“I Go In The Closet In My Head”

Trauma and Dissociation in Children Living with Domestic Violence

(Originally published in ISSTD News, October 2018)
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Photo: Pixabay

 

Eli, age seven, lives with his younger sister, Marianne, age four, and their mother, Lisa, in New York City. They had lived in a domestic violence shelter for a year, and before that with his stepfather, Mark, till Lisa fled with the kids following repeated violence. Huddled in his bed, Eli had often heard his stepdad beating his mother. He’d wait helplessly till she sought refuge in the children’s room once Mark stormed out. She’d sob herself to sleep on the floor by his bed as he lay awake, worrying his stepdad would return and hit her more.

Mark was the only father Eli knew. His biological father left shortly after he was born. Eli adored his stepdad. He loved it when Mark took him to the park and showed him “how to build muscles” on the monkey-bars. He also hated Mark for hurting his mother, and felt guilty for admiring the very strength that brutalized her. When one night his bruised mother took him, still in pajamas, to a “hotel for mommies,” Eli wanted to go back home. He cried and screamed and it made his mother cry. One of the shelter’s women told Eli he was being “selfish” and that if he “wanted to grow up to be a decent man” he would “stop hurting his mom.” Eli felt confused. Was he hurting his mommy like his stepdad hurt her? Sometimes his stepdad would apologize in the morning and say “he didn’t know his own strength.” Did Eli also not know his own strength? Did he hurt his mommy without meaning to?

Eli stopped fussing, but he still missed his stepdad. There were no dads in the shelter, only whiny babies, toys big kids wouldn’t share, and mommies with scared eyes and scary bruises. He didn’t like it there. He couldn’t go to his own school. He couldn’t see his friends or go to the park where he’d played catch with Mark. Instead, he had school in the shelter and played at the playroom where the carpet smelled funny. Eli tried to be good but still his mommy cried at night. Maybe he was hurting her by his thoughts of wanting to go home? He didn’t know how to stop wanting to go home.

Even when they finally left the shelter they didn’t go home. His mommy said their new apartment was “home, sweet home,” but it wasn’t. It wasn’t even near the park and he had a new school with different everything. Also, his mommy was scared again. She had a lot of locks on the door, and slept on the floor by his bed again. Like before. She cried even though Mark wasn’t there to hit her. Eli tried to take care of his mommy but he didn’t know how. He was doing it all wrong. He didn’t know what to do.

When I met Eli, he was repeating Kindergarten and showed difficulty with attending,
comprehending, and meeting academic demands. Teachers reported he could be talkative but mostly seemed to be “in his own little world” and frequently complained of stomach-aches, asking for his mother to take him home. His occasional explosive aggression led to questions about whether he needed a more restrictive environment “for the protection of everyone involved.” Both Eli and Marianne had attended a therapeutic play group at the shelter, and the counselor there noted that Eli had “tended to keep to himself” and was “always with one ear to the door, listening if his mom was okay.” The little boy hadn’t been aggressive toward others at the shelter, but the counselor wasn’t surprised to hear “some of that rage bubbled up eventually.”

“Lions are strong,” Eli emphasized. “They eat the deer.”
We had just finished reading a story about forest animals and their needs, and he seemed disappointed that no one got eaten.
“Yes,” he added, smacking his palm on the closed book. “Later, he’ll beat her up and then he’ll eat her. He can kill her …”
He shuddered and looked up at me and appeared a lot younger than seven. “That sounds very scary,” I noted gently.
He pointed to the deer on the cover of the book. “Can she hide?” he asked.
I nodded and pointed in the direction of a napkin. I wanted to give him space to go where he needed. It was obvious this wasn’t about deer and lions.
Eli took in a trembling breath.
“I hide.” He whispered and reached for my hand. “I hide inside the closet in my mind.”

It’s what he did when mommy was being hurt and when she cried and when he missed his stepdad and when he didn’t know what to do: he went inside the closet inside his mind. Not the real closet, where people can find you, but a better one, in his head: A closet where only he could open the doors, where no bad sounds or smells got in. It wasn’t scary in his closet, just quiet. But sometimes he forgot to open the doors and pay attention and the teachers said he wasn’t a good listener and kids said he was stupid. His mommy told him that if she kept missing work to take him home from school she’d lose her job and they’d lose their apartment. But he worried about her. He heard her tell a friend on the phone that she was scared Mark would shoot her at work. Like on TV. He wanted mommy to take him home so she won’t be at work where Mark can come. And sometimes he thought he heard scary Mark coming so he’d jump out of his closet fast and hit but then people told him he was being bad, too. It made him want to go back in the closet inside his head but he needed to look after his mother. He was “the man of the house” now. He didn’t know what to do.

