Christine A. Courtois, PhD
Psychologist, Independent Practice
Christine A. Courtois, PhD & Associates, PLC, Washington, DC
This article is written primarily for beginning therapists and practitioners. It provides an overview of what constitutes complex traumatization, common initial and long-term responses and symptoms and their diagnostic conceptualization as complex PTSD or DESNOS (Disorder of Extreme Stress Not Otherwise Specified). It also provides an overview of treatment sequencing and stages.
What is complex trauma and what makes it different from other forms of psychological trauma?Complex trauma generally refers to traumatic stressors that are interpersonal, that is, they are premeditated, planned, and caused by other humans, such as violating and/or exploitation of another person.
In general, interpersonal traumatization causes more severe reaction in the victim than does traumatization that is impersonal, the result of a random event or an “act of God,” such as a disaster (i.e., a natural disaster such as a hurricane or tsunami, a technological disaster) or an accident (i.e., a motor vehicle or other transportation accident, a building collapse) due to its deliberate versus accidental causation. A third type of trauma, a crossover between the two, refers to accidents or disasters that have a human cause (i.e., technological disaster such as the recent Gulf oil leak or a transportation or building accident caused by human error, neglect, or malfeasance). Traumatic stressors of this type have been found to cause reactions that are more severe than those that are impersonal and less severe than those that are strictly interpersonal.
While interpersonal violence can be a one-time occurrence that takes place without warning and “out of the blue” usually perpetrated by a stranger (i.e., a robbery, a physical assault, a rape), when it occurs within the family between family members or in other closed contexts that involve significant roles and relationships, it is usually repeated and can become chronic over time. Child abuse of all types (physical, sexual, emotional, and neglect) within the family is the most common form of chronic interpersonal victimization. Such abuse is often founded on problematic and insecure attachment relationships (between parent and child or others who have primary caretaking responsibilities). Parents and other caregivers who abuse exploit a child’s physical and emotional immaturity and dependent status to meet their own needs or do so in response to their own inadequacies or distress, quite often their own history of unresolved trauma and/or loss.
Rather than creating conditions of protection and security within the relationship, abuse by primary attachment figures instead becomes the cause of great distress and creates conditions of gross insecurity and instability for the child including misgivings about the trustworthiness of others. When it occurs with a member of the family or someone else in close proximity and in an ongoing relationship with the child (i.e., a clergy member, a teacher, a coach, and a therapist), it often occurs repeatedly and, in many cases, becomes chronic and escalates over time. The victimization might take place on a routine basis or it might happen occasionally or intermittently. Whatever the case, the victim usually does not have adequate time to regain emotional equilibrium between occurrences and is left with the knowledge that it can happen again at any time. This awareness, in turn, leads to states of ongoing vigilance, anticipation, and anxiety. Rather than having a secure and relatively carefree childhood, abused children are worried and hypervigilant. The psychological energy that would normally go to learning and development instead goes to coping and survival.
Child abuse, occurring in the context of essential relationships, involves significant betrayal of the responsibilities of those relationships. In addition, it is often private and the child is cautioned or threatened to not disclose its occurrence. Unfortunately, when such abuse is observed or a child does disclose, adequate and helpful response is lacking, resulting in another betrayal and another type of trauma that has been labeled secondary traumatization or institutional trauma. It is for these additional reasons that complex traumatization is often compounded and cumulative and becomes a foundation on which other traumatic experiences tragically occur over the course of the individual’s lifespan. Research studies have repeatedly found that when a child is abused early in life, especially sexually, it renders him/her much more vulnerable to additional victimization. Such child victims can become caught in an ongoing cycle of violence and retraumatization over their life course, especially if the original abuse continues to go unacknowledged and the aftereffects unrecognized and untreated.
Cumulative adversities faced by many persons, communities, ethno-cultural, religious, political, and sexual minority groups, and societies around the globe can also constitute forms of complex trauma. Some occur over the life course beginning in childhood and have some of the same developmental impacts described above. Others, occurring later in life, are often traumatic or potentially traumatic and can worsen the impact of early life complex trauma and cause the development of complex traumatic stress reactions. These adversities can include but are not limited to:
- Poverty and ongoing economic challenge and lack of essentials or other resources
- Community violence and the inability to escape/re-locate
- Disenfranchised ethno-racial, religious, and/or sexual minority status and repercussions
- Incarceration and residential placement and ongoing threat and assault
- Ongoing sexual and physical re-victimization and re-traumatization in the family or other contexts, including prostitution and sexual slavery
- Human rights violations including political repression, genocide/”ethnic cleansing,” and torture
- Displacement, refugee status, and relocation
- War and combat involvement or exposure
- Developmental, intellectual, physical health, mental health/psychiatric, and age-related limitations, impairments, and challenges
- Exposure to death, dying, and the grotesque in emergency response work
To summarize: complex traumatic events and experiences can be defined as stressors that are:
(1) repetitive, prolonged, or cumulative (2 ) most often interpersonal, involving direct harm, exploitation, and maltreatment including neglect/abandonment/antipathy by primary caregivers or other ostensibly responsible adults, and (3) often occur at developmentally vulnerable times in the victim’s life, especially in early childhood or adolescence, but can also occur later in life and in conditions of vulnerability associated with disability/ disempowerment/dependency/age /infirmity, and so on.
