Module 5
Trauma and Stressor Related Disorder
a. Developmental Tasks and Challenges Related to Stress and Coping
Stress occurs when the demands of the individual exceed his or her available
resources. Coping involves the regulatory processes that are activated in response to
stress (Compas, 2009). From birth onward, stressors abound. They include everyday
events, such as parents leaving infants to go to work, physical exams and inoculations,
playground mishaps, homework that is too difficult, conflicts with friends, and
forgetting one’s lines in a school play. They also include not-so-everyday events, such
as the birth of a sibling, a move to a new state, failing a grade, and breaking up with
one’s first romantic partner. Each of these events requires some kind of response from
a child or adolescent. Whether these coping efforts are successful or unsuccessful
influences a number of important developmental outcomes.
The stress–response system is an evolutionarily influenced, hierarchically
organized, and integrated brainbased system. Brain regions involved in stress
responses include the hippocampus, the amygdala, and the prefrontal lobes, as well as
the circuitry that connects those regions. Stress triggers the activation of the
hypothalamus-pituitary-adrenal (HPA) axis and the release of stress hormones such as
cortisol. Receptors for these stress hormones are located throughout the brain. The
stress hormones initiate a coordinated physiological response involving autonomic,
neuroendocrine, metabolic, and immune system components. Following activation of
the stress system, feedback loops signal for regulation and shutdown of the HPA axis
and a return to homeostasis. Two constructs help describe this process: allostasis,
“meaning the process of maintaining stability (homeostasis) by active means, namely,
by putting out stress hormones and other mediators,” and allostatic load (or allostatic
overload), “meaning the wear and tear to the body and the brain by use of allostasis,
particularly when the mediators are dysregulated, i.e., not turned off when the stress is
over or not turned on adequately when they are needed” (McEwen, 2007, p. 874). The
constructs of allostasis and allostatic load make clear the role of the brain in the
regulation of feedback, that biological set points are dynamic (in that they respond to
changing contexts), and that there are predictable variations in stress sensitivity across
development.
The stress system is organized to expend both physiological and psychological
energy as it attempts to meet typical (or expected) and atypical (or unexpected)
demands. According to Gunnar and Loman (2011, p. 97), “If there is an immediate
threat to our survival, we do not need to put energy into fighting off a virus, digesting
our lunch, or growing an extra inch. We need that energy to fuel the mental and
physical processes that increase our chances of surviving to face tomorrow. As this
example suggests, stress is not necessarily detrimental. The capacity to mount an
effective stress response allows us to adapt to the changing and sometimes extreme
demands of our daily existence, to stretch our abilities, and to achieve more than we
might were we to avoid situations of high demand.” These high-demand
circumstances need to be followed by periods of rest and repair. If they are not, there
may be negative consequences, both in the immediate aftermath and in upcoming
months and years.
The effects of stress are observed across the lifespan, from the prenatal period,
across infancy and childhood, and through adolescence and adulthood. A “life cycle”
model of stress describes changes in various brain structures related to the timing of
stress. Exposure to prenatal and postnatal stress has programming effects on the
developing brain and HPA axis. These programming effects involve changes in gene
function (i.e., not in the genetic code or composition, but in the way in which the
genetic information operates). These effects are examples of epigenetics, or the
environmental regulation of gene expression.
Early adversity appears to alter the magnitude of the stress response (usually
in the direction of hyperreactivity, but also sometimes hyporeactivity) and the poor
regulation of that response (Meaney, 2010; Obradović, 2012). In addition, epigenetic
mechanisms such as methylation help account for the links between exposure to
extreme stress in early life and higher rates of poor physical and mental health
outcomes in children. The experience of stress in early development is buffered by
responsive caregiving. Indeed, research has confirmed “the incredible importance of
the attachment relationship in regulating stress in infancy,” (Gunnar, 2016, p. 181),
and current studies are focused on better understanding the mechanisms and outcomes
of social buffering across childhood, adolescence, and adulthood.
Investigations of other developmental periods also provide critical information
about the stress-response system. Adolescence is associated with heightened
responses of the HPA axis, and adolescent brain development (especially in the frontal
cortex) is likely affected by this activity. Compared to early childhood, there is
relatively less parental buffering of the stress–response system, so demands on that
system—particularly social demands or social threats—may be especially
challenging. Given the increasing emphasis on peer relationships, the resolution of
these types of stressful social experiences may be particularly meaningful. In addition
to the immediate consequences of these new experiences, the cumulative effects of
early adversity are observed in adolescence. Individual differences in stress reactivity
and regulation are linked to both genes and experience. As noted, one very important
contributor to individual differences in the pathways and organization of the stress–
response system is early caregiving and attachment security. Temperament (e.g., high
reactivity) is another factor that influences the development and functioning of the
stress response system. High-risk families, in which interparental conflict and
aggression are present, are another source of variation in children’s stress responses.
One environmental factor with significant impact is poverty. Growing up in
impoverished circumstances is associated with chronic stress and increased allostatic
load. Adverse environments may be especially challenging for highly reactive
children, who are more responsive than less reactive children to both highly
supportive and highly stressful environments—that is, the orchid and dandelion
children.
Early adversity is often discussed in tandem with toxic stress (Shonkoff et al.,
2012). The National Scientific Council on the Developing Child describes three types
of stress responses observed in young children. Positive stress responses include brief,
mild-tomoderate responses, usually with a supportive caregiver (e.g., dealing with
everyday frustration or typical experiences such as the first day of preschool).
Tolerable stress responses involve atypical stressors (such as serious illness, frequent
interparental conflict, or a natural disaster) that trigger a more widespread and
possibly longer-lasting response. For many children in these situations, protective
adults help to buffer the stress response and promote a return to typical functioning.
Toxic stress responses are the result of “strong, frequent, or prolonged activation of
the body’s stress response systems in the absence of the buffering protection of a
supportive, adult relationship” (Shonkoff et al., 2012, p. e236). Toxic stress is
associated with permanent changes in the structure and function of the brain and
stress-response systems. It is important to emphasize that children are not just passive
recipients of stress; they are also active agents in dealing with it. Indeed, as noted,
exposure to multiple instances of stress (or challenge) may be necessary for the
typical development of problem-solving or coping strategies (Grant et al., 2014).
Zimmer-Gembeck and Skinner (2011) provide a developmental framework for
thinking about coping. In their framework, they describe age-related transitions in 12
“families of coping and adaptive processes”. Their descriptions “allow the
identification of healthy pathways through which children can acquire robust
resources for dealing constructively with challenges, obstacles, failure, and loss”. The
various types of coping responses in each family are constrained by age and ability;
each is also linked to more- and less-likely positive outcomes. For each family of
coping responses, a developmental progression can be described.
