TED SIMONS: Welcome to Ask a Child Trauma Expert. I'm Ted Simons. Tonight, we will hear from a panel of experts about early life conditions that can cause a lifetime of suffering. Childhood trauma can be caused by physical, sexual or emotional abuse, as well as divorce, the death of a parent or incarceration of a loved one. Trauma can lead to many physical and psychological problems. We'll talk about the causes and symptoms of childhood trauma along with the best ideas for treatment. You are invited to call in and ask a child trauma expert. Your questions and concerns will be addressed by experts, who will be taking calls throughout the show at the statewide toll-free number appearing on the screen. Phone lines will remain open until 9:30 p.m. and we do invite you to call. Joining me tonight for Ask a Child Trauma Expert is Alison Steier of Southwest Human Development; Bernadette Melnyk, dean of Arizona State University's College of Nursing and Health Innovation; Kim Skrentny, children's lead clinical advisor with the Arizona Department of Health Services and Marcel Duclos, clinical director of the Northland Family Help Center. Thank you all for joining us tonight.
MARCEL DUCLOS: You're welcome.
TED SIMONS: Let's get it started with the basics. What is childhood trauma?
ALISON STEIER: Trauma is a single event or a series of connected events, like repeated air raids or a condition of chronic injuring stress, like chronic domestic violence, that is perceived by the person as life-threatening—life-threatening, or so overwhelming that a person feels they can't cope with it.
TED SIMONS: Is that--that life threatening aspect part of it—is that what separates stress from trauma?
BERNADETTE MELNYK: That is a good differentiation; the person has to feel that they're being seriously threatened in terms of physical injury, in terms of death or witnessing that that they feel that for a loved one as well.
TED SIMONS: With that in mind, can a baby -- can a toddler experience childhood trauma?
MARCEL DUCLOS: That's just what I was just thinking about. When those adverse experiences occur at a pre-verbal state and stage, even in early infancy, even pre-birth, all of those events change the central nervous system, especially the autonomic nervous system.
TED SIMONS: Can you talk more about the special challenges with very early childhood trauma? I mean we're talking about folks—little folks that can't speak yet.
ALISON STEIER: That's true. Well, I think it's really important that people realize, and probably most people don't realize, that very young children, babies and toddlers, can develop mental health difficulties and that includes symptoms of trauma. And without effective intervention, trauma doesn't get better by itself. It shows itself in different ways across the lifespan, and it may be more challenging at times, and it may recede a bit, but it doesn’t go away by itself. And there are effective treatments. And one thing we struggle with is a wish for infancy and early childhood to be a period of protection. You know, and for adults to be able to protect children from pain, and that it would be a period of exemption from pain. But, in fact, that's not the case.
TED SIMONS: Talk about the special challenges of especially early childhood trauma.
KIM SKRENTNY: Well I think when you’re talking about children who don't have that ability to be able to communicate what is really going on with them--In the mental health system in Arizona’s Public Behavioral Health System, what we see is that we have to train our professionals to be able to observe--observe the relationship that's going on between that young child and their primary caregiver, and through those observation and the questions, that's how we start to get at the information that we need. We also look at ways that we can kind of assess a child's developmental abilities, and so, are they reaching those milestones and if they’re aught, and there’s some concerns there, we need to look at services and supports do we need to put into place.
TED SIMONS: And a reminder: the telephone number at the bottom of the screen is for you to call to ask a child trauma expert. Give the number a call; experts will be standing by until 9:30 this evening to take your calls on childhood trauma. The causes. I think people would understand physical and sexual abuse, even emotional abuse, but what are we talking about here in terms of-- of things like divorce, or the death of a parent, or the death of a loved one.
BERNADETTE MELNYK: I think again, it is how that person perceives that particular stressful event. Again, if they’re perceiving it as having serious injury or harm to themselves or a loved one, that falls in the category of trauma. Stress, for instance, all people experience, children too. Normal stress responses course, they're perceiving it as having serious injury or harm to themselves or a loved one, that falls in the category of trauma. Stress, for instance, all people experience, children too, normal stress responses to something frightening that happens. But not -- not all children then fall into having a diagnosis such as post-traumatic stress disorder. There is acute stress that happens within four weeks after a stressful event occurs, but anything lasting beyond that four weeks--that child is experiencing symptoms, and it's interfering with their functioning. You have to consider a more chronic diagnosis, like post-traumatic stress disorder.
