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Psychotherapeutic Treatment of Traumatized

Infants and Toddlers: A Case Report

THEODORE JOHN GAENSB AUER

Private Practitioner, Denver, USA

A B S T R AC T
The treatment of children traumatized under the age of 3 years has presented
particular challenges. The cognitive immaturity, lack of verbal fluency and uncertain
memory capacities of very young children have made it difficult to know how trau-
matic events are represented internally and how their effects may be alleviated.
Addressing these difficulties, this article describes the psychotherapeutic treatment
of a 3-year-old boy traumatized at 22 months of age by a medical illness and its
associated treatments. The goals of the therapy were to relieve symptoms and help
the child integrate the traumatic experience, while promoting the parents’ crucial
role in the child’s recovery. The case material illustrates the usefulness of active
structuring of the child’s play as a vehicle for understanding the child’s experience
of a trauma. It also documents the child’s impressive memory for the medical events
and his comprehension of their implications, as well as the influence of the rapid
developmental changes occurring in early childhood on the processing of the
trauma. Lastly, the case highlights the disruptive impact of traumatically induced
anger on children’s development and the importance of facilitating its appropriate
expression so that a traumatic experience can be resolved fully.

K E Y WO R D S
developmental effects of trauma; early memory; infants and toddlers; psychotherapy;
trauma

children traumatized in the pre-verbal period presents special

T H E T R E AT M E N T O F
challenges. Besides the inability to express reactions in words, significant difficulties
presented by very young trauma victims include the absence of reliable methods for

T H E O D O R E J . G A E N S B A U E R , M D , is in private practice in Denver, Colorado, and is an

Associate Clinical Professor in the Department of Psychiatry at the University of Colorado
Health Sciences Center. He has had long-standing research and clinical interests in under-
standing adaptive and maladaptive emotional regulation in infancy and the impact of trau-
matic experience on early development.

Clinical Child Psychology and Psychiatry 1359–1045 (200007)5:3 Copyright © 2000

SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 5(3): 373–385; 013052

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accessing their inner world, their overall cognitive immaturity and their inability to
participate purposefully in a therapeutic process. Further complicating matters are the
rapid developmental changes occurring during the first years of life. These changes not
only alter the child’s inner representations of a trauma over time, but also determine the
types of therapeutic intervention likely to be helpful at any given age period.
Despite these challenges, there is reason for optimism regarding our ability to provide
effective help. A growing clinical literature (Scheeringa & Gaensbauer, 2000), recent
systematic studies on post-traumatic reactions in infants and toddlers (Scheeringa,
Zeanah, Drell, & Larrieu, 1995), and emerging understanding of early memory and
cognitive processing capabilities (Bauer, Hertsgaard, & Dow, 1994; McDonough &
Mandler, 1994; Meltzoff, 1995) are providing a basis for the advancement of knowledge
in this area. Building on these recent developments, this article describes therapeutic
work with a boy who was traumatized by a medical illness and its associated treatments
prior to the onset of verbal fluency. From the standpoint of therapeutic technique the
case illustrates the usefulness of active structuring of the child’s play as an avenue for
understanding the child’s experience of a trauma. In keeping with traditional post-
traumatic treatments, the goal of the therapy was to facilitate the child’s internal rework-
ing of the traumatic experience, while incorporating the child’s parents into the
therapeutic process in ways that promoted their essential role in the child’s recovery. The
clinical material documents the young child’s abilities to remember traumatic events and
to understand their implications. It also illustrates the influence that developmental
changes have on both the therapeutic processing of an early trauma and the emergence
of new meaning and conflicts, as the trauma is reinterpreted in the light of subsequent
developmental stages. Lastly, the case highlights the disruptive impact of traumatically
induced anger on young children’s development and the importance of facilitating the
appropriate expression of this anger in order that a traumatic experience can be resolved
fully.

Case report
Background
Mark’s parents consulted me when he was 35 months of age because of difficulties related
to a series of medical treatments that had occurred 13 months earlier. At 22 months he
had been hospitalized for a cellulitis under his eye that required intravenous medication.
Because of heavy bandaging, a severe infiltration at the intravenous site on the back of
his right hand went undetected despite his prolonged fussing. By the time it was dis-
covered, his arm had puffed out like a balloon up to his shoulder and collarbone. The
spaces between his fingers were obliterated and in many areas the skin had split
completely. A series of emergency procedures followed. Multiple punctures of the skin
were made to measure the fluid pressure, followed by surgery under general anesthesia.
Two 3-inch-long incisions extending deep into the muscle compartments were made on
each side of his forearm, extending to the back of his hand and his palm, and left open
for drainage. Two days later the incisions were closed surgically. His mother recalled that
when he was returned to his room after the second surgery he turned his back on her.
After discharge from the hospital Mark was followed with daily outpatient visits for
cleansing of the inflamed areas and dressing changes. Owing to short-term sensory nerve
damage from the original swelling, he experienced little pain and participated happily in
the bathing activities. One week later two follow-up outpatient surgeries were carried
out under general anesthesia: surgical debridement of the necrosed tissue on the back of
his hand and a skin graft. He was very defensive about any manipulation of his arm. He