Such complex stressors are often extreme due to their nature and timing: some are actually life-threatening due to the degree of violence, physical violation, and deprivation involved, while most threaten the individual’s emotional mental health and physical well-being due to the degree of personal invalidation, disregard, deprivation, active antipathy, and coercion involved. Many of these experiences are chronic rather than one-time or time-limited and they can progress in severity over time as perpetrators become increasingly compulsive or emboldened/entitled in their demands, as trauma bonds develop between perpetrator and victim/captive, and/or as their original effects become cumulative and compounded and the victims increasingly debilitated, despondent, or in a state of adaptation, accommodation, and dissociation. Because such adversities occur in the context of relationships and are perpetrated by other human beings, they involve interpersonal betrayal and create difficulties with personal identity and relationships with others.
It is now understood that ongoing abuse or adversity over any developmental epoch but especially over the course of childhood can have major impact on the individual’s development in a variety of ways and involve all life domains. In fact, recent studies have documented that abuse and other trauma result in changes in the child’s neurophysiological development that, in turn, result in changes in learning patterns, behavior, beliefs and cognitions, identity development, self-worth, and relations with others, to name the most common. Although some individuals who were traumatized as children manage to escape relatively unscathed at the time or later (often due to personal resilience or to having had a restorative and secure attachment relationship with a primary caregiver that countered the abuse effects), the majority developed a host of aftereffects, some of which were posttraumatic and met criteria for Posttraumatic Stress Disorder (PTSD). But the PTSD diagnosis as currently defined in the Diagnostic and Statistical Manual IV-TR of the American Psychiatric Association (American Psychiatric Association, 2000) (the mental health “Bible” that therapists and others use to make diagnoses) does not account for many of the aftereffects seen in children and later in adults abused as children, and is not, in fact, a diagnosis for childhood PTSD. As of yet, no such diagnosis has been included in the DSM, although a proposal for a Developmental Trauma Disorder (DTD) has been proposed submitted for its inclusion in the next edition (van der Kolk, 2005).
In recognition of this omission and the misfit encountered in applying many of the complex trauma reactions to the criteria of “standard” PTSD, a review of the most common aftereffects of chronic childhood abuse resulted in their organization into seven criteria sets that were included in a new diagnostic conceptualization labeled Complex PTSD or DESNOS (Disorders of Extreme Stress Not Otherwise Specified) (Herman, 1992 a & b). Complex PTSD was suggested as a means of organizing and understanding the often perplexing array of aftereffects that had been identified into one comprehensive and overarching diagnosis. Moreover, the diagnosis was a way to de-stigmatize aftereffects and symptoms by acknowledging their origin as outside the individual and not due to the character (or character defect) of the individual.
Unfortunately, these negative points of view have been held by many mental health practitioners over the years that impacted their compassion for and treatment of traumatized individuals. Sadly, Complex PTSD was not included as a freestanding mental health diagnosis in the DSM IV and was instead considered as an associated feature form of PTSD, although this might change in the future revisions with additional research findings. In the meantime, many therapists who treat children and adults with complex trauma histories and complex trauma reactions use this conceptualization because it matches what they see in their clients’ presentations and helps them to explain and organize the symptoms and to further organize their treatment. In fact, Complex PTSD/DESNOS was immediately accepted and used by a wide variety of clinicians treating patients with complex trauma histories because it had face validity in that it matched the varied presentations made by their clients and was a more parsimonious and less stigmatizing way to understand and diagnose the symptom constellation they presented.
The “traditional” or “classical standard” criteria that make up the original diagnosis of PTSD in theDSM III-TR (American Psychiatric Association, 1980) were derived from the study of war trauma and adult soldiers and included: (1) intrusive re-experiencing of traumatic memories, (2) emotional numbing and avoidance of reminders of the trauma, including memory loss, and (3) hyperarousal, in addition to various associated features such as depression and anxiety and other co-morbidities. Complex traumatic stress disorders routinely include a combination of additional DSM-IV TR Axis I and Axis II (developmental/personality) disorders and symptoms, Axis III physical health problems, and severe Axis IV psychosocial impairments. Due to the complex traumatic antecedents (in the distant past as well as in the present) and the resultant array of traumatic stress symptoms and other impairments, complex traumatic stress disorders tend to be difficult to diagnose accurately and treat effectively. It would be useful to have a diagnostic conceptualization that is encompassing to understand and organize the various aftereffects.
The seven categories of additional aftereffects include the following:
1. Alterations in the regulation of affective impulses, including difficulty with modulation of anger and of tendencies towards self-destructivenesss. This category has come to include all methods used for emotional regulation and self-soothing, even those that are paradoxical such as addictions and self-harming behaviors;
2. Alterations in attention and consciousness leading to amnesias and dissociative episodes and depersonalization. This category includes emphasis on dissociative responses different than those found in the DSM criteria for PTSD. Its inclusion in the CPTSD conceptualization incorporates findings that dissociation tends to be related to prolonged and severe interpersonal abuse occurring during childhood and, secondarily, that children are more prone to dissociation than are adults;
3. Alterations in self perception, predominantly negative and involving a chronic sense of guilt and responsibility, and ongoing feelings of intense shame. Chronically abused individuals (especially children) incorporate abuse messages and posttraumatic responses into their developing sense of self and self-worth;
4. Alterations in perception of the perpetrator, including incorporation of his or her belief system. This criterion addresses the complex relational attachment systems that ensue following repetitive and premeditated abuse and lack of appropriate response at the hands of primary caretakers or others in positions of responsibility;
5. Alterations in relationship to others, such as not being able to trust the motives of others and not being able to feel intimate with them. Another “lesson of abuse” internalized by victim/ survivors is that other people are venal and self-serving, out to get what they can by whatever means including using/abusing others. Abuse survivors may be unaware that other people can be benign, caregiving, and not dangerous;
6. Somatization and/or medical problems. These somatic reactions and medical conditions may relate directly to the type of abuse suffered and any physical damage that was caused or they may be more diffuse. They have been found to involve all major body systems and to include many pain syndromes, medical illnesses and somatic conditions;
7. Alterations in systems of meaning. Chronically abused and traumatized individuals often feel hopeless about finding anyone to understand them or their suffering. They despair of being able to recover from their psychic anguish.
