Psychotherapeutic Treatment of Traumatized Infants and Toddlers: A Case Report

THEODORE JOHN GAENSB AUER

Private Practitioner, Denver, USA

A B S T R AC T The treatment of children traumatized under the age of 3 years has presented particular challenges. The cognitive immaturity, lack of verbal uency and uncertain memory capacities of very young children have made it difcult to know how traumatic events are represented internally and how their effects may be alleviated. Addressing these difculties, this article describes the psychotherapeutic treatment of a 3-year-old boy traumatized at 22 months of age by a medical illness and its associated treatments. The goals of the therapy were to relieve symptoms and help the child integrate the traumatic experience, while promoting the parents crucial role in the childs recovery. The case material illustrates the usefulness of active structuring of the childs play as a vehicle for understanding the childs experience of a trauma. It also documents the childs impressive memory for the medical events and his comprehension of their implications, as well as the inuence of the rapid developmental changes occurring in early childhood on the processing of the trauma. Lastly, the case highlights the disruptive impact of traumatically induced anger on childrens development and the importance of facilitating its appropriate expression so that a traumatic experience can be resolved fully. K E Y WO R D S developmental effects of trauma; early memory; infants and toddlers; psychotherapy; trauma

T H E T R E AT M E N T O F

children traumatized in the pre-verbal period presents special challenges. Besides the inability to express reactions in words, signicant difculties presented by very young trauma victims include the absence of reliable methods for

T H E O D O R E J . G A E N S B A U E R , M D , is in private practice in Denver, Colorado, and is an Associate Clinical Professor in the Department of Psychiatry at the University of Colorado Health Sciences Center. He has had long-standing research and clinical interests in understanding adaptive and maladaptive emotional regulation in infancy and the impact of traumatic experience on early development.

Clinical Child Psychology and Psychiatry 13591045 (200007)5:3 Copyright 2000 SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 5(3): 373385; 013052 373

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accessing their inner world, their overall cognitive immaturity and their inability to participate purposefully in a therapeutic process. Further complicating matters are the rapid developmental changes occurring during the rst years of life. These changes not only alter the childs inner representations of a trauma over time, but also determine the types of therapeutic intervention likely to be helpful at any given age period. Despite these challenges, there is reason for optimism regarding our ability to provide effective help. A growing clinical literature (Scheeringa & Gaensbauer, 2000), recent systematic studies on post-traumatic reactions in infants and toddlers (Scheeringa, Zeanah, Drell, & Larrieu, 1995), and emerging understanding of early memory and cognitive processing capabilities (Bauer, Hertsgaard, & Dow, 1994; McDonough & Mandler, 1994; Meltzoff, 1995) are providing a basis for the advancement of knowledge in this area. Building on these recent developments, this article describes therapeutic work with a boy who was traumatized by a medical illness and its associated treatments prior to the onset of verbal uency. From the standpoint of therapeutic technique the case illustrates the usefulness of active structuring of the childs play as an avenue for understanding the childs experience of a trauma. In keeping with traditional posttraumatic treatments, the goal of the therapy was to facilitate the childs internal reworking of the traumatic experience, while incorporating the childs parents into the therapeutic process in ways that promoted their essential role in the childs recovery. The clinical material documents the young childs abilities to remember traumatic events and to understand their implications. It also illustrates the inuence that developmental changes have on both the therapeutic processing of an early trauma and the emergence of new meaning and conicts, as the trauma is reinterpreted in the light of subsequent developmental stages. Lastly, the case highlights the disruptive impact of traumatically induced anger on young childrens development and the importance of facilitating the appropriate expression of this anger in order that a traumatic experience can be resolved fully.