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became quite withdrawn following the debridement, and showed great distress when he
was taken from his parents to the operating theatre for the skin graft and when the
bandage covering the skin graft site was pulled off his thigh a week later. Following these
procedures he wore a half cast for a month and bandages for the next several months.
During the recovery period he repeatedly attempted to remove his bandages, requiring
his parents to place a sock over his hand. The arm eventually healed with good muscle
control and no long-term sensory loss, but with a thick 11/2 inch2 scar covering the back
of his hand and two very visible scars on his forearm.

Symptomatology
When he returned home, Mark’s overall mood was significantly dampened and he
showed obvious signs of anxiety and developmental regression. He was fussy, wanted to
be held, and sharply increased the use of his pacifier. His general activity decreased and
his walking became somewhat unsteady. At the time of the surgeries his language
consisted of individual words, but no sentences. For several months there was no increase
in language usage. By the time I met him, however, his language had progressed expo-
nentially, such that his sentence usage was in advance of his peers, although accompa-
nied by an intermittent stutter that was particularly evident under stress. On the positive
side, the surgical procedures were bracketed around the Christmas holidays and he was
able to enjoy the festivities and respond to the attention of visiting relatives, evidencing
his fundamentally solid emotional development. He also slept well, without distressed
awakenings.
Beginning within a month of his surgeries and continuing intermittently up to the time
of our first meeting, he engaged in post-traumatic play. Most striking to his parents were
two occasions when he peeled the skin off a hot dog and placed it over the site of his
skin graft. He put napkins around his head and pillows over his face or over his mother’s
face, pretending to be the doctor, or rubbed his mother’s arm, saying ‘I’m fixing [it]’. His
stuffed animals were subjected to a number of medical procedures. Throughout his
recovery Mark remained preoccupied with his arm, paying close attention to his wounds
and spontaneously showing them to other people. Even after it healed, he hesitated to
use it. Whereas previously he had been right-handed, at the time of our meeting he used
his left hand predominantly and his right hand only for support.
Perhaps the most prominent after-effect of the traumatic experience was an increased
vulnerability to stress and difficulty in modulating his emotions, particularly anxiety and
aggression. Prior to the surgery he had been relatively compliant, with infrequent and
mild shows of temper. Subsequently, he showed a strong need to control his environment.
He became bossy and demanding, prone to temper tantrums that included hitting and
kicking his mother and older sister when he did not get his way. After losing his temper
he would become very anxious and need reassurance, despite his parents’ calm handling
of his angry outbursts. The traumatic experience became intertwined with developmental
issues of anger control, parental discipline and retaliatory fears, contributing to subjec-
tive confusion about how his injuries had occurred. In the month prior to our first meeting,
following a doctor’s visit Mark had become very defiant, to the point of hitting his mother
during a diaper change. Following this angry outburst, as she was putting him down for a
nap, he pointed to his ‘scratches’ and said: ‘You did that to me’.
Notwithstanding his lack of language at the time of the trauma and his subjective
confusion about the origins of his injuries, Mark evidenced an impressive memory for
specific events. For example, a year after his hospitalization he came across a toy that a
nurse had given him to distract him during his outpatient hand bathing. He spon-
taneously asked the name of ‘that woman who washed my hand’ and remembered that

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the toy was ‘her toy’. He then asked: ‘What was the yellow stuff?’ His mother realized
that he was referring to the yellow gauze that was used for his bandages. To his parents’
knowledge, none of this had been discussed with him subsequent to the actual
experience.

Developmental history
Mark was the second child in a close and warm family, with a sister 12 years older. He
had shown normal motor, behavioral, social and cognitive development prior to his
medical problems at 22 months, and had experienced no unusual stresses. He was the
product of a normal pregnancy and was delivered without complications by elective
C-section. His parents described him as a happy and sociable child, gentle and calm in
disposition. His mother remained at home with him during his first three years, utilizing
occasional day care. At day care he enjoyed playing with the other children and had not
shown any notable separation reactions. Developmental milestones were within the
normal range, although at the slow end of the scale; he walked at 18 months. He was not
toilet trained at the time of his surgeries and had not made any progress subsequently.