Exposure to domestic violence hurts children (Edleson 1999, Sousa et al 2011). Witnessing violence impacts children as much—and sometimes more—than being hit. It is unbearable to a child to be helpless to save the caregiver they need, and it can be even worse when the one harming the caregiver is also someone the child depends on. Children often convince themselves that the violence—and its prevention—is somehow theirs to control (Levendovksi et al 2003, Sousa et al, 2011). In a child’s mind, if only they were better, quieter, and less needy, the people they rely on would not become terrified or terrifying.

The very words that accompany domestic violence can be confusing. Did mom “ask for it?” Did stepdad “only hit her because he loved her?” Does saying “I’m sorry” mean it didn’t happen? Unable to make sense of what is happening around them, children—like Eli retreating into his “closet inside his mind”—might shut-down and dissociate. They can appear unemotional and numb, stop attending, and fall behind socially and at school. They might mirror the aggression they’d seen. Very often children feel guilty if they love the person who hurts the other person they love, and guilty for hating the person they love for hurting another person they love. They rarely have the words or space to describe any of this. Children who apply dissociation to cope with terror and helplessness may also shut down at reminders of the trauma, reinforcing dissociation and resulting in children who are less available for processing information and utilizing available support (Siegel 2012, Silberg 2013, Wieland 2011, Yehuda 2005, 2016).

Even after a parent flees domestic violence, strain often continues, and children might mirror it in ways that reflect not only past trauma, but also current issues. A parent who escaped domestic violence can still be vulnerable. They might still be scared. They might have limited financial, social, and emotional resources. Children sense this, and may hide their own difficulties to protect the parent from distress. When feelings of resentment, anger, worry, or grief inevitably overwhelm them, the children can feel doubly guilty. Unfortunately, just as Eli was scolded at the shelter, children might be chided if they misbehave and be told “there’s already enough to deal with.” They might dissociate to avoid added shame and helplessness. They might become hyper-aware of the parent’s mood and try to accommodate it (Ostrowski et al 2007, Lyons-Ruth & Block 1996).

A loss of home—even the mere risk of it—can be overwhelming and preoccupying, leaving children anxious, wary, worried, angry, or withdrawn. The parent may be managing depression, posttraumatic stress, financial insecurity, and grief; all of which can inadvertently reinforce unhealthy dynamics. This is why it is crucial anyone who works with families fleeing domestic violence, understands children’s behaviors and the functions they serve.

Domestic violence hurts children. While children don’t always communicate their distress verbally, they almost always do so in their behaviors: In aggression and acting out, in shutting down, in falling behind, in what they won’t talk about, in what they do or cannot do (Silberg 2013, Waters 2005, 2016, Yehuda 2005, 2011, 2016). It is paramount we hear them, for our reaction may become the measure of whether they believe help is available.

Eli’s mother was depressed, but she was also determined to keep her children safe and to minimize the impact of trauma on their future. She entered counseling to deal with her own unresolved history, and enrolled Eli in a therapeutic playgroup. She became more involved in his therapy with me, and learned to support his narrative when he spoke of his feelings, including difficult ones about the violence he’d witnessed. Together, at his request, we made a visual representation of the “closet inside his mind” using a shoebox that the two of them painted to fit his inner representation. Eli was able to put his “big feelings” into the closet-box for safe keeping so that he can attend better at school. He was delighted when his mother made a small blanket for his closet “so even the biggest feelings can be cozy and safe.”

With his mother less frightened and himself less alone, Eli was able to let in play, instruction, joy, and praise. His explosive aggression ceased, and he was catching up on language, academics, and friendships.

“Remember when I told you about my closet in my mind?” he said at one of our sessions. “I don’t need to hide there anymore. It’s old and it’s too small for me,” he added without judgment. “I was little, but now I can speak up and if I get scared I can go to mommy or the teacher … or you. I don’t need that closet. The bad memories can rest there.”

 

Bibliography:
Edleson, J.L. (1999). Children’s witnessing of adult domestic violence, Journal of Interpersonal Violence, 14:839-870.

Levendosky, A.A., Huth-Bocks, A.C., Shapiro, D.L., Semel, M.A. (2003). The impact of domestic violence on the maternal–child relationship and preschool-age children’s functioning, Journal of Family Psychology, 17(3):275–287.

