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"I would love for someone to be able to explain to me how you can educate a child or teach a child social skills if that child is in a state of hypervigilence and hyperalertness as a result of traumatic stress.
It's not going to happen .... it's not going to happen"
-- Carl Bell
Carl Bell, M.D.:
First speaker at Creation of a Self: Color and Trauma in the Life of a Child
Mixing personal reminiscence, clinical experience, and empirical research, Dr. Bell clearly presented a psychoanalytically relevant and informed public health perspective. The following is a full-report of his remarks:
- Starting Points
- A Public Health Realization -- "The Rat is Violence"
- Community Studies
- Consequence #1: Different Kinds of Stress
- Consequence #2: Impact of Stress Varies Greatly
- Case #1: Witness to Father's Murder
- Case #2: Abused by her Father
- What's Next?
In 1976 at a Chicago City Department of Mental Health Clinic, Dr. Bell found himself working with a 4 year old child who had seen her mother stabbed to death. Not knowing what to do or where to turn, he did what every good resident does and turned to the literature. Not finding much of direct relevance he read Freud and Brewer's Studies on Hysteria, useful in describing the traumatic influence of what those patients had experienced, but of limited value for the current situation since the patient was only 4 years old and not past adolescence as were all the patients described by Freud and Breuer. Not knowing what else to do, he did no harm and provided what he could in terms of a supportive environment and someone to talk to you and play with. Shortly after he began working with the child the family relocated and his contact with that child ended.
Although not specifically helpful with children, Bell did find that Freud and Brewer's work helpful in treating some of his adult patients who presented at his community clinic with symptoms of anxiety and migraines. After years of talking about making the unconscious conscious, he reported delighted amazement to see the process actually working -- symptoms being alleviated through talk-therapy.
A Public Health Realization -- "The Rat is Violence"
In medical school Dr. Bell said he was taught that if a child came in with a rat bite and you treated that child, you were a good doctor. But if 50 children came in with rat bites and you did nothing to go out into the community and get rid of the rat, you ought to have your medical license revoked. In the poor, urban community he was serving, which in that instance was predominantly African American, he felt an obligation to go after the "rat" and in this case the rat was violence.
Some important facts:
- Since 1929, homicide rates have been 6 to 12 times higher among African American communities than in white communities.
- When you control for SES (Socio-Economic Status, a rough indication of economic class), that difference in homicide drops out and there is no difference between African-American and European-American communities.
- Varying rates of violence in African-American communities has to do with the absence or presence of an intact social fabric and social infrastructure; where there is social cohesion, there are less murders, and where there is chaos there is more violence.
One consequence that occurred to Bell was that children are probably present during many homicides. After all, in the United States most homicides are not stranger, predatory kinds of murders. Rather, they are eruptions of violence usually between family and friends. This carries a high probability that children will be exposed to traumatic violence during these incidents. It seems to be an area ripe for research, to look and see if America's children really are being exposed to the "public-health rat" of violent trauma.
Dr. Bell related the results of several community studies that confirmed his initial ideas and extended them in interesting and important ways. There is an epidemic of children being exposed to violent trauma and ways to help those children are being developed.
The first community study of children's exposure to violence was undertaken in 1984. Bell and his colleagues studied 536 children in their catchment area from the 2nd through the 8th grade. They found that fully 1/3 of these children had seen a shooting or stabbing. Bell emphasized a distinction between lethal violence which results in murder, and sub-lethal violence such as shootings and stabbings. While Chicago has about 950 homicides per year, it has 16,000 shooting and stabbings total. The rates of traumatic violence in poor communities are higher (recall that differences in homicide rates between black and white communities drop away when SES is controlled for). As a result children in certain urban populations--poor Black, poor Hispanic, and poor White communities--are more likely to be traumatized by violence in their environment.
The next study involved patients coming to a community mental health council for treatment. Dr. Bell and his colleagues found that 1/3 of the women reported being raped. The evidence for a high level of trauma being present was clear. Yet, as noted by Dr. Bell and his colleagues, there was a general lack of awareness on the part of the staff and the systems treating these patients about the presence of this trauma and a corresponding absence of information as to how best to deal with the actual impact of violence.