According to Zimmer-Gembeck and Skinner (2011), age-related transitions in
coping occur from infancy to toddlerhood (about age 2); between ages 5 and 7; from
late childhood to early adolescence (from ages 10 to 12); from early to middle
adolescence (from ages 14 to 16); and from middle to late adolescence (from ages 18
to 22). Among the most common types of coping, across much of development, are
problem solving, support seeking, distraction, and escape. Escape is the most common
maladaptive strategy. There are certainly developmentally influenced changes in the
frequency of use. In the preschool period, for instance, “young children seek support
from adults or use overt behaviors to get what they want.” Support seeking seems to
be an “all-purpose strategy,” and escape is the “primary alternative” when other
strategies are ineffective. In middle childhood, children “become increasingly self-
reliant and their coping strategies become more differentiated and sophisticated” (p.
12). Cognitive strategies are increasingly deployed, and support seeking appears more
focused. In adolescence, there is an overall increase in coping repertoires, with more
planful problem solving and better emotion regulation, as well as the matching of
coping strategies to types of stressors.
There are several key distinctions related to coping. The first is the distinction
between automatic and controlled processes. In the memory system, for example,
biases to attend to threatening information are automatic, whereas the purposeful
shifting of attention observed in distraction is controlled (Compas, 2009). Another
distinction involves antecedent regulation (i.e., coping that anticipates a
psychologically demanding event) and response-focused regulation (i.e., coping that
follows the psychologically demanding event) (Ochsner & Gross, 2008). Differences
in the motives and goals associated with coping, such as those related to personal
well-being and/or the well-being of others, must also be considered. Differences in
goals may also be linked to whether stress is controllable or uncontrollable.
Many factors influence individual differences in coping repertoires and coping
success. These include physiological factors, like brain development; psychological
factors, such as temperament and the development of the self; and social factors,
including parent and peer relationships. Parent support of children’s coping, as well as
parent assistance, may be especially important when high levels of stress are
encountered and/or when the child’s coping resources are taxed. Abaied and Rudolph
(2010) provide a detailed description of the role of parents in the socialization of
children’s coping. In their description, parents both instruct and model a variety of
coping strategies. Engagement strategies include problem solving, support seeking,
and positive thinking. Disengagement strategies include avoidance and denial. Parents
can also reinforce or redirect children’s coping. And, of course, parents’ contributions
to children’s coping can be helpful or ineffective. Overall, across development, the
ongoing interactions of stress and coping are evident every day. For many children,
whose stressful experiences are typical and whose coping is supported by concerned
adults, these interactions contribute to a sense of self-efficacy, accomplishment, and
well-being. For other children, whose stressful experiences are unusually frequent and
severe and whose coping is not adequately supported, developmental outcomes are
more likely to include significant distress and dysfunction.
b. Maltreatment
Wyatt is a four-year-old boy who was recently removed from his home and
placed in foster care along with his younger sister. Until recently, Wyatt and his sister
lived with his mother and her current boyfriend in a somewhat isolated rural
community. Wyatt’s mother has struggled with polydrug addiction, including alcohol
and methamphetamine, since before Wyatt’s birth. Although not physically abusive to
her children, Wyatt’s mother’s cycle of addiction, recovery, and relapse has led to
multiple periods of physical neglect and emotional unavailability.
Wyatt was removed from the home by child protective services when he was
one year old, when a visiting county social worker found him suffering from severe
neglect, including untreated eye and ear infections and signs of malnutrition. He spent
several months in a foster home while his mother completed a rehab program and
gave birth to his sister. Wyatt was then returned home, where he and his sister lived
for the next three years. During this time, Wyatt’s mother continued to cycle through
periods of active drug and alcohol abuse followed by brief periods of sobriety.
While assessing Wyatt as part of a prekindergarten screening program, the
evaluator noted multiple bruises on Wyatt’s face and legs. A follow-up evaluation by
child protective services found further bruising on Wyatt’s back and buttocks. Wyatt
told the child protection worker that his mother’s boyfriend routinely struck him with
his hand or a stick in response to any behaviors of which he disapproved. This
included even mild oppositional behavior, as well as unintentional behaviors such as
wetting the bed or spilling a drink. Wyatt’s mother confirmed that the abuse had been
occurring, but she defended her boyfriend by noting that he behaved violently only
when drunk or high and was otherwise kind to her and provided for her family.
Following the investigation, both Wyatt and his sister, who was not physically abused,
were removed from the home and placed in separate foster care homes. Wyatt’s
mother again entered a residential treatment program, and her boyfriend was arrested
and charged with multiple counts of child abuse.
Wyatt now lives with experienced and loving foster parents and is enrolled in
a therapeutic preschool. Wyatt’s foster parents express surprise that he almost never
mentions his mother or sister. They report that he settled quickly into his new
surroundings and routine. Both at home and at preschool, Wyatt is noted to be acutely
aware of and reactive to even mild disapproval. In fact, he quickly recognizes
frustration or anger in his environment even when it is not directed toward him. Over
time, Wyatt has become more trusting of his foster parents, though he also becomes
anxious if he is not in the same room as them. Wyatt has struggled to manage the
complexity and energy typical of a preschool classroom. He has difficulty joining in
with other children and becomes easily frustrated and emotionally reactive to even
minor frustrations and problems. At such times, he may exhibit either internalizing
behaviors, such as hiding or crying; or externalizing behaviors, such as throwing toys
or hitting other children.
Further assessment indicates that Wyatt is experiencing mild-to-moderate
delays in general cognitive functioning and expressive language ability. Wyatt’s
teachers are developing a comprehensive plan combining structured, small-group play
opportunities with speech therapy and remedial school readiness training. All those
currently working with Wyatt remain both hopeful that he can continue to make
progress and concerned about whether or not his mother will choose for Wyatt to
continue the current therapeutic program if he returns home to live with her.
Definitions of maltreatment vary, depending on context and culture,
professional background, and purposes of definition (e.g., involving lawmakers and
legal issues or mental health professionals and treatment issues). Even so, basic
definitions can be provided (Cicchetti, 2016). Sexual abuse involves sexual contact or
attempted sexual contact between an adult and a child. Physical abuse refers to
injuries that are inflicted by nonaccidental means. Neglect involves failure to provide
minimum standards of care (e.g., regarding shelter, safety or supervision, nutrition)
that leads to harm or endangerment. Emotional (or psychological) abuse refers to
ongoing and extreme disregard or thwarting of basic emotional needs. Additional
classification considerations include the frequency, severity, and timing of
maltreatment.
Maltreatment has been conceptualized as a “failure of the average expectable
environment”. “For infants, the expectable environment includes protective, nurturant
caregivers and a larger social group to which the child will be socialized, whereas for
older children, the normative environment includes a supportive family, a peer group,
and continued opportunities for individuals to dynamically.
Once maltreatment reports are made to child protective services (CPS),
children from minority backgrounds face a series of disparities that affect their
placement and outcomes within the child welfare system. Research has consistently
shown that these children are more likely to be placed out of their homes compared to
their peers from non-minority backgrounds. This overrepresentation in out-of-home
placements is a significant issue that underscores systemic biases and inequities
within the child welfare system.