Lyons-Ruth, K., Block, D., (1996). The disturbed caregiving system: Relations among childhood trauma, maternal caregiving, and infant affect and attachment, Infant Mental Health Journal, 17(3):257-275,

Ostrowski, S.A., Norman, M.A., Christopher, C., Delahanty, D.L. (2007). Brief report: The impact of maternal Posttraumatic Stress Disorder symptoms and child gender on risk for persistent Posttraumatic Stress Disorder symptoms in child trauma victims, Journal of Pediatric Psychology, 32(3):338–342.

Siegel, D.A. (2012). The Developing Mind: How relationships and the brain interact to shape who we are, 2nd Edition, New York: The Guilford Press.

Silberg J.L. (2013). The Child Survivor: Helping Developmental Trauma and Dissociation, New York: Routledge Publishers.

Sousa. C., Herrenkohl, T.I., Moylan, C.A., Tajima A.E., Klika, J.B., Herrenkohl, R.C., Russo, M.J. (2011) Longitudinal study on the effects of child abuse and children’s exposure to domestic violence, parent–child attachments, and antisocial behavior in adolescence, Journal of Interpersonal Violence, 26(1):111–136.

Waters, F. (2005). When treatment fails with traumatized children. . .Why? Journal of Trauma and Dissociation, 6:1–9.

Waters, F. (2016). Healing the Fractured Child: Diagnosis and treatment of youth with dissociation, Springer, New York.

Wieland, S. (Ed.) (2011). Dissociation in Traumatized Children and Adolescents: Theory and clinical interventions, Psychological Stress Series, Routledge Publishers.

Yehuda, N. (2005). The language of dissociation. Journal of Trauma and Dissociation, 6:9–29.

Yehuda, N. (2011). Leroy (7 Years Old)—“It Is Almost Like He Is Two Children”: Working with a dissociative child in a school setting, in Wieland’s (Ed.) Dissociation in Traumatized Children and Adolescents: Theory and clinical interventions, New York: Routledge, Psychological Trauma Series.

Yehuda, N. (2016) Communicating Trauma: Clinical presentations and interventions with traumatized children, Routledge, New York.

 

For more information about trauma and development: check the Resources, Trauma and Development and Publications pages on this site.

 

ADHD or Trauma?–The Likelihood for Mistaken Diagnosis

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A new study shows that a child with an ADHD diagnosis is more likely to have also experienced stress and trauma early in life.

Clinicians working with traumatized children and adolescents have long noticed–and noted–that it was not unusual for children with trauma histories to be diagnosed (and possibly all too often misdiagnosed) with ADHD. 

What complicates the clinical picture is that a child can have ADHD and trauma history (or Autism and trauma history). In fact, children with ADHD and children with communication disorders are more likely to be maltreated than children without these issues.

As the article below states, and what is very important to take into account, is the need to rule out trauma as the cause–or contributor–to the child’s clinical presentation, rather than simply assume that a distracted, inattentive child has ADHD. Assessment needs to address the possibility of trauma, and intervention approaches must be adjusted accordingly. For example, medication for ADHD may not be appropriate for a child whose inattentiveness is due to hypervigilance. It is crucial to ensure that past trauma be treated and ongoing trauma be addressed, so that the child can let go of the coping skills adopted to manage overwhelm.

 

The article is copied below. You can also read it on the original webpage by clicking on the title below. For more information about trauma and development, click here.

 

News Analysis: Are We Misdiagnosing Childhood Traumas as ADHD?

Children with attention deficit hyperactivity disorder (ADHD) receive a diagnosis based on their behavior: age-inappropriate fidgeting, inattentiveness, hyperactivity, and trouble sitting still and concentrating. However, according to new research presented today at the Pediatric Academic Societies annual meeting in Vancouver, Canada, these behaviors may also be linked to childhood trauma.

A research team analyzed data about 65,680 children ages 6 to 17. (The data was taken from the 2011-2o12 National Survey of Children’s Health.) The children’s parents answered questions about whether their kids had been diagnosed with ADHD, how severe their symptoms were, and whether they were taking any ADHD medications. The parents also reported on whether the children had had any of nine adverse childhood experiences (ACEs): poverty, divorce, the death of a parent or guardian, domestic violence, neighborhood violence, substance abuse, incarceration, familial mental illness, or discrimination.

“Diagnoses of ADHD have increased over the last decade, and there has been a concomitant rise in stimulant medication use,” said Nicole Brown, an assistant professor of pediatrics at the Children’s Hospital at Montefiore and lead author of the study, in an interview with Healthline. “Many of my patients also experience trauma during childhood, which often exacerbates ADHD symptoms and poses diagnostic challenges with respect to teasing out whether their symptoms directly result from the trauma they experience.”