In 1989 they surveyed 1,000 children from 6 different schools and found:
- 40% had seen a shooting
- 23% had witnessed a murder
- 10% had been shot
- 4% had been stabbed and in juvenile detention centers the percentage of children either shot or stabbed increases to about 26%.
A rational system would, for example, put programs into place in juvenile detention centers to address these issues of victimization and traumatic stress. But yet they do not. In general, a lack of awareness of victimization and traumatic stress directly hinders childrens' rehabilitation and education. As Dr. Bell said, "I would love for someone to be able to explain to me how you can educate a child or teach a child social skills... if that child is in a state of hypervigilence and hyperalertness as a result of traumatic stress. It's not going to happen, it's not going to happen."
The most recent study, done in 1992, looked at 203 children between 13 and 18 years old, living in the police precinct with one of the highest murder rates in the city of Chicago. This study (which has been replicated in other cities) showed that:
- 60% of the children surveyed had seen shooting
- 45% had seen a stabbing,
- 43 % had seen a murder.
The similarity of findings indicates that there is a sizable population of children in the United States who have been through traumatic stress, either as witnesses or actual victims of violence.
Consequence #1: Different Kinds of Stress
In the most recent study Dr. Bell and his colleagues extended the documentation of exposure to traumatic violence and began looking for symptoms of anxiety in children, including signs of post traumatic stress disorder (PTSD). As expected, a large number of the children did have anxiety disorders. However, they were also interested to find behavioral disturbances and academic disturbances as consequences of exposure to traumatic violence. There was a high incidence of aggression, and of children who engaged in weapon carrying behavior. Bell began to understand that there are 2 types of children in the study:
- The acute type: Children exposed exposed to one, acute traumatic stress. They tend to manifest PTSD and anxiety problems
- The chronic type: Children exposed to chronic, repeated stresses. The tend to have behavioral, academic problems. Bell also found a correlation between children with substance abuse problems and traumatic stress.
In a related study conducted in New York , among cocaine addicted women it was shown that 85% had been repeatedly sexually assaulted before the age of 18. Well before they became cocaine users, they were victims of violent trauma and yet, when one looks at the treatment of addicted women, it is unusual to find the perspective of traumatic stress used to help victims deal with these incidents of violence.
Consequence #2: Impact of Stress Varies Greatly
One thing learned from the studies that have been done to date is that the impact of stress on children varies greatly:
- Early Experience:
Some children have good relationships with their caregivers as infants, and when these children are traumatized they are able to establish relationships with a therapist more easily. But some children do not get that kind of nurturing at an early age. Therapists need to rely on those strengths when present and work in other ways when not.
Dr. Bell notes that gender is a factor. Females have more anxiety symptoms while males are more likely to act out and exhibit antisocial behavior. As a result these boys' get categorized as having conduct disorders and are relegated to the criminal justice system, despite findings that it is the same cause, traumatic stress, that prompts the anxiety symptoms in girls and antisocial behavior in boys.
- Other factors that account for the variability of impact of traumatic stress include:
- the child's proximity to the violence
- whether the violence is acute or chronic violence
- the relationship of victim to witness
- the degree of traumatic helplessness,
- the support systems available to the child after exposure to the violence
Dr. Bell emphasized that given the range of factors, there is a rich environment to study resiliency in this population of children. It should be noted that where there is variability there is hope that therapeutic interventions can be designed to weight the odds in favor of better outcomes.
Case #1: Witness to Father's Murder
Dr. Bell tells of the case of an 11 year old child who came to see him; this boy had been a B student and had dropped to a D. When he asked the boy how did your grades change, had he been under any stress or trauma-- the boy responded that he did not know. However, through further questioning it came out that this boy's father used to help him with his homework. And that his father was now dead. The father had been shot in an elevator with his son present. The two were bystanders to an argument that became shooting. As the elevator went up 6 flights, the boy helplessly witnessed his father's death. A gunshot wound to his abdomen was fatal and as he died in the confined space of the elevator, the contents of the father's stomach emptied into the confined space and the boy vomited. Now, and as a result of this trauma, whenever the boy tried to study he became nauseous.
