Ricky Greenwald, PsyD
Correspondence concerning this article should be addressed to
Ricky Greenwald, Psy.D., P.O. Box 575, Trumansburg, NY 14886.
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His home page is at: http://www.clarityconnect.com/webpages/rickygr
Contemporary child mental health care is compared unfavorably to its medical counterpart, which offers prevention and early intervention in addition to treatment of symptoms. Child trauma, broadly defined, is characterized as a ubiquitous, under-treated, primary source of psychopathology. Traumatic experiences which remain unintegrated accumulate as a trauma burden, leading to reactivity and impairment. Two recently developed trauma-focused interventions are described: critical incident stress debriefing (CISD) and eye movement desensitization and reprocessing (EMDR). Combined with screening and early identification of traumatized children, CISD and EMDR can be used economically for widespread elimination of the trauma burden.
CHILD TRAUMA, CISD, EMDR, TREATMENT, PREVENTION
I wish to take the unusual step of opening a modestly formal scholarly paper with some personal observations. In this paper I take a position which may be viewed as premature, unrealistic, radical, or (I like to think) visionary. I first submitted a version of this paper for publication in 1993; it was rejected again as recently as 1996. Perhaps it is finally reaching the public now because more supportive data is available, because of growing awareness of the child trauma problem, because I am becoming a better writer. Perhaps. I suspect that the main factor is the Internet. There is simply more room now for divergent views to be expressed.
I am certainly grateful for this long-awaited opportunity, and pleased also with the symbolic value of publishing this particular piece here. As part of the Internet, this journal represents a technological development with awesome potential, already beginning to be realized. What better forum for discussing the awesome potential of technological developments in children's mental health?
The "21st Century" has long referred to the fantastic, distant future - but now it is close upon us. Will the reality live up to our hopes and dreams? Or surpass them? The good news in our field is that we now have the ability to help children grow up with an unprecedented degree of freedom from psychological problems. At least, we have the knowledge, and hopefully the will as well.
Children's mental health care has traditionally been offered primarily as a response to pathology, pain, or disruption. Similarly, medical care once also consisted of just treating wounds and illnesses, but now supports healthy development through routine immunizations, screenings, and checkups. We are on the verge of being able to provide a similar level of mental health care for children, which can be widespread, economical, timely, and effective. This will, of course, require a real shift in our approach to children's mental health. (Educational interventions, such as programs for divorcing parents, are beyond the scope of this paper.) I will make specific proposals in this regard, but first I would like to describe how I came to this position.
In December of 1992 I served as a therapist on a research project in Miami, which provided brief eye movement desensitization and reprocessing (EMDR) treatment to over 100 people who were still having emotional difficulties several months after Hurricane Andrew (see Grainger, Levin, Allen-Byrd, Doctor, & Lee, in press). The therapists were struck by the consistency with which subjects reported earlier traumatic memories which were thematically similar to the most upsetting parts of their hurricane experience. In other words, our subjects were not simply traumatized by the hurricane; they were re-traumatized. For example, a woman who had been molested as a child described the worst part of the hurricane experience as being her inability to protect herself afterwards, having no doors or windows to lock. While many subjects were surprised to find that they were still reactive to the old memory, they came to recognize the continuing negative influence the memory had exerted over time - including its contribution to the current symptoms.
Here is a conceptualization of the process underlying the apparent cumulative effect of traumatization (see Figley, 1985; Peterson, Prout & Schwarz, 1991). Psychological integration of an upsetting experience involves facing and working through the various elements of the memory. However, experiences perceived as overwhelming may be rejected instead. When a traumatic experience has not been integrated, or processed through normal memory channels, the memory is left in its original, raw state, "waiting at the door" for a chance to get in. Elements of the memory (e.g., imagery, fear, helplessness, etc.) may suddenly burst into awareness, triggered by a stimulus with some resemblance to the initial memory. Reactivity to thematically similar stimuli is increased, to the extent that the current reaction encompasses prior unprocessed painful emotions as well as those evoked by the new event. The non-integrative response style, used to avoid the painful emotions, increases in value at each successive trauma, as the amount of pain in the reaction accumulates with each additional traumatic experience. Thus, as the trauma burdenincreases, so also does thematically related reactivity and predisposition to a non-integrative response style.
