DIR®-informed approach to anxiety and trauma in school age children

DIR®-informed approach to anxiety and trauma in school age children”

Galina Itskovich

Interdisciplinary Council on Development and Learning, New York, USA


This paper examines presenting problems of latency age children, stemming from anxiety and/or psychological trauma of various kinds. An author shares experience in addressing symptomatology from the cluster of anxiety disorders in therapeutic work, using Developmental, Individual differences and Relationship based approach (DIR®) originated by Stanley Greenspan and Serena Wieder. Developmental, Individual differences and Relationship model describes the developmental capacities to achieve throughout the formative years of human life, unique ways of information processing (this includes motor control, praxis, visual spatial capacities and integration of sensory information supplied by five organs of sense and vestibular, visceral and proprioceptive systems) and language capacities, and affective relationships promoting all the above.

DIR® model can be utilized for the purpose of differential diagnosis; it also provides an invaluable philosophical base. This diagnostic and treatment paradigm allows scrutiny of co-occurring problems, developmental capacities and multitude of variations in sensory, medical, familial and environmental characteristics that serve as prequel to symptoms. Additionally, DIR® approach lends us not only understanding of the impact of individual differences on anxiety manifestations, but also treatment philosophy that leaves room for the individuality of the child. In Erik Erikson’s terms, school age children resolve issues of inferiority versus industry; they can greatly benefit from therapeutic relationship that promotes a sense of competency.

As dwellers of our planet get overwhelming amount of information and live coverages of scary, traumatizing and horrifying events around the globe, anxiety takes the front seat in the clinical landscape. Children are more susceptible to anxiety mainly because of lack of control over their lives, actual helplessness, operating largely on clues and adult whisper rather than on confirmed (and comprehended by them) facts and, frequently, having no impact on own future. Because of linguistic limitations of different nature (age-appropriate limited vocabulary or delayed speech development), children are shortchanged in their choice of neuro-integration via verbalization of experiences, worries or fears. As a result, instead of labelling their prevailing emotion of the hour as anxiety, they present many changes in behavior, from school refusal to psychosomatic problems to behavioral storms. Naturally, all the above greatly depends on individual patterns of resilience. Prior history of trauma is the most important marker of emerging symptoms of anxiety and anticipatory anxiety. Mechanisms of processing, as well as history of trauma and vicarious trauma should be closely examined in the process of assessment and addressed in treatment regardless of the scope of presenting problem.

Another, not less important, predictor of anxiety is ability to self-regulate and the speed with which the child can recover from stress or perceived danger and, shutting down the initial response of hypervigilance, go back to the state of homeostasis. Excessive anxiety can manifest itself as aggression, “striking out”, low frustration tolerance and impulsivity. Additionally, many highly anxious children may struggle with issues around sensory reactivity that usually go unnoticed and unaddressed. Sensory reactivity can put such children in the perpetual (or frequent) state of sensory overload, when anxious mood is exacerbated by the malfunctioning ability to process sensory information. Helping children to recover from the emotional and sensory overload means decrease in self-blame, in polarized and inflexible thinking, anticipatory anxiety, and senses of helplessness and inadequacy.

Application of the DIR®-informed diagnosis and treatment is discussed in four case examples: dealing with the hostile environment; sense of impending doom based on prior experience; living in the uncertain future; and being “an unwanted child” and dealing with anxious attachment. DIR®-informed treatment calls for respect. Its unique premise is following the child, thus returning them a “missing link” - a sense of competence and control instrumental to alleviation of symptoms.

Keywords: DIR®, anxiety, psychological trauma, school aged children, differential diagnosis, therapeutic use of self.

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