Children from minority backgrounds, particularly African American, Hispanic,
and Native American children, are more frequently removed from their homes and
placed into foster care settings. This higher rate of removal can be attributed to a
combination of factors, including socioeconomic disparities, implicit biases among
child welfare professionals, and a lack of culturally competent services and
interventions. These children often come from communities that experience higher
levels of poverty, limited access to quality education and healthcare, and greater
exposure to systemic racism and discrimination. These conditions can contribute to
higher rates of reported maltreatment and more severe outcomes when interacting
with CPS.
Once placed in foster care, minority children tend to stay in the system longer
than their non-minority counterparts. Several factors contribute to these extended
stays, including a shortage of foster homes that are willing or able to provide
culturally sensitive care, challenges in finding appropriate placements that meet the
children's needs, and systemic delays in case processing and service delivery. The
prolonged time in foster care can have detrimental effects on children's emotional and
psychological well-being, disrupting their sense of stability and continuity. They may
experience multiple placements, which can lead to further trauma and hinder their
ability to form secure attachments with caregivers.
Furthermore, minority children in foster care are less likely to be reunited with
their parents compared to children from non-minority backgrounds. Reunification
efforts are often complicated by a range of factors, including biases in decision-
making processes, inadequate support services for families of color, and structural
barriers that hinder parents' ability to comply with reunification plans. For instance,
parents from minority backgrounds may face greater challenges in accessing mental
health services, substance abuse treatment, housing, and employment opportunities,
all of which are critical components of reunification plans. Additionally, cultural
misunderstandings and language barriers can impede effective communication and
collaboration between families and child welfare professionals.
The disparities in reunification rates also reflect broader systemic issues within
the child welfare system. Minority families are more likely to be subjected to punitive
measures rather than supportive interventions, which can exacerbate the challenges
they face and reduce the likelihood of successful reunification. For example, African
American families may be more harshly judged and less likely to receive preventative
services that could help address the underlying issues leading to maltreatment reports.
This punitive approach not only undermines the goal of family preservation but also
perpetuates cycles of disadvantage and marginalization.
Efforts to address these disparities must involve comprehensive reforms that
promote equity and cultural competence within the child welfare system. This
includes implementing bias training for child welfare professionals, developing
culturally responsive assessment and intervention strategies, and increasing support
for minority families to prevent unnecessary removals and facilitate successful
reunifications. Additionally, policies and practices should be informed by data and
research that highlight the unique needs and experiences of minority children and
families within the child welfare system.
Community-based initiatives and partnerships can also play a critical role in
supporting minority families and reducing disparities in foster care. By engaging with
community organizations, faith-based groups, and culturally specific service
providers, child welfare agencies can better address the needs of minority children
and families. These collaborations can help bridge gaps in services, provide culturally
relevant resources, and foster trust and collaboration between families and the child
welfare system.
In conclusion, once maltreatment reports are made to child protective services,
children from minority backgrounds face a range of disparities that result in higher
rates of out-of-home placements, longer stays in foster care, and lower rates of
reunification with their parents. These disparities are driven by systemic biases,
socioeconomic inequities, and a lack of culturally competent services. Addressing
these issues requires comprehensive reforms, increased support for minority families,
and strong community partnerships to promote equity and improve outcomes for all
children in the child welfare system.
c. Trauma-and Stressor-Related Disorders
Simone is eight years old and in third grade. Until recently, she lived with her
mother in an apartment in the city. Simone’s parents had a highly conflictfilled
relationship and had been separated for several months following an incident in which
police responded to a domestic dispute call and found her mother badly bruised and
reporting that her husband had hit her. Frightened and confused by her husband’s
erratic behavior, Simone’s mother obtained a restraining order in an effort to keep
herself and Simone safe.
Simone, aware of her parents’ conflict, was becoming increasingly anxious
and protective of her mother. After a quiet period of several weeks, Simone woke one
night to a loud argument and realized that her father was in the house. Eventually,
Simone fell back asleep. In the morning, she went looking for her mother after calling
to her but receiving no answer. Simone found her mother’s body on the kitchen floor
in a pool of blood. Slowly realizing that her mother was dead, Simone, confused and
in shock, remained alone with her mother’s body for several hours until a concerned
neighbor, who had heard the argument the night before, let herself into the apartment,
called the police, and took Simone to stay with her in her nearby apartment.
In the weeks following this traumatic incident, Simone went to live with her
maternal grandmother. Her grandmother reports that, prior to the murder of Simone’s
mother, Simone was a generally shy, quiet, and guarded girl. Although she tended to
be somewhat anxious in new situations, Simone would usually become comfortable
after a short time and enjoyed being with friends, both at school and in the
neighborhood. However, since the day she found her mother’s body, she has been
especially withdrawn, resists going to school, and has been unable to answer
questions about finding her mother’s body. Simone now complains of frequent
nightmares and insists on sleeping with her grandmother. She appears tired most days,
is emotionally reactive, and reports experiencing frequent stomachaches.
Simone has recently begun seeing a therapist who specializes in working with
children who experience trauma. Although still unable to describe the events
surrounding her mother’s death, Simone has begun to draw pictures that include her
mother. These pictures likely represent initial attempts to work through the complex
psychological effects of the trauma. For example, Simone has drawn a series of
pictures of her mother encountering threatening creatures such as ferocious dinosaurs
and monsters. Proceeding slowly and carefully, Simone’s therapist has begun to help
her talk about these drawings in some detail. Although this is a tentative and indirect
process at this point, Simone has begun to organize and acknowledge some of the
thoughts and feelings related to both the sudden loss of her mother and the traumatic
experience of finding her body. Some of Simone’s more challenging symptoms—such
as emotional volatility and sleep disturbance— have begun to lessen in intensity and
frequency. However, others—such as difficulty separating from her grandmother—
have shown little change.
“Bad things happen. As much as we might wish otherwise, close friends and
relatives die, painful things happen to our bodies, there are natural disasters and war,
and sometimes people do senselessly horrible things to other people” (Bonanno &
Mancini, 2008, p. 369). When traumatic events occur, many children and adolescents
experience distress and dysfunction. There are a number of types of trauma- and
stressor-related disorders in DSM-5. Reactive attachment disorder and disinhibited
social engagement disorder are included in this category. Acute stress disorder
involves the display of multiple symptoms from any combination of categories (e.g.,
related to intrusion, dissociation, avoidance, and arousal) following exposure to a
traumatic event. Acute stress disorder is diagnosed when the duration of symptoms
lasts up to one month. Posttraumatic stress disorder (PTSD) involves the experience
of trauma and the display of symptoms from each category; PTSD is diagnosed when
symptoms last longer than one month. Intrusion symptoms include recurrent
memories of the trauma, frightening dreams, or flashbacks. Avoidance symptoms
include efforts to avoid people, places, or situations that are associated with the
trauma. Alterations in cognition or mood include dissociative symptoms (such as
difficulties with memory), negative beliefs about the self or others or the world, or
persistent negative mood (such as fear, anxiety, or shame). Alterations in arousal and
reactivity include hypervigilance, irritability, and extreme responses.
