) had a minimum of 16 hours of training, which covered the differences between grief and trauma, DSM-IV criteria, the use of drawing as part of the intervention, and trauma-specific questions to encourage the telling of the story. The remaining 31 clinicians had completed an additional 48 hours of training as part of the Institute’s certification program for Trauma and Loss Consultant or Trauma and Loss School Specialist provided by the National Institute for Trauma and Loss in Children. All clinicians in the field trial attended a one-day training session on the use of the Trauma Response Kit. The purpose of this session was to familiarize clinicians with protocols and forms rather than intervention, as all had a minimum of the same two days of training related to the basic intervention process, as described above. Research requirements, assessment tools, special issues and time tables were also covered.

Clinicians obtained parental consent for any participation in the field trial. In addition, consent forms were completed by adolescent participants. The identities of both children and their parents were known only to the clinicians. Researchers received completed instruments that were assigned a case ID number only. Participants were told of all risks and benefits of participating in the trial and were informed that they could discontinue their participation at any time without penalty.

Clinicians recruited participants into the field trial who had been exposed to one or more traumatic incidents. These included murder, suicide, physical or sexual assault, car fatalities, house fires, drowning, cancer, dog attacks, critical injuries, divorce, foster care placement, or residence with a substance-abusing parent, or a chronically mentally ill parent. Exposure to such incidents included being a victim, being a witness to such incidents, or being related to the victim/survivor.

At the time of the first session (intake), exposure may have been as recent as one week prior to intake or up to seventeen years from the date of initial exposure. Questionnaires were administered verbally to children and adolescents while parents were asked to complete their questionnaires in writing. Instruments were administered at intake prior to the intervention model, at termination of treatment (after eight sessions), and three months after the termination of treatment. Parents were seen at intake to complete intake information which included the Parent Questionnaire (PQ) in addition to a standard family/child psychosocial history. The Parent Questionnaire captured parental recollections of their child's behavior prior to trauma and their observations of their child's current behavior. The specific details of the trauma(s) experienced were also obtained at this time. Parents were presented with either a video or booklet describing the differences between grief and trauma, trauma-specific behaviors, and helpful ways for them to respond to those behaviors. They were informed as to the nature of interventions to be used with their child and the importance of their attendance at two additional sessions. The second session was structured to update them on their child's status, but most specifically to prepare them for their involvement in a parent/child session in which their child tells his story by reviewing the work done in each session.

Results and Discussion

Analysis was carried out on the entire group of children and parents involved in the study.

Analysis
Matching Parent & Child/Adolescent Questionnaires

Analysis of the data collected was conducted to identify cases in which time series data was available for both child and parent. The analysis yielded 100 such cases. Demographics of these clients appear below (Table 1):

Child/Adolescent Questionnaire

For the children in this group (N=100) means at intake, discharge and three-month follow-up appear in the chart below. Means for each subscale from intake to discharge and from discharge to follow-up show a consistent pattern of reduction of symptoms as follows (Table 2):

Analysis of these means (Table 3) for each subscale was conducted at intake, discharge and three-month follow-up utilizing ANOVA to identify between group differences. Means were significantly different at intake and discharge indicating that PTSD symptoms had ameliorated between intake and discharge at a statistically significant level. However, although PTSD symptoms continued to ameliorate after discharge for the majority of children, a smaller number of children stayed the same or lost some of the gains made in treatment. Therefore the improvement between discharge and follow-up was not statistically significant at the 0.05 alpha level.

Parent Questionnaire

Means (Table 4) demonstrate an amelioration of PTSD symptoms from intake to discharge and further amelioration of symptoms between discharge and three-month follow-up. At three-month follow-up parents perceived that their children’s PTSD symptoms were only slightly higher than pre-trauma, as follows:

An analysis of these means was conducted at intake, discharge and three-month follow-up utilizing ANOVA to identify between group differences. Means were significantly different from each other between intake and discharge. However, although posttraumatic stress symptoms continued to ameliorate for the majority of children, a smaller number of children stayed the same or lost some of the gains made in treatment. Therefore the improvement between discharge and follow-up was not significant at the 0.05 alpha level (Table 5).

Multivariate Analysis

Multivariate quantitative analysis was used to describe participant’s level of trauma, as well as, to assess the effectiveness of the intervention in reducing trauma levels after controlling for differences in age, gender, ethnicity, socio-economic status, traumatic events, and time since traumatic event occurred. Linear regression models were utilized to predict each of the subscales at intake, discharge and three-month follow-up, as well as, to run models predicting overall change in the three subscales (avoidance, arousal, re-experiencing) at intake, discharge and three-month follow-up.
Gender, ethnicity, socio-economic status, type of traumatic incident and time since the onset of the incident were not significant predictors of overall change across the three subscales. However, age at the time of the trauma was a significant predictor of positive change at discharge for the arousal subscale (III), and came close to attaining statistical significance as a predictor of change for reexperiencing (I) and avoidance (II) subscales. The older the child at the time of the trauma, the greater the positive change.

Discussion

This study documented that children could experience severe levels of PTSD symptoms following non-assaultive, as well as, violent incidents. It further documented that levels of trauma could continue to exist years after exposure without trauma-specific intervention. It demonstrated that use of the Trauma Response Kit by trained trauma specialists and consultants did, in fact, assist in the reduction of symptoms across all diagnostic subcategories and, for most, continued that reduction three months after the last intervention. (Findings related to age suggested support for immediate intervention with younger age children whose physical, emotional, social level of vulnerability may be more at risk than older children.)

