SITCAP Preliminary Outcomes

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

Traumatized Adjudicated and At-Risk Children:
Adaptation of TLC’s Structured Sensory Intervention Program for Children, Adolescents and Parents (SITCAP)
PRELIMINARY OUTCOMES
Jacquelyn Jacobs

PREFACE by William Steele
     Research indicates that millions of American children are exposed each year to traumatic maltreatment with approximately 30% of these children developing Post-Traumatic Stress Disorder (PTSD) as a result of their victimization. Symptoms of PTSD can have devastating consequences to a child’s ability to learn and adapt to healthy, appropriate patterns of social interaction. Recent research indicates that juvenile offenders are a population which appears to have a high incident of PTSD. Unfortunately, efforts by the juvenile court systems to remediate the delinquent behavior of these youths have largely overlooked trauma specific intervention for this population group. However, Jacquelyn Jacobs, Certified TLC Trauma Specialist/Consultant Supervisor, recent introduction of the Structured Sensory Intervention for Traumatized Children, Adolescents and Parents (SITCAP) (Steele & Raider, 2001) into three juvenile court systems in Georgia appears to have very promising results as a remediation tool for juvenile offenders.
     This paper presents a summary review of preliminary outcomes following the application of TLC’s Structured Sensory Intervention for Traumatized Children, Adolescents and Parents – Adjudicated and At-Risk Children adjusted program (SITCAP-ARC). The ARC version of SITCAP goes beyond the sole use of cognitive behavioral treatment (CBT). Research substantially documents, in fact, that children “frozen” in trauma have difficulty accessing and using primary cognitive functions i0nvolving the processing of information, “making sense” of one’s experience, and identification and verbal expression of their emotions, memory, the ability to attend and focus and retain information.
     ARC integrates cognitive strategies with “sensory”, “implicit” strategies. It pursues the successful cognitive re-ordering of traumatic experiences by victims in ways they can better manage, in ways that move them from victim to survivor thinking and in ways that allow them to become more resilient to future traumas. A brief discussion of what we mean by “sensory”, “implicit” interventions is appropriate to understanding the focus of ARC.
     Research supports that children exposed to violence 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.
     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 level 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 child 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 overstimulated 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 (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 helps 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).
Ms. Jacobs begins with a very brief identification of the problem, followed by a discussion of the ARC component followed by preliminary outcomes. These preliminary findings were significant enough to support additional support for this program in juvenile courts in Georgia. (TLC is currently seeking resources to engage in evidenced based research as well as be able to provide the Adjudicated-At Risk Children’s version in a manualized format. Should you have access to research possibilities and funding do contact Dr. William Steele, TLC Director, at 1-877-306-5256 or bsteele@tlcinstitute.org. TLC is a non-profit organization who’s mission is to increase accessibility to trauma specific interventions for traumatized children and families.)

