Crystal Collins was nine, and her dad would buy her nice clothes. Crystal’s mother had given her up at birth, and her dad had raised her. He’d always seemed to take good care of her, tending toward overprotectiveness, picking her up from school and being selective about her playmates.

One day Crystal walked into her school and disclosed a secret. Some months later, in a journal entry titled “Introduction of My Life’s Story,” she wrote: “When I was 6 years old, I was sexually abused by my dad. Then I couldn’t take it any more. He would do bad things to me…. He hurt me…. I thought I did something wrong.”

Crystal (her family has requested that her real name not be used) revealed that the abuse had begun one day in her dad’s car; she ran, he followed and returned her to the car, then took her to a McDonald’s. Crystal said the abuse continued regularly for the next four years. There was physical evidence of sexual abuse. Her father had often choked her, she said. In kindergarten, around the time the abuse began, a social worker had described Crystal as being like a “caged animal,” fidgety and distracted.

Savannah Akin never spoke of anything amiss at her daycare center, but she’d been having nightmares and was often irritable. Savannah had attended the center, run by a husband and wife, relatives of a neighbor, for three years, since she was fifteen months old. Several months after Savannah left to start attending preschool at her church, her mom, Ashley, received a call from a detective. The center had been shut down, he told her, because of allegations of sexual abuse.

Bit by bit, Savannah began to speak of abuse. “We just tried to be supportive of her, but not ask a lot of questions, just wait for her to talk with us when she was ready,” says her mom.

After six months of therapy, Fiona Gardner seemed to be coping reasonably well with the death of her brother. But in time, it was discovered that she was struggling with the truth about that tragedy, a truth yet unrevealed—much too much for a four-year-old to process.

Kids are generally pretty resilient; their bones heal more quickly than those of an adult, and slights are more readily forgotten. But few have all the tools to effectively respond to deeply traumatic experiences. As a result, such experiences in childhood often lead to prolonged, and debilitating, mental-health issues. Research conducted by the Centers for Disease Control and Prevention has shown that adults reporting one or more adverse childhood experiences are considerably more susceptible to health and social problems, including alcoholism, domestic violence, depression, and pulmonary disease.

 “Most kid mental-health problems are a function of their environment, something bad they’ve experienced or something bad they were exposed to,” says Dana Hagele, codirector, with Duke professor Lisa Amaya-Jackson, of the North Carolina Child Treatment Program, which is working to help children overcome trauma. Many children have trauma in their lives, and most will get past it quickly. But some experience trauma at a level that’s considered traumatic stress, overwhelming their ability to cope, says Hagele, a child-abuse pediatrician and assistant professor of social medicine and pediatrics at the University of North Carolina at Chapel Hill.

“Technically, it has a mental-health diagnosis—like post-traumatic stress disorder, adjustment disorder, separation- anxiety disorder—it technically has a definition that we work with,” Hagele says. “But really what we’re doing is treating symptoms, whether they’re behavioral or emotional,” to help them feel better and cope more effectively.

“It was little bits and pieces every time, just chipping away,chipping away.”

Hagele and Amaya-Jackson are leading a novel child-trauma treatment program now being taught to community health-service providers across North Carolina. The North Carolina Child Treatment Program—a partnership among the National Center for Child Traumatic Stress, the UNC School of Medicine, and the Center for Child and Family Health, which is a collaboration of Duke, North Carolina Central University, UNC, and Child and Parent Support Services— employs an approach called trauma-focused cognitive behavioral therapy, or TF-CBT. The therapy is an evidence-based treatment that addresses behavioral and emotional difficulties in children following serious trauma or loss.



Moments of joy: Therapy has helped Savannah Akin to let go of her anger and confusion. [Chris Hildreth]


Kids in TF-CBT are taught deep-breathing and guided-imagery exercises, and they learn about healthy sexuality and when and how to ask for help. The treatment makes frequent use of stories, drawings, exercises, and games to help therapists interact with children in crisis. During one session with Savannah Akin, for example, Morganton, North Carolina, therapist Melinda Clontz gave the six-year-old a dream catcher—a webbed hoop adorned with feathers—and asked her if she had a specific nightmare.

Savannah did; it involved a wolf and a dog (there were dogs at her daycare center) coming to hurt her mother. Clontz worked with her to rewrite the dream, with words and drawings. Savannah shows her dream catcher and describes how it works: “At night, if you have bad dreams, [the dream catcher] hangs up above your wall. And then [the dream] comes out of your head, and then it comes in here, and then it catches it so it won’t go back in your head.” Every night, Savannah’s dad, Scott, would read to Savannah the dream she had rewritten—in which the dog and wolf now dress in a cat suit and a clown suit, and a truck with a sign that reads “Happy birthday wofe dog!!” carries the wolf away—and now it no longer troubles her sleep.