MARCEL DUCLOS: And if -- if an early adverse event occurs in a family, in which there is a substratum of affective relationships, if there's—there’s containment, and their safety, and their security and then there's a event that occurs in that, even as serious as a brutal sexual event against a child, that child has a much higher possibility--a greater possibility with intervention and with the family to overcome that event. But if that occurs in a family in which there was no affect or very little, there was confusion, there was mixed messages, then that child has an additional burden of confusion, which will, in fact, affect cognitive, and emotional, and psychosocial and ethical development.
TED SIMONS: Does that make sense to you?
ALISON STEIER: Yeah, I'm thinking about how subjective trauma is. And in early childhood, because children don't have all the understanding and experience that older people have, there are events that they don't realize actually are life-threatening, and there are events that occur that are not life-threatening, like we would know as adults are not life-threatening, that are perceived by the baby as life-threatening. My students, I have them read a case study of an 11-month-old who developed post-traumatic stress disorder after a lawnmower was started up next to him, and it terrified him. Now we would know that a lawnmower is not a life-threatening device, but he did not know that.
TED SIMONS: In terms of services, and in terms of dealing with these folks, both when they’re young and when they get older, it is subjective. How do you differentiate between someone who I think we would all agree suffers a really traumatic experience and someone who as a baby may not even know why a lawnmower makes them jump four feet in the air. I mean, how do you differentiate these things?
KIM SKRENTNY: Absolutely, I think within our system, what we've done is we’ve developed a clinical assessment that's actually very specific to children, aged birth to five and we've been using that for probably about 10 years now, and what we found is that that's really conducive to the things that you're going to see, the symptoms you're going to see in those early and young-aged children. We've also got another assessment that's just for children who are at the age of five going up through adulthood that's structured a little bit differently. When we look at trying to address trauma as it occurs in our system between behavioral health and child protective services--because when a child is removed from a home, that's a very traumatic experience. And so, what we've done is we’ve set up collaborative efforts between Behavioral Health and Child Protective Services to be able to go in and assess those children within a 72-hour time frame. Because what we're looking for is, “Are there are any immediate behavioral health crises we have to stabilize?” or “What are those presenting concerns with that child and what kind of services can we provide and help to prepare for that preliminary protective hearing that the CPS worker goes into?”
TED SIMONS: Talk about symptoms and what you would look for in a little person as far as, “Something’s not right here.”
BERNADETTE MELNYK: Absolutely. Parents know their children best, and they are most in tune with what is normal emotions and behaviors for their children. The main thing is that parents should watch for anything that's not the normal for their child. Many children who are subjected to trauma, to stress, young children, especially, go back, they regress; they start behaving--taking on behaviors that they had when they were younger. Maybe a five-year-old who starts sucking their thumb again, or wetting the bed. Young children also can get very restless, showing signs of anxiety. Older children can too, but older children, and adolescents in particular, it's common for them to have anger and a lot of outbursts. Many older children and teens also feel a lot of guilt in certain circumstances, so you're dealing with that component on top of the trauma itself.
TED SIMONS: And you're saying a lot of this has to do with the brain's architecture? If that's the case, how do you deal with it?
MARCEL DUCLOS: Many years ago, we did not take into account--and I'm the oldest person in the room, so I can that and leave everybody out--we did not think that emotional, verbal, interpersonal interactions was changing the brain. We now know that all of our interventions, if they are effective, are actually changing neural networks; we're attempting to change the neural networks that were developed in contexts and situations that you were just describing. Also, in the manifestation of -- of a symptomology of abuse and neglect, there's -they're the children that you just described, and at the end of that other continuum, it’s the parentified child who then begins to act as if he or she is the parent in the family.
TED SIMONS; Interesting.
MARCEL DUCLOS: So it's -- it's – it runs—it runs the gamut.
