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Trauma and Its Effects on Children, Adolescents and Adults: The Role of the Occupational Therapist
Vivyan Alers
Occupational Therapy private practitioner, Midrand, South Africa
Director, Acting Thru Ukubuyiselwa NPO, Johannesburg, South Africa
Introduction
The resilience of the human spirit to traumatic experiences cannot be underestimated. Traumatic experiences may be physical and emotional injury from various sources, during various stages of life and with various degrees of severity. Occupational therapy intervention contributes to breaking the perpetuation of violence and trauma through the generations and preventing the resultant mental health problems and enhancing the occupational performance of the trauma survivor (Kellerman & Hudgins 2000). Traumatic experiences are part of everyone’s lifespan, whether it is death of a loved one, unemployment, vehicle accidents, divorce, war or natural disasters or physical, emotional or sexual abuse. Traumatic experiences may be individual or communal and result in dysfunctional occupational performance in domestic, school and work settings, having a trajectory on developmental stages throughout the lifespan. Traumatic experiences have a resultant influence on all the relevant people involved.
Children are the nation’s future as today’s children are tomorrow’s youth and adults, and tomorrow’s adults are the livelihood of their own country. Today’s adults are the guiding role models for today’s children and youth and as such have a responsibility to support and teach safety, containment and responsible survival. When adults in a community neglect this responsibility, it then falls on health professionals, including occupational therapists.
Trauma has a powerful impact on healthy growth and development. Often, traumatic experiences are not verbalised and are buried under layers of defences and stigma. Occupational therapists are at the forefront of developing therapeutic relationships with traumatised children, adolescents and adults. They have the opportunity to positively contribute to development through the lifespan and to provide a new meaningful, self-affirming experience that is stable and allows safety and containment, which in turn allows the person to participate optimally in activities of daily living and occupational performance.
If occupational therapists aim to work holistically and ignore the imposed problems of trauma that exist in our society today and just focus on the presenting problems, the true philosophy of occupational therapy is not being followed. Often, occupational therapists treat a child’s perceptual problems and overlook his/her emotional problems and their sources or an adolescent’s drug addiction without addressing their sexual abuse. When rehabilitating a paraplegic, the occupational therapist may overlook his/her emotional anger at the perpetrator who caused the disability or overlook the vicarious trauma of the alcoholic policeman. Often, these aspects are not addressed directly in therapy, and the superficial presenting problem is only treated. Therefore, as professionals who pride themselves as working holistically, there is a responsibility to address these underlying needs. In paediatric occupational therapy, there is a trend towards ‘early intervention’ to remediate and prevent developmental delay. However, there is a significant lack of occupational therapists remediating and preventing developmental delay who recognise that children showing academic or perceptual problems may have suffered a traumatic experience. Occupational therapists also need to take cognisance of the effects of the developmental maturation of functional or dysfunctional attachment styles of the developing person. Trauma is part of living through the lifespan. Traumatic experiences are interpreted differently by each individual with the adaptive response and interpretation of the experience being unique and varying in the severity of the response. It is often mistakenly thought that the individual who was directly involved with the trauma is the only one affected, yet its effects are far reaching, affecting, for example, the caregivers, family, those who witnessed the trauma and those who hear about the trauma. Traumatic events vary, for example, being bullied at school, divorce, death of a loved one or being a witness or survivor of a rape. The severity of the reaction to the same traumatic event varies with each individual.
Occupational therapists dealing with survivors of trauma need to understand that the brain develops and is organised in a hierarchical manner from the brainstem to the cortex. Interventions need to be developmentally appropriate and sequentially following this hierarchy. Healing will often not be a linear, straightforward process but rather characterised by progress and regression or setbacks. During healing, the trauma survivor will display functional problems related to his/her coping mechanisms in all spheres of daily living. The desired outcome however is that the individual returns to the previous optimal level of functioning.
DSM-5 criteria
The criteria include the identification of the trigger for post-traumatic stress disorder, and the resultant functioning of the person encompasses a wider functional capacity. A clearer line is drawn detailing what constitutes a traumatic event. Sexual assault is specifically included. Language specifying an individual’s response is omitted. Attention is given to the behavioural symptoms, and they are described as four distinct diagnostic clusters, namely, re-experiencing, negative cognitions and mood, avoidance and arousal. The disturbance should be present for longer than a month. There is an addition of post-traumatic stress disorder (PTSD) in children younger than six years and PTSD with prominent dissociative symptoms (American Psychiatric Association (APA) 2013).