For many years, young children were not diagnosed with PTSD; their
developmental status was thought to be associated with forgetting and “bouncing
back” from terrible events. We now know that even infants and toddlers display some
of the symptoms of PTSD and that these may be appropriately conceptualized as
PTSD. In DSM-5, there are no differences in the set of diagnostic criteria for children
and adolescents (compared to adults). However, there is a subtype of PTSD for
preschool children, with fewer symptoms in the set of diagnostic criteria and some
developmentally informed adjustment in the descriptions of symptoms. It is important
to recognize that children frequently display subclinical symptoms, particularly
connected to more common and lower-magnitude stressors such as interpersonal loss.
Many of the children who display subclinical symptoms have experienced multiple
stressful events.
PTSD is more likely to be diagnosed in children and adolescents if there are
repeated, multiple, or prolonged experiences of trauma, more direct or severe
exposure, and/or a perceived lack of protection (e.g., trauma perpetrated by caregiver
or trusted adult, or trauma experienced when a child is separated from parents)
(Masten & Narayan, 2012). PTSD is a disorder that unfolds over time. In the
immediate wake of the trauma, all aspects of children’s adjustment are likely to be
affected.
During the acute stress period, emotions such as terror, helplessness, shame,
and sadness are common; intense physiological responses and behaviors are
additional complications (Keller & Feeny, 2014). Pynoos, Steinberg, and Piacentini
(1999, p. 1544) describe a seven-year-old who reported, “My heart was beating so fast
I thought it was going to break.” Cognitive functioning is disrupted, with confusion,
uncertainty, and misunderstanding. Younger children, for instance, are less likely to
appreciate the uncontrollable nature of intrusive thoughts (Sprung & Harris, 2010).
Appraisal and misappraisal of ongoing events and their likely causes and
consequences are particularly important developmental constructs to consider (Keller
& Feeny, 2014). For example, changing expectations of responsibility for personal
safety, as well as individual differences in appraisal processes and stress responses,
may exacerbate children’s reactions to trauma.
Adjustment to the trauma, or lack of adjustment, is related to many child
factors, including developmental status and neurobiological maturation, temperament
and attachment, and anxiety sensitivity; outcomes are also influenced by external
factors related to the nature of the trauma itself, parents and families, other life events,
and schools and larger social communities. The elements of trauma include the
frequency, intensity, and duration of exposure, and the specific form of trauma (e.g.,
natural disaster versus parental abuse), with longer, more intense trauma and trauma
involving human perpetrators associated with more severe and persistent PTSD.
Trauma details and reminders are often upsetting; they may come from unexpected
sources such as media reports. Children’s adjustments are sometimes embedded in the
adjustments of others as they witness the distress and horror of loved ones and their
continuing struggles to recover; indeed, there may be cascades of additional stressful
experiences that continue to negatively affect children.
A recent review of child development in the context of mass trauma
experiences such as disaster, war, and terrorism provides much-needed perspective on
the scope and impact of this awful global phenomena (Masten & Narayan, 2012).
Across countries and investigations, several findings are clear. First, children’s
exposure to danger and disaster varies widely, depending on geography,
socioeconomic status (SES), and political circumstances. Older children and
adolescents experience more adversity than younger children, and there are
cumulative effects with multiple stressful and traumatic experiences. Increased risks
are associated with separation from parents, proximity to threat, severity of threat,
dislocation, greater exposure to death of family and friends, and rape.
Understanding gender differences related to risk and disorder is complicated.
Boys are more likely to experience traumatic events, but girls are more frequently
diagnosed with PTSD. The effects of gender may be stronger for older youth. The
most salient protective factor is the availability of an attachment figure. Indeed, “the
buffering effect of proximity to parents and other attachment figures for children in
the midst of terrifying experiences is one of the most enduring findings in the
literature on war and other lifethreatening disasters” (Masten & Narayan, 2012, p.
229). In addition to these types of natural disasters and manmade horrors, everyday
tragedies can be associated with the emergence of PTSD. Serious car accidents, for
example, are a common cause.
Interpersonal trauma (such as maltreatment) is also clearly associated with
high-risk status (Cicchetti, 2016). Maltreatment coupled with exposure to family
violence is common (Gewirtz & Edleson, 2007). For children who experience
repeated interpersonal trauma, it is important to keep in mind that events intended to
provide safety are also often upsetting. Given the literature on the development of
attachment in maladaptive relationships, and that “parents provide children’s primary
protection from real or perceived danger, and thus, children’s and young adolescents’
perceptions of danger and how to stay safe,” it is not surprising that children who
were placed in foster care following maltreatment reported that the most frightening
event that they experienced was “placement in foster care”
Recent studies of children and adolescents who experience multiple and
complex interpersonal trauma (e.g., recurrent or chronic physical or sexual abuse)
suggest that a new diagnostic category be included in upcoming editions of the DSM:
developmental trauma disorder, a disorder involving both exposure and adaptation to
chronic trauma, with exposure often occurring in the context of a child’s caregiving
environment. Exposure to traumatic events is not uncommon, with estimates ranging
from one-fourth to two-thirds of children reporting some traumatic history by age 16.
Although we usually think of trauma in terms of the direct and lifethreatening
experiences just described, indirect forms of exposure (such as living in dangerous
environments or exposure to domestic or gun violence) are increasingly frequent
(Margolin & Vickerman, 2011). Because increased risk is associated with additional
exposure, the experience of both direct and indirect forms of trauma in ethnic
minority children from disadvantaged backgrounds is especially troubling.
d. Developmental Course
As emphasized previously, maltreatment is not a disorder for which a single
developmental course can be described. Instead, it is a risk factor whose impact may
be experienced in multiple domains and in various pathways over time. In the
physiological domain, a number of negative consequences of maltreatment have been
identified. With respect to brain structures and development, multiple regions, neural
circuits, and neurotransmitter systems are adversely affected, with impairments
frequently observed across the frontallimbic networks. The timing of maltreatment
matters. “Children may be especially vulnerable to the effects of maltreatment or
other pathological experiences during periods of rapid creation or modification of
neuronal connections”
Maltreatment, as well as exposure to toxic or chronic stress, also negatively
affect the developing HPA axis and hormone systems (Cicchetti, 2016; Pollak, 2015).
As described earlier, epigenetic changes affecting gene function are also set in motion
(Romens et al., 2015). These atypical physiological patterns may be associated with
both short-term advantages and long-term disadvantages. For example, one aspect of
disrupted neurological function has to do with regions of the brain involved in
emotion experience and regulation, including the processing of others’ facial
emotions. Abused children exhibit enhanced sensitivity to angry faces; their
perceptions are fine-tuned to respond to the most salient aspects of their social
environments (Pollak, 2015). Although these perceptions are exceedingly important to
attend to, especially in environments with ongoing threats, this hypersensitivity often
interferes with the development of effective and flexible self-regulation in later, less
threatening contexts.
