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Child abuse' means harm or threatened harm to a child's health or welfare that occurs through nonaccidental physical or mental injury, sexual abuse, sexual exploitation, or maltreatment by a parent, a legal guardian, or any other person responsible for the child's health or welfare or by a teacher, a teacher's aide, a member of the clergy, or an individual aged 18 or older who is involved with a youth program.

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Report Abuse & Neglect

If you suspect abuse or neglect, call 855-444-3911 any time day or night. This toll-free phone number allows you to report abuse or neglect of any child or adult. One number.

One call. One person can make a difference.

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Information on the Children's Protective Services Program, child abuse reporting procedures, and help for parents in caring for their children.

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Potential Indicators of Abuse or Neglect

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Potential Indicators of Abuse or Neglect

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Determining when to report suspected child abuse or neglect can be difficult. A bruise on a toddler's forehead may be the result of learning to walk or the result of abuse. When in doubt, contact the local MDHHS office for consultation.

Listed on this resource are some of the commonly accepted physical and behavioral indicators of abuse and/or neglect.

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Determining when to report suspected child abuse or neglect can be difficult. A bruise on a toddler's forehead may be the result of learning to walk or the result of abuse. When in doubt, contact the local MDHHS office for consultation.

Below are some of the commonly accepted physical and behavioral indicators of abuse and/or neglect. Please note that the physical and behavioral indicators listed are not the only indicators of child abuse and neglect and if present, do not always mean a child is being abused or neglected.

Physical Neglect - Physical Indicators

Unattended medical needs.

Lack of supervision.

Regular signs of hunger, inappropriate dress, poor hygiene.

Distended stomach, emaciated.

Significant weight change.

Physical Neglect - Behavioral Indicators

Regularly displays fatigue or listlessness, falls asleep in class.

Steals/hoards food, begs from classmates.

Reports that no caretaker is at home.

Physical Abuse - Physical Indicators

Unexplained bruises (in various stages of healing), welts, loop marks.

Adult/human bite marks.

Bald spots or missing clumps of hair.

Unexplained burns/scalds.

Unexplained fractures, skin lacerations/punctures or abrasions.

Swollen lips/chipped teeth.

Linear/parallel marks on cheeks and temple area.

Crescent-shaped bruising.

Puncture wounds.

Bruising behind the ears.

Physical Abuse - Behavioral Indicators

Self-destructive/self-mutilation.

Withdrawn and/or aggressive-behavior extremes.

Uncomfortable/skittish with physical contact.

Arrives at school late or stays late as if afraid to be at home.

Chronic runaway (adolescents).

Complains of soreness or moves uncomfortably.

Wears clothing inappropriate to weather, to cover body.

Lack of impulse control (e.g. inappropriate outbursts).

Sexual Abuse - Physical indicators

Pain or itching in genital area.

Bruises or bleeding in genital area.

Sexually transmitted disease.

Frequent urinary or yeast infections.

Extreme or sudden weight change.

Pregnancy under 12 years of age.

Sexual Abuse - Behavioral Indicators

Withdrawal, chronic depression.

Sexual behaviors or references that are unusual for the child's age.

Seductive or promiscuous behavior.

Poor self-esteem, self-devaluation, lack of confidence.

Suicide attempts (especially adolescents).

Hysteria, lack of emotional control.

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Potential Indicators of Child Abuse and/or Neglect

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Determining when to report suspected child abuse or neglect can be difficult. A bruise on a toddler's forehead may be the result of learning to walk or the result of abuse. When in doubt, contact the local MDHHS office for consultation. Below are some of the commonly accepted physical and behavioral indicators of abuse and/or neglect.

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Understanding childhood trauma and abuse 

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Understanding childhood trauma and abuse 

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In this TED Talk, Tanya talks abut the abuse she suffered as a child by a family member. She details about the abuse not being at the fault of the child and how she overcame being victimized.

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Understanding childhood trauma and abuse | Tanya Waymire | TEDxFlowerMound

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Shedding Light on Disorganized Attachment and Trauma

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Shedding Light on Disorganized Attachment and Trauma

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Details what causes disorganized attachment, the signs, definition, and how it related to trauma.

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Invisible Wounds: Shedding Light on Disorganized Attachment and Trauma — Embodied Wellness, PLLC

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Did you know disorganized attachment and trauma are connected? You will learn the signs, causes, & treatments. Start trauma therapy in Detroit, Michigan.

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This blog article identifies how trauma relates to the different attachment styles. It also includes healing strategies.

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Complex PTSD occurs as a result of repeated or ongoing traumatic events. While complex trauma can happen at any time in life, this post focuses on attachment trauma related to childhood abuse or neglect. Most often there is a combined wound, in which you experience deficient nurturance from loving caregivers coupled with inadequate protection from dangerous situations or people. Growing up within an environment of fear, chaos, or rejection, and abandonment has significant and long-lasting repercussions on physical and emotional health.

As a result of attachment trauma, you might carry beliefs that you are damaged, not lovable, or that you cannot trust anyone. You might have feelings of shame, unworthiness, or helplessness. Perhaps, you feel plagued by anxiety or believe that you don't belong in this world.

"Attachment trauma can lead you to withdraw from relationships in order to avoid further rejection or hurt. Or, you might feel overly dependent upon others and fearful of rejection. If you relate to these symptoms, it is important to know that you are not alone. These painful emotions are remnants of your past."
~Dr. Arielle Schwartz

Complex PTSD and Childhood Trauma

Growing up with childhood trauma inhibits creativity and replaces curiosity with fear. Your ability to feel confident in your friendships or successful in school becomes hindered. Over time, feelings of insecurity and inadequacy inform your sense of self-they become your identity.

Often complex trauma begins in infancy. The nervous system of an infant is completely dependent upon caregivers to help them feel safe, connected, and calm. Growing up with parents who were dysregulated, abusive, or neglectful shapes a child's vulnerable nervous system. This can lead to long-lasting patterns of emotional and physiological distress that get carried into adulthood.

Sometimes, memories of physical or sexual abuse can lead to strong emotions and body sensations without a well-developed ability to explain your experience with words. These feelings can be difficult to understand. There may be parts of your memories that are unclear or forgotten. These experiences can evoke feelings self-doubt. Moreover, your ability to care for yourself as an adult is often a reflection of how you were cared for as a child.

Understanding Attachment Trauma

The first three years of life is referred to as the attachment phase of development. During this time, we need to feel safe and secure in our relationships with our mother, father, and other primary caregivers. This allows us to develop a healthy sense of self that forms the foundation for our ability to develop meaningful, healthy relationships as adults. If you have experienced C-PTSD in childhood, then these early relationships were most likely frightening, unpredictable, threatening, or unavailable. Your ability to form a "secure attachment" was likely disrupted.

Children respond to these earliest relationships by developing attachment styles which have been categorized into secure, insecure ambivalent, insecureavoidant, and disorganized attachment. Let's take a closer look:

Secure

This attachment style forms when a primary caregiver was predictable, consistent, and trustworthy. Your parents did not have to be perfect. In fact, times of disconnection or misunderstanding are inevitable. However, a "good enough" parent provides opportunities to repair these moments of disconnection which builds your capacity to handle stress. A child who feels securely attached typically views a parent as a source of comfort and feels comfortable exploring, learning, and playing. As an adult, this security translates into the ability to develop meaningful connections with others while handling inevitable conflicts skillfully.

Insecure ambivalent

This attachment style arises when a primary caregiver was inconsistent and unpredictable. There may have been times in which you felt cared for; but these were interspersed with experiences of being yelled at or rejected for expressing your needs. These mixed messages typically lead to feelings of uncertainty because you could not trust that a loving and caring parent would be there when you needed them. In adulthood, it is common to feel fearful about being abandoned accompanied by strong dependency needs toward others.

Insecure Avoidant

This attachment style arises when a primary caregiver was disengaged, distant, and unavailable. Typically, your needs to be loved, accepted, seen, and understood were dismissed or ignored. As a result, you learned to take care of your own needs by becoming independent and self-reliant. In adulthood, it is common to maintain a dismissive attitude toward your own emotions and extend this same position in your relationships with others. As a result, you might struggle with intimacy; especially when your partner desires a deeper connection.

Disorganized

This attachment style arises when a primary caregiver was chaotic and abusive. Instead of being a source of love and care, the parent was a source of terror. Because we have an innate, biological drive toward attachment, children still attach to parents, even if they are aggressive and cruel perpetrators of abuse. There is an inherent double bind between our inborn need for closeness and the equally strong need to escape danger. Over time, this unsolvable dilemma leads to feelings of helplessness and hopelessness. In adulthood, it is common to alternate between feeling high arousal emotions of fear, irritability, or anger and low arousal emotions of defeat, despair, or depression. It is also common to repeat the relational patterns learned in childhood either by choosing partners who are abusive or behaving in abusive manner yourself.

Of note, most of us develop a combination of different attachment strategies. In part, because we have more than one parent who may have treated us differently. Therefore, you might notice that you have a mixture of secure, insecure, and disorganized strategies.

Earned Secure Attachment

Most importantly, you have the capacity to develop "earned secure attachment" in which you learn how to feel securely attached in adulthood. An essential component of earned secure attachment is to recognize the impact of childhood events on your sense of self. In other words, you take responsibility for how your past has shaped you. The ability to coherently and accurately talk about your past is sign of earned security. Knowledge of your attachment deficits allows you to practice reaching out for support from others and tolerating increasing amounts of authentic connection. Furthermore, such self-awareness also helps you to successfully create repair when you have misunderstood or hurt a loved one.

Healing Strategy: Anchor your Adult Self

Unresolved attachment trauma is often held by a young part of self. This is commonly referred to as your inner child. At times, you might feel identified with this young part of you that feels small or insecure. Other times, you might feel more connected to your adult self, helping you to feel confident and strong.

This healing strategy helps you to connect your adult self so that you can reconnect to your resources. Remember, as an adult, you have a range of choices that weren't available to you as a child. You can recognize that your painful feelings are connected to memories from your past. Most importantly, you can recognize that the events of past are over now. As an adult, you can compassionately attend to the vulnerable feelings and emotions of held by a younger part of yourself. The following list of suggestions can be used to help anchor your adult self.

Say to yourself, "I know that I am an adult now and that I am safe."

Visualize an image of yourself as a child. Can you imagine looking into the eyes of your young self in a loving and compassionate manner?

Notice if you find it difficult to feel warmth or compassion toward your young self. If so, can you imagine another person who could be a loving ally for this young part of you? Can you imagine that person turning toward that part of you with kindness and love?

Imagine your adult self or loving ally to speak lovingly to your young self. Speak in a way that offers comfort, unconditional acceptance, protection, or reassurance to your young self.

If you find that you are having difficulty with this practice, remember that you do not need to heal alone. Often, the work of healing a young part of self is best accomplished in the compassionate care of a therapist.

In time, it is possible to reclaim a secure sense of self. With practice, you develop greater faith in your capacity to sustain a positive mindset and hopeful outlook toward your future. Remember, your hard-earned insights and experiences of empowerment cannot be taken away from you. Eventually, you can reach a tipping point of growth in which you no longer identify with the shame and burdens of your childhood wounds.

A Practical Guide to Complex PTSD

This post is an excerpt from my book, A Practical Guide to Complex PTSD: Compassionate Strategies for Childhood Trauma, which is meant to provide compassionate support for the process of healing from childhood trauma. You can think of it as a lantern that will illuminate the dark spaces and provide a sense of hope in moments of despair. The practical strategies you will learn in this book are taken from the most effective therapeutic interventions for trauma recovery. You will learn the skills to improve your physical and mental health by attending to the painful wounds from your past without feeling flooded with overwhelming emotion. My wish is to help you discover a new sense of freedom. The traumatic events of your past no longer need to interfere with your ability to live a meaningful and satisfying life. Click here to Order on Amazon.

Want to learn more about healing PTSD?

Connect to this post? The EMDR Therapy and Somatic Psychology book, is available on Amazon! Click here to increase your toolbox for healing. An integrative and effective approach to healing from trauma.

Enhance your Resilience

Read The Post Traumatic Growth Guidebook: Practical Mind-Body Tools to Heal Trauma, Foster Resilience, and Awaken your Potential. Within the pages of this book, you will find an invitation to see yourself as the hero or heroine of your own life journey. A hero's journey involves walking into the darkness on a quest for wholeness. This interactive format calls for journaling and self-reflection, with practices that guide you beyond the pain of your past and help you discover a sense of meaning and purpose in your life. Successful navigation of a hero's journey provides opportunities to discover that you are more powerful than you had previously realized. Click here to order the book on Amazon.

My Bestselling Workbook

In The Complex PTSD Workbook, you'll learn all about Complex PTSD Recovery and gain valuable insight into the types of symptoms associated with unresolved childhood trauma, while applying a strength-based perspective to integrate positive beliefs and behaviors. The Complex PTSD Workbook is available on Amazon! Click here to check it out.

Posted in Attachment, Complex PTSD, Mindfulness, Resilience Psychology Tagged Attachment Trauma, Complex PTSD, Parts Work Therapy, resilience-informed-therapy permalink

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Complex PTSD and Attachment Trauma - Arielle Schwartz, PhD

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Attachment trauma is related to childhood abuse or neglect. A wound of deficient nurturance from loving caregivers and inadequate protection from danger...

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This article talks about how disorganized children feel insecure in their attachment much like the other attachment styles, but how it relates to feeling unsafe as well.

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Helping connect the dots between your childhood experiences and your present-day struggles.

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Understanding Child Abuse And Neglect Statistics

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Understanding Child Abuse And Neglect Statistics

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This resource illustrates child abuse and neglect statistics, risks, effects, and action plans.

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Understanding Child Abuse And Neglect Statistics

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Lemonly is a visual design agency known as “Home of the World’s Best Infographics”. We create clarity through visuals by designing infographics, animated explainer videos, microsites, reports, and presentations.

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This resource lists the risk factors, protective factors, and consequences of child abuse and violence. This will help guide the approach to strengthen the people in your community.

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VetoViolence | Resources for violence prevention

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Violence can be stopped before it starts. Learn how with VetoViolence, CDC’s online violence prevention resource.

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ACEs prevention focuses on creating safe, stable, and nurturing environment. The experiences may be emotional or physical and increases health and behavioral challenges later in life.

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Ten Things You Can Do to Prevent Child Abuse

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Ten Things You Can Do to Prevent Child Abuse

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This is a toolkit that includes resources and materials for individuals and community organizations to use.

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Department of Children, Youth & Families

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DCYF is a cabinet-level agency focused on the well-being of children. Our vision is to ensure that Washington state’s children and youth grow up safe and healthy—thriving physically, emotionally and academically, nurtured by family and community.

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This toolkit includes resources for educators, parents and caregivers on understanding childhood traumatic stress. It also deep dives into the psychological and behavioral impact that trauma has on preschool, elementary, middle school, high school children.

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How Trauma is Changing Children's Brains

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How Trauma is Changing Children's Brains

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This article talks about the severe stress that effects students, and how understanding their traumatic stress helps the teacher to connect and create a trauma-sensitive classroom.

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For several years, John Snelgrove began his workweek with a lengthy fax from the local police, listing the home addresses where officers had answered domestic violence calls over the weekend.

Snelgrove, head of guidance services for Brockton (Mass.) Public Schools, would check those addresses against the district's student database. When a match came up, he'd alert the counselor at that child's school, who, in turn, would take a red envelope and deliver it to the child's teacher. Inside was a slip of paper with a student's name and a quick prescription for "TLC."

A Sunday night, disrupted by violence, panic, and 911 calls, surely will make it difficult for a child to settle down to learn on Monday morning. But, even more than that, researchers have found that exposure to unrelenting stress and repeated traumas can change a child's brain, making it easier to "fight or flee" from perceived dangers and harder to focus and learn. Understanding this neuroscience makes it possible for educators to create trauma-sensitive classroom.

"It's more than one or two children in your class of 28, it could be closer to 30 percent or more," Snelgrove tells his colleagues. But even children who haven't experienced trauma will benefit from the strategies that Brockton teachers and education support professionals have learned through years of training with the Massachusetts-based Trauma and Learning Policy Initiative, and their partnerships with local police, mental health, and child welfare agencies.

"Be consistent, be kind, focus on connecting with kids," he urges.

The Traumatized Brain

Back in the 1990s, Dr. Vincent Felitti, working with very obese adults, discovered that a shocking majority of his patients had suffered significant traumas during childhood. Eventually, his work led to a mega-study, involving tens of thousands of patients, which showed the long-lasting effects of "adverse childhood experiences," or ACEs, such as child neglect or abuse, or a parent with addiction or imprisoned. Those children often grow up to be adults who are more likely to be sick, to be violent, to miss work, and to marry often.

Since then, it's become clear that the damaging effects of trauma are not saved until adulthood. It starts early and it affects students and teachers: in fact, kindergartners who have had tough experiences score below-average in reading and math, even when other factors like household income and parental education are considered, a study published this year found. Those traumatized 5-year-olds also are three times more likely to have problems with paying attention, and two times more likely to show aggression.

What neuropsychologists have found is that traumatic experiences actually can alter children's brains. In times of great stress, or trauma, the brain activates its deeply instinctive, "fight, flight, or freeze" responses, while dialing down the areas of the brain where learning, especially around language, takes place. When this happens over and again, especially in children under age 5, the brain is fundamentally changed. Basically, it adapts for survival under the worst conditions.

"It's an appropriate adaptation to their circumstances," says Amanda Moreno, professor of early-child development at the Erikson Institute in Chicago. "But it comes at enormous cost to schooling, especially with the way we do schooling in this country, which is very standardized."

Traumatized 5-year-olds are three times more likely to have problems with paying attention, and two times more likely to show aggression.

Veteran Illinois special education teacher Kathi Ritchie knows what this looks like in a classroom: "You will see kids struggling with all areas of language, word retrieval, writing... memory suffers hugely. They tend to be forgetful. They don't remember content-area ideas that have been taught to them; the next day it's like they never were taught," she says. "The other thing that is huge is the behavior."

Living in a constant, fear-activated state of hyper-awareness means these children can be quick to rage, Ritchie has seen. In their subconscious efforts to self-protect, they often can be perceived as defiant, disrespectful or overly aggressive. Others may look like they're zoning out or drifting off, she says. "It can look like kids are shutting down, but their brain is telling them, 'you need to be safe.'"

Calming Colors, Safe Spaces, Mindfulness

So what's an educator to do? First, here's what not to do: Punish a child for showing the symptoms of a medical disorder. Trauma and stressor disorders can be found in the most up-to-date Bible of mental health disorders and diagnoses, the DSM-V, which means they are a real medical issue. Out-of-school suspensions are an inappropriate response and likely feed the school-to-prison pipeline.

Instead, what helps is to create a trauma-sensitive classroom where kids can feel safe and build resilience. Although Snelgrove no longer receives faxes from the local police because of revised confidentiality requirements, he hopes the "universal precautions" that Brockton teachers and education support professionals have embraced will catch any student who has experienced trauma.

Trauma-sensitive teachers often offer a "comfort zone" to their students, a safe space where kids can retreat and calm down. Sometimes it's as simple as a beanbag chair. Their classrooms also are neat and uncluttered. Think about how you feel coming home to a messy house, Snelgrove says. A little overwhelmed, right? It's worse for hyper-aroused children. Cool colors reign on the walls.

Ritchie also recommends teaching strategies that include predictable classroom routines with advance warning to students of any changes; asking students to repeat verbal instructions, using more written instructions, and also using visual prompts for multi-step directions, like a sticky post-it note on a desk. All students can benefit from short "movement breaks" every 30 minutes to "reframe the brain," she says.

Moreno's research currently involves the effects of mindfulness exercises on students in some of Chicago's roughest neighborhoods. Although her study is not yet complete, teachers and principals have told her that the time they are spending on mindfulness actually is leading to more time for instruction. Students refocus more quickly after transitions, and calm down after upsets. This makes classrooms more efficient, but it also helps with an even bigger goal: Helping children grow up to be healthy adults.

You will see kids struggling with all areas of language, word retrieval, writing... memory suffers hugely.

- Kathi Ritchie, special education teacher.

Apart from employing a mindfulness curricula, or classroom yoga practices, which also are gaining popularity, simply greeting students at the start of the day and "acknowledging their humanity" before diving into tasks will help, Moreno says. With all the demands placed on teachers, it can be difficult, even "radical," for teachers to slow down the pace of their classes and to take time with every student, but it will pay dividends, she says.

In Brockton, Snelgrove appreciates his district's leaders for investing in years of trauma-related training for teachers and education support professionals, and developing partnerships with police, mental health, and child welfare agencies. This isn't the stuff that appears on state-mandated standardized tests, he acknowledges. But it is the stuff that engages the "hearts and minds" of teachers and education support professionals, he says.

"We're not perfect, and I know we have a way to go, but when we talk about the 'whole child,' we mean it."

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How Trauma is Changing Children's Brains | NEA

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Understanding how severe stress affects students is the important first step in creating trauma-sensitive classrooms.

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Disorganized Attachment Style: Traits and Ways to Cope

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Disorganized Attachment Style: Traits and Ways to Cope

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This resource is a detailed article about disorganized attachment. It refers to the causes, symptoms, triggers, relationships and how it relates to adults.

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Disorganized attachment, also known as fearful-avoidant, is an insecure attachment style characterized by a fear of close relationships.

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5 Signs of Disorganized Attachment in Kids, and How to Support Them

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5 Signs of Disorganized Attachment in Kids, and How to Support Them

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This is a great resource for educators and parents on understanding the attachment style and how we can support them. This has a checklist on the signs that children has developed a disorganized attachment.

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5 Signs of Disorganized Attachment in Kids, and How to Support Them

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Children who experience disorganized attachment often fear their caregivers, but crave their attention. If you think your child has a disorganized attachment, here’s how experts say you can begin to heal your relationship.

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In this video, Dr. May describes how frightened or frightening parents can lead to a variety of negative effects on children. She describes the way disorganized children relate to their parents and the emotional and cognitive presentation of people with a disorganized attachment style. Toward the end, suggestions are provided for moving toward an "earned secure" attachment.

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What causes disorganized attachment in children?

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What causes disorganized attachment in children?

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This article reviews how the attachment forms in early childhood. What specifically causes it and how you can change and heal from disorganized attachment.

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Disorganized Attachment Style: Everything You Need to Know

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A disorganized attachment style (fearful-avoidant) develops when the child’s caregivers – the only source of safety – become a source of fear.

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Children who are traumatized are at risk for developing complications with attachment.

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Children who are traumatized are at risk for developing complications with attachment.

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This article goes over all types of trauma, the impact of trauma, the factors that lead to it and the psychopathology to what leads to trauma.

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Attachment
According to attachment theory created by John Bowlby [19], attachment patterns are "formed in the context of early experiences with caregivers and maintained by later interpersonal relationships in adulthood" [4].

Over time, attachment patterns become internalized and shape how individuals see the self and others in close relationships, which in turn influence how individuals perceive and cope with stress through the lifespan [4].

A researcher named Mary Ainsworth identified three categories of infant attachment styles: secure, insecure avoidant, and insecure ambivalent/resistant [20].

Securely attached babies and children "feel confident that the attachment figure will be available to meet their needs. They use the attachment figure as a safe base to explore the environment and seek the attachment figure in times of distress" [21].

Insecure avoidant children "do not seek contact with the attachment figure when distressed. Such children are likely to have a caregiver who is insensitive and rejecting of their needs. The attachment figure may withdraw from helping during difficult tasks and is often unavailable during times of emotional distress" [21].

Insecure ambivalent/resistant children fail to "develop any feelings of security from the attachment figure. When distressed they are difficult to soothe and are not comforted by interaction with the attachment figure. This behavior results from an inconsistent level of response to their needs from the primary caregiver" [21].

Research has also shown that trauma involving caregivers may significantly disrupt caregiver-child attachment, leading to insecure or disorganized attachment.

Insecure Attachment and Trauma

Inconsistent or unavailable caregivers disrupt children's formation of secure attachments and promote reliance on ineffective emotion regulation strategies, leading to the formation of insecure attachment [26].

Early life traumatic events, such as child maltreatment by caregivers, can disrupt the formation of secure attachment [4].

Longitudinal research suggests that insecure attachment may increase over time among individuals with severe trauma histories and disrupt the developmental process [27].

Insecure parental attachment may lead to negative consequences including increased levels of stress hormones, negative views of themselves and others, and poor regulation of emotion and and/or behavior [1].

Inconsistent and inadequate attachment relationships may also lead to externalizing behaviors (e.g., aggression, bullying) that are linked with subsequent conduct problems [1].

As a result of insecure attachment, feelings of fearfulness and helplessness are generally pervasive through the lifespan and are commonly demonstrated in infant and child behavior [16].

Research shows that fearfully attached individuals are more likely to perceive and interpret events as stressful, which in turn increases their vulnerability to experience adverse psychological symptoms and develop severe psychopathology [25].

The effects of trauma may also be transmitted within relational exchanges that occur between parents and children:

If a parent has untreated trauma, when the parent re-experiences states of terror or rage, the children may be traumatized by the parent's traumatized state and feel frightened by the parent, rather than soothed by them. Consequently, the children may become traumatized themselves [2].

Children may exhibit a tendency to block out or constrict feelings of vulnerability and painful experiences as modeled by attachment figures; over time, children may develop problems identifying and managing their own feelings [16].

Adult survivors of childhood maltreatment are more likely to have insecure rather than secure attachment styles [14]. Trauma survivors with insecure attachment report more trauma-related symptomatology in adulthood [4].

Insecure attachment predicts avoidance of memories of the abuse and avoidant, dependent, self-defeating, and borderline personality disorders in adulthood among incest survivors [12] [13].

Insecurely attached individuals also show higher depression, distress, and posttraumatic stress symptoms than traumatized people who exhibit secure-based attachment [4] [13].

Additionally, older adults who experienced their worst trauma in childhood or adolescence report a higher number of traumatic events through their lifespan compared to older adults who encountered their worst trauma in adulthood [24].

Disorganized Attachment, Trauma, and Dissociation

A fourth category of attachment style was later identified as the "disorganized/disoriented" type [22]. Children exhibiting disorganized behaviors did not fit into the other categories of attachment.

Behaviors coded as disorganized/disoriented included overt displays of fear of the caregiver, contradictory behaviors or affects, misdirected or jerky movements, or freezing and apparent dissociation when approaching the caregiver [23].

