What color is your hurt? TRAUMA INTERVENTION PROGRAM
William Steele, PsyD, MSW Cindy Ciocco, MPA
What Color Is Your Hurt? Manual
A Structured Sensory Intervention Program for Traumatized Preschoolers
A program of TLC’s Structured Sensory Interventions
for Traumatized Children, Adolescents and Parents (SITCAP®)
Cindy Ciocco, Caelan Kuban and William Steele
Revised 2010 ISBN 1-931310-19-X ©1998 TLC
The National Institute for Trauma and Loss in Children 13725 Starr Commonwealth Road, Albion, MI 49224 Phone 877.306.5256 www.starr.org/tlc TLC@starrtraining.org NOTICE TO NON-PROFESSIONALS
The information contained in this book is not intended as a substitute for consultation with health-care professionals.
What Color Is Your Hurt? Trauma Intervention Program Manual
Publisher’s Note
We are very excited to release this new and completely rewritten comprehensive trauma
intervention program based upon the TLC SITCAP® model. This 2010 edited version has
retained the name of the previous version, however it contains 5 additional sessions and
ALL NEW sensory-based activities and worksheets to use with traumatized preschool
aged children.
The new What Color Is Your Hurt? Program highlights include:
n Fifteen sessions that focus on all of the themes of trauma including: worry, hurt,
fear, anger, guilt and moving the child from victim to survivor. Each theme is sup-
ported by several sensory-based activities.
n How and why to incorporate Sand Tray into your practice with traumatized children.
n Discussion of trauma-like symptoms and reactions that are often mistaken for
other disorders such as depression and attention-deficit hyperactivity disorder.
n Spanish translations of parent intake forms.
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What Color Is Your Hurt? Trauma Intervention Program Manual
Dedication This book is dedicated to my wonderful husband, Tom, and my two endearing children,
Marina and Tommy who fill my life with laughter and love.
It is also dedicated to the countless professionals that are committed to working with
young, traumatized children, and who diligently implement TLC’s Structured Sensory In-
terventions for Traumatized Children, Adolescents and Parents (SITCAP®). Thank you for
taking the time and for having the courage to make a difference in the lives of these chil-
dren.
Special Thanks To William Steele, PsyD, Founder of TLC and Caelan Kuban, LMSW, CTC-S, Director, from the
National Institute of Trauma and Loss in Children for allowing me the opportunity and
privilege of taking on this amazing project. I would like to thank my editor, and life line,
Deva Ludwig that brought this program to fruition. I would also like to thank Dr. Kather-
ine Leslie who first introduced me to TLC and the many wonderful programs that have
made a tremendous impact on the work that I do with young children. Finally, Dr. Cathy A. Malchiodi, whose work and books have truly been a great inspiration.
©TLC Revised 2010
What Color Is Your Hurt? Trauma Intervention Program Manual
Cindy Ciocco Cindy is a TLC certified Trauma Consultant-Supervisor and has over 19
years of experience working with preschool aged children in the public
and private sector. She holds a Master’s Degree in Educational Leader-
ship along with N.J. State Principal Certification. She has earned a Bachelor’s Degree in Pre-
School through Grade Eight Early Childhood/Elementary Education with a minor in Psychology.
She has additional backgrounds in Special Education and Early Childhood Curriculum. Her experi-
ence includes positions such as Director of Early Childhood for Rutgers University, Camden Cam-
pus, Master Teacher and Director of Schools. In addition she served as an adjunct professor at a
local Community College and has earned TLC’s National Trauma Consultant of the Year Award for
2008. She currently works as a Behavior/Trauma Specialist in a public school setting and owns a
private Child Care Center for young children.