Treatment
Therapeutic work with Mark entailed two separate courses of treatment. Initial treat-
ment involved 12 sessions extending over three months. A follow-up course of treatment
began five months after the first termination and consisted of nine additional sessions
extending over a seven-month period. Early goals were to assess the affects associated
with the various medical procedures, identify areas of emotional conflict, and help him
develop a clearer understanding of the circumstances of his injuries. An immediate task
was to facilitate recognition that the playroom setting could provide an opportunity to
communicate his feelings about his treatments.
At our first meeting, Mark was quiet but very good-natured, with a nice smile and a
confident manner. His interaction with his mother was affectionate and mutually respon-
sive. As he started to explore the playroom, his mother described a recent visit to the
surgeon. When I asked Mark why he had seen the doctor, he immediately pointed to his
hand and, stuttering, said that the doctor ‘made a bad cut on my arm.’ He compliantly
showed me his hand, pointing specifically to the area between his thumb and first finger,
and said it ‘was broken’. His mother noted that this had been one of the worst areas of
inflammation. When I asked if it hurt, Mark said, ‘Yes’. Asked if he felt angry, he replied,
‘No’. He nodded when I asked him if he had felt sad. Holding a Barbie doll, he then said,
‘This Mommy was angry’. The comment was an accurate observation. His mother was
indeed mad at the hospital because of what happened. In addition, however, it seemed
a projection of his own anger and a reflection of underlying anxiety about his mother
being mad at him.
To make our discussion of the injuries more vivid, I drew a picture of a boy in a hospi-
tal bed with intravenous tubing in his arm, picturing, as he had described the situation,
the boy with a sad face and his mother with an angry face. I then outlined a figure with
a swollen arm and asked him to show me where his ‘cuts’ were. With the marker he
pointed to areas of the drawing accurately centering on the injury sites on his arm and
hand, and then excitedly began scribbling all over the arm. He then wanted to turn the
page over to demonstrate the ‘cuts’ on the other side of his arm. After I drew a new
figure, he again made specific marks on the forearm and in the areas between the fingers.
He also scribbled over his feet, which reminded his mother that he had had IVs on his
feet as well. In order to complete the scene, I suggested we draw a picture of the doctor.
Mark wanted to draw the doctor himself. Instead of a figure he drew two long red lines.

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Long lines were a recurrent drawing theme throughout the therapy, clearly referencing
his surgical incisions. Toward the end of the session, he found a toy lion and used it to
attack his mother in a playful but aggressive way.
At the end of this first session, given that Mark remembered a number of specific
details but was confused as to exactly how and why his injuries had come about, I
suggested to his mother that she tell him the ‘story’ about what had happened to him. I
hoped that this would help him develop a coherent and accurate narrative and enable
his parents to empathize with his emotional experience. It would also give them the
opportunity to describe their own reactions and allow Mark to appreciate that they were
not angry with him but were similarly sad and distressed. At naptime, his mother told
him about ‘the little boy who went to the hospital’. Mark was immediately and intensely
engaged. For the next three weeks he asked her to tell the story at every naptime and
bedtime.
In our second session, as his mother described the storytelling I brought out a box of
hospital toys. Very curious about the toys, Mark pulled out a boy doll. I made a refer-
ence to the boy being like Mark and said the boy had to go to the hospital. Taking a red
marker, I asked Mark where we should draw marks to indicate his ‘owies’. He immedi-
ately pointed to the doll’s arm, but interestingly, also pointed to the area around the
doll’s eye. His mother observed that his eye had been purple and swollen shut when he
entered the hospital. As Mark played with the hospital furniture, I asked his mother to
tell the ‘story’. As she did so, I engaged him in playing it out with the dolls and hospital
equipment. Initially intrigued but hesitant, he acknowledged that the play made him
think about his arm and made him scared.
Over the next several sessions, utilizing drawing material and the hospital toys, Mark
focused on several difficult aspects of his medical experience. For example, in the next
session he drew several lines across the page that he indicated were ‘scratches’. He then
drew a series of splotches on the page, which he described as ‘pokes’. He spontaneously
asked his mother to tell the ‘story’, and especially to ‘tell about the needles!’ As she
began, he completely blanketed the body of a boy that we had previously drawn with
forceful ‘pokes’. When I drew a picture of a doctor poking the little boy with a needle,
in order to highlight the actual event, he practically pounded on the page with the
marker. To address his helplessness and promote a feeling of mastery, as well as to vali-
date his anger and wishes to resist, I encouraged the image of the boy to say ‘No!’ to the
poking. Mark immediately yelled a forceful, resonating ‘No!’ Evidencing his conflicted
feelings about anger and strong identification with helping adults, he then provided a
rationale for the poking, saying that the doctors were giving the boy medicine.
A particularly difficult experience was identified as we played out the series of surg-
eries using toy operating room equipment. As his mother described Mark being taken
from his parents’ arms to surgery by the nurse, his play became disorganized, reflecting
feelings of confusion and abandonment. He repeatedly moved the parent dolls away and
then brought them back, saying ‘go away’ in what appeared to be an enactment of the
nurse sending his parents away but also an expression of his own anger. Another facet
of the hospital play was Mark’s dislike of bandages, consistent with his behavior at the
time of his surgeries. The first time I tried to enlist him in ‘bandaging’ the boy doll’s arm
with tissue and tape, he emphatically said ‘No’, reached over and took the bandage off.
This resistance to bandaging was repeated whenever we got to this point in the treat-
ment re-enactments. Mark could not explain his dislike of bandages, and it was not until
much later that the meaning of this behavior became clear.
Over the course of the initial sessions, Mark’s engagement in the play re-enactments
and storytelling began to mobilize his internalized feelings. After the second session, his