Types of trauma
Trauma can be classified in different ways according to how the trauma is experienced and is as follows:
- Primary trauma – when an individual directly experiences the trauma, for example, car accident, hijacking, war
- Secondary trauma – when the trauma is directly related to the primary trauma, for example, a rape survivor going to court
- Vicarious trauma – trauma as a result of hearing or being exposed to other people’s trauma, for example, journalists, those involved in the justice system, caregivers and health professionals
Trauma can be acute or complex in nature. An acute trauma is sudden, unexpected and over after the incident, for example, death of a sibling, but may have long-lasting effects. Complex trauma is a prolonged repeated traumatic event, for example, domestic violence and battered women. In complex cases, a relationship often exists between the victim and the individual who causes the trauma, for example, the spouse who inflicts the trauma. The victim is usually under the control of the perpetrator and often feels powerless to escape, for example, a wife who is being physically and sexually abused by her husband and has no financial means to leave and file for divorce. A more acceptable terminology for a victim is a ‘trauma survivor’. It is also important to differentiate between intra-familial trauma and extrafamilial trauma.
The neurological impact of trauma
The effects of trauma on the brain are manifold and very complex. A simplification of the hierarchy is that the brainstem level is involved with arousal and attention; the complex limbic system follows on with the emotions including stress, followed by the cortex, which is involved in memory, cognitive processes and somatosensory processes. The cortex functions as a right brain, which is the seat of implicit memory, and a left brain, which is the seat of explicit memory. Implicit memory is related to ‘core consciousness’ and ‘attachment and affect regulation processes’ (Hug in Hudgins & Toscani 2013, p. 113). Explicit memory is related to ‘reflective consciousness, language processing, analytical reasoning and temporal ordering’ (Hug in Hudgins & Toscani 2013, p. 114). Perry (2006) relates to the hierarchy of the brain and the importance of the brainstem functions being stable before moving to higher functions in the brain. Modulation at the brainstem level relates to hyper- or hypo-arousal resulting in whether the higher centres of the brain can be accessed or not.
The limbic system is a complex integrated system and is the seat of survival instincts and reflexes including stress reflexes of fight, flight and freeze. It regulates emotional experiences and expressions and to some extent the ability to control our impulses. It is also involved in the basic drives of sex, aggression, hunger and thirst. The limbic system consists of the amygdala, hippocampus and other structures. The amygdala and hippocampus are the structures involved in understanding traumatic memory. The amygdala is involved in implicit memory, motivated behaviour and emotional states. It is involved in the processing and storing of emotions and reactions to emotionally charged events and is active when there are flashbacks. The hippocampus is known as the data processor of sequential personal experience and is involved in explicit memory. The cortex performs the sensory and motor functions. This regulates higher cognitive and emotional functions. Broca’s area is involved in expressive speech, and when traumatic stress is excessive, this area is shut down. Thus, no words are then available to process the trauma, so this has implications for therapy. Hug in Hudgins and Toscani (2013) explains that trauma-induced changes in the brain and cause the left and right brain to be unbalanced, hyper-arousal of the amygdala occurs affecting self-regulation and the malfunction of the hippocampus causes fragmentation of working memory around the trauma and spontaneity loss. van der Kolk in Wylie (2004) explains that ‘talk therapy’ only accesses the left brain and that theatre work involves movement thus integrating the left and right brain functions to access the trauma memories and make meaning of them. This is why action methods, psychodrama, projective techniques and guided imagery are effective in aiding the trauma survivor to process the trauma material from the right brain and give accurate labelling, via the left brain, to what has happened (Hudgins 2002).
Signs and symptoms of trauma
There are a number of signs and symptoms that people experience when faced with trauma. The assessment by the occupational therapist is likely to find physical, cognitive, emotional, motivational and behavioural signs. These signs and symptoms vary according to the age of the individual and in children show clusters of behaviour in preschool children, primary school children and adolescents:
- Physical signs may include aches and pains such as headaches, backaches and stomach aches, sudden sweating and or heart palpitations, changes in sleeping patterns, appetite and libido, constipation or diarrhoea, lowered immunity and increased or decrease in appetite, hyper-vigilance and being easily startled by noises or unexpected touch.
- Cognitive signs include poor problem-solving and decision-making, confusion and disorientation, poor concentration and memory, possibly nightmares and rationalisation and minimisation of the experience.