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What Color Is Your Hurt? Trauma Intervention Program Manual
Table of Contents 1
Overview: About this Program
47
Session 1: This Is Me
53 57 61 67 71 75 79 83 89 91
1 Worksheet 1.2
Session 2: Making Us a Witness
1 Worksheets 2.2, 2.3, 2.4
Session 3: Family and Home
1 Worksheets 3.1, 3.2
Session 4: Identify Feelings
1 Worksheets 4.1, 4.2, 4.3, 4.4 Session 5: Where it Hurts
1 Worksheets 5.1a & b, 5.2 a-d Session 6: Worry
1 Worksheets 6.1, 6.2 a & b and 6.3 a-e Session 7: Anger
1 Worksheets 7.2 and 7.3 Session 8: Sand Tray
1 Worksheet
Session 9: Sense of Safety
1 Worksheets 9.1 and 9.3 Session 10: Relaxation
1 Worksheet 10.1
Session 11: Favorite Things
1 Worksheets 11.1 and 11.2 ŠTLC Revised 2010
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95
99 101 105 109
Session 12: Feelings and Emotions
1 Worksheets 12.1, 12.2 and 12.3 Session 13: Survivor Thinking
1 Worksheet 13.1
Session 14: I Am a Survivor
1
Worksheets 14.2 a & b
Session 15: This Is Me NOW!
1 Worksheets 15.1 a & b, 15.3 and 15.4 References
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What Color Is Your Hurt? Trauma Intervention Program Manual
OVERVIEW About This Program
What is trauma? What does trauma look like? How do we help traumatized young children find relief from their trauma? In this manual, we are going to look at how trauma discloses itself in young children and
ways to help them overcome their trauma. Specific sensory-based activities will be pro-
vided which address the most common trauma reactions seen in young children. What
this program will do is help you, the specialist, identify trauma- specific reactions in pre-
school aged children. It will also provide individual and group activities to help them find
relief from their terror, and those reactions which can hinder their learning, cognitive,
physical, social and emotional development.
Children express what they experience through all kinds of challenging behaviors and
emotions. Hyperactivity, aggressive behavior, severe temper tantrums, withdrawal, de-
pression, sensory integration problems, low self-esteem and insecure attachment behav-
ior are just a few ways young children let us know something isn’t quite right.
Recognizing and treating such behaviors and issues can be difficult and sometimes easy
to mistake for something else. Many times young children can receive diagnoses such as
Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), Hyper-
sensitive Regulatory Disorder, Separation Anxiety Disorder, Oppositional Defiant Disor-
der (ODD) and even Bi-polar Disorder when they are in fact traumatized children that are mis-diagnosed.
The goal of this book is to enhance your ability to effectively:
n Identify those children who have been traumatized by violent or non-violent incidents
n Identify specific trauma reactions being experienced and engage trauma-specific ©TLC Revised 2010
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What Color Is Your Hurt? Trauma Intervention Program Manual
activities to assist preschool aged children overcome the terror of their trauma
and prevent the kinds of trauma induced learning, emotional and behavioral
problems which are debilitating when left unattended.
The Need According to Child Maltreatment 2008, the most recent report of data from the National
Child Abuse and Neglect Data System, approximately 772,000 children were found to be
victims of abuse or neglect in 2008. Millions of children from across the world are ex-
posed to traumatic experiences every day. Up to five million children in the United States
alone are traumatized each year. (Landy, 2008). These experiences may be chronic (in-
cest or war time) or time limited (natural disaster, such as Hurricane Katrina or the Haiti
Earthquake). These experiences all have an impact on young children’s development
making the millions of children growing up with domestic or community violence at
great risk for profound emotional, behavioral, physiological, cognitive and social prob-
lems. (Schwarz & Perry, 1994). Trauma is an experience, one that can alter a young
child’s life and mind forever.
In the lives of most infants and young children adults oftentimes minimize or misinter-
pret the impact that trauma can have on their children. However, during the critical ages
of zero to six is when the mind is most vulnerable to the effects of trauma. In the last ten
years alone our society has spent billions of dollars studying and treating adult trauma
victims. In comparison, few resources have been dedicated on treating the traumatized
young child (Perry 1994a, 1995). The developing child is a miracle of complexity. For centuries, it has been known in order to express full human potential is in relation to the
balance of developmental opportunities and challenges that young children face. (Perry & Hambrick, 2008). In extreme cases of challenges such as maltreatment and trauma
young children can express a range of serious emotional, behavioral, cognitive and physiological problems. Millions of children remained scarred by childhood trauma expressing only a fraction of their full potential. (Perry & Hambrick, 2008).
Neuropsychiatrists (Perry, 2000; Schore, 2002; Stein & Kendell, 2004; Perry & Szalavitz,
2006) assert that traumatic, insecure attachment histories such as those experienced in
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What Color Is Your Hurt? Trauma Intervention Program Manual
maltreated children profoundly impact brain development. Evidence shows that early re-
lational trauma (abuse, neglect) is expressed predominately in right-brain deficits. The
right brain region is responsible for processing social-emotional information (Klorer,
2008). The functions of the left-brain are damaged as a result of the arousal and surge in
stress-hormones when a child is traumatized. Marked left-brain deficits in language pro-
cessing, memory and executive functioning were also noted that suggest that the stress
of early deprivation of a secure attachment figure is involved in long-term cognitive and
behavioral deficits (Chugani et al., 2002).
Young children must receive care that is developmentally appropriate. An example of
this would look like intervention that is provided in a safe environment that includes
positive nurturing interactions with trustworthy adults and caretakers. Intervention that
is age appropriate and that includes drawing, sensory-based activities and story telling
activities provided by a positive, nurturing adult is critical. Therefore, based on the most
current research on young children, the neuro-science of the brain and the impact and
effects of trauma on preschool aged children the What Color is Your Hurt Trauma Inter-
vention Program has been updated and revised for this purpose. Traumatized young children need:
n To know they are not alone with the their terror and grief n To hear the stories and see the reactions of peers also traumatized by either a violent or non-violent yet traumatic incident
n The opportunity to express their terror, fear, worry and sadness n A vehicle which allows them to express these feelings safely in a format which
comes far more naturally and innately than questions like “How do you feel?” or “How mad are you about what happened?”
n To be educated as to normalcy of their reactions as well as to reactions they might yet experience as a result of their trauma
n The opportunity to re-attach emotionally to the adult world which they often perceive to have betrayed them by letting this happen
n To have the time and trauma-specific attention needed to help them find relief from their terror and develop a sense of power over the terror
n To replace the terror and the sadness with happy memories
What Color is Your Hurt? was designed to help accomplish these tasks. ©TLC Revised 2010
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What Color Is Your Hurt? Trauma Intervention Program Manual
Traumatizing Incidents While supposedly watching his 10 month
old brother, 5 year old Ken got engaged in
playing in a different room. The baby
crawled near the fire with his ‘blankie’,
caught on fire, and in his panic fell into the
fireplace. Ken was oblivious to what hap-
pened. When his mother came home from
the market, she discovered her baby’s death, and to cover her own culpability at leaving
a five year old to take care of an infant, turned ferociously on Ken. At the age of three Joey had already been
abandoned by his birth mother, had a series
of step-mom’s, and had a father who was
emotionally unavailable to him at the time. In addition, at the age of three he saw his
pet get tragically killed in an automobile ac-
cident. Despite the trauma that this young
boy incurred, interestingly enough the one
that affected him the most was the witnessing of the death of his pet. It was so sudden
and unexpected that Joey felt powerless and thus, he began to feel quite guilty about
not being able to save him. The emotional toll that this placed on him was so powerful
that he began to think that something this bad and horrible could happen to other peo-
ple in his family that he felt close to and so, he began to “act out” with aggressive like
behaviors to help alleviate some of the guilt that he was experiencing. He also had difficulty sleeping and had a lot of nightmares and asked questions like, “if only’ and “what if” and ultimately blamed himself for this tragedy.
Mary was four years old when her mother began to
think something wasn’t quite right with her daughter.
Her mother said Mary had been having nightmares, bit-
ing her nails, exhibiting nervous and hyperactive behav-
ior at home and was no longer talking to her. Mary 4
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What Color Is Your Hurt? Trauma Intervention Program Manual
apparently was afraid of a “Big Bear,” and she was afraid to go to sleep. Mary’s mother
stated that she and Mary’s father recently got divorced and Mary no longer had any con-
tact with her dad. This was sudden and extremely traumatic for Mary.
By the age of five Jenny had witnessed chronic do-
mestic violence and physical abuse between her par-
ents. She had also been homeless for a period of her
life and spent countless nights in shelters and in
homes of people whom she did not even know. Her
neighborhood was unsafe and when she came to
school she was often times “hypervigilant”, always frightened and on some days appeared to “zone
out” completely even after various attempts made
on her teachers part. The trauma of Jenny’s early experiences was evident in her behav-
ior. She responded to others’ attempts at interaction by using foul language and at times
refusing to participate in various activities. Jenny’s behavior was so problematic that her
mother would shuffle her around from one family member to another so that she didn’t
have to deal with it on a daily basis. This inconsistency of care caused Jenny to display a
lot of dissociative like behaviors in and out of school. Timothy was 5 years old when Hurricane Fran hit his
town. He is now 6 1/2 years old. According to his
mother, Timothy becomes easily frustrated, pes-
simistic, irritable, sleeps on the floor, and wets his
bed. Apparently, Timothy was afraid that the hurri-
cane could come back again at any time. His sleeping on the floor was his way of being ready to take cover
at any moment. It was reported that Timothy is easily startled, and reexperiences different parts of the hurricane in the form of intrusive thoughts, nightmares and images.
Some of the kinds of violent and non-violent incidents which can leave preschool children traumatized include:
n Murder n Suicide
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What Color Is Your Hurt? Trauma Intervention Program Manual
n Physical/sexual abuse n Divorce/separation n Domestic violence n Car accidents n House fires n Drowning n Critical injuries n Death of a pet n Terminal illness n Hurricanes/Floods n House Foreclosures n Surgery n Foster care placement n Homelessness n Environmental tragedies n Moving/ job promotions
What is Trauma? By definition, trauma is a sudden, unexpected, dramatic, forceful or violent event which
involves emotional shock and mental confusion. It sometimes involves bodily harm such
as physical/sexual abuse or domestic violence. Trauma also refers to the overwhelming,
uncontrollable experiences that psychologically impact victims by creating feelings of
helplessness, vulnerability, loss of safety and loss of control (James, 1989). Up to five million children in the United States are traumatized each year (Landy, 2008). In the United
States child abuse is the leading cause of death in young children while ninety percent of inner city children in the U.S. witness a murder by the time they are eighteen years
(Landy, 2008). In addition, many millions of young children across the world are exposed to traumatic experiences.
Traumatic incidents may be violent or non-violent. Children are exposed to trauma, by the following four means:
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What Color Is Your Hurt? Trauma Intervention Program Manual
n As surviving victims (physical/sexual abuse, car fatalities, house fires, etc.) n As witnesses to violent or non-violent incidents n By being related to the victim as a family member, friend, peer, or simply because they live in the same community or go to the same school where a trauma oc-
curred
n By simply listening to the details of the traumatic incident It is important to realize that children can be witnesses via television such as in the Haiti
Earthquake, Nashville, Tennessee Flooding, Hurricanes Katrina and Rita. They may be re-
lated to the victim(s) because of similarities in age, race, culture or environment.
For example, some pre-school aged children who were affected by the trauma of Hurri-
cane Katrina did not experience it firsthand. They were either witnesses through their
parents or the media. Some of these children knew friends whose loved ones have been
displaced, lost or killed. Not all children traumatized knew anyone related to them or to
the hurricane or its aftermath. These children had been terrorized as witnesses via tele-
vision to the Hurricane because they were similar in age and environment to the chil-
dren who were killed in the hurricane, they became hyper-vigilant- a trauma-specific
reaction. Young children, in particular, do not understand these reactions. (The National
Organization for Victim Assistance, 2010)
Traumatic experiences shake the foundations of our beliefs about safety, and shatter our
assumptions of trust. Traumatic events provoke reactions that feel strange and “crazy”.
Even though these reactions are disturbing, they are typical and expectable, even in
young children. They are normal responses to abnormal events. These symptoms may appear soon after the traumatic experience, or they may be delayed for months or
years. Traumatic events can produce intrusive thoughts that may affect both daily activities and dreaming. They may grow worse as they are triggered repeatedly by conditions
similar to the original trauma (i.e. a young child that is a victim of physical abuse). Multiple or chronic experiences are likely to become more difficult to overcome than most
single incidents. If untreated, the child’s response can have devastating long-term consequences. This can range from being more sensitive and hyper-vigilant to similar wounds in the future to long-term learning and behavioral problems, depression, anxiety and mood disorders.
©TLC Revised 2010
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What Color Is Your Hurt? Trauma Intervention Program Manual
Although many people generally think of trauma as violence induced, it is critical to un-
derstand that non-violent incidents such as drowning, hurricanes, house fires, car fatali-
ties, floods, critical injuries, surgeries, divorce, homelessness, and foster care placement
also induce trauma. In addition, things one might suspect as having a positive impact on
a young child such as moving (from a high crime location to a “better” neighborhood), or
the parent or guardian receiving a job promotion (with added weekly hours and/or
changes in shift) may actually have a negative, traumatic impact on a young child. When
a young child moves, no matter what the circumstance, they can lose their “sense of
self” and “sense of safety”, even if the parent regards the neighborhood as “unsafe”.
When a parent receives a job promotion they may be less available to the child, emo-
tionally and physically, and the child may become confused, worried and feel aban-
doned, no matter how much more the job promotion pays or what material benefits the
child receives. Also critical to helping the traumatized child is the use of trauma-specific
interventions. In order to do this, one must first know how trauma differs from grief.
How is Trauma Different than Grief? Trauma reactions are different from grief reactions. Trauma reactions overpower grief
reactions. Check the following Grief vs Trauma chart to help you determine if the child
you are working with is experiencing trauma or grief.
This is a self-portrait of a normal 4 year old girl.
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This is a self-portrait of a 4 year old who has experienced a trauma.
What Color Is Your Hurt? Trauma Intervention Program Manual
GRIEF
vs
Generalized reaction is SADNESS
TRAUMA Generalized reaction is TERROR
Grief reactions stand alone
Trauma reactions generally include
Grief reactions are generally known to the
Trauma reactions, especially in children,
public and the professional
In grief, most can generally talk about
what happened
In grief, pain is the acknowledgement
of the loss
In grief, anger is generally non-destructive
and non-assaultive
grief reactions
are largely unknown to the public and
often professionals
In trauma, most do not want to talk
about what happened
In trauma, pain triggers tremendous
terror and an overwhelming sense of
powerlessness and loss of safety
In trauma, anger often becomes
assaultive even after non-violent
trauma
In grief, guilt says “I wish I
Trauma guilt says, “It was my fault.
would/would not have...”
Grief generally does not attack nor
I could have prevented it.”
Trauma generally attacks, distorts and
“disfigure” our self image
“disfigures” our self image
deceased
potential victim
In grief, dreams tend to be of the Grief generally does not involve trauma
reactions like flashbacks, startle reactions, hypervigilance, numbing, etc.
In trauma, dreams are about self as Trauma involves grief reactions in
addition to the trauma-specific reactions we have discussed
From What Parents Need to Know, by William Steele, TLC, 1997
©TLC Revised 2010
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What Does Trauma Look Like? Posttraumatic Stress Disorder (PTSD) is the main disorder that arises from traumatic ex-
periences. PTSD can occur at any age, including childhood. Children exposed to trauma
may also develop depressive disorders, anxiety disorders, dissociative disorders, phobias
and behavioral disorders. Posttraumatic features and trauma reactions speciďŹ c to pre-
school age children include the following categories and examples. The three categories of traumatic experiences are: 1. Reexperiencing
Ways a young child reexperiences a trauma:
n Intrusive or involuntary thoughts or images (thinking about the trauma when you don’t mean to or when you are trying hard not to think about it or visualizing im-
ages of the trauma)
n Recurring nightmares or bad dreams about the trauma (also, sleep talking or frightening dreams without recognizable trauma references or content)
n Reenactments of the traumatic event through repetitive play, intense psychological reactions triggered by exposure to events or objects that resemble some as-
pect of the trauma
n Physical reactions when exposed to events that are similar to or symbolize the traumatic event (headaches, stomach aches, sweating, vomiting)
2. Avoidance
Ways a young child tries to avoid a trauma memory when triggered by people, places, or conditions similar to the traumatic event:
n Cognitive avoidance - unwilling to talk about the trauma even when asked n Emotional avoidance - through dissociative reaction n Physical avoidance - physically avoids actual reminders or displaces fear into
other situations such as not wanting to go to school. Phobic or obsessive compulsive behavior can, in fact, be an attempt to avoid/control trauma memories.
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3. Hyperarousal
Ways a child experiences increased arousal after a trauma:
n Sleep disturbance (difficulty falling or staying asleep, sleeping on the floor, sleep walking)
n Irritability or outbursts of anger (throwing things, hitting people or things, yelling or shouting at family members or friends, impulsive-like fighting)
n Difficulty concentrating (easily distracted, has trouble listening to others or following directions, problems with retention, memory, learning)
n Hypervigilance or overprotectiveness towards oneself and others (extremely
concerned with one’s safety and the safety of others, or anxious in crowds, seek-
ing out “safe spots”, sleeping on the floor)
n Exaggerated startle response (jumping or otherwise overreacting to noises or the sudden appearance of a person)
n Attachment reactions (wanting to sleep with a parent, pet, etc., not wanting to be alone; often referred to as clinging)
The following behaviors in young children indicate the likelihood that the child has been
traumatized. The DSM-IV-TR is currently being revised to include trauma reactions com-
monly seen in young children.
n n n n n n n n n n n n n n
Fails to finish things he/she starts
Difficulties concentrating, paying attention Inattentive, easily distracted
Daydreams or gets lost in his/her thoughts Impulsive or acts without thinking Difficulty following directions
Fails to carry out assigned tasks
Afraid to or not wanting to sleep alone
Regression in learned behaviors (bed wetting, thumb sucking, etc.) Seems sad, withdrawn or detached
Is easily startled or fearful without good reason, jumpy Seems worried
Clings to adults/does not want to be alone, acts whiny, has temper tantrums Cries without good reason
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What Color Is Your Hurt? Trauma Intervention Program Manual
Information adapted from the National Organization for Victim Assistance, Washington,
D.C., February, 1987.
Adapted from the book Trauma in the Lives of Children, by Kendall Johnson, PhD, 1989. Additional information adapted from the Pediatric Emotional Distress Scale, by Saylor,
Swenson & Stokes, 1994.
Special Considerations We have a professional responsibility to understand not only how trauma can seriously
retard a young child’s learning and developmental growth, emotional and social devel-
opment, but to also be able to identify those children who have been exposed to trauma
so we can appropriately and effectively help them overcome their terror.
The fact that young children can experience posttraumatic stress and all of its debilitat-
ing symptoms remains as relatively new information for many. It was not until 1994 that the psychiatric world formally acknowledged that children as young as the age of two
can experience trauma. In fact, children that are old enough to laugh can also be old
enough to be traumatized.
As we learn more about the face of trauma, we have discovered that trauma can easily
go undetected because its reactions are similar to depressive behaviors, attention
deficit, oppositional defiant, regulatory sensory issues, and mood and attachment disorders. Now through the various TLC Structured Sensory Interventions for Traumatized
Children, Adolescents and Parents (SITCAP®), there are thousands of people who are
specifically trained in recognizing these signs and symptoms. They can assist young children in overcoming their fears and provide them with a safe outlet to express them-
selves at their own time and pace. These signs and symptoms should not be ignored, as they are the only child’s way of indicating that something is wrong and they need help.
The earlier the child receives this structured sensory intervention the better the chance for success the child will have in school and throughout his life.
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