This boy had no one to talk to about the incident. His mother couldn't handle talking about it and there were no other apparent symptoms of PTSD that brought him to the attention of other adults. It wasn't until therapy that they were able to connect the recurring nausea with the original experience of vomiting. After that, the boy was increasingly able to study again without reliving and fearing to relive the trauma of his father's death.
Dr. Bell pointed out that this is a classic case of somatization--studying reminded this boy of his father, and rather than think about the unthinkable experience of his father's death, he developed the symptom of nausea. Somatization is easier to see in children than in adults, whose behavior may be in response to a trauma they have covered over as a method of coping. One of the "clinical take-homes" from the day was that the sooner someone talks about the trauma, the better the result.
Case #2: Abused by her Father
In another case Bell was working with a 13 year old girl, an A student who had been referred to him for school failure. The child's history revealed that at the age of 6 she had twice been sexually assaulted by her father. Her father had been sent to prison and the girl had had 2 years of play therapy and had returned to a relatively uneventful childhood with no apparent problems. When Bell questioned this girl she said she felt she had dealt with her father's assault through therapy. As she described her problem, when she would try to study her mind would go blank. After further questioning she revealed that rather than blanking out, she couldn't help thinking about what her father had done to her. She reported that until she turned 11, the experience had had little meaning for her. Now that she was older, she realized the significance of the event and was re-traumatized by the memory.
Bringing his discussion back to the psychoanalytic literature, Bell related this child's symptoms to the case histories of Freud and Breuer, where children who were sexually traumatized at a young age did not develop symptoms until adulthood. Bell expressed concern that those who should be watching out for this girl had "gone asleep at the wheel," not taking into account the fact that people can be re-traumatized by a past event as they pass through successive developmental stages, especially when the new developmental stage includes features of the original trauma. Dr. Bell said he hopes someone will watch out for this girl when, for example, she gets married, has a child, or has a daughter turn 6 years of age.
Dr. Bell then turned his discussion toward the work that needs to be done. He said that he was disheartened at the lack of awareness and interest in these issues on the part of analysts, counselors and others who have the role of watching out for these children. Relying on a sense of humor present throughout, Bell described his own "psychoanalytic post traumatic stress disorder" from a time he presented this material at the Psychoanalytic Institute in Chicago. One of those listeners had listened patiently and then questioned the relevance of Bell's subject to psychoanalysis -- "what does this have to do with us". He went on, "Hopefully I will not be retraumatized by this group during our discussion." He then reiterated that the empirical observations of psychoanalysts are extremely useful in identifying the problems of traumatized children as well as adults. The difference between those patients who are very close to a trauma and those who are 3, 4, or 5 years away from a trauma is great. The farther away the trauma, the harder it is to get at the problem with the patient. The person who is 15 years away from a trauma is so far from it that they can not see the impact. It is clear by looking at this continuum how important early intervention can be.
Related to early intervention, he called for more public health systems building, citing the work of Dr. Stephen Marins as extremely important. He went on that when children are exposed to these traumas their brains become, in a sense, hard-wired, locked into state of hyper-aroused states; Perry in Houston says medication is necessary for these children to listen and participate in the talking therapy. There is evidence that if you can get to a victim within 48 hours, you can help prevent the hard wiring of the trauma. Bell briefly described his work with the American Academy of Pediatrics Task Force on Assault Victims Needs, which involves the training of emergency room staffs to try to help deal with adolescent rape victims and other traumatic stress victims.
Bell concluded his talk with another anecdote and addressing the need for much more public awareness and government funding for victims of traumatic stress. He described his experience of going to congress to advocate for this cause and the lack of interest that was shown; despite the number of experts he had brought, he was given 15 minutes to make his case. By contrast, Mary Tyler Moore was given 1 1/2 hours to present her case on juvenile diabetes and Congress was adjourned for picture taking. Bell suggested that Mary Tyler Moore may have earned funding for her cause through her status as a prominent icon of popular culture, and that such a public figure is needed to bring attention and funding to traumatic stress in children. He closed by reiterating that too many people have fallen asleep on this issue, and addressing the psychoanalytic audience specifically, that too many have forgotten what Freud had to say on the issue of traumatic stress.
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