With respect to cognitive processes, attention, memory, and problem solving
are all affected (Pollak, 2015). Although basic memory processes in maltreated
children appear generally similar to children who have not been maltreated, there is
evidence of difficulty with recalling specific autobiographical memories. These
difficulties may be related to the avoidance of negative emotion associated with
painful memories. Executive functioning (i.e., planning and behavior regulation) is
also impaired; risky decision making and problematic risk behaviors are frequently
observed. These are likely related to the atypical development of the prefrontal cortex.
Negativity bias, deficits in social information processing, and impaired problem
solving have all been described. Academic achievement is often compromised
(Schelble, Franks, & Miller, 2010). Chronicity must also be considered, with longer
histories of maltreatment associated with poorer cognitive outcomes.
Deficits in the self-system (i.e., self-concepts, selfregulation, autonomy) are
notable (Cicchetti, 2016). Some children and adolescents exhibit dissociation,
including atypical experiences of perception, memory, and identity. These dissociative
experiences are distinct from more typical dissociative states displayed by children
(often involving imaginative play and more permeable boundaries between fantasy
and reality). Dissociation following maltreatment is hypothesized to be related to
multiple episodes of trauma and the avoidance of painful emotions and memories, and
reflects the “collapse” of coping and regulation.
Peer difficulties have also been repeatedly observed. Maltreated children are at
increased risk for both bullying and victimization (Cicchetti, 2016; Luke & Banerjee,
2013). Some findings suggest that physically abused boys are more likely to display
physical aggression toward peers, whereas sexually abused girls are more likely to
display relational aggression. Poly-victimization, the experience of high levels of
many types of victimization, is a particularly distressing outcome. Children who
endure poly-victimization “experience physical and emotional abuse by caregivers,
assaults and harassment by peers, sexual victimizations by acquaintances and
strangers, and are exposed to crime and violence in their communities and
neighborhood—all this over the course of a relatively short period of time”
There are four pathways to becoming a poly-victim. Living in a dangerous
community involves exposure to violence and crime, neighborhood chaos, and a lack
of social ties and support, all of which contribute to an individual’s vulnerability in
multiple contexts. Living in a dangerous family involves intrafamily maltreatment
that leads to emotional dysregulation and problematic peer interactions, which in turn
lead to an individual being the target of bullies. Having a chaotic, multiproblem
family environment may include parental illness, unemployment, psychiatric
disorders, and poor supervision and neglect, all of which are associated with
vulnerability in both family and peer contexts. Having emotional problems that
increase risky behaviors and compromise adaptation is a pathway possibly related to
temperament; characteristics perceived as annoying, frustrating, disruptive, or overly
passive lead to heightened risk for maltreatment in family and peer contexts. This last
pathway is associated with earlier onset of poly-victimization. Two periods are linked
with spikes in onset: entry into elementary school and entry into high school.
There is a continuum of outcomes related to personality, psychopathology, and
physical health. Individuals with histories of maltreatment are at higher risk for
anxiety disorders, mood disorders, conduct disorders, substance abuse disorders,
personality disorders, and various poor health outcomes. Much of the research and
clinical attention has focused on the trajectory from maltreatment to mood disorders.
Children from minority backgrounds appear to be at higher risk for negative
outcomes (Cicchetti, 2013, 2016). We must also consider subclinical difficulties
(where the child or adolescent doesn’t meet the full set of diagnostic criteria) that
adversely affect individuals’ well-being. The results of a longitudinal investigation of
the impact of sexual abuse on the development of girls provide compelling data on
outcome variability. Three patterns of abuse and outcome were observed. The first
pattern involved sexual abuse by the biological father, early onset, and longer
duration. The second pattern involved abuse by the stepfather/mother’s boyfriend or
other relative, later onset, shorter duration, and less frequent violence. The third
involved abuse by multiple perpetrators, short duration, and severe violence. The first
pattern of abuse, involving the biological father, was associated with the poorest
outcomes. Across all the patterns of abuse, poor outcomes included atypical physical
development (e.g., early puberty, more obesity); more psychological and psychiatric
symptoms (dysregulated stress–response system, atypical cognitive development and
academic underachievement, atypical sexual attitudes and beliefs, and risky sexual
behaviors); ongoing victimization and sexual violence; and later, domestic violence.
Intergenerational consequences (such as less frequent secure attachment relationships
with their own children) were also noted.
Not all maltreated children display maladaptive outcomes. Many maltreated
children exhibit resilience. Resilience is a dynamic construct that encompasses many
levels of adaptation, including physiological, psychological, and social levels
(Cicchetti, 2010; Masten, 2011). In addition, each child’s resilience is embedded in
larger systems (e.g., families, communities, and cultures) that are themselves more or
less adaptive. When conceptualized in this way, resilience, as noted many times
previously, is not an all-or-nothing phenomenon.
A number of protective factors that promote resilience or recovery following
maltreatment have been identified, including genetic predispositions; child
characteristics such as average or above-average intelligence, positive emotionality
and optimism, and perceived self-efficacy and better self-regulation; and relationship
characteristics such as secure attachment and friendships. In one study of the well-
being of adults who had experienced child sexual abuse, greater life satisfaction was
reported by women, better-educated adults, employed adults, and adults who were in
positive relationships. As we consider the range of potential outcomes for maltreated
children, keep in mind the earlier example of maltreated children who are very
attentive to the expression of anger, and think about the ways in which young
children’s attempts to adapt to abusive or neglectful environments may lead to
maladaptation over time. One example of the connection between earlier adaptation
and later maladaptation might be that “a rigidly applied avoidant coping response
protects a child growing up amid violence and victimization, but can also lead to
clinical levels of anxiety or depression”. These connections between children’s
responses to maltreatment as it happens and their later difficulties are especially
important to consider in the context of chronic and uncontrollable stressors. “Children
who experience chronic stress (e.g., family conflict, economic hardship, exposure to
violence and victimization) tend to rely on cognitive and behavioral avoidance”; these
forms of coping may be the best available options in the short run, but they may
compromise long-term health and well-being.
The developmental course of PTSD varies. For some, symptoms improve over
time; for others, symptoms go from bad to worse. Many children and adolescents
display a “mixed picture of resilience and lingering vulnerability and harm”. Several
distinct PTSD pathways have been described, including a resilient (i.e., stress-
resistant) pathway, a response and recovery pathway, a delayed breakdown pathway,
and a chronic dysfunction (i.e., breakdown without recovery) pathway.
For those children and adolescents who struggle, the effects of stress and
trauma are noted across multiple levels and in multiple domains. PTSD is linked to
physiological changes involving both structure and function, with impairments similar
to those observed in children who have been maltreated. Damage to the hippocampus,
as well as atypical frontal lobe anatomy and volume, have been documented. In fact,
as summarized in the first section, the “effects of experience can become biologically
embedded in a developing organism,” and “bad timing . . . can disrupt development,
with longlasting implications for adaptive capacity, health, and vulnerability to later
trauma experiences”
Psychological maladaptation is also observed across domains of cognitive,
emotional, and behavior functioning. Again similar to children who have been
maltreated, children who experience traumatic stress display memory and problem-
solving difficulties, emotion dysregulation, and many types of behavior problems.