This classification has been found to be a risk factor for later developmental problems and tends to be associated with experiencing trauma such as maltreatment during infancy or childhood [23].

In normal, middle class families, about 15% of infants develop disorganized attachment behavior; however, in unhealthy social contexts and in clinical groups this percentage is 2 or even 3 times higher [15].

A meta-analysis revealed that 48% of infants classified as disorganized were assessed by social services as having experienced abuse or neglect [23].

Disorganized caregiver-child attachment is associated with increased vulnerability to later psychological difficulties, especially dissociative experiences [2].

Many dissociative patients may have had disorganized attachment with at least one attachment figure in childhood [8].

Longitudinal research demonstrates that disorganized attachment in infancy specifically predicts dissociation in childhood and early adulthood [7].

Experiencing trauma in infancy also has an enduring impact on the maturation of the right side of the brain [11].

Disorganized attachment may result from parental abuse, neglect, and/or frightening, intrusive, or insensitive behaviors [7].

Parental "frightened and/or frightening behavior" experienced in infancy also leads to an increased vulnerability to dissociative disorders [8].

Dissociative and helpless or withdrawing behaviors in parents have also been found to predict infants' disorganized attachment behaviors [23].

Parents' ongoing experiences of anxiety disorders or forms of social and economic disadvantage have additionally been found to predict disorganized attachment behaviors [23].

Although childhood abuse contributes to the development of dissociative identity disorder (DID), attachment difficulties also likely play a central etiological role in many cases [5].

Blizard (1997) states, "When a child is dependent for survival on a parent or caregiver who is abusive, the child faces an extraordinary dilemma in finding a way to preserve attachment to the caregiver while trying to survive terrifying abuse" [6].

Furthermore, parental loss or other severe life events within the first 2 years of a child's life are also risk factors for the development of dissociative disorders [10].

Severe life events may affect the parental relationship in the crucial period when attachment develops, and contribute to disorganized attachment, which may increase the likelihood of dissociation in later life [10].

[1] Anderson, S. M., & Gedo, P. M. (2013). Relational trauma: Using play therapy to treat a disrupted attachment. Bulletin of the Menninger Clinic, 77(3), 250-268.

[2] Brothers, D. (2014). Traumatic attachments: Intergenerational trauma, dissociation, and the analytic relationship. International Journal of Psychoanalytic Self Psychology, 9(1), 3-15.

[3] Zilberstein, K. (2014). Neurocognitive considerations in the treatment of attachment and complex trauma in children. Clinical Child Psychology and Psychiatry, 19(3), 336-354.

[4] Ogle, C. M., Rubin, D. C., & Siegler, I. C. (2015). The relation between insecure attachment and posttraumatic stress: Early life versus adulthood traumas. Psychological Trauma: Theory, Research, Practice, and Policy, 7(4), 324-332.

[5] Barach, P. M. (1991). Multiple personality disorder as an attachment disorder. Dissociation: Progress in the Dissociative Disorders, 4(3), 117-123.

[6] Blizard, R. A. (1997). The origins of dissociative identity disorder from an object relations and attachment theory perspective. Dissociation: Progress in the Dissociative Disorders, 10(4), 223-229.

[7] Blizard, R. A. (2003). Disorganized Attachment, Development of Dissociated Self States, and a Relational Approach to Treatment. Journal of Trauma & Dissociation, 4(3), 27-50.

[8] Liotti, G. (1992). Disorganized/disoriented attachment in the etiology of the dissociative disorders. Dissociation: Progress in the Dissociative Disorders, 5(4), 196-204.

[9] Lyons-Ruth, K. (2008). Contributions of the mother-infant relationship to dissociative, borderline, and conduct symptoms in young adulthood. Infant Mental Health Journal, 29(3), 203-218.

[10] Pasquini, P., Liotti, G., Mazzotti, E., Fassone, G., & Picardi, A. (2002). Risk factors in the early family life of patients suffering from dissociative disorders. Acta Psychiatrica Scandinavica, 105(2), 110-116.

[11] Schore, A. N. (2009). Attachment trauma and the developing right brain: Origins of pathological dissociation. In P. F. Dell, J. A. O'Neil, P. F. Dell, J. A. O'Neil (Eds.). Dissociation and the dissociative disorders: DSM-V and beyond (pp. 107-141). New York, NY: Routledge/Taylor & Francis Group.

[12] Alexander, P. C. (1993). The differential effects of abuse characteristics and attachment in the prediction of long-term effects of sexual abuse. Journal of Interpersonal Violence, 8(3), 346-362.

[13] Alexander, P. C., Anderson, C. L., Brand, B., Schaeffer, C. M., Grelling, B. Z., & Kretz, L. (1998). Adult attachment and longterm effects in survivors of incest. Child Abuse & Neglect, 22(1), 45-61.

[14] Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1989). Disorganized/disoriented attachment relationships in maltreated infants. Developmental Psychology, 25(4), 525-531.

[15] van Ijzendoorn, M. H., Schuengel, C., & Bakermans-Kranenburg, M. J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and Psychopathology, 11(2), 225-249.

[16] Lyons-Ruth, K., Yellin, C., Melnick, S., & Atwood, G. (2005). Expanding the concept of unresolved mental states: Hostile/Helpless states of mind on the Adult Attachment Interview are associated with disrupted mother-infant communication and infant disorganization. Development and Psychopathology, 17(1), 1-23.

[17] Lyons-Ruth, K., Bronfman, E., & Parsons, E. (1999). Maternal frightened, frightening, or atypical behavior and disorganized infant attachment patterns. Monographs of the Society for Research in Child Development, 64(3), 67-96.

[18] Main, M., & Hesse, E. (1990). Parents' unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism?. In M. T. Greenberg, D. Cicchetti, E. M. Cummings, M. T. Greenberg, D. Cicchetti, E. M. Cummings (Eds.). Attachment in the preschool years: Theory, research, and intervention (pp. 161-182). Chicago, IL: University of Chicago Press.

[19] Bowlby, J. (1969). Attachment and loss, volume 1: Attachment. New York, NY: Basic Books.

[20] Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49-67.

[21] McLeod, S. A. (2014). Mary Ainsworth. Retrieved from www.simplypsychology.org/mary-ainsworth.html

[22] Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M.T. Greenberg, D. Cicchetti & E.M. Cummings (Eds.), Attachment in the preschool years (pp. 121-160). Chicago, University of Chicago Press.

[23] Duschinsky, R. (2015). The emergence of the disorganized/disoriented (D) attachment classification, 1979-1982. History of Psychology, 18(1), 32-46.

[24] Ogle, C. M., Rubin, D. C., & Siegler, I. C. (2013). The impact of the developmental timing of trauma exposure on PTSD symptoms and psychosocial functioning among older adults. Developmental Psychology, 49, 2191-2200.

[25] Pielage, S., Gerlsma, C., & Schaap, C. (2000). Insecure attachment as a risk factor for psychopathology: The role of stressful events. Clinical Psychology and Psychotherapy, 7, 296 -302.

[26] Goodman, G. S., Quas, J. A., & Ogle, C. M. (2010). Child maltreatment and memory. Annual Review of Psychology, 61, 325-351.

[27] Mikulincer, M., Ein-Dor, T., Solomon, Z., & Shaver, P. R. (2011). Trajectories of attachment insecurities over a 17-year period: A latent growth curve analysis of the impact of war captivity and posttraumatic stress disorder. Journal of Social and Clinical Psychology, 30, 960 -984.

[28] Kumar, S., & Mattanah, J. F. (2016). Parental attachment, romantic competence, relationship satisfaction, and psychosocial adjustment in emerging adulthood. Personal Relationships. doi:10.1111/pere.12161

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Trauma's Impact on Attachment - TeachTrauma

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Children who are traumatized are at risk for developing complications with attachment. Attachment According to attachment theory created by John Bowlby [19], attachment patterns are "formed in the context of early experiences with caregivers and maintained by later interpersonal relationships in adulthood" [4]. Over time, attachment patterns become internalized and...

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Empathic Care for Children With Disorganized Attachments: A Model for Mentalizing, Attachment and Trauma-informed Care

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Empathic Care for Children With Disorganized Attachments: A Model for Mentalizing, Attachment and Trauma-informed Care

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This book is a practical guide to caring for children and young people with disorganized attachment and related emotional and psychological difficulties. Synthesising attachment, trauma and mentalization theory into a useful practice model, Empathic Care for Children with Disorganized Attachments proposes ways of meeting the needs arising in children and young people with disorganized attachments. Focusing on the importance of interpersonal bonds to facilitate the child's capacity to mentalize, it aims to equip the reader with the appropriate skills to provide effective, sustained and, most importantly, empathic care to the most vulnerable and troubled children.

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Empathic Care for Children With Disorganized Attachments: A Model for Mentalizing, Attachment and Trauma-informed Care [Taylor, Chris] on Amazon.com. *FREE* shipping on qualifying offers. Empathic Care for Children With Disorganized Attachments: A Model for Mentalizing, Attachment and Trauma-informed Care

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This article goes into detail about how attachment problems happen, how to children react to certain situations and their responses.

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Vol. 19, No. 3
July 2014

Understanding the quality of a child's attachment with his caregivers can help you intervene more effectively to promote safety, well-being, and permanence.

Every Child Has Attachment
Before we go further, it's important to understand one fundamental concept about attachment. The question isn't whether or not children are attached to their caregivers. Attachment isn't something a child has or doesn't have.

Attachment develops even in the face of maltreatment and severe punishment. It is the quality of the attachment relationship that is compromised in these circumstances, not the presence or strength of attachment (Carlson, et al., 2003).

In other words, no matter how harmful a child's parents might seem, the child still has a strong attachment to them that needs to be respected. A child removed from an abusive or neglectful home will experience just as much pain and trauma, and possibly even more, than a child separated from a healthy and loving parent. As you probably know from experience, children are unlikely to be relieved or grateful at being "rescued," regardless of how clear-cut the danger may appear to us. In fact, for children who lack a safe and secure attachment figure in their lives, being removed from their home is likely to reinforce their negative beliefs about themselves and the world around them.

The table below provides detail on the different categories of attachment and what you might see in each when a child is in distress. As the table indicates, there are two main categories of attachment--organized and disorganized.

Organized Attachment
When most people hear the words "organized attachment," they usually think of secure attachment. This is natural. Most children have attachment that can be described as secure. The benefits and hallmarks of this type of attachment are described in detail in the preceding article.

Yet some children's attachment can be considered "organized," even though it is not secure. When caregivers are unable or unwilling to respond to a child's basic need for food, comfort, and nurturing, children figure out other ways to get their needs met. In the process they may develop patterns of behavior with their caregiver that elicits what they need despite the lack of consistent, sensitive care. Some of these patterns are considered "organized" because, in a sense, the child knows what to do and does the same things repeatedly.

While to an outsider the behavior looks problematic, it helps the child survive. It is a coping mechanism that makes sense in the context of the child's primary relationship. However, when transferred to other people, these behaviors create barriers and can make others turn away from giving the child what he most needs: safe, consistent care.

There are two types of insecure attachment:

Insecure-Avoidant

Child explores with minimal interaction or checking in with the caregiver.

No extra emotion in sharing delight or upset with parent.

Child doesn't seek interaction or closeness to the caregiver after separation or when distressed, and doesn't respond when caregiver provides it.

When distressed, child avoids parent and minimizes emotions.

Insecure-Resistant

Child seems wary of strangers and shows little interest in normal exploration.

Child often cries or seeks caregiver even before separation. Unable to happily move away.

Having the caregiver return or attempt to provide comfort doesn't help or reassure. Child alternates between actively seeking contact and struggling/crying/stiffness.

Child shows anger and anxiety when caregiver attempts to comfort.

When distressed, child exaggerates resistance and distress to try to get needed attention from inconsistent or unresponsive caregiver.

(Benoit, 2004; Carlson, et al., 2003; Flaherty & Sadler, 2011)
Disorganized Attachment
This is the category that describes children with the most significant attachment problems. It's likely you work with children who have this type of attachment due to their histories of abuse and severe neglect. In a large analysis that looked at over 80 studies, up to 80% of children with a history of parental maltreatment or drug abuse had disorganized attachment. By contrast, only about 15% of children from low-risk families had disorganized attachment (Van Ijzendoorn et al. 1999, cited in Green & Goldwyn 2002).

Disorganized Attachment

Caregiver's behavior is "frightening, frightened, dissociated, sexualized, or otherwise atypical" (Lyons-Ruth, et al., 1997).

Child shows apparently undirected, inconsistent, and sometimes contradictory responses to parent (e.g., an infant who kicks, struggles, fails to focus attention on any one person or activity, without any apparent pattern or rhyme or reason).

Sometimes child shows abnormal behavior (freezing, repetitive self-stimulating behaviors).

Child's behavior believed to result from caregiver being a source of fear; child is in conflict between wanting to flee to and flee from the caregiver.

(Benoit, 2004; Carlson, et al., 2003; Flaherty & Sadler, 2011)

These children exist in a chronic, low-level state of arousal and stress: in survival mode. If you have learned that people who try to care for you are dangerous or untrustworthy, then even a caring and well-meaning foster parent who tries to offer comfort could be perceived as a threat.

Children with attachment insecurity, especially disorganized attachment, are at increased risk for oppositional defiant disorder (ODD) and related behavioral disorders, as well as dissociative disorders, and are more likely to have academic and social deficits (Boris, et al., 2007).

If You Suspect Attachment Problems
The next article offers suggestions for what to do if you suspect a family you are working with is struggling with insecure or disorganized attachment.

Before you turn the page, it may be helpful to note that not all children will continue to have severe attachment problems throughout their lives. In one of the few long-term studies that has been done, 25% of children who were attachment disorganized as infants did not show disorganized attachment at age seven (Lyons-Ruth et al. 1997, cited in Green & Goldwyn, 2002).

References for this and other articles in this issue

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Vol. 19, No. 3 July 2014 Understanding the quality of a child's attachment with his caregivers can help you intervene more effectively to promote safety, well-being, and permanence. Every Child Has Attachment Before we go further, it's important to understand one fundamental concept about attachment.

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Assessment materials and other resources for clinicians and researchers focused on trauma-related assessment of children and/or adolescents.

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Child/Adolescent Trauma Assessments | International Society for Traumatic Stress Studies

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This resource talks about the different systems with screening and assessments. It also details what the focus of assessment for young children and the instruments you can use for assessing traumatic stress.

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The National Child Traumatic Stress Network

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Screening and Assessment Within Multiple Systems

Due to the particular developmental risks associated with young children's traumatic experiences, it is essential that vulnerable children be identified as early as possible after the trauma. Many community resources-including health systems, Early Intervention programs, child welfare agencies, Head Start, child care programs, and early education systems-play an important role in identifying children, and in linking them and their families with services.

Some of these systems now try to address possible traumatic experiences by including questions about specific traumas into their intake and/or assessment protocols. For example, both Head Start and Early Intervention intake protocols include questions about domestic violence in families. Other protocols may include targeted questions about accidents, loss of family members, and/or significant medical history. Most young children are seen at regular intervals by providers in the pediatric health care system, enabling repeated opportunities for identifying early childhood trauma. As such, medical providers can also play an important role in diminishing risks and in maximizing protective factors associated with young children's exposure to trauma. They can supply information to prevent accidents and can incorporate questions about stressful and traumatic experiences into their interviews with families.

Focus of Assessment for Young Children

Assessment of trauma in young children must focus on the presenting problem in the context of the child's overall development. This information can be gathered though interviews with the parents and significant caregivers in the child's life, observation of the parent/caregiver-child interaction, and standardized assessment tools. Clinical assessment should include review of the specifics of the traumatic experience including:

Reactions of the child and parents/caregivers

Changes in the child's behavior

Resources in the environment to stabilize the child and family

Quality of the child's primary attachment relationships

Ability of parents/caregivers to facilitate the child's healthy socioemotional, psychological, and cognitive development

When conducting an assessment of a young child, it is also important to assess developmental delays (e.g., gross/fine motor, speech/language, sensory processing), which may indicate that the child could benefit from evaluation and/or services from another professional (e.g., occupational therapist, speech/language therapist, physical therapist). It is often helpful to consult and to work collaboratively with these professionals.

Instruments for Assessing Traumatic Stress in Young Children

Below is a list of some of the standardized instruments used within the NCTSN to assess traumatic stress in young children.

Child Behavior Checklist (CBCL): Achenbach, and Rescorla (2001). Ages 1½-5

Posttraumatic Stress Disorder Semi-Structured Interview and Observation Record: Scheeringa and Zeanah (1994). Ages 0-4

Posttraumatic Symptom Inventory for Children (PT-SIC): Eisen (1997). Ages 4-8

Preschool Age Psychiatric Assessment (PAPA): Egger and Angold (1999). Ages 2-5

PTSD Symptoms in Preschool Aged Children (PTSD-PAC): Levendosky, Huth-Bocks, Semel, and Shapiro (2002). Ages 3-5

Traumatic Events Screening Inventory-Parent Report Revised (TESI-PRR): Ghosh et al. (2002). Ages 0-6

Trauma Symptom Checklist for Young Children (TSCYC): Briere et al. (2001). Ages 3-12

Violence Exposure Scale for Children-Preschool Version (VEX-PV): Shahinfar, Fox, and Leavitt (2000). Ages 4-10

Violence Exposure Scale for Children-Revised Parent Report (VEX-RPR): Shahinfar, Fox, and Leavitt (2000). For parents of preschool-aged children aged 4-10

# data[].attributes.attachment_link.description
Due to the particular developmental risks associated with young children's traumatic experiences, it is essential that vulnerable children be identified as early as possible after the trauma. Many community resources-including health systems, Early Intervention programs, child welfare agencies, Head Start, child care programs, and early education systems-play an important role in identifying children, and in linking them and their families with services.

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This goes in-depth about the assessment of the impact of trauma a child has experienced, how the trauma impacts the relationships with their caregivers and it also recommendations for services or community supports for the child and family/caregivers.

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A comprehensive trauma assessment is an in-depth assessment of the impact of trauma a child has experienced, how the trauma impacts the relationship with the child’s caregivers and the child’s functioning, and recommendations for services or community supports for the child and family/caregivers.

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9 Childhood Trauma Tests & Questionnaires 

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9 Childhood Trauma Tests & Questionnaires 

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This resource details how childhood trauma assessments help identify past experiences affect their emotional and psychological development.

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Childhood trauma is a difficult topic to navigate. We don't like to think or talk about children being hurt.

But if we're working with clients who may have been traumatized, we really need to understand it - what it means, how it manifests, and how to identify it.

Accurate childhood trauma tests are an important part of the therapeutic process if we suspect that trauma may have occurred.

In this article, we highlight examples and signs of childhood trauma. We also provide a list of proven childhood trauma tests for clinical practice and research. We end with a look at post-traumatic growth and positive psychology strategies to work with trauma and to foster resilience and positive growth.

Before you continue, we thought you might like to download our three Resilience Exercises for free. These engaging, science-based exercises will help you effectively deal with difficult circumstances and give you the tools to improve the resilience of your clients, students, or employees.

8 Examples of Childhood Trauma

Childhood trauma can take many forms and have lasting effects on an individual's emotional, psychological, and even physical wellbeing (Van der Kolk, 2003).

Below are just a few examples of childhood trauma; each individual's experience is unique.

1. Abuse

Abuse is defined by its intention to harm and can be physical, emotional, or sexual in nature (Terr, 2003). Abuse involves various forms of harm inflicted upon children by caregivers, significantly impacting their wellbeing (Legano et al., 2009).

2. Neglect

Childhood neglect refers to the failure of caregivers to provide for a child's basic needs, including food, shelter, supervision, and emotional support (Gould et al., 2012; Young & Widom, 2014).

Childhood neglect, which also includes emotional neglect, can lead to significant developmental, emotional, and psychological consequences, including difficulties forming healthy relationships, low self-esteem, and increased vulnerability to mental health issues later in life (Legano et al., 2009).

3. Witnessing violence or trauma

Children who witness violence or trauma, such as domestic violence, accidental injury, car crashes, or the death of a loved one, can experience feelings of fear, helplessness, and confusion resulting in trauma, even if they are not directly abused themselves (McCloskey & Walker, 2000).

4. Separation or loss

Loss of a parent through death, divorce, abandonment, or other circumstances can have severe traumatic effects for a child (Benz et al., 2004).

5. Natural disasters

Children who experience or witness natural disasters such as an earthquake, flood, fire, or hurricane may develop trauma-related symptoms, including anxiety, nightmares, and fear of similar events occurring again (Kousky, 2016).

6. Severe illness or hospitalization

Children who experience chronic illness or frequent hospitalizations may experience trauma related to their medical experiences, separation from family, and fear of their own mortality (Stuber & Shemesh, 2006).

7. Bullying

Being exposed to bullying at school, online, or within the community can be traumatic for children, leading to feelings of isolation, low self-esteem, and depression (Vanderbilt & Augustyn, 2010). Interestingly, the findings of this study also suggest that children may be traumatized by bullying even if they are involved in perpetrating or witnessing the bullying.

Understanding childhood trauma and abuse - Tanya Waymire

Tanya Waymire's TEDx talk about understanding childhood trauma and abuse provides a detailed personal perspective.

6 Signs of Childhood Trauma

Signs of childhood trauma are varied, subtle, and nuanced (Terr, 2003). Just as every child is unique, so is their response to adversity and their experience of trauma. Some of the more obvious signs of childhood trauma include:

1. Behavioral changes

Aggression, withdrawal, regressive behaviors (such as baby talk, bed-wetting, or thumb-sucking), acting out, or excessive compliance and clinginess may indicate that a child has experienced some kind of trauma (Milot et al., 2010).

However, more subtle changes, such as changes in appetite, sleeping patterns, ability to concentrate, school performance, and avoidant behaviors, may also indicate that a child may have experienced something traumatic (Perry, 2003).

2. Nervous system dysregulation & hypervigilance

Childhood trauma can dysregulate the nervous system, leading to heightened reactivity to stressors and alterations in brain structure and function, particularly in regions involved in emotion regulation such as the amygdala and prefrontal cortex (Elbers et al., 2018).

This dysregulation can result in hypervigilance, difficulties in managing emotions, increased sensitivity to triggers, and a heightened risk of mood swings, depression, anxiety, panic attacks, hypervigilance, or emotional numbness (Elbers et al., 2018).

3. Difficulty trusting others

Childhood trauma can affect a child's ability to trust others, as it disrupts the development of secure attachment bonds and may lead to a pervasive sense of fear, betrayal, or fear of abandonment (Beaton & Thielking, 2020).

This difficulty in trusting others may manifest as guardedness, avoidance of intimacy, and/or clinginess, resulting in challenges in forming and maintaining healthy relationships (Beaton & Thielking, 2020).

4. Low self-esteem

Children who have experienced trauma may experience feelings of worthlessness, self-blame, shame, or guilt, presenting as low self-esteem (Downey & Crummy, 2022).

5. Physical symptoms

Unexplained aches and pains, headaches, stomachaches, or other physical symptoms without medical cause may also indicate that a child is struggling to process trauma (Roelofs & Spinhoven, 2007).

6. Flashbacks or nightmares

Repeatedly experiencing the traumatic event through flashbacks, nightmares, or intrusive memories is a definite sign that a child is struggling to process a traumatic event (Tareen et al., 2007).

Taking a Closer Look: The ACE Childhood Trauma Test

If you suspect that a child or client has been traumatized, you may want to look a little closer. One childhood trauma test, the Adverse Childhood Experiences (ACE) Test, is a widely used questionnaire that assesses individuals' exposure to adverse experiences during childhood (Felitti et al., 1998).

The ACE Study, which used the ACE Test, revealed significant findings regarding the impact of childhood trauma on health outcomes later in life (Felitti et al., 1998).

This and further studies have found a strong association between childhood trauma as well as a wide range of health problems in adulthood (Felitti et al., 1998; Zarse et al., 2019). These may include mental health issues, a higher likelihood of engaging in risky behaviors, and struggling to form and maintain healthy relationships.

Felitti et al. (1998) and Zarse et al. (2019) further found that childhood trauma was associated with lower educational attainment, reduced job stability, and lower income levels in adulthood. Worryingly, there was also evidence to suggest that the effects of childhood trauma could be passed down to future generations, as individuals who experienced trauma in childhood were more likely to have children who experienced similar adversities.

Overall, there is compelling evidence of the long-term and wide-ranging impact of childhood trauma on physical health, mental health, social functioning, and overall wellbeing, highlighting the importance of early testing, intervention, and trauma-informed care to mitigate these effects.

4 More Childhood Trauma Tests & Quiz Options

There are several other childhood trauma tests and quizzes available that assess different aspects of childhood adversity and its impact on individuals.

Here are a few options.

1. Childhood Trauma Screener (CTS)

The CTS is a concise screening tool designed to identify individuals who may have experienced childhood trauma (Grabe et al., 2012).

It consists of a brief set of questions covering various types of childhood adversity. While it doesn't provide detailed information, you can use it as an initial assessment in situations where you suspect abuse. You can download the CTS to use in your own practice.

2. Brief Adverse Childhood Experiences Questionnaire

This shortened version of the ACE questionnaire focuses on key adverse childhood experiences such as abuse, neglect, and household dysfunction (Wade et al., 2017).

It offers a quick assessment of childhood trauma exposure, making it suitable for initial screenings.

3. The Childhood Trauma Questionnaire-Short Form (CTQ-SF)

The CTQ-SF is a concise self-report measure that assesses childhood trauma experiences, including emotional, physical, and sexual abuse, as well as emotional and physical neglect (Hagborg et al., 2022).

It provides a brief yet comprehensive overview of childhood trauma exposure, suitable for initial screenings.

4. Childhood Experience of Care and Abuse (CECA) Interview

The CECA is a semi-structured interview used to gather detailed qualitative information about childhood experiences of care and possible abuse (Bifulco et al., 1994). It explores parental behaviors, family dynamics, and specific traumatic events, offering rich insights into the impact of childhood trauma on individuals' wellbeing (Smith et al., 2002).

These are just a few examples of childhood trauma tests and quizzes available for assessing different aspects of childhood adversity and its impact. It is important to choose a tool that aligns with the specific therapeutic context of each client. Additionally, the interpretation of results should take context as well as all clinical and individual considerations into account.

Remember that your client is an individual person with unique experiences, so a person-centered approach is required.

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4 Childhood Trauma Questionnaires for Research

If you're undertaking childhood trauma research, you may need more in-depth childhood trauma tests and questionnaires that have been validated for research purposes. Here are a few options.