Savannah hasn’t yet completed her sessions with Clontz, but, incrementally, she’s made great strides in addressing her fears. More than 600 children in North Carolina have now completed the program, and the results are striking. At the beginning and conclusion of the sessions, kids are given standardized tests that address their behavioral and emotional functioning. Ninety percent of the children in the program start out showing partial or full post-traumatic stress disorder, says Hagele. “What the research shows is that more than 80 percent of the kids will be fine after the treatment, and our program is higher than 90 percent,” she says. “Ninety percent of the kids will drop below the threshold where we consider them to not have a problem anymore.”

The therapy has been tested and shown to work for ages three to nineteen. Clients have included children who have experienced sexual abuse, medical trauma, domestic violence, and traumatic grief, including some who have witnessed horrible deaths. To be considered evidence- based, a treatment must be proven effective by multiple research studies and through clinical evidence. TF-CBT was given the highest level of empirical sup- port in the U.S. Department of Justice’s Child Physical and Sexual Abuse: Guide- lines for Treatment report.

It’s a short-term course of treatment and as such is relatively inexpensive. The current Medicaid rate is less than $2,000 per child for completion. “We can train people to do it systematically and then expect them to do it systematically,” Hagele says.

The core of the treatment is the development of a “trauma narrative,” through words or drawings or both, which children present at the end of the sessions to their parents or guardians. “Interestingly, when you talk to a kid who has been sexually abused or is telling someone for the first time, our assumption would be that [the abuse] is the worst thing in their lives, or the thing that’s giving them their symptoms,” Hagele says.

Steady progress: Scott Akin says his daughter shared her anxieties in bits and pieces. [Chris Hildreth]

“What I’ve learned about trauma,” she says, “is that you can’t make assumptions and rank somebody else’s experience.” The proximate issue “might be the ongoing domestic violence in that house, or it might be that the only resource in that crazy environment was a grandmother who just died.” Finding the key to the gateway is the therapist’s task; the narrative then turns the key.

 In the case of Fiona Gardner, that key was unlocking a deeply held secret.

When Fiona was four, she witnessed her brother, Malachi, five, drown in their grandmother’s backyard swimming pool.

At first, Fiona experienced grief and some guilt about having argued with Malachi shortly before he died, but no major behavioral problems. She met with Jean Huryn, a psychologist in New Bern, North Carolina, for six months, and then stopped, seemingly doing well. But when her father went away for four months of military training, she began to have intense outbursts, sometimes in public, and couldn’t be calmed.

In Fiona’s sessions with Huryn, she had drawn a series of frames of the events of the day Malachi died—a long scroll, unfurling her memories. In it, she depicted her brother as a leaf. As she continued to describe the moments illustrated in her scroll, it emerged that Fiona was struggling with a more pro- found guilt—that maybe she’d done something wrong that had led to her brother’s death.

“That hadn’t even crossed our minds,” Huryn says. The account that had been given was that Malachi had wandered out to the pool, unnoticed, on his own. As Fiona continued to open up, her mother, Deb, detected significant discrepancies between what Fiona was saying and the original account. In fact, Fiona’s grandmother had left the children alone in the pool. Fiona had warned her brother not to go into the deep end, but had been helpless to do more.

“In the process of telling the story, you’re asking them to describe the emotions,” Huryn says, and to let all the secrets out. With Fiona, there still was that secret. “I think what she was doing was knowing that Grandma doesn’t want Mom to know, so I can’t let Mom know.” Confusion was stacked upon guilt; in time, it tumbled. Her parents then resumed her sessions with Huryn.

Now seven and in first grade, Fiona re- members snippets of her visits with Huryn—blowing soap bubbles, the bigger the better, because it means you’re breathing slowly; throwing a big squishy ball back and forth; breathing deeply while thinking of floating on clouds above. She remembers that it was fun, that she played. “It has to be fun for the child,” Huryn says. “Otherwise, you’re making trauma on trauma.”

Fiona had drawn a series of frames of the events of the day Malachi died—a long scroll, unfurling her memories.

[Chris Hildreth]

The active participation of a parent or guardian in TF-CBT treatment is also essential. “If the child does treatment alone, they may reduce their trauma symptoms, but it will likely not have as much of a reduction in depressive symptoms and their sense of the shame,” says Clontz, who’s led five children through completion of the program. She encourages parents to work rwith their child on the same exercises that she conducts in her office. Clontz has seen parents grow through the experience. Give the parent some direction, she says, “and the child will follow.”

