Sample Chapter from: 'Gentling: a Practical Guide to Treating PTSD in Abused Children'

5 The Stress Episode

As therapists, one of our major tools is our words. Most adults, when they witness a child who is severely upset over what appears to not want to follow a directive, will label the behavior a “tantrum”, or at best “acting out”. In most cases, this is a fairly accurate term for the behavior that the child is exhibiting.
When a stress disordered child engages in similar behaviors, the source and quality of the behaviors will be different at different times. A stress-disordered child may indeed have a tantrum or act out from time to time, but they also have a different, discrete behavior set expressing their PTSD. The more accurate and effective term for these discrete behaviors is “stress episode”.

The word “tantrum” implies that the child has control over their behavior, and that the behavior is intended to make some advantage or gain for the child. Tantrums are behavior manipulations by the child that usually only last a few minutes. Though stress episodes can be very brief (minutes), the difference between stress episodes and simple tantrums will be quite evident if the observer is careful in their observations. The telling difference between a “tantrum” and a “stress episode” is the quality, duration, intensity, frequency, and known history of trauma.

By insisting on precision in describing the upset behavior, we help the child by educating other helping adults. By consistently using the more accurate “stress episode”, we help others to fully understand the source of the behavior being seen is not simple opposition, stubbornness, manipulation, or a spoiled child. When this is accomplished, we are on the way to help teachers, parents, foster parents, and other caregivers to depersonalize the child’s reactive behaviors. After all, the child may be directing their behavior towards me, but they are really reacting to something or someone in their past.

Children’s stress episodes seem to follow a roughly four-phase process. The first phase begins with a Cue and Trigger. A cue or trigger to a stress disordered person is some internal or external reminder of their trauma. There can be literally hundreds of possible cue-triggers.

Some the victim may be aware of, while others cannot be cited with any accuracy. The younger the victim, the more invisible to the observer triggers tends to be. Sometimes, caregivers can determine specific triggers, or very close observations by a Behavior Specialist may be needed. When the triggers are discovered, they should be shared with the entire treatment team and carefully recorded.

In younger children, who cannot verbally relate their trauma in treatment, identification of cues and triggers can help the clinician gain a generalized view of and hypothesis of what the details of the trauma may have been. This information is not to be used to test the child’s memory, or to lead the child to some conclusion, but rather to help the clinician more fully understand the reactivity protocol that the child has. In turn, this helps to focus treatment and eventual work on inoculating the child to those particular cue-triggers.

Triggers can be sights, sounds, smells, tactile sensations, places, times of the day or year, or even intrusive memories and dreams. Thus, the world around the child becomes full of potential conscious and unconscious reminders: books, songs, stories, a piece of clothing, a color of paint in a room, the smell of bacon, a vocal tone….on and on it goes.

It should be noted that just because a child experiences a cue, it doesn’t mean that they will trigger. The process of the cue triggering a reaction is likely dependent upon the child’s overall level of stress. If you think of a glass, almost filled with water, there is no problem until the glass gets overfilled. Thus, it can become confusing for the clinician observing the child’s behaviors: a cue on one day may trigger a stress episode, but not trigger on another day.

Once the cue is received, and the stress reaction is triggered, the child will escalate with physical and emotional agitation. Essentially, the child’s fear reaction motivates a flight or fight reaction, often with lightening speed. Chemicals of various sorts rush into the child’s bloodstream, and the allostatic process begins, uncontrolled. Heartbeat, respiration, and blood pressure rise. Muscles tense, vision may blur and the child may become unresponsive to directives or support.

The escalation time-table may vary form child to child or from episode to episode, but most children follow a predictable, unique pattern. Once the escalation reaches certain, hard to determine point, the stress episode is almost impossible to stop. Like a runaway freight train, it will continue until the tracks run out.
It is important to understand that the increasing physical agitation at first may be undetectable to the observer. In some children, there is a “slow burn” kind of reactivity, while in others; the reaction is very explosive and instantaneous. “Slow burn” type children make the job of trying to discern cues and triggers that much more difficult for the clinician, as the first signs of a stress episode may be several minutes to hours after the cue-trigger.

The Escalation Phase may include age regressed behaviors, physical combativeness, foul or nonsensical language, flight (running away long or short distances) or hiding behaviors, oppositional expressions, flat affect, pupil dilation, radical personality change, wetting or soiling, and self harm attempts. The behaviors may reach a plateau and continue for a brief or moderately long period of time.

Fight behaviors include physical combativeness in various degrees, from aggressive, targeted attacks of individuals to a generalized physical posturing of threat. There may be present physical gestures of warding off, or defensive behaviors such as waving of the arms, covering the face, or curing up in the fetal position with occasional kicks. These often present in stark opposition to the situation at hand. In one event in my work, a simple placement of my hand on a young boy’s shoulder triggered him into a highly defensive posture, waving his hands in front of his face, as if to ward off blows to his face.

Some children may exhibit strong flight behavior during their escalation phase. Flight behaviors can take many forms: while treating a child once in a school, he ran away from me, out of the building, and all the way to his home, several blocks away. In another situation, a child consistently ran a short distance from the treatment area to a coat-room, hiding among the coats.

During a session in a foster home, I watched a little four year old boy move rapidly from frozen fear to falling asleep, standing up, while the foster parent was gently trying to correct his behavior. If I had not been there to see it, I don’t think I would have believed it. All of these behaviors qualify as flight.