1. Childhood Trauma Questionnaire (CTQ)

The CTQ is ideal for researching childhood trauma due to its comprehensive assessment of various trauma types, including abuse and neglect (Bernstein et al., 1994).

Its structured format and reliability make it easy to administer, providing valuable data for understanding the prevalence, severity, and impacts of childhood trauma in research studies (Georgieva et al., 2021).

2. Traumatic Events Screening Inventory for Children (TESI-C)

The TESI-C is a self-report measure designed to assess trauma exposure in children and adolescents aged 7 to 18 (Ford et al., 2002). It covers various types of traumatic events, such as accidents, disasters, and interpersonal violence.

3. Trauma Symptom Checklist for Children (TSCC)

The TSCC is beneficial for research due to its ability to assess trauma-related symptoms in children and adolescents, providing valuable insights into their psychological wellbeing (Briere, 1996).

It reliably measures various symptom clusters, including anxiety, depression, post-traumatic stress, sexual concerns, and dissociation, aiding in comprehensive analysis (Wherry & Herrington, 2018).

4. Trauma History Questionnaire (THQ)

The THQ is a comprehensive questionnaire that assesses exposure to various types of traumatic events across the lifespan, including childhood trauma (Hooper et al., 2011).

It covers a wide range of traumatic experiences beyond those typically included in ACE assessments. So, if you're looking for more depth in your assessment, this may be a good option for you.

Explaining Test Scores & Questions

When interpreting childhood trauma test scores and questions on childhood trauma questionnaires, it is crucial to understand the context and implications of each assessment (Sparta, 2003).

You should also read up on the use of the questionnaire, as different childhood trauma tests may have specific guidelines for interpreting scores.

Scores usually reflect the severity or frequency of traumatic experiences reported by the individual, with higher scores indicating greater exposure to adversity during childhood. It is important to interpret scores cautiously, considering individual differences, cultural factors, and the potential for underreporting due to stigma or memory biases.

When explaining test scores to clients or parents, offer a clear and understandable interpretation. Start by discussing what the test measures and why it is relevant to their situation. Then, provide a breakdown of scores, emphasizing strengths and areas for improvement.

Offer support, answer questions, and discuss next steps or interventions based on the results. Use plain language and examples to ensure comprehension and foster trust in the assessment process.

Childhood Trauma & Post-Traumatic Growth

Beyond the profoundly negative impact of childhood trauma, there is an opportunity for post-traumatic growth (PTG). PTG can manifest in various ways, such as increased resilience, greater appreciation of life, enhanced relationships, new perspectives, and increased inner strength (Quan et al., 2022).

It is important to note that PTG is not a simple or linear process, and it does not negate the challenges or negative effects of trauma. It represents a complex and multifaceted process of adaptation and growth in response to adversity.

Some individuals may naturally experience PTG in response to trauma, wherein they undergo positive psychological changes and personal development because of their traumatic experiences (Vloet et al., 2017).

Many, however, will need support and therapy to achieve growth, and the extent of growth can vary greatly among individuals (Henson et al., 2021). Factors that may influence PTG include coping strategies, social support, personality traits, and the nature of the trauma itself (Tedeschi et al., 2004a).

Supporting PTG in therapy involves fostering a therapeutic environment that encourages acceptance, exploration, reflection, and resilience building (Zoellner & Maercker, 2006).

Positive psychology strategies, such as mindfulness and acceptance, a strengths-based approach, cultivating gratitude, and meaning making, can be instrumental in supporting these elements of PTG in therapy (Linley & Joseph, 2004). These strategies foster resilience, promote personal development, and cultivate a sense of meaning and purpose, all of which are necessary for PTG (Tedeschi et al., 2004b).

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Empower others with the skills to manage and learn from inevitable life challenges using these 17 Resilience & Coping Exercises [PDF], so you can increase their ability to thrive.
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Helpful Resources From PositivePsychology.com

We have several masterclasses that will support you and your trauma clients, and the Realizing Resilience Masterclass© will be particularly helpful if you're supporting clients who need to build their resilience to trauma and move toward PTG. This six-module resilience training provides an in-depth exploration of resilience from a positive psychology perspective.

For further reading, check out our selection of blog articles related to childhood trauma. In particular, you may want to read:

If you're looking for more science-based ways to help others overcome adversity, check out this collection of 17 validated resilience and coping exercises. Use them to help others recover from personal challenges and turn setbacks into opportunities for growth.

A Take-Home Message

Childhood trauma encompasses a range of adverse experiences, including abuse, neglect, witnessing violence, and separation, which can have a profound and lasting effect on a child's wellbeing. Understanding the signs and effects of trauma is crucial for providing appropriate support and intervention to affected clients.

Identifying and implementing appropriate childhood trauma tests to recognize the signs of trauma, such as behavioral changes, nervous system dysregulation, and difficulty trusting others, is essential for clinicians and caregivers to be able to intervene early and effectively to mitigate the impact of trauma and promote healing.

Employing positive psychology strategies can further support the process of post-traumatic growth, foster resilience, and promote wellbeing. Strategies such as mindfulness and acceptance, strengths-based approaches, cultivating gratitude, and promoting meaning making can empower individuals to navigate their trauma experiences, find purpose and meaning in their journey, and ultimately thrive despite adversity.

We hope you enjoyed reading this article. Don't forget to download our three Resilience Exercises for free.

Frequently Asked Questions

Signs of childhood trauma can include

recurring flashbacks or nightmares,

emotional numbness,

difficulty trusting others,

mood swings,

unexplained physical symptoms, and

behavioral issues.

Therapy and self-reflection can help identify underlying trauma.

Beaton, J., & Thielking, M. (2020). Chronic mistrust and complex trauma: Australian psychologists' perspectives on the treatment of young women with a history of childhood maltreatment. Australian Psychologist, 55(3), 230-243.

Benz, U., & Axelrod, T. (2004). Traumatization through separation: Loss of family and home as childhood catastrophes. Shofar, 23(1), 85-99.

Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Wenzel, K., Sapareto, E., & Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. The American Journal of Psychiatry, 151(8), 1132-1136.

Bifulco, A., Brown, G. W., & Harris, T. O. (1994). Childhood Experience of Care and Abuse (CECA): a retrospective interview measure. Journal of Child Psychology and Psychiatry, 35(8), 1419-1435.

Briere, J. (1996). Trauma Symptom Checklist for Children (TSCC): Professional manual. Psychological Assessment Resources.

Downey, C., & Crummy, A. (2022). The impact of childhood trauma on children's wellbeing and adult behavior. European Journal of Trauma & Dissociation, 6(1), Article 100237.

Elbers, J., Jaradeh, S., Yeh, A. M., & Golianu, B. (2018). Wired for threat: Clinical features of nervous system dysregulation in 80 children. Pediatric Neurology, 89, 39-48.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258.

Ford, J. D., Racusin, R., Rogers, K., Ellis, C., Schiffman, J., Ribbe, D., & Edwards, J. (2002). Traumatic Events Screening Inventory for Children (TESI-C) Version 8.4. National Center for PTSD and Dartmouth Child Psychiatry Research Group.

Georgieva, S., Tomas, J. M., & Navarro-Pérez, J. J. (2021). Systematic review and critical appraisal of Childhood Trauma Questionnaire - Short Form (CTQ-SF). Child Abuse & Neglect, 120, Article 105223.

Gould, F., Clarke, J., Heim, C., Harvey, P. D., Majer, M., & Nemeroff, C. B. (2012). The effects of child abuse and neglect on cognitive functioning in adulthood. Journal of Psychiatric Research, 46(4), 500-506.

Grabe, H. J., Schulz, A., Schmidt, C. O., Appel, K., Driessen, M., Wingenfeld, K., Barnow, S., Spitzer, C., John, U., Berger, K., Wersching, H., & Freyberger, H. J. (2012). A brief instrument for the assessment of childhood abuse and neglect: The Childhood Trauma Screener (CTS). Psychiatrische Praxis, 39(3), 109-115.

Hagborg, J. M., Kalin, T., & Gerdner, A. (2022). The Childhood Trauma Questionnaire-Short Form (CTQ-SF) used with adolescents: Methodological report from clinical and community samples. Journal of Child & Adolescent Trauma, 15(4), 1199-1213.

Henson, C., Truchot, D., & Canevello, A. (2021). What promotes post traumatic growth? A systematic review. European Journal of Trauma & Dissociation, 5(4), Article 100195.

Hooper, L. M., Stockton, P., Krupnick, J. L., & Green, B. L. (2011). Development, use, and psychometric properties of the Trauma History Questionnaire. Journal of Loss and Trauma, 16(3), 258-283.

Kousky, C. (2016). Impacts of natural disasters on children. The Future of Children, 26(1), 73-92.

Legano, L., McHugh, M. T., & Palusci, V. J. (2009). Child abuse and neglect. Current Problems in Pediatric and Adolescent Health Care, 39(2), 31.e1-31.e26.

Linley, P. A., & Joseph, S. (Eds.). (2004). Positive psychology in practice. Johns Wiley & Sons.

McCloskey, L. A., & Walker, M. (2000). Posttraumatic stress in children exposed to family violence and single-event trauma. Journal of the American Academy of Child & Adolescent Psychiatry, 39(1), 108-115.

Milot, T., Éthier, L. S., St-Laurent, D., & Provost, M. A. (2010). The role of trauma symptoms in the development of behavioral problems in maltreated preschoolers. Child Abuse & Neglect, 34(4), 225-234.

Perry, B. D. (2003). Effects of traumatic events on children. The Child Trauma Academy.

Quan, L., Lü, B., Sun, J., Zhao, X., & Sang, Q. (2022). The relationship between childhood trauma and post-traumatic growth among college students: The role of acceptance and positive reappraisal. Frontiers in Psychology, 13, Article 921362.

Roelofs, K., & Spinhoven, P. (2007). Trauma and medically unexplained symptoms: Towards an integration of cognitive and neuro-biological accounts. Clinical Psychology Review, 27(7), 798-820.

Smith, N., Lam, D., Bifulco, A., & Checkley, S. (2002). Childhood Experience of Care and Abuse Questionnaire (CECA. Q): Validation of a screening instrument for childhood adversity in clinical populations. Social Psychiatry and Psychiatric Epidemiology, 37, 572-579.

Sparta, S. N. (2003). Assessment of childhood trauma. In A. M. Goldstein (Ed.), Handbook of psychology: Forensic psychology (vol. 11, pp. 209-231). John Wiley & Sons.

Stuber, M. L., & Shemesh, E. (2006). Post-traumatic stress response to life-threatening illnesses in children and their parents. Child and Adolescent Psychiatric Clinics, 15(3), 597-609.

Tareen, A., Garralda, M. E., & Hodes, M. (2007). Post-traumatic stress disorder in childhood. Archives of Disease in Childhood-Education and Practice, 92, ep1-ep6.

Tedeschi, R. G., & Calhoun, L. G. (2004a). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1-18.

Tedeschi, R. G., & Calhoun, L. G. (2004b). A clinical approach to posttraumatic growth. In P. A. Linley & S. Joseph (Eds.), Positive psychology in practice (pp. 405-419). John Wiley & Sons.

Terr, L. C. (2003). Childhood traumas: An outline and overview. Focus, 1(3), 322-334.

Van der Kolk, B. A. (2003). The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatric Clinics, 12(2), 293-317.

Vanderbilt, D., & Augustyn, M. (2010). The effects of bullying. Paediatrics and Child Health, 20(7), 315-320.

Vloet, T. D., Vloet, A., Bürger, A., & Romanos, M. (2017). Post-traumatic growth in children and adolescents. Journal of Traumatic Stress Disorders & Treatment, 6(4).

Wade Jr, R., Becker, B. D., Bevans, K. B., Ford, D. C., & Forrest, C. B. (2017). Development and evaluation of a short adverse childhood experiences measure. American Journal of Preventive Medicine, 52(2), 163-172.

Wherry, J. N., & Herrington, S. C. (2018). Reliability and validity of the Trauma Symptom Checklist for Children and Trauma Symptom Checklist for Young Children screeners in a clinical sample. Journal of Child Sexual Abuse, 27(8), 998-1010.

Young, J. C., & Widom, C. S. (2014). Long-term effects of child abuse and neglect on emotion processing in adulthood. Child Abuse & Neglect, 38(8), 1369-1381.

Zarse, E. M., Neff, M. R., Yoder, R., Hulvershorn, L., Chambers, J. E., & Chambers, R. A. (2019). The Adverse Childhood Experiences Questionnaire: Two decades of research on childhood trauma as a primary cause of adult mental illness, addiction, and medical diseases. Cogent Medicine, 6(1), Article 1581447.

Zoellner, T., & Maercker, A. (2006). Posttraumatic growth and psychotherapy. In L. G. Calhoun & R. G. Tedeschi (Eds.), Handbook of posttraumatic growth: Research & practice (pp. 334-354). Lawrence Erlbaum Associates.

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2.1. What is attachment?

Infants are born equipped with a range of innate behaviours to maximise their survival. Attachment behaviour allows the infant to draw others towards them at moments of need or distress ( Fonagy et al., 1995). Infants who experience a secure attachment relationship develop a reasonably firm expectation of feeling protected and safe, which in turn allows them to explore their world more confidently.

Our instinct for attachment, which is shared by most mammals, is a basic adaptation for survival in infancy. When infants (or indeed adults) are frightened, stressed, feel unwell or are under threat, their attachment system is alerted. Infants in this state will initiate proximity-seeking behaviours (such as crying, clinging, or following with their gaze in babies; more verbal or sophisticated behaviours in older children) towards their primary attachment figure (normally a parent or the main caregiver). Once proximity and reassurance have been achieved, the attachment system can be deactivated. Seeking help and the different approaches an individual uses to obtain help constitute the building blocks of the attachment process.

More broadly, attachment theory also describes the ways in which individuals handle their most intimate relationships with their attachment figures (their parents, children and life partners). But as we have developed an increasingly sophisticated understanding of the relationship between early brain development, early psychosocial experiences and developmental psychopathology, it has also become clear that the role of attachment in humans goes significantly beyond its primary evolutionary purpose, the immediate survival of an infant ( Crittenden, 1999; Perry, 2009; Siegel, 2001; Van der Kolk et al., 1991). Although some researchers express scepticism about whether attachment is an innate mechanism, the majority of the field (considered broadly) accept that children have a basic, biologically rooted, need to form a lasting bond with their carers. Even if this relationship is strained for reasons such as poverty or domestic abuse, the child can form 'attachment-like' relationships with other adults, for example their teachers ( Bergin & Bergin, 2009).

The attachment strategies that a child develops are shaped by their environment, and this has major implications for the ways in which children learn to behave in close interpersonal relationships. From birth, the interactions of an infant with their primary carers will establish a base for personality development and will mould subsequent close relationships, expectations of social acceptance, and attitudes to rejection. Through interacting with others, infants learn about their role within the relationship and in time they begin to make sense of their own psychological states and those of others ( Fonagy et al., 2002).

A secure base is formed when the attachment figure provides stability and safety in moments of stress, which allows the infant to explore their surroundings. Ainsworth and others also highlight the importance of parental sensitivity for a child to form a secure base ( Ainsworth, 1993). Sensitivity is measured as the parent's ability to respond to the particular needs and cues of an individual child. The parent's capacity to do this takes place, or is influenced by, the systemic context (that is, contextual stressors, personal history, couple relationship and so on).

In response to parenting behaviour, the child creates a set of mental models of itself and of others in social interactions ('internal working models'), based on repeated interactions with significant others ( Bowlby, 1973). These early attachment relations are thought to be crucial for later social relationships, the acquisition of capacities for emotional and stress regulation, self-control, mentalisation and emotional maturity. Therefore, a child who develops insecure or disorganised attachments, possibly due to neglect or being placed in numerous foster care homes, is more likely to struggle in these areas and to experience emotional and behavioural difficulties.

It is worth noting that attachment may not be responsible for all interpersonal interactions with primary caregivers. For instance, Trevarthen and colleagues have demonstrated the importance of the intersubjective relationship experience between the infant and their carer, and that this complements, but is different from, their attachment relationship experience ( Trevarthen & Aitken, 2001).

Attachment is a developmental process, for which behavioural and affectional aspects have their counterpart in brain development. However, far less is known about the latter than the former ( Coan, 2008). One aspect which has been studied is the association between secure attachment and lower stress reactivity.

2.2. Terminology used in this guideline

This guideline covers children (defined as aged 0-12 years) and young people (defined as aged 13-17 years) who are adopted from care (and those adopted in England who are from overseas), in special guardianship, looked after by local authorities in foster homes (including kinship foster care), residential units and other accommodation, or on the edge of care.

The term 'attachment difficulties' refers to an insecure or disorganised attachment or diagnosed attachment disorders. The latter may be an inhibited/reactive attachment disorder or a disinhibited attachment disorder, now termed 'disinhibited social engagement disorder' in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) ( American Psychiatric Association, 2013).

Disorganised attachment and attachment disorder largely do not overlap ( Boris et al., 2004). Disorganised attachment (as assessed by Ainsworth's Strange Situation Procedure [SSP] by a trained, reliable coder) and an attachment disorder (as diagnosed by a psychiatric assessment) are very different phenomena. Nonetheless, in this guideline, the term 'attachment difficulties' is used to refer to children who have either a diagnosis of an attachment disorder or who have been placed by a reliable coder in the disorganised attachment classification.

2.3. Types of attachment difficulties

Four attachment behavioural patterns have been defined in young children:

These patterns are relatively stable over time in the absence of changes to caregiving. This stability is underpinned by continuities in a child's 'internal working models of attachment' that develop as a result of early interactions between the parent and child. The insecure avoidant and resistant patterns, while less optimal, are organised attachment patterns for retaining some proximity to the attachment figure and adapted to the anticipated response of the attachment figure. In contrast, children who are classified as disorganised, appear to lack an organised strategy for achieving closeness with their attachment figure when distressed.

Although particular types of attachment pattern, especially disorganised attachment, may indicate a risk for later problems (see Section 2.9), they do not represent a disorder. Furthermore, these categories of attachment are referred to as the ABCD model, however there are other approaches that are important, and not necessarily in opposition with this framework, such as the dynamic maturational model ( Farnfield, 2009).

Disorders related to attachment have been described in the literature and are defined in the DSM and The International Classification of Diseases and Related Health Problems, 10 th edition (ICD-10) for Mental and Behavioural Disorders: reactive attachment disorder and disinhibited attachment disorder or disinhibited social engagement disorder.

2.3.1.1. Secure attachment

Children who have a 'secure' attachment are generally able to be comforted by their caregivers when distressed and to use their caregiver as what is known as a 'secure base' from which to explore their environment when they are not distressed.

2.3.1.2. Insecure avoidant attachment

Children who develop an 'avoidant' attachment pattern are thought to maintain proximity to their caregiver by 'down-regulating' their attachment behaviour: they appear to manage their own distress and do not strongly signal a need for comfort. Most importantly, when reunited with a caregiver after a brief separation, these children may be quite distant, and tend to avoid contact with the caregiver. It is worth noting that these behaviours are observed during the SSP when the child is exposed to a stressful situation (separation-reunion procedure) and avoidant children are not necessarily avoidant all the time. Nevertheless, avoidant behaviour can be observed in the home using the Attachment Q-Set tool.

2.3.1.3. Insecure resistant (ambivalent) attachment

Children who have a resistant (ambivalent) attachment pattern are thought to maintain proximity to their caregiver by 'up-regulating' their attachment behaviour: when they are separated from a caregiver, they may become very distressed and may be angry, and resist contact when the caregiver returns, and not quickly calmed when comfort is offered. These children are less confident in terms of exploring their environment and may be wary of strangers.

2.3.1.4. Disorganised attachment

It is important to note that behaviours reflecting disorganised attachment are only observed during an assessment, like the SSP, and may not be displayed by the child in their home (unlike insecure attachment), and that disorganised attachment may only be short-lived and can be resolved once the child is reunited and in a stable relationship with their primary caregiver. Neither the behaviour described by the Main and Solomon indices, nor a classification of disorganised attachment in the SSP, can be used in any valid way to assess a child for maltreatment. Although correlated with it, maltreatment cannot be inferred from infant disorganised attachment. Conversely, it is possible for children who are abused not to show disorganised attachment (for example, if the abuse is less severe and less frequent).

Other children, such as those on the autistic spectrum, can also exhibit disorganised attachment in the absence of maltreatment. Finally, some children will show disorganised attachment when they are frightened for their carer, for example when a parent is terminally ill or subjected to violence from another individual (typically, domestic abuse).

2.3.1.5. Attachment disorder

The term 'attachment disorder' refers to a highly atypical constellation of behaviours indicative of children who find it extremely difficult to form close attachments.

Reactive attachment disorder (RAD) refers to a consistent and pervasive pattern of behaviour in which a child shows extremely withdrawn behaviour, particularly a marked tendency to not show attachment behaviour toward caregivers (not seeking proximity when distressed, and not responding when comforted), accompanied by a general lack of responsiveness to others, limited positive affect and/or episodes of marked sadness, fearfulness or irritability. The diagnosis requires that there is clear evidence of pathogenic care, such as severe neglect or repeated changes in caregivers (for example, through multiple foster care placements or institutional care), and the difficulties should be evident before the age of 5.

Disinhibited attachment disorder (currently in ICD-10) ( World Health Organization, 2010), which has more recently been relabelled as 'disinhibited social engagement disorder' (DSED) in DSM-5 ( American Psychiatric Association, 2013), refers to a marked and pervasive tendency to not show appropriate cautiousness with respect to unfamiliar adults and a failure to be sensitive to social boundaries. Examples include going off willingly with a stranger with no hesitation, overly familiar verbal and physical interaction with a stranger and limited or absent checking back to a caregiver when in a new place. As in the case of RAD, DSED is only considered when there is clear evidence of a history of pathogenic care.

2.4. Assessment and measures of attachment in childhood and adolescence

The assessment of patterns of attachment is complex. Attachment is assessed for its quality or pattern, not quantitatively for its intensity and there are different ways of assessing attachment that are appropriate to different ages on the basis of observed behaviour, representation of attachment relationships and coherence of the child's account regarding their attachment relationships. Based on longitudinal studies and concurrent assessments using different methods, there is an assumption that the different methods are measuring the same concept.

The SSP, which is used between the ages of 12 and 24 months approximately, assesses the infant's attachment behaviour towards their attachment figure following a significant stressor of separation. There is also a similar assessment of a more prolonged separation for preschool-age children. Another observational method uses Q-sort to assess attachment behaviour during a more prolonged observation period. Representations of attachment patterns of children between the ages of 4 and 8 years can be assessed using the child's verbal and toy-enacted completion of beginnings ('stems') of a number of stories that depict stressful scenarios involving a child and their parents (MacArthur Story Stem Battery [MSSB]; Manchester Child Attachment Story Task [MCAST]). For older school-age children, attachment is assessed by verbal and non-verbal responses using 2 different procedures. In the dynamic maturational model of attachment the child is presented with a number of pictures of stressful scenarios and is invited to describe the response of a hypothetical child as well as their own responses to the scenarios. In the Child Attachment Interview (CAI), which extends into adolescence, the child or young person is invited to describe their relationships with their caregivers in various stressful situations. In this procedure, the focus of assessment is the coherence of the child or young person's account, as well as their demeanour during the interview.

There is widespread recognition regarding the importance of addressing attachment difficulties in older children and adolescents who have experienced highly disrupted care, but currently the literature is lacking clear consensus about how these should be defined and measured ( Kay & Green, 2013) and very few prospective studies have addressed the factors that cause them.

A recent observational measure of attachment disorganisation has been introduced that is coded from a 15 minute interaction between parent and adolescent (Goal-Corrected Partnership in Adolescence Coding System [GPACS]; Obsuth et al., 2014). The GPACS has shown promise as a measure of attachment among at-risk adolescents, in that it is related to disorganisation in infancy, as well as to current unresolved Adult Attachment Interview (AAI) states of mind. The GPACS has also been robustly related to current maladaptation in adolescence, including increased depressive symptoms, dissociative symptoms, borderline personality disorder features, suicidality, and overall psychopathology on a standard psychiatric diagnostic interview( Obsuth et al., 2014) ( Lyons-Ruth et al., 2014; Vulliez-Coady et al., 2013) It also relates significantly to abusive behaviour in romantic relationships. However, further work is needed in other samples to be sure these results will replicate broadly.

For each of these methods or procedures, there are coding manuals with variations for each of the methods.

Attachment may also be assessed indirectly by examining the primary caregiver's sensitivity to the child, particularly in response to the child's distress or fear, because a significant association has been found between maternal sensitivity and child security of attachment.

Attachment disorders are typically assessed using structured interviews with carers, and may be supplemented by questionnaires and direct observation of the child or young person's behaviour.

2.5. How common are attachment difficulties?

It is estimated that around two-thirds of children in population samples have a secure pattern of attachment across cultures ( Van Ijzendoorn & Kroonenberg, 1988; van IJzendoorn et al., 1999), although this falls rapidly to around one-third in disadvantaged populations ( Carlson, 1998; Weinfield et al., 2004) and less in maltreated populations.

Estimates suggest that around 8-10% of children are insecure-ambivalent ( van IJzendoorn et al., 1999) and around 9% of children are insecure-avoidant ( van IJzendoorn et al., 1999).

Around 15-19% of population samples ( De Wolff & van Ijzendoorn, 1997) to 40% of disadvantaged populations ( Carlson, 1998; Weinfield et al., 2004) and as many as 80% of maltreated populations ( Carlson et al., 1989; Cyr et al., 2010) are thought to have a disorganised attachment.

The prevalence of attachment disorders in the general population is not well established, but is likely to be low ( Minnis et al., 2013; Skovgaard et al., 2007). RAD and DSED are seen at substantially higher rates among young children raised in institutional care or exposed to severe abuse or neglect.

2.6. The causes of attachment difficulties

A significant body of research has investigated the causes of variations in the attachment patterns shown by infants and young children. The evidence is quite clear that the causal factors giving rise to security versus insecurity are distinct from those influencing the development of attachment disorders ( Rutter et al., 2009). Each of these is considered separately below.

There is widespread recognition regarding the importance of addressing attachment difficulties in older children and adolescents who have experienced highly disrupted care, but currently the literature is lacking clear consensus about how these should be defined and measured ( Kay & Green, 2013) and very few prospective studies have addressed the factors that cause them.