Case report Background

Marks parents consulted me when he was 35 months of age because of difculties related to a series of medical treatments that had occurred 13 months earlier. At 22 months he had been hospitalized for a cellulitis under his eye that required intravenous medication. Because of heavy bandaging, a severe inltration at the intravenous site on the back of his right hand went undetected despite his prolonged fussing. By the time it was discovered, his arm had puffed out like a balloon up to his shoulder and collarbone. The spaces between his ngers were obliterated and in many areas the skin had split completely. A series of emergency procedures followed. Multiple punctures of the skin were made to measure the uid pressure, followed by surgery under general anesthesia. Two 3-inch-long incisions extending deep into the muscle compartments were made on each side of his forearm, extending to the back of his hand and his palm, and left open for drainage. Two days later the incisions were closed surgically. His mother recalled that when he was returned to his room after the second surgery he turned his back on her. After discharge from the hospital Mark was followed with daily outpatient visits for cleansing of the inamed areas and dressing changes. Owing to short-term sensory nerve damage from the original swelling, he experienced little pain and participated happily in the bathing activities. One week later two follow-up outpatient surgeries were carried out under general anesthesia: surgical debridement of the necrosed tissue on the back of his hand and a skin graft. He was very defensive about any manipulation of his arm. He
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became quite withdrawn following the debridement, and showed great distress when he was taken from his parents to the operating theatre for the skin graft and when the bandage covering the skin graft site was pulled off his thigh a week later. Following these procedures he wore a half cast for a month and bandages for the next several months. During the recovery period he repeatedly attempted to remove his bandages, requiring his parents to place a sock over his hand. The arm eventually healed with good muscle control and no long-term sensory loss, but with a thick 11/2 inch2 scar covering the back of his hand and two very visible scars on his forearm.

Symptomatology
When he returned home, Marks overall mood was signicantly dampened and he showed obvious signs of anxiety and developmental regression. He was fussy, wanted to be held, and sharply increased the use of his pacier. His general activity decreased and his walking became somewhat unsteady. At the time of the surgeries his language consisted of individual words, but no sentences. For several months there was no increase in language usage. By the time I met him, however, his language had progressed exponentially, such that his sentence usage was in advance of his peers, although accompanied by an intermittent stutter that was particularly evident under stress. On the positive side, the surgical procedures were bracketed around the Christmas holidays and he was able to enjoy the festivities and respond to the attention of visiting relatives, evidencing his fundamentally solid emotional development. He also slept well, without distressed awakenings. Beginning within a month of his surgeries and continuing intermittently up to the time of our rst meeting, he engaged in post-traumatic play. Most striking to his parents were two occasions when he peeled the skin off a hot dog and placed it over the site of his skin graft. He put napkins around his head and pillows over his face or over his mothers face, pretending to be the doctor, or rubbed his mothers arm, saying Im xing [it]. His stuffed animals were subjected to a number of medical procedures. Throughout his recovery Mark remained preoccupied with his arm, paying close attention to his wounds and spontaneously showing them to other people. Even after it healed, he hesitated to use it. Whereas previously he had been right-handed, at the time of our meeting he used his left hand predominantly and his right hand only for support. Perhaps the most prominent after-effect of the traumatic experience was an increased vulnerability to stress and difculty in modulating his emotions, particularly anxiety and aggression. Prior to the surgery he had been relatively compliant, with infrequent and mild shows of temper. Subsequently, he showed a strong need to control his environment. He became bossy and demanding, prone to temper tantrums that included hitting and kicking his mother and older sister when he did not get his way. After losing his temper he would become very anxious and need reassurance, despite his parents calm handling of his angry outbursts. The traumatic experience became intertwined with developmental issues of anger control, parental discipline and retaliatory fears, contributing to subjective confusion about how his injuries had occurred. In the month prior to our rst meeting, following a doctors visit Mark had become very deant, to the point of hitting his mother during a diaper change. Following this angry outburst, as she was putting him down for a nap, he pointed to his scratches and said: You did that to me. Notwithstanding his lack of language at the time of the trauma and his subjective confusion about the origins of his injuries, Mark evidenced an impressive memory for specic events. For example, a year after his hospitalization he came across a toy that a nurse had given him to distract him during his outpatient hand bathing. He spontaneously asked the name of that woman who washed my hand and remembered that
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the toy was her toy. He then asked: What was the yellow stuff? His mother realized that he was referring to the yellow gauze that was used for his bandages. To his parents knowledge, none of this had been discussed with him subsequent to the actual experience.

Developmental history
Mark was the second child in a close and warm family, with a sister 12 years older. He had shown normal motor, behavioral, social and cognitive development prior to his medical problems at 22 months, and had experienced no unusual stresses. He was the product of a normal pregnancy and was delivered without complications by elective C-section. His parents described him as a happy and sociable child, gentle and calm in disposition. His mother remained at home with him during his rst three years, utilizing occasional day care. At day care he enjoyed playing with the other children and had not shown any notable separation reactions. Developmental milestones were within the normal range, although at the slow end of the scale; he walked at 18 months. He was not toilet trained at the time of his surgeries and had not made any progress subsequently.

