When Cognitive Interventions Fail with Children of Trauma

The National Institute for Trauma and Loss in Children
A program of Children's Home of Detroit

When Cognitive Interventions Fail with Children of Trauma:
Memory, Learning, and Trauma Intervention

William Steele

Pending Publication

Abstract: Research supports that children exposed to violence (and other trauma inducing incidents) are at a greater risk for cognitive dysfunctions. The ability to attend, focus, retain and recall which are primary learning functions begins to diminish. The ability to process verbal information, identify and verbalize internal emotional experiences also suffer and negatively weaken a child's ability to communicate to others in a way that allows others to be helpful. (Steele 2003; Steele and Raider 2001; VanDalen 2001; Perry, 2000; Morse and Wiley, 1997). In short it becomes difficult to help traumatized children using traditional cognitive processes. Sensory “implicit” interventions which can be provided in school or agency settings, can help restore cognitive functions in traumatized children.

If one understands the state of arousal, the term used to identify the neurophysiological responses to trauma, one understands that a traumatized child's predominant processes will be in the sub cortical and limbic areas of the brain which deal with non-verbal information (Perry, 2000), not the neocortex area of the brain that involves reasoning, linear thinking, analysis, the ability to make sense of one's experience and to reorder that experience, when needed, in ways that are manageable. The child who is lingering or frozen in a state of arousal due to past or current trauma simply has difficulty reassigning or thinking things through (Roemer and Lebowitz, 1998).

These cognitive deficiencies, therefore, dictate the need for non-cognitive approaches to help children overcome or minimize the learning, emotional and behavioral problems they can experience due to failing cognitive processes resources resulting from traumatic arousal. To define an alternative to traditional cognitive approaches, we need to delineate between “explicit” and ‘implicit” memory processes.

Memory has two functions “implicit” and “explicit”. Explicit memory sometimes referred to as “declarative” memory refers to primary cognitive processes. In “explicit” memory we have access to language. We have words to describe what it is we are thinking and feeling. Explicit memory allows us to process information, to reason, to make sense of our experiences. Such cognitive processes help us cope.

Unfortunately, unless trained by the military or law enforcement to respond cognitively to threatening situations, the majority of children, even adults are going to respond or experience a trauma in "implicit" memory. In "implicit" memory there is no language. There simply are no words to describe or communicate what is being experienced. Position Emission Tomography or PET scans have found that trauma also creates changes in the Broca's area of the brain that lead to difficulties in identifying and verbalizing our experiences (Van Dalen, 2001), a process normally accessible via explicit memory processes. In implicit memory our senses contain the memory - what we see, what we hear, sensations of smell, touch and taste become the “implicit” containers of that experience (Rothchild, 2000).

If there is no language in “implicit” memory to help verbalize what that experience is like, how then is it defined and explained? It is defined through an implicit process referred to as "iconic symbolization" (Michaesu and Baettig, 1996). Iconic symbolization is the process of giving our experience a visual identity. Images are created to contain all the elements of that experience - what happened, our emotional reactions to it, the horror and terror of the experience. The trauma experience therefore is more easily communicated through imagery. “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, 1987, p. 289). When memory cannot be linked linguistically in a contextual framework, it remains at a symbolic levels for which there are no words to describe it. 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 (Steele, 2003).

In order to access this experience we must therefore use "sensory" interventions that allow children the opportunity to actually make us witnesses to their experiences, to present us with their "iconic" representations, to give us the opportunity to see what they are now seeing as they look at themselves and the world around them following their exposure to a traumatic experience. In this sense “a picture is worth a thousand words”. Drawings provide a representation of those “iconic” symbols that implicitly define what that experience was like for the child.

When one understands trauma as an "implicit" experience versus an "explicit" (cognitive) experience, it follows that drawing becomes an effective almost necessary avenue to help children release the horrid, terror filled "iconic" memories of their traumatic experiences. Bryers (1996) cited numerous studies that illustrated the use of drawing to help children access those traumatic memories and channel them into a trauma narrative, which could then be reworked explicitly (cognitively) in ways that became manageable for them. Magwaza, Killian, Peterson and Pillay (1993) achieved similar results with South African children exposed to community violence. Following 9/11, The World Trade Center Children's Mural Project was unveiled in March 19, 2002 and depicted over 3,100 portraits drawn by children. This drawing project "served to lessen feelings of isolation and helplessness felt among those children who had difficulty understanding (cognitively) the complexity of this tragedy (Berberian, Bryant and Landsberg, 2003)." These children could not “explicitly” communicate the many ways 9/11 impacted them but they could “implicitly” define it through then self-portraits.