It seems clear from the research literature, however, that attachment difficulties are almost always caused by inappropriate parenting; behavioural genetic studies show very little genetic influence on attachment patterns, so that it is rare to observe significant attachment difficulties in the context of normatively sensitive and responsive parenting. Thus, children with attention deficit hyperactivity disorder (ADHD) and autism usually have secure attachments to their parents.

There is a growing literature on the neurobiological effects of child abuse and neglect. Child maltreatment is stressful, often repetitive or persistent and may be traumatogenic. The abusers or those neglecting the child are most often also primary attachment persons. Given the strong causal association between child maltreatment and attachment difficulties, it is likely that the neurobiological changes associated with maltreatment will be found in children with attachment difficulties. However, these changes are not explanations of the attachment difficulties.

2.6.1.1. Attachment security/insecurity

A key issue concerns the extent to which attachment security versus insecurity reflects the influence of the environment (including the behaviour of the caregiver), rather than the child's genetically-based behavioural and emotional dispositions. Several twin studies have consistently indicated that attachment security in infancy and toddlerhood is almost exclusively influenced by the environment, and minimally by genetics ( Bokhorst et al., 2003; Roisman & Fraley, 2008), consistent with the emphasis within the field of attachment research on the preeminent role of parenting.

Early intensive observational work conducted by Mary Ainsworth (1969) identified variation in parental sensitivity in particular as a critical variable in determining the child's attachment security as assessed in procedures like the SSP. Broadly speaking, parental sensitivity refers to the tendency of a parent to be aware of a child's more or less subtle cues and communications, particularly (though not exclusively) those relating to distress, to interpret those cues accurately and to respond contingently to them with an appropriate response. Sensitive parenting is typically characterised by harmonious, smooth and responsive interactions in which the parent is able to read - and therefore be attuned to - the child's behaviours and cues, to accurately imagine what the child's feelings, thoughts and focus of attention might be and to respond appropriately. It is generally not considered to be equivalent to warmth, and in research studies these 2 constructs may or may not be correlated, depending on the way they are measured and the populations concerned ( Mesman & Emmen, 2013). Parental sensitivity can only be measured properly by direct observation of interactions, ideally over a significant period of time, and in more than 1 context or occasion. Insecure attachment is generally considered to be associated with parenting that is insensitive, either because the parent's behaviour is intrusive (not following the child's cues, rigid or forcing the direction of interactions), rejecting (negative response to, or discouraging of the child's bids for contact or comfort), hostile, withdrawn or the parent is inconsistently available to the child.

2.6.1.2. Disorganised attachment

A substantial number of studies have found that standard assessments of sensitivity do not reliably predict disorganised attachment ( van IJzendoorn et al., 1999). Instead, existing studies indicate that disorganised attachment is associated with a cluster of parenting behaviours that include 'frightening/frightened', extreme intrusiveness, unmarked frightening facial expressions, unusual vocal tone and dissociative behaviour. Several studies have also indicated that a broader range of 'atypical' parenting behaviour may be involved, including affective communication errors, role/boundary confusion, and withdrawal (see Jacobvitz et al., 2006; Out et al., 2009). Disorganised attachment has also been observed at high rates in samples of infants and young children who have been exposed to maltreatment ( Cyr et al., 2010; van IJzendoorn et al., 1999a) and, to a lesser extent, among children who have been adopted or are in foster care. Less research has been done to rigorously test in intervention studies the causal nature of these observed associations than that concerning the role of parental sensitivity.

2.6.1.3. Attachment disorders

2.7. When do attachment difficulties start and how long do they last?

Studies of normative development suggest that clear selective attachment bonds become evident sometime between the ages of 6 and 9 months, as indicated by preferential seeking of comfort from selected individuals, distress triggered by being separated from them and stranger wariness ( Schaffer, 1966). Prior to that, early interactive processes most likely important for the subsequent development of attachment are clearly observed (for example, mutual eye contact, social smiling, contingent interactions, provision of contact and comfort), although remarkably little research has investigated in detail the role that these play in the formation of attachments. Standard assessments (like the SSP) are generally used from the end of the first year and can reliably categorise attachment patterns and behaviours. It is therefore generally accepted that insecure or disorganised attachments can be clearly observed at 1 year of age, although it is not straightforward to conclude that they are not present earlier, and the parent-infant interaction patterns that are believed to give rise to them are certainly present, and measurable, earlier than that.

Similarly, structured interview techniques and related observational procedures are used at this age to assess the presence of attachment-related disorders and their associated behaviours ( Zeanah & Gleason, 2014). Furthermore, diagnosis of RAD requires that signs of RAD must have been present before the age of 5 years. For both RAD and DSED highly insufficient care must have been present and would typically have occurred in infancy or early childhood.

The question of how stable attachment patterns and disorders are is a complex one, partly because there is a general lack of measurement tools that can reliably assess attachment in the same way for all age groups. Nevertheless, there is some consensus on the following key points. First, attachment patterns in infancy and early childhood show some stability over time, but are also open to change. Second, short- and medium-term change in attachment patterns (for example, from insecure to secure) tends to be linked to changes in caregiving (for example, from relatively insensitive to relatively sensitive), or other family circumstances (for example, marital difficulties or separation). Third, long-term stability in attachment security (that is, from infancy into late adolescence or adulthood) is limited, but later attachment outcomes are related to a broader assessment of the quality of familial experiences occurring right across childhood, for example, quality of care, divorce and parental wellbeing; see Groh and colleagues (2014).

RAD shows relatively high stability in the short-term (a requirement for diagnosis) in the context of a stable environmental context, for example within an institutional care setting or treatment-as-usual foster care ( Gleason et al., 2011), but resolves quite quickly when appropriate stable attachment figures are provided, for example in foster care with suitably trained foster carers ( Rutter et al., 2009). By contrast, DSED shows quite high levels of persistence over time in studies that have been conducted to date both in early childhood and into adolescence ( Zeanah & Gleason, 2014), even when appropriate foster care has been in place for some time. However, it is important to note that the great majority of these studies have focused on children previously raised in institutions and less work has examined the stability of DSED or RAD in the context of children who entered foster care, or were adopted, from non-institutional circumstances. An example of the work that has been conducted on children in foster care, the children showed high levels of indiscriminate friendliness, a symptom or RAD, but they had experienced serious maltreatment and numerous placements ( Pears et al., 2010). Thus, it is still unclear how likely symptoms of RAD or DSED are found in children living in a stable, loving foster care placement or who were adopted.

2.8. What mental health problems and behaviours are associated with attachment difficulties?

In people with RAD there is an increased prevalence of anxiety, fears and phobias. DSED is not necessarily associated with a diagnosable mental health problems, although as might be expected, there is an increased risk of both internalising (anxiety, depression) and externalising problems (conduct and aggressive problems) and a risk that social disinhibition may lead the individual to become abused by unscrupulous older children and adults, and to go down the path of antisocial behaviour, drug misuse and promiscuity. For both RAD and DSED, there can be disturbances of emotions and behaviour that will be associated with the neglect or abuse that led to them, including emotional dysregulation and poor temper control, leading to oppositional defiant disorder, and dysregulated mood disorder. In the English Romanian adoptee study, there were 4 specific patterns associated with severe neglect/privation: a quasi-autistic syndrome, ADHD, social disinhibition similar to DSED, and impaired cognitive ability ( O'Connor & Rutter, 2000). Thus, a child with the disinhibited attachment picture could have any or all of the other 3 mental health problems.

The association of insecure attachment patterns with mental health problems is more complex. Here an insecure attachment pattern will be taken to include a disorganised attachment as well as avoidant and ambivalent patterns. A meta-analysis of a large number of studies found no increase or a modest increase in prevalence of all kinds of mental health problems associated with avoidant and ambivalent patterns, but significant and greater increases in mental health problems (particularly externalising problems) among children displaying disorganised attachment ( Solomon & George, 2011). Children with earlier disorganised attachment frequently develop coercive controlling or compulsive caregiving behaviour.

One particular mental health problem that seems to have a higher prevalence than the others is oppositional defiant disorder/conduct disorder. Meta-analyses suggest that around 55% of children with oppositional defiant disorder/conduct disorder have any pattern of insecure attachment (compared with around 30 to 40% in controls), of whom about 30% have disorganised attachment (compared with 15% in controls); thus in children with oppositional defiant disorder/conduct disorder, the odds ratio (OR) of having disorganised attachment is nearly 4-fold.

Disorganised attachment, and to a lesser extent avoidant and resistant attachment patterns, are associated with externalising problems (anger, aggression), more so in boys. Avoidant attachments are associated with internalising problems (depression, anxiety, social withdrawal, somatic complaints) in both boys and girls. Disorganised, insecure avoidant and resistant attachment patterns in both boys and girls are associated with later poor social competence with peers.

Perhaps because of the overlap with maltreatment, it is not uncommon for professionals to use the term 'attachment difficulties' to cover a wider pattern of behaviour that might include the sequelae of maltreatment or be otherwise experienced relatively commonly by children in the care system or adopted from care. This may mean people conflate attachment difficulties with other developmental problems, such as:

aggression, oppositional or defiant behaviours

hyperactivity, poor concentration and risk-taking

lying, stealing and manipulative behaviours.

Also, the apparent overlap in the behaviour of a child with attachment difficulties and a child with a different neurological condition, may lead to a child being misdiagnosed (with conditions such as ADHD or Williams syndrome), before the extent of the attachment and trauma issues have been recognised. Thus it is important that healthcare professionals take into account all manner of explanations and causes during an assessment that may lead to a single or dual diagnosis.

In conclusion, for insecure attachment patterns, any mental health problem is likely to be more common, but particularly among children with disorganised attachment. However, this is not to say that the attachment difficulty has led to the behaviour problem; rather, it is much more likely that the disturbed parenting has had effects on making the child more anxious, more frustrated and aggressive, less able to comfort themselves and more emotionally dysregulated, and physiologically more prone to become rapidly emotionally aroused and to take longer to calm down and return to a more normal physiological and mood state. More severe neglect may also affect a child's neurological configuration (and continue to affect it into adolescence) and their attention span and ability to make social relationships ( Cozolino, 2014; Siegel, 2001; Van der Kolk et al., 1991).

2.9. How do attachment difficulties manifest in education, healthcare, social care and criminal justice settings?

2.9.1. Education

Attachment may be an important influence on pupils' academic success and wellbeing at school. First, security of child-parent attachment has been found to influence a number of areas of child development that are extremely important in the school setting - self-regulation (controlling one's behaviour, sustaining attention, controlling emotions), willingness to take on challenges and persist in the face of setbacks, social competence with peers and less aggressive behaviour ( Bergin & Bergin, 2009). Furthermore, children can and do form relationships with teachers that have an attachment quality to them, and serve a similar function of creating a feeling in the child of safety and security. The quality or security of that relationship in turn may influence the child's emotional wellbeing and engagement with learning. For young people with attachment difficulties, the challenging business of learning and coping in the classroom can be very difficult.

Behaviours associated with attachment difficulties, such as disruptive behaviour in the classroom, difficulties forming relationships with teachers or positive peers, and difficulty in establishing a moral code (linked to their value of an authority figure), are commonly seen in schools. Some children may display clinginess to teachers; older children may have difficulties with boundaries. Other children may be quiet and not engage because they are internalising their issues, and because they appear to be coping they could be overlooked.

For teachers, it is really important to be able to 'read' these behaviours and respond appropriately. It is a concern that the majority of teachers will not have covered such issues in their training.

It is important to note that an awareness and understanding of children's attachment difficulties should not obviate the need to examine additional reasons for a child's difficulties in the educational setting, such as physical health problems (sight, hearing) and specific learning and reading difficulties, which tend to be masked by more overt behavioural or emotional difficulties and are under-diagnosed in looked-after children. It is also important to manage the sequelae of trauma and maltreatment. For children who have been maltreated or exposed to trauma, learning is more difficult, as the normal and necessary 'fight, flight or freeze' response is triggered very easily. Changes of placement often involve a change of school. The resulting sense of dislocation and disruption to relationships, the need to negotiate new settings and relationships and to enter already established friendship groups increases levels of stress and decreases the ability to learn.

2.9.2. Healthcare

Healthcare settings cover a wide range of care provision, including primary, secondary and more specialised settings, for both mental and physical heath.

Direct manifestations of attachment difficulties may be observed when a child does not show distress in situations when this might be expected, does not seek comfort or shows difficulty in accepting comfort from a carer when frightened or feeling threatened. Another aspect that may be observed is a child's indiscriminate friendliness and approach to strangers, as might occur in an inpatient healthcare setting.

Attachment difficulties are also correlated with a range of emotional and behavioural problems, which will be noted in healthcare settings or for which the child may be referred, especially to child and adolescent mental health services (CAMHS). These difficulties include both internalising (such as anxiety, depression, social withdrawal and somatic complaints) and externalising problems (such as difficult and challenging behaviour or aggression and threatening behaviour). However, possible attachment difficulties cannot be assumed to be present, but, upon assessment, may be considered as part of a formulation of a child's difficulties.

Neglectful, unresponsive, insensitive or hostile parent-child interactions may be observed in healthcare settings. While these may lead to attachment difficulties, the latter cannot be assumed to be present, although if these parent-child interactions are persistent, it is likely that they will have led to attachment difficulties. Thus, it could be said that attachment difficulties are markers of some form of maltreatment within the family and that the child's behaviour is a survival response that, if left untreated, will become a hardwired, stress reaction (that is, an attachment difficulty is an indicator not an end diagnosis).

2.9.3. Social care

Within social care settings, children and young people may be placed in a variety of placement types (that is, adopted home, foster care, residential care or kinship care) with varied contact arrangements and levels of insight about why they no longer live with their family of origin. They are often cared for by people who have not had specific training about attachment difficulties, who may perceive the child's behaviour simply as 'problem behaviour' and struggle to connect it to their past experiences or to respond with consistency and sensitivity. Children in care settings may show 1 of 2 patterns of relationships with their carers that may be a cause of concern. One group consists of children who are likely to become very agitated in their new surroundings, as well as with their new carers, especially if they have experienced disrupted placements over a short period of time ( McDonald & Millen, 2012). For them, the world of relationships will have become unpredictable, to the point where their 'best' strategy for survival is to be unpredictable themselves. This offers them a way (albeit short-term) of being noticed. Consequently, these children externalise their behaviour and tend to be aggressive, demanding and hostile. The second group consists of children who are, in some respects, more worrying because they appear to internalise their distress and trauma. They tend not to show their feelings and can become superficially compliant and undemanding. They appear to 'settle in well', but underneath the facade these children are often in turmoil and experience considerable distress.

Both of these groups of children who have experienced highly troubled attachment relationships in the past can struggle to trust adults ( Barton et al., 2011). Confusingly, they can become very demanding if they are offered a genuinely secure base and safe haven in, for instance, an adoptive home. They are not used to adults being predictable, kind and nurturing, so they inadvertently reject the very people they need in order for them to grow and develop emotionally, and to help them survive traumatic childhood experiences ( Rivard et al., 2005). Adoptive parents, special guardians, foster carers, kinship carers, residential staff and birth parents may all need additional support to help them understand these behaviours and to prevent them from jeopardising placements.

2.9.4. Criminal justice system

Young people in contact with the youth justice system are known to have higher levels of mental health problems ( Chitsabesan et al., 2006) and other unmet needs than their peers ( Chitsabesan & Bailey, 2006). Although less is known specifically about attachment difficulties in this population, many of them have either been looked-after children or have had multiple carers ( Harrington et al., 2005), and they have had a high level of exposure to traumatic events ( Abram et al., 2004), all of which may be associated with attachment difficulties. Additionally, they have often had multiple education placements and are likely to have come into contact with many professionals, either directly as a result of their offending behaviour, or as an indirect consequence (due to placement breakdown and so on). A recent policy change (Legal Aid, Sentencing and Punishment of Offenders Act 2012; ( LASPO, 2012) explicitly acknowledged their need for additional support, and now young people remanded either to custody or to the care of the local authority are deemed to be looked-after children.

This instability of relationships with primary caregivers, and the sheer number of professionals with whom they have had contact, means that young people within the justice system often have difficulty in trusting professionals they meet. As a result professionals may find that these young people constantly 'test out' the relationship in a number of different ways, or that it is difficult to engage them at all. It may take multiple contacts with a young person before they feel willing to engage at any level with a new professional. Some young people may focus on short-term gains within any encounter with a professional, and hence initially engage well, but the professional may have difficulty sustaining the engagement when difficult topics are broached or the young person feels challenged. Some young people have found that escalating their behaviour is an effective way to regulate relationships with professionals, as the immediate behaviour (rather than underlying issues) becomes the focus of the interaction.

Professionals may well have difficulty establishing relationships with these young people (probably at the end of a long chain of contacts with professionals), meaning that it is harder to work with this population. They may present with low empathy or escalate behaviours when challenged, have problematic relationships with staff and peers and are likely to make multiple transitions that will exacerbate problems. Behavioural problems arise in residential/custodial settings (escalation to make problems go away or in hope of ending placement). Children and young people will also present with the same difficulties that would occur in any residential setting (see the section on social care above).

2.10. Perspectives and experiences of care-leavers and carers: daily life, family and relationships

As looked-after children's relationships with previous caregivers are often disrupted and unreliable, they are unlikely to have experienced secure and stable attachments. By the very nature of entering the care system, another attachment has been disrupted. This leads children to perceive parental figures as unreliable and incapable of providing protection. Children who experience insecure attachments begin to develop defensive behavioural techniques to protect themselves from a world of insecurity and hostility ( Howe et al., 2001a). Moreover, if children experience high levels of arousal and have no strategies in which to deal with them, they will face further problems, such as sleeping and eating problems ( McNamara et al., 2003).

For those who have lived in the care system, each loss of caregiver or placement is a big change, and even where the feelings are not evident to an observer or are covered with challenging behaviour, these are losses that lead to a grieving process. Having nobody that you can trust and confide in becomes a fact of life, and you learn to invest less in each subsequent relationship. To the child, it feels like the problems (including placement breakdowns) are all because of something wrong with them, leading to intense feelings of shame, sadness, anger or isolation. Learning to trust in relationships again enough to share their experiences and feelings can be a slow and often painful process that needs to be given time and support. But it is the most important experience for these young people.

Birth family relationships, although not always healthy, are often very important to children who are looked after. Contact can be de-stabilising as it may bring up old wounds, but it can also be reassuring to know that relatives are still alive and care enough to come ( Sinclair, 2005), this is particularly important if the care is short-term, or there are plans for the child to return to their birth family. However older children tend to make their own decisions and arrangement about the amount and type of contact they want with their birth families ( Selwyn, 2004). Young people may be very concerned for the wellbeing of parents or siblings (particularly where there have been issues with alcohol or substance use, self-harm, domestic violence). Maintaining a relationship with siblings can be an important source of identity and shared experiences, as well as the longest relationships in people's lives.

Adopted children with attachment difficulties can have further difficulties in many aspects of daily life. They need to be and feel safe, to live in a caring, nurturing and structured home. Their attachment difficulties, and their behaviour needs to be fully understood by their adoptive parents, educators and supporters. The number and quality of foster care placements and previous maltreatment will impact on the attachment pattern that they bring into their adoptive placements ( Sinclair et al., 2007). It is important to them to control many areas of daily life and this can often be difficult for parents, teachers and supporters to understand. Adopted children, will present with many overlapping difficulties ( Schmid et al., 2013b), but regardless of age and the length of time that they are in their adoptive families, they need their parents to be attuned to all of those needs. If parents do not receive consistent support and education to be sensitive to their child's attachment needs, adopted children can - and often do - present with challenging behaviours ( Selwyn et al., 2014); and even when adoptive parents are sensitive to the child's needs, the child may still go on to develop those behaviours.

2.11. Treatment and management of attachment difficulties in England and Wales

2.11.1. Psychological interventions

There is much less evidence for later developmental periods, including middle childhood and adolescence. The recently published naturalistic National Institute of Child Health and Human Development longitudinal study found that children who moved from insecure attachment to secure attachment as they grow up experienced an associated improvement in their parenting they received and in their living circumstances, again suggesting that improving parenting will lead to greater attachment security and better outcomes generally. However this process may be longer and require more support for older and more traumatised children, and relies on a stable placement with high levels of parental sensitivity.

Additionally, there are a number of approaches with looked-after children that aim to improve parenting, and which may also improve attachment security. Standard parenting programmes such as the incredible years have been shown to improve sensitive responding, which is likely to lead to more attachment security. Other parenting programmes specifically for Foster carers that are based on evidence-based principles also appear to show an improvement in child attachment security ( Briskman et al., 2014).

There is a wide range of other relationship-based therapies available, but none appear to have been subject to an RCT. Some are widely used within the UK and may promote secure attachment in children on the edge of care or in care. Others are abusive, not therapeutic and make unsubstantiated claims about improving brain function. Any form of 'therapy' involving physical restraint, coercion, the child lying or sitting on the therapist or any form of aversive stimulation (for example, 'holding therapy') not only has no evidence base, but is associated with harm to children and should be considered malpractice (see the Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems).

An attractive notion is that giving a child individual psychotherapy will help them come to terms with an abusive parent and so improve their attachment security in relation to that person, by enabling them to talk about them in a balanced and coherent way, so called 'earned security'. However, to date, these ideas are untested and therefore individual psychotherapy is of uncertain value. Although use of creative and non-directive therapies is popular with this population, there is no evidence for the efficacy of any form of individual therapy done with primary school-age children in terms of addressing attachment difficulties. The evidence available shows parent-child psychotherapy or trauma-focused cognitive therapy for both the child and parent may improve parental sensitivity or attachment security in children and young people who have been maltreated with related trauma ( Cicchetti et al., 2006; Cohen et al., 2004).

It is important for healthcare professionals to understand that a child's behaviour in care can be very complex and may be due to a past trauma, not necessarily the result of poor parenting provided by the foster carers or adoptive parents. Thus, complex trauma (in the presence of attachment difficulties) should be identified and addressed separately to an intervention that aims to improve the attachment between the child and their foster carer or adoptive parents.

With respect to the associated problems (such as complex trauma), standard evidence-based treatments should be offered to children with attachment difficulties, just as they should be with children who do not have attachment difficulties. Thus, with older children therapeutic techniques such as cognitive behavioural therapy (CBT), interpersonal therapy, eye movement desensitisation and reprocessing, dialectical behaviour therapy, cognitive analytic therapy, family therapy that have a proven evidence base should be used for problems that they have already shown to be effective for in other populations of children. It is important to note that these interventions have primarily been assessed in children without attachment difficulties. Thus, future research should focus on how to better adapt these interventions for this population.

It is important that there is also understanding of the child's psychological needs and a consistent, empathic and containing environment within school.

There is evidence that respite as part of an overall parent training and support package is effective with looked-after children who have previously been traumatised, showing good effects both on reducing the likelihood of placement disruption and potentially increasing attachment security ( Hudson & Levasseur, 2002; Redding et al., 2000; Rhodes et al., 2001; Triseliotis, 1997). Brief periods of time out, in the context of a loving relationship, are unlikely to recreate traumatic experiences and provide temporary relief for foster parents to rejuvenate from the stress of fostering

Because it is a relatively small population group whose needs are highly complex, services often span (or fall between) health and social care, and the priority is normally to find and support stable placements for looked-after children, which should be within a family wherever possible ( Winokur et al., 2014). It is often hard for families and carers to access therapeutic support due to the pressures in the public sector to limit CAMHS to working with diagnosed mental health problems, rather than the sequelae of maltreatment, but specialist therapeutic support is highly valued by participants. Sadly, it remains the case that straightforward, evidence-based interventions are often very hard to access for adopters, both because overall therapeutic provision is low, and secondly because even where they are available, they are not offered to children on the edge of care and fostered and adopted children.

2.11.2. Pharmacological interventions

Pharmacological interventions are not the mainstay of interventions for attachment difficulties. It is difficult to conceive of medication that would enhance a child's expression of their distress or which would increase the child's capacity to receive and accept comfort. However, there may be circumstances in which treating another disorder may help a parent to be more sensitive and responsive because the child's behaviour may be more manageable, which in turn may support a secure attachment.

There are medications that ameliorate some of the emotional and behavioural difficulties associated with attachment difficulties, such as ADHD or depression, but there is no theoretical explanation why this should affect attachment.

Regarding caregiver sensitivity, this could in theory be enhanced by the administration of oxytocin. To date, there have been no studies showing increases in attachment security in children in relation to use of oxytocin.

2.12. The economic cost

Children who are on the edge of care, looked after, or adopted from care are at high risk of both insecure and disorganised attachment. In England in 2011 a majority of children were in care as a result of abuse and neglect (55%) ( Curtis, 2014; Department for Education and Skills, 2005), and as many as 80% of children who have experienced maltreatment have a disorganised attachment ( Carlson et al., 1989; Cyr et al., 2010).

In England gross expenditure on looked-after children was estimated to be £2.5 billion in 2013/14. The majority of expenditure was on foster care services (55% of expenditure, around £1.4 billion, caring for 51,340 children and young people), and children's homes (36% of expenditure, around £0.9 billion, caring for 6,360 children and young people) ( Harker & Heath, 2014). Estimates of the average social care cost per looked-after child range from £33,634 a year for children with no additional support needs to £109,178 for those with complex emotional or behavioural needs. The cost of providing and maintaining the placement accounts for over 90% of the costs of a care episode. As well as reflecting different levels of activity from social care staff, the substantial variations in cost incurred by children with different needs reflect variations in the type and cost of placements they receive. The weekly cost per child is £2,995 for a local authority care home (2013/14 prices), £2,947 for a non-statutory care home (that is, voluntary and private sector care homes) and £700 for local authority foster care ( Curtis, 2014).

In England the average weekly social services cost per child who experienced abuse/neglect is £163 if supported in their families or independently, and £756 if looked after ( Curtis, 2014). The social services' costs include: the costs of field and centre staff time carrying out social services activities with, or on behalf of, identified children in need and their families; the costs of providing care and accommodation for looked-after children (and similar regular, ongoing expenditure that can be treated in the same way); and one-off ad hoc payments and purchases for children in need or their families. Similarly, the costs associated with adoption are high. The average cost per day across all adoption services (including the private and voluntary sector) is £230 (2013/14 prices). This estimate includes adoption allowances paid and other staff and overhead costs associated with adoption including the costs of social workers seeking new and supporting existing adoptive parents.

