It is not uncommon for children to display some level of avoidance or anxiety in response to the gradual exposure process. Therapists are encouraged to be creative in their selection of gradual exposure exercises that may appeal to children's particular interests and preferences. For example, flexibility can always be offered in terms of giving the child a choice of activities, such as drawing, writing, or reading about sexual abuse. The choice allows the child some control over the session but does not allow him or her to avoid the topic completely. In many cases, a general discussion about child sexual abuse can be used as a low-level gradual exposure exercise until the child can tolerate discussing specific details of his or her own experience. Parents should also be forewarned that children may begin to complain about treatment as therapy focuses increasingly on their traumatic experiences. If and when this happens, parents should be reminded of this forewarning and encouraged to maintain a firm commitment to attending sessions on a weekly basis. Not surprisingly, more consistent attendance greatly facilitates children's abilities to work through their trauma-related avoidance and/or anxiety.
Another common obstacle may stem from the therapist's own level of avoidance. For example, if a child displays anxiety or distress during session, a natural empathic response for the therapist would be to take a break from discussing the abuse for some time. However, this response may reinforce the child's avoidance and is counterproductive to the gradual exposure process. Another obstacle of using a model that encourages detailed descriptions of abuse is the risk of the therapist experiencing vicarious trauma. For this reason, it is important for therapists to be aware of their own feelings and reactions to hearing about trauma and the inadvertent impact of their responses on the child's progress. Supervision, case consultation, continuing education, and a balance between professional and personal endeavors can alleviate some of the stress a therapist may experience.
Supportive caregiver involvement is the ideal for the model described above; however, this involvement may not always be possible. Although the model can be applied to children individually, it is best to find some outside source of adult support. If a caregiver is not available, other adults in the child's life, such as a caseworker, relative, or family friend, may be able to participate in some aspects of treatment. in cases where a caregiver is present but does not believe the child's allegations of abuse and is clearly standing by the perpetrator, it may be best to recommend individual therapy for the caregiver. A long-term goal could be to reunite the child and caregiver for joint sessions, once the caregiver is able to provide more appropriate levels of support to the child. on the other hand, nonoffending parents who are trying to be supportive but are struggling with initial feelings of shock, disbelief, and/or ongoing feelings for the perpetrator may respond well to this treatment model, though extended sessions may be necessary.
Children often present with complex problems, demonstrate a broad constellation of symptoms, and have histories that include multiple traumas. Although the treatment model outlined in this chapter focuses primarily on reducing PTSD symptoms resulting from child sexual abuse, it can be modified to treat PTSD symptoms resulting from other types of traumas, including exposure to domestic violence, physical abuse, traumatic bereavement, and community violence. A critical step in addressing each of these traumas is that of providing education to both children and parents about the identified trauma in terms of its prevalence, characteristics, psychosocial impact, etc. For example, it is important for mothers to be made aware of the dramatic behavioral impact that exposure to domestic violence can have on children, despite the fact that the children may have never been physically harmed by the batterer. Educational information can be shared and explored with children, using question-and-answer games as well as educational books. There are, in fact, quite a few books available that can help children cope with exposure to family and/or community violence. Similarly, psychoeducation in treatment of traumatic grief might involve reading a book about death and discussing the family's beliefs about death and dying.
The other components of this treatment model can also be applied to children who have suffered a wide array of traumatic experiences. Coping skills training, for example, can help reduce anxiety and distress surrounding any traumatic experience. Coping skills exercises for a child who has witnessed community violence might focus on facilitating the child's affective reactions to the crime witnessed and its aftermath. The gradual exposure and cognitive processing component for children who have experienced violence or a traumatic loss would follow the same procedure outlined above, with a focus on encouraging children to recount the traumatic experiences as well as their associated thoughts and feelings. it is important to note that different traumas may produce highly distinct emotional reactions that are likely to be driven by unique developing beliefs that may be dysfunctional. For example, therapists may find that children who have lost a loved one may experience guilt because they are inappropriately making a connection between the loved one's death and something they said or did. During exposure and processing exercises, children exposed to domestic violence may also reveal that they believe that they were the cause of their parents' fighting, perhaps describing ongoing feelings of guilt and sadness long after the exposure to the violence has ended.
Education and cognitive coping exercises can help children develop more accurate conclusions about "why" the traumas happened. It is important to note, however, that additional treatment components may need to be added to the model described in this chapter, depending on the nature of the trauma. For example, in cases of domestic violence and physical abuse, the development and rehearsal of a personal safety plan is essential (Runyon, Basilio, Van Hasselt, & Hersen, 1998) to reduce the risk of future harm. Children should role-play and rehearse responses to potentially dangerous situations, such as a caregiver coming home intoxicated, and identify concrete steps to help ensure their safety (e.g., go to a neighbor's home, call 911, go to a safe place in their home). The treatment of childhood traumatic grief should help children incorporate components of the normal grieving process, such as accepting the reality of the loss, expressing pain associated with the death, adjusting to daily life without the presence of the individual, honoring the memory of the individual, and developing new relationships (Worden, 1996; Wolfelt, 1996; Cohen et al., in press).
ultimately, regardless of the type of trauma, this treatment model is designed to help children and parents cope more effectively. The education, skill building, and exposure/processing exercises are all designed to help children make sense of their experience(s) in ways that allow them to feel empowered rather than victimized. Thus it is important for children to develop narratives that incorporate cognitive corrections as well as positive experiences that help them place their traumatic experience(s) in a context that encourages realism as well as optimism about the future.
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