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parents saw a significant upsurge in distress and symptoms. Immediately after the
session, he woke up from his nap upset, although was unable to say why. He began to
show symptoms that had been seen in the immediate post-treatment period, including
clinginess, fragility of mood, and increased upsets when he did not get his way. Follow-
ing the third session, he aggressively ‘poked’ his sister and became very anxious when
he was sent to time out. That same day during storytelling he punched his mother and
vigorously shook his head, saying ‘No! No! No!’ as his mother described how the boy
received the pokes and scratches.
As therapeutic work continued, a similar pattern of reliving of various aspects of the
hospital events was observed, both at home and in the sessions. His mother and I increas-
ingly filled in details, introducing what we felt were important elements to be addressed
while providing play settings that dramatized the events being discussed and identifying
the various affects we felt he was experiencing. We provided opportunities for him to
play out every aspect of his experience, including the bathing of his hand and the painful
removal of the graft site bandage. These latter situations did not elicit a great deal of
affect, and did not become a significant part of the working-through play. Particular
attention was given to feelings of anger. With his mother’s and my encouragement, Mark
acknowledged verbally and in his play that he was angry at the doctors and his parents
about his ‘owies’. But he also expressed positive identification with them, describing how
they did these things to help him. Expressions of anger were often followed by acts of
restitution, such as poking the doctor doll or the dolls representing his parents and then
giving them a kiss. In the course of these re-enactments, Mark also demonstrated his
memory for a number of details. Putting the boy doll to bed after a ‘surgery’, for example,
he placed the doll’s arm in the air, then took a plastic stick and attempted to attach it
between the arm and the IV pole. This replicated the placement of his arm in the hospi-
tal. He also placed the mother’s chair at the foot of the bed, where she indeed had sat.
Over time, the opportunity to identify different emotions and develop a coherent
narrative in the context of play re-enactments and storytelling seemed quite helpful to
Mark. His parents’ described him as happier and much more ‘like his old self’. Symp-
toms of anxiety were no longer observed and his stuttering had decreased markedly. He
began to be less interested in the story at home. In the office, he was no longer completely
engaged in the hospital play and pursued other activities such as puzzles and building
materials. With this significant improvement, the initial phase of therapy was terminated.
We had reviewed the important elements of Mark’s experience, and his parents had an
excellent grasp of his needs. The only persisting symptoms, the need to control situations
and a tendency to become distressed when he did not get his way, were much improved
and felt by his parents to be manageable. Although his mother and I believed that these
persisting symptoms were carryovers of his feelings of anger and helplessness related to
his hospitalization, we had been unable to help him make this connection. At this point
in his development he did not have sufficient cognitive sophistication to make a link
between current and past feelings of helplessness. I hoped that the dialog that had been
established between Mark and his parents would facilitate increased understanding of
this linkage over time.

Follow-up treatment
For the next four months Mark did well, until a new medical event upset the equilibrium.
While at home with a babysitter, he had a febrile seizure and was taken to the emergency
room in an ambulance. A complete neurological work-up was negative. Following this
episode there was a resurgence of his previous symptoms, to the point that interactions
with his family were disrupted significantly. One month later we arranged a follow-up