- Emotional signs include shock and disbelief, fear and anxiety, grief and denial, hyper-vigilance, irritability and emotional lability, emotional numbing and isolation, intrusive thoughts and an increased need to control everyday experiences.
- Behavioural signs may include substance abuse and increased or decreased food intake, crying constantly or for no apparent reason, excessive checking of security, anger outbursts, social withdrawal and suspiciousness, avoiding anything that is associated with the trauma and self-blame or survivor guilt and difficulty trusting others.
- Past traumatic experiences may resurface, and there may be a diminished interest in activities that were once pleasurable.
Children show behavioural signs most prominently and often have self-guilt and project their fears onto concrete objects and act out. They may show regressive behaviour such as bedwetting, thumb sucking and emotional outbursts. Children may have difficulty sleeping and have nightmares. Pre-schoolers may re-enact the traumatic event in their play, become clingy to their caregivers, become passive, quiet and regress with feeding or toileting problems. School age children may show sleep problems, concentration problems, psychosomatic problems and be emotionally labile. Adolescents fear that their flashbacks are abnormal, may try to avoid thoughts and memories of the event by using drugs and alcohol, are irritable and have concentration problems. Sleep problems may be disguised as late night socialising or studying (Jelly Beanz Inc 2013).
It is important to stress that these reactions are often ‘normal reactions to abnormal events’, and this needs to be conveyed in a warm, caring and sensitive way. Everyone who has gone through a trauma will experience some of the aforementioned symptoms. It is important to realise that these symptoms do not necessarily indicate psychopathology, yet as mental health professionals, occupational therapists need to be aware of the risk factors for the development of PTSD (APA 2013). These are not limited to but can include previous history of abuse or significant emotional losses, prolonged and extended exposure to danger, pre-trauma anxiety and depression or other mental health problems, lack of social and familial support, chronic and acute medical conditions and substance abuse. Referral to a psychologist or psychiatrist or child psychiatrist is very important in such cases.
Normal reaction to abnormal events
People that have been traumatised are in need of a feeling of safety and containment both physically and emotionally. Containment relates to their safety so that their thinking is not overwhelmed by their affect (Hug in Hudgins & Toscani 2013). Their physical and emotional boundaries need to be overtly respected, and they need to be asked if they want to be alone or have physical touch. If touch is not wanted, this request must be confirmed and demonstrated that they will not be touched. Traumatised individuals need to feel accepted, not judged. They have a right to have the opportunity to talk in a place that they perceive as emotionally and physically safe. Their feelings are of utmost importance, and they need to have an empathetic individual to listen to them attentively.
Models related to trauma
The Sinani/KwaZulu-Natal programme for survivors of violence model
This model describes the cycle of violence and the belief that reconciliation is possible (Sinani/KwaZulu-Natal Programme for Survivors of Violence 2003; Alers & Ancer in Crouch & Alers 2005). Sinani has also launched programmes for Peace Building, Poverty Alleviation and HIV and AIDS. Within the Peace Building programme, they have a ‘Hlonipha’ (respect in isiZulu) campaign, which is promoting respectful ways of interacting amongst different people in the community. ‘Respect for others’ is to combat violence and to build the fabric of society that was destroyed by past injustices.
Trauma debriefing model
This is a directive proactive process. It is a structured procedure to engage people in the telling of their experiences that traumatised them (Alers & Ancer in Crouch & Alers 2005). Again, containment and safety are of utmost importance to prevent re-traumatisation:
- Retelling the story. The purpose of this is to allow a cognitive formulation of the experience. Retelling is a means of helping the individual to remember the experience differently and not to try to forget it. This is done by reviewing the facts, verbalising thoughts that occurred during and after the crisis and verbalising feelings during and since the crisis.
- Normalising the symptoms. This is the process of reassuring the individual that the symptoms that he/she is experiencing are a normal reaction to an abnormal situation. This is of utmost importance to assist the individual to understand his/her reactions and to realise that these are coping mechanisms.
- Reframing. Reframing helps the individual to regain control of his/her thoughts and to see the situation from a different perspective. People often feel that they were inadequate at the time of the trauma and will question what they did or did not do. The observing ego (Hudgins 2002) is helpful for this as it gives the perspective as a ‘fly on the wall’ non-judgemental observation.
