Treatment options for children and adolescent trauma survivors can include cognitive behavioral therapy (CBT) and crisis management to reduce anxiety, worry, and fear of repeated trauma. Play therapy is an effective method often used with young children with posttraumatic stress disorder because they often have difficulty dealing with trauma directly. Cases in which a child or adolescent is acting out sexually in response to a sexual trauma or in which he or she may be using drugs or alcohol as a coping mechanism as a result of trauma often require additional treatment modalities.
For this Assignment, review the media program Trauma and consider the symptomology of PTSD and how trauma can affect children and adolescents. Then, select a different type of childhood or adolescent trauma from the one you selected for the Discussion. Consider the posttraumatic stress symptoms that are likely to occur and what type of treatment interventions you might use to treat the child or adolescent. Also, think about how you might support or educate parents or guardians as they attempt to support their child or adolescent.
The Assignment (2–3 pages):
• Describe a major trauma or event that may occur to children and/or adolescents.
• Describe three potential symptoms of posttraumatic stress disorder that may occur as a result of the major trauma or event, and explain why these symptoms may occur.
• Describe one intervention you might use in treating this type of trauma. Justify the selection of your intervention using the week’s resources and current literature.
• Explain two ways you might educate or support the parents/guardians as they help their child or adolescent through the trauma. Be specific.
[MUSIC PLAYING] NARRATOR: Trauma is not restricted to age groups or gender. However, helping
children and adolescent clients who experience trauma is very different than
helping adults. Doctors John Sommers-Flanagan and Eliana Gil explain the
difference in working with children and adolescent clients who have experienced
trauma, how to assess them, and what techniques they have used to address the
JOHN SOMMERS-FLANAGAN: The Diagnostic and Statistical Manual refers to
the core symptoms of PTSD, or post-traumatic stress disorder, as exposure to a
traumatic event and intrusive recollection of that event and numbing and
avoidance experienced by the individual and kind of a hyper-arousal. And so I’m
wondering about that presentation as it initiates the referral process.
And in your work, Eliana, because I know you work a lot with traumatic problems
in youth, I wonder how you see those symptoms as they present to you within an
ELIANA GIL: It’s an interesting constellation of symptoms, because often you
have the hyper-arousal. Kids are actually having intrusive thoughts or nightmares
of very specific pictures of things that have happened to them and scared them.
Kids also are able to do, through play, some of the reenactments of things that
have occurred. And so looking at it from far way, you look at the play, and you
think, wow, what is that about?
Is that pretend? Is that fantasy? Or is that something that the child is actually
experiencing? But the play is very unusual. So there’s actually a lot of literature
on what’s called post-trauma play, which tends to be very different than generic
play, in that it’s very literal. It’s very robotic. Kids are really engaged in the play,
as they usually are, like with pretend talk or role-play or something like that.
And it’s play that’s very repetitive. And as kids do it, their affect is very guarded.
And when you encounter post-trauma play, you know that something is very
different here and that this is really a way that kids begin to show that they’re
living in the climate of the trauma. So definitely we see kids who come in
because there’s intrusive thoughts or memories, through nightmares in particular.
They’re waking up with night terrors.
And we see the post-trauma play that the kids are doing at home or sometimes in
a school setting. And then also, there is the child who appears with this very, very
flat affect, where they’re disengaged, they don’t do the regular things that kids do,
they don’t play, they’re not spontaneous, their social interactions are very
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unusual. I think that one of the insidious lessons of child abuse, talking about
interpersonal trauma, is that people who love you hurt you.
And so I think that what kids develop is this expectation that the world will not be
safe and that this other kid at school is probably going to hurt you, or that adults
in your life are going to continue to hurt you. And that produces in them both a
feeling of wanting to fight first—so the best defense is offense. But the other
possibility is that they just simply withdraw from any kind of interaction, because
it’s just not safe enough.
And so all of these behaviors can bring kids in or can get kids referred to us. And
probably the most typical is after a trauma is disclosed and someone becomes
aware that the child has had some traumatic experience. Then we have the
referral to really rule out post-traumatic stress disorder. And so that’s a very
common presentation as well.
JOHN SOMMERS-FLANAGAN: As you were talking, it made me think about the
whole process of how often, social, interpersonal interactions will develop into
kind of a psychological internal working model. And when you referred to the
whole concept of young people then expecting things to not be safe. And so that
leads me to ask you, how do you intervene with that? How do you help the
children develop new working models so that they might see the world as more
ELIANA GIL: And I do think that with internal working models, we can make a
contribution in counseling and in therapy. And that process is really important.