Treatment
Therapeutic work with Mark entailed two separate courses of treatment. Initial treatment involved 12 sessions extending over three months. A follow-up course of treatment began ve months after the rst termination and consisted of nine additional sessions extending over a seven-month period. Early goals were to assess the affects associated with the various medical procedures, identify areas of emotional conict, and help him develop a clearer understanding of the circumstances of his injuries. An immediate task was to facilitate recognition that the playroom setting could provide an opportunity to communicate his feelings about his treatments. At our rst meeting, Mark was quiet but very good-natured, with a nice smile and a condent manner. His interaction with his mother was affectionate and mutually responsive. As he started to explore the playroom, his mother described a recent visit to the surgeon. When I asked Mark why he had seen the doctor, he immediately pointed to his hand and, stuttering, said that the doctor made a bad cut on my arm. He compliantly showed me his hand, pointing specically to the area between his thumb and rst nger, and said it was broken. His mother noted that this had been one of the worst areas of inammation. When I asked if it hurt, Mark said, Yes. Asked if he felt angry, he replied, No. He nodded when I asked him if he had felt sad. Holding a Barbie doll, he then said, This Mommy was angry. The comment was an accurate observation. His mother was indeed mad at the hospital because of what happened. In addition, however, it seemed a projection of his own anger and a reection of underlying anxiety about his mother being mad at him. To make our discussion of the injuries more vivid, I drew a picture of a boy in a hospital bed with intravenous tubing in his arm, picturing, as he had described the situation, the boy with a sad face and his mother with an angry face. I then outlined a gure with a swollen arm and asked him to show me where his cuts were. With the marker he pointed to areas of the drawing accurately centering on the injury sites on his arm and hand, and then excitedly began scribbling all over the arm. He then wanted to turn the page over to demonstrate the cuts on the other side of his arm. After I drew a new gure, he again made specic marks on the forearm and in the areas between the ngers. He also scribbled over his feet, which reminded his mother that he had had IVs on his feet as well. In order to complete the scene, I suggested we draw a picture of the doctor. Mark wanted to draw the doctor himself. Instead of a gure he drew two long red lines.
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Long lines were a recurrent drawing theme throughout the therapy, clearly referencing his surgical incisions. Toward the end of the session, he found a toy lion and used it to attack his mother in a playful but aggressive way. At the end of this rst session, given that Mark remembered a number of specic details but was confused as to exactly how and why his injuries had come about, I suggested to his mother that she tell him the story about what had happened to him. I hoped that this would help him develop a coherent and accurate narrative and enable his parents to empathize with his emotional experience. It would also give them the opportunity to describe their own reactions and allow Mark to appreciate that they were not angry with him but were similarly sad and distressed. At naptime, his mother told him about the little boy who went to the hospital. Mark was immediately and intensely engaged. For the next three weeks he asked her to tell the story at every naptime and bedtime. In our second session, as his mother described the storytelling I brought out a box of hospital toys. Very curious about the toys, Mark pulled out a boy doll. I made a reference to the boy being like Mark and said the boy had to go to the hospital. Taking a red marker, I asked Mark where we should draw marks to indicate his owies. He immediately pointed to the dolls arm, but interestingly, also pointed to the area around the dolls eye. His mother observed that his eye had been purple and swollen shut when he entered the hospital. As Mark played with the hospital furniture, I asked his mother to tell the story. As she did so, I engaged him in playing it out with the dolls and hospital equipment. Initially intrigued but hesitant, he acknowledged that the play made him think about his arm and made him scared. Over the next several sessions, utilizing drawing material and the hospital toys, Mark focused on several difcult aspects of his medical experience. For example, in the next session he drew several lines across the page that he indicated were scratches. He then drew a series of splotches on the page, which he described as pokes. He spontaneously asked his mother to tell the story, and especially to tell about the needles! As she began, he completely blanketed the body of a boy that we had previously drawn with forceful pokes. When I drew a picture of a doctor poking the little boy with a needle, in order to highlight the actual event, he practically pounded on the page with the marker. To address his helplessness