Sleep disturbances are common. Addressing sleep problems such as nightmares may
improve PTSD outcomes. PTSD may also disrupt a child’s management of age-
related tasks and challenges (BriggsGowan et al., 2010). Children who experience
family violence in early childhood, for instance, display disrupted and atypical
development related to attachment, self-regulation, and social and peer competence.
To the extent that trauma is related to disaster or war, and homes, neighborhoods,
schools, and economies are damaged or destroyed, a range of other childhood
experiences are also likely to be affected.
Although several protective factors appear to balance the risk for poor
outcomes, PTSD is associated with the later emergence of both internalizing and
externalizing disorders. Noninterpersonal trauma appears to be linked more often with
anxiety disorders. Chronic exposure to stress and trauma is associated with worse
outcomes, and gene-by-environment effects are implicated in worse outcomes for
girls and young women. Children who live in multirisk environments are likely to
display cascading effects of trauma, involving both atypical resolutions of
developmental challenges and internalizing or externalizing disorders. In addition to a
range of mental health outcomes, physical health may be adversely affected across the
lifespan (Moffitt, 2013). The construct of allostatic load may be especially useful in
thinking about mental and physical health trajectories.
One issue that remains unresolved is whether exposure to stress and adversity
involves inoculation versus sensitization effects (Masten & Narayan, 2012). With
inoculation effects, early exposure to stress allows children and adolescents to
develop and practice a variety of coping responses and may provide one kind of
protective effect. With sensitization effects, early exposure leads to physiological and
psychological changes that likely increase risk. Research suggests that moderate stress
(not the kind experienced in PTSD) may have beneficial effects, whereas “exposure to
overwhelming or capacity-depleting levels of adversity” is more likely to lead to
increased vulnerability. To take advantage of any stress-related benefits,
“interventions designed to build capacity for resilience would need to scaffold or in
other ways ensure an adaptive response in order to avoid risk of breakdown or
depletion of resilience capacity”
Many researchers and clinicians have suggested that resilience in the face of
trauma is more common than we might think. Bonanno differentiates resilience (i.e.,
the maintenance of pretrauma trajectories) from recovery (i.e., a trajectory
characterized by maladaptation following trauma, followed by gradual improvement).
Factors such as chronic versus acute stressors influence the timing and scope of
resilience, and may contribute to a mix of resilience and ongoing struggles (Bonnano
& Diminich, 2013). Factors that are associated with resilience and recovery include
child characteristics, family and relationship characteristics, and sociocultural
characteristics. Child factors include intelligence and positive personality
characteristics. Relationship factors include the availability and quality of attachment
figures and positive peers. As with the findings related to maltreatment, parenting is a
key source of support for children, even when the trauma involves domestic violence
in which the parent is the victim.
Peer support is also important. Children who were able to receive support
from classmates following Hurricane Katrina displayed better outcomes; these better
outcomes were likely related, in part, to the effects of shared experiences (Moore &
Varela, 2010). Community support also has been described as helpful. Former child
soldiers who were exposed to harrowing trauma displayed better outcomes in the
presence of community acceptance and social reintegration; opportunities for
schooling were particularly important. Sociocultural belief systems and traditions
(such as religious faith or rituals) may be an especially meaningful factor for positive
outcomes.
In addition to resilience and recovery, posttraumatic growth is possible.
Posttraumatic growth involves positive changes following trauma. These changes
include identification of personal strengths, appreciation for life, enhanced spirituality,
better relationships with others, and new possibilities for change and growth.
Posttraumatic growth “only occurs if trauma has been upsetting enough to drive the
survivor to (positive) meaning-making of the negative event”. Like resilience,
posttraumatic growth may be experienced along with periodic or ongoing distress and
dysfunction.
e. Etiology
Single-factor explanations of maltreatment (e.g., related to parent
psychopathology, parent’s own history of abuse, or poverty) have given way to more
complex models, such as the ecological–transactional model of child maltreatment
(Cicchetti, 2016). In that model, for example, multiple factors contribute to high-risk
outcomes. A number of parent factors increase the likelihood of maltreatment. Many
studies identify parents’ own histories of maltreatment as an important risk factor,
although rates of subsequent maltreatment vary widely. Additional parent factors
include younger parents, a history of psychiatric disorders, and parenting beliefs and
attitudes, such as those related to discipline (Lansford et al., 2015). The youngest and
poorest caregivers display the most negative parenting strategies. Parents with
intellectual disabilities are also more likely to neglect their children.
For instance, Kopp (2009) notes that toddlers most annoy their mothers when
they persistently whine, act aggressively, and fail to listen, whereas preschoolers are
most upsetting when they argue or talk back. “For some parents, positive interludes
are sufficiently satisfying to encourage their own coping, whereas for others, the
combination of rapid developmental change, child negatives, and unpredictability
promotes harsh, withdrawn, or imprudent childrearing”. In a recent study across 17
low- and middle-income countries, children with intellectual, language, sensory, and
motor disabilities were more likely to experience physical punishment, physical
aggression, and severe physical violence than children without disabilities. Providing
treatment to children, educating parents about caregiving in stressful circumstances,
and implementing broader social policies to address the high-risk status of these
children are vital concerns are require coordinated action (Hendricks et al., 2014).
Children’s internalizing and externalizing behaviors also increase the likelihood of
abuse, neglect, or both.
Family factors such as angry, conflictual, and violent relationships between
adults, chaotic and unstable home lives, and social isolation also increase the risk of
maltreatment. Sociocultural factors, including poverty and communities and cultures
that accept corporal punishment and violence as typical, also contribute to higher rates
of maltreatment (Lansford et al., 2015). The evidence for the intergenerational
transmission of maltreatment is mixed, with multiple factors influencing whether
children who experience abuse go on to abuse or neglect their own children.
Explaining the emergence of trauma- and stressorrelated disorders begins with
exposure to traumatic experiences. We need to understand children’s distress and
dysfunction in the context of particular traumatic events. Then, we need to account for
the specific factors that, in combination with trauma, lead to disorder.
Pretrauma factors, such as individual differences in genes that are involved in
the experience and regulation of stress, are likely to interact with environmental
factors to increase risk for some children exposed to acute or chronic trauma. Several
of these gene-by-environment effects have been described. For example, children and
adolescents with certain alleles are at higher risk for poor outcomes following
maltreatment compared to those without these alleles. Another example of gene-by-
environment impact involves the “biology of misfortune,” in which stress reactivity
combined with chronic stressors such as low SES and impoverished circumstances
lead to uneven distributions of mental and physical illness and disorder.
