Treating Chronically Traumatized Children

The Sleeping Dogs Method

Arianne Struik

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429664410
• Edition: 2
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

When children refuse or seem unable to talk about their traumatic memories, it might be tempting to 'let sleeping dogs lie'. However, if left untreated, the memories of childhood abuse and neglect can have a devastating effect on the development of children and young people. How can these children be motivated and engage in trauma-focused therapy? Treating Chronically Traumatized Children: The Sleeping Dogs Method describes a structured method to overcome resistance and enable children to wake these sleeping dogs safely, so these children heal from their trauma.

The 'Sleeping Dogs method' is a comprehensive approach to treating chronically traumatized children, first preparing the child to such an extent that he or she can engage in therapy to process traumatic memories, then by the trauma processing and integration phase. Collaboration with the child's network, the child's biological family including the abuser-parent and child protection services, are key elements of the 'Sleeping Dogs method'. The underlying theory about the consequences of traumatization, such as disturbed attachment and dissociation, is described in a comprehensive, easy-to-read manner illustrated with case studies and is accompanied by downloadable worksheets. This new edition has been updated to include the clinical experience in working with this method and the most recent literature and research, as well as entirely new chapters that apply the 'Sleeping Dogs method' to the experiences of children in foster care and residential care, and those with an intellectual disability.

Treating Chronically Traumatized Children will have a wide appeal, including psychologists, psychiatrists, psychotherapists, counsellors, family therapists, social workers, child protection, frontline, foster care and youth workers, inpatient and residential staff and (foster or adoptive) parents.

Chapter 1

What is the impact of traumatization in children?

Chronically traumatized children can have huge problems in daily life, moving from placement to placement. Their parents, foster caregivers or residential staff are struggling to manage their behaviours, but they say that they feel fine, or deny that anything has happened. They do not need any therapy and they are not traumatized. Some refuse to see a therapist, or have walked out of sessions and refuse to come back. They are afraid to talk about their traumas, afraid of becoming angry, of things getting stirred up again and causing them nightmares. It is too pain ful to talk about and they rather avoid. Some do not even realize that their symptoms are caused by their experiences in the past. Chronically traumatized children can have severe problems in daily life as a consequence of their trauma. If they would participate in trauma treatment, those problems could be resolved, but what to do if that is not possible?

Other children actually manage quite well. They are seemingly stable and never talk about the past. Sometimes the therapist may be unaware of what they have been through, because they never talk about it. They suspect some trauma, based on their symptoms, but do not know how to address it. Parents, caregivers or therapist can believe it is better to focus on the child’s behaviour, rather than their trauma. ‘He does not talk about the sexual abuse, so he probably forgot. Let’s not “wake up sleeping dogs” by talking about the abuse because it might make him upset again. We should focus on medication for his ADHD.’ They are afraid to upset the child and make things worse.

This was the case with Sandra.

Sandra (1)

Sandra is seven years old and has been living with her foster family, the Smiths, for three years. She is referred for assessment of her learning difficulties. She has been subjected to serious abuse, neglect and sexual violence. She never talks about it anymore and denies her past. ‘My last name is Smith’, she says. When her foster family talk about her biological family, she yells: ‘Shut up, stop it!’ She is doing fairly well. Sometimes she gets very angry but it is manageable. The only thing that is out of the ordinary is that her foster parents have the feeling of being exchangeable. Sandra does not seem to have formed an attachment relationship with them. When they hug her, Sandra freezes. When she hurts herself, she laughs and does not seek comfort. The foster parents worked very hard and Sandra’s behaviour has improved a lot. They do not want trauma treatment for Sandra because they are afraid it will stir up old memories again and her violent behaviour will get worse. They just want to enjoy the stability they have reached.

Because it is so obvious that Sandra does not want to talk about what happened to her, it might be tempting to avoid disturbing the relative balance. Sandra has managed to survive by herself, and she has suppressed her memories –it seems unwise to stir things up. However it is unwise to leave such traumas untreated.

Children like Sandra are chronically stressed and alert, they trust no one and are attached to no one. They are lonely, are afraid to seek comfort and yet are unable to soothe themselves. These children do need help, but it is not clear where to start or how to find an opening. They do not want to talk about their memories or the child and/or caregivers or professionals believe the child will decompensate or destabilize or dissociate when the traumatic memories would be addressed. This chapter describes the impact of chronic traumatization on children, to demonstrate why it is needed to address the trauma.

1.1 Traumatizing events

Most of these children have been exposed to traumatizing events at an early age (before the age of eight), such as psychological, physical and sexual abuse, emotional and physical neglect (e.g. by parents with psychiatric problems or drug and alcohol abuse), domestic violence, threats and/or conflicts between parents witnessed by the child, war circumstances, discontinuity in the attachment process caused for instance by the death of a parent, adoption or a prolonged hospitalization, or an emotionally unavailable parent or painful medical procedures or diseases. The traumatization has happened within their families. Their parents or another caregiver such as grandparents or a stepparent, who are supposed to provide safety and protect them, have abused them. Child protection services have been involved and many are or have been removed from their biological parents.

