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Ethical Boundaries: Treating Childhood Sexual Trauma
Childhood Sexual Trauma continuing education psychologist CEUs

Section 16
Memories of Trauma in the Treatment of Children: Boundary Issues

CEU Question 16 | CEU Answer Booklet | Table of Contents | Child Abuse
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs


Andy is a 6-year-old boy who is referred because he is 'hyperactive" in his kindergarten class. He is repeating this grade because of his social and academic immaturity. His parents are appropriately concerned and come to the evaluation with the request for treatment, as a trial of psychostimulant medication had not been effective. Andy's 3-and-a-half-year-old sister Ally is seen as developing normally.

Pertinent history to this case includes the maternal stepgrandfather, who had joined the family late in life and was an important father figure and babysitter. He died suddenly when the patient was 20 months old. Andy's mother was subsequently sad, preoccupied, and at times physically absent while settling her ill mother into a nursing home.

During his sessions with me, Andy is a very active boy who likes to move around, throwing dart balls and playing loud games. He also plays with puppets and animals but not long enough to develop a story line. Only the make-your-own-puppet kit engages his repeated and somewhat prolonged interest, and soon becomes part of a weekly ritual: on a Velcro head, he attaches various pieces, creating a great variety of noses surrounded by furry parts.

After several weeks of meetings, Andy's mother reports an incident that upset everyone. As they were talking about grandfather, she brought out a family photo album. Ally pointed to a picture of the grandfather, commenting that he is "all bald and smooth." Andy disagreed vehemently, saying grandfather was not bald, and started crying, then screaming, which turned into a temper tantrum. He was put in his room and soon fell asleep. His mother also reports that he has become inseparable from favorite teddy, now brought to therapy. Andy says that Joe, the bear, used to have stiff hair, but that he has always loved the soft velvety paws best. In the next hour, he is distressed about having forgotten Joe at home. He makes a puppet and buries his face in its fuzzy cheeks. He seems distraught. The therapist mentions separation and loss (from the bear, but implying grandfather's death and mother's absences). Andy cries, quietly sucking his thumb before wildly dashing about the room. At home his parents wonder whether he is masturbating more openly. They see him as battling against his sad feelings which he has called "babyish."

A new play activity with clay emerges in treatment. The sequence seems quite stereotyped: a ball of clay, digging holes into it with his fingers, and rolling it into a cigar or snake shape. A later variation of the clay play involves sticking the tops of magic markers into the clay, smoothing clay over them, and tricking the therapist into believing it is soft instead of hard. Sometimes Andy adds fuzzy balls or feathers and tickles his own cheek. Once, when he accidentally pokes himself, he seems surprised, gets very excited and cries "grandfather did have hair and he had a beard too.', He seems to be rubbing himself against the back of the small chair and looks dazed before dashing about the room, making incoherent grunting noises. As it is time to go, his mother needs to come in to help him leave. She says that she has heard the grunting noises before, when Andy gets overexcited.

An update on Andy's history, with his parents, focuses on his normal to precocious development until his grandfather died, after which he spent more time with adequate, but in his parents' eyes, less stimulating babysitters. Andy always seemed very excited to see his grandfather. He was usually asleep when his parents came back, even if it was not his nap time. They remember laughing about how he wore himself out with excitement. They cannot understand why Andy insists that his grandfather had hair and a beard, and refuses to look at pictures confirming the opposite. Andy seems to be getting increasingly distressed, waking up with amorphous bad dreams, acting more clinging as well as restless and angry, especially at bedtime.

This presentation raises a variety of complex questions of a theoretical nature as well as a practical one. Why does Andy appear agitated when remembering his step-grandfather? What is Andy saying, in words and in play? Is it something based on fact, or fantasy, or impulse? Is it a combination of fantasy, metaphor and actual experience? How important is it to know the difference? How can one ever gain access to what has shaped his memory so early in his life? How should parents and the therapist react in the face of such uncertainty? Whose need to know drives the exploration: the child's (as measured by his distress), the parents' (because of their distress, or their own histories), or the therapist's (because he is eager to help, or because he has a particular bias)?