But even more important is for that to be duplicated outside our weekly
psychotherapy, which sometimes really is not sufficient. But as an example, I
worked with a little girl who was six years old.
And I worked with her for a number of months. And she came in one day, and
she brought me a Ping-Pong paddle. And she said to me, “Here, this is for you.”
And I said, “Oh, what’s it for?”
“For you to hit me.”
And I looked at, and I said, “Now, why would I hit you?” And she said, “Well, you
like me, don’t you?” And it was clear in her mind that as soon as I liked her or she
felt liked by me, the next thing that would happen is that I would injure her.
And that’s a very interesting dynamic, because she’s also bringing me something
to do it. Now, I look at that, and I say, wow, that’s a child who really has figured
out a way to decrease the anticipatory anxiety about getting hurt by just saying,
here, here’s the thing, do it, let’s get it over with. And then we can move on.
© 2016 Laureate Education, Inc. 2
Some people, unfortunately, will look at that, whether it’s a paddle or whether it’s
a child that’s being provocative, as a way that the child is saying, basically I
deserve this, or do this, or provokes them, because I think that sometimes kids
who are pushing a lot and push our buttons, as it were, sometimes as those
working with children, we do have these responses that they’re pulling for. So in
terms of helping that particular child, first and foremost, patience, and secondly,
consistency, and third, really trying to up the therapy experience for her so that it
wasn’t just a weekly situation, but I could see here two or three times a week,
and then the engagement of her foster care system, in this case, to provide the
same kinds of messages and responses that I was doing.
What I found, very interesting, that initially I would try to be very supportive and
warm. That scared kids. And so I found them actually withdrawing. So my
fantasies—this was when I was very young and first starting out in this work—my
fantasy was, I would sit and rock these children who had been injured in a chair
or do something affectionate and warm. And when I came to find was that that
actually increased their anxiety so much, because it was so unfamiliar. And
somehow the familiar interaction, the, you’re going to hurt me, was the one they
expected, felt more comfortable with in a way, tolerated better, and definitely
So I had to go into neutral mode. And so when I work with kids, often it’s the
neutral, non-directive play therapy approach, where you basically are doing
empathic listening. And you’re giving them feedback from time to time about what
you notice them to be doing, but not a lot of positive validation or my intuitive
responses about trying to be warm and much more positive in terms of validation
with them, because they need to develop, stretch their comfort zone around
these new behaviors that they’ve never encountered, and get past the anxiety
that that provokes, and then also keep testing it constantly, because that little girl,
I think I worked with her for another year before she really believed that I would
not hurt her.
It took that long. And so one of the things that I always keep in mind is, repetition
is so valuable and so critical that it’s not enough to do it once. It’s not enough to
do it 100 times. You just have to be really patient, not allow for the pulling of the
children to guide responses that are impatient, perhaps harsh, or anything like
that that we just have to be so careful. And the relationship gets built up, I think,
in a very careful way, because it’s a fragile system at that particular juncture.
But again, I emphasize that without an external caretaker, someone who’s
invested in the child, a relationship I can promote outside the therapy, I think that
again, these efforts in our therapy would not be sufficient.
JOHN SOMMERS-FLANAGAN: When I here you use the “patience,” I think
you’re also talking about for us, as counselors, our expectations. I know we live in
a culture that expects quick change. But I remember just reading recently a
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research study by Michael Lambert, where he said that, contrary to the short
term four to eight session EAP model, in order for individuals to experience—
50% percent of clients who come to counseling to experience significant benefits,
we need a model that is 20 to 25 sessions. And although I know a lot of times,
we can’t work within that bigger, more expanded model, I think it’s really
important for us to keep our expectations in check so that we’re not thinking, oh,
yes, I can just create that safe environment, and that young traumatized person
will experience it.
Of course, as you’re saying, it’s not just the office safe environment. You need to
start building safe environment outside of the office. Otherwise you will be really
confusing the child in terms of whether things are safe and not safe.
ELIANA GIL: I think one of the most optimistic movements has been the
movement towards the understanding of the development of the brain and the
neuroscience of interpersonal trauma and how that affects the child at different
developmental junctures. And what’s so optimistic about that is, thinking about
perhaps the brain having more plasticity that there is no quick fix, but that also at
the basic premise of all this is the relationship and how important the relationship
is to the establishment of these interventions that are designed to do some good
and to stimulate parts of the brain and the child that may be haven’t had an
opportunity to grow.
So I feel good about that, and I think it also challenges a little bit this model of,
let’s do this in four to six sessions. I get concerned that we get economically
driven sometimes and that when we’re talking about kids who’ve had histories of
trauma, severe neglect, severe sexual abuse, physical abuse, just general
maltreatment, that what they come in with is really a distrust of adults and
caretaking of them, kind of a lack of grounding and anchoring in possibilities
around the development of relationships and that there are often hyper-aroused
by things that we’re not even aware of it.
So I can wear, for example, a particular color, and that could trigger a child who’s
been traumatized to have a very active re-experiencing of fear and anxiety that I
may not even understand. Sometimes I’m talking to schoolteachers, and they
say, well, I was talking loudly, but I wasn’t yelling. And I don’t understand why
that child would suddenly have to leave the room. And they don’t understand that
it’s possible that that cues the child that we’re about to have a violent episode
here. I better get out of here, because I need to stay safe.
JOHN SOMMERS-FLANAGAN: What’s coming next?
ELIANA GIL: What’s coming next? So we just have to be so careful to
understand that this process takes time. At least for the people that I’ve worked
with, it’s never a quick fix. Now, within the whole context of trauma, yes, there are
some kids who fare better than others. Trauma, I think is very phenomenological.
© 2016 Laureate Education, Inc. 4
The experience of the child and how that child experiences power and control, if
any, during a traumatic event or what defenses they use, this will set the stage
for basically how receptive they may be to interventions that come along. But it
also is in an important precursor to what kind of symptoms they’re going to
develop and how they’re going to fare. So I always think it’s really important to
look at assessing the traumatic impact, because we can’t just assume that every
child is going to react the same.
And honestly, some of them have internal resources that they use. Some of them
have even things like having a pet that they can really talk with, that they can
hold, and that they sleep under the covers with. That can make a huge difference
in their perception of how safe or how nurtured or how connected they are to
something else that then impacts their other responses to these events that are
happening that may be obviously serious stressors and traumatic stressors. So I
find this assessment piece a very important piece of the puzzle in terms of trying
to understand how we approach children.
I’m amazed at natural reparative healing systems and how some kids can
engage, even in post-trauma play, and be able to, in some ways, do their own
gradual exposure. We talk a lot about cognitive behavioral therapy, this
desensitization that often is provided as a therapeutic intervention. This is what I
think children do in post-trauma play.
When they’re repeating the trauma externally, they’re exposing themselves to
this play, and they’re interacting with it. And they’re in some ways managing it
and resolving things and answering their own questions. And it’s a beautiful thing
to watch when it works towards its proposed goal. Every now and then, I
encounter kids who do that, and they get stuck in it.
And so the actual gradual exposure isn’t as effective, because they just keep reexperiencing the traumatic memory the same way, and nothing changes. And in
those cases, I have to be more actively involved.
JOHN SOMMERS-FLANAGAN: I’m thinking of the desensitization model. And
that’s going to link us to evidence-based treatments. But I’m also reminded of a
case I’m supervising of a graduate student, who’s working with a 17-year-old
young man. The young man just can’t even talk in this session.
And so I said, “Lower your expectations,” to the graduate student. “Just bring
some games.” And so he took in backgammon. They had contracted to three
sessions, where they would just work together. And then the young man, the
client could decide whether he wanted to continue.
And they mostly played backgammon for three sessions but talked a little bit
while they’re playing. In the third session, the young man says to the therapist, to
© 2016 Laureate Education, Inc. 5
the counselor, well, this is our third session. I guess we have to decide whether
we’re going to continue working together.
And the counselor said, “Yeah, what do you think?” And the client said—who had
been completely opposed to this process, but after three sessions of playing
backgammon, he says, “Well, whatever you think,” kind of giving over the choice,
which I saw as a very clever way to avoid rejection. He doesn’t have to say, “Yes,
I want counseling,” and then have the counselor reject him.
And so the counselor said, “Well, how about if we keep meeting then?” And
session after session, just like in a desensitization model, this 17-year-old who
couldn’t speak about his own personal experiences with another person gets
better and better and more and more able to speak. And I found that process to
be just very, very kind of joyful for me to watch the development of that
relationship and the trust build.
ELIANA GIL: It’s interesting when you say that example, because sometimes
people look at that and they say, well, they just played. There’s nothing going on.
Or someone, a graduate student, might say, well, how do I document that in my
notes? And is that legitimate?
Can I do this and call it therapy? And I think there’s so much to playing a game
together; because it is something you do with another. And it has rules, and it
has a structure, and you get to experience this person without any demands.
There’s so much going on when kids are playing games. But especially the older
kids really seem to enjoy it. And it’s a way to begin to get their feet wet into this
new kind of environment, where they don’t have a lot of control. So I think it’s a
beautiful example of how valuable that can be and how much we have to take
JOHN SOMMERS-FLANAGAN: And I would say we could document that as
desensitization and social skills, training, and there’s all that going on in addition
to just the building of trust in the relationship. So let’s talk for a moment about
evidence-based strategies. I know with PTSD, post-traumatic stress disorder,
there are a number of evidence-based strategies.
One of the challenges in counseling is, how do we transform or translate the
information from the scientific research into our clinical practice? And so I’m
wondering how you do that, what kinds of evidence-based information you find
useful in your practice.
ELIANA GIL: I welcome the evidence-based practices, and I’ve been very
interested in learning whatever I can. What I think of now is integrating evidencebased principles and practices into my clinical practice, often because now,
there’s a movement towards, we have to do this in order to get reimbursed. So
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there’s a movement towards, you won’t get paid if you’re not doing some
This is a starting in California and certainly moving all the way across the
country. And that’s good. It’s an accountability. I think that that’s an important
Where I end up a little bit concerned is the model of one size fits all. And that’s
where I have the concern. I value what people do in research. And I value some
of the outcomes, but I also understand that because one particular method is
proven, someone’s had the money and the environment in which to conduct
research, it doesn’t mean that what other people are doing isn’t equally valuable.
It just hasn’t been proven yet. So in the area that I work in, which has to do really,
with children who have been abused, the evidence-based model is traumafocused cognitive behavioral therapy. And it is a model that I’ve obviously taken a
lot of training in. And it’s a model that we’ve implemented.
We actually even did a small research study comparing TFCBT to what we do,
which is trauma-focused integrated play therapy. And my feeling is that they’re
both effective. I think that the rigid application of anything is problematic, and with
TFCBT, really, there isn’t a demand for fidelity.
So the original research was done quite a while ago now. I think it’s been at least
10 years. And now where we are is that there’s a hybrid model. And I went to a
recent training by a certified TFCBT trainer, and that’s what she said. So this new
hybrid model, even though it’s evidence-based, is really a new development of
incorporating the feedback from the world out there as people began to present
this to their clients.
And what they found is that it didn’t fit everybody. Children are children. And
sometimes the cognitive behavioral strategies are not as inviting to them. It may
feel more like school to them, and if we’re talking about four and five and sixyear-olds, it kind of falls flat.
Now, some other people have started looking at CBT in a playful way. So they’ve
actually combined the two and started saying, we can teach this in this kind of
fun way. And that engages the kids a little bit more. So we may not do TFCBT in
terms of the actual way it was designed way back in the research, where you do
this in the first few sessions, and then you move to this and you move to this.
But obviously we incorporate the basic principles of it, which is a real focus on a
direct movement of understanding of the trauma and that the narratives are
important. And the narrative we do may not be verbal. But we may have the kids
draw things out or play things out or do things in the sand tray. And that all
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works, as long as for that person there’s an understanding of what was, what this
Some of the compartmentalized feelings and thoughts and reactions are
explored. They feel a restoration of power and control. And they have had the
opportunity to release affect. And they have a good support system.
And as long as all of that is happening, I think the incorporation of the evidencebased principles might be the most effective way to go. There are also some
other evidence-based practices. One of them is called parent-child
psychotherapy, which was done by Lieberman and Van Horn in San Francisco,
with children who witness domestic violence.
That’s an interesting program, because that has the parents and the kids doing
play therapy together. But in addition to that, there’s a co-construction of a
narrative between a parent and a child. Again, the focus is the restoration of
power and the perception of each other in a different way. Especially in domestic
violence, the kids perceive their parents as having not a lot of power and being
helpless or something like that—so the restoration of a different perception of
And there’s also PCIT, parent child interaction therapy. That model is probably, of
all of them, the least accessible right now, because it’s a very expensive training
program. And then there’s a lot of fidelity requirements that a lot of agencies will
have trouble implementing. I understand from some of the people who work with
that that they’re looking to soften the guidelines a little bit so that more programs
can implement it.
And that’s a good model. And then we have something called child-parent
relationship therapy, which is a play therapy base model based on filial therapy,
which has been very well researched. So it’s kind of like an explosion of these
models that are appearing on the scene. And I think there’s a common ground
among all of us who have been doing trauma work for a while.
And I like right now to call what I do evidence informed and continue to have a
model that’s integrated so that whenever possible, we will utilize the evidencebased models. And again, in your private practices or in your agencies, there’s
going to have to be an implementation process. So in the agencies that we work,
there’s going to have to be the implementation of and adaptation of these models
so that it makes sense to the people providing the services.
And then there’s, of course, the whole other issue of education and training. So
we’re telling counselors and therapists, you need these basic things to graduate.
And then suddenly, what happens is that they are told, well, actually, no, you’re
going to have to go get some certifications now. TFCBT is about to launch a
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So it’s going to require people to go back and take training and then consult and
so forth and so on. So I think it’s interesting. And I think for all of us, it’s a
challenge to figure out how much of it we can integrate and in what ways and
what fits best for the families that we’re working with.
JOHN SOMMERS-FLANAGAN: I love the integration of the play with the CBT,
because I think they fit well together. A couple specific questions—what are your
thoughts on EMDR and/or medications in the treatment of children and
adolescents with trauma
ELIANA GIL: I think over the last 20 years or so, what we’ve seen the emergence
of the MDR for the treatment of PTSD. And I think that anyone doing any trauma
work needs to be trained in it, to be honest. And it’s a very powerful training. I
think it gives you another set of tools that I think can be used in the treatment
process that you have.
The evidence is pretty clear that it works. The evidence on it working as well with
children is now growing. So I think again, if you’re working with kids and/or adults
and there’s PTSD trauma backgrounds, you have to be able to know that and be
conversant with it and use it. I’ve taken the training.
There are some clients who respond very well to it. It’s again, one of those
questions that you ask yourself about, does it lead the way in the practice that
you do? Like, there are some people who say, I do EMDR and a therapist might
refer to that clinician to do 10 or 12 sessions of EMDR. Or do you incorporate it
into your practice and use it as you believe it’s indicated?
So I tend to do it in that way rather than referring out for it. And I think it’s a very
valuable tool. And again, that’s evidence-based. And also, we can’t ignore it. It’s
been shown over and over and over again to work. Nobody seems to quite
JOHN SOMMERS-FLANAGAN: It’s a little mystical.
ELIANA GIL: A little mystical, but that’s fine. And things like that, I’m really very
well oriented towards, if there’s something that really would help me and that I
can learn from. That’s why the neuroscience, for example, the work of Bruce
Perry and his neuro-sequential model of therapy, these are really important
things for us to be aware. They are sort of on the horizon.
People are really trying to standardize some tools. And I think we’re going to be
practicing with a broader lens from this point on.
JOHN SOMMERS-FLANAGAN: How about medications?
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ELIANA GIL: In terms of medication, I have always felt that it’s very useful to be
aware of the new medications and how they work and how they can be effective
and to have a very good psychiatric consultant. I’ve been lucky in my lifetime that
I’ve worked with people who have had the point of view that medication is really
something you go to after you try more of the traditional therapies and that you
refer, consult, and then sometimes it’s a really good adjunct to the psychotherapy
experience with children.
So meds can definitely be a big part of helping the child regulate emotions,
stabilize, so we can do the work that they need to do. And again, my only
concern is having that as the first response, and some people do that, and that’s
just a different approach. But I think from my point of view, we try other things
and try to get a contextual understanding of the problem first.
And then if we see a continuation of symptoms that are not relieved, then we
have things that are very dangerous for kids to be experiencing that at some
point we do the consultation. And I have some very good working relationships.
And when the kids are on medications, that’s great.
One of the problems that I see sometimes is, the kids will go into a hospital
setting. And they get put on a cocktail of medications. Then they’re released, and
there’s not a lot of follow-up. So the parents are withdrawing the medications, or
they say they didn’t like that one. I thought I’d give them this.
And that gets really tricky, very problematic, and potentially dangerous as well.
JOHN SOMMERS-FLANAGAN: It seems to me that the medication cocktails,
there’s really no evidence to predict how individual children and adolescents are
going to respond to these mixes of different, very potent medications. And that, to
me, is a bit frightening.
One pet peeve of mine is the whole idea that medications are going to somehow
restore balance in some chemicals in the brain, when, in fact, there’s no good
empirical evidence for a chemical imbalance in the first place. And so I think to
myself, well, a pill is not a skill, although it may be, as you’re saying, a kind of a
supplementary, may be helpful in some ways.
But what we really need to work on is to help the individual through some human
experiences to develop the skills to function more effectively in the world.
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