About 12 percent of the children who participated in the survey had been diagnosed with ADHD. Parents reported that these children had also experienced higher rates of all of types of ACEs than children without ADHD.

The children with ADHD were also more likely to have experienced a greater number of adverse events. Seventeen percent of children with ADHD had experienced four or more ACEs, as opposed to 6 percent of children without ADHD. The children who had dealt with four or more ACEs were almost three times are likely to be using an ADHD medication as children with three or fewer ACEs, and their parents rated their ADHD as being more severe.

ADHD and Trauma: The Chicken and the Egg

How is ADHD connected to stress and trauma? There could be a number of explanations.

First, it’s possible that doctors are simply mistaking the signs of trauma in children for ADHD. “What we find is that there is often an overlap in the symptoms of children who have ADHD and children who have experienced trauma, particularly small children,” said Alicia Lieberman, professor and vice chair for academic affairs at the University of California, San Francisco, Department of Psychiatry and the director of the Child Trauma Research Program at San Francisco General Hospital, in an interview with Healthline. “The inability to concentrate, the fidgetiness, the inability to pay attention, the distractibility, the restlessness, and the irritability are often behaviors that trigger a diagnosis of ADHD. And often, the people making the diagnosis do not ask what happened to the child, what kind of experiences the child has had.”

Brown agrees that this may explain her findings. “Studies have also shown that symptoms of post-traumatic stress disorder (PTSD) or acute stress disorder resulting from adverse life events closely resemble ADHD symptoms, so there is a high likelihood for clinicians to diagnose ADHD and overlook a possible trauma history,” she said.

Another explanation is that children with ADHD may be more likely to get into trouble and to experience traumatic events as a result. “Children with ADHD can become more impulsive, can be more annoying to parents that might be depleted, so children with ADHD might be at greater risk for being maltreated or getting into accidents, which might in turn trigger PTSD,” explained Lieberman.

Finally, researchers know that stress in the early life environment might affect the development of the brain. “It’s also possible that being exposed to a traumatic event increases the likelihood of developing psychiatric disorders that have a range of manifestations, including anxiety, post-traumatic stress disorder, and ADHD,” Lieberman said.

“When a child is presenting difficult behavior, the first thing to ask is ‘What happened to the child?’ rather than ‘What is wrong with the child?’”

Under this lens, ADHD is only one of many possible outcomes that can result from early-life trauma. And even then, ADHD might just be a sign of what’s to come. “We know that early life adversity produces developmental changes consistent with ADHD, but it produces many other effects as well,” explained Regina Sullivan, a professor of child and adolescent psychiatry at the New York University School of Medicine. “As a child is developing, and there’s a neurobehavioral deficit, how that is expressed changes during development. ADHD can sometimes be symptoms of neurobehavioral problems that will emerge later in development.”

Sullivan added, “Early life trauma and stress can interact with genetics to produce different disorders based on the age the trauma was experienced and the particular type of stress or trauma. Different-aged children, and children with different genetics, and children with different personalities, will respond differently to a given stress.”

Are We Medicalizing Stress?

Rising rates of ADHD diagnosis and medication use raise the question: are we turning normal levels of life stress into a medical condition? Lieberman points out that more than 60 percent of children report that they have been exposed to some kind of victimization in the previous year, and more than 10 percent have had five or more exposures. For many children, ACEs aren’t rare, they’re the norm.

And when kids are under stress, they’re more likely to act out. “When a child is presenting difficult behavior, the first thing to ask is ‘What happened to the child?’ rather than ‘What is wrong with the child?’” said Lieberman. “The recommendation that the authors of the study make about the importance of screening for trauma exposure in every child that is showing symptoms that can be associated with ADHD is extraordinarily important and timely.”

In these circumstances, medications probably aren’t the answer. “While stimulant medications may prove beneficial for some children, they may not be the most effective management strategy for all children,” said Brown. “Children with ADHD diagnoses who have experienced trauma may additionally benefit from specific behavioral interventions that are tailored to addressing their underlying trauma histories.”

However, Sullivan cautions against drawing too many conclusions about a child’s past from his or her diagnosis of ADHD. “Not all children with ADHD have had early life adversity,” she said. ADHD also isn’t necessarily a sign of other disorders to come. “Sometimes, when someone has ADHD, they maintain those ADHD symptoms throughout life, changing somewhat, but they still have the diagnosis of ADHD.”

It will be many years before the root causes of ADHD are fully understood. Until then, doctors must try to figure out which symptoms are caused by trauma, while also ensuring that children with ADHD get proper treatment for the disorder itself.

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