Drawing is by no means a new vehicle for self-expression. Machooen (1949) many years ago noted the fact that the most expressive part of the body and the center of communication is one’s face. Saigh (1999) suggested, "children prepare sketches of their stressful experience and verbally repeat (narrate) the content of their experience" (p. 370). Drawing does provide children with a focal point and an impetus to tell their story and to thereafter translate their experience into a narrative (Malchiodi, 1998). Riley (1997) indicated that the act of drawing is a form of externalization, a way for the children to put the experience outside themselves to make it real and concrete. Drawing is a way for that child to allow us to become a witness to what that experience was like by giving us a visual representation of the way they see it (Steele, 2003). Gil (2003) wrote when children draw, they do so on paper of specific physical dimensions with set boundaries. Once the images are placed on the space on the paper the child has in essence contained what might otherwise feel staggering. What might be experienced as disorganized or chaotic may then take on qualities of something that is manageable. Random thoughts and feelings might render children over stimulated and confused. Thoughts and feelings “shrunk down” enough to appear within specified dimensions may give children a sense of control (p. 156).

Drawings help children in the following ways (Steele and Raider, 2001):

Drawing is a psychomotor activity that helps to trigger the sensory memories of the traumatic experience when it is trauma focused.
Drawing provides a safe vehicle to communicate what children, even adults, often have few words to describe.
Drawing engages the child/adult in active involvement in their own healing. It takes them from a passive to an active, directed, controlled externalization of that trauma experience.
Drawing provides a symbolic representation of the trauma experience in a format that makes us a witness to the experience so we can now see what the child sees as he looks at himself and the world around him.
Drawing provides a visual focus on details that encourage the client via trauma-specific questions, to tell his story, to give it a language so it can be reordered in a way that is manageable.
Drawing also provides for the diminishing of reactivity (anxiety) to trauma memories through repeated visual reexposure in a medium that is perceived and felt by the client to be safe.
Drawing helps the child externalize the experience, remove it to a safe container (chewing paper) outside himself.
The drawing itself becomes a concrete representation the child can manipulate anyway needed to now feel power over it. The sensory memory of terror-feeling totally unsafe and powerless is replaced with the sensory experience of regaining power over it as well as feeling safe once again as the experience is now contained and outside himself. He can experience putting distance between himself and the experience and thereby feeling safer.

However, to be helpful and safe, drawing activities must be structured and focused on the specific themes (experiences) of trauma such as, terror, hurt, worry, anger, and accountability. The telling of the story must be guarded by trauma specific questions that again help the child stay focused on the “themes” of experience. Once the child can put a story to his experience, the entire experience can then be encoded by “explicit” memory and thereafter reordered in ways the child can now manage, in ways that no longer trigger the fear, terror, worry, hurt, the absence of a sense of safety, the sense of being powerless. Once this is accomplished trauma symptoms begin to diminish (Steele and Raider, 2001; Malchiodi, 2003).

For more detailed decriptions of the use of drawing we recommend Structured Sensory Interventions for Traumatized Children, Adolescents, and Parents.

REFERENCES
Beyers, J. (1996), Children of the stones: Art therapy interventions in the West Bank. Art Therapy: Journal of the American Art Therapy Association, 13, 238-243.

Berberian, M., Bryant L., Landsburg, M., (2003) Interventions with Communities Affected by Mass Violence In Malchiodi, C., (Ed) Handbook of Art Therapy, New York, Guilford Publications.

LeDoux, I.E., Romanski, L. & Xagoraris, A., (1991), Indelibility of sub cortical emotional memories. Journal of Cognitive Neuroscience, 1, 238-243.

Magwaza, A., Killian, B. Peterson, I., & Pillay, Y. (1993). The effects of chronic stress on preschool children living in South African townships. Child Abuse and Neglect, 17, 795-803.

Malchiodi, C. (1998). Understanding children's drawings. New York: Guilford.

Malchiodi, C. (Ed) (2003). Handbook of Art Therapy. New York: Guilford.

Michaesu, G., & Baettig, D. (1996). An integrated model of posttraumatic stress disorder. European Journal of Psychiatry, 10(4), 243-245.

Perry, B. (2000). Violence and childhood: How persisting fear can alter the developing child's brain. The Child Trauma Academy. childtrauma@bcm.tmc.edu.

Riley, S. (1997). Children's art and narratives: An opportunity to enhance therapy and a supervisory challenge. The Supervision Bulletin, 9, 2-3.

Rothchild, B. (2000). The body remembers. New York: W.W. Norton.

Saigh, P., & Bremner, J. (1999) Posttraumatic stress disorder. Boston: Allyn and Bacon.

Starknum, P.A., Gebarski, M.N., Berent, S.S., & Schterngart, D.E. (Eds). (1992). Hippocampal formation volume, memory of dysfunction, and cortisol levels in patients with Cushing's syndrome. Biology Psychiatry, 32, 756-765.

Steele, W., & Raider, M. (2001). Structured sensory intervention for children, adolescents, and parents (SITCAP). New York: Mellen Press.

Steele, W., (2003). Helping Traumatized Children. In Straussner S., and Phillips, N. (Eds) Understanding Mass Violence, New York. Allyn and Bacon, 42-56.

vanDalen, A., (2001) Juvenile violence and addiction: Tangle roots in childhood trauma. Journal of Social Work Practice in the Additions, I, 25-40.

van der Kolk, B., McFarlane, A., & Weisaeth, L. (1996). (Eds.). Traumatic stress disorder: The effects of overwhelming experience on mind, body, and society. New York: Guilford.

Weinstein, D. (2000, Oct.). PTSD and ADHD. ADHD Report, 8 (5).