Problem Identification

     I have spent the great majority of my life in the service of children who seriously struggle with the ability to learn, to engage in socially acceptable behavior and to feel good about who they are in this world. Unfortunately, my involvement with many of these children has come as a result of my behavior intervention work with the juvenile court system. One of the things that I have found to be common among a high percentage of these delinquent and at risk youths is the role that trauma has played in their lives. For many of these youths, their trauma experience goes beyond exposure to a single incident. Too often you find within the juvenile court system children who have experience repeated, prolonged abuse and/or multiple and varied incidents of traumatic exposure. Therefore, among this population, you will find children who not only meet the criteria for posttraumatic stress disorder (PTSD) or Type I trauma (Terr, 1990) i.e. exposure to a single event but, as a result of their multiple traumatic exposure and/or repeated, prolonged exposure to a situation such as abuse, they may more specifically meet the criteria for Complex Cumulative Trauma Disorder (CTD) or Disorder of Extreme Stress Not Otherwise Specified [DESNOS] which are referred to as Type II and Type III trauma (Rothschild, 2000).
     As one who has worked closely for many years with delinquent youth, I find more and more evidence that the various forms of maltreatment and/or the loss of a significant caregiver underlies the confusion, distress, anger, and behavior and learning issues of a significant number of these traumatized, delinquent youths. In fact, research indicates that between 24% and 51% of male juvenile offenders (Berton & Stabb, 1996; Burton et al., 1994; McMackin et al., 1998; Nadel, Spellman, Alvarez-Canino, Lausell-Bryant, & Landsberg, 1996) and 49% of female juvenile offenders (Cauffman et al., 1998) suffer from PTSD. In addition, research over the past two decades confirms that trauma can significantly interfere with a child’s ability to learn, interact socially, problem solve and function as a healthy, normal child or adolescent (Briere, 2001; Deblinger, Lippman and Steer, 1996; Michaesu & Battig, 1996; Terr, 1990; Pynoos and Eth, 1986). I would also venture to say, based on my experience with juvenile offenders, that unfortunately a great majority of these youth have never received trauma specific intervention to address these concerns.
     Furthermore, the impact of untreated, traumatic maltreatment and single event traumas can have prolonged, devastating consequences for our youth and society. Of great concern is the fact that recent statistics on the well being of children in the United States, indicates that this pattern of traumatic exposure, which leads to delinquent behavior among many of today’s youth, has become a national epidemic. In 2001, almost 1 million children were confirmed by state child protective service agencies to be victims of child abuse and neglect. “More than half of child victims (57 percent) suffered neglect; 2 percent suffered medical neglect; 19 percent were physically abused; 10 percent were sexually abused; and 7 percent were psychologically maltreated” (National Clearinghouse on Child Abuse and Neglect Information [NCANDS], 2001, p.2). Adding to the horror of these statistics is the fact that many cases of child maltreatment go unreported. In fact, it is estimated that the prevalence for sexual and physical abuse of children in our nation is closer to 3 million a year (Shalev and Hannemon, 1999; Wang and Daro, 1997).
     It is important to note, however, that for some resilient children the effect of abuse, neglect and other traumatic exposures are minimal and these children develop into productive, caring adults and citizens. For example, it is estimated that 59% of children from alcoholic homes do not develop serious coping problems versus 41% that do. Unfortunately, for too many children, the trauma of maltreatment has a significant impact on their emotional, behavioral and cognitive functioning. “Experts say that traumatic early experiences can cause a normal child to become developmentally delayed or develop serious emotional problems” (Massachusetts Citizens for Children, 2001, p.1). More specifically, many of these children develop an inability to maintain self-control in uncomfortable situations. They constantly stand hyper-vigilant in scanning their environment for danger, and often misinterpret the actions of others (Steele, 2003).
     In addition, it is estimated that over 30% of the millions of children that are exposed to traumatic events each year will develop symptoms severe enough to be clinically diagnosed with PTSD (Perry, 1999). As a result, many children develop negative coping mechanisms that often take the form of oppositional/defiant and aggressive behavior, often warranting juvenile court intervention. There are also a number of long term problems experienced by untreated, traumatized children. These include difficulty maintaining adult or peer relationships, attention problems, drug and alcohol dependency, increased risk of dropping out of school, recurring physical and mental health problems, repeated delinquent behavior leading to adult criminal behavior as well as growing up to repeat the abusive and neglectful behaviors modeled by their caretakers (van Dalen, 2001).
     Maltreated, traumatized children also have greater difficulty adapting to school and learning environments. “30%...have some form of language or cognitive disability; 50% or more have difficulty in school, including poor attendance and misconduct; 22% or more have a learning disorder; 25% require special education services at some time” (Steele, 2003; Massachusetts Citizens for Children, 2001, p. 4, Weinstein, 2000).