This concept of the trauma burden may explain the "sleeper effect" shown by those without apparent long-term effects from trauma, when challenged in a thematically related area (e.g., Kantor, 1980; Wallerstein, Corbin, & Lewis, 1988). Recent research has also shown increased vulnerability to post-traumatic reactions, following a traumatic experience, among those with prior trauma history (Riise, Corrigan, Uddo, & Sutker, 1994; Scott & Gardin, 1994). At some point of critical mass, the burden of reactivity may simply overwhelm the containment mechanisms (or competing schemas) and become more generalized and apparent, manifesting in symptoms of depression, anxiety, or PTSD. Our subjects in Florida were at this stage.
While working through these early traumatic memories with EMDR, it was common for subjects to experience great sadness in regard to the burdens and limitations they had carried from the time of the trauma. I shared that sadness. And I started to wonder: "Why can't we take care of children when they need it, so they don't have to grow up emotionally crippled? Why can't we intervene right after a traumatic experience, to assist in integration, and prevent the reactivity and avoidant style from taking hold?"
In fact, we can. It's just a matter of applying knowledge we already possess. The convergence of several recent developments in child mental health creates possibilities for the implementation of new intervention strategies with enormous preventive potential. These developments include increased recognition of the consequences and prevalence of child trauma, and increasingly effective methods of treatment.
Consequences of Child Trauma
For present purposes, child trauma will be defined in a broad sense to include any experience in which the child experiences overwhelming fear or pain, along with helplessness (Krystal, 1978). This would include child abuse, scary accidents, witnessing violence, and similar experiences. Since highly upsetting events such as divorce or death in the family may lead to a virtual post-traumatic response (Heatherington, Stanley-Hagan, & Anderson, 1989; Newcorn & Strain, 1992), potentially including all features except hyperarousal (Pynoos, 1990), such experiences are also included in this discussion.
The effects of unintegrated traumatic experiences can become permanently "locked in," possibly leading to a variety of post-traumatic symptoms, and, arguably, forming the basis of most psychopathology (e.g., Brom, 1991; Conaway & Hansen, 1989; Famularo, Kinscherff, & Fenton, 1992; Green, 1983; Kendall-Tackett, Williams, & Finkelhor, 1993; Terr, 1991; van der Kolk, 1987). Even if acute symptoms fade, the traumatized child often remains vulnerable in thematically related areas (as described above). This leads to increased sensitivity and reactivity when faced with similar challenges, making new upsetting experiences seem even more overwhelming due to the additive effect. Thus, traumatized children can become progressively more reactive, vulnerable, and symptomatic as the trauma burden grows, leading to a range of problems and limitations in quality of life.
Prevalence of Child Trauma
The data on the prevalence of traumatic events in childhood are primarily indirect and suggestive, yet persuasive and alarming (e.g., Pynoos, 1990). Recent research has found astonishingly high incidence rates for prior experience of at least one Criterion A stressor among young adults - most of which presumably occurred during childhood or adolescence. For example, Riise et al (1994) found an 85% incidence among a military population (only a minority of which were military trauma), and Vrana and Lauterbach (1994) found an 84% incidence among college students (for more discussion, see Vrana & Lauterbach, 1994). When major loss experiences are also taken into account, it becomes increasingly clear that child trauma is ubiquitous.
Treatments for Child Trauma
Treatments for child trauma may take many forms, including individual symbolic/expressive and cognitive-behavioral approaches, as well as family and group interventions. In the 1980's, two treatments for single-incident trauma were introduced that have shown a degree of efficacy and efficiency unprecedented in the mental health field: critical incident stress debriefing (CISD) and eye movement desensitization and reprocessing (EMDR).
CISD (Mitchell & Everly, 1993) is a structured sequence of discussion activities, conducted with a group (or individual) soon after exposure to a traumatic event. It is considered the state of the art in group interventions for disaster and critical incident response, and is widely used. The CISD procedure seems to help participants to maintain an integrative approach to the traumatic material, minimizing the proportion of the memory that gets "stuck" and becomes part of the trauma burden. A single one- to three-hour CISD session can be expected to dramatically reduce the frequency and severity of later mental health problems related to the event (Mitchell & Everly, 1993). The basic principles of this approach have been adapted to disaster and critical incident response with children (e.g., O'Hara, 1994; Poland, 1994; Purvis, 1991; Pynoos & Eth, 1986; Pynoos & Nader, 1988; Thompson, 1993), often by combining it with other interventions involving expressive activities and/or family work.
