Editor’s note: While most of this series on post-traumatic stress disorder has dealt with military service members, they aren’t the only ones who are challenged by trauma and its aftermath. So, too, are some of the most vulnerable in society — children.
Anyone who visits the Children’s Advocacy Center of Comal County must come through the back door.
That includes law enforcement.
The only ones allowed to go through the front door are children with their parents or guardians with appointments.
On this morning a forensic interview is being conducted. Privacy is necessary. The child will be able to speak about their experience. Hopefully it will be one of the very few times.
This is one of the ways the center helps kids who have experienced trauma such as physical abuse or sexual assault.
Entering the back door, it leads to a room where the counseling for a child happens after their experience.
Cherri Mettler, a licensed professional counselor at the CACCC, greets the guest as if welcoming them to her home. She offers water, a soda or a snack.
“I’m sorry, I’m so used to doing this,” she said.
Mettler, who is also trauma-focus certified, does this to help the child feel comfortable and welcome.
The room doesn’t look like a counselor’s or psychologist’s office. There is no stereotypical couch where one lies down to talk about one’s problems.
Instead, there is a small, colorful picnic bench in the middle of the room. There is a table against the wall covered with books and toys. In another room, there are more toys.
Dinosaurs, a playhouse, blocks, trucks, a drawing board, and a puppet stage. It could be a child’s dream.
Right above the little kitchen set is a painting separated into three columns with the words, “Always talk nice to yourself,” in bold.
These tools are utilized as Mettler, along with CACCC counselor Megan Smith, help the children to express themselves. It also helps prepare them during the counseling sessions, when they eventually speak about the traumatic experience.
According to the National Child Traumatic Stress Network, post-traumatic stress disorder can sometimes be confused with attention-deficit/hyperactivity disorder.
Both ADHD and PTSD have symptoms that overlap, such as difficulty concentrating and learning, being easily distracted, often appearing to not be listening and difficulty sleeping. That overlap increases with age.
To further complicate the diagnosis, studies show a traumatic event can make an underlying psychological condition worse, resulting in greater symptoms.
That means in many cases, there’s a misdiagnosis.
In the case at the CACCC, they only deal with children who have traumatic experiences. However, they do not diagnose the child.
“We don’t actually diagnose for PTSD officially. We have assessments that have aspects of PTSD diagnosis but we’re not diagnosing kids with PTSD,” Smith said. “It’s not safe to assume that if they’re having flashbacks or things like that when they’re experiencing PTSD symptoms at a minimum.”
Instead, Mettler and Smith try to reduce the big symptoms they experience — helping them regulate emotions when triggers and flashbacks occur after the trauma.
“It hits all the symptomology that you would put a PTSD diagnosis that’s really not a necessary thing,” Smith said. “Now if we notice that there are still not sleeping or they’re really depressed and there’s something we need — that next level of care, then we will help do more like a treatment team where you’re combining medication and counseling together.”
When counseling begins for the child, Mettler and Smith do not immediately take the child to the traumatic event.
Rather, they provide the tools for the child to use when they eventually get to that time, called gradual exposure. In each session, the child is bringing up the experience, little by little.
“In that process they’re automatically bringing up those thoughts and feelings, and we’re starting to hear that cognitive distortion where they’re really telling themselves a lot of unhelpful or untruthful thought,” Mettler said. “And that’s when we pick up on those and then we kind of bring in whatever activity we need to for that individual child.”
Each child is different, so they have to ensure the activities they are using are going to meet that child’s needs.
These activities are also based on the child’s age. For toddlers and younger, who may not speak well yet, those activities may include playing with toys, while Mettler or Smith observe how the toddler plays.
Sometimes, the toddler reenacts the event with the toys.
For those 6 and older, this includes playing with toys, drawing, painting and writing.
In all age groups, the majority of the time the child is expressing him or herself through these activities, the feelings they are experiencing at the moment. Mettler and Smith watch to see if there are patterns or themes of play.
“Trauma focused cognitive behavioral therapy is front loaded with skills at the front, and then you deal with the trauma and process trauma at the end on purpose,” Smith said.
Without these skills, Smith said it would be like kicking someone in the deep end of a pool who doesn’t know how to swim.
“You got to teach them the skills first, then you get in the pool,” she said.
The therapy also works on changing the thought patterns as well as behavioral patterns, according to American Psychological Association.
If a child encounters a hallway where the trauma happened, or a location appears similar, the child may do breathing exercises before attempting to walk down the hallway.
“It can take many different forms. Like we had kids do paintings, sand tray therapy, drawing it through art — they get to make that choice,” Mettler said. “They’ve got the trauma narrative, so the kids make it look exactly the way they wanted to look, not how we want it to look.
It’s how the kids can process it in a safe way rather than re-traumatizing them.
“They get to choose how they want that story to be told,” Mettler said.
The healing and skills do not happen overnight.
“Parents can tend to be frustrated, like, ‘Why aren’t we doing anything? Things aren’t getting better!’ and we have to explain on the front end of things that it’s because we’re teaching all the skills first and we’re not heavy processing the trauma yet,” Smith said. “Once we get to the trauma that’s when you see a lot of resolve and improvement.”
The parents or guardian also learn about the child’s skills and triggers.
“So first it’s like ‘Okay, this is what you do for ups and downs,’” Smith said. “This is what trauma is, this is what trauma does. This is the impact of trauma. ‘Here’s how to handle it with coping skills,’ ‘Here’s about feelings, ‘Here’s about thoughts.’ Now let’s process your trauma step.”
And processing their trauma is them speaking about what happened eventually.
When they get to their story, when all those thoughts, feelings, and trauma get triggered, they know to use their skills.
As a plus, Smith and Mettler said this also works at home, too, when they don’t get their way, or when they have a fight with their siblings.
“They need to learn how to emotionally regulate anyway and that’s essentially what we’re teaching them,” Smith said.
Therapy length varies from child to child. Some kids finish in two to three months. Others take up to a year.
At the end, they write their own story, too. They write about themselves, who they are, what they love in the first chapter. Then they write about the good and bad memories that they shared with the perpetrator, because somebody is both good and bad, and trying to rectify the difference.
Then they write about their trauma, what happened and if it was multiple traumas. They will write about the first, the worst and the last time it happened.
The last chapter is how they got through it.
“That trauma narrative is so important for them to take that back because we always say it would be better for that child to process that story with a counselor who they feel safe with or wait and not talk about it and then have to process that story on the stand in front of a jury,” Mettler said. “That’s the importance of that of this type of therapy,”
Once they finish and “graduate,” many leave notes for the next child walking into the big house with toys and snacks.
These are words of encouragement letting the next survivor know they got through it.
They will, too.