The Need

As a behavioral consultant to a number of juvenile court judges, it has been my role to consult on the intervention program that would best serve the remediation of the child’s behavior. A common intervention which I had routinely suggested for many of these delinquent youths is cognitive-behavioral counseling. However, for a significant number of these children, we were finding that the traditional counseling approach and other court provided intervention programs such as anger management were not bringing about the behavior remediation we were expecting. It was not until I began attending the trauma workshops provided by the National Institute for Trauma and Loss in Children (TLC), that I realized that many of my delinquent youth clients might benefit from a trauma specific sensory intervention approach as a pre-requisite to the traditional cognitive-behavioral therapy I had been recommending.
What I discovered, through my training with TLC, is that with a structured, sensory approach to trauma intervention, the child is able to more effectively and safely debrief and process their trauma reactions in a way that leads to a reduction in the active arousal/defense state triggered by the autonomic nervous system. This allows for the normalizing of the trauma reactions, a decrease in negative behavioral responses, improvement in cognitive functioning and potential learning capacity and the beginning of the healing process. Furthermore, with the increased cognitive functioning, the child has a greater chance of benefiting from therapy that addresses the maladaptive coping behaviors characteristic of children who have experienced long term trauma reactions. Of course, it is also important that protective factors be implemented, such as parent education on trauma and, when necessary, the involvement of protective community agencies to minimize the possible reoccurrence or continuance of the child’s traumatic exposure.

Preliminary Evaluation

Armed with this information about trauma and its impact on behavior and learning as well as my initial TLC trauma training in the TLC Structured Sensory Short Term Trauma programs, I made a proposal two years ago to Judge Russell Jackson of the Forsyth County Juvenile Court in Cumming, Georgia that we conduct a very small, informal trial to determine if TLC’s Structured Sensory Intervention for Traumatized Children, Adolescents and Parents (SITCAP) (Steele & Raider, 2001), would prove beneficial in addressing the needs of the traumatized adolescents brought before Judge Jackson’s juvenile court. This initial trial consisted of five youths under the juvenile court system having both behavioral and academic problems. Each child was provided with individual intervention utilizing the SITCAP program for adolescents. What we found in this initial study, although we would not expect 100% success on a consistent basis, was that all five youths improved both in their behavior and academics and reported that they felt much better after completing the trauma program. (Data on subsequent pages is based on interventions with 85 youth).
Further successful results with both court and school system referrals lead to Judge Jackson’s approval, with the knowledge of Dr. William Steele, founder and director of TLC, to develop court protocols for establishing the Structured Sensory Trauma Intervention Program for Adjudicated and At Risk Children (SITCAP-ARC) (Jacobs, 2003). This program utilizes TLC’s Trauma Intervention for Adolescents (Steele & Raider, 2001)) along with relaxation and imagery techniques which I have incorporated into the ARC as an adjunct to the TLC program. To accommodate the juvenile court needs, the program is provided most often in a group format but is also offered in an individual format as required. Dr. William Steele has also approved some formatting changes to the original program in order to accommodate the group setting.
I am excited to say that this program continues to be successful and has expanded to the Hall County Juvenile Court System in Gainesville, Georgia, the Pickens County Truancy Court and the Pickens County Juvenile Court System in Jasper, Georgia. An assessment of our progress to date with the SITCAP-ARC program indicates that approximately 76% of those youth referred through the court system for PTSD evaluation are referred on for participation in the program. To date, 100% of the 85 participants report a reduction in their trauma symptoms as indicated by a comparison of pre-trauma intervention and post-trauma intervention PTSD scores. In addition, 90% of the youths completing the program have indicated that they feel much better after completing the program with over half of the 90% indicating that they feel definitely better, i.e. a score of 9 or 10 on a 1 to 10 scale. The remaining 10% indicated that they felt the same, even though their PTSD scores indicated a reduction in their trauma symptoms. It is important to note, however, that I have found, as a result of two month post-trauma intervention follow-ups using TLC’s PTSD evaluation instrument, that trauma reactions continue to decline. Furthermore, many participants have indicated that the program is the first intervention that they believe has been immediately helpful to them.

