In previous publications (Webb, 1991, 1999, 1993, 2001), and in several chapters of this book

(Chapters 4, 10, 11, and 12), I have utilized variations of tripartite crisis assessment to
demonstrate the interactive influences among three groups of factors in evaluating the
significance of a particular crisis event or events:

1. Factors related to the individual.

2. Factors related to the crisis situation.

3. Factors in the support system.

Figure 14.1 illustrates the specific elements that must be considered in evaluating the impact of a
particular crisis situation, such as physical or sexual abuse in the family. (See Webb, 1999, for a
full discussion of this assessment.) Two forms that can be used in recording the individual and
situational components of the crisis assessment are reproduced in the Appendices. The eco-map
(see Chapters 2, 3, and 4) is useful in assessing essential information about the support system.

When a child is being evaluated for abuse, special attention should be given to the child's
history of loss, to recurring experiences of abuse, and to the possibility that the child believed
that the abusive experience endangered his or her or another family member's or a pet's life. Fear
of death or serious injury is an essential condition for the diagnosis of PTSD (see the next
section).

In addition, a child's developmental and cognitive level will determine the manner in which
the child interprets the abuse experience. For example, the preschool or early latency-age child
(up to approximately age 8) is still egocentiic in his or her thinking and may believe that he or
she is "bad" and therefore caused the abuse. Of course, a perpetrator, playing into a child's
normal narcissism, often reinforces these feelings by using guilt and secrecy tactics to keep the
child from disclosing the abuse.

THE ASSESSMENT O F THE TRAUMATIZED CHILD:

POSTTRAUMATIC STRESS DISORDER IN CHILDREN

The symptoms of PTSD (American Psychiatric Association, 2000) may develop in children who
have been exposed to a life-threatening event (such as community violence) or who have been
physically or sexually abused. It is important for child welfare workers and other social workers
to be familiar with the signs and symptoms of this condition, because it is often confused with
depression or conduct-disordered ("acting-out") behavior. Children with symptoms of PTSD
require treatment from someone who is trained both in child therapy and in trauma counseling.
Therefore, a referral to a child-trauma specialist may be appropriate once the diagnosis has been
made.
Nature of the crisis situation

Psychosocial and environmental

problems (DSM-IV-TR, Axis IV)

Single versus recurring event

Solitary versus shared experience

Presence of loss factors

Separation from family members

Death of family members

Loss of familiar environment

Loss of familiar role/status

Loss of body part or function

Physical injury/pain

Presence of violence

Witnessed and/or experienced

Element of stigma

Presence of life threat (to self/family/ others)

Individual factors

Age/innate factors

Developmental stage

Cognitive level

Moral development

Temperamental characteristics

Precrisis adjustment

Home

School
Interpersonal/peers

Medical

Coping style/ego assessment

Past experience with crisis

Global Assessment of Functioning

(DSM-IV-TR, Axis V)

Perception of crisis events (specific meaning)

Factors in the support system

Nuclear family

Extended family

School

Friends

Community

FIGURE 14.1. Interactive components of a tripartite crisis assessment. Adapted from Webb
(1999, p. 5). Copyright 1999 by The Guilford Press. Reprinted in Social Work Practice with
Children (2nd ed., 2003) by Nancy Boyd Webb . Permission to photocopy this figure is granted
to purchasers of this book for personal use only (see copyright page for details).

Components of PTSD

The foundation for PTSD was established when a person "experienced, witnessed, or was
confronted with an event or events that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others" (American Psychiatric Association, 2000, p.
467), causing the person to respond with "intense fear, helplessness, or horror" (p. 467). In
response to this traumatic event, the individual with PTSD demonstrates three different types of
behavioral reactions over the course of a month or more:

1. Reexperiencing the traumatic event. In children, the reexperiencing often occurs through
dreams that cause intense fear and helplessness that resemble the emotions associated with the
traumatic experience, even though the dreams may not reflect the exact circumstances of the
traumatic experience. In addition to or instead of dreams, children sometimes engage in
repetitive play that symbolizes the trauma.
2. Avoidance and numbing. Children may show a restriction in their ability to display positive
feelings to others, or they may deliberately avoid people, activities, or places that are associated
with the trauma.

3. Increased arousal. Children may have difficulty getting to sleep or staying asleep, may be
more irritable, and/or may have difficulty concentrating in school or while doing homework.

More details about this diagnosis are available from the American Psychiatric Association
(2000). Because the classification of PTSD originated with adult soldiers in the Vietnam War, its
application to children is based on the work of child psychiatiists (Eth & Pynoos, 1985; Terr,
1983, 1988, 1989), social workers (James, 1989; Doyle & Bauer, 1989; Webb, 1999), and child
psychologists (Gil, 1991; Fletcher, 2003).