Research has shown that individuals who have symptoms that meet criteria for the complex trauma diagnosis may or may not have the additional symptoms associated with standard forms of PTSD (Ford & Kidd, , 1998); that is, they may have all of the complex trauma criteria but may or may not have PTSD symptoms, per se.
Of note, many of the major characteristics resemble the symptom picture of emotional lability, relational instability, impulsivity, unstable self-structuresense of self, and self-harm tendencies most associated with borderline personality disorder (BPD; American Psychiatric Association, 1994). The BPD diagnosis has carried enormous stigma in the treatment community where it continues to be applied predominantly to women clients in a pejorative way, usually signifying that they are irrational and beyond help. In recent years, this diagnosis that has come to be understood as a posttraumatic adaptation to recurrent and severe childhood abuse, attachment trauma, and personal invalidation, giving therapists another way to understand and treat it. We Conceptualizing and understanding BPD from a complex trauma perspective can assist the clinician in being more empathic towards the client and more even-handed in terms of treatment and personal reactions (countertransference and vicarious trauma).
Despite these shifts in orientation understanding the aftereffects and their origins, the individuals with CPTSD/DESNOS (or BPD) diagnosis can be a difficult population to treat. Psychotherapy is fraught with many complications (Chu, 1992; Linehan, 1993) due to the number of issues symptoms the client might experience, issues with personal safety, and deficiencies in the ability to regulate affect and to apply other life skills.; Exposing these patients clients too directly to their trauma history in the absence of their ability to maintain safety in their lives or to self-regulate strong emotions can lead to retraumatization, and associated decompensation, and inability to function.
In recent years, treatment for patients with the “classic” form of PTSD has increasingly emphasized the use of cognitive-behavioral interventions (CBT), including prolonged exposure (PE) and cognitive restructuring (CR), techniques for which empirical research support has become available (Foa, Friedman, Keane, Friedman, & Cohen, 2008). The research substantiation of the effectiveness of these techniques in ameliorating the often refractory symptoms of PTSD is laudable. Unfortunately, the wholesale application use of CBT exposure techniques to in patients with CPTSD/DESNOS (even those who clearly have PTSD symptoms) may be problematic if applied too early in treatment and before the client is stable and safe.
CPTSD/DESNOS (even those who clearly meet criteria for PTSD) may be problematic and resurface some of the problems described in the previous paragraph. In response to this, the recommended course of treatment from those experienced in treating CPTSD (Chu, 1998; Courtois, 1999, 2004; Courtois, Ford, & Cloitre, 2009; Ford, Courtois, Van der Hart, Nijenhuis, & Steele, 2005) involves the sequencing of healing tasks across several main stages of treatment. These stages include (1) pre-treatment assessment, (2) early stage of safety, education, stabilization, skill-building, and development of the treatment alliance, (3) middle stage of trauma processing and resolution, and (4) late stage of self and relational development and life choice There is overlapping therapeutic work throughout the stages and often a need to rework stabilization skills over the course of treatment. But as each stage builds on the previous work, the trauma survivor acquires growing control and mastery, which directly counteract the powerlessness of victimization and its continuing aftereffects.
The pre-treatment assessment should be comprehensive, with attention to diagnosis within the posttraumatic/dissociative spectrum, posttraumatic and other symptoms, safety, and comorbidity (particularly substance abuse, medical illness, eating disorders, and affective disorders). It is useful to complete all five axes of the DSM, with emphasis on current stressors and available resources for use in the development of a treatment plan. This is also the time to take a broad look at needs and resources, including available health care resources, which can so easily be limited by a client’s disability or by managed care insurance coverage or by his/her own motivation or emotional capacity for treatment.
The early stage focuses on safety, stabilization, and establishing the treatment frame and the therapeutic alliance. Measured by mastery of the necessary skills and not by duration, this stage of treatment may be the most important since it is directly related to the clients’ capacity to function. Education in complex trauma and elements of the human response to trauma provide a foundation for skill-building. Skills to be developed include healthy boundaries, safety planning, assertiveness, self-nurturing and self-soothing, emotional modulation, and strategies to contain trauma symptoms such as spontaneous flashbacks and dissociative episodes. Additionally, attention to wellness, stress management and any medical/ somatic concerns is needed. Medications such as antidepressants and anti-anxiety drugs are often helpful and should be considered to target posttraumatic symptoms and those associated with depression, anxiety, and sleep disorders.
The middle stage of treatment begins only after stabilization skills have been developed and are utilized as needed. This stage involves revisiting and reworking the trauma with careful processing to integrate traumatic material along with its associated but often avoided emotion. This stage typically involves the expression of pain and profound grief but with the support and witnessing of the therapist. The re-working of trauma is always destabilizing, so the skills learned in the early stage of treatment provide the frame and skill-set needed to face and integrate the previously avoided traumatic material. A wide variety of techniques have been developed for processing trauma that are applicable to this treatment stage including prolonged or graduated exposure, cognitive processing therapy, cognitive restructuring, narrative exposure, and reprocessing, testimony, and Eye Movement Desensitization and Reprocessing, to name the most common.