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session with the hope that a review of the recent events would be helpful. Mark’s verbal
skills had improved significantly since our last meeting. In addition to playing out the
events with hospital toys, he articulately described his emotions: his fears during the
ambulance ride and the various examinations, his distress that his mother wasn’t there
when he had the seizure, and his anger, ‘I screamed at the hospital because I didn’t want
to be there.’
Unfortunately, this abreactive session did not bring about a diminution in symptoms.
Toilet training and the giving up of his pacifier remained stymied as well. For a variety
of reasons, I believed that the emergency room visit had triggered unresolved feelings
related to his earlier medical treatments and that unresolved conflicts about his anger
were central. As noted, in our previous work Mark had been unable to connect his feel-
ings of anger and helplessness about his hospitalization to his current need to have his
way. I further believed that the previous work had insufficiently accessed the depth of
anger and disorganization Mark had experienced. Given his strong affection for his
parents, Mark had been uncomfortable expressing anger, tending to qualify it with
rationalizations regarding parents’ and doctors’ good intentions or mitigating it with
some form of restitution. I also felt that his parents’ sensitivity and tact were inadver-
tently interfering with the full expression of his rage. At the end of sessions, for example,
when he was at the edge of distress, I had repeatedly observed his mother effectively
calm his anger and redirect his attention, such that he never completely broke down. Her
discomfort at being the target of his anger and her artfulness in re-channeling it were
exemplified by her response when Mark aggressively bit at her with a whale puppet. She
gently redirected his attack, saying that whales ate plants rather than people. With this
background, I proposed a further course of therapy with a primary goal of helping Mark
express his anger. Because strong displays of anger did not come naturally for anyone in
the family, with his parents’ assent, I was prepared to take an active role in bringing this
set of feelings to the surface.
The hypothesis regarding unresolved anger was confirmed in our first follow-up
session. Manifesting both age-typical boyish interests and continuing preoccupation with
angry feelings, Mark immediately picked out a set of ‘GI Joe’ toy figures and initiated a
fight between the good guys and the bad guys. At an appropriate moment, using the tran-
sition of the fighting theme and the fact that the good guys and the bad guys were mad
at each other, I directed his attention to the hospital furniture and the boy doll we had
utilized in the past. I remarked that I thought the boy was mad at the doctors, and, using
the doll, knocked over two doctor figures. Confirming that I was on the right track,
Mark’s initial reaction was a big smile. He grabbed the doll and used it to aggressively
knock over dolls and pieces of hospital equipment. Then, reflecting his conflict, he had
a robot figure shoot the boy in retaliation. I persisted with the theme of anger, comment-
ing with dramatic emotional emphasis that the boy was mad because the hospital had
made his arm hurt and swell. I again used the boy doll to knock over the hospital bed
and IV equipment.
I then introduced the mother doll and communicated that I thought the boy was mad at
the mother because she didn’t take him home. Participating actively, Mark’s mother
reminded him that he had turned his back to her following his second surgery. Playing out
this scene, Mark creatively conveyed the idea of anger by covering the boy doll with a
blanket so the mother doll could not see him as he turned away. He had the robot figure
shoot the mother doll and knock her over, saying that the mother was dead. Immediately
afterward, however, he undid this act. Lifting the mother doll up, he asked, ‘Why would
the boy be mad at the mother? She loves him.’ This play allowed us to discuss his conflicted
feelings – anger at his parents for not preventing his injuries, fears of retaliation, and his

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underlying knowledge that his parents loved him and did not wish him ill. After another
aggressive act with the doll, Mark became increasingly uncomfortable. Putting the hospi-
tal toys away, he declared, ‘I’m finished playing with this.’ He stuttered as he spoke, some-
thing his mother had not observed for many months. Mark acknowledged that he did not
want the boy to be angry. When we wondered if he was scared that his mother would be
mad or wouldn’t love him if he got angry, he said ‘no’. Shortly after, however, he asked his
mother, ‘Will you still love me if I’m mad?’ allowing his mother again to express her under-
standing and acceptance of his anger.
This pattern of anger followed by anxiety was seen repeatedly over the next several
sessions, although with support and interpretive work he became more comfortable with
the feelings. In one session, when his mother asked him to tell me about the angry feel-
ings they had been talking about at home, he could only acknowledge being mad at the
doctors and the needles. Our observation that it was hard to be angry at his mother was
met with a denial of anger, although he sought out a whale puppet and a gun which he
had used in aggressive play toward his mother in earlier sessions. Once more I decided
to take the initiative. Putting the mother, father and doctor dolls in the whale’s mouth,
I observed that the whale was ‘really mad!’ Mark promptly reached for the whale, asking,
‘Can I do it?’ He very aggressively grabbed and squeezed the mother and then the father
doll with the puppet. Then taking a toy gun, he pointed it directly at his mother and me.
He was stuttering throughout this sequence. As we continued talking about how he was
angry because his parents hadn’t stopped the doctors from hurting him, Mark spon-
taneously searched for the boy doll and repeated the action of hiding the boy from the
mother with the blanket that had symbolized his anger in the previous session. He then
placed a cast on the boy doll’s arm. This sequence of an aggressive act followed by a
reference to an injury to the boy was seen a number of times, making clear the close
association between his feelings of anger and his view of his medical treatments as retali-
ation. On each occasion we interpreted his belief that the past hurtful treatments had
occurred because he had been bad (i.e. angry) and his fear that anger in the present
would produce a similar punishment.
Subsequent sessions saw increasingly uninhibited expressions of aggression, such as
excitedly and repeatedly using a dinosaur puppet to knock the mother doll to the floor
and jabbing a marker so hard the tip broke off to demonstrate how his favorite stuffed
animal didn’t want the doctors to poke him ‘like this!’ A notable moment occurred when
his mother took the whale puppet and knocked over the hospital equipment and the
parent dolls as a way of expressing her understanding of his feelings. This uncharacter-
istically aggressive act on his mother’s part initially left him at a loss but then appeared
to give him pleasure and a further sense of permission. Although I did not have a sense
that he completely understood what his mother and I were trying to do, Mark enthusi-
astically took advantage of the offered opportunities to express his aggression, even
though they inevitably brought feelings of anxiety. In our modeled actions we were trying
to capture not just a feeling of anger, but a whole set of confused and chaotic feelings
involving rage, fright, betrayal and helplessness that had resulted from the hurtful hospi-
tal treatments. It was in order to capture this quality of feeling in the play that I modeled
the exaggeratedly aggressive and chaotic crashing of the hospital toys and dolls. By facili-
tating a less inhibited acting out of this chaotic rage and despair, we drew much closer
to the real feelings than had been the case in the previous course of therapy. Mark’s
increased cognitive maturity also allowed us to label these feelings for the first time as
‘hospital feelings’, in a way that Mark himself could recognize. This provided his parents
with a necessary tool for making the connection between his hospital experiences and
his upset feelings at home.

