Paula and Ben Sajdak felt more and more helpless as they watched their 3-year-old foster son Liam, full of anger and frustration, hit himself in the head and throw his toys across the room. Their concern grew to fear as he turned his aggressive behavior toward them and their 2-year-old son, Dax.
“We realized pretty quickly that we needed help,” said Paula. Through Children’s Hospital of Wisconsin Community Services, the Milwaukee couple enrolled in Parent Child Interaction Therapy (PCIT), a specialized treatment that helps children and parents build secure relationships and establish safe, consistent behavioral routines.
Behaviors like Liam’s are not unusual for children who have experienced trauma, according to Children’s Hospital of Wisconsin therapist Penny Dixon, who worked with the family. Prior to being placed with the Sajdaks, Liam had lived with his mother who struggled with addiction. He had also experienced unstable housing, and had lived in many homes in just a couple of years.
These events are examples of adverse childhood experiences, known as ACEs. The more ACEs a child or adult has experienced, the more negative physical and psychological effects they may develop, according to a trove of recent research that documents the effects of traumatic stress on kids’ developing brains and bodies.
“When kids don’t have their needs met, they have a difficult time feeling safe and secure,” said Penny. “Liam had been through so much, and he didn’t know who to trust or how to cope with his feelings.”
Troubles like Liam’s are just one example of the kind of trauma that affects kids’ development. Twenty years ago, a groundbreaking study by the Center for Disease Control and Kaiser Permanente introduced the concept of Adverse Childhood Experiences (ACEs) — events that include witnessing violence in the home, or losing a parent to divorce, death or incarceration.
But these weren’t “other people’s problems.” The data showed people across the country, regardless of social or economic status, experienced ACEs — with 64 percent of the population reporting at least one ACE. More disturbing was the strong correlation between multiple ACEs and chronic, lifelong physical and mental challenges. People who experience four or more ACEs have a greatly increased risk of chronic health problems, including heart disease, cancer, adult-onset diabetes, alcoholism and suicide. The lifespan of people with six or more ACEs is shortened by 20 years.
Without early support or invention to promote resilience in the face of early adversity, little Liam could have been headed towards these chronic health and psychological challenges.
The good news is, resilience is a skill that can be learned. When kids can establish trusting relationships with caregivers to buffer them during stressful events, the brain begins to heal, changing pathways from “fight or flight” responses to more positive ways of managing and coping with stress.
Resilience — a person’s ability to adapt to and carry on after stress — is enhanced by “protective factors” that shield the developing body and brain from harm. And the most important factor is a stable, nurturing relationship with at least one caring adult, which helps kids maintain their equilibrium when faced with stressful situations.
Children’s Hospital of Wisconsin has been on the forefront of issues around trauma and resilience through initiatives like providing trauma-informed care in emergency rooms, and helping establish Sojourner Family Peace Center, a place where Milwaukee families who’ve experienced domestic violence go to find safety and healing. Two Children’s Hospital of Wisconsin doctors serve on the steering committee of Wisconsin First Lady Tonette Walker’s Fostering Futures, a coalition working to change the way children who’ve experienced trauma are recognized and treated statewide.
But Children’s Hospital of Wisconsin is also developing research-based solutions to directly serve families and children in the community who have experienced adversity. In 2016, Children’s Hospital of Wisconsin established the Institute for Child and Family Well-Being in partnership with University of Wisconsin-Milwaukee. “We’re focused on bringing brain science to bear on some of the most difficult social issues facing our communities by developing solutions to help the more than 30 percent of Milwaukee kids who have two or more ACEs,” said Gabriel McGaughey, the institute’s co-director.
Through a recent three-year grant from the Alliance for Strong Families and Communities, the Institute for Child and Family Well-Being implemented innovative treatment models, like Parent Child Interaction Therapy and Trauma-Focused Cognitive Behavioral Therapy, that result in measurable changes in how a parent and child interact. “That’s the key, since we know that a strong parent-child relationship is the ultimate protective factor in helping kids stay resilient,” said Gabriel.
For families like the Sajdaks, it has made all the difference.
Parent Child Interaction Therapy consists of two phases: child-directed interaction and parent-directed interaction. During the initial therapy sessions, the child leads the play while the parent participates, praising and affirming the child throughout. The therapist observes from behind a one-way mirror or from a distance in the room, giving the parent continual feedback and direction through an earpiece.
The Sadjak’s first session was brief. “Liam was so overwhelmed, he just pushed all the toys off the table. Then he flipped the table over,” said Paula.
Gradually, through intensive coaching from Penny, Paula and Ben were able to connect with Liam, following his lead and giving him constant positive feedback. “We would get down on his level and encourage and praise everything he was doing.
“By the end of the session, Ben and I would both be exhausted,” said Paula. “But it was also wonderful, because we could be 100 percent present with Liam, which was what he needed.”
The second phase of therapy is the parent-led portion. During play, Paula and Ben would give Liam a directive, gently but firmly, establishing a consequence if he chose not to comply. This portion of the therapy helps establish boundaries to keep kids feeling safe. “Liam learned that there were limits, and also that we would still love and care for him no matter what.”
Equally importantly, Liam will soon begin attending interactive therapy with his birth mother, as part of the effort to reunite the family.
Shawna Cravillion, a therapist at Children’s Hospital of Wisconsin, sees the effects of trauma on the teens she serves through Children’s Hospital of Wisconsin Community Services programs.