It demonstrated that the most severe (multiple traumas) saw the greatest reduction in reactions, contrary to the myth that little can be done to help those exposed to multiple traumas. Of the seven participants who saw an increase of reactions at the three-month follow-up, all had experienced additional traumas from the final session to the follow-up. Interestingly, their follow-up scores, although higher than final session scores, were not as high as the intake scores, suggesting that coping skills learned and the change from victim thinking to survivor thinking lessened the impact of these additional traumas. It also demonstrated that a single model of intervention could be effective with varied trauma inducing incidents. Many research questions remain to be evaluated. Research is critical and essential to our understanding of trauma and response to its victims.

Conclusion

Eleven years of research, field testing, and case studies with traumatized children and adolescents in school and agency settings has led to a structured sensory intervention model for traumatized children, adolescents, and parents (SITCAP). The Institute has certified over 2,000 Trauma and Loss School Specialists and Consultants that are now providing structured, sensory intervention to a minimum of 40,000 traumatized children and adolescents yearly. Institute members who conduct interventions on a daily basis continue to provide feedback, anecdotal information, and recommendations related to intervention practices that guide the Institute’s efforts to provide practical, clinically sound interventions for use in agency settings and especially school settings where children are the most accessible for intervention.

References

Abbenante, J. (1982). Art therapy with victims of rape. In A. DiMaria, E.S., Kramer, & E. Roth (Eds.), Art Therapy: Still Growing, Proceedings of the 13th Annual Conference of the American Art Therapy Association (pp. 34-38) Baltimore, MD: AATA
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV). (4th ed.). Washington, D.C.
Beck, A.T. (1976). Cognitive therapy and emotional disorders. New York: International University Press.
Beyers, J. (1996). Children of the stones: Art therapy interventions in the West Bank. Art Therapy: Journal of the American Art Therapy Association, 57, 152-157.
Emery, P. (1996). The inner world in the outer world: The phenomenology of posttraumatic stress disorder from a psychoanalytic perspective. Journal of the American Academy of Psychoanalysis, 24(2) 273-291.
Golub, D. (1985). Symbolic expression in posttraumatic stress disorder: Vietnam combat veterans in art therapy. The Arts in Psychotherapy, 12, 285-296.
Herl, T. (1992). Finding the light at the end of the funnel: Working with child survivors of the Andover Tornado. Art Therapy: Journal of the American Art Therapy Association, 9 (1) 42-47.
Johnson, D. (1987). The Role of Creative Art Therapies in the Diagnosis and Treatment of Psychological Training. The Arts in Psychotherapy, 14, 7-13.
Malchiodi, C. (1998). Understanding children’s drawings. New York, Guilford.
Malleson, N. (1959). Panic and phobia: A possible method of treatment. Lancet, 1, 225-227.
Magwaza, A., Killian, B., Petersen, I., & Pillay, Y. (1993). The effects of chronic violence on preschool children living in South African townships. Child Abuse and Neglect, 17, 795-803.
Marks, I.A. (1972) Flooding (implosion) and allied treatments. In S. Argas (Ed.), Behavior Modification: Principles and Clinical Applications (pp. 151-211). MA. Little Brown.
McFarlane, A.C. (1988) Recent life events and psychiatric disorder in children: The interaction with preceding extreme adversity. Journal of Clinical Psychiatry, 29 (5), 677-690.
Meichenbaum, D. (1974) Self-instructional methods. In F.H. Kanfer & A.P. Goldstein (Eds.), Helping People Change (pp. 357-391). New York: Pergamon Press.
Mihaescu, G., Baettig, D. (1996). An integrated model of posttraumatic stress disorder. European Journal of Psychiatry, 10 (4), 243-245.
Mower, O.A. (1960). Learning theory and behavior. New York: Wiley.
Piers, C. (1996) A return to the source: Rereading Freud in the midst of contemporary trauma theory. Psychotherapy, 33/Winter 1996, 540-547.
Pynoos, R. & Eth, S. (1985). Witness To violence: The child interview. Journal of the American Academy of Child Psychiatry. 25, 306-319.
Rachman, S.J. (1966). Studies in desensitation-II: Flooding. Behavior Research and Therapy, 4, 1-6.
Riley, S. (1997). Children’s art and narratives: An opportunity to enhance therapy and a supervisory challenge. The Supervision Bulletin, 9 (3), 2-3.
Roje, J. (1995). LA '94 earthquake in the eyes of children: Art therapy with elementary school children who were victims of disaster. Art Therapy Journal of The American Art Therapy Association, 12, 237-243.
Saigh, P., (1987). In vitro flooding of a childhood posttraumatic stress disorder. School Psychology Review, 16, 203-2211.
Saigh, P. & Bremner, J. (1999). Posttraumatic Stress Disorder. Needham Heights, MA; Allyn and Bacon.
Stampfl, T.G., (1961). Implosive therapy: A learning theory derived psychodynamic technique. Unpublished manuscript, John Carroll, University of Cleveland.
Steele, W., (1995). I Feel Better Now! Grosse Pointe Woods, MI, TLC Institute.
Steele, W., (2001). Parents in Trauma: Learning to Survive, Grosse Pointe Woods, MI, TLC Institute.
Steele, W., (1997). Trauma Response Kit, Grosse Pointe Woods, MI, TLC Institute.
Steele, W., Kordas, P., (1998). What Color Is Your Hurt?, Grosse Pointe Woods, MI, TLC Institute.
Steele, W., (1999). Trauma Debriefing for Schools and Agencies, Grosse Pointe Woods, MI, TLC Institute.
Thompson, J.A., Charlton, P.F.C., Kerry, R., Lee, D., & Turner, S.W. (1995). An open trial of exposure therapy based on deconditioning for posttraumatic stress disorder. British Journal of Clinical Psychology, 31, 407-416.
Van der Kolk, B., McFarlane, A., & Weisaeth, L. (1996). (Eds.). Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford.
Webb, N, (Ed.) (1991). Play therapy with children in crisis. New York: Guilford.