- Encouraging mastery. The purpose of this is to help restore the individual’s coping capacity and to reduce a dysfunctional response to trauma. By encouraging mastery, the individual is assisted to address a traumatic situation from a position of coping rather than helplessness and to consciously recognise his/her own strengths and coping mechanisms. This process leaves the individual empowered (Alers & Ancer in Crouch & Alers 2005)
The most important aspect of healing is to have a supportive family member and friends who listen, support and sensitively deal with the traumatic experiences. The guidelines for these trusted people are to understand that the trauma survivor’s reaction is normal and usually improves over time. Safety and support are needed for the survivor to talk it through when ready to do so. Never force any person to talk about the experience, rather explain that there is a listening space for him/her when ready. Be careful not to enquire about detail of the incident for the listener’s benefit, as the talking process is for the trauma survivor’s benefit. Be careful that the talking does not re-traumatise the survivor and remind him/her of the present safe position. Children may be helped to draw pictures about the traumatic event. The person needs to be given space to talk about his/her anger because the anger is justified. When enough space is given and the anger is acknowledged as righteous anger, he/she will finally choose not to take revenge. Thus, the trauma survivor will understand not to develop to be a perpetrator. The person needs to be given space to talk about the guilt, and then it is important to point out that it was not his/her fault. ‘No shame, no blame’ was a saying with an upward unloading physical body motion that developed out of a Therapeutic Spiral Model (TSM) workshop conducted in a community setting in South Africa during 2001. The trusted person needs to help the survivor work out coping strategies when memories are overwhelming and techniques that are most helpful when upset. Suggestions may be to structure his/her time and encourage physical exercise.
Neuro-sequential Model of Therapeutics
It is described by Perry and Hambrick (2008) to map neurobiological development. Core principles of traumatology and neurodevelopment are integrated into a comprehensive approach for the child, family and community. The assessment reviews the main insults, stressors and difficulties that were present during development. The child’s relational history during development gives clues to attachment styles, which may relate to resiliency or vulnerability affecting functional development. Then the current functioning of the child is correlated with the hierarchical neural systems of the brain to link the neuropsychiatric symptoms and assets of the child. From this assessment, the developmentally appropriate interventions are addressed in their hierarchical order. Thus, the brainstem functions of arousal, attention and self-regulation will be focused on initially, until the calm alert state is reached. This is achieved with rhythmic, repetitive somatosensory input together with calming vestibular input. Only when the calm alert state is reached can the limbic system be accessed. The routines, predictability and caregiver support must be consistent. The relational aspects can be worked on through therapeutic techniques such as play therapy, psychodrama or action therapies. Opportunities to partake in age-appropriate activities only now become meaningful. When functional relationships are restored, then the verbal and cognitive behavioural or psychodynamic approaches can be used. However, throughout this healing sequence, the consistent presence and interaction of positive nurturing relationships with trustworthy peers, teachers and caregivers is essential over a period of time. The somatosensory system needs to be regulated with calming, safe, predictable and repetitive stimuli (Perry & Hambrick 2008).
Attachment theory
It is an important framework for fieldwork to consider styles of attachment of individuals with mental health problems. Attachment theory was developed by John Bowlby during the 1950s when he became aware of the problems children experienced when separated from their parents during World War II. Attachment behaviour is activated when a child seeks proximity to his/her caregiver due to being lost, frightened, being injured or at risk of injury, needing comfort or when hungry. All higher primates come inbuilt with the capacity for attachment as a biological survival mechanism. Children develop different attachment patterns with different carers, but the style of the attachment between the child and his or her main carer will become the child’s ‘internal working model’ and form the template for future relationships.
Mary Ainsworth developed the attachment theory further with her seminal study on the quality of attachment (Ainsworth et al. 1978) and gave empirical data and conceptual breadth to the theory. Ainsworth developed the ‘Strange Situation’ procedure (McLeod 2008).
The importance of attachment styles is that the experiences of attachment and safety are laid down early in life and have a long-lasting effect.
Ainsworth conceptualized the A/B/C patterns that are depicted by Crittenden in the Dynamic-Maturational Model (DMM) of Attachment and Adaptation. Patricia Crittenden continued with her research to develop this model and included family functioning and community contexts (Crittenden 2013).
The Dynamic–Maturational Model of Attachment and Adaptation
Forensic Psychiatry and Occupational Therapy
Occupational Therapy for Anxiety, Somatic and Stressor-related Disorders