TED SIMONS: A reminder: we have a child trauma expert standing by. The telephone number at the bottom of your screen, call that if you have questions or concerns. An expert is standing by, and will be standing by throughout the show until 9:30 this evening to answer your calls. Haven’t—and I'm asking this question rhetorically here, but haven't we all experienced trauma to some degree and if so, how come some of us handle it, some of us don't? What’s going on here?
ALISON STEIER: No, not really, not everyone has experienced trauma. In its truest form where you’ve actually had the experience of feeling that your life was in danger, or that you were in danger of great injury or harm, or that somebody that you felt connected to and close to was in that danger In fact, you know, in very young children, the best predictor that they will develop post-traumatic stress disorder, and the best predictor that they will have serious post traumatic stress disorder is not whether something happened to them directly; it's whether something was threatening to their mom or their caregiver. I mean, little children are that connected to the adults that care for them. And not every baby has had that experience, fortunately, although we know that too many have.
TED SIMONS: You mentioned relationships and you—please go ahead, because I think you want to add to what Alison said.
MARCEL DUCLOS: I mean it's such a vast -- every time we say one thing, it's a whole world that opens up. I was just remembering working as a consultant therapist in an emergency room. A 5-year-old girl comes in, she's got three teeth knocked out, her nose is broken, other teeth are coming through her lips. In the interview, she says, “I've been bad. I didn't shut up when my daddy said and so he hit me.” The whole phenomenon of child abuse and the identification of the one who has been harmed with the perpetrator, which is a little bit linked to your question about why do some folks who have been seriously severely harmed early on in their lives end up being kind and generous, and giving their life’s blood to help, and others perpetrate.
TED SIMONS: How do you see that, the idea that some folks will take a traumatic episode and seem to shoulder on --soldier on, I should say—even young folks, and others--the lawnmower example, maybe something else along those lines, shatters them. How do you deal with that?
KIM SKRENTNY: I think it depends on the individual child, their resiliency and maybe coping skills that they have. Also, do they have a strong emotional attachment to a parent or a primary caregiver that kind of grounds them into that? You can have a child that is going through a life-threatening illness, and is hospitalized and going through significant medical treatment, and you can have them say when they're getting some kind of treatment that's painful, you know, “I'll stop, I’ll be good. It's trying to help them understand that you're trying to help them. So it's that perception piece. The coping, the resiliency, their temperament. There’s a lot of different factors that come into play.
TED SIMONS: Can you add to that?
BERNADETTE MELNYK: Absolutely. I really think too, we have to remember these protective factors that do exist; if a child has wonderful support from their family after a traumatic episode, that child, we know from research, has a chance of faring better than a child who doesn't. Where it gets really sticket--sticky wicket is when the child is being abused, potentially by somebody in their family, and actually that's how abuse many times happens; it's not by strangers, but it’s by people in their own family.
TED SIMONS: Talk about treating a situation where it is the parent; the parent is the perpetrator. Obviously, you've got psychotherapy, you’ve got psychotropic drugs, you’ve got the whole nine yards. Can you—can you talk through traditional therapy talk with a child who—with a child with a parent in the room, with the parent in the building, with the parent still on earth. I mean, how do you do this?
ALISON STEIER: It's by individual case. When children are so activated in the presence of somebody who's been harmful to them, we don't require that they be in the room together while they’re still, you know, while that child is still getting her grounding, or his grounding. The whole point is they now have to learn that, in fact, relationships can have something useful to offer. So they have to unlearn what's been learned in the context of one relationship through a safe and dependable other relationship. And over time, it may be possible to bring the perpetrator back into the life of the child. And they will need to do work of their own. So these things, I think, are done on an individual case-by-case basis.
TED SIMONS: I want to get back to brain architecture a little here. Can you unlearn what's been learned?
MARCEL DUCLOS: Yes, even at my age. Yes. That's the—that’s the whole reality of psychotherapy. The best treatment will take into account every dimension of the human organism. So yes, we can -- it's hard to change different structures in the brain if, in fact, early on, the adverse event was such that someone has, let's say, a much smaller hypothalamus that didn't quite develop, and so is in stress. But we can change the networks and if you change the networks, you can actually change what's going on in the synapses. There's evidence that taking a baby, and just singing to it and rubbing its tummy will produce as many endorphins as a pharmaceutical.