The late stage of treatment involves identity and self-esteem development and concurrent development of improved relational skills and relationships. The important issues of intimacy, sexuality, and current life choices, including whether to continue certain relationships and vocational choices typically occurs in this stage, if they have not been addressed earlier. Additionally, clients at this stage often encounter an existential crisis associated with a new sense of self and must struggle with the meaning of the now integrated trauma memories and with the losses they have endured. Survivors at this stage often struggle to embrace life with renewed energy and hope for the future. For some, meaning-making may involve a commitment to make a difference in the world, particularly with respect to decreasing violence. This is sometimes referred to as a “survivor mission.”
The course of treatment and its duration can vary quite dramatically and a variety of different treatment strategies might be used across the stages of treatment. Some clients stay in therapy for years (especially those with the most extensive trauma histories and those with insecure attachment styles) may never move beyond the first stage, while others move through the three stages in much less time, and still others only engage in treatment episodically as needed. Shorter-term and “hybrid” approaches (Cloitre, Cohen, & Koenen, 2006; Ford & Russo, 2006; Gold, 2000) are now under development. The important consideration is that new and different approaches to the treatment of complex trauma are now available and effective. Survivors who were once confused by their symptoms and who despaired of ever receiving understanding and assistance now have the opportunity to receive effective treatment, to heal, and to get their lives back and on track.
Christine A Courtois, PhD & Associates, PLC is a private practice that specializes in the treatment of adults experiencing the effects of childhood incest/sexual abuse and other types of trauma. Dr. Courtois has worked with these issues for 30 years and has developed treatment approaches for complex posttraumatic and dissociative conditions for which she has received international recognition.
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Young children are especially susceptible to exposure to trauma. Rates of abuse and neglect among this population are staggering. This article presents a review of relevant literature, including research findings specific to early childhood vulnerability to trauma, symptoms associated with traumatic events, diagnostic validity of early childhood trauma, and treatments for young children. In the past, misconceptions about the mental health of young children have hindered accurate diagnosis and treatment of trauma-related mental illness. Due to the prevalence of trauma exposure in early childhood, counselors are encouraged to become familiar with ways that clients and families are impacted and methods for treatment. Implications for future research also are presented.
Keywords: early childhood, trauma, treatment, mental health, mental illness
Children from birth to age 5 are at a particularly high risk for exposure to potentially traumatic events due to their dependence on parents and caregivers (Lieberman & Van Horn, 2009; National Child Traumatic Stress Network, 2010). Traumatic events are incidents that involve the threat of bodily injury, death or harm to the physical integrity of self or others and often lead to feelings of terror or helplessness (National Library of Medicine, 2013). The American Psychological Association (APA) Presidential Task Force on Posttraumatic Stress Disorder (PTSD) and Trauma in Children and Adolescents (2008) indicated that traumatic events include suicides and other deaths or losses, domestic or sexual violence, community violence, medical trauma, vehicle accidents, war experiences, and natural and manmade disasters. With more than half of young children experiencing a severe stressor, they are especially susceptible to accidents, physical trauma, abuse and neglect, as well as exposure to domestic or community violence (National Child Traumatic Stress Network, 2010).
Over 20 years ago, Straus & Gelles (1990) estimated that three million couples per year engage in severe in-home violence toward each other in the presence of young children. The Administration on Children, Youth, and Families (2003) reported that in 2001, 85% of abuse fatalities occurred among children younger than 6 years of age, and half of all child victims of maltreatment are younger than 7. More recently, the Child Welfare Information Gateway (2014) indicated that 88% of child abuse and neglect fatalities occurred among children 7 years of age and younger. Often, there is an overlap between domestic violence and child physical and sexual abuse (Osofsky, 2003). In addition to domestic violence, young children also are vulnerable to community violence.
A study conducted by Shahinfar, Fox, and Leavitt (2000) suggested that the majority of young children enrolled in Head Start experienced violence in their communities. Young children also are exposed to traumatic stressors such as accidental burns or falls resulting in hospitalization or death (Grossman, 2000). It is common for children to experience more than one traumatic event (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008).
Young children birth to age 5 are especially vulnerable to adverse effects of trauma due to rapid developmental growth, dependence on caregivers and limited coping skills. However, despite decades of statistical data, counselors generally have limited knowledge of the impact of traumatic events on younger children in comparison to older children and adolescents (De Young, Kenardy, & Cobham, 2011). Reasons for this disparity in knowledge include a historical resistance to the notion that early childhood mental health is important and concerns about diagnosing young children with mental disorders.
Research in early childhood mental health has developed rapidly over the past 20 years. Practitioners and researchers who work with this population continue to contribute to the understanding of trauma and early childhood mental health. However, the broader counselor population seems less informed which hinders referrals for this vulnerable population of young children. For example, a counselor may work with a victim of domestic violence who has young children. However, due to the counselor’s limited knowledge of early childhood trauma and the impact of domestic violence, the counselor may not consider support services for the children. The present article examines the history and diagnostic validity of trauma-related mental illnesses in young children, the symptoms of trauma in early childhood, the longitudinal impact of early childhood trauma, the protective and risk factors associated with trauma in early childhood, and current and emerging treatments for this vulnerable population.
Mental Health, Trauma and Young Children: A Historical Perspective
Historically, researchers have spent little time and energy researching the effects of trauma exposure in early childhood. A widely held misconception has been that infants and young children lack the perception, cognition and social maturity to remember or understand traumatic events (Zeanah & Zeanah, 2009). Additionally, mental health counselors have been hesitant to diagnose trauma-related mental illness as a result of the associated stigmas that plague young children. In some cases when a child is diagnosed with mental illness, society focuses on the diagnosis and not the child.