Foster placement instability is a significant problem with large numbers of children, particularly teenage children, experiencing as many as 3 moves in the first year ( Ward & Skuse, 2001). Attachment and other forms of emotional disturbance are 1 of a number of factors influencing the stability of such placements ( Sinclair, 2005). Multiple placements of this sort have significant cost implications. In a recent report, Hannon and colleagues (2010) explored the consequences associated with 2 care journeys, which represent the best and the worst current system. One journey was designed to reflect the experience of the very top range of 5-10% of children in care who are fortunate enough to have long-term, stable placements and supported transitions. The other scenario reflected the 5-10% of children who have a journey characterised by instability, disruption and abrupt exits. The authors found significant variation in costs: 'Child A' with a stable care journey cost £352,053 over a 14-year period, while 'Child B' with unstable care journey cost in total £393,579 over a 7-year period (a difference in total cost of £41,526). This translates to a substantial difference in annual costs per year (£23,470 for 'Child A' and £56,225 for 'Child B') once their length of stay in care is taken into account (15 versus 7 years), difference of £32,755 per year.

The authors went on to consider adult outcomes that might be associated with each scenario to estimate the possible costs to the state up to the age of 30. It was assumed that 'Child A' leaves care at the age of 18 following a stable placement, with good qualifications. 'Child B' was assumed to leave care at 16.5, with no qualifications, and with mental health problems. 'Child A' may cost the state £20,119 by age 30 if they go on to university and secure a graduate job. 'Child B' may cost the state £111,924 if they experience unemployment, underemployment and mental health problems. Between the age of 16 and 30 there is a difference between the costs of 'Child A' and 'Child B' to the public sector of £91,805, or £6,558 per annum. Greater stability and improved mental health can reduce immediate costs to the local authority by reducing social workers' time, use of expensive agency and residential placements, and therapeutic support.

Attachment difficulties are strongly associated with later problems. A review of 69 studies that examined the association between insecure or disorganised attachment and externalising problems found significantly increased risk for both insecure (Cohen's d [d] = 0.31, 95% confidence interval [CI]: 0.23 to 0.40, with larger effects for boys [d = 0.35], clinical samples [d = 0.49], and observation-based outcome assessments [d = 0.58]) and disorganised children (d = 0.34, 95% CI: 0.18 to 0.50), with weaker effects for avoidance (d = 0.12, 95% CI: 0.03 to 0.21) and resistance (d = 0.11, 95% CI: 0.04 to 0.26) ( Fearson et al., 2010). Externalising problems of this nature are strongly associated with a range of later problems including substance misuse and criminality ( Allen et al., 1996). Conduct disorder, substance dependency and crime impose significant social costs and harm to individuals and their victims, families and carers, and to society at large. The cost of proven offending to the criminal justice system, including the costs of police, courts, offender management teams and custody was estimated to be approximately £8,000 per young offender (in 2008/09 prices) ( National Audit Office, 2011). Criminal behaviour can persist into adulthood imposing immense costs to society. For example, the lifetime costs of crime attributable to conduct disorder in childhood range from £75,000 to £225,000 per case ( Health, 2009).

The authors of a recent Health Technology Assessment (HTA) report ( Wright et al., unpublished) estimated the expected budget impact of screening strategies and treatment for disorganised attachment within the context of a clinical commissioning group (CCG). The authors assessed budget impact of screening and treating disorganised attachment by various target populations (for example, general population, middle class children, born into poverty, alternative caregiver [that is, adopted or fostered], and maltreated). Assuming all children born in a CCG were to be screened (a general population programme) at a certain age after birth the number of screens per year would be equal to the number of births. If the average CCG in the UK covers 264,039 individuals and assuming the general population screening strategy aimed to screen all children born in that CCG at a pre-defined time from birth, the expected cohort that could be screened in the general population would be 3,237 newborn children with a total cost of identification to the average CCG of £93,873, and subsequent treatment would cost, on average, £219,987. This suggests that the total cost to screen the general population and change disorganised attachment would approximate to £313,860 per year (2011/12 prices). The above estimates assume use of the SSP at a cost of £29 per case, average treatment cost of £2,265 per case, and expected prevalence of 3%.

Attachment difficulties and associated mental health problems during childhood therefore place a considerable financial burden on health and social care services, the criminal justice system and society. As such, it is important to identify cost-effective interventions that can help to reduce the burden to service users, their families and carers and society as a whole.

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Infants are born equipped with a range of innate behaviours to maximise their survival. Attachment behaviour allows the infant to draw others towards them at moments of need or distress (Fonagy et al., 1995). Infants who experience a secure attachment relationship develop a reasonably firm expectation of feeling protected and safe, which in turn allows them to explore their world more confidently.

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This resource will familiarize you with how children develop insecure attachment styles, what specifically causes anxious attachment in children, and how you can change and heal from anxious attachment.

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Anxious attachment is one of the three insecure attachment styles. Referred to as anxious ambivalent attachment in children, anxious attachment develops in early childhood. Most often, anxious attachment is due to misattuned and inconsistent parenting.

Low self-esteem, strong fear of rejection or abandonment, and clinginess in relationships are common signs of this attachment style. Although it does require effort, individuals with such attachment issues can develop a secure attachment style over time.
We will cover the most common questions around anxious attachment:

How does attachment form in early childhood?

How do children develop insecure attachment styles?

What specifically causes anxious attachment in children?

Which children have a higher risk of developing anxious attachment?

What are relationships with anxious adults like?

Can you change an anxious attachment style?

How to heal from anxious attachment?

Everything you need to know about anxious attachment

Appreciation, attention, and support. Many of us crave that. We want to be loved, we want to feel secure, valued, and appreciated. No one likes to be left out in the cold. It is normal to seek approval, help, and emotional responsiveness from your family, friends, and partners.

It is also normal to fear losing someone's love. But what if these needs and fears become too strong? Can the need for safety and the fear of abandonment be so powerful that they control your relationships? It might not always be easy to recognize an insecure attachment style in adults.

Patterns in social relationships might be inconsistent or barely noticeable. There are, however, particular signs that hint each type of attachment. The Q&A below will guide you through understanding what causes the development of the anxious attachment style, how you can spot it in yourself (and others), and what to do about it.

First, a short intro on attachment theory

Let's look at attachment theory, which dates back to the 1950's.

According to psychiatrist and psychoanalyst John Bowlby, a child's early relationship with their caregivers forms the way this child will approach social interactions and relationships throughout life.

The concept is relatively easy to grasp. When a baby is born, the first social bond they encounter is with the caregivers (in most cases, parents). This is when the child's brain starts to form a perception of social interactions.
If the child is brought up in a warm and nurturing environment, where the caregivers are responsive to the child's emotional needs, a secure bond (referred to as secure attachment) is formed.
The child is taught, indirectly, that his or her emotions and needs will be recognized, that he or she will be supported and loved, and that people, in general, can be trusted.
On the contrary, when a child perceives that his or her needs are not met, the child is not able to build a secure and stable bond with the caregivers.
This leads to a distorted perception of how relationships work.

There are three types of insecure attachment in adults:

1. Anxious (also known as preoccupied)

2. Avoidant (also known as dismissive)

3. Disorganized (also known as fearful-avoidant)

What causes anxious attachment style in childhood?

The development of an anxious/preoccupied attachment style (referred to as anxious ambivalent in children) is often associated with an inconsistent parenting pattern.

Sometimes, the parents will be supportive and responsive to the child's needs. At other times, they will be misattuned to the child.

This inconsistency might make it difficult for the child to understand what the parents' behavior means and what kind of response to expect in the future. The child might end up confused about his or her relationship with the caregivers, whose behavior sends mixed signals.

Another factor that is linked to the development of an anxious ambivalent attachment style in children is the so-called " emotional hunger " of the caregivers.

In that case, the caregivers would seek emotional/physical closeness with the children in order to satisfy their own needs, rather than their children's.

Such parents might appear intrusive or over-protective. They might use the child to satiate their own 'hunger' for love, or to present their own selves in a certain light (for example, as the perfect parent).

It should be noted that raising a child in such a manner might also be an automatic and unrealized pattern in adults who were raised the same way.

Caregivers, whose child develops an ambivalent attachment style, are likely to have an anxious attachment style themselves. And this is not about genetics, but about the continuity of behavioral patterns throughout generations.
Don't know your attachment style? Take our short 5 minute quiz to find out now. It's completely free.
Which children have a higher risk of developing anxious (ambivalent) attachment?

The previous paragraph provides an overview of what caregiver behaviors might threaten the child's ability to form a secure attachment style.

Inconsistent responsiveness to a child's emotional needs, misattunement and emotional distance, as well as preoccupation with and intrusiveness in the child's life, are some of the risk factors for the development of an ambivalent attachment style in children.
In addition to that, there are a few less common risk factors, such as:

Physical or psychological abuse

Early separation from the caregiver

[It is essential to note that having an insecure attachment style is not a mental disease or disorder. It is common among adults, and in most cases, is nothing to worry about. Still, having an unstable/insecure attachment style can cause distress, or harm relationships.]
Symptoms of having an anxious attachment style as an adult

How to recognize a person with an anxious attachment style? Adults with an anxious/preoccupied attachment style might think highly of others but often suffer from low self-esteem.

These individuals are sensitive and attuned to their partners' needs, but are often insecure and anxious about their own worth in a relationship.

If the loved one rejects them or fails to respond to their needs, they might blame themselves or label themselves as not being worthy of love.

Generally, adults with anxious attachment need constant reassurance that they are loved, worthy, and good enough.
The strong fear of abandonment might often cause anxious adults to be intensely jealous or suspicious of their partners.
This fear might also lead them to become desperate, clingy, and preoccupied with their relationships. Adults with an anxious attachment style are often afraid of or even incapable of being alone.

They seek intimacy and closeness and are highly emotional and dependent on others. The presence of the loved one appears to be a remedy for their strong emotional needs.

Anxious attachment style in relationships

Having an insecure attachment style can be tiring. It could feel like you are on an emotional roller-coaster all the time.

It might cause anxiety, stress, unhappiness, and low life satisfaction. When it comes to adults with anxious attachment styles, relationships might be both 'life-saving' and 'life-threatening'.

On the one hand, the fear of being alone or being rejected is the poison - a disturbing feeling, which leads to constant doubt and worry. On the other hand, the presence of the loved one, and more importantly, their demonstration of affection is the remedy.

Furthermore, an anxious individual might be insecure about where they stand in a relationship and whether their partner loves them as much as they do in return. Consequently, the slightest disappointment or sign of rejection from the partner could be harmful to the already low self-esteem.

We recommend you also read our complete guide on anxious attachment in relationships and articles on how anxious attachment affects you in the bedroom and in the workplace.

Can you change your attachment style and how?

Luckily, attachment styles can change. Sometimes, the change can happen by itself: a relationship with a securely attached individual could facilitate emotional closeness and a sense of calmness and stability.

This new experience can lead to a shift in perception and to new habits and patterns. Other times, you might need to work harder on your attachment style. You cannot change your past, but you can change the present.

One key to healing an insecure attachment style is to make sense of the way you interact with your loved ones, especially with your partner. Recognizing your behavioral patterns in relationships and being mindful of them will make the issue easier to solve. Self-reflection is important. Analyzing and making sense of your childhood experiences is also an essential step.

Realizing that past experiences do not have to affect and/or predict the present and the future will make it easier to break free from established behavioral patterns and habits.

Obviously, working with a therapist on this pattern would potentially be the most beneficial way to move forward with earning secure attachment. We are offering attachment repair groups and online courses for you to move forward.

Either way, if you want to change your attachment style, you need to put effort in it. Whether you are working through it with a close friend, a therapist, or a book, consistency and effort are fundamental.
If you prefer to go the route of a workbook, we recently released our first series of attachment style digital workbooks.

Our anxious attachment style digital workbook includes:

204 pages and 28 practical exercises

How anxious attachment affects you in over 10 different areas of life

8 case studies on anxious attachment

Groundbreaking and up-to-date research on anxious attachment

Section recaps and areas for reflection

Empower your Instagram feed

If you liked this post and want to learn more about attachment theory, then we recommend following The Attachment Project on Instagram. We aim to help you make sense of your attachment style in various contexts of your life.

Sources:

Ainsworth, MD, Bell, SM.(1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41(1), 49-67.

Bowlby J. (1958). The nature of the child's tie to his mother. International Journal of Psychoanalysis, 39, 350-371.

Bowlby J.(1982). Attachment and Loss: Volume 1 Attachment. 2nd ed. New York: Basic Books.

Mikulincer, M., Shaver, P.R. (2007). Attachment in Adulthood: Structure, Dynamics, and Change. Guilford Press.

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Anxious Attachment Style Guide: Causes & Symptoms

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How does anxious attachment develop in childhood and what are 10 common behaviors that manifest later in adult relationships?

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How Anxious Ambivalent Attachment Develops in Children

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How Anxious Ambivalent Attachment Develops in Children

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This article will tell you about how children you have anxious-ambivalent attachment styles develop that attachment style. It describes how children are distressed when their caregiver leaves them but are inconsolable when they return.

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Children who have an anxious-ambivalent attachment style are described as being distressed when their caregiver leaves them but are then inconsolable on their return. Anxious-ambivalent children fear abandonment but cannot trust their caregiver to be consistent.

Anxious-ambivalent attachment is one of the insecure attachment styles proposed by John Bowlby in the 1950s.

Anxious-ambivalent attached is believed to be a rarer type, comprising 7-15% of most American infants (Cassidy & Berlin, 1994).

Bowlby proposed that children develop an attachment style in early life depending on the parenting of their primary caregiver.

Individuals with an anxious-ambivalent attachment may hold a negative self-image and a positive image of others, meaning that they can have a sense of unworthiness but generally evaluate others positively.

As such, they strive for self-acceptance by attempting to gain approval and validation from their relationships with significant others. They may also require higher levels of contact and intimacy in relationships with others.

A child with an anxious-ambivalent attachment style may express that their peers do not want to be good friends with them as much as they want to be good friends with them. They may also be afraid that others do not love them or believe that other children avoid them (Grady et al., 2021).

Additionally, they are preoccupied with dependency on their parents and still actively struggle to please them.

Some of the key traits that a child may have an anxious-ambivalent attachment style include:

Clinging to caregivers

A fear of strangers

Extreme distress when separated from their caregivers

Inconsolable when upset - not easily comforted

Poor relationships with other children

Limited exploration of their environment

Difficulty regulating and controlling negative emotions

Appearing anxious in general

Signs of Ambivalent Attachment

Children with an anxious-ambivalent attachment style express distress when their caregiver leaves and are difficult to soothe when they return.

The child is often uncertain whether they can rely upon the caregiver and may resent being abandoned.

An anxious-ambivalent child may never know whether their caregiver will respond to them or not. Thus, they learn that love and support will not always be there for them.

Anxious at separation

A child who is anxious-ambivalent finds it very difficult to let go of their caregivers at times of separation.

They may refuse to go to school or be cared for by anyone other than their primary caregiver and display extreme signs of distress when separation occurs.

It is common for children with an anxious-ambivalent attachment to develop separation anxiety disorder (SAD). This is an anxiety disorder generally diagnosed in early childhood.

Children with SAD may refuse to go to school for fear of being separated from their caregivers and experience extreme anxiety when they are separated.

Rejecting of caregiver

Despite being anxious at separation, the child often rejects the caregiver when they return to the child.

The child may feel hurt, rejected, and angry, holding onto this sadness no matter what comfort comes from the caregiver. The child may not make eye contact upon the caregiver's return.

The anxious-ambivalent child may be very hard to please, and nothing anyone does is right for them.

Limited exploration

Anxious-ambivalent children are often insecure about exploring their world. They may find it hard to go off and play on their own without seeking constant reassurance and attention from their caregiver.

In the school playground, the anxious-ambivalent child may choose to stand close to the teacher rather than go off to play with other children since this feels safer. Thus, they may appear unsociable and find it hard to make friends with peers.

Attention-seeking

Children who are anxious-ambivalent are likely to have many emotional outbursts. In an attempt to remain connected to their caregiver, the child may have to rely on emotional strategies as a way to seek attention (Grady et al., 2021).

At school, the child is often person-focused rather than task-focused. They may spend much of their time in class trying to talk to others and the teacher rather than on their work.

They may be so concerned with trying to gain and maintain the attention of the adults that they may also struggle to focus and absorb instructions, and they may repeatedly ask questions to ensure they have been noticed.

Once they have their caregiver's attention, they are usually unwilling to let them go for fear that they will not get them back. Therefore, they often appear very clingy.

Reliance on others

Anxious-ambivalent children are often too anxious to do anything alone and may constantly ask for help. This can include always wanting to have a safe person with them wherever they go.

Moreover, these children are not able to regulate their own needs and may often rely on others to regulate them.

Cause of Ambivalent Attachment

What parenting causes ambivalent attachment?

While it may not always be clear why a child may develop an ambivalent attachment style, it is often a result of the parenting by the caregivers.

Some of the possible ways in which parenting styles can cause an ambivalent attachment style include the following:

Inconsistent parenting

Those with an anxious-ambivalent attachment style are thought to have experienced caregivers who are inconsistent and unpredictable (Grady et al., 2021).

Parenting is inconsistent when there are times of support and responsiveness to the child's needs, but not at other times. At other times, the caregiver may be cold, insensitive, or emotionally unavailable.

The child may become confused about their relationship with a caregiver who is always sending them mixed signals.

This inconsistency can make it difficult for the child to predict what their parent's behavior is going to be at any given time, resulting in elevated insecurity and anxiety.

Emotional distance

A caregiver who is emotionally distant or neglectful can leave a child feeling insecure and unstable. If a caregiver is not meeting the emotional needs of the child, especially when they are distressed or anxious, these feelings are likely to worsen.

If a caregiver is neglectful of a child's needs, the child is likely to develop an insecure attachment style.

Intrusive parenting

An intrusive caregiver is one who gives intrusive attention to their child.

They have poor emotional boundaries, intrude on the child's state of mind, and can be overbearing. The child may feel smothered by the caregiver and that they do not have enough room to grow or be themselves.

Intrusive parenting can also include mirroring the child. This is where the caregiver reflects on how the child is feeling, amplifying the child's negative reaction rather than soothing it. For instance, if a child is anxious, the caregiver becomes anxious; when the child cries, the caregiver also cries.

Caregiver's 'emotional hunger'

When caregivers seek emotional or physical closeness with the child for the purpose of satisfying their own needs, this is known as fulfilling their 'emotional hunger.'

If the caregiver is using the child to satisfy their own needs, they may be neglecting the child's emotional and physical needs. These types of caregivers can also appear intrusive and preoccupied with their child's life. They may also replace actual love and affection for their child with using the child to feed their own needs.

The child, therefore, does not get their needs met and may go on to put everyone else's needs above their own as they get older since this is what they have been used to doing.

Anxious-ambivalent caregivers

It is likely that if a child has an anxious-ambivalent attachment style, their caregiver also has this attachment style.

This is not likely due to genetic reasons; rather, it is a continuation of behavioral patterns repeated throughout generations.

Without addressing the insecure attachment of the child, they may grow up to have a child who is also anxious-ambivalent.

Attachment theory was proposed by psychologist John Bowlby in the 1950s. He proposed that children develop an attachment style in early life depending on the parenting of the primary caregiver.

The concept involves one's confidence in the availability of the attachment figure for use as a secure base from which one can freely explore the world when not in distress as well as a safe haven from which one can seek support, protection, and comfort in times of distress.

Bowlby argued that one's sense of security as a child is critical to attachment style as an adult.

It is generally accepted that there are four attachment styles (Ainsworth, Blehar, Waters, & Wall, 1978):

Ambivalent - also known as anxious attachment, children with this style have problems trusting others. They often worry that people will abandon them so that they may be clingy or needy with others.

Avoidant - this attachment style is characterized by problems with intimacy and low emotional investment in relationships.

Secure - this is characterized by feelings of trust and safety in relationships. Children who are securely attached feel safe and supported by their caregivers. Securely attached adults are capable of forming lasting relationships.

Disorganized - this is marked by a mix of behavior that can range from avoidance to clinginess. People with this attachment style often long for close relationships but fear trusting others and getting hurt (Main & Solomon, 1986).

The attachment style you develop in early childhood is thought to have a lifelong influence on your ability to communicate your emotions and needs, respond to conflict, and form expectations about your relationships.

Although the attachment style you were raised with does not explain everything about your relationships and who you become as an adult, understanding your style may help explain patterns you notice in relationships.

Frequently Asked Questions

How can a caregiver support a child to become more secure?

There is no perfect way to parent a child, and there may be many obstacles to navigate around. Raising a securely attached child can depend entirely on the child and caregiver.

However, there are five areas that Brown and Elliot (2016) have indicated key areas caregivers should strive for:

1. Ensuring the child feels safe
2. Making sure the child feels seen and known
3. Comforting the child
4. Valuing the child
5. Ensuring the child feels supported for being their best self

Are attachment styles universally accepted?

It is worth bearing in mind that much of the foundational research on attachment theory is based on American samples.

For instance, Mary Ainsworth's class study of The Strange Situation (1970) used only American infants - the findings of which were generalized to explain attachment for all infants.

This is a type of ethnocentric research. While the American standard for what is considered 'secure attachment' may present a certain way, this may not be how it presents in other cultures.

What are anxious-ambivalent adults like in romantic relationships?

Adults who have an anxious-ambivalent attachment style may present as clingy in their romantic relationships.

They may crave emotional intimacy with a partner but are anxious that others do not want to be with them. They may also find it hard to accept boundaries and become panicked or fearful if their partner is not around.

Likewise, they may have low self-esteem and find it hard to accept that their partner loves them, and may struggle with trust issues.

Are anxious-ambivalent children at higher risk of developing anxiety?

Compared to children who were securely attached in infancy, children who are anxious-ambivalent may have higher levels of school phobia and social phobia later in childhood (Bar-Haim et al., 2007).

Likewise, those with an anxious-ambivalent attachment style as an infant may be at a higher risk of being diagnosed with an anxiety disorder in late adolescence (Warren et al., 1997).

References

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Lawrence Erlbaum.

Baldwin, M.W., & Fehr, B. (1995). On the instability of attachment style ratings. Personal Relationships, 2, 247-261.

Bar-Haim, Y., Dan, O., Eshel, Y., & Sagi-Schwartz, A. (2007). Predicting children's anxiety from early attachment relationships. Journal of anxiety disorders, 21(8), 1061-1068.

Bartholomew, K., & Horowitz, L.M. (1991). Attachment Styles Among Young Adults: A Test of a Four-Category Model. Journal of Personality and Social Psychology, 61 (2), 226-244.

Bowlby, J. (1969). Attachment and Loss: Volume I. Attachment. London: Hogarth Press.

Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment: An integrative overview. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (p. 46-76). The Guilford Press.

Brennan, K. A., & Shaver, P. R. (1995). Dimensions of adult attachment, affect regulation, and romantic relationship functioning. Personality and Social Psychology Bulletin, 21 (3), 267-283.

Brown, D. P., Elliott, D. S. (2016). Attachment Disturbances in Adults: Treatment for Comprehensive Repair. New York: W.W. Norton.

Caron, A., Lafontaine, M., Bureau, J., Levesque, C., and Johnson, S.M. (2012). Comparisons of Close Relationships: An Evaluation of Relationship Quality and Patterns of Attachment to Parents, Friends, and Romantic Partners in Young Adults. Canadian Journal of Behavioural Science, 44 (4), 245-256.

Cassidy, J., & Berlin, L. J. (1994). The insecure/ambivalent pattern of attachment: Theory and research. Child development, 65 (4), 971-991.

Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment styles in maltreated children: A comparative study. Child Psychiatry and Human Development, 31 (2), 113-128.

Grady, M. D., Yoder, J., & Brown, A. (2021). Childhood maltreatment experiences, attachment, sexual offending: Testing a theory. Journal of interpersonal violence, 36(11-12), NP6183-NP6217.

Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52 (3), 511-524.

Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood and adulthood: A move to the level of representation. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory and research. Monographs of the Society for Research in Child Development, 50 (1-2), 66-104.

Main, M., & Solomon, J. (1986). Discovery of an insecure-disorganized/disoriented attachment pattern. In T. B. Brazelton & M. W. Yogman (Eds.), Affective development in infancy. Ablex Publishing.

Warren, S. L., Huston, L., Egeland, B., & Sroufe, L. A. (1997). Child and adolescent anxiety disorders and early attachment. Journal of the American Academy of Child & Adolescent Psychiatry, 36(5), 637-644.

Waters, E., Merrick, S., Treboux, D., Crowell, J., & Albersheim, L. (2000). Attachment security in infancy and early adulthood: A twenty-year longitudinal study. Child Development, 71 (3), 684-689.

Further Information
Hazan, C., & Shaver, P. R. (1994). Attachment as an organizational framework for research on close relationships. Psychological inquiry, 5(1), 1-22. McCarthy, G. (1999). Attachment style and adult love relationships and friendships: A study of a group of women at risk of experiencing relationship difficulties. British Journal of Medical Psychology, 72(3), 305-321. Greater Good Magazine of Berkeley University of California. How to stop attachment insecurity from ruining your love life. BPS Article- Overrated: The predictive power of attachment How Attachment Style Changes Through Multiple Decades Of Life Saul Mcleod, PhD
Educator, Researcher

Saul Mcleod, Ph.D., is a qualified psychology teacher with over 18 years experience of working in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
Olivia Guy-Evans, MSc
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

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How Anxious Ambivalent Attachment Develops in Children

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Children who have an anxious-ambivalent attachment style are described as being distressed when their caregiver leaves them but are then inconsolable on their

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Attachment Styles in Children (& How to Raise Secure Kids)

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Attachment Styles in Children (& How to Raise Secure Kids)

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This article details the childhood attachment styles-- secure, avoidant, ambivalent, and disorganized how the impact on emotional and relational development into adulthood. This article can help you understand attachment styles and guide interventions to improve emotional wellbeing and relationships.

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Attachment Styles in Children (& How to Raise Secure Kids)

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Attachment styles refer to how one individual relates to another.

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This video details 9 signs that you mat have an anxious attachment style. It also talks about how the anxious attachment style is a type of insecure attachment style that is rooted in fear of abandonment and an insecurity of being underappreciated.

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Psychologist On What Helps Anxiously-Attached Heal | Healing An Anxious Attachment Style

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Anxious Attachment: Signs in Children and Adults, Causes, and More

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Anxious attachment is thought to develop in early childhood, and may be related to inconsistent parenting. Learn about this attachment type, including signs, causes, and management tips.