Incredible as it may seem, only a fraction of individuals exposed to traumatic experiences

demonstrate behavioral responses indicative of PTSD. As previously discussed in Chapter 8,
McFarlane (1990) states that "even after extreme trauma, only about 40 percent of an exposed
population develop PTSD" (p. 74). According to Fletcher (2003, pp. 337-338) "most research to
date confirms the general conclusion that the diagnostic symptom clusters of DSM-IV apply to
traumatized children of all ages, from preschool to adolescence, as well as they do to traumatized
adults." However, children develop other responses to trauma as well.

Jenkins and Bell (1997, p. 17) have created a table that lists 17 traumarelated disorders other
than PTSD in children and adolescents. Some other typical responses of traumatized children, in
addition to PTSD, include aggressive or antisocial behavior (about 18% of the time) and
regressive behavior (about 13% of the time; Fletcher, 2003). Whatever the particular responses,
w e must recognize the serious detrimental effects of traumatic experiences on children's normal
developmental course, whether or not they develop full-blown PTSD.

The Distinction between Victimization and Traumatization

It is important to distinguish between victimization and traumatization. Gil (1991) points out that
a person may be victimized without being traumatized. That is, the person who experiences
trauma is a victim during the traumatic event, but not every experience of being victimized
qualifies as a traumatic experience in terms of causing responses of intense fear, helplessness, or
horror. Thus, not all children who witnessed the New York World Trade Center bombing or who
have been sexually abused react with the intense fear that results in PTSD. Furthermore, resilient
children may not exhibit any overt signs of disturbed behavior. However, the fact that children
do not respond immediately and conspicuously to the experience of abuse and trauma does not
mean that it has had no effect on them.

On an emotional level, child witnesses to family and community violence may experience a
range of feelings, from fear to helplessness to violent revenge fantasies. It can be very helpful to
them to draw and/or verbalize their wishes for revenge in a debriefing interview that "partially
corrects the passive helplessness of the witness role" (Pynoos & Eth, 1986, p. 316).

Another typical reaction of children who witness family and community violence is
posttraumatic guilt, connected to the children's imagined failure to intervene and prevent the
violence. This response needs to be challenged with gentleness and reality testing, in terms of a
child's size and dependent role in a family, in comparison with the size and controlling role of
adults. Bevin (1999), in a case demonstration, illustrates how to permit a boy's wish for revenge
on the man who raped his mother, while realistically questioning the possibility of a 9-year-old's
being physically able to defend his mother against the attack of an adult male. Similar responses
of gentle disbelief by a social worker can reduce a child's feelings of responsibility about
somehow contributing to or failing to prevent a parent's death by not intervening in a situation of
community violence, such as a drive-by shooting or a terrorist bombing.

A particularly terrifying experience for a child witness is the death of a sibling, especially
when it occurs through the neglect or intent of a parent in a family that routinely uses battering
and other forms of violence to settle marital disputes and to "discipline" children. The case of the
siblings of Elisa Izquierdo (Bruni, 1995) illustrates the horror of alleged maternal homicide in
families in which the deceased child was both physically and sexually abused by the parents.

Bereavement after homicide routinely generates a pathological response in survivors that is

related to the nature of the death, which involves a combination of violence, violation, and
volition, according to Rando (1993, citing Rynearson, 1987). The response of a child to a
homicidal death in the family or community may be intensified by the "degree of identification
with the victim" (Rando, 1993, p. 538). Thus the closer in age and gender the child is to the
victim, the more threatening the death. Steele (1998), in a video involving three siblings of a
murdered 16-year-old girl, used a drawing method to help each child deal with the traumatic
memories by having them draw their mental picture of how their sister's body looked after she
was dead. The children appeared to experience relief after completing the drawing, as this
allowed them to mourn and to share their internalized trauma picture with the social worker who
supported and validated their feelings.

SELECTED HELPING METHODS

Most children in therapy would benefit from activities and exercises that help them learn to
identify their own feelings. However, children with chronic abuse histories and associated
attachment problems may be very deficient in this area and require a great deal of help in
understanding their own feeling responses, as well as the reactions of other people. As previously
discussed, these children are confused about the appropriate expression of feelings. The drawing
exercises described here help children identify their own feelings and understand more fully how
emotions lead to behaviors. The exercises can be used in individual or group therapy.

Drawing Exercises to Identify Feelings

 Because many abused children come from family backgrounds in which love and aggression
were confused, and because this may create uncertainty about how to relate to peers and adults, it
is often helpful to establish a therapy goal of naming and talking about a range of different
feelings, such as "sad," "angry," "happy," "guilty," and "proud." The task of the social worker
and others involved with such children is to help them "own" their feeling reactions to the events
in their present lives, with the expectation that this will facilitate the gradual sorting out of the
confused feelings related to their past experiences of abuse.