and promote a feeling of mastery, as well as to validate his anger and wishes to resist, I encouraged the image of the boy to say No! to the poking. Mark immediately yelled a forceful, resonating No! Evidencing his conicted feelings about anger and strong identication with helping adults, he then provided a rationale for the poking, saying that the doctors were giving the boy medicine. A particularly difcult experience was identied as we played out the series of surgeries using toy operating room equipment. As his mother described Mark being taken from his parents arms to surgery by the nurse, his play became disorganized, reecting feelings of confusion and abandonment. He repeatedly moved the parent dolls away and then brought them back, saying go away in what appeared to be an enactment of the nurse sending his parents away but also an expression of his own anger. Another facet of the hospital play was Marks dislike of bandages, consistent with his behavior at the time of his surgeries. The rst time I tried to enlist him in bandaging the boy dolls arm with tissue and tape, he emphatically said No, reached over and took the bandage off. This resistance to bandaging was repeated whenever we got to this point in the treatment re-enactments. Mark could not explain his dislike of bandages, and it was not until much later that the meaning of this behavior became clear. Over the course of the initial sessions, Marks engagement in the play re-enactments and storytelling began to mobilize his internalized feelings. After the second session, his
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parents saw a signicant upsurge in distress and symptoms. Immediately after the session, he woke up from his nap upset, although was unable to say why. He began to show symptoms that had been seen in the immediate post-treatment period, including clinginess, fragility of mood, and increased upsets when he did not get his way. Following the third session, he aggressively poked his sister and became very anxious when he was sent to time out. That same day during storytelling he punched his mother and vigorously shook his head, saying No! No! No! as his mother described how the boy received the pokes and scratches. As therapeutic work continued, a similar pattern of reliving of various aspects of the hospital events was observed, both at home and in the sessions. His mother and I increasingly lled in details, introducing what we felt were important elements to be addressed while providing play settings that dramatized the events being discussed and identifying the various affects we felt he was experiencing. We provided opportunities for him to play out every aspect of his experience, including the bathing of his hand and the painful removal of the graft site bandage. These latter situations did not elicit a great deal of affect, and did not become a signicant part of the working-through play. Particular attention was given to feelings of anger. With his mothers and my encouragement, Mark acknowledged verbally and in his play that he was angry at the doctors and his parents about his owies. But he also expressed positive identication with them, describing how they did these things to help him. Expressions of anger were often followed by acts of restitution, such as poking the doctor doll or the dolls representing his parents and then giving them a kiss. In the course of these re-enactments, Mark also demonstrated his memory for a number of details. Putting the boy doll to bed after a surgery, for example, he placed the dolls arm in the air, then took a plastic stick and attempted to attach it between the arm and the IV pole. This replicated the placement of his arm in the hospital. He also placed the mothers chair at the foot of the bed, where she indeed had sat. Over time, the opportunity to identify different emotions and develop a coherent narrative in the context of play re-enactments and storytelling seemed quite helpful to Mark. His parents described him as happier and much more like his old self. Symptoms of anxiety were no longer observed and his stuttering had decreased markedly. He began to be less interested in the story at home. In the ofce, he was no longer completely engaged in the hospital play and pursued other activities such as puzzles and building materials. With this signicant improvement, the initial phase of therapy was terminated. We had reviewed the important elements of Marks experience, and his parents had an excellent grasp of his needs. The only persisting symptoms, the need to control situations and a tendency to become distressed when he did not get his way, were much improved and felt by his parents to be manageable. Although his mother and I believed that these persisting symptoms were carryovers of his feelings of anger and helplessness related to his hospitalization, we had been unable to help him make this connection. At this point in his development he did not have sufcient cognitive sophistication to make a link between current and past feelings of helplessness. I hoped that the dialog that had been established between Mark and his parents would facilitate increased understanding of this linkage over time.