Educational Component

     It is also of value to mention that, participants consistently report that the trauma educational component, which is designed into all TLC trauma programs, has been extremely helpful and encouraging to them. A key reason for this is that many of the adjudicated youth come to the SITCAP-ARC program with a belief that they lack intelligence because of the historical difficulty they tend to have with their academic progress. Many of these juvenile offenders also have a belief, because of the long term nature of their trauma reactions, that they have a mental illness which they have no chance of escaping. Without the understanding of the role that trauma has played in their learning and cognitive abilities, these children are left to adopt these negative beliefs which can have a devastating impact on their self-esteem and sense of motivation.
     Therefore, because of the importance of both the child and parent understanding the connection between their trauma experience and learning and cognitive abilities, I have developed and incorporated into the program, in addition to the trauma education provided as part of the TLC program, a simple and brief presentation which educates both the child and the parents on the psychophysiology of trauma i.e. brain and the survival response, and how it relates to the symptoms experienced as a result of the traumatic exposure. Once the participants understand the link between the trauma experience and the difficulty they are experiencing with concentration, memory and learning, as well as other symptoms such as insomnia, fear and anger, they tend to feel more hopeful about their abilities and more confident that they can overcome their trauma reactions and regain a sense of well being.
     After years of working and talking with at-risk youth populations, it appears to me that the only programs that have a chance of succeeding and making a difference in the lives of these children are the ones that give them a sense of empowerment and clearly links them to a better future. This is especially true of adjudicated populations whom I find tend to display a greater sense of distrust and hopelessness than other youth populations. Our findings to date, supports other research (Greenwald, 2002) and indicates that a significant number of juvenile offenders are suffering from post-traumatic stress disorder which is believed to be a key factor in the behaviors exhibited by these individuals. As indicated by 90% of the adjudicated participants, the SITCAP-ARC program has brought about an increased sense of well being.
     Participants also come away from the program with an understanding of the link between their trauma experience/s and their delinquent behavior, such as aggression, defiance, substance abuse, and truancy. In addition, during this short, eight to ten week program, most participants learn, through experience, that they can begin to feel better with proper intervention. This knowledge and understanding seems to play a role, with many of the adjudicated participants, in improving the individual’s sense of hope, sense of self and the willingness of many participants to be more cooperative and open to additional therapeutic interventions which are often needed to assist with the relearning of more appropriate and healthy behavior patterns.

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About the Author

      Jacquelyn Jacobs is a Behavior Intervention Consultant and Certified TLC Trauma Specialist/Consultant Supervisor pursuing her PhD in Psychology from Northcentral University, Arizona. She has earned a M.Ed degree in Behavior and Learning Disorders and a B.S. Degree in Psychology from Georgia State University. In addition, she has a M.Ed. in Educational Leadership from the University of Georgia and received her Advanced Level Trauma Consultant Supervisor Certification from the National Institute for Trauma and Loss in Children (TLC) located in Grosse Pointe Woods, Michigan.
     Jacquelyn has years of experience in the public school system working with children with severe emotional and behavioral disorders. She also has extensive experience in the evaluation, design and implementation of behavior intervention programs that address the needs of the unruly child and other at-risk populations. She currently runs her own Behavior Intervention Consultative Service and non-profit Behavioral and Trauma Intervention Center for Children working with community agencies as well as private individuals. Her work includes providing consultative services to school systems as well as several Juvenile Court Judges on behalf of adjudicated special needs children. Also, Jacquelyn has established a Trauma Intervention Program for Adjudicated and At Risk Children which has been adopted by three Juvenile Court Systems in Georgia. In addition, the National Institute for Trauma and Loss in Children named Jacquelyn The National Trauma Consultant/Supervisor of the Year for 2003 for her unique trauma work with the Juvenile Courts and community.
     Jacquelyn has been very instrumental in establishing collaborative protocols between school systems, juvenile courts, the department of juvenile justice and other community agencies. This collaborative approach has resulted in more efficient utilization of the resources needed to address the underlying issues impacting a child’s behavior and ability to learn.
    Jacquelyn is the author of Classroom Guidelines and Strategies for Managing Severe Emotional and Behavioral Disordered Students. She also conducts training workshops for teachers, administrators and parents that concentrates on strategies for working with children with emotional and problematic behavior.
    A major focus for Jacquelyn is working with children who have been exposed to traumatic incidents and lifestyles. Her intervention support utilizes the Structured Sensory Intervention Programs developed by The National Institute for Trauma and Loss in Children for children ages 3-18 and adults.