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The effectiveness of this therapeutic work was evidenced by an improvement in his

symptoms. Within several weeks of the first follow-up session described earlier, Mark
became fully toilet trained. Able to separate out his anger at the medical treatments, he
was less resistant to appropriate parental requests or restrictions. By the fourth session,
temper outbursts had disappeared, even at bedtime, traditionally the most difficult time.
He was also able to give up his pacifier. He began to assertively resist his older sister’s
efforts to protect and control him, and was much more able to express his anger verbally.
When he couldn’t wear a shirt that he wanted, he told his mother, ‘I don’t like you’. When
his mother described this anecdote in our session, he turned to her affectionately and
said, ‘But I do’.
As he became less conflicted, although still influenced by his earlier trauma, Mark’s
aggression in the sessions was incorporated into age-typical play with army toys or
swords created out of tinker toys. During a playful sword fight with his mother he
directed his thrusts specifically toward her hand, touching it gingerly and then telling her
she was dead. The immediate inspiration for this sword play became clear when his
mother explained that he had been repeatedly watching the Star Wars films and had told
his mother that he especially liked the movie that had ‘the part about Luke getting his
hand cut off’. (In the second movie in the series the hero’s hand is cut off in a sword fight
by the chief villain, who, unbeknown to the hero, is actually his father. The hand is subse-
quently completely repaired.) During the period he was watching Star Wars, Mark
became defensive of his arm while being bathed. When I asked if watching the movie
gave him ‘hospital feelings’, he replied ‘yes’ matter-of-factly, as if it were self-evident.
Given the movie scenario the next question seemed an obvious one, but one I had not
previously considered because I had not thought he would have had such a conceptual-
ization at so early an age. I asked whether, with all the cuts and scratches, he had worried
about his hand being cut off in the hospital. He nodded yes in a similarly matter-of-fact
way. His mother was immediately reminded that after each surgery he would want his
bandages off, and that once they were off he would seem relieved. Asked if he removed
his bandages to see if his hand was still there, he again replied with a very matter-of-fact
‘Yes’.
At an age (almost four) when mutilation fears are normally prominent, Mark’s height-
ened concerns about bodily integrity were understandable in light of his earlier trauma.
More surprising, however, was the suggestion that these mutilation fears had not simply
crystallized at this later developmental period, but that an integrated body concept and
corresponding fear of losing a body part were present at the time of his treatments. By
removing his bandages Mark was operating adaptively to reassure himself about the
continued integrity of his hand. Validating this fear, his mother remembered at least two
occasions when the surgeon had explained in Mark’s presence that he wasn’t sure that
the arm could be saved. Mark himself said he did not remember these discussions. One
can only speculate to what extent fears were aroused by the doctor’s words and to what
extent they were based on Mark’s own synthesis of what was happening to him.
During the next few months, Mark continued to deal with issues of mutilation. His
concerns expanded into age-typical concerns about the integrity of other parts of his
body, including his genitals. On one occasion, he had a babysitter cut length-wise slits in
sections of drinking straws, which he placed over the arms of his Star Wars figures. There
was much talk at home about being cut open, such as asking what would happen if his
head opened up and it ‘showed your brain’, and about losing appendages such as noses
and ears. There was also discussion, especially in the bathroom, about how everything
is ‘attached’. On one occasion he asked what would happen if his penis ‘burst’, adding,
‘It could happen with a knife’. (It is possible that he noted the swelling of his penis during