Today it is widely accepted that children have the capacity to perceive and remember traumatic events. From birth, the tactile and auditory senses of a child are similar to those of an adult, which suggests that a child can experience stressful events (De Young et al., 2011). At 3 months of age, a child’s visual sensory development increases exponentially. A study by Gaensbauer (2002) suggested that infants as young as 7 months of age can remember and reenact traumatic events for up to 7 years. By 18 months of age, children begin to develop autobiographical memory; however, it is unlikely that memories from before that age can be recalled verbally (Howe, Toth, & Cicchetti, 2006). Researchers have demonstrated that infants and young children have the perceptual ability and memory to be impacted by traumatic events (De Young et al., 2011; Howe et al., 2006).
While research findings have confirmed that traumatic events can impact children, clinicians without proper training in early childhood mental health may have difficulty diagnosing trauma-related mental illness in childhood. Children younger than 5 years of age typically experience rapid developmental changes that often are misinterpreted or not fully accounted for which hinders proper diagnosis and intervention (Zero to Three, 2005). Given time and insurance reimbursement constraints, there can be difficulties observing children’s behaviors across settings (Carter, Briggs-Gowan, & Davis, 2004). Although verbal skills develop rapidly in early childhood, children may lack the communication skills necessary to accurately express their thoughts, emotions and experiences (Cohen, 2010). When conducting assessments, mental health professionals rely on parental feedback, inventories and reports from multiple sources, thus increasing the accuracy of the assessment (Carter, Briggs-Gowan, Jones, & Little, 2003).
There is a lack of psychometrically sound diagnostic tools for directly assessing trauma symptoms in children (Strand, Pasquale, & Sarmiento, 2011). Those tools currently available do not appropriately consider the developmental levels of young children (Carter et al., 2004; Egger & Angold, 2006; Strand et al., 2011). However, there are well-designed instruments for early childhood that utilize indirect assessments such as clinician observations and parent/teacher reports (Yates et al., 2008).
Diagnostic tools and assessments developed for children over age 5 are not suitable for assessing young children. For example, young children may not fully understand the directions or the vocabulary used in certain assessment tools. Furthermore, the diagnostic criteria for specific mental health issues (e.g., PTSD) are not developmentally appropriate for children younger than 5 (Scheeringa & Haslett, 2010). The APA Presidential Task Force on PTSD and Trauma in Children and Adolescents (2008) argues that children are not being appropriately identified or diagnosed as having trauma histories and do not receive adequate help.
From a historical perspective, mental health counselors as well as society as a whole have hesitated to acknowledge the plight that young children face in terms of trauma exposure. Several historical factors have contributed to counselors’ general lack of knowledge and expertise regarding this population. However, recent advances in research and in the counseling profession, such as the new American Counseling Association division, the Association for Child and Adolescent Counseling, have begun to broaden counselor knowledge in this area.
Symptoms of Trauma in Early Childhood
Trauma reactions can manifest in many different ways in young children with variance from child to child. Furthermore, children often reexperience traumas. Triggers may remind children of the traumatic event and a preoccupation may develop (Lieberman & Knorr, 2007). For example, a child may continuously reenact themes from a traumatic event through play. Nightmares, flashbacks and dissociative episodes also are symptoms of trauma in young children (De Young et al., 2011; Scheeringa, Zeanah, Myers, & Putnam, 2003).
Furthermore, young children exposed to traumatic events may avoid conversations, people, objects, places or situations that remind them of the trauma (Coates & Gaensbauer, 2009). They frequently have diminished interest in play or other activities, essentially withdrawing from relationships. Other common symptoms include hyperarousal (e.g., temper tantrums), increased irritability, disturbed sleep, a constant state of alertness, difficulty concentrating, exaggerated startle responses, increased physical aggression and increased activity levels (De Young et al., 2011).
Traumatized young children may exhibit changes in eating and sleeping patterns, become easily frustrated, experience increased separation anxiety, or develop enuresis or encopresis, thus losing acquired developmental skills (Zindler, Hogan, & Graham, 2010). There is evidence that traumas can prevent children from reaching developmental milestones and lead to poor academic performance (Lieberman & Knorr, 2007). If sexual trauma is experienced, a child may exhibit sexualized behaviors inappropriate for his or her age (Goodman, Miller, & West-Olatunji, 2012; Pynoos et al., 2009; Scheeringa et al., 2003; Zero to Three, 2005).
The symptoms that young children experience as a result of exposure to a traumatic event are common to many other childhood issues. Many symptoms of trauma exposure can be attributed to depression, separation anxiety, attention-deficit/hyperactivity disorder, oppositional defiant disorder or other developmental crises (see American Psychiatric Association, 2013). It is important for counselors to consider trauma as a potential cause of symptomology among young children.
Long-Term Consequences of Early Childhood Trauma
Recently, researchers have focused on how trauma during early childhood impacts mental and physical health later in life. Symptoms of mental illness can manifest immediately after a trauma, but in some cases symptoms do not emerge until years later. PTSD, anxiety disorders, behavior disorders and substance abuse have all been linked to traumatic events experienced during early childhood (Kanel, 2015). The types and frequencies of traumatic events and whether they were directly or indirectly experienced also can have various effects on physical and mental health later in adulthood. In a review of literature, Read, Fosse, Moskowitz and Perry (2014) described support for the traumagenic neurodevelopmental model. This model proposes that brain functioning changes following exposure to trauma during childhood. These biological factors often lead to psychological issues and physical and mental health concerns in adulthood.