Follow-up treatment
For the next four months Mark did well, until a new medical event upset the equilibrium. While at home with a babysitter, he had a febrile seizure and was taken to the emergency room in an ambulance. A complete neurological work-up was negative. Following this episode there was a resurgence of his previous symptoms, to the point that interactions with his family were disrupted signicantly. One month later we arranged a follow-up
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session with the hope that a review of the recent events would be helpful. Marks verbal skills had improved signicantly since our last meeting. In addition to playing out the events with hospital toys, he articulately described his emotions: his fears during the ambulance ride and the various examinations, his distress that his mother wasnt there when he had the seizure, and his anger, I screamed at the hospital because I didnt want to be there. Unfortunately, this abreactive session did not bring about a diminution in symptoms. Toilet training and the giving up of his pacier remained stymied as well. For a variety of reasons, I believed that the emergency room visit had triggered unresolved feelings related to his earlier medical treatments and that unresolved conicts about his anger were central. As noted, in our previous work Mark had been unable to connect his feelings of anger and helplessness about his hospitalization to his current need to have his way. I further believed that the previous work had insufciently accessed the depth of anger and disorganization Mark had experienced. Given his strong affection for his parents, Mark had been uncomfortable expressing anger, tending to qualify it with rationalizations regarding parents and doctors good intentions or mitigating it with some form of restitution. I also felt that his parents sensitivity and tact were inadvertently interfering with the full expression of his rage. At the end of sessions, for example, when he was at the edge of distress, I had repeatedly observed his mother effectively calm his anger and redirect his attention, such that he never completely broke down. Her discomfort at being the target of his anger and her artfulness in re-channeling it were exemplied by her response when Mark aggressively bit at her with a whale puppet. She gently redirected his attack, saying that whales ate plants rather than people. With this background, I proposed a further course of therapy with a primary goal of helping Mark express his anger. Because strong displays of anger did not come naturally for anyone in the family, with his parents assent, I was prepared to take an active role in bringing this set of feelings to the surface. The hypothesis regarding unresolved anger was conrmed in our rst follow-up session. Manifesting both age-typical boyish interests and continuing preoccupation with angry feelings, Mark immediately picked out a set of GI Joe toy gures and initiated a ght between the good guys and the bad guys. At an appropriate moment, using the transition of the ghting theme and the fact that the good guys and the bad guys were mad at each other, I directed his attention to the hospital furniture and the boy doll we had utilized in the past. I remarked that I thought the boy was mad at the doctors, and, using the doll, knocked over two doctor gures. Conrming that I was on the right track, Marks initial reaction was a big smile. He grabbed the doll and used it to aggressively knock over dolls and pieces of hospital equipment. Then, reecting his conict, he had a robot gure shoot the boy in retaliation. I persisted with the theme of anger, commenting with dramatic emotional emphasis that the boy was mad because the hospital had made his arm hurt and swell. I again used the boy doll to knock over the hospital bed and IV equipment. I then introduced the mother doll and communicated that I thought the boy was mad at the mother because she didnt take him home. Participating actively, Marks mother reminded him that he had turned his back to her following his second surgery. Playing out this scene, Mark creatively conveyed the idea of anger by covering the boy doll with a blanket so the mother doll could not see him as he turned away. He had the robot gure shoot the mother doll and knock her over, saying that the mother was dead. Immediately afterward, however, he undid this act. Lifting the mother doll up, he asked, Why would the boy be mad at the mother? She loves him. This play allowed us to discuss his conicted feelings anger at his parents for not preventing his injuries, fears of retaliation, and his