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an erection, the connection with the swelling of his arm creating a heightened castration
fear.) Although initially rather serious in tone, over time these discussions became
increasingly light-hearted, almost teasing, as his anxiety appeared to diminish.
At this point in the therapy, Mark appeared to be doing very well. Although obviously
more preoccupied about bodily integrity than many boys would be, Mark’s fears were
being integrated adaptively within the context of his overall Oedipal development,
rather than being unassimilated. Over and above the hand association, his identification
with Luke Skywalker had a very typical Oedipal quality to it. He described that the
reason the Star Wars movies made him happy was because ‘Princess Leia made him
(Luke) a hero’. He did not appear preoccupied with his hand in day-to-day activities.
Upsets around control issues were minimal and he was appropriately accepting parental
guidance and limit setting. He was playing happily and co-operatively with other chil-
dren at his pre-school, with no unusual behaviors noted by his teachers. His right hand
had regained the dominance present prior to his injuries and he was taking on a number
of activities that involved high levels of hand coordination, including piano lessons.
His parents felt that he had ‘sorted it out’ and mastered the difficult experience.
Although a number of issues were still in process, I believed that we had effectively
addressed the anger issue, that the developmental anxieties were well on their way to
appropriate resolution, and that Mark and his parents would be able to deal with the
ongoing issues productively. We thus agreed on termination. Although sad, Mark
handled the termination quite appropriately as we reviewed his therapeutic experience.
His playful request, when saying goodbye, for a bandage for a small cut on his foot re-
capitulated many themes from our work together. A reference to an interaction involv-
ing my giving him a Band-Aid that had occurred several times in the course of the
therapy, it captured the essence of our relationship, that I was a doctor who helped him
with his injuries. At the same time, it signaled his ongoing sense of vulnerability to
‘owies’, for which an appeal for help was a continuing element in the process of mastery.
The experience with his arm, including the permanent reminders in the form of scarring,
would undoubtedly remain with him, influencing his sense of self and his view of the
world. At the same time, I believed the trauma had been integrated significantly and was
quite hopeful that it would not produce significant long-term developmental distortions.
A telephone follow-up 16 months after termination indicated that Mark was continu-
ing to do well. There were no signs of emotional or behavioral difficulty at home and his
school adjustment was excellent. In particular, his mother noted that there was no self-
consciousness or defensiveness related to the use of his hand.

Discussion
The therapeutic work with Mark illustrates several important issues relevant to work with
very young children who have experienced a trauma. It is consistent with the assumption
that traumatic reactions in infants and toddlers share essential features seen in older chil-
dren and adults, from both phenomenological and therapeutic standpoints. In particular,
the essential elements of treatment applicable to older children (Pynoos, 1990) and adults
(van der Kolk, McFarlane, & van der Hart, 1996) appear to be applicable to children
under four. These include: the establishment of a sense of safety, both in real life and in
the therapeutic setting; reduction of the intensity of arousal and the overwhelming affects
generated by the trauma; development of a coherent narrative from the often fragmented
traumatic memories; psychological integration of the traumatic events and achievement
of a sense of mastery over them; assistance with the various secondary effects, including
developmental distortions and behavioral disturbances which have emanated from the

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original trauma; and support and guidance to the patient’s family in order that they may
both help the patient and deal with their own reactions (Scheeringa & Gaensbauer, 2000).
All of these elements were present in Mark’s therapy.
From the standpoint of therapeutic technique, the work highlights the crucial role of
therapists and caretakers in actively facilitating the internal reworking of the young
child’s traumatic experience. In the home setting this can take the form of ‘storytelling’,
parent–child discussions about the trauma, and parental participation in therapeutic re-
enactment play. In therapy, the provision of structured play situations as a vehicle for
developing a coherent narrative and working through the child’s various traumatic feel-
ings is extremely useful. The therapist can utilize play materials to recreate the traumatic
context in sufficient detail for the child to recognize the references, and then encourage
the child to play out ‘what happens next?’ As children play out their memories,
emotional reactions and psychological understanding, the therapist can make use of a
variety of traditional play therapy techniques to facilitate the therapeutic process
(Gaensbauer & Siegel, 1995). The structuring is fluid in nature, taking the form of a
vehicle for dialog rather then a rigid formula, and allowing exploration of every aspect
of the traumatic experience so that no important areas of unresolved feeling are missed.
An important caveat in regard to this approach is that it assumes that the therapist has
accurate knowledge of the trauma. When such specific knowledge is not available, the
therapist must proceed much more cautiously.
This structuring activity on the part of therapists and parents, while associated with
the risk of inappropriately leading the child, is at the same time consistent with develop-
mental understanding of the young child’s needs. Memory researchers have shown that
young children are better able to convey memories if cues are provided (Fivush, 1993).
Moreover, young children, as they move from pre-verbal to verbal levels of develop-
ment, depend strongly on caregivers to provide psychological explanations and
emotional labels for their experiences (Nelson, 1990). To be most effective, therapists
and parents must not only provide opportunities for young children to express their
understanding, but must draw inferences from non-verbal behavior and translate it into
verbal terms. The parents’ storytelling at home, which was such an important element in
Mark’s recovery and involved a great deal of explanation and elaboration of Mark’s
experiences and feelings, epitomizes the risks and benefits of this active structuring.
There is the potential for overriding or distorting the child’s feelings when not done
empathetically. When done sensitively it creates a ‘co-constructed narrative’ (Fivush &
Fromhoff, 1988), a shared experience that can help restore trust and become the basis
for ongoing communication about early events.
Structured situations facilitating play re-enactment in action have other benefits as
well. For young children play re-enactments may come closer to capturing the original
traumatic affects in ways that verbal labeling and interpretation cannot. This was true in
Mark’s case, where our initial verbal support of his anger was insufficient to convince
him of its acceptability and did not tap into its full intensity. The provision of cues in
structured play also provides an opportunity for the child to demonstrate the extent of
memory for various events in a manner that is not dependent on verbal recall. As with
Mark, it has been my consistent experience that pre-verbal children, given the oppor-
tunity, can show a remarkable degree of memory for salient aspects of a traumatic experi-
ence (Gaensbauer, 1995). Mark not only retained numerous specific memories, but also
appeared to have had a meaningful comprehension of the psychological concept of
bodily integrity prior to 2 years of age.
The rapid developmental changes occurring in the early years complicate therapeutic
work in both positive and negative ways. During the second phase of therapy, when Mark