Mental health professionals are often challenged to accurately diagnose PTSD in early childhood, leading to inconclusive reports of the actual prevalence of post-traumatic stress (De Young et al., 2011). Still, there is a clear relationship between PTSD diagnoses and trauma experienced in childhood. For example, higher rates of PTSD are reported among children residing in urban populations where neighborhood violence is prevalent (Crusto et al., 2010; Goodman et al., 2012). Briggs-Gowan et al. (2010) found an association between family and neighborhood violence exposure and oppositional defiant disorder, attention-deficit/hyperactivity disorder, conduct disorder and substance abuse. Additionally, noninterpersonal traumatic events (e.g., car accidents, burns, animal attacks) are associated with PTSD as well as anxiety, phobias, seasonal affective disorder and major depressive disorder (Briggs-Gowan et al., 2010).
Violence exposure is associated with externalizing problems while nonpersonal traumatic events are associated with internalizing problems (Briggs-Gowan et al., 2010). In a more recent study, Briggs-Gowan, Carter, & Ford (2011) found that exposure to neighborhood and family violence in early childhood is associated with poor emotional health and poor performance in school. Low socioeconomic status and traumatic events in early childhood also are correlated with low academic achievement in school (Goodman et al., 2012). Similarly, De Bellis, Woolley, and Hooper (2013) found maltreated children demonstrated poorer neuropsychological functioning and aggregate trauma was negatively related to academic achievement.
According to Schore (2001a), children and adults who experienced relational trauma during infancy are often faced with the struggles of mental disorder due to right brain impairment (p. 239). More recently, Teicher, Anderson, and Polcari (2012) found exposure to maltreatment and other types of stress as a child impacts hippocampal neurons leading to alterations in the brain and potential developmental delays. Additionally, there is evidence of relationships between mistreatment, bullying and accidents in early childhood and the development of delusional symptoms in later childhood (Arseneault et al., 2011). Young children who experience trauma and later use cannabis in adolescence are also at a higher risk for experiencing psychotic symptoms (Harley et al., 2010). Other studies have shown a correlation between early childhood trauma and development of schizophrenia later in life (Bendall, Jackson, Hulbert, & McGorry, 2008; Morgan & Fisher, 2007; Read, van Os, Morrison, & Ross, 2005). Changes in the brain may mediate these relationships between trauma exposure and mental health, as suggested by Schore (2001a, 2001b) and others.
Infants exposed to trauma are often inhibited by emotional and behavioral dysregulation in childhood and as an adult (Ford et al., 2013; Schore, 2001a, 2001b). Dysregulation resulting from trauma is predictive and related to substance use and functionality (Holtmann et al., 2011). For example, findings from a study by Strine et al. (2012) suggested that early childhood trauma and substance abuse are directly correlated. Children who had experienced more than one traumatic event were found to be 1.4 times more likely to become alcohol dependent. Strine et al. (2012) noted that females who experience trauma are more likely than males to abuse or become dependent on alcohol. The relationship between trauma and alcohol use and dependence often stems from untreated psychological distress (Strine et al., 2012).
In addition, there is ample evidence that early childhood trauma impacts later physical health. Some of the most well-known data on this topic come from the adverse childhood experiences study (Edwards et al., 2005). Multiple studies have found that early childhood trauma is associated with autoimmune disorders (Dube et al., 2009), headaches (Anda, Tietjen, Schulman, Felitti, & Croft, 2010), heart disease (Dong et al., 2004), lung cancer (Brown et al., 2010) and other illnesses. In fact, these studies often have found that the more frequent the exposure to early childhood trauma, the higher the risk of poor health outcomes in adulthood (Felitti et al., 1998).
Researchers have found clear evidence that children who experience traumatic events in early childhood are impacted well beyond their youth. Mental health disorders as well as alcohol and substance abuse emerge intermittently with age. Changes in brain functioning and physical health issues are also associated with early childhood trauma.
Risk and Protective Factors
Researchers have begun to explore factors that interact with trauma and the effects they may produce in young children. Environmental and demographic factors as well as parent–child relationships significantly impact outcomes for young children exposed to traumatic events (Briggs-Gowan et al., 2010). These factors may either insulate a child from adverse effects of trauma or increase the child’s risk for developing psychological distress.
Briggs-Gowan et al. (2010) found that symptoms of psychopathology and trauma were related to factors such as economic disadvantage and parent depressive and anxious symptoms. While ethnicity of the minor, parental education level and number of parents were associated with violence exposure, those factors were not associated with symptoms of mental illness. A more recent study found that young children exposed to a traumatic event along with a combination of socio-demographic factors (e.g., poverty, minority status, single parent, parental education less than high school, teenage parenting) are at greater risk for mental illness (Briggs-Gowan et al., 2011). Additionally, Crusto et al. (2010) found that high levels of parental stress are associated with adverse trauma reactions in young children. Parental dysfunction, family adversity, residential instability and problematic parenting can increase the impact of traumatic events as well (Turner et al., 2012). Young children exposed to chronic and pervasive trauma in addition to these risk factors are especially vulnerable to adverse effects (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008).