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underlying knowledge that his parents loved him and did not wish him ill. After another aggressive act with the doll, Mark became increasingly uncomfortable. Putting the hospital toys away, he declared, Im nished playing with this. He stuttered as he spoke, something his mother had not observed for many months. Mark acknowledged that he did not want the boy to be angry. When we wondered if he was scared that his mother would be mad or wouldnt love him if he got angry, he said no. Shortly after, however, he asked his mother, Will you still love me if Im mad? allowing his mother again to express her understanding and acceptance of his anger. This pattern of anger followed by anxiety was seen repeatedly over the next several sessions, although with support and interpretive work he became more comfortable with the feelings. In one session, when his mother asked him to tell me about the angry feelings they had been talking about at home, he could only acknowledge being mad at the doctors and the needles. Our observation that it was hard to be angry at his mother was met with a denial of anger, although he sought out a whale puppet and a gun which he had used in aggressive play toward his mother in earlier sessions. Once more I decided to take the initiative. Putting the mother, father and doctor dolls in the whales mouth, I observed that the whale was really mad! Mark promptly reached for the whale, asking, Can I do it? He very aggressively grabbed and squeezed the mother and then the father doll with the puppet. Then taking a toy gun, he pointed it directly at his mother and me. He was stuttering throughout this sequence. As we continued talking about how he was angry because his parents hadnt stopped the doctors from hurting him, Mark spontaneously searched for the boy doll and repeated the action of hiding the boy from the mother with the blanket that had symbolized his anger in the previous session. He then placed a cast on the boy dolls arm. This sequence of an aggressive act followed by a reference to an injury to the boy was seen a number of times, making clear the close association between his feelings of anger and his view of his medical treatments as retaliation. On each occasion we interpreted his belief that the past hurtful treatments had occurred because he had been bad (i.e. angry) and his fear that anger in the present would produce a similar punishment. Subsequent sessions saw increasingly uninhibited expressions of aggression, such as excitedly and repeatedly using a dinosaur puppet to knock the mother doll to the oor and jabbing a marker so hard the tip broke off to demonstrate how his favorite stuffed animal didnt want the doctors to poke him like this! A notable moment occurred when his mother took the whale puppet and knocked over the hospital equipment and the parent dolls as a way of expressing her understanding of his feelings. This uncharacteristically aggressive act on his mothers part initially left him at a loss but then appeared to give him pleasure and a further sense of permission. Although I did not have a sense that he completely understood what his mother and I were trying to do, Mark enthusiastically took advantage of the offered opportunities to express his aggression, even though they inevitably brought feelings of anxiety. In our modeled actions we were trying to capture not just a feeling of anger, but a whole set of confused and chaotic feelings involving rage, fright, betrayal and helplessness that had resulted from the hurtful hospital treatments. It was in order to capture this quality of feeling in the play that I modeled the exaggeratedly aggressive and chaotic crashing of the hospital toys and dolls. By facilitating a less inhibited acting out of this chaotic rage and despair, we drew much closer to the real feelings than had been the case in the previous course of therapy. Marks increased cognitive maturity also allowed us to label these feelings for the rst time as hospital feelings, in a way that Mark himself could recognize. This provided his parents with a necessary tool for making the connection between his hospital experiences and his upset feelings at home.
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The effectiveness of this therapeutic work was evidenced by an improvement in his symptoms. Within several weeks of the rst follow-up session described earlier, Mark became fully toilet trained. Able to separate out his anger at the medical treatments, he was less resistant to appropriate parental requests or restrictions. By the fourth session, temper outbursts had disappeared, even at bedtime, traditionally the most difcult time. He was also able to give up his pacier. He began to assertively resist his older sisters efforts to protect and control him, and was much more able to express his anger verbally. When he couldnt wear a shirt that he wanted, he told his mother, I dont like you. When his mother described this anecdote in our session, he turned to her affectionately and said, But I do. As he became less conicted, although still inuenced by his earlier trauma, Marks aggression in the sessions was incorporated into age-typical play with army toys or swords created out of tinker toys. During a playful sword ght with his mother he directed his thrusts specically toward her hand, touching it gingerly and then telling her she was dead. The immediate inspiration for this sword play became clear when his mother explained that he had been repeatedly watching the Star Wars lms and had told his mother that he especially liked the movie that had the part about Luke getting his hand cut off. (In the second movie in the series the heros hand is cut off in a sword ght by the chief villain, who, unbeknown to the hero, is actually his father. The hand is subsequently completely repaired.) During the period he was watching Star Wars, Mark became defensive of his arm while being bathed. When I asked if watching the movie gave him hospital feelings, he replied yes matter-of-factly, as