In Andy's case, the therapist began constructing several alternative hypothetical pathways leading to the current presentation. They were on a continuum rather than either/or, and went from loss of an important attachment figure to overstimulation to sexual abuse. Andy's play was observed more carefully for clues, and he was invited, somewhat more insistently, to settle down and play. He was offered a variety of toys that could portray family configurations (puppets, small animals, dolls). He chose elephants, and included a grandfather when the therapist suggested that relatives might be coming to visit. The grandfather often stood over the little elephant, or poked him with his tusks until he rolled over, all in good fun. His physical boundaries were different from those of other elephants. Overstimulation emerged as an issue in the play, but had Andy been traumatized?

Parallel to the work with the child, Andy's parents were introduced to these hypotheses, which had already crossed their minds. They contacted the stepgrandfather's biological family, who had often seemed angry and cold towards him. They were told of several incidents of inappropriate sexual behavior.

With Andy, the parents' instinctive reaction was to avoid all mention of his grandfather. On the advice of the therapist, they brought the grandfather back into the realm of what could be talked about. They asked nonspecific questions, remaining affectively open but neutral. They wondered about Andy's special times with him, asking what he remembered. Andy remembered lollipops. His parents commented that he hates them. He sometimes made gagging and grunting sounds. His parents, containing their intense affective reaction, asked if he ever felt hurt. Andy seemed surprised, but said he didn't remember.

At this point, parents and therapist together decided that the issue should be pursued more actively in the therapy, rather than waiting for things to unfold. This was due mostly to the parents' difficulty tolerating their intense anxiety, which they saw as starting to interfere with their relationships with both children. Andy was more "hyper" than ever, in school and at home, and sleeping poorly. In the next session, the therapist explained that there were some real-life questions she needed to ask, that were different from the play and pretend that had ruled so far. She ascertained that Andy did, indeed, understand the difference between real and pretend. Andy was suddenly very attentive, as if he had been waiting for this moment. Asked a general question about his grandfather, he said he had a "secret dream" he couldn't tell his parents, especially his mother who loved her (step)father so much. He described himself as being in a "forest of sort of white hair" in which he searches for something and then sucks on it. The dream "comes back" to him when he tries to fall asleep. He had wanted to tell me before, but it was "too gross." He looked very sad. Asked whether this dream could mean something real, he said "I did it, sucked it."

The practical considerations raised by this case are comparatively simple: the parents are supportive, there is no threat of family disruption or feud following the disclosure, there is no question of whether to contact Child Protection Services, or to press charges. Yet the technical and theoretical issues raised are of paramount importance. Without the family interchange about the grandfather's appearance, would the experiences troubling Andy have surfaced during his childhood? Although it is impossible to answer that question, it can be said that this new understanding of Andy's history had important consequences. Diagnostically, Andy's "hyperactivity" is now more likely a post-traumatic stress disorder (PTSD)-related reaction. Cognitively, he is now free to use his brain to remember, in all areas. In the family, the dynamics have changed. His parents' ability to reach out affectively and effectively, to listen and to understand, to help him make sense of his life history, his impulses and conflicts, has been put back on the right track. He is now truly back in the lap of his family, as opposed to having a secret, unspeakable past that was on the verge of becoming encapsulated as a verbally unretrievable piece of himself.

This family outcome may not be attainable when multigenerational abuse forces parents to cope with their own memories of abuse as they are trying to respond to their child's disclosure. Unravelling what really happened when can be a near impossible task, leading to hypotheses that are difficult to validate. In addition, many parents find it impossible to remain calm or listen empathically to what their child is trying to say or show without jumping to conclusions, which can be false positive or false negative.

Andy's therapy continued. He talked about his grandfather, and played out elephant stories that became more aggressive, as the little elephant started to fight back. At home and at school, after an initial period of intense affective liability, Andy seemed much calmer and focused. He stopped being the class clown, made two friends, and started to catch up academically. Periodic follow-up into his ninth year indicated normal adjustment.
- Appelbaum, Paul, Uyehara, Lisa, & Mark Elin, Trauma and Memory: Clinical and Legal Controversies, Oxford University Press: New York, 1997.
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #2
The preceding section contained information about memories of trauma in the treatment of children. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 16
What did Appelbaum attribute Andy's hyperactivity to? Record the letter of the correct answer the CEU Answer Booklet.

 
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