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Anxious Attachment: How Childhood Experiences Shape Your Adult Relationships

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This article details how you may have an anxious attachment style in adulthood based upon the quality of relationships you had as a child from your caregiver figures. If you feel nervous when the other person leaves or doesn't reply fast enough or fear that the relationship will end at anytime, are characteristics of an anxious attachment style.

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Integrated Care Clinic | Saint Petersburg, FL

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Anxious Attachment: How Childhood Experiences Shape Your Adult Relationships - Integrated Care Clinic | Saint Petersburg, FL

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Discover how anxious attachment forms in childhood, its impact on adult relationships, and steps for healing. Contact ICC today!

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The 4 Attachment Styles and How They Impact You

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Is your attachment style secure, anxious, avoidant or disorganized? Learn about attachment styles from a clinical psychologist.

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Avoidant attachment: Causes, signs, and effects

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Fearful Avoidant Attachment: Breaking the Cycle as Parents

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Parenting can be challenging, even for the best of us. However, some parents may find it even more difficult due to their insecure attachment style parenting. Identifying the signs of your attachment style and working towards recovery can have a lasting impact on fostering secure attachment styles in your children. No matter your struggles, we offer holistic addiction treatment and are ready to help you begin your journey to healing.

Types of Attachment Styles

Our attachment styles develop in childhood and grow with us into adulthood. It's important to note that attachment styles can change-we all want to grow into a healthy and secure attachment style with our friends, family, and with our children. Here are four main attachment styles:

Adults with a secure attachment style are comfortable with intimacy, trust their partners, and aren't afraid to be close to others.

The anxious preoccupied attachment style is characterized by low self-esteem, a positive view of others, and a dependence on relationships, leading to panic and fear about their partners.

Dismissive-avoidant attachment styles value their independence greatly. As a result of an avoidant childhood, they often avoid attachment all together, regarding themselves positively and others negatively.

While anxious avoidant attachment styles (also known as fearful avoidant attachment) desire close and intimate relationships, they struggle with closeness and find it hard to trust or depend on others.

A Closer Look at Fearful-Avoidant Attachment

This attachment style struggles to form emotional bonds. It is usually caused by inconsistent or unpredictable caregiving, making it difficult for children to trust others. As a result, they may exhibit anxious behavior, such as seeking reassurance or being overly clingy, while also being distant or dismissive.

Children with a fearful avoidant childhood attachment style are more prone to experience feelings of loneliness, anxiety, and low self-esteem throughout their lives. They may also have difficulty forming healthy relationships with others. Consequently, fearful-avoidant parents may feel frustrated and hopeless as they struggle to connect emotionally with their children.

Despite the challenges fearful-avoidant attachment presents, there is hope. With guidance, support, and trauma-informed care parents can break free from their patterns of insecure attachment and model a more secure and loving bond with their children.

Recognizing Fearful-Avoidant Triggers

A variety of factors lead to fearful-avoidant attachment, such as early childhood trauma, neglect, or inconsistent caregiving. Certain parenting behaviors can contribute to the development of fearful avoidant attachment in children. It's important to reflect on these from your own childhood, and also in your parenting. These behaviors include:

Inconsistent caregiving: Regularly changing parenting styles, being emotionally unavailable, or providing inconsistent physical and emotional support to children creates a sense of instability and mistrust.

Overprotectiveness: Overly protecting children from challenges or allowing them too much independence can create a sense of insecurity and hinder their ability to form secure attachments.

Rough handling: Physical punishment or harsh disciplining techniques can create a fear of intimacy and hinder the development of a secure bond between parent and child.

Negative communication: Criticizing or dismissing a child's emotions can discourage open communication and hinder the development of a secure attachment.

When a person experiences one or more of these during childhood, they may respond by developing anxious or avoidant behaviors. Common triggers of fearful-avoidant attachment include:

Separation from caregivers: This can include temporary absences or more significant separations, such as moving to a different home or school.

Transitions: Changes in routine or environment can cause distress and increase anxious or avoidant behaviors.

Stressful events: Traumatic events or periods of intense stress can exacerbate attachment issues.

Practical Tips for Parents to Establish Secure Attachments

Some parents find it challenging to establish healthier attachment styles for themselves. If you are a parent who struggles with fearful-avoidant attachment in yourself, a qualified mental health caregiver can help identify any insecure attachment patterns in your life and support you as you help your children develop healthy attachment styles.

Unfortunately, most people who struggle with an insecure attachment style either modeled it after their own parents or caregivers, or developed it as a response to poor parenting. Thankfully, each generation has the opportunity to recognize their own destructive behavior and create new patterns for themselves and their children. With trauma-informed care and a heart-centered approach, ILC offers trauma treatment and anxiety treatment to help identify, understand, and heal from unwanted behaviors.

Positive Parenting Techniques

Parents can break the cycle of fearful-avoidant attachment and create a secure and loving bond, even with an insecure avoidant attachment child. By implementing positive parenting techniques, parents help their children develop healthy attachments and feel more confident and secure in their relationships. Some effective positive parenting techniques include:

Consistency: Consistent parenting practices, including discipline, expectations, and emotional support, can help create a predictable and secure environment for children.

Nurturing touch and affection: Providing physical affection, such as hugs and kisses, can help children develop a sense of security and trust in their parents.

Active listening: Encouraging open communication and actively listening to your child's thoughts and feelings can help build trust and reassurance.

Emotional regulation: Modeling healthy emotional regulation by managing one's own emotions helps children develop healthy, secure emotional coping skills.

Play and exploration: Engaging in playful activities and creating opportunities for exploration and adventure helps children develop self-confidence and independence.

Setting boundaries: Establishing clear boundaries and expectations helps children feel safe and secure in their relationships.

Nurturing Secure Attachment in Children

Creating a secure attachment bond between parent and child is crucial for a child's emotional and psychological well-being. Nurturing secure attachment involves providing consistent care, love, and support, and responding to a child's needs lovingly and sensitively. You can accomplish this many ways, such as:

Predictability: Creating routines and structures that provide stability can help children feel safe and cared for.

Recognition and validation: Acknowledging and validating a child's feelings and experiences help build a secure attachment bond.

Empathy and sensitivity: Being attuned to your child's needs and responding in a supportive and nurturing manner helps create a secure attachment.

Together time: Spending quality time together, engaging in shared activities, and creating a strong emotional connection helps strengthen attachment bonds.

Effective communication: Encouraging open dialogue, providing age-appropriate explanations, and addressing concerns can help build trust and a secure attachment.

Communicating Openly with Your Child

Open and honest communication is at the core of building a secure attachment. As you communicate with your child, using the following methods helps reinforce the child's bond with you, modeling how they treat others and how they expect to be treated in future relationships.

Active Listening: Respond to your child with empathy and understanding, and encourage them to share their thoughts and feelings.

Reflection: Reflecting your child's experiences, thoughts, and feelings back to them helps validate their experience and strengthen the bond.

Setting Boundaries: Communicate boundaries and expectations to your child while allowing for flexibility and understanding.

Modeling Effective Communication: Demonstrating healthy communication styles helps children learn effective communication skills.

Repairing Relationship Breakdowns

If you have already raised your children to adulthood and now recognize fearful-avoidant attachment in their upbringing, it might be helpful to consider how you can repair any lingering damage. You can begin by using some of these methods to repair brokenness in the parent-child relationship:

Acknowledge your past behavior and apologize to your child for any harm you may have caused.

Engage in an honest conversation with your child, listening to their perspective and feelings without being dismissive or defensive.

Show interest in your child's life and be available to offer support and guidance whenever they need it. Make your child's needs a priority by being emotionally accessible and responsive.

Consult a therapist or counselor if you need help developing a secure attachment style. This can help you understand the root causes of your avoidant behavior and develop healthier ways to relate to your children.

Repairing a damaged relationship takes time and effort, but with consistency and a willingness to change, even the most damaged relationship can improve.

Recovery is Possible at Integrative Life Center

Attachment styles aren't permanent, and they aren't always the same relationship to relationship. If you notice fearful-avoidant attachment in your own life, you don't have to continue in it!

At ILC, we take a holistic approach to identifying and healing insecure attachment styles and the difficulties that come along with them. We've joyfully witnessed many beautiful transformations in our clients and seen them spread healthy patterns throughout their close relationships, undoing and repairing years of harmful patterns.

The best way to break an unhealthy pattern is to take actions outside that pattern. Why not start your journey to a healthier self today? You can begin by calling us at (615) 645-3735. We would love to be a part of your journey to break fearful-avoidant patterns and change your family tree.

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Fearful Avoidant Attachment: Breaking the Cycle as Parents

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Discover how to break free from fearful-avoidant parenting patterns. Nurture secure attachments for lasting emotional well-being. Contact ILC to learn about our mental health treatment centers.

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Understanding your child's attachment style is crucial for their emotional, social, and cognitive development. This video will help you identify the signs of each attachment type and provide actionable tips to support your child, especially if they aren't securely attached. Whether your child is independent, clingy, or seems confused, we have strategies to strengthen your bond and promote a healthier emotional connection.

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Avoidant attachment is an attachment style you may develop during childhood as a result of having an emotionally absent parent. If you have this attachment style, you may deny the importance of certain feelings or deal with them alone. Most people are able to manage avoidant attachment disorder symptoms and improve relationships through talk therapy. (

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Avoidant attachment is when people avoid emotional closeness. Learn about the causes, symptoms, and treatment options for this condition today.

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Attachment – Jacob Ham: Avoidant Attachment

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Attachment – Jacob Ham: Avoidant Attachment

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This video is part of the Attachment classroom-based training theme in the NTDC curriculum. The video was created by Dr. Jacob Ham, a clinical psychologist who is the Director of the Center for Child Trauma and Resilience at Mt. Sinai Hospital in New York, to show what the Avoidant attachment style looks like in the behaviors of children.

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Administration for Children and Families (ACF)

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NTDC Classroom: Attachment – Jacob Ham: Avoidant Attachment

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Avoidant Attachment Style: Causes & Symptoms

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Avoidant Attachment Style: Causes & Symptoms

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This article details how attachments form in early childhood, what specifically causes it and what relationships look like as an adult with an avoidant attachment style.

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Avoidant Attachment Style: Causes and Adult Symptoms

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Get to know the underlying causes of an avoidant attachment style from childhood and the behaviors that manifest in adult relationships.

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This video was a reenactment of situations and responses that would lead to an avoidant attachment style.

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Reactive attachment disorder (RAD) is a rare condition where children don’t form an emotional bond with their caretakers. Children who are adopted may experience RAD. Treatment focuses on repairing and/or creating emotionally healthy family bonds.

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What are the symptoms of reactive attachment disorder?

Symptoms of reactive attachment disorder are unique to each child. Common symptoms among infants and young children with RAD include:

Not showing positive emotions, like comfort, love or joy when interacting with others.

Avoiding eye contact and physical touch.

Expressing fear or anger by throwing tantrums or frequently showing unhappiness or sadness.

Trying to find things in their environment that they can control, which makes them likely to break rules.

What is the difference between inhibited reactive attachment disorder and disinhibited social engagement disorder?

Inhibited reactive attachment disorder (RAD) is related to disinhibited social engagement disorder (DSED), but there are differences between each type.

RAD

Children with reactive attachment disorder are aware of what happens around them, but they don't respond emotionally to what's going on. They may not show or seek affection from caregivers or others and prefer to be alone. Symptoms of inhibited reactive attachment disorder include:

Avoids caretakers.

Withdraws from social situations.

Resistant to signs of comfort (hugging).

DSED

Children with disinhibited social engagement disorder may be overly friendly toward strangers and even go to them without checking with their parents. In most cases, children act younger than their age and may seek out affection from others in an unsafe way. Symptoms of DSED include:

Selective relationships.

Attention seeking from anyone.

Showing behavior that is not appropriate for their age.

Not understanding social boundaries.

What causes reactive attachment disorder?

There is no exact cause for children diagnosed with reactive attachment disorder. Studies suggest that there could be several factors that contribute to a child who doesn't form a bond with their caretakers including:

Abuse or neglect: The child feels abandoned or alone.

Food insecurity: The child's basic needs aren't being met.

Safety: The child fears that they are in danger.

Lack of hygiene: The child sits in soiled diapers for hours at a time without being changed.

Multiple caretakers: The child doesn't know who to trust.

Inconsistent caregiving: The child's needs are only being met some of the time, particularly if they don't know when to expect their caregivers to reward or console them.

Young children form healthy relationships when their basic needs are consistently attended to. This builds a sense of trust between the child and their caretakers. If a child's physical and emotional needs aren't being met, they are at risk of developing RAD.

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Reactive Attachment Disorder (RAD): Causes, Symptoms & Treatment

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Reactive attachment disorder (RAD) is a condition that affects children who don't form a secure, healthy emotional bond with their primary caretakers.

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Reactive attachment disorder (RAD) is an attachment disorder in which a child has a difficult time emotionally connecting with others, including their parents. While some children are naturally introverted, a child with RAD can be extremely withdrawn and have a hard time managing their emotions. They rarely seek comfort when they’re distressed, and when their temper tantrums or moodiness spur you to comfort them, they tend to resist. A child with RAD will often ignore your soothing gestures, whether they’re cuddles, hugs, or verbal reassurances.

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Reactive Attachment Disorder (RAD): Symptoms, Causes, Help

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Children with RAD have a hard time accepting love and seeking comfort. But you can manage the symptoms and guide your child’s development.

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An aversion to touch and physical affection: Children with RAD often flinch, laugh or even say “ouch” when touched. Rather than producing positive feelings, touch and affection are perceived as a threat.

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Reactive Attachment Disorder: Signs and Symptoms

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Symptoms of RAD are commonly found in children who have been abused, bounced around in foster care, loss of primary caregiver.

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Reactive Attachment Disorder of Infancy or Early Childhood

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Reactive Attachment Disorder of Infancy or Early Childhood

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RAD can have negative effects on a child’s development. It may stop them from forming future relationships. It’s a lasting condition, but most children with RAD are eventually able to develop healthy and stable relationships with others if they get treatment and support.

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According to the Mayo Clinic, the symptoms of RAD will appear before the age of 5, often when a child is still an infant. The symptoms in infants may be more difficult to recognize than in older children and may include:

listlessness

withdrawal

no interest in toys or games

not smiling or seeking comfort

not reaching out to be picked up

Older children will show more noticeable symptoms of withdrawal, such as:

appearing awkward in social situations

avoiding comforting words or actions from others

hiding feelings of anger

displaying aggressive outbursts toward peers

If RAD continues into the teen years, it may lead to drug or alcohol abuse.

As children with RAD grow older, they may develop either disinhibited or inhibited behavior. Some children develop both.

Disinhibited behavior

Symptoms of this type of behavior include:

attention-seeking from everyone, even strangers

frequent requests for help

childish behavior

anxiety

Inhibited behavior

Symptoms of this type of behavior include:

avoiding relationships

refusing help

refusing comfort

showing limited emotions

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Reactive Attachment Disorder of Infancy or Early Childhood

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Reactive attachment disorder (RAD) is a serious condition that prevents children from forming a healthy bond with their parents.

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Reactive Attachment Disorder, Causes, Signs and Symptoms, Diagnosis and Treatment.

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Reactive Attachment Disorder, Causes, Signs and Symptoms, Diagnosis and Treatment.

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Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children.[1][2] RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited form". In the DSM-5, the "disinhibited form" is considered a separate diagnosis named "disinhibited attachment disorder".

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Reactive Attachment Disorder, Causes, Signs and Symptoms, Diagnosis and Treatment.

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Therapy for Reactive Attachment Disorder: Hope and Healing

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Therapy for Reactive Attachment Disorder: Hope and Healing

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Understanding and treating Reactive Attachment Disorder (RAD) is a journey, but with the right support, kids can form healthy bonds. RAD stems from early trauma or neglect and shows up as trouble connecting with others and managing emotions. Key steps include recognizing symptoms like avoiding affection, getting a professional diagnosis based on specific criteria, and understanding it’s often confused with other disorders. Early help is crucial for these kids to thrive.

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Top Therapy for Reactive Attachment Disorder | Heal Now

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Discover effective therapy for reactive attachment disorder. Learn strategies to support your child’s healing journey and foster healthy attachments.

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If untreated, children with RAD grow up to be adults who cannot truly ever feel love.  It is suggested that many of these adults will eventually be labeled as sociopaths or psychopaths.

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Reactive Attachment Disorder in teenagers

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Reactive Attachment Disorder in teenagers

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Reactive attachment disorder (RAD) in teens is a rare, but complex mental illness. This lifelong condition occurs when infants or toddlers do not form adequate bonds (or attachments) with parents or primary caregivers. While the causes of reactive attachment disorder are still being investigated, the onset of RAD may be because the child’s basic needs for comfort, interaction, or nurturing are not being met.

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Polaris Teen Center: Premier Adolescent Treatment Center in Los Angeles

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Reactive Attachment Disorder | Polaris Teen Center

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Reactive attachment disorder in teens is a rare, but complex mental illness. Don’t hesitate to contact Polaris Teen Center for help today.

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With appropriate treatment, children who have reactive attachment disorder may develop more stable and healthy relationships with caregivers and others. Treatments for reactive attachment disorder include learning how to create a stable, nurturing environment and providing positive child and caregiver interactions. Parent or caregiver counseling and education can help.

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Overview

Reactive attachment disorder is a rare but serious condition in which an infant or young child doesn't establish healthy attachments with parents or caregivers. Reactive attachment disorder may develop if the child's basic needs for comfort, affection and nurturing aren't met and loving, caring, stable attachments with others are not established.

With treatment, children with reactive attachment disorder may develop more stable and healthy relationships with caregivers and others. Treatments for reactive attachment disorder include psychological counseling, parent or caregiver counseling and education, learning positive child and caregiver interactions, and creating a stable, nurturing environment.

Products & Services

Symptoms

Reactive attachment disorder can start in infancy. There's little research on signs and symptoms of reactive attachment disorder beyond early childhood, and it remains uncertain whether it occurs in children older than 5 years.

Signs and symptoms may include:

Unexplained withdrawal, fear, sadness or irritability

Sad and listless appearance

Not seeking comfort or showing no response when comfort is given

Failure to smile

Watching others closely but not engaging in social interaction

Failing to ask for support or assistance

Failure to reach out when picked up

No interest in playing peekaboo or other interactive games

When to see a doctor

Consider getting an evaluation if your child shows any of the signs above. Signs can occur in children who don't have reactive attachment disorder or who have another disorder, such as autism spectrum disorder. It's important to have your child evaluated by a pediatric psychiatrist or psychologist who can determine whether such behaviors indicate a more serious problem.

Causes

To feel safe and develop trust, infants and young children need a stable, caring environment. Their basic emotional and physical needs must be consistently met. For instance, when a baby cries, the need for a meal or a diaper change must be met with a shared emotional exchange that may include eye contact, smiling and caressing.

A child whose needs are ignored or met with a lack of emotional response from caregivers does not come to expect care or comfort or form a stable attachment to caregivers.

It's not clear why some babies and children develop reactive attachment disorder and others don't. Various theories about reactive attachment disorder and its causes exist, and more research is needed to develop a better understanding and improve diagnosis and treatment options.

Risk factors

The risk of developing reactive attachment disorder from serious social and emotional neglect or the lack of opportunity to develop stable attachments may increase in children who, for example:

Live in a children's home or other institution

Frequently change foster homes or caregivers

Have parents who have severe mental health problems, criminal behavior or substance abuse that impairs their parenting

Have prolonged separation from parents or other caregivers due to hospitalization

However, most children who are severely neglected don't develop reactive attachment disorder.

Complications

Without treatment, reactive attachment disorder can continue for several years and may have lifelong consequences.

Some research suggests that some children and teenagers with reactive attachment disorder may display callous, unemotional traits that can include behavior problems and cruelty toward people or animals. However, more research is needed to determine if problems in older children and adults are related to experiences of reactive attachment disorder in early childhood.

Prevention

While it's not known with certainty if reactive attachment disorder can be prevented, there may be ways to reduce the risk of its development. Infants and young children need a stable, caring environment and their basic emotional and physical needs must be consistently met. The following parenting suggestions may help.

Take classes or volunteer with children if you lack experience or skill with babies or children. This will help you learn how to interact in a nurturing manner.

Be actively engaged with your child by lots of playing, talking to him or her, making eye contact, and smiling.

Learn to interpret your baby's cues, such as different types of cries, so that you can meet his or her needs quickly and effectively.

Provide warm, nurturing interaction with your child, such as during feeding, bathing or changing diapers.

Offer both verbal and nonverbal responses to the child's feelings through touch, facial expressions and tone of voice.

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Reactive attachment disorder - Symptoms and causes

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Reactive attachment disorder is a rare but serious condition in which an infant or young child doesn't establish healthy attachments with parents or caregivers. Reactive attachment disorder may develop if the child's basic needs for comfort, affection and nurturing aren't met and loving, caring, stable attachments with others are not established.

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Quick Guide to Reactive Attachment Disorder

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Quick Guide to Reactive Attachment Disorder

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Children with reactive attachment disorder (RAD) are not able to form the important bond that usually develops between a child and their caregivers. Children with reactive attachment disorder seem sad, fearful, or irritable, and they have a hard time interacting with others. Reactive attachment disorder can happen to young children whose basic needs for comfort, nurturing, and affection have not been consistently met.

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What is reactive attachment disorder?

Children with reactive attachment disorder (RAD) are not able to form the important bond that usually develops between a child and their caregivers. Children with reactive attachment disorder seem sad, fearful, or irritable, and they have a hard time interacting with others. Reactive attachment disorder can happen to young children whose basic needs for comfort, nurturing, and affection have not been consistently met.

Reactive attachment disorder is rare. It is only diagnosed in children between the ages of nine months and five years.

What are the symptoms of reactive attachment disorder?

Signs that a child might have reactive attachment disorder include:

Not smiling

Being irritable for no reason

Seeming sad and fearful, especially around caregivers

Not feeling better when an adult tries to comfort them

Calming down more easily when left alone

Not showing interest in or looking at other people around them

Not reacting when picked up by an adult

Not laughing or playing interactive games like peek-a-boo

How is reactive attachment disorder diagnosed?

Children are only diagnosed with reactive attachment disorder between the ages of nine months and five years. A doctor will make sure that the child does not have autism before diagnosing reactive attachment disorder, since the two disorders have some of the same symptoms.

To be diagnosed, the child must be seem sad or fearful and not respond when their caregiver tries to make them feel better. The child must also have experienced serious abuse or neglect, or multiple changes in caregivers at a young age.

It's important to note that not all children who experience abuse or neglect develop reactive attachment disorder.

How is reactive attachment disorder treated?

Because kids with RAD are so young, therapy involves both the child and the parents or main caregivers. Parents learn how to create a consistent, responsive, and safe environment with positive child and caregiver interactions. It usually combines a few different therapies, including:

Individual psychotherapy for the child and sometimes for the parents too

Family therapy for the child, siblings and parents

Parenting training to teach parents how to help their child bond with them

Special education services can also help kids with RAD.

Young children who have been neglected or abused may also have developmental delays and delays in their physical growth. Older children may be at risk for disorders including eating disorders, anger issues, depression, anxiety, problems in school and drug and alcohol abuse.

This guide was last reviewed or updated on December 18, 2024.

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Quick Guide to Reactive Attachment Disorder - Child Mind Institute

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Download our free guide to reactive attachment disorder. Children with reactive attachment disorder (RAD) do not form the important bond that usually develops between a child and their caregivers. Children with reactive attachment disorder seem sad, fearful or irritable and have a hard time interacting with others.

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Trauma Assessment for Adults - Self-report (TAA)

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Trauma Assessment for Adults - Self-report (TAA)

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The 17-item self-report Trauma Assessment for Adults (TAA) examines different types of stressful life events. It assesses 14 life events such as combat exposure during military service, physical or sexual assault, surviving a serious car accident, and others stressful events using a yes/no format. Each life event endorsed asks about presence of injury ("yes" or "no"), perception of danger ("yes" or "no"), and ages when it happened (first and last time). The TAA is appropriate for clinical or research purposes.

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Resnick, Falsetti, Kilpatrick, & Freedy, 1996

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Apply for and manage the VA benefits and services you’ve earned as a Veteran, Servicemember, or family member—like health care, disability, education, and more.

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The pages below provide more information about trauma-informed screening and assessment—including the types of tools that are available and strategies for engaging families—as well as considerations for implementation. In addition, the searchable NCTSN Measures Review Database provides easy access to comprehensive clinical and research information on a variety of measures important for the field of child traumatic stress.

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The National Child Traumatic Stress Network

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Trauma-informed screening and assessment practices help providers identify children's and families' needs early in the process and to tailor services to meet those needs.

Trauma Screening refers to a tool or process that is a brief, focused inquiry to determine whether an individual has experienced one or more traumatic events, has reactions to such events, has specific mental or behavioral health needs, and/or needs a referral for a comprehensive trauma-informed mental health assessment. Screening is a "wide-net" process.

Trauma-Informed Mental Health Assessment refers to a process that includes a clinical interview, standardized measures, and/or behavioral observations designed to gather an in-depth understanding of the nature, timing, and severity of the traumatic events, the effects of those events, current trauma-related symptoms, and functional impairment. Clinicians use the assessment to understand a child's trauma history and symptom profile; to determine whether a child is developmentally on target in the social, emotional, and behavioral domains; to inform case conceptualization and drive treatment planning; and to monitor progress over time.

The pages below provide more information about trauma-informed screening and assessment-including the types of tools that are available and strategies for engaging families-as well as considerations for implementation. In addition, the searchable NCTSN Measures Review Database provides easy access to comprehensive clinical and research information on a variety of measures important for the field of child traumatic stress.

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Trauma-informed screening and assessment practices help providers identify children's and families' needs early in the process and to tailor services to meet those needs.

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The Child and Adolescent Trauma Screen (CATS) questionnaire is a brief, freely accessible screening instrument based on the DSM-5 criteria for Posttraumatic Stress Disorder (PTSD). It is a measure of potentially traumatic events and of posttraumatic stress symptoms (PTSS).

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Overview

The Child and Adolescent Trauma Screen (CATS) questionnaire is a brief, freely accessible screening instrument based on the DSM-5 criteria for Posttraumatic Stress Disorder (PTSD). It is a measure of potentially traumatic events and of posttraumatic stress symptoms (PTSS).