When she first met 16-year-old Christina (to protect her privacy, this is not her real name), the teen was in foster care, reeling from the effects of physical abuse from her father. Christina had been removed from of a couple of foster placements already, and placement with her grandmother was now in jeopardy because of her difficult behaviors. “Christina was one step away from being put in a group home,” said Shawna.
Like many kids who have experienced trauma, Christina’s oppositional behaviors were putting her at risk. Although 13 years older than Liam, the trauma in Christina’s life put her in a constant state of “fight or flight.” “Without help processing and recovering from trauma, kids naturally protect themselves by being hypervigilant — which looks like aggression — or by just checking out. The kids who check out are sometimes even harder to spot and harder to reach.”
The result is many kids who are incorrectly labeled with disorders ranging from ADHD to oppositional-defiant disorder. “The root of their issues is actually trauma,” said Shawna.
Shawna worked with Christina using Trauma Focused Cognitive Behavioral Therapy (TF-CBT). This short-term therapy model helps teens reframe their experience of trauma, and develop emotion regulation skills like mindfulness and planning for future triggers. “For the first time, Christina could take control of what happened to her, she could tell own her story which helped take away the shame of being abused and replace it with a feeling of agency.”
TF-CBT also includes the caregiver, and by working with Christina and her grandmother, Shawna helped Christina improve patterns of communication that had emerged from her traumatic response. Ultimately, Christina’s grandmother became her legal guardian, giving the teen her first ever stable home.
The initial results from Children’s Hospital of Wisconsin’s TF-CBT program are powerful. All of the teens treated experienced a measurable reduction in post-traumatic stress behaviors. Other positive outcomes include more stability in their foster placements, improved academic performance and the ability to hold a job.
Far from being isolated incidents, trauma often spans generations. In the past, parents of kids entering the child welfare system were rarely questioned about their own trauma backgrounds. “Instead, we waited until things got bad and kids needed removal,” said Gabriel McGaughey.
A recent study showed that 87 percent of parents whose children were being removed actually welcomed questions about their own trauma backgrounds. Parents who themselves experienced trauma may be negatively triggered by their own children’s reactions to stress. Interventions like PCIT and TF-CBT aim to break this pattern by engaging parents and children together to create stronger, more stable relationships.
Samantha Wilson, PhD, is a staff psychologist at Children’s Hospital of Wisconsin International Adoption Program. In her work with families who adopt domestically, out of foster care or internationally, she considers her role to be helping parents see kids differently, with more compassion for their lived experiences.
“For me, success is helping parents know what a child needs to feel safe,” she said. She tells the story of a family that adopted a child who had experienced physical abuse as a toddler. “On the surface, this child approached the world with anger, irritability and opposition. Previous experiences had taught this child that to be vulnerable with an adult was to be hurt.”
Through trauma-informed therapy with the adoptive mother and child, Dr. Wilson helped the mother understand the world from the child’s lens and give voice to the fear that was at the root of many negative behaviors. This understanding led to many more healing moments between the parent and child outside of therapy.
“One day, the mom redirected the child’s aggressive behavior towards a family role-play. Together, the family pretended that a large stuffed animal was the child’s birth mother. The child and mom together expressed feelings of hurt, anger and sadness. That moment allowed the child to feel safe with the adoptive mother in a new way and led to more positive changes in the parent-child relationship. My favorite part was that it was a therapeutic moment that the family created in their home, because Mom was able to honor the child’s earliest experiences,” said Dr. Wilson.
Dr. Wilson also supports teachers and other caregivers, encouraging them to ask “What does this child need to feel safe with me?” and to see negative behaviors as problems in self-regulation. “This changes the adults’ approach, making it more likely that they can ensure a sense of safety for the child.”
The whole approach shifts how adults often perceive children with difficult behaviors. Instead of asking “What’s wrong with you?” adults can ask “What has happened to you?” and work to support the child’s need for safety and connection.
“The client in my therapy sessions is the relationship — not just the parent or the child,” said Dr. Wilson. “It’s the strong relationship that helps regulate a child’s stress response.”
In the past, success in the world of foster care was measured in numbers — by how many children exited the system or found placement homes. “Now we know that measuring the actual changes in the parent/child functioning is critical,” said Gabriel. It’s also much harder.
Like any 3-year-old, Liam still struggles with his emotions sometimes. But through the family’s experience with therapy, he is now thriving in preschool and at home — and will soon be reunified with his birth mother who has worked hard to strengthen her relationship with Liam. Paula and Ben will remain in Liam’s life in some way. “We’re so grateful we could give Liam what he needed,” said Paula.
In a world where children live in poverty, experience domestic abuse and witness community violence, trauma isn’t going away anytime soon. The Institute for Child and Family Well-Being promotes empirically-supported therapeutic models, and continues to advocate for improved schools, housing and community services that can bolster resiliency and reduce instances of early adversity.
But on a smaller scale, behind closed doors at therapy sessions and in imperfect but loving homes, Children’s Hospital of Wisconsin is also supporting kids like Liam and Christina, breaking the cycle of trauma and helping build strong relationships in a step towards healing.
Update: After this article was published, Liam and his birth mother successfully completed Parent Child Interaction Therapy, and they have now been reunited for more than two years. The family is doing great. Liam’s mom and his former foster parents are grateful for the support they received from their therapists at Children’s Hospital of Wisconsin, which led to the ultimate goal of foster care –– Liam’s healthy reunification with his family.
Protecting foster children and their families is important to us, and Children's Hospital of Wisconsin is committed to respecting the privacy of all our patients and families. Written consent was obtained by Children's Hospital of Wisconsin from all family members involved in this story.