Neurodevelopmental models of early abuse and posttraumatic stress provide
details about changes in brain systems associated with threat perception and threat
response. In these models, physiological dysfunction is conceptualized first as an
underlying vulnerability (i.e., present in some children before the experience of
trauma) and second as a consequence of noxious experiences that disrupt normal
functioning (i.e., resulting in additional, perhaps permanent, dysfunction). Indeed,
newborns whose mothers experienced trauma during pregnancy (i.e., chronic and war-
related stressors) displayed changes in gene function connected to regulation of the
HPA axis (Kertes et al., 2016). Further, the “chronic destabilization of neuronal
networks in the hippocampus or cerebral cortex, combined with enhanced fear circuits
in the amygdala” may lead to the development of disorders such as PTSD (Flinn,
2006, p. 151). The trajectories underlying various disorders may depend on the timing
of brain development and stress. “Exposure to adversity at the time of hippocampal
development could lead to hippocampus-dependent emotional disorders, which would
be different from disorders arising from exposure to adversity at times of frontal
cortex development”
There are mixed data related to child age, with some studies suggesting that
younger children are more vulnerable to PTSD and others suggesting that older
children are at increased risk. These findings are likely related to a combination of
factors, including cognitive and emotional development, adult and peer support, and
type of stressor (Keller & Feeny, 2014). Gender plays a role, but a complex one, with
girls exhibiting more internalizing symptoms and boys more externalizing symptoms
(Keller & Feeny, 2014). Children with difficult temperaments experience greater risk.
Because temperamental characteristics are genetically influenced and associated with
the reactivity and regulation of emotionality and stress, this increased risk is not
surprising. In addition, trait anxiety and anxiety sensitivity are each associated with
the increased frequency of the somatic symptoms of PTSD (Hensley & Varela, 2008).
Protective roles for child and adolescent coping, intelligence, and positive personality
characteristics that reduce risk in the presence of atypical stressful experiences have
already been described in the previous section on the developmental course of PTSD.
Parents can influence the development of PTSD, for example, via the shotgun
effect, the lack of protective shield effect, and/or a toxic family effect. The shotgun
effect involves trauma that is so overwhelming that it produces anxiety symptoms in
all family members. In other words, parents as well as children struggle to deal with
the aftermaths of awful experiences such as the loss of a home in a fire or flood. The
lack of protective shield effect involves parents who, for varied reasons, cannot
provide the comfort, support, and security necessary for recovery. In these cases,
parents may not recognize or they may minimize the impact of a particular trauma on
children, believing that children are less affected by stress or that ignoring distress and
dysfunction will help a child move on. And the toxic family effect has to do with the
ways in which parent responses to trauma actually elicit and maintain anxiety
symptoms in their children. In some cases, for instance, parents may exacerbate their
children’s distress by having their children repeatedly recall the traumatic experience
or consider the possibility of new or repeat trauma.
Parents also contribute to children’s risk or resilience via socialization of
coping. Abaied and Rudolph (2010) describe two models that predict varied
outcomes. The first, the amplification-effects model, suggests that there are “stronger
risk effects for maladaptive coping suggestions and stronger protective effects for
adaptive coping suggestions.” The second, the differential effects model, suggests that
“socialization of coping has different, but equally significant, effects of risk for
psychopathology in the context of high versus mild stress”. Abaied and Rudolph also
note that girls and boys may respond to socialization of coping differently. Girls are
often more socially competent than boys and may be better prepared to implement
coping suggestions that require social skills. These varied parental responses to
stressful experiences are embedded, of course, in overall family environments that are
generally adverse or supportive.
The type of trauma that is experienced is important. Whether the experience
involves an objective or perceived threat, interpersonal or noninterpersonal trauma, or
single versus multiple or cascading traumatic events (e.g., toxic stress) influences the
development of disorder. Availability and access (or lack of availability or access) to a
range of resources and support may influence the development of trauma- and
stressor-related disorders. Following natural or humanmade disasters, or in war-torn
regions, economic factors (e.g., continued employment, and costs for food, housing,
and other essentials), political factors (e.g., discrimination, marginalization), and
community-based factors (e.g., schools and religious institutions) come into play and
may exacerbate or improve children’s and adolescents’ initial functioning.
f. Assessment and Diagnosis
Special clinical skills are very important when assessing children who have
been traumatized. Depending on the type of trauma, various accommodations related
to developmental and physical status, or legal requirements, may be necessary.
Assessment and diagnosis in very young children is especially challenging
(Lieberman et al., 2011). Sociocultural factors (such as family and cultural norms,
values, and available supports) must be appropriately addressed (Fontes & O’Neill-
Aran, 2008). In most cases, it will be useful to expand assessments beyond a focus on
the symptoms of disorder to include coping resources and social supports; at times,
crisis intervention will need to take place immediately screening for PTSD during all
initial mental health assessments. Parents should be included in evaluation whenever
possible. Questions related to exposure to traumatic events and children’s responses
should be specific.
For instance, the American Academy of Child and Adolescent Psychiatry
(AACAP) emphasizes the importance of using specific, targeted questions in
assessing children's responses to potentially traumatic events. Questions such as
"When you went past the house where the event occurred, did you get upset?" are
recommended because they are more likely to elicit useful information compared to
open-ended, more general inquiries.
The rationale behind using specific questions lies in their ability to prompt
detailed and specific responses from children who may have difficulty articulating
their experiences. Specific questions help focus the child's attention on particular
aspects of the event, making it easier for them to recall and describe their reactions
and emotions. This approach is especially crucial when assessing children who have
experienced trauma, as traumatic events can be overwhelming and may lead to
fragmented memories or difficulty organizing their thoughts.
AACAP also highlights the importance of using validated stressor checklists
and interview protocols in trauma assessment. These tools are designed to
systematically gather information about the child's exposure to potentially traumatic
events, their emotional and behavioral responses, and the impact of these experiences
on their functioning. By using standardized checklists and protocols, clinicians can
ensure consistency in assessment practices and obtain comprehensive information that
informs diagnosis and treatment planning.
Stressor checklists typically include a range of specific events that children
may have experienced, such as physical abuse, sexual abuse, witnessing violence,
accidents, natural disasters, or sudden loss of a loved one. These checklists allow
clinicians to identify and document the types of stressors the child has been exposed
to, providing a structured framework for further assessment and intervention.
Interview protocols complement stressor checklists by guiding clinicians
through a systematic process of gathering detailed information about the child's
experiences and responses to trauma. These protocols often include a combination of
open-ended questions, specific inquiries about the timing and context of traumatic
events, and prompts to explore the child's thoughts, feelings, and behaviors related to
the trauma. By following a standardized interview protocol, clinicians can ensure that
all relevant aspects of the child's experience are addressed while maintaining
sensitivity to the child's developmental stage and communication style.
Moreover, AACAP emphasizes the importance of conducting trauma
assessments within a supportive and culturally sensitive framework. Clinicians are
encouraged to consider the child's cultural background, family dynamics, and
community context when assessing trauma exposure and its impact. Cultural
competence in trauma assessment involves understanding and respecting diverse
beliefs, practices, and values related to trauma, resilience, and help-seeking behaviors
within different cultural groups.
In addition to using specific questions, stressor checklists, and interview
protocols, AACAP recommends a multidimensional approach to trauma assessment.
This approach may involve gathering information from multiple sources, including
the child, caregivers, teachers, and other relevant individuals who can provide insights
into the child's behavior and functioning across different settings. Collateral
information from these sources helps clinicians develop a comprehensive
understanding of the child's strengths, challenges, and support systems, which is
essential for developing targeted interventions.
Furthermore, trauma assessment often includes evaluating the child's
symptoms and functioning in relation to established diagnostic criteria for trauma-
related disorders, such as post-traumatic stress disorder (PTSD), acute stress disorder,
and adjustment disorders. Clinicians assess the presence and severity of symptoms
such as intrusive memories, avoidance behaviors, negative alterations in mood and
cognition, and hyperarousal. This diagnostic process guides treatment planning and
helps determine the most appropriate interventions to address the child's needs.
In summary, AACAP's guidelines underscore the importance of using specific,
targeted questions and validated assessment tools in trauma assessment with children.
By employing structured stressor checklists, interview protocols, and culturally
sensitive approaches, clinicians can gather comprehensive information about trauma
exposure, assess its impact on children's functioning, and develop tailored
interventions to promote healing and resilience. These evidence-based practices
support effective trauma-informed care and enhance outcomes for children who have
experienced traumatic events.
Assessments related to maltreatment are often multidisciplinary, involving
mental health professionals, physicians, and individuals from police and law agencies.
These assessments are often initiated by social service agencies such as child
protection units. Knowledge of best practices and ethical issues related to privacy and
informed consent is essential. Age- and gender-sensitive techniques, as well as the use
of multiple informants for sexually abused children and for children who have
witnessed family violence, are recommended.
Few children and adolescents report maltreatment. Patterns of disclosure in
youth range from no disclosure at all, to seeking help from peers, to seeking help from
adults (neighbors, teachers, school counselors, police officers), to displaying
internalizing or externalizing behaviors. Reticence to disclose may be related to
anxiety about disclosure, loss of control following disclosure, unpredictability of
events following disclosure, negative personal consequences (e.g., physical harm), or
worries about jail or legal consequences for the perpetrator. A close victim–perpetrator
relationship is associated with delayed disclosures. Asking children or adolescents
about emotional or psychological abuse is less frequent, but critically important.
Children and adolescents who have suffered because of natural disasters such as
earthquakes and hurricanes or because of terror attacks, or who live in war zones amid
widespread violence, also benefit from knowledgeable and compassionate
assessments.
Issues related to differential diagnosis and comorbidity are likely to involve
decisions about anxiety disorders, mood disorders, ADHD, or externalizing disorders,
and whether clinical presentations are consistent with single or multiple diagnoses
Margolin & Vickerman, 2011). Because of the frequent display of somatic symptoms
in children and adolescents who experience trauma, physical examinations are always
important.
g. Intervention
“In an ideal world, treatment would be readily available and strongly
encouraged at the time of disclosure” (Trickett, Noll, & Putnam, 2011, p. 469).
Treatments for children who have experienced maltreatment must address multiple
levels of distress and dysfunction. The Attachment and Biobehavioral Catch-up
(ABC) program is a brief, manualized intervention that targets three key behaviors:
providing nurturant care when children are distressed; following children’s leads
when they are not upset; and not exhibiting frightening behavior (Dozier & Roben,
2015). Although focused on promoting secure attachments, the ABC intervention is
also effective in enhancing children’s biological regulation. For children who
experience out-of-home placements or placement changes following maltreatment,
caregiver-based interventions mitigate HPA axis dysregulation (Fisher, Van Ryzin, &
Gunnar, 2011). Interventions that directly support children’s coping efforts may also
be especially important “for repairing and recalibrating physiological stress systems
(e.g., the HPA) that have adapted to chronic stress”
For young maltreated children, the goals of child– parent interventions include
amelioration of symptoms and support for ongoing development. Beneficial effects
related to secure attachment, the development of positive self-systems, and improved
parenting have all been described (Cicchetti, 2011, 2016). Child–parent
psychotherapy (CPP) is “an exemplar of a contemporary evidence-based, relational
treatment designed to intervene in and prevent child maltreatment via home
visitation”. Originally influenced by psychoanalytic models that emphasized the ways
that parents who failed to understand how their own histories of abuse and neglect
carried forward negative parenting attitudes and practices that compromised their
relationships and hurt their children, current CPP interventions incorporate a variety
of cognitive and behavioral techniques that are associated with positive outcomes.
Comprehensive, multilevel interventions that comprise both child-focused and
family-centered treatments are also recommended. These interventions include risk-
focused strategies, which reduce or prevent further risk; protection-focused strategies,
which add resources to counterbalance risk; and process-focused strategies, which
promote the development of well-being in domains of self-regulation and
relationships. For better outcomes, implementation of these varied interventions takes
racial and ethnic differences into account (Cicchetti, 2016). For children and
adolescents dealing with multiple kinds of maltreatment and victimization, timely
identification and treatment is necessary before any additional traumas are
experienced.
With respect to the treatment of PTSD, there is clear need for both acute,
crisis-oriented interventions and ongoing support (Layne et al., 2011; Masten &
Narayan, 2012). Crisis management often includes immediate support for the child
and all resources necessary to ensure health and well-being. The central components
of PTSD treatment involve reestablishing a sense of safety for the child, processing
and eventually reducing the intensity of emotional experiences, helping the child to
understand the impact of the traumatic event, addressing secondary stresses, and
providing support and guidance to the child’s caregivers (La Greca & Silverman,
2009). For experiences related to mass trauma, five principles are at the core of
intervention efforts: promote a sense of safety, promote calming, promote a sense of
self-efficacy and collective efficacy, promote connectedness, and promote hope
(Hobfoll et al., 2007). Treatments that take into account sociocultural resources,
community values, and important rituals and traditions are likely to achieve better
outcomes.
Cognitive and cognitive-behavioral approaches for PTSD have received the
most empirical support. Trauma-focused cognitive behavior therapy (TF-CBT) is a
multicomponent model that includes parent treatment, psychoeducation, relaxation
and stress management skills, cognitive coping skills, emotion regulation skills,
trauma narrative and cognitive processing of the traumatic experience, in vivo
desensitization to trauma reminders, joint parent–child sessions, and enhancement of
safety and future development. It is difficult to acknowledge that many children
experiencing chronic, uncontrollable stress “cannot be magically transported to safe
and nurturing environments”; working to build and strengthen their coping skills in
harsh settings is imperative. The National Child Traumatic Stress Network is an
organization focused on raising awareness and improving access to care for children
and adolescents who experience trauma. NCTSN identifies a number of evidence-
based treatments, supports efforts to disseminate those treatments, and provides
training for mental health professionals and nonprofessionals.
Individual, group, and family formats all appear to be successful; group
treatment may be especially useful in situations in which social and economic
resources are limited. Along with psychotherapy, many children and adolescents take
medications, but there is limited evidence that medications provide significant added
benefits (Keller & Feeny, 2014). For PTSD that follows maltreatment, there are a
number of comprehensive, structured interventions that are efficacious; these
interventions target the many domains of development that have been adversely
affected by ongoing trauma.