Author/Publisher Details

The developers are Prof. Lutz Goldbeck (Ph.D.) & Prof. Lucy Berliner (Ph.D.)

The CATS Consortium consists of Prof. Lucy Berliner (Ph.D.), Cedric Sachser (Ph.D.), Elisa Pfeiffer (Ph.D.), Prof. Tine Jensen (Ph.D.), Prof. Elizabeth Risch (Ph.D.), Prof. Rita Rosner (Ph.D.), Prof. Lutz Goldbeck (Ph.D.)

Corresponding Author: Cedric Sachser, Ph.D., cedric.sachser@uniklinik-ulm.de

Date

Description

The CATS is based on the DSM-5 and is a measure of potentially traumatic events and of posttraumatic stress symptoms (PTSS). The CATS can be administered as a self-report or as an interview and is appropriate for pre-schoolers, children and adolescents. There is a self-report measure for 7-17 year old children/youth, and two caregiver versions; one for 3-6 year old children and one for 7-17 year old children/youth. The younger child version conforms to the DSM-5 3-6 year old PTSD symptom criteria. The interview format may be preferable with younger children or youth with reading comprehension challenges.

The CATS has 15 items measuring traumatic events, 20 items measuring DSM-5 PTSD symptoms, and 5 items measuring psychosocial functioning, and can be administered in approximately 15 minutes.

The CATS is available in several languages, including German, Norwegian, Spanish, Swedish, Arbabic, Dari, Farsi, Paschtu, Tigrinya, Turkish. Please contact the corresponding author for further information on these translations.

Access

The measure can be freely accessed by clicking below. There are no copyright or licensing fees associated with the assessment. Feel free to contact the corresponding author for other versions of the CATS.

Scoring and Interpretation

The CATS is a screening instrument for posttraumatic stress symptoms (PTSS) in children and adolescents. A clinical diagnosis of PTSD should not be based on completion of the CATS alone. Positive results on the CATS should be followed up with a semi-structured clinical interview.

To score the CATS, respondents need to verify whether they have experienced at least one potential traumatic event (PTE) (A-criterion). For those without any reported PTE the assessment is finished. Those respondents with at least one endorsed PTE indicate their (child's) most distressing event and rate their (child's) stress symptoms (criteria B, C, D and E) on page 2. Additional items describe any restrictions of functioning in different domains. The 4-point symptom response scales indicate the reported frequency/severity of each symptom. There are differences in calculating the scores for children from age 7 and adolescents vs. preschool children (see below).

Using the DSM-5 algorithm:
You can use the stop light sheet or scoring sheet to guide you through the process.

Using the total symptom score:
The determination of preliminary cutoff scores was done based on an estimation derived from the validation of a previous DSM-IV based questionnaire (see below).

Ages 3-6: The total symptom score is calculated by summing up the items 1-16 (possible range = 0-48). We recommend to use a cut-off ≥ 16 as indication of a clinically relevant level of symptoms in preschool children.

Ages 7-17: A total symptom score is calculated by summing up the raw scores of items 1-20 (possible range = 0-60). We recommend to use a cut-off ≥ 21 as indication of a clinically relevant level of symptoms.

Include scoring for total scores and subscale scores as well as information on diagnostic or severity cut offs (if any).

Psychometrics

An international validation study (Sachser et al., 2017) proved good to excellent reliability with α ranging between .88 and .94. The convergent-discriminant validity pattern showed medium to strong correlations with measures of depression (r = .62-.82) and anxiety (r = .40-.77) and low to medium correlations with externalizing symptoms (r = −.15-.43) within informants in all language versions. Using CFA the underlying DSM-5 factor structure with four symptom clusters (reexperiencing, avoidance, negative alterations in mood and cognitions, hyperarousal) was supported (n = 475 for self-report; n = 424 for caregiver reports).

Key/Core References

Sachser, C., Berliner, L., Holt, T., Jensen, T. K., Jungbluth, N., Risch, E., ... & Goldbeck, L. (2017). International development and psychometric properties of the Child and Adolescent Trauma Screen (CATS). Journal of affective disorders, 210, 189-195.
https://pubmed.ncbi.nlm.nih.gov/28049104/

Nilsson, D., Dävelid, I., Ledin, S., & Svedin, C. G. (2020). Psychometric properties of the Child and Adolescent Trauma Screen (CATS) in a sample of Swedish children. Nordic Journal of Psychiatry, 1-10. https://www.tandfonline.com/doi/full/10.1080/08039488.2020.1840628

Akkuş, P. Z., Serdaroğlu, E., Kömürlüoğlu, A., Asena, M., Bahadur, E. İ., Özdemir, G., ... & Özmert, E. N. (2021). Screening traumatic life events in preschool aged children: cultural adaptation of Child and Adolescent Trauma Screen (CATS) Caregiver-report 3-6 years version. Turkish Journal of Pediatrics, 63(1). http://www.turkishjournalpediatrics.org/abstract.php?id=2262

Manual

Administration of the CATS should be conducted as a clinical encounter. The CATS may be part of routine assessment procedures and/or occur at a later point with the assigned clinician. It may be used as a stand-alone screening or be part of a larger assessment and clinical interview. The Clinical Guide for administering the CATS is available here

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The Child and Adolescent Trauma Screen (CATS) questionnaire is a brief, freely accessible screening instrument based on the DSM-5 criteria for Posttraumatic Stress Disorder (PTSD). It is a measure of potentially traumatic events and of posttraumatic stress symptoms (PTSS). The developers are Prof. Lutz Goldbeck (Ph.D.) & Prof. Lucy Berliner (Ph.D.)

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Trauma screening is generally used to identify exposure to traumatic events but also can include items specific to traumatic stress symptoms or reactions.

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The CTS is a concise screening tool designed to identify individuals who may have experienced childhood trauma.

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The Child Health and Development Institute of Connecticut, Inc.

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Childhood Experience of Care and Abuse (CECA) Interview

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Childhood Experience of Care and Abuse (CECA) Interview

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The CECA is a semi-structured interview used to gather detailed qualitative information about childhood experiences of care and possible abuse. It explores parental behaviors, family dynamics, and specific traumatic events, offering rich insights into the impact of childhood trauma on individuals’ wellbeing.

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The CECA is a measure of childhood and adolescent experience of neglect and abuse. It has been developed and used over a 20 year period. It original use was by researchers to investigate lifetime risk factors for psychological disorder.

The CECA has been used in a large number of research contexts. Although its original purpose to examine lifespan factors in the genesis of depression and anxiety disorders, it has since been used to study a range of clinical disorders, including conduct disorders, substance abuse, bi-polar disorder, personality disorders and schizophrenia and psychotic symptoms. Results show that childhood adversity increase risk of many such disorders, with causal models developed to explore mediating and moderating disorders specific to different outcomes.

Increasingly the CECA is being used as an assessment tool in clinical, forensic and social work practice. For example, ongoing action research by the CATS centre with St Christopher's Fellowship is utilising the CECA in assessing young people in residential care as part of their SHARP intervention and scoring information from both interviews and case file information. This together with face-to-face interview on their attachment style and self-esteem allows for a comprehensive coverage of their psychosocial risks and resilience factors. As another example, an evaluation was carried out on the use of the CECA in Royal Borough of Kingston's Child Safeguarding Services. The study trained 8 social workers in the CECA and examined how it can be used to inform chronologies for court proceedings and the categorization of maltreatment and severity ratings for care planning.

The CECA interview has also been used internationally, not only in the USA and Canada, but also in Belgium, Italy, Portugal and Germany, and therefore exists in translation.

The Questionnaire: CECA.Q2

A brief self-report version has been validated against the interview. This assesses loss of parents, neglect, antipathy from main carers and physical and sexual abuse. Support in childhood is also included. The measure shows acceptable sensitivity and specificity against the interview measure, and published cut-off scores are available. The CECA.Q has been translated into a number of languages, including Italian, German, Spanish, Portuguese, Chinese, and has been used in Europe, USA, Canada, South America and the Far East.

The measure is associated with both the Parental Bonding Instrument and the Childhood Trauma Questionnaire3, but has wider coverage of maltreatment, shows a dose-response effect in relation to lifetime clinical depression and has improved improved prediction of disorder.

CECA.Q3 is a version of the original CECA Questionnaire that offers additional sections of psychological abuse and role reversal. These are included in the later version because of their key relationship to later depression and self-harm behaviour in adolescents.

Download CECA.Q (the original questionnaire) here.
Download CECA.Q3 (with added psych abuse and role reversal) here.
Download CECA Questionnaire Scoring Guide here.

Bifulco A & Moran P (1998) Wednesday's Child: Research into women's experience of neglect and abuse in childhood and adult depression. Routledge, London, New York. link

Bifulco A, Bernazzani O, Moran PM & Jacobs C (2005) Childhood Experience of Care and Abuse Questionnaire (CECA.Q) Validation in a community series. British Journal of Clinical Psychology, 44: 563-581. link

Bifulco A, Moran PM, Baines R, et al. (2002) Exploring Psychological Abuse in Childhood: II. Association with Other Abuse and Clinical Depression. Bulletin of the Menninger Institute, vol 66(3) 240-258. link

Bifulco A, Moran PM, Ball C, et al. (2002) Childhood adversity, parental vulnerability and disorder: Examining inter-generational transmission of risk. Journal of Child Psychology and Psychiatry; 43, 1075-1086. link

Bifulco A, Brown GW, Lillie A et al. (1997) Memories of childhood neglect and abuse. Corroboration in a series of sisters. Journal of child psychology and psychiatry; 38: 365-374. link

Bifulco A, Brown GW & Harris TO (1994) Childhood Experience of Care and Abuse (CECA): A retrospective interview measure. Journal of Child Psychology and Psychiatry; 35 (8), 1419-1435. link

Moran PM, Bifulco A, Ball C, et al. (2002) Exploring Psychological Abuse in Childhood: I. Developing a New Interview Scale. Bulletin of the Menninger Institute, vol 66(3), 213-240. link

Troop NA & Bifulco A (2002) Childhood social arena and cognitive sets in eating disorders: A preliminary investigation. British Journal of Clinical Psychology; 41: 205-21. link

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Childhood Experience of Care and Abuse (CECA) Interview - introduction and background The CECA is a measure of childhood and adolescent experience of neglect and abuse. It has been developed and used over a 20 year period. It original use was by researchers to investigate

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It highlights common short- and long-term responses to traumatic experiences in the context of individuals who may seek behavioral health services. This resource discusses psychological symptoms not represented in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013a), and responses associated with trauma that either fall below the threshold of mental disorders or reflect resilience. It also addresses common disorders associated with traumatic stress. This explores the role of culture in defining mental illness, particularly PTSD, and ends by addressing co-occurring mental and substance-related disorders.

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Trauma-informed care (TIC) involves a broad understanding of traumatic stress reactions and common responses to trauma. Providers need to understand how trauma can affect treatment presentation, engagement, and the outcome of behavioral health services. This chapter examines common experiences survivors may encounter immediately following or long after a traumatic experience.

Trauma, including one-time, multiple, or long-lasting repetitive events, affects everyone differently. Some individuals may clearly display criteria associated with posttraumatic stress disorder (PTSD), but many more individuals will exhibit resilient responses or brief subclinical symptoms or consequences that fall outside of diagnostic criteria. The impact of trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors.

This chapter begins with an overview of common responses, emphasizing that traumatic stress reactions are normal reactions to abnormal circumstances. It highlights common short- and long-term responses to traumatic experiences in the context of individuals who may seek behavioral health services. This chapter discusses psychological symptoms not represented in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013a), and responses associated with trauma that either fall below the threshold of mental disorders or reflect resilience. It also addresses common disorders associated with traumatic stress. This chapter explores the role of culture in defining mental illness, particularly PTSD, and ends by addressing co-occurring mental and substance-related disorders.

TIC Framework in Behavioral Health Services-The Impact of Trauma

Sequence of Trauma Reactions

Survivors' immediate reactions in the aftermath of trauma are quite complicated and are affected by their own experiences, the accessibility of natural supports and healers, their coping and life skills and those of immediate family, and the responses of the larger community in which they live. Although reactions range in severity, even the most acute responses are natural responses to manage trauma- they are not a sign of psychopathology. Coping styles vary from action oriented to reflective and from emotionally expressive to reticent. Clinically, a response style is less important than the degree to which coping efforts successfully allow one to continue necessary activities, regulate emotions, sustain self-esteem, and maintain and enjoy interpersonal contacts. Indeed, a past error in traumatic stress psychology, particularly regarding group or mass traumas, was the assumption that all survivors need to express emotions associated with trauma and talk about the trauma; more recent research indicates that survivors who choose not to process their trauma are just as psychologically healthy as those who do. The most recent psychological debriefing approaches emphasize respecting the individual's style of coping and not valuing one type over another.

Foreshortened future: Trauma can affect one's beliefs about the future via loss of hope, limited expectations about life, fear that life will end abruptly or early, or anticipation that normal life events won't occur (e.g., access to education, ability to have a significant and committed relationship, good opportunities for work).

Initial reactions to trauma can include exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect. Most responses are normal in that they affect most survivors and are socially acceptable, psychologically effective, and self-limited. Indicators of more severe responses include continuous distress without periods of relative calm or rest, severe dissociation symptoms, and intense intrusive recollections that continue despite a return to safety. Delayed responses to trauma can include persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks, depression, and avoidance of emotions, sensations, or activities that are associated with the trauma, even remotely. Exhibit 1.3-1 outlines some common reactions.

Common Experiences and Responses to Trauma

A variety of reactions are often reported and/or observed after trauma. Most survivors exhibit immediate reactions, yet these typically resolve without severe long-term consequences. This is because most trauma survivors are highly resilient and develop appropriate coping strategies, including the use of social supports, to deal with the aftermath and effects of trauma. Most recover with time, show minimal distress, and function effectively across major life areas and developmental stages. Even so, clients who show little impairment may still have subclinical symptoms or symptoms that do not fit diagnostic criteria for acute stress disorder (ASD) or PTSD. Only a small percentage of people with a history of trauma show impairment and symptoms that meet criteria for trauma-related stress disorders, including mood and anxiety disorders.

The following sections focus on some common reactions across domains (emotional, physical, cognitive, behavioral, social, and developmental) associated with singular, multiple, and enduring traumatic events. These reactions are often normal responses to trauma but can still be distressing to experience. Such responses are not signs of mental illness, nor do they indicate a mental disorder. Traumatic stress-related disorders comprise a specific constellation of symptoms and criteria.

Emotional

Emotional reactions to trauma can vary greatly and are significantly influenced by the individual's sociocultural history. Beyond the initial emotional reactions during the event, those most likely to surface include anger, fear, sadness, and shame. However, individuals may encounter difficulty in identifying any of these feelings for various reasons. They might lack experience with or prior exposure to emotional expression in their family or community. They may associate strong feelings with the past trauma, thus believing that emotional expression is too dangerous or will lead to feeling out of control (e.g., a sense of "losing it" or going crazy). Still others might deny that they have any feelings associated with their traumatic experiences and define their reactions as numbness or lack of emotions.

Emotional dysregulation

Some trauma survivors have difficulty regulating emotions such as anger, anxiety, sadness, and shame-this is more so when the trauma occurred at a young age ( van der Kolk, Roth, Pelcovitz, & Mandel, 1993). In individuals who are older and functioning well prior to the trauma, such emotional dysregulation is usually short lived and represents an immediate reaction to the trauma, rather than an ongoing pattern. Self-medication-namely, substance abuse-is one of the methods that traumatized people use in an attempt to regain emotional control, although ultimately it causes even further emotional dysregulation (e.g., substance-induced changes in affect during and after use). Other efforts toward emotional regulation can include engagement in high-risk or self-injurious behaviors, disordered eating, compulsive behaviors such as gambling or overworking, and repression or denial of emotions; however, not all behaviors associated with self-regulation are considered negative. In fact, some individuals find creative, healthy, and industrious ways to manage strong affect generated by trauma, such as through renewed commitment to physical activity or by creating an organization to support survivors of a particular trauma.

Traumatic stress tends to evoke two emotional extremes: feeling either too much (overwhelmed) or too little (numb) emotion. Treatment can help the client find the optimal level of emotion and assist him or her with appropriately experiencing and regulating difficult emotions. In treatment, the goal is to help clients learn to regulate their emotions without the use of substances or other unsafe behavior. This will likely require learning new coping skills and how to tolerate distressing emotions; some clients may benefit from mindfulness practices, cognitive restructuring, and trauma-specific desensitization approaches, such as exposure therapy and eye movement desensitization and reprocessing (EMDR; refer to Part 1, Chapter 6, for more information on trauma-specific therapies).

Numbing

Numbing is a biological process whereby emotions are detached from thoughts, behaviors, and memories. In the following case illustration, Sadhanna's numbing is evidenced by her limited range of emotions associated with interpersonal interactions and her inability to associate any emotion with her history of abuse. She also possesses a belief in a foreshortened future. A prospective longitudinal study ( Malta, Levitt, Martin, Davis, & Cloitre, 2009) that followed the development of PTSD in disaster workers highlighted the importance of understanding and appreciating numbing as a traumatic stress reaction. Because numbing symptoms hide what is going on inside emotionally, there can be a tendency for family members, counselors, and other behavioral health staff to assess levels of traumatic stress symptoms and the impact of trauma as less severe than they actually are.

Case Illustration: Sadhanna

Sadhanna is a 22-year-old woman mandated to outpatient mental health and substance abuse treatment as the alternative to incarceration. She was arrested and charged with assault after arguing and fighting with another woman on the street. At intake, Sadhanna reported a 7-year history of alcohol abuse and one depressive episode at age 18. She was surprised that she got into a fight but admitted that she was drinking at the time of the incident. She also reported severe physical abuse at the hands of her mother's boyfriend between ages 4 and 15. Of particular note to the intake worker was Sadhanna's matter-of-fact way of presenting the abuse history. During the interview, she clearly indicated that she did not want to attend group therapy and hear other people talk about their feelings, saying, "I learned long ago not to wear emotions on my sleeve."

Sadhanna reported dropping out of 10th grade, saying she never liked school. She didn't expect much from life. In Sadhanna's first weeks in treatment, she reported feeling disconnected from other group members and questioned the purpose of the group. When asked about her own history, she denied that she had any difficulties and did not understand why she was mandated to treatment. She further denied having feelings about her abuse and did not believe that it affected her life now. Group members often commented that she did not show much empathy and maintained a flat affect, even when group discussions were emotionally charged.

Physical

Diagnostic criteria for PTSD place considerable emphasis on psychological symptoms, but some people who have experienced traumatic stress may present initially with physical symptoms. Thus, primary care may be the first and only door through which these individuals seek assistance for trauma-related symptoms. Moreover, there is a significant connection between trauma, including adverse childhood experiences (ACEs), and chronic health conditions. Common physical disorders and symptoms include somatic complaints; sleep disturbances; gastrointestinal, cardiovascular, neurological, musculoskeletal, respiratory, and dermatological disorders; urological problems; and substance use disorders.

Somatization

Somatization indicates a focus on bodily symptoms or dysfunctions to express emotional distress. Somatic symptoms are more likely to occur with individuals who have traumatic stress reactions, including PTSD. People from certain ethnic and cultural backgrounds may initially or solely present emotional distress via physical ailments or concerns. Many individuals who present with somatization are likely unaware of the connection between their emotions and the physical symptoms that they're experiencing. At times, clients may remain resistant to exploring emotional content and remain focused on bodily complaints as a means of avoidance. Some clients may insist that their primary problems are physical even when medical evaluations and tests fail to confirm ailments. In these situations, somatization may be a sign of a mental illness. However, various cultures approach emotional distress through the physical realm or view emotional and physical symptoms and well-being as one. It is important not to assume that clients with physical complaints are using somatization as a means to express emotional pain; they may have specific conditions or disorders that require medical attention. Foremost, counselors need to refer for medical evaluation.

Advice to Counselors: Using Information About Biology and Trauma

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Frame reexperiencing the event(s), hyperarousal, sleep disturbances, and other physical symptoms as physiological reactions to extreme stress.

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Communicate that treatment and other wellness activities can improve both psychological and physiological symptoms (e.g., therapy, meditation, exercise, yoga). You may need to refer certain clients to a psychiatrist who can evaluate them and, if warranted, prescribe psycho-tropic medication to address severe symptoms.

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Discuss traumatic stress symptoms and their physiological components.

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Explain links between traumatic stress symptoms and substance use disorders, if appropriate.

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Normalize trauma symptoms. For example, explain to clients that their symptoms are not a sign of weakness, a character flaw, being damaged, or going crazy.

Support your clients and provide a message of hope-that they are not alone, they are not at fault, and recovery is possible and anticipated.

Biology of trauma

Trauma biology is an area of burgeoning research, with the promise of more complex and explanatory findings yet to come. Although a thorough presentation on the biological aspects of trauma is beyond the scope of this publication, what is currently known is that exposure to trauma leads to a cascade of biological changes and stress responses. These biological alterations are highly associated with PTSD, other mental illnesses, and substance use disorders. These include:

Changes in limbic system functioning.

Hypothalamic-pituitary-adrenal axis activity changes with variable cortisol levels.

Neurotransmitter-related dysregulation of arousal and endogenous opioid systems.

As a clear example, early ACEs such as abuse, neglect, and other traumas affect brain development and increase a person's vulnerability to encountering interpersonal violence as an adult and to developing chronic diseases and other physical illnesses, mental illnesses, substance-related disorders, and impairment in other life areas ( Centers for Disease Control and Prevention, 2012).

Hyperarousal and sleep disturbances

A common symptom that arises from traumatic experiences is hyperarousal (also called hypervigilance). Hyperarousal is the body's way of remaining prepared. It is characterized by sleep disturbances, muscle tension, and a lower threshold for startle responses and can persist years after trauma occurs. It is also one of the primary diagnostic criteria for PTSD.

Hyperarousal is a consequence of biological changes initiated by trauma. Although it serves as a means of self-protection after trauma, it can be detrimental. Hyperarousal can interfere with an individual's ability to take the necessary time to assess and appropriately respond to specific input, such as loud noises or sudden movements. Sometimes, hyperarousal can produce overreactions to situations perceived as dangerous when, in fact, the circumstances are safe.

Case Illustration: Kimi

Kimi is a 35-year-old Native American woman who was group raped at the age of 16 on her walk home from a suburban high school. She recounts how her whole life changed on that day. "I never felt safe being alone after the rape. I used to enjoy walking everywhere. Afterward, I couldn't tolerate the fear that would arise when I walked in the neighborhood. It didn't matter whether I was alone or with friends-every sound that I heard would throw me into a state of fear. I felt like the same thing was going to happen again. It's gotten better with time, but I often feel as if I'm sitting on a tree limb waiting for it to break. I have a hard time relaxing. I can easily get startled if a leaf blows across my path or if my children scream while playing in the yard. The best way I can describe how I experience life is by comparing it to watching a scary, suspenseful movie-anxiously waiting for something to happen, palms sweating, heart pounding, on the edge of your chair."

Along with hyperarousal, sleep disturbances are very common in individuals who have experienced trauma. They can come in the form of early awakening, restless sleep, difficulty falling asleep, and nightmares. Sleep disturbances are most persistent among individuals who have trauma-related stress; the disturbances sometimes remain resistant to intervention long after other traumatic stress symptoms have been successfully treated. Numerous strategies are available beyond medication, including good sleep hygiene practices, cognitive rehearsals of nightmares, relaxation strategies, and nutrition.

Cognitive

Traumatic experiences can affect and alter cognitions. From the outset, trauma challenges the just-world or core life assumptions that help individuals navigate daily life ( Janoff-Bulman, 1992). For example, it would be difficult to leave the house in the morning if you believed that the world was not safe, that all people are dangerous, or that life holds no promise. Belief that one's efforts and intentions can protect oneself from bad things makes it less likely for an individual to perceive personal vulnerability. However, traumatic events-particularly if they are unexpected-can challenge such beliefs.

Cognitions and Trauma

The following examples reflect some of the types of cognitive or thought-process changes that can occur in response to traumatic stress.

Cognitive errors: Misinterpreting a current situation as dangerous because it resembles, even remotely, a previous trauma (e.g., a client overreacting to an overturned canoe in 8 inches of water, as if she and her paddle companion would drown, due to her previous experience of nearly drowning in a rip current 5 years earlier).

Excessive or inappropriate guilt: Attempting to make sense cognitively and gain control over a traumatic experience by assuming responsibility or possessing survivor's guilt, because others who experienced the same trauma did not survive.

Idealization: Demonstrating inaccurate rationalizations, idealizations, or justifications of the perpetrator's behavior, particularly if the perpetrator is or was a caregiver. Other similar reactions mirror idealization; traumatic bonding is an emotional attachment that develops (in part to secure survival) between perpetrators who engage in interpersonal trauma and their victims, and Stockholm syndrome involves compassion and loyalty toward hostage takers ( de Fabrique, Van Hasselt, Vecchi, & Romano, 2007).

Trauma-induced hallucinations or delusions: Experiencing hallucinations and delusions that, although they are biological in origin, contain cognitions that are congruent with trauma content (e.g., a woman believes that a person stepping onto her bus is her father, who had sexually abused her repeatedly as child, because he wore shoes similar to those her father once wore).

Intrusive thoughts and memories: Experiencing, without warning or desire, thoughts and memories associated with the trauma. These intrusive thoughts and memories can easily trigger strong emotional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive thoughts and memories for a while. For instance, individuals who inadvertently are retraumatized due to program or clinical practices may have a surge of intrusive thoughts of past trauma, thus making it difficult for them to discern what is happening now versus what happened then. Whenever counseling focuses on trauma, it is likely that the client will experience some intrusive thoughts and memories. It is important to develop coping strategies before, as much as possible, and during the delivery of trauma-informed and trauma-specific treatment.

Let's say you always considered your driving time as "your time"-and your car as a safe place to spend that time. Then someone hits you from behind at a highway entrance. Almost immediately, the accident affects how you perceive the world, and from that moment onward, for months following the crash, you feel unsafe in any car. You become hypervigilant about other drivers and perceive that other cars are drifting into your lane or failing to stop at a safe distance behind you. For a time, your perception of safety is eroded, often leading to compensating behaviors (e.g., excessive glancing into the rearview mirror to see whether the vehicles behind you are stopping) until the belief is restored or reworked. Some individuals never return to their previous belief systems after a trauma, nor do they find a way to rework them-thus leading to a worldview that life is unsafe. Still, many other individuals are able to return to organizing core beliefs that support their perception of safety.