There are factors that may help protect young children from the negative impact of exposure to trauma. Turner et al. (2012) found that nurturing familial relationships can insulate children from psychological distress associated with traumatic events. Other factors such as safety and stability also might serve as protective factors. Safety implies that the child is free from harm or fear of harm, both physically and socially. Stability indicates consistency in the family environment, while nurturing suggests availability, sensitivity and warmth of caregivers or parents. Well-established, secure parent–child relationships are likely to provide protection from negative effects of trauma experienced by young children. A secure parental attachment has been shown to help children effectively regulate emotional arousal (Aspelmeier, Elliot, & Smith, 2007). Emotional regulation may be a mechanism that protects young children from extreme trauma reactions (De Young et al., 2011). Similarly, Crusto et al. (2010) found that caregiver support and healthy family functioning reduce the risk of psychological distress in young children after a traumatic event.
Early intervention and treatment can minimize the social and emotional impact of a child’s exposure to a traumatic event. Professional counselors should consider making referrals to counselors trained in providing early childhood mental health support. If the professional counselor has difficulties finding a referral source, the counselor’s basic counseling skills can provide the foundation for a safe, secure and trusting relationship between the counselor, family and child. Demonstrating empathy, genuine care and acceptance also fosters rapport among stakeholders (Corey, 2009). Mental health counselors can emphasize strengths and resources for the child and family.
Incorporating existing coping strategies can serve to minimize family stress and foster rapport with the child. Providing information about community support groups or other mental health agencies and resources also can help support and encourage the family. Informing parents and caregivers about symptoms common to young children exposed to traumatic events can foster awareness and allow for adequate support during the treatment process. Counselors can help the family establish or reestablish routines that begin to restore stability for the child, minimizing the adverse effects of the trauma (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008; Clay, 2010).
There are several evidence-based methods available to counselors treating trauma symptoms in young children. Evidence-based approaches are rooted in theory, evaluated for scientific rigor and tend to yield positive results (National Registry of Evidence-Based Programs and Practices, 2012). Trauma-focused cognitive behavioral therapy (TF-CBT) is a popular evidence-based treatment used with children aged 3–18. Based on cognitive behavioral therapy, humanism and family systems theory, TF-CBT includes many therapeutic elements for children and caretakers (Child Welfare Information Gateway, 2012). This form of therapy helps children develop different perceptions and a more adaptive understanding of the traumatic event (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008). Caretakers learn parenting and communication skills as they play active roles throughout the TF-CBT process. Multiple studies demonstrate the effectiveness of TF-CBT in reducing symptoms of trauma in early childhood (see Cohen & Mannarino, 1996, 1997; Deblinger, Stauffer, & Steer, 2001).
While TF-CBT is an established treatment for children and adolescents, there are evidence-based treatments developed specifically for treating trauma in children between birth and 6 years of age. Child–parent psychotherapy (CPP), one of the most widely used interventions for young children, was created to address exposure to domestic violence, although it can treat a variety of traumatic experiences (Lieberman & Van Horn, 2008). In this form of dyadic therapy, the child and the caregiver reestablish safety and security in the parent–child relationship (Lieberman & Van Horn, 2008). CPP is one of the few early childhood treatments validated for use with ethnic minorities (Lieberman & Van Horn, 2008). The primary goal of CPP is to equip parents to meet the psychological needs of their child and maintain a secure relationship after treatment has ended.
Attachment and biobehavioral catch-up (ABC) is another treatment option that is designed primarily for use with young children who have experienced neglect (Dozier, 2003). This approach was developed specifically for low-income families and later adapted for use with foster families. ABC is based on the neurobiology of stress and attachment theory. The goal of ABC is to foster the development of the child’s optimal regulatory strategies by equipping parents with tools for effective response (Dozier, 2003; Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008).
Counselors also can utilize parent–child interaction therapy (PCIT) when working with traumatized youth. PCIT is a structured technique for children ages 2–8 years in which the counselor teaches the parent or caregiver how to interact with the child and set effective limits (Chaffin et al., 2004). In this form of therapy, the counselor often assumes the role of coach, instructing the client on specific skills. Counselors frequently use PCIT when working with children abused by a caregiver. PCIT has been implemented successfully with various populations including Hispanic and Latino clients (Chaffin et al., 2004). The focus of PCIT is on improving the quality of the parent–child relationship as well as child behavior management (Chaffin et al., 2004; McCabe, Yeh, Garland, Lau, & Chavez, 2005).
The treatment interventions previously mentioned are geared toward very young children, all incorporating play as a treatment modality. Since young children do not have extensive vocabularies, they often communicate information about themselves, their trauma and relationships with their caregivers through play (Landreth, 2012). Play therapy intervention research using samples with children between birth and 5 years of age is scant; however, several case studies indicate that play therapy is effective with trauma in early childhood. For example Dugan, Snow, and Crowe (2010) utilized play with a 4 year old exhibiting PTSD symptomology after experiencing Hurricane Katrina in 2005. Anderson and Gedo (2013) provided a case study in which play was used to treat a 3 year old with aggressive behaviors who was separated from his primary caregiver. There also are intervention examples of using play therapy with young children exposed to domestic violence (Frick-Helms, 1997; Kot, Landreth, & Giordano, 1998).
Finally, there are emerging approaches specifically for treating young children exposed to trauma. Tortora (2010) developed Ways of Seeing, a program combining movement and dance therapy with Laban movement analysis to create a sense of regulation and homeostasis for the child exposed to a traumatic event. The Ways of Seeing program does not yet have empirical evidence of its effectiveness. However, it is rooted in attachment theory, multisensory processing, play and sensorimotor psychotherapy. Counselors can use this program to determine how a parent and child experience each other, implement creative interventions for healthy bonding, and renew a sense of efficacy for the parent and child. While much more research is needed, this program appears to be a promising approach to treating trauma in early childhood (see http://www.suzitortora.org/ waysofseeing.html).
