Collaborative BWP Writing

Using Bibliotherapy with Traumatized Children
By Mary Lynn Crow, Ph.D.
Educator and Psychologist

Posttraumatic Stress Disorder (PTSD) in children is a severe anxiety disorder that has unfortunately been scientifically understudied regarding its clinical presentation, etiology, and treatment (Beidel & Turner, 2005, p. 308). The disorder begins with an identifiable traumatic event that includes national disasters like hurricanes, man-made disasters such as automobile accidents, and childhood physical or sexual abuse. Not everyone exposed to these traumas develops PTSD*, but those who do experience very painful symptoms. Specifically the criteria for a diagnosis of PTSD includes recurrent and intrusive recollections or dreams of the event, reliving the experience including (among young children) possibly reenacting the event, and intense distress on exposure to anything resembling or reminding them of the event. In addition children could also experience a sense of detachment, avoid activities or places that cause them to remember, become unable to remember, have difficulty sleeping and concentrating, have an exaggerated startle response or hyper vigilance, and be irritable or have anger outbursts (DSM IV, 2000). Some children regress to behaviors more typical of a younger age such as bed wetting, thumb sucking, and fear of the dark. School performance is often negatively affected. While depression is the most common comorbid condition (Beidel & Turner, 2005, p. 300), disruptive behavior disorders are not uncommon.
The research literature often describes treating such children with cognitive behavioral therapy. This involves exposure therapy to elicit memories of the event and cognitive restructuring to directly confront conflicts and maladaptive cognitive structures (Silva, 2004, p. 259). These treatments have, however, been used more with victims of child sexual abuse than with natural disasters like hurricanes. Other treatments in the literature have included group psychotherapy; family psychotherapy; individual psychotherapy; eye movement desensitization and reprocessing treatment; imaginal and in vivo exposure; relaxation training; anger management; training in coping skills;
play or art therapy; and sertraline and SSRI medications (Freemont, 2004; Chemtob, Nakashemia, & Carlson, 2002; Layne et al, 2001; Brown et al, 2004; Beidel & Turner, 2005). In general, the literature suggests the importance of focusing directly on the traumatic event and including both children and their caretakers (Friedrich 1996, in Silva, 2004, p. 266). In 1994 following Hurricane Andrew (August 1992), Annette LaGreca et al from the University of Miami created a school-based intervention manual to help children who were traumatized by that hurricane and includes activities to use in schools for different holiday seasons following the disaster as well as a Reaction Index to measure children’s thoughts and feelings about the disaster. It may be found online at www.psy.miami.edu/child/childclinical/helpingchildrencope.phtml
Bibliotherapy is another useful treatment technique. It may be defined as the use of books (biblio) that are intended to be therapeutic (therapy) for the children who read them or hear them. These stories or books describe a real-life problem or situation that is similar to the one the child has experienced and allows the child to (1) know that he or she is not alone in their feelings and problems and (2) see how another child has coped or resolved the problem.
Dr. Tom McIntyre, Professor of Special Education at the City University of New York, posits 3 stages children pass through to receive the benefits of Bibliotherapy:
Identification - the youngster identifies with a book character and events in the story, either real or fictitious. Sometimes it is best to have a character of similar age to the youngster who faces similar events. At other times, cartoon characters and stories are best.
Catharsis - the youngster becomes emotionally involved in the story and is able to release pent-up emotions under safe conditions (often through discussion or art work); and
Insight - the youngster, after catharsis (with the help of the teacher), becomes aware that his/her problems might also be addressed or solved. Possible solutions to the book character's and one's own personal problems are identified (2004).
After reading the story or book, children discuss the story, either individually or in a group setting, with particular reference as to how it is applicable to their own experiences. They can also write, draw, or even act out their feelings and reactions.
Bibliotherapy is frequently described in the professional literature, and the books
themselves are regularly available for purchase in educational and psychological catalogues. Materials are typically categorized by topics or issues and usually provide the appropriate age and reading level*.
The primary reason for using Bibliotherapy, journaling, creative writing, and drawing with children who have been traumatized by hurricanes or other disasters is that it allows these children a safe audience and outlet for them to “talk out” their feelings without judgment or pressure toward premature closure. It is even more useful because the book or story or trigger incident informs them that they are not alone in their distress and that someone else in a similar circumstance has been able to prevail/heal/survive. The role of the parent or teacher is empathic, supportive, and nonjudgmental. The use of open-ended questions allows the child to make the appropriate personal connections to their own experiences without the fear of sarcasm, platitudes, or preaching from the adult listener.
Overall, the intent is to allow the child to continue to work through his or her feelings at his or her time and through whatever medium that is most natural or comfortable to the child – typically talking, drawing, writing, or acting. Depending upon the severity of the trauma and the severity of the child’s reaction to it, the teacher or adult may be able, through the use of Bibliotherapy, to provide support to the child. If the child has been more severely affected however, this then should alert the teacher that the child needs to be referred to a mental health professional.

References
DSM IV (2000)
Beidel, D. C., & Turner, S. M. (2005). Childhood anxiety disorders. New York: Routledge.
Brown, E. J. (2003). Child physical abuse: risk for psychopathology and efficacy of interventions. Curr Psychiatry Rep, 5(2), 87-94.
Chemtob, C. M., Nakashemia, J., & Carlson, J. G. (2002). Brief treatment for elementary school children with disaster-related posttraumatic stress disorder: A field study. Journal of Clinical Psychology, 58(1), 99-112.
Freemont, W. P. (2004). Childhood reactions to terrorism-induced trauma: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 381-392.
LaGreca, A. M., Vernberg, E. M., Silverman, W. K., Vogel, A. L., & Prinstein, M. J. (2006). Helping children cope with disaster. Retrieved July 19, 2006, from http://www.psy.miami.edu/child/childclinical/helpingchildrencope.phtml
Layne, C. M., Pynoos, R. S., Saltzman, W. R., Arslanagić, B., Savjak, N., Popović, T., Duraković, E., Mušić, M., Ćampara, N., Djapo, N., & Houston, R. (2001). Trauma/grief-focused group psychotherapy: School-based postwar intervention with traumatized Bosnian adolescents. Group Dynamics: Theory, Research, and Practice, 5(4), 277-290.
McIntyre, T. (2004). Bibliotherapy. Retrieved July 12, 2006, from http://maxweber.hunter.cuny.edu/pub/eres/EDSPC715_MCINTYRE/Biblio.html
Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52-71.
Silva, R. R. (Ed.). (2004). Posttraumatic stress disorders in children and adolescents: Handbook. New York: Norton.