Perhaps the most notable flaw in all of the current treatment methods of treating children for stress disorders, including acute stress and post traumatic stress, is that they are modeled largely on the experiences and diagnostic criteria of adults. Not much treatment development has been made from existing research about the bio-chemical nature of stress disorders to address alternate models for specific treatment of children. Thus, the cognitive-behavioral restructuring, "talk therapy", and "flooding" approaches are largely based on adult experiences, and at that, adults who had a fairly normative and undamaged ego structure prior to their critical events. What about a child, whose whole life has been one constant and intensely interpersonally stressed event?
There are countless children who have grown up in incredibly stressful situations. Think about the child who has only known war, insurgency, and death their entire life. Or the child who's single parent is addicted to crack, and has had multiple partners, some of whom sexually abused the child? If the child has never had a healthy, intact ego, how can treatments that assume that the victim has had a healthy intact ego at some time prior to the trauma work? Clearly, a better model of treatment for children who have had repeated, chronic and acute stressors their entire lives needs to be developed.
When the adult model and treatment modalities are used with children, and we accept the theory that the child's ego is far from being at an optimum state of normalcy and health, then repeated review and "flooding" the child with the images of their critical incidents is not just simply ineffective (since they have no suitable ego structure to reassess their trauma experience), but becomes abusive and re-assaulting. One may argue that "play therapy" models would serve to be appropriate methods of treatment. While the "play" in and of itself may be a quite useful or benign tool, the philosophy of the therapist providing the play therapy is critical. If the therapist's foundation is that the child must repeatedly speak about their critical incidents in order to get better, the "play" simply becomes moot.
This is not to suggest that the child should not speak about their traumatic events. It simply means that the child should be in total control of their revelations, and never pressed. And once they have spoken, they should not be pressed for more details. Often, children who are victims of interpersonal abuse are pressed by doctors, police, social workers, and even mental health professionals to give details so that legal proceedings may ignite. All too often, this just serves to traumatize the child further, and make subsequent treatment difficult, as the child undoubtedly has had a very unpleasant experience in being pressed to related torrid details. If the child comes into treatment (as they often do) with a stress disorder diagnosis as a result of interpersonal abuse, a therapist does not necessarily need the details from the child to make progress. All too often, over focus on the details of the abuse "miss the forest for the trees." The need for a better treatment protocol is glaringly self evident.
The mainstream treatment system also tends to under diagnose or misdiagnose stress disorders in children. Typically, the child comes into treatment for their behavioral symptoms, and the system then treats them based on symptoms, not on likely causations. A good bit of this effect can be placed squarely on the shoulders of 'managed care', which often limits the time and extent of treatment. Behavioral, brief therapy driven models treatment may work rather well for biologically based diagnoses, like ADHD or depression, but it is a disaster with PTSD. Stress disorder treatment, especially in reference to interpersonal trauma, takes time. This is likely due to the fundamental fact that the child's trust in other human beings has been profoundly damaged. Another reason for under or misdiagnosis is that there is a surprisingly high number of treatment specialists, who even when having a PTSD diagnosis in hand, are severely uncomfortable in addressing the critical incidents. This, of course, is a natural human reaction: who want s to hear a young child describe their rape?
Since most available public based treatments for childhood mental health disorders are focused on highly generic behavioral interventions, these measures often only serve to escalate the stress disordered child's overall dysfunction in relation to their PTSD. Because such strictly behavioral measures simply do not work for childhood PTSD, the treating system moves from desperate modality to desperate modality, never to find a really effective means of helping the child...and all because no one has yet discovered that the real problem is PTSD. Children with undiagnosed or untreated PTSD will usually have a very long list of medications tried, various levels of treatment, including hospital stays and residential treatment, and a dismal school record. All of the erroneous attempts at helping the child result in simply further brutalizing and confusing the child. Many children begin to assess themselves, after some time in the inadequate system, as being "crazy", "bad", and hopeless. They also seem to develop a wide variety of co-morbid disorders.
In this writer's experience, young children who have spent a significant amount of time under stress express their stress symptoms (both Acute stress and PTSD) differently than adults do. Their symptom profile often does not match the adult model for PTSD. In addition, they require and respond far better in treatment when the treatment is based on what is intuitively understood by all caring adults when a child is hurting: gentleness and patience. Years of treatment development and growing success with young children who have been deeply wounded by interpersonal abuse have demonstrated that a 'gentling' approach works.
"Gentling" is as much a comprehensive philosophy of treating young children with stress disorders as it is a specific set of techniques. The structure follows a somewhat standard path of helping the child to feel safe in all environments, sensitizing the child to their own stress reactivity cues and patterns, educating the child on how to interrupt and treat their own reactivity, and finally, a process of stress inoculation that emphasizes age normative behavioral expectations along with a very high structure and nurture component. It is imperative that the pace of the treatment be controlled by the child, not by the care givers or treating professionals.
The child is never pressed for repetitive relating of the details of their critical incidents. Generally, a child comes to a point in treatment where this does occur, and it is treated with all due respect and examination, but once stated, it is only returned to if the child desires it, and then, only once. The focus then returns to strong and enthusiastic support of their age normative development.
There is a clear and specific cognitive-behavioral component to Gentling: the child is taught that they can change their painful reality of uncomfortable stress episodes, and that their stress disorder is never and excuse for poor behavior. It is conveyed to the child that while it is understood that they will be cued, triggered, and enter into stress episodes, it is not acceptable to hurt themselves, others, or destroy property. Children are taught to self recognize the initial stages of stress reactivity, and take measures that they have learned to alter the usual outcomes. They need to develop trust in a trustworthy team of helpers to help guide them to use the skills that they have learned, and to accept the support that will be given when a full fledged stress episode occurs.
Every effort is made to recognize the child's early behavioral "tells" that demonstrate and predict stress episodes. This is done in order to make intervention during a very narrow window of time when heading off a full blown episode. The point is to avoid repeated stress episodes, as this only drives the symptoms deeper, and can permanently alter the child's bio-chemistry, making it impossible to re-set and calm the child's chemical-emotional homeostasis.
Daily work by the care givers of the child focuses on frequent reminders to the child (and themselves) of the fundamentals of the Gentling philosophy and approach. The caregivers closely attend to the child's stress levels through trained observations of the unique behavioral signs that indicate stress in the child. When a set level of stress is reached, the adult intervenes, helping the child to take some sort of "stress break".
There are strict protocols for intervention when the child's stress has blossomed into a full stress episode. This includes constant self assessment by the person intervening; they must remain calm and not personalize the likely attacks (both verbal and physical) that he child may engage in during the stress episode. The support protocol also includes a scrupulous examination of any need for restraining the child during the stress episode. In essence, this is to be avoided at all costs.
Any touch initiated during the stress episode by the helper is only with the clear consent of the child, or, only if the child is in genuine, imminent danger of life threatening harm to themselves or someone else. The adult helper avoids giving commands, but relies on neutral tones in giving simple directives to the child, such as: "sit down so that you can calm down." The overall affective approach that the helper maintains is one of extreme, genuine, respectful gentleness that is devoid of condescension of any kind. This helper countenance takes practice to learn.
Perhaps the most difficult task of the Gentling approach is to get all other adults on board the philosophy, approaches, and techniques. Because children with stress disorders become oppositional, unpredictable, and sometimes violent, adults can quickly revert to an assumption that the child's behaviors are not based in their history of abuse, but based simply in wanting to manipulate, disobey, or anger the adult who is trying to help. Some adults have a very hard time holding on to the Gentling philosophy and techniques when confronted with a child who is cursing, spitting, and kicking them.
Novices to the approach may raise objections to the "stress breaks", alleging that the child is simply engaging in a behavior in order to manipulate and avoid school work, for example. In this clinician's experience, such manipulation is exceedingly rare; most stressed disordered children are quite eager to learn and please adults when they are not in a stressed state. Like any therapeutic approach, Gentling requires a philosophical 'buy in', takes skill building, practice, attentiveness, and self discipline on the part of the therapist.