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was closer to 4 years of age, developmentally normal fears associated with age-typical
Oedipal issues of gender identity and bodily integrity were intensified by his earlier trau-
matic experiences. However, because his fears could be framed in more comprehensible
forms, such as the scenario from Star Wars, he was able to communicate his fears more
clearly, including the fear of losing his hand that had been present much earlier but had
not been recognized. He was also much more able to make use of interpretive insights,
such as the link between his current anger and his earlier ‘hospital feelings’.
Mark’s treatment brings into bold relief the necessity of dealing with the intense feel-
ings of anger that are the inevitable result of a trauma. It was not always possible to
differentiate the components of his anger–rage at being hurt, defensive attacks driven
by fear, modeling based on identification with the aggressor, self-assertion in the service
of mastery, explosive discharge of overwhelming arousal, to name a few. Nonetheless,
the overall support that his parents and I provided for anger expression was clearly
crucial to his recovery, a finding consistent with previous reports on traumatized toddlers
describing the emergence of the capacity to express anger as a critical turning point in
relieving many of the child’s symptoms (Drell, Gaensbauer, Siegel, & Sugar, 1995;
Gaensbauer, 1994).
The expression of appropriate anger toward a perpetrator, a long-standing element of
therapeutic work with trauma victims, may have special importance for young children
for whom temper tantrums and struggles to learn self-control are the norm. The intense
anger associated with a trauma will significantly complicate the child’s normative efforts
to regulate this important affect. At the same time, a trauma will predictably be experi-
enced as a punishment for being bad. Thus, the child’s often overdetermined expressions
of anger can become associated with frightening images of retaliation inspired by the
original trauma. This association will not only create intense internal conflict about
anger, but can profoundly affect parent–child disciplinary interactions. The child may
react to parental discipline and punishments in light of the traumatic experience, with
feelings of being attacked, angry defensive reactions and fears of retaliation complicat-
ing the child’s ability to experience parental authority as supportive.
Assuming adequate grounds for inferring its presence, whether the encouragement of
anger in the context of specific play re-enactments of a trauma has a therapeutic effect
or whether it increases internal conflict and/or aggression is an important empirical ques-
tion. In my experience, the support of trauma-specific anger expression occurring in the
context of circumscribed episodes of trauma (as opposed to repeated abuse), although
often associated with initial anxiety, has the long-term effect of validating the child’s feel-
ings and reducing the amount of anger acted out at home.
Lastly, the work with Mark and his parents highlights the value of having parents
participate in the therapy sessions. Parents’ involvement can be particularly important in
restoring the mutual trust that is often lost as a result of a trauma. In the sessions his
mother was able to observe how Mark continued to be affected by the trauma, communi-
cated information regarding his behavior at home and helped me understand the signifi-
cance of his play in light of the actual events. She was also able to talk of the impact of
Mark’s trauma on other members of the family, especially his sister, who had also experi-
enced medical problems and had been profoundly affected by Mark’s plight. Because of
this ongoing communication, his parents and I were able to work very closely and co-
operatively to help Mark with his feelings. Mark’s parents were particularly sensitive and
capable, able to carry out much of the therapeutic work at home. As a result, Mark did
not require intensive or long-term individual therapy. With young children the effects of
a trauma are not likely to be resolved definitively at any particular point in time, but will
be continually reinterpreted by the child in light of subsequent developmental experience.

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The establishment of a dialog between parents and child about the trauma creates a basis
for dealing with future complications as they emerge and is thus an essential therapeutic
accomplishment.
In summary, despite the challenges, we are at a very promising point in the treatment
of post-traumatic reactions in young children. I believe that the therapeutic work with
Mark exemplifies how this growing knowledge can be used to alleviate the pathogenic
effects of early trauma.

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