EMDR (Shapiro, 1995) is a client-centered exposure procedure which, to oversimplify, features concentrating intensely on the traumatic memory while moving the eyes rapidly from side to side (by following the therapist's moving hand). It is somewhat newer than CISD and less well understood, but already has a strong track record in helping individuals to rapidly "work through" and integrate traumatic memories, particularly under the following conditions: when treatment is conducted by practitioners with formal, supervised EMDR training; and when the symptoms arise from a small number of traumatic memories (see Greenwald, 1994b, 1996).
Although EMDR is still relatively new, its effectiveness (and superiority) is already supported by more controlled studies than any other psychotherapy approach for trauma (Shapiro, 1996). To date, most of the controlled studies have addressed adult treatment. However, the first controlled EMDR studies involving children and adolescents (Chemtob & Nakashima, 1996; Datta & Wallace, 1996; Puffer, Greenwald, & Elrod, in press; Scheck, Schaeffer, & Gillette, 1996), as well as numerous case reports (Cocco & Sharpe, 1993; Greenwald, 1994a; Mendoza- Weitman, 1992; Pellicer, 1993; Shapiro, 1991; see also Greenwald, 1993), have been consistent with the findings on EMDR with adults (Greenwald, 1997). A single 30-90 minute session with a child can often lead to complete resolution of psychological problems arising from the traumatic memory. It appears likely that EMDR will prove to constitute a quick and effective individual treatment for children, that can eliminate both trauma-related symptomatology and the trauma burden itself. Further studies with children are underway.
What We Should Do
Ultimately, just as children undergo an annual physical examination, they should undergo an annual "mental health" checkup conducted by a child therapist. EMDR may play a central role in these sessions, when indicated. Recent traumatic memories could sometimes be addressed within the checkup session, and children with further needs could be appropriately referred. Of course, this is far from a simple proposition, and would probably require (among other things) a universal health insurance system in which the provider perceived a vested interest in the child's long-term health. The implications for psycho-social development and quality of life could be profound.
Meanwhile, much can be done without delay. Treatment should be made available to children following recognized traumatic experiences, such as natural disaster, school violence, car accident, and bereavement, when the child's need and accessibility are greatest. This is worthwhile even if the child appears to have recovered, as a hidden trauma burden may remain. Family or group CISD interventions, when applicable, can be followed by individual EMDR treatment for those in need of further assistance. This model is effective and efficient, with relatively low cost and high preventive value. This approach has already met with success in at least one major disaster site (Chemtob & Nakashima, 1996), and is under consideration at others.
Of course, children may also be traumatized by experiences with less social visibility, such as physical, sexual, or emotional abuse; maltreatment by peers; family discord or breakup; exposure to violence; and injury or illness of self or family member. Many such children are never treated, while others may receive a wide variety of diagnoses, without recognition of the possible traumatic component.
Therefore, a concerted effort should be made to better identify traumatized children, so that appropriate treatment can be provided. This can be partially accomplished by educating parents, teachers, pediatricians, and others involved with children. Also, the development and dissemination of simple, brief screening instruments (e.g., Greenwald & Rubin, in press) can alert those concerned with child problems to the possibility of a traumatic component. For example, a pediatrician might administer such screening instruments when a child presents with frequent stomach aches, or with some of the behavioral markers of attention deficit disorder.
Although various social and biological forces also threaten children's healthy development, it is clear that untreated child trauma makes a major contribution to the development of psychopathology and impaired functioning. Elimination of the trauma burden would enable growing children to more fully realize their potential. I believe that CISD and EMDR can be used to reduce suffering, and enhance development, on such a broad scale that the world would truly be a better place.
We will enter the 21st Century with the technological capacity to efficiently and effectively identify and treat child trauma on a widespread basis. I hope we use it.
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Version 1.0 First Published June 1997
Last amended: 18/02/00.