1.2 Symptoms

As a result of traumatizing events, children may develop diverse trauma-related symptoms affecting most areas of development, such as:

• Affective and physiological dysregulation. For instance, children may be impulsive and become very angry or anxious without being able to control themselves. Or conversely, they may seem detached and without emotion. They can have diminished awareness and dissociation of sensations and emotions.

• Attentional and behavioural dysregulation. The children may have trouble learning or concentrating at school. Or they may be hyper-alert and easily distracted. They can be preoccupied with danger, have too much or too little self-protection, or they may self-harm.

• Self and relational dysregulation. They can have a disturbed self-image and distorted ideas about others and the world (guilt, blame, distrust). The children may fight a lot and have few friends and are often unable to sustain long-term relationships. They may keep their attachment figures at a distance, or conversely cling to them.

• Posttraumatic spectrum symptoms such as flashbacks, nightmares, avoidance (Van der Kolk et al., 2009).

David is such a child.

David (1)

Ten-year-old David has witnessed domestic violence since birth and his father was physically violent towards his mother and the children on a regular basis. His father was a sadistic man who enjoyed humiliating and tormenting David. At the age of seven, David called the police when his father assaulted his mother once again. His father became so angry that he almost strangled David. After that, his mother divorced his father and started a relationship with a new boyfriend. David does not see his father anymore.

David’s teacher thinks that he has ADHD. He has trouble concentrating and learning. He has fallen behind considerably in arithmetic and reading comprehension, and his integrative and deductive capacities seem limited. David cannot sit still for a second. He is always on the move and is unable to relax. He is quickly irritated, shouts out in class and has fits of rage in which he attacks other children and throws chairs. He often feels no one loves him and complains. He requires a lot of attention, but this never seems to be enough. When the teacher is helping another child, David will misbehave up to the point where the teacher has to intervene and send him out of the classroom.

David is suspicious and distrustful. David is reckless and sometimes deliberately hurts himself. He does not show pain and does not ask to be comforted. He seems unhappy, but never talks about his feelings. The teacher has never seen him enjoy himself. David is dominant and when he plays with other children, it invariably leads to fighting. David then behaves aggressively, and his eyes turn ‘mean’. He says things like: ‘I’ll stab you to death, I’ll rip you open and tear your guts out.’ At home, David attacks his younger brother, and sometimes his stepfather has to intervene because David loses control completely, kicking, screaming and biting, seemingly in a trance and out of reach. ‘Stop it, don’t hit me,’ he screams.

David is not popular at school. He bullies other children and they are afraid of him. He tries to trip them, punches them ‘by accident’ and then innocently says: ‘Oh, sorry.’ Frequently things go missing or are broken in school with David being the suspected culprit, but he denies any involvement and cannot explain why he behaves in this way. David does not seem to realize the consequences of his actions and he does not learn from his experiences.

He prefers playing games involving violence, his drawings are full of violence and death. His mother has found notes written by David which read: ‘I am going to kill myself, that is better for you. I hate myself.’ When she confronts him, David denies having written them.

David has trouble falling asleep and his mother frequently hears him screaming in his sleep: ‘Stop it, let me go!’ He says he does not have nightmares, but his mother suspects that he does. When they are having a good time, David tends to ruin the occasion by picking a fight. A pleasant evening always ends negative.

Chronic traumatization can also lead to different symptoms. Children may be confused and disoriented, have fragmented perception, be forgetful and chaotic, dreamy and absent, they may dissociate or have flashbacks and nightmares. They may literally be out of touch with their body and their feelings, like five-year-old Demi below.

Demi (1)

Five-year-old Demi was sexually abused by her grandfather between the ages of two and four years. A year ago the abuse stopped when Demi told her mother. Mother had suspected for quite some time that something was wrong. Demi had inexplicable stomach-aches and headaches, twice had a sexually transmitted disease and complained about an itch around her genitals.

Demi sometimes wets herself during daytime and night-time. She has nightmares and sleeps with her mother because she is afraid to sleep alone. Demi is afraid to sleep over, to go to the bathroom alone or to go upstairs alone. She does not play outside and she does not ask other children to come and play. When she is invited, she usually refuses the invitation. Demi sometimes talks in an infantile way and acts like a baby. Demi is often tired and hangs on the couch. She hardly ever plays. Most days she doesn’t want to go to school and clings to her mother. Demi is dreamy at school and has trouble concentrating. She has few friends because she makes weird, inappropriate remarks and does not know how to interact with other children.