if it were self-evident. Given the movie scenario the next question seemed an obvious one, but one I had not previously considered because I had not thought he would have had such a conceptualization at so early an age. I asked whether, with all the cuts and scratches, he had worried about his hand being cut off in the hospital. He nodded yes in a similarly matter-of-fact way. His mother was immediately reminded that after each surgery he would want his bandages off, and that once they were off he would seem relieved. Asked if he removed his bandages to see if his hand was still there, he again replied with a very matter-of-fact Yes. At an age (almost four) when mutilation fears are normally prominent, Marks heightened concerns about bodily integrity were understandable in light of his earlier trauma. More surprising, however, was the suggestion that these mutilation fears had not simply crystallized at this later developmental period, but that an integrated body concept and corresponding fear of losing a body part were present at the time of his treatments. By removing his bandages Mark was operating adaptively to reassure himself about the continued integrity of his hand. Validating this fear, his mother remembered at least two occasions when the surgeon had explained in Marks presence that he wasnt sure that the arm could be saved. Mark himself said he did not remember these discussions. One can only speculate to what extent fears were aroused by the doctors words and to what extent they were based on Marks own synthesis of what was happening to him. During the next few months, Mark continued to deal with issues of mutilation. His concerns expanded into age-typical concerns about the integrity of other parts of his body, including his genitals. On one occasion, he had a babysitter cut length-wise slits in sections of drinking straws, which he placed over the arms of his Star Wars gures. There was much talk at home about being cut open, such as asking what would happen if his head opened up and it showed your brain, and about losing appendages such as noses and ears. There was also discussion, especially in the bathroom, about how everything is attached. On one occasion he asked what would happen if his penis burst, adding, It could happen with a knife. (It is possible that he noted the swelling of his penis during
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an erection, the connection with the swelling of his arm creating a heightened castration fear.) Although initially rather serious in tone, over time these discussions became increasingly light-hearted, almost teasing, as his anxiety appeared to diminish. At this point in the therapy, Mark appeared to be doing very well. Although obviously more preoccupied about bodily integrity than many boys would be, Marks fears were being integrated adaptively within the context of his overall Oedipal development, rather than being unassimilated. Over and above the hand association, his identication with Luke Skywalker had a very typical Oedipal quality to it. He described that the reason the Star Wars movies made him happy was because Princess Leia made him (Luke) a hero. He did not appear preoccupied with his hand in day-to-day activities. Upsets around control issues were minimal and he was appropriately accepting parental guidance and limit setting. He was playing happily and co-operatively with other children at his pre-school, with no unusual behaviors noted by his teachers. His right hand had regained the dominance present prior to his injuries and he was taking on a number of activities that involved high levels of hand coordination, including piano lessons. His parents felt that he had sorted it out and mastered the difcult experience. Although a number of issues were still in process, I believed that we had effectively addressed the anger issue, that the developmental anxieties were well on their way to appropriate resolution, and that Mark and his parents would be able to deal with the ongoing issues productively. We thus agreed on termination. Although sad, Mark handled the termination quite appropriately as we reviewed his therapeutic experience. His playful request, when saying goodbye, for a bandage for a small cut on his foot recapitulated many themes from our work together. A reference to an interaction involving my giving him a Band-Aid that had occurred several times in the course of the therapy, it captured the essence of our relationship, that I was a doctor who helped him with his injuries. At the same time, it signaled his ongoing sense of vulnerability to owies, for which an appeal for help was a continuing element in the process of mastery. The experience with his arm, including the permanent reminders in the form of scarring, would undoubtedly remain with him, inuencing his sense of self and his view of the world. At the same time, I believed the trauma had been integrated signicantly and was quite hopeful that it would not produce signicant long-term developmental distortions. A telephone follow-up 16 months after termination indicated that Mark was continuing to do well. There were no signs of emotional or behavioral difculty at home and his school adjustment was excellent. In particular, his mother noted that there was no selfconsciousness or defensiveness related to the use of his hand.