Secondary sets of behaviors, closely related to “fight” behaviors are those of self-harm or disregard for personal safety during an episode. Some children will bite themselves, bang their heads, or throw themselves to the floor or into walls with apparently no discomfort or caution. The child, unable to strike out at the perpetrator, takes the rage out by fighting him or herself. This behavior also likely has to do with the tendency for numbing during both the original trauma and during stress episodes. As friend of mine, who is a victim of trauma, says: “the soldier does not pay too much attention to his wounds until he is out of the battle.”
In some cases, a child may cycle through this phase multiple times before moving on to the next phase. It often appears that the escalation process itself is a trigger for repeated escalation. In effect, the chemical “switch” that has been turned on gets stuck, producing round after round of episodes. This “training” or chaining effect can last hours, even days in some severe cases.

The third noted phase I call Emotional Release. During this time, a child may move from hostile, defensive behaviors to a deeper age regression that may include wetting or soiling him or herself, sucking their thumb, baby talk, and tears or deep weeping. The child could begin at this time to spontaneously relate traumatic memories.

It should be noted that the child may not be willing to share history at this time, and sharing should not be pushed upon the child. The movement from phase to phase is usually not clear and concise. Some children will move clearly rapidly from hostile and aggressive to vulnerable and needy. In most cases, though, there will be gradual transition form the highly agitated state to a more withdrawn, and regressed expression.
The fourth phase of the stress episode might be called Exhaustion/Return. Following the intensity of the tears or weeping, the child seems to return to normal, often very rapidly. It almost may seem like an invisible switch has been thrown: the child suddenly has a normal affect, may even be cheerful, and behaves as if nothing has even happened.

A second possible behavioral effect is that the child will become quite sleepy, and appear completely exhausted. Often, if you quiz the child at this time about what it was that upset them so, they will not be able to tell you. They are not lying; they often actually do not recall the trigger.
This may be due to the fact that a very similar dissociative process takes place during the stress episode as it did during the actual critical incident. When an individual is in a highly stressed state, they are not able to mentally record details, because they have other concerns: self-preservation. While in this dream like state, the child’s memories are severely skewed.

The child’s vulnerability to triggers and stress episodes has two important variables: how strong the child’s ego wrapping is in any particular moment, and what the level of their overall stress load is. Remember that the stress “glass” can only hold so much water. Once too much water is added, the overflow of stress signs occurs. Recognition, monitoring, and management of the child’s stress loads, capacity, and ego state become one key to treatment.

Ralph, age five, had been under my care for some twenty-two months. Ralph and his sister Matilda, age six, had come from a very abusive family situation. Their biological mother was very low functioning, was addicted, and had been in prison for prostitution. They had been routinely locked in a bedroom with a box of crackers and a bottle of water for hours on end. They had lived with their biological father and his mother for some time before coming into foster care. It was determined that both the father and grandmother had also physically abused the children, and sexual abuse by the father on Matilda was suspected.

Both children were highly reactive when they came into foster care. They triggered so often and the stress episodes were so intense, that it was difficult to discern discrete episodes or triggers. It seemed as if the children were always either on their way through a dramatic escalation, having an emotional release, or were exhausted from the entire process. Each of them could easily trigger each other. Through close observation over a long period of time, each child’s unique set of triggers and process started to be discerned.
Over the course of treatment, both children’s stress episodes decreased in length and intensity, but did still continue. One notable fact is that even over the course of the twenty-two months of treatment, ever new stress behaviors and triggers were presented. For example, Ralph accompanied his foster family to a visit to family friends. The foster father noticed that he had not seen Ralph for some few minutes, and went looking for him. The foster father found Ralph in the bathroom, standing in front of the toilet, with head, shoulders, and shirt wet. In addition, Ralph held a flat affect and had glazed eyes. It became clear that Ralph had stood in front of the toilet, and had dunked his head in the bowl.

Though Ralph had never done this behavior before in the foster home, he had in the past had very stressed behaviors while in bathrooms to bathe, or to clean up after toileting accidents. It was reasonable, in this case, to conclude that the behavior was stress reactive to some trigger Ralph had just experienced. One could also extrapolate that the behavior perhaps was a re-enactment of an abusive punishment in his past.
Wally, age eight, had been repeatedly pushed into a closet by his intoxicated father when he became angry with Wally. During one of these critical incidents, the father got a box of screws and a power screwdriver, and screwed the door shut on Wally. When his mother discovered him hours later, he had nearly pulled all of his fingernails off trying to pry and scratch his way out of the closet. In school, Wally was having difficulty in a particular classroom. He repeatedly shut down and was placed by the teacher sitting on the floor outside of the classroom.

During these times he became uncommunicative, held himself tightly, cried, and rocked back and forth, and at times clawed at the air around him. This behavior could last hours. In observing the teacher and Wally interact, it became clear that the way she corrected Wally was a trigger for his shutting down: she used a forceful, loud tone of voice when she thought Wally was becoming resistive to her directives.

The more he became “oppositional”, the more the teacher raised and firmed her voice. In turn, Wally became even more defensive. At some point, the intensity of the teacher’s voice and pressure would trigger Wally’s stress reactivity, and his body simply did what it had done during his abuse. Eventually, Wally would “come out of” his stress episode, and returned to class as if nothing had happened. The entire process would then repeat when the teacher once again perceived Wally as becoming oppositional.

A child’s stress episode is packed with behavioral information that can help in so many ways. It can help define a particular behavior set in connection with a particular incident. It can present a well defined enactment that can be used as material in treatment. It can help the clinician help others to depersonalize the child’s behaviors towards them. Lastly, it can provide a route to giving gentle empathy to the child. Those who dismiss the stress episode as simply a set of difficult behaviors to extinguish are missing out on a great therapeutic tool for healing.