Demi has a negative self-image and thinks she is stupid. She is insecure and has a fear of failure. She thinks that other children laugh at her or think she is stupid without any reason. She cannot stand up for herself and does not seem to have an opinion of her own. She copies other children and has a hard time making her own choices. She can be manipulated into bullying another child, for which she then takes the blame. She then feels very bad and guilty.

Demi masturbates every day and also touches her genitals with other people around. Sometimes she inserts objects into her vagina. Mother caught her one time while she was pushing a pencil into the anus of her three-year-old cousin, who of course was crying loudly. A few times she sat on a man’s lap, rubbed against him and tried to kiss them on the mouth. She seems to flirt with men. She may suddenly take off all her clothes in public. She somehow attracts ‘dirty old men’. Her aunt has twice caught her in the hot tub of the swimming pool, sitting next to a man whom her aunt did not trust. Demi does not seem to sense any danger. Her mother, who was sexually abused herself, does not sense it either. She allowed Demi to stay in the hot tub beside those men. This surprises the aunt, because Demi’s mother should know better.

Demi does not want to talk about the abuse because she is ashamed. But she does often play sexual and violent games with her Barbie dolls.

Adolescents may be ashamed of their vulnerability and suppress their emotions. Some tend to blame themselves and have more internalizing problems such as depression, fear and feelings of guilt, learning difficulties, self-harming, suicidal thoughts or attempts, and substance abuse. Tracy is such a girl.

Tracy is sixteen years old. Together with her brother Roger, she grew up in an environment of emotional neglect. Their father is an introverted man who is always working. Their mother displays traits of borderline personality disorder and is emotionally unstable. She can become very angry and then humiliate her children and abuse them psychologically. From quite an early age Tracy has often had to comfort her mother. Roger was a child with behavioural problems, in need of a lot of attention. There were many conflicts, and Tracy always kept quiet so as not to cause any problems.

Tracy is depressed and has negative thoughts about herself. She smokes cannabis daily, saying that it helps her to sleep. She has trouble concentrating at school and her grades are getting worse. She is mistrustful of her boyfriend and jealous. When she feels bad, she shuts him out. She then cuts herself and picks fights with him. She shouts at him, telling him she does not need him and that she hates him, until he leaves. Then she feels guilty and bad about herself, and sometimes drinks a lot of alcohol. The following day she then apologizes and is pleasing and extra-sweet to him.

Some children cover up their negative feelings with externalizing behavioural problems, trying to put the blame outside themselves. They misbehave at school, have conflicts, abuse alcohol and drugs, and are violent. Some re-enact the traumatizing events in their behaviour. Such is the case with Roger, Tracy’s brother, who re-enacts the rejection by his biological parents.

Roger is seventeen years old and was adopted from Colombia at the age of two. In the children’s home where he was since birth he was physically and emotionally neglected. After the adoption he hardly responded to contact, which only improved after a year. In the following years his behavioural problems became worse. Roger was expelled from two schools and was sentenced to community service for stealing. He keeps promising to do better, but he never succeeds. Roger feels really bad about doing this to his parents, but he never manages to keep his promises. He steals money from his mother, stays out all night and frequently uses drugs. Roger has friends who have a bad influence on him and sometimes manipulate him into doing things he does not want to do. He is afraid of saying no to them because he worries that they will think he is a loser. His mother says that Roger is insensitive and not social. He has trouble anticipating other people’s behaviour and often has no clue what others might think or feel. His parents wonder whether he is autistic. Roger thinks this is nonsense.

Roger is probably right; his symptoms seem autistic, but they may very well be caused by traumatization. Traumatization of children or adolescents may present in different ways, sometimes covered up with behavioural problems or not visible at all. During or after traumatic experiences there may be a period in which the child seems not to have symptoms. Trying to survive, he cannot afford to stand out and show any strong reaction. Nonetheless, his development is seriously threatened, making treatment necessary.

1.3 The impact of traumatization on the body and brain

1.3.1 The three parts of the brain

In their book Trauma and the Body, Ogden, Minton and Pain (2006) describe a theory about the brain and the body and the way it functions, which i...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Acknowledgements
• Introduction
• 1 What is the impact of traumatization in children?
• 2 Why children become avoidant and resistant
• 3 What is needed to overcome resistance?
• 4 The Sleeping Dogs method
• 5 Psychoeducation to increase motivation
• 6 Interventions to overcome barrier 1: Safety
• 7 Interventions to overcome barrier 2: Daily life
• 8 Interventions to overcome barrier 3: Attachment
• 9 Interventions to overcome barrier 4: Emotion regulation
• 10 Interventions to overcome barrier 5: Cognitive shift
• 11 The Motivation and Nutshell Checks
• 12 Trauma processing and integration
• 13 Children in out of home care
• 14 Specific target groups
• 15 Planning and the treatment process
• Appendices
• Worksheets
• References
• Index