Huryn agrees. At the end of a session she explains to the parent, “This is what we did; this is the coping mechanism you need to learn.” Confidentiality, though, is also critical. “Until we get to the final session, they may not have talked with their parent about what they’re telling me.” She thus must first get permission from the child to talk with the parents about what’s been discussed.

“A lot of parents come to us feeling like failures, like they missed the signs or some- how are responsible for their child’s trauma or suffering,” says Ashley Fiore of Morgan- ton. Fiore received funding from The Duke Endowment to develop the Southmountain Center of Excellence in Evidence-Based Treatment in Morganton, and she has helped spread TF-CBT to five counties in western North Carolina. It’s important, Fiore says, to give parents the skills to help their child heal, to be a catalyst in their child’s return to a healthy life. “I love the parallel process that happens between the therapist and the caregiver,” she says. “We’re using the same skills with the parent that we want them to use with their children, and this is what changes behavior.”

“We’re making parents and children experts on trauma,” she continues, “which means giving parents and children the courage to face the trauma—to remember the experience but be freed from the emotional pain associated with it so they can label what happened to them as unacceptable and move on with their lives.”

Family unity:Fiona with her parents and younger brother, Jobin.

Ashley and Scott Akin wondered if they should have known that something was wrong in Savannah’s life. “She had a lot of anger issues and a lot of insecurities and fear,” Ashley says. Savannah had trouble sleeping, often waking with nightmares. She was afraid to walk alone down the hall to the bathroom. Being first-time parents, “we didn’t know if that just might be a stage.”

“When she started talking,” Ashley says, “it seemed she was glad to get it out.” “It was little bits and pieces every time,” Scott says, “just chipping away,chipping away.”

“It’s definitely working for her, for whatever reason,” he says of Savannah’s sessions with Clontz. “Her demeanor, her behavior, her fears, her anger—everything is just significantly better.”

Dearly Departed: Fiona in her bedroom with a photo of her brother, Malachi, on the ledge above.

Savannah still has some trouble sleeping, still has days in which she’s scared and upset; just a couple of weeks ago she was going through a “weird stage,” her mother says. But her breathing exercises have helped. She’s now in kindergarten. And the Akins now have a dog, Savannah having over- come what was once a deep fear of them. This past Christmas, Fiona Gardner was both a gray mouse and a white rabbit in the Nutcracker. A year or so after Malachi drowned, she asked to take swimming les- sons. She was afraid that if she couldn’t swim, she too would drown, and her mom and dad would be left with no kids. “That was her protection of us,” Deb Gardner says. She now has a younger brother, Jobin.

Fourteen (“and a half,” she adds) now, and in the eighth grade, Crystal Collins dreams of attending Johnson & Wales University in Charlotte and becoming a chef. She’s living with her great aunt, who’s been her rock, committed to Crystal’s treatment. She’s playing clarinet in the school band.

For a while, after she’d been removed from her father’s house, Crystal imagined that the mom she’d never met would soon come for her. Huryn explained to her that families come in a number of forms, and that in many ways she’s a lucky young woman. Her life is defined by many things; each day she rewrites her story.

“Terrible things can happen to kids, and it doesn’t have to be who they are, or it can give them strengths,” Dana Hagele says. “What we call that in our model is ‘normalizing’ these experiences. It doesn’t mean it was good to be sexually abused.

But lots of people are sexually abused, and it’s not shameful any more than asthma or a car crash or anything else is. It’s just, ‘I was sexually abused.’ That’s how we approach it.” A trauma narrative is an encapsulation of a child’s experience, “and it’s just a good way to learn…. A trauma narrative can get to the heart of it.” 

In her narrative, Crystal wrote about the decision to speak up: “So I told a counselor—I was tired of it! Then the counselor took me to his office. I forgot what he said, and he called Social Services. I was feeling happy because my father would no longer rape me.”

“I didn’t know if it was wrong, and I didn’t know if he did,” she says today of her confusion then. “I thought, ‘What did I do?’ I thought it was my fault. I was nervous.” She’s now learned: “You can’t be afraid to tell.”

“I’m writing a book now, like Maya Angelou,” Crystal says. “I read I Know Why the Caged Bird Sings. That inspired me.”

Her journal entry closes: “I was happy that I told. I was relieved. And you, too, can tell other people.” 


Sisk is a North Carolina-based writer and editor.

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