Another emerging treatment, known as Honoring Children, Mending the Circle (HC-MC), is based on TF-CBT. The HC-MC approach was developed to address the spiritual needs of young Native American and Alaska Native children exposed to trauma. This method emphasizes preestablished relationships, wellness and healing during the treatment process. Spirituality is a critical component of healing and is integrated throughout the HC-MC approach. The goal of HC-MC is to help the traumatized child attain and reestablish balance (BigFoot & Schmidt, 2007, 2010). Additional research is needed on the efficacy of the HC-MC approach in working with Native American and Alaska Native youth.
A third emerging treatment, Trauma Assessment Pathway, is an assessment-based treatment that focuses on providing triage to young children exposed to traumatic events (Conradi, Kletzka, & Oliver, 2010). In this approach, the counselor uses assessment domains to determine the focus of treatment, provides triage to identify an appropriate pathway for intervention and establishes referrals to community resources if needed (Chadwick Center for Children and Families, 2009). The trauma assessment pathway method, which includes the trauma wheel, is a versatile mode of treatment available for the child and family. However, in many instances counselors may determine that an evidence-based practice, such as CPP, is the most appropriate mode of treatment (see Chadwick Center for Children and Families, 2009).
Each method of treatment offers specific strategies for working with traumatized young children and their families. However, findings from most studies investigating the effectiveness of these treatments are inconclusive (Forman-Hoffman et al., 2013). The strength of evidence for these and many other interventions are relatively low while the magnitudes of treatment effects are small (see Fraser et al., 2013). Common to the treatment models presented is the emphasis on system support, the importance of relationships in the recovery process and developmentally appropriate intervention modalities. These factors likely will serve as integral components of future methods focused on the treatment of traumatized young children.
Discussion and Implications
Young children are at high risk for exposure to traumatic events and are particularly vulnerable for several reasons. They are dependent upon caregivers and lack adequate coping skills. Children also experience rapid development and growth, leaving them particularly impressionable when faced with a traumatic event. Young children benefit from preventive psychoeducation aimed at teaching parents and caregivers about child development and parenting skills (McNeil, Herschell, Gurwitch, & Clemens-Mowrer, 2005; Valentino, Comas, Nuttall, & Thomas, 2013). Counselors who work with this population endeavor to increase protective factors and decrease risk factors while exploring preventive methods, which may reduce young children’s exposure to traumatic events. Similarly, legislators can influence public policy related to enhancing childhood mental health. For example, legislation can address prevention and offer incentives to parents participating in psychoeducation focused on enhancing protective factors and reducing childhood trauma exposure.
In recent years research has emerged that provides an understanding of how trauma impacts young children. Researchers and clinicians know that infants, toddlers and preschoolers have the capacity to perceive trauma and are capable of experiencing psychopathology following a traumatic event. Although these children can experience mental illnesses often associated with older children, adolescents and adults, the symptomology can manifest in various ways. Additionally, professional counselors working with children in a variety of settings should consider the residual impact of traumatic events experienced in early childhood. School-aged children may experience behavioral problems and have difficulty learning and forming relationships as a result of early childhood trauma (Cole, Eisner, Gregory, & Ristuccia, 2013; Cole et al., 2005). A number of studies indicate that trauma is a strong predictor of academic failure (Blodgett, 2012). Therefore, school counselors serving as mediators between academics and wellness should explore ways to advocate for and support students with known or suspected exposure to traumatic events in early childhood. For example, the trauma-sensitive schools initiative provides school counselors with a framework for fostering schoolwide awareness and creating a safe and supportive environment (Cole et al., 2013). School counselors can easily embed these types of preventive measures as part of a comprehensive school counseling program. These efforts will presumably result in increases in student success, wellness and awareness, three outcomes that will benefit all children exposed to traumatic events.
While great strides have been taken recently in understanding and treating early childhood trauma, there are clear gaps in the dissemination of information to counselors. Professional counselors should receive training in specifically designed interventions and attempt to raise public awareness of early childhood trauma in hopes that young children will receive necessary treatment. The findings of this literature review suggest that various methods of treatment might effectively reduce symptoms experienced by traumatized children. Parent–child relationships and other environmental factors also can have significant influence on children’s reaction to trauma.
A major purpose of this article is to educate counselors about the impact of trauma in early childhood and advocate for appropriate assessment and treatment of these traumatic exposures. While not all counselors choose to work with this vulnerable population, they often work with clients who have extended families with young children. Counselors who work with adult clients can provide psychoeducation about this important issue and initiate referrals to counselors trained to work with early childhood trauma. There is a body of information about trauma in early childhood available for further review. Sources include the National Child Traumatic Stress Network (nctsnet.org), the California Evidence-Based Clearinghouse for Child Welfare (cebc4cw.org), and the Association for Child and Adolescent Counseling (acachild.com). Counselors interested in learning more about this issue can review these online resources.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of
interest or funding contributions for
the development of this manuscript.
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Kristen E. Buss, NCC, is a counselor at Hope-Thru-Horses, Inc. in Lumber Bridge, NC. Jeffrey M. Warren, NCC, is an Assistant Professor at the University of North Carolina-Pembroke. Evette Horton is a clinical instructor at the UNC OBGYN Horizons Program at the University of North Carolina-Chapel Hill. Correspondence can be addressed to Jeffrey Warren, The University of North Carolina-Pembroke, P.O. Box 1510, School of Education, Pembroke, NC 28372, email@example.com.