Discussion
The therapeutic work with Mark illustrates several important issues relevant to work with very young children who have experienced a trauma. It is consistent with the assumption that traumatic reactions in infants and toddlers share essential features seen in older children and adults, from both phenomenological and therapeutic standpoints. In particular, the essential elements of treatment applicable to older children (Pynoos, 1990) and adults (van der Kolk, McFarlane, & van der Hart, 1996) appear to be applicable to children under four. These include: the establishment of a sense of safety, both in real life and in the therapeutic setting; reduction of the intensity of arousal and the overwhelming affects generated by the trauma; development of a coherent narrative from the often fragmented traumatic memories; psychological integration of the traumatic events and achievement of a sense of mastery over them; assistance with the various secondary effects, including developmental distortions and behavioral disturbances which have emanated from the
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original trauma; and support and guidance to the patients family in order that they may both help the patient and deal with their own reactions (Scheeringa & Gaensbauer, 2000). All of these elements were present in Marks therapy. From the standpoint of therapeutic technique, the work highlights the crucial role of therapists and caretakers in actively facilitating the internal reworking of the young childs traumatic experience. In the home setting this can take the form of storytelling, parentchild discussions about the trauma, and parental participation in therapeutic reenactment play. In therapy, the provision of structured play situations as a vehicle for developing a coherent narrative and working through the childs various traumatic feelings is extremely useful. The therapist can utilize play materials to recreate the traumatic context in sufcient detail for the child to recognize the references, and then encourage the child to play out what happens next? As children play out their memories, emotional reactions and psychological understanding, the therapist can make use of a variety of traditional play therapy techniques to facilitate the therapeutic process (Gaensbauer & Siegel, 1995). The structuring is uid in nature, taking the form of a vehicle for dialog rather then a rigid formula, and allowing exploration of every aspect of the traumatic experience so that no important areas of unresolved feeling are missed. An important caveat in regard to this approach is that it assumes that the therapist has accurate knowledge of the trauma. When such specic knowledge is not available, the therapist must proceed much more cautiously. This structuring activity on the part of therapists and parents, while associated with the risk of inappropriately leading the child, is at the same time consistent with developmental understanding of the young childs needs. Memory researchers have shown that young children are better able to convey memories if cues are provided (Fivush, 1993). Moreover, young children, as they move from pre-verbal to verbal levels of development, depend strongly on caregivers to provide psychological explanations and emotional labels for their experiences (Nelson, 1990). To be most effective, therapists and parents must not only provide opportunities for young children to express their understanding, but must draw inferences from non-verbal behavior and translate it into verbal terms. The parents storytelling at home, which was such an important element in Marks recovery and involved a great deal of explanation and elaboration of Marks experiences and feelings, epitomizes the risks and benets of this active structuring. There is the potential for overriding or distorting the childs feelings when not done empathetically. When done sensitively it creates a co-constructed narrative (Fivush & Fromhoff, 1988), a shared experience that can help restore trust and become the basis for ongoing communication about early events. Structured situations facilitating play re-enactment in action have other benets as well. For young children play re-enactments may come closer to capturing the original traumatic affects in ways that verbal labeling and interpretation cannot. This was true in Marks case, where our initial verbal support of his anger was insufcient to convince him of its acceptability and did not tap into its full intensity. The provision of cues in structured play also provides an opportunity for the child to demonstrate the extent of memory for various events in a manner that is not dependent on verbal recall. As with Mark, it has been my consistent experience that pre-verbal children, given the opportunity, can show a remarkable degree of memory for salient aspects of a traumatic experience (Gaensbauer, 1995). Mark not only retained numerous specic memories, but also appeared to have had a meaningful comprehension of the psychological concept of bodily integrity prior to 2 years of age. The rapid developmental changes occurring in the early years complicate therapeutic work in both positive and negative ways. During the second phase of therapy, when Mark
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was closer to 4 years of age, developmentally normal fears associated with age-typical Oedipal issues of gender identity and bodily integrity were intensied by his earlier traumatic experiences. However, because his fears could be framed in more comprehensible forms, such as the scenario from Star Wars, he was able to communicate his fears more clearly, including the fear of losing his hand that had been present much earlier but had not been recognized. He was also much more able to make use of interpretive insights, such as the link between his current anger and his earlier hospital feelings. Marks treatment brings into bold relief the necessity of dealing with the intense feelings of anger that are the inevitable result of a trauma. It was not always possible to differentiate the components of his angerrage at being hurt, defensive attacks driven by fear, modeling based on identication with the aggressor, self-assertion in the service of mastery, explosive discharge of overwhelming arousal, to name a few. Nonetheless, the overall support that his parents and I provided for anger expression was clearly crucial to his recovery, a nding consistent with previous reports on traumatized toddlers describing the emergence of the capacity to express anger as a critical turning point in relieving many of the childs symptoms (Drell, Gaensbauer, Siegel, & Sugar, 1995; Gaensbauer, 1994). The expression of appropriate anger toward a perpetrator, a long-standing element of therapeutic work with trauma victims, may have special importance for young children for whom temper tantrums and struggles to learn self-control are the norm. The intense anger associated with a trauma will signicantly complicate the childs normative efforts to regulate this important affect. At the same time, a trauma will predictably be experienced as a punishment for being bad. Thus, the childs often overdetermined expressions of anger can become associated with frightening images of retaliation inspired by the original trauma. This association will not only create intense internal conict about anger, but can profoundly affect parentchild disciplinary interactions. The child may react to parental discipline and punishments in light of the traumatic experience, with feelings of being attacked, angry defensive reactions and fears of retaliation complicating the childs ability to experience parental authority as supportive. Assuming adequate grounds for inferring its presence, whether the encouragement of anger in the context of specic play re-enactments of a trauma has a therapeutic effect or whether it increases internal conict and/or aggression is an important empirical question. In my experience, the support of trauma-specic anger expression occurring in the context of circumscribed episodes of trauma (as opposed to repeated abuse), although often associated with initial anxiety, has the long-term effect of validating the childs feelings and reducing the amount of anger acted out at home. Lastly, the work with Mark and his parents highlights the value of having parents participate in the therapy sessions. Parents involvement can be particularly important in restoring the mutual trust that is often lost as a result of a trauma. In the sessions his mother was able to observe how Mark continued to be affected by the trauma, communicated information regarding his behavior at home and helped me understand the signicance of his play in light of the actual events. She was also able to talk of the impact of Marks trauma on other members of the family, especially his sister, who had also experienced medical problems and had been profoundly affected by Marks plight. Because of this ongoing communication, his parents and I were able to work very closely and cooperatively to help Mark with his feelings. Marks parents were particularly sensitive and capable, able to carry out much of the therapeutic work at home. As a result, Mark did not require intensive or long-term individual therapy. With young children the effects of a trauma are not likely to be resolved denitively at any particular point in time, but will be continually reinterpreted by the child in light of subsequent developmental experience.
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The establishment of a dialog between parents and child about the trauma creates a basis for dealing with future complications as they emerge and is thus an essential therapeutic accomplishment. In summary, despite the challenges, we are at a very promising point in the treatment of post-traumatic reactions in young children. I believe that the therapeutic work with Mark exemplies how this growing knowledge can be used to alleviate the pathogenic effects of early trauma.

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