TED SIMONS: Talk about pharmaceuticals, and talk therapy, and all these different kinds of treatments and what you see out there.
KIM SKRENTNY: Generally what we've found so far is that there's not a whole lot of research that supports medication use in very young children. It really kind of just supports therapies that kind of address the symptoms and what's going on. I think when we take a look at very young children and children in general, we want to be very careful about the prescribing of medications, and so toward that end, the state of Arizona has developed a clinical guidance documents and we give best practice guidelines around medication use, especially for children as young as age birth to five.
TED SIMONS: Is that how you see it as well as far as medication for very young children?
BERNADETTE MELNYK: Absolutely. The other thing too I really want to emphasize is we've done research with parents in primary care, and their children come in to see their nurse practitioner or pediatrician. Parents in general have a lot of worries about mental health in their children, but they have told us they don't usually tell their primary care provider about those worries and very importantly, they have told us, because the primary care provider often doesn't call the questions. So being a nurse practitioner, I just really want to encourage parents that if you have any worries about your children at all, if they're behaving in a way that's different than they usually do, as a first stop, talk to your nurse practitioner, talk to your pediatrician about these issues.
TED SIMONS: And you can talk to a child trauma expert by calling the phone number at the bottom of your screen. Experts will be standing by until 9:30 this evening to take your call. That number is for you. So go ahead, we invite you to call a child trauma expert. This business of a parent being involved has got to be just the most difficult to work your way around. Are there other things? Is biofeedback still—is playing with a child -- other methods of getting a child to open up or getting a fix on a situation?
ALISON STEIER: You know for older toddlers and preschoolers, play is the language of childhood, and so a therapist is in a position to translate children's play for caregivers so they can understand how children are thinking and feeling about what has happened to them. So play therapy is time honored, very useful technique. And what I think is when a parent can be available to be in the room with the child playing, it gives the child a message that this is their go-to person. So I've been through something or we've been through something, and we're going through it together. And so therapists can help parents stay in the room.
MARCEL DUCLOS: The psychiatrist and psychologist Bruce Barry, you know, underscores that. It has to deal with music, and movement, and space and especially getting reconnected with one's body. When you were talking earlier on about trauma, defining it as, you know, it’s life-threatening, in the subtext is-- it's an event that has such an adverse effect on me as a human, that I actually lose my sense of self. And when I lose my sense of self, I don't exist anymore.
TED SIMONS: Okay, let's take that, we’ve got--for a last question; we have a couple minutes left. If we you have a child, or you know of a child that you wonder about, that may have lost his or her sense of self, but you don't know what to do; you don’t know where to go or how to move forward, you're afraid maybe even just to hug the child because you don't know what's going--what do you do?
BERNADETTE MELNYK Well I think for one, talk. You have to get help in that particular situation. A lot of people--for instance, a wife that may be in a abusive situation with her husband, she's afraid; she's afraid to talk to somebody. It's almost, you know, more comforting for her to stay in that relationship in some ways than to go into the scary realm of talking to someone about it, and her whole life change. I mean abuse in itself is such a different situation to deal with, versus dealing with a child who has witnessed 9/11 on the television screen; they’re very different situations.
TED SIMONS: Where to go, what to do if you're worried and you think something’s going on.
BERNADETTE MELNYK: First, you need to go in; you need check with your doctor and see if you need to get a mental health evaluation that's done, depending if it's through the Public Behavioral Health System or private insurance, making sure that you know what is available through your insurance coverage and then going to the professionals to be evaluated so you can get the help and support that you need to do that for your child.
TED SIMONS: Alison, last word on this: if someone is really concerned, what do they do?
ALISON STEIER Get help from -- there are people who know children very well and can help families and when do you that, you not only alleviate stress in the moment, but you return development to its proper pathway and prevent, you know, big problems down the road.
TED SIMONS: Alright, very good. Excellent discussion. Thank you all for joining us.
MARCEL DUCLOS: Thank you.
TED SIMONS: Very good stuff. And remember, child trauma experts will be available to take your calls toll-free at the number on your screen until 9:30 p.m. You also can visit our website for more information and links to additional resources. That web address is azpbs.org/childtrauma. Thank you for joining us. I'm Ted Simons.