Many factors contribute to cognitive patterns prior to, during, and after a trauma. Adopting Beck and colleagues' cognitive triad model ( 1979), trauma can alter three main cognitive patterns: thoughts about self, the world (others/environment), and the future. To clarify, trauma can lead individuals to see themselves as incompetent or damaged, to see others and the world as unsafe and unpredictable, and to see the future as hopeless-believing that personal suffering will continue, or negative outcomes will preside for the foreseeable future (see Exhibit 1.3-2). Subsequently, this set of cognitions can greatly influence clients' belief in their ability to use internal resources and external support effectively. From a cognitive- behavioral perspective, these cognitions have a bidirectional relationship in sustaining or contributing to the development of depressive and anxiety symptoms after trauma. However, it is possible for cognitive patterns to help protect against debilitating psychological symptoms as well. Many factors contribute to cognitive patterns prior to, during, and after a trauma.

Feeling different

An integral part of experiencing trauma is feeling different from others, whether or not the trauma was an individual or group experience. Traumatic experiences typically feel surreal and challenge the necessity and value of mundane activities of daily life. Survivors often believe that others will not fully understand their experiences, and they may think that sharing their feelings, thoughts, and reactions related to the trauma will fall short of expectations. However horrid the trauma may be, the experience of the trauma is typically profound.

The type of trauma can dictate how an individual feels different or believes that they are different from others. Traumas that generate shame will often lead survivors to feel more alienated from others-believing that they are "damaged goods." When individuals believe that their experiences are unique and incomprehensible, they are more likely to seek support, if they seek support at all, only with others who have experienced a similar trauma.

Triggers and flashbacks

Triggers

A trigger is a stimulus that sets off a memory of a trauma or a specific portion of a traumatic experience. Imagine you were trapped briefly in a car after an accident. Then, several years later, you were unable to unlatch a lock after using a restroom stall; you might have begun to feel a surge of panic reminiscent of the accident, even though there were other avenues of escape from the stall. Some triggers can be identified and anticipated easily, but many are subtle and inconspicuous, often surprising the individual or catching him or her off guard. In treatment, it is important to help clients identify potential triggers, draw a connection between strong emotional reactions and triggers, and develop coping strategies to manage those moments when a trigger occurs. A trigger is any sensory reminder of the traumatic event: a noise, smell, temperature, other physical sensation, or visual scene. Triggers can generalize to any characteristic, no matter how remote, that resembles or represents a previous trauma, such as revisiting the location where the trauma occurred, being alone, having your children reach the same age that you were when you experienced the trauma, seeing the same breed of dog that bit you, or hearing loud voices. Triggers are often associated with the time of day, season, holiday, or anniversary of the event.

Flashbacks

A flashback is reexperiencing a previous traumatic experience as if it were actually happening in that moment. It includes reactions that often resemble the client's reactions during the trauma. Flashback experiences are very brief and typically last only a few seconds, but the emotional aftereffects linger for hours or longer. Flashbacks are commonly initiated by a trigger, but not necessarily. Sometimes, they occur out of the blue. Other times, specific physical states increase a person's vulnerability to reexperiencing a trauma, (e.g., fatigue, high stress levels). Flashbacks can feel like a brief movie scene that intrudes on the client. For example, hearing a car backfire on a hot, sunny day may be enough to cause a veteran to respond as if he or she were back on military patrol. Other ways people reexperience trauma, besides flashbacks, are via nightmares and intrusive thoughts of the trauma.

Advice to Counselors: Helping Clients Manage Flashbacks and Triggers

If a client is triggered in a session or during some aspect of treatment, help the client focus on what is happening in the here and now; that is, use grounding techniques. Behavioral health service providers should be prepared to help the client get regrounded so that they can distinguish between what is happening now versus what had happened in the past (see Covington, 2008, and Najavits, 2002b, 2007b, for more grounding techniques). Offer education about the experience of triggers and flashbacks, and then normalize these events as common traumatic stress reactions. Afterward, some clients need to discuss the experience and understand why the flashback or trigger occurred. It often helps for the client to draw a connection between the trigger and the traumatic event(s). This can be a preventive strategy whereby the client can anticipate that a given situation places him or her at higher risk for retraumatization and requires use of coping strategies, including seeking support.

Source: Green Cross Academy of Traumatology, 2010.

Dissociation, depersonalization, and derealization

Dissociation is a mental process that severs connections among a person's thoughts, memories, feelings, actions, and/or sense of identity. Most of us have experienced dissociation-losing the ability to recall or track a particular action (e.g., arriving at work but not remembering the last minutes of the drive). Dissociation happens because the person is engaged in an automatic activity and is not paying attention to his or her immediate environment. Dissociation can also occur during severe stress or trauma as a protective element whereby the individual incurs distortion of time, space, or identity. This is a common symptom in traumatic stress reactions.

Dissociation helps distance the experience from the individual. People who have experienced severe or developmental trauma may have learned to separate themselves from distress to survive. At times, dissociation can be very pervasive and symptomatic of a mental disorder, such as dissociative identity disorder (DID; formerly known as multiple personality disorder). According to the DSM-5, "dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior" ( APA, 2013a, p. 291). Dissociative disorder diagnoses are closely associated with histories of severe childhood trauma or pervasive, human-caused, intentional trauma, such as that experienced by concentration camp survivors or victims of ongoing political imprisonment, torture, or long-term isolation. A mental health professional, preferably with significant training in working with dissociative disorders and with trauma, should be consulted when a dissociative disorder diagnosis is suspected.

Potential Signs of Dissociation

Sudden flattening of affect

Responses not congruent with the present context or situation

Excessive intellectualization

( Briere, 1996a)

The characteristics of DID can be commonly accepted experiences in other cultures, rather than being viewed as symptomatic of a traumatic experience. For example, in non-Western cultures, a sense of alternate beings within oneself may be interpreted as being inhabited by spirits or ancestors ( Kirmayer, 1996). Other experiences associated with dissociation include depersonalization-psychologically "leaving one's body," as if watching oneself from a distance as an observer or through derealization, leading to a sense that what is taking place is unfamiliar or is not real.

If clients exhibit signs of dissociation, behavioral health service providers can use grounding techniques to help them reduce this defense strategy. One major long-term consequence of dissociation is the difficulty it causes in connecting strong emotional or physical reactions with an event. Often, individuals may believe that they are going crazy because they are not in touch with the nature of their reactions. By educating clients on the resilient qualities of dissociation while also emphasizing that it prevents them from addressing or validating the trauma, individuals can begin to understand the role of dissociation. All in all, it is important when working with trauma survivors that the intensity level is not so great that it triggers a dissociative reaction and prevents the person from engaging in the process.

Behavioral

Traumatic stress reactions vary widely; often, people engage in behaviors to manage the aftereffects, the intensity of emotions, or the distressing aspects of the traumatic experience. Some people reduce tension or stress through avoidant, self-medicating (e.g., alcohol abuse), compulsive (e.g., overeating), impulsive (e.g., high-risk behaviors), and/or self-injurious behaviors. Others may try to gain control over their experiences by being aggressive or subconsciously reenacting aspects of the trauma.

Behavioral reactions are also the consequences of, or learned from, traumatic experiences. For example, some people act like they can't control their current environment, thus failing to take action or make decisions long after the trauma (learned helplessness). Other associate elements of the trauma with current activities, such as by reacting to an intimate moment in a significant relationship as dangerous or unsafe years after a date rape. The following sections discuss behavioral consequences of trauma and traumatic stress reactions.

Reenactments

A hallmark symptom of trauma is reexperiencing the trauma in various ways. Reexperiencing can occur through reenactments (literally, to "redo"), by which trauma survivors repetitively relive and recreate a past trauma in their present lives. This is very apparent in children, who play by mimicking what occurred during the trauma, such as by pretending to crash a toy airplane into a toy building after seeing televised images of the terrorist attacks on the World Trade Center on September 11, 2001. Attempts to understand reenactments are very complicated, as reenactments occur for a variety of reasons. Sometimes, individuals reenact past traumas to master them. Examples of reenactments include a variety of behaviors: self-injurious behaviors, hypersexuality, walking alone in unsafe areas or other high-risk behaviors, driving recklessly, or involvement in repetitive destructive relationships (e.g., repeatedly getting into romantic relationships with people who are abusive or violent), to name a few.

Self-harm and self-destructive behaviors

Self-harm is any type of intentionally self-inflicted harm, regardless of the severity of injury or whether suicide is intended. Often, self-harm is an attempt to cope with emotional or physical distress that seems overwhelming or to cope with a profound sense of dissociation or being trapped, helpless, and "damaged" ( Herman, 1997; Santa Mina & Gallop, 1998). Self-harm is associated with past childhood sexual abuse and other forms of trauma as well as substance abuse. Thus, addressing self-harm requires attention to the client's reasons for self-harm. More than likely, the client needs help recognizing and coping with emotional or physical distress in manageable amounts and ways.

Resilient Responses to Trauma

Many people find healthy ways to cope with, respond to, and heal from trauma. Often, people automatically reevaluate their values and redefine what is important after a trauma. Such resilient responses include:

Increased bonding with family and community.

Redefined or increased sense of purpose and meaning.

Increased commitment to a personal mission.

Increased charitable giving and volunteerism.

Case Illustration: Marco

Marco, a 30-year-old man, sought treatment at a local mental health center after a 2-year bout of anxiety symptoms. He was an active member of his church for 12 years, but although he sought help from his pastor about a year ago, he reports that he has had no contact with his pastor or his church since that time. Approximately 3 years ago, his wife took her own life. He describes her as his soul-mate and has had a difficult time understanding her actions or how he could have prevented them.

In the initial intake, he mentioned that he was the first person to find his wife after the suicide and reported feelings of betrayal, hurt, anger, and devastation since her death. He claimed that everyone leaves him or dies. He also talked about his difficulty sleeping, having repetitive dreams of his wife, and avoiding relationships. In his first session with the counselor, he initially rejected the counselor before the counselor had an opportunity to begin reviewing and talking about the events and discomfort that led him to treatment.

In this scenario, Marco is likely reenacting his feelings of abandonment by attempting to reject others before he experiences another rejection or abandonment. In this situation, the counselor will need to recognize the reenactment, explore the behavior, and examine how reenactments appear in other situations in Marco's life.

Among the self-harm behaviors reported in the literature are cutting, burning skin by heat (e.g., cigarettes) or caustic liquids, punching hard enough to self-bruise, head banging, hair pulling, self-poisoning, inserting foreign objects into bodily orifices, excessive nail biting, excessive scratching, bone breaking, gnawing at flesh, interfering with wound healing, tying off body parts to stop breathing or blood flow, swallowing sharp objects, and suicide. Cutting and burning are among the most common forms of self-harm.

Self-harm tends to occur most in people who have experienced repeated and/or early trauma (e.g., childhood sexual abuse) rather than in those who have undergone a single adult trauma (e.g., a community-wide disaster or a serious car accident). There are strong associations between eating disorders, self-harm, and substance abuse ( Claes & Vandereycken, 2007; for discussion, see Harned, Najavits, & Weiss, 2006). Self-mutilation is also associated with (and part of the diagnostic criteria for) a number of personality disorders, including borderline and histrionic, as well as DID, depression, and some forms of schizophrenia; these disorders can co-occur with traumatic stress reactions and disorders.

It is important to distinguish self-harm that is suicidal from self-harm that is not suicidal and to assess and manage both of these very serious dangers carefully. Most people who engage in self-harm are not doing so with the intent to kill themselves ( Noll, Horowitz, Bonanno, Trickett, & Putnam, 2003)-although self-harm can be life threatening and can escalate into suicidality if not managed therapeutically. Self-harm can be a way of getting attention or manipulating others, but most often it is not. Self-destructive behaviors such as substance abuse, restrictive or binge eating, reckless automobile driving, or high-risk impulsive behavior are different from self-harming behaviors but are also seen in clients with a history of trauma. Self-destructive behaviors differ from self-harming behaviors in that there may be no immediate negative impact of the behavior on the individual; they differ from suicidal behavior in that there is no intent to cause death in the short term.

Advice to Counselors: Working With Clients Who Are Self-Injurious

Counselors who are unqualified or uncomfortable working with clients who demonstrate self-harming, self-destructive, or suicidal or homicidal ideation, intent, or behavior should work with their agencies and supervisors to refer such clients to other counselors. They should consider seeking specialized supervision on how to manage such clients effectively and safely and how to manage their feelings about these issues. The following suggestions assume that the counselor has had sufficient training and experience to work with clients who are self-injurious. To respond appropriately to a client who engages in self-harm, counselors should:

Screen the client for self-harm and suicide risk at the initial evaluation and throughout treatment.

Learn the client's perspective on self-harm and how it "helps."

Understand that self-harm is often a coping strategy to manage the intensity of emotional and/or physical distress.

Teach the client coping skills that improve his or her management of emotions without self-harm.

Help the client obtain the level of care needed to manage genuine risk of suicide or severe self-injury. This might include hospitalization, more intensive programming (e.g., intensive outpatient, partial hospitalization, residential treatment), or more frequent treatment sessions. The goal is to stabilize the client as quickly as possible, and then, if possible, begin to focus treatment on developing coping strategies to manage self-injurious and other harmful impulses.

Consult with other team members, supervisors, and, if necessary, legal experts to determine whether one's efforts with and conceptualization of the self-harming client fit best practice guidelines. See, for example, Treatment Improvement Protocol (TIP) 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( Center for Substance Abuse Treatment [CSAT], 2005c). Document such consultations and the decisions made as a result of them thoroughly and frequently.

Help the client identify how substance use affects self-harm. In some cases, it can increase the behavior (e.g., alcohol disinhibits the client, who is then more likely to self-harm). In other cases, it can decrease the behavior (e.g., heroin evokes relaxation and, thus, can lessen the urge to self-harm). In either case, continue to help the client understand how abstinence from substances is necessary so that he or she can learn more adaptive coping.

Work collaboratively with the client to develop a plan to create a sense of safety. Individuals are affected by trauma in different ways; therefore, safety or a safe environment may mean something entirely different from one person to the next. Allow the client to define what safety means to him or her.

Counselors can also help the client prepare a safety card that the client can carry at all times. The card might include the counselor's contact information, a 24-hour crisis number to call in emergencies, contact information for supportive individuals who can be contacted when needed, and, if appropriate, telephone numbers for emergency medical services. The counselor can discuss with the client the types of signs or crises that might warrant using the numbers on the card. Additionally, the counselor might check with the client from time to time to confirm that the information on the card is current.

TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment ( CSAT, 2009a), has examples of safety agreements specifically for suicidal clients and discusses their uses in more detail. There is no credible evidence that a safety agreement is effective in preventing a suicide attempt or death. Safety agreements for clients with suicidal thoughts and behaviors should only be used as an adjunct support accompanying professional screening, assessment, and treatment for people with suicidal thoughts and behaviors. Keep in mind that safety plans or agreements may be perceived by the trauma survivor as a means of controlling behavior, subsequently replicating or triggering previous traumatic experiences.

All professionals-and in some States, anyone-could have ethical and legal responsibilities to those clients who pose an imminent danger to themselves or others. Clinicians should be aware of the pertinent State laws where they practice and the relevant Federal and professional regulations.

However, as with self-harming behavior, self-destructive behavior needs to be recognized and addressed and may persist-or worsen-without intervention.

Consumption of substances

Substance use often is initiated or increased after trauma. Clients in early recovery- especially those who develop PTSD or have it reactivated-have a higher relapse risk if they experience a trauma. In the first 2 months after September 11, 2001, more than a quarter of New Yorker residents who smoked cigarettes, drank alcohol, or used marijuana (about 265,000 people) increased their consumption. The increases continued 6 months after the attacks ( Vlahov, Galea, Ahern, Resnick, & Kilpatrick, 2004). A study by the Substance Abuse and Mental Health Services Administration ( SAMHSA, Office of Applied Studies, 2002) used National Survey on Drug Use and Health data to compare the first three quarters of 2001 with the last quarter and reported an increase in the prevalence rate for alcohol use among people 18 or older in the New York metropolitan area during the fourth quarter.

Interviews with New York City residents who were current or former cocaine or heroin users indicated that many who had been clean for 6 months or less relapsed after September 11, 2001. Others, who lost their income and could no longer support their habit, enrolled in methadone programs ( Weiss et al., 2002). After the Oklahoma City bombing in 1995, Oklahomans reported double the normal rate of alcohol use, smoking more cigarettes, and a higher incidence of initiating smoking months and even years after the bombing ( Smith, Christiansen, Vincent, & Hann, 1999).

Self-medication

Khantzian's self-medication theory ( 1985) suggests that drugs of abuse are selected for their specific effects. However, no definitive pattern has yet emerged of the use of particular substances in relation to PTSD or trauma symptoms. Use of substances can vary based on a variety of factors, including which trauma symptoms are most prominent for an individual and the individual's access to particular substances. Unresolved traumas sometimes lurk behind the emotions that clients cannot allow themselves to experience. Substance use and abuse in trauma survivors can be a way to self-medicate and thereby avoid or displace difficult emotions associated with traumatic experiences. When the substances are withdrawn, the survivor may use other behaviors to self-soothe, self-medicate, or avoid emotions. As likely, emotions can appear after abstinence in the form of anxiety and depression.

Avoidance

Avoidance often coincides with anxiety and the promotion of anxiety symptoms. Individuals begin to avoid people, places, or situations to alleviate unpleasant emotions, memories, or circumstances. Initially, the avoidance works, but over time, anxiety increases and the perception that the situation is unbearable or dangerous increases as well, leading to a greater need to avoid. Avoidance can be adaptive, but it is also a behavioral pattern that reinforces perceived danger without testing its validity, and it typically leads to greater problems across major life areas (e.g., avoiding emotionally oriented conversations in an intimate relationship). For many individuals who have traumatic stress reactions, avoidance is commonplace. A person may drive 5 miles longer to avoid the road where he or she had an accident. Another individual may avoid crowded places in fear of an assault or to circumvent strong emotional memories about an earlier assault that took place in a crowded area. Avoidance can come in many forms. When people can't tolerate strong affects associated with traumatic memories, they avoid, project, deny, or distort their trauma-related emotional and cognitive experiences. A key ingredient in trauma recovery is learning to manage triggers, memories, and emotions without avoidance-in essence, becoming desensitized to traumatic memories and associated symptoms.

Social/Interpersonal

A key ingredient in the early stage of TIC is to establish, confirm, or reestablish a support system, including culturally appropriate activities, as soon as possible. Social supports and relationships can be protective factors against traumatic stress. However, trauma typically affects relationships significantly, regardless of whether the trauma is interpersonal or is of some other type. Relationships require emotional exchanges, which means that others who have close relationships or friendships with the individual who survived the trauma(s) are often affected as well-either through secondary traumatization or by directly experiencing the survivor's traumatic stress reactions. In natural disasters, social and community supports can be abruptly eroded and difficult to rebuild after the initial disaster relief efforts have waned.

Survivors may readily rely on family members, friends, or other social supports-or they may avoid support, either because they believe that no one will be understanding or trustworthy or because they perceive their own needs as a burden to others. Survivors who have strong emotional or physical reactions, including outbursts during nightmares, may pull away further in fear of being unable to predict their own reactions or to protect their own safety and that of others. Often, trauma survivors feel ashamed of their stress reactions, which further hampers their ability to use their support systems and resources adequately.

Many survivors of childhood abuse and interpersonal violence have experienced a significant sense of betrayal. They have often encountered trauma at the hands of trusted caregivers and family members or through significant relationships. This history of betrayal can disrupt forming or relying on supportive relationships in recovery, such as peer supports and counseling. Although this fear of trusting others is protective, it can lead to difficulty in connecting with others and greater vigilance in observing the behaviors of others, including behavioral health service providers. It is exceptionally difficult to override the feeling that someone is going to hurt you, take advantage of you, or, minimally, disappoint you. Early betrayal can affect one's ability to develop attachments, yet the formation of supportive relationships is an important antidote in the recovery from traumatic stress.

Developmental

Each age group is vulnerable in unique ways to the stresses of a disaster, with children and the elderly at greatest risk. Young children may display generalized fear, nightmares, heightened arousal and confusion, and physical symptoms, (e.g., stomachaches, headaches). School-age children may exhibit symptoms such as aggressive behavior and anger, regression to behavior seen at younger ages, repetitious traumatic play, loss of ability to concentrate, and worse school performance. Adolescents may display depression and social withdrawal, rebellion, increased risky activities such as sexual acting out, wish for revenge and action-oriented responses to trauma, and sleep and eating disturbances ( Hamblen, 2001). Adults may display sleep problems, increased agitation, hypervigilance, isolation or withdrawal, and increased use of alcohol or drugs. Older adults may exhibit increased withdrawal and isolation, reluctance to leave home, worsening of chronic illnesses, confusion, depression, and fear (DeWolfe & Nordboe, 2000b).

Neurobiological Development: Consequences of Early Childhood Trauma

Findings in developmental psychobiology suggest that the consequences of early maltreatment produce enduring negative effects on brain development ( De Bellis, 2002; Liu, Diorio, Day, Francis, & Meaney, 2000; Teicher, 2002). Research suggests that the first stage in a cascade of events produced by early trauma and/or maltreatment involves the disruption of chemicals that function as neurotransmitters (e.g., cortisol, norepinephrine, dopamine), causing escalation of the stress response ( Heim, Mletzko, Purselle, Musselman, & Nemeroff, 2008; Heim, Newport, Mletzko, Miller, & Nemeroff, 2008; Teicher, 2002). These chemical responses can then negatively affect critical neural growth during specific sensitive periods of childhood development and can even lead to cell death.

Adverse brain development can also result from elevated levels of cortisol and catecholamines by contributing to maturational failures in other brain regions, such as the prefrontal cortex ( Meaney, Brake, & Gratton, 2002). Heim, Mletzko et al. (2008) found that the neuropeptide oxytocin- important for social affiliation and support, attachment, trust, and management of stress and anxiety-was markedly decreased in the cerebrospinal fluid of women who had been exposed to childhood maltreatment, particularly those who had experienced emotional abuse. The more childhood traumas a person had experienced, and the longer their duration, the lower that person's current level of oxytocin was likely to be and the higher her rating of current anxiety was likely to be.

Using data from the Adverse Childhood Experiences Study, an analysis by Anda, Felitti, Brown et al. (2006) confirmed that the risk of negative outcomes in affective, somatic, substance abuse, memory, sexual, and aggression-related domains increased as scores on a measure of eight ACEs increased. The researchers concluded that the association of study scores with these outcomes can serve as a theoretical parallel for the effects of cumulative exposure to stress on the developing brain and for the resulting impairment seen in multiple brain structures and functions.

The National Child Traumatic Stress Network ( http://www.nctsn.org) offers information about childhood abuse, stress, and physiological responses of children who are traumatized. Materials are available for counselors, educators, parents, and caregivers. There are special sections on the needs of children in military families and on the impact of natural disasters on children's mental health.

Subthreshold Trauma-Related Symptoms

Many trauma survivors experience symptoms that, although they do not meet the diagnostic criteria for ASD or PTSD, nonetheless limit their ability to function normally (e.g., regulate emotional states, maintain steady and rewarding social and family relationships, function competently at a job, maintain a steady pattern of abstinence in recovery). These symptoms can be transient, only arising in a specific context; intermittent, appearing for several weeks or months and then receding; or a part of the individual's regular pattern of functioning (but not to the level of DSM-5 diagnostic criteria). Often, these patterns are termed "subthreshold" trauma symptoms. Like PTSD, the symptoms can be misdiagnosed as depression, anxiety, oran other mental illness. Likewise, clients who have experienced trauma may link some of their symptoms to their trauma and diagnose themselves as having PTSD, even though they do not meet all criteria for that disorder.

Combat Stress Reaction

A phenomenon unique to war, and one that counselors need to understand well, is combat stress reaction (CSR). CSR is an acute anxiety reaction occurring during or shortly after participating in military conflicts and wars as well as other operations within the war zone, known as the theater. CSR is not a formal diagnosis, nor is it included in the DSM-5 ( APA, 2013a). It is similar to acute stress reaction, except that the precipitating event or events affect military personnel (and civilians exposed to the events) in an armed conflict situation. The terms "combat stress reaction" and "posttraumatic stress injury" are relatively new, and the intent of using these new terms is to call attention to the unique experiences of combat-related stress as well as to decrease the shame that can be associated with seeking behavioral health services for PTSD (for more information on veterans and combat stress reactions, see the planned TIP, Reintegration-Related Behavioral Health Issues for Veterans and Military Families; SAMHSA, planned f).

Case Illustration: Frank

Frank is a 36-year-old man who was severely beaten in a fight outside a bar. He had multiple injuries, including broken bones, a concussion, and a stab wound in his lower abdomen. He was hospitalized for 3.5 weeks and was unable to return to work, thus losing his job as a warehouse forklift operator. For several years, when faced with situations in which he perceived himself as helpless and overwhelmed, Frank reacted with violent anger that, to others, appeared grossly out of proportion to the situation. He has not had a drink in almost 3 years, but the bouts of anger persist and occur three to five times a year. They leave Frank feeling even more isolated from others and alienated from those who love him. He reports that he cannot watch certain television shows that depict violent anger; he has to stop watching when such scenes occur. He sometimes daydreams about getting revenge on the people who assaulted him.

Psychiatric and neurological evaluations do not reveal a cause for Frank's anger attacks. Other than these symptoms, Frank has progressed well in his abstinence from alcohol. He attends a support group regularly, has acquired friends who are also abstinent, and has reconciled with his family of origin. His marriage is more stable, although the episodes of rage limit his wife's willingness to commit fully to the relationship. In recounting the traumatic event in counseling, Frank acknowledges that he thought he was going to die as a result of the fight, especially when he realized he had been stabbed. As he described his experience, he began to become very anxious, and the counselor observed the rage beginning to appear.

After his initial evaluation, Frank was referred to an outpatient program that provided trauma-specific interventions to address his subthreshold trauma symptoms. With a combination of cognitive- behavioral counseling, EMDR, and anger management techniques, he saw a gradual decrease in symptoms when he recalled the assault. He started having more control of his anger when memories of the trauma emerged. Today, when feeling trapped, helpless, or overwhelmed, Frank has resources for coping and does not allow his anger to interfere with his marriage or other relationships.

Although stