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Case Study - Page 2

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Because Ella was more watchful than most ADHD children, even though her eye contact was intermittent, I began wondering about the source of her vigilance. I noticed times when she’d tune out briefly (stare off and make no comment) or quickly change the subject. As I watched for a pattern to these episodes, it became clear that the tuning out increased when we said anything about her biological father, who was divorced from her mother and in jail. The subject of her father seemed to increase Ella’s level of physiological and emotional arousal. I suspected that Ella’s inattention and high arousal might actually be dissociation or avoidance related to her father.

When I finished my interview with the mother, I turned to Ella to ask why she thought she was coming in to see me.

Without hesitation, she said, “I’m bad at school and I don’t like my teacher. I won’t sleep in my own bed, and mommy says I have a bad attitude. My daddy is in jail for hurting mommy and me.” She paused and added, “Dr. Pat, my daddy lied to me. He took me away, and he wouldn’t let me go home to my mommy.”

Aha! There it was—a clear clue as to why Ella felt so powerless and needed to take charge. Something traumatic must have happened to her and her mother at the hands of her father. I knew I needed to explore what had happened, see how it was affecting the relationship between Ella and her mother, and help them process the trauma. For this to happen, both Ella and her mother would need to be involved in treatment. Her mother’s anxiety was palpable and contagious for Ella. What Ella needed was a strong, take-charge, nurturing protector. Instead, Ella seemed to sense her mother’s victim stance and acted out to communicate her fear and vulnerability. When behaving provocatively and making demands, Ella was pushing and challenging her mother to take charge.

At this point, I realized that Ella was a brave little girl who was just as worried about her mother as her mother was about her. By volunteering information about her father’s mistreatment of her and her mother, she showed she was purposely recruiting me as a partner to fix her and her mother’s shared problems. She displayed many traits of insecurely attached children whose parents are fearful, anxious, or depressed. Such parents are inconsistent in caregiving, and their children have to take care of themselves or make increasingly high demands on parents to notice them.

It turned out that Ella had been abducted by her father, and when her mother had gone to retrieve her they’d both been physically assaulted. When her father was subsequently put in jail, Ella’s symptoms emerged. Ella’s mother began showing symptoms of post-traumatic stress as well: she was irritable and short with Ella, lacked patience, and found herself being critical and negative instead of comforting or nurturing. She didn’t understand that Ella was responding out of fear, not defiance. Since Ella’s mother could see that she was sometimes contributing to her daughter’s problems, she agreed to participate in treatment.

For Ella’s part, like most traumatized children, she had trouble talking about her feelings and reactions to what had happened with her father. She said it was her fault that her mother had gotten hurt, and she feared her father would come back and hurt her again. At the same time, she wanted to be the one who’d magically change her father into a “nice daddy” and be worthy of his love.

Young children almost always have ambivalent feelings toward an abusive or neglectful parent. Early on, Ella’s play indicated that she experienced loss, love, sadness, anger, and fear toward her father. She used the sand tray to enact power and control scenes where frightened victims fought back against a “mean bad guy.” The dollhouse became an orphanage for babies and children whose “mean daddies” were in jail, and they cried for them at night. I wanted to help Ella express her feelings and understand that she wasn’t responsible for her father’s behavior. I planned therapy activities that would allow Ella to “feel felt” by her mother and allow her mother to show empathy and protectiveness. She also needed to trust that her mother could handle whatever might happen and keep her safe. As her mother became less anxious and worried, I believed that many of Ella’s symptoms would spontaneously dissipate.

To this end, I taught them relaxation and breathing practices early on to help them lower their anxious arousal. We ended most sessions with our eyes closed, listening to a Tibetan bell bowl and holding stones to warm them. With practice, Ella became able to remain still and quiet, letting her fear and anger move into the stones. Body–mind approaches are helpful in trauma work, since calming the body and its arousal is essential for self-regulation. Together, she and her mother practiced breathing at bedtime, and their anxiety subsided. Also, claiming it chased away her nightmares and allowed her to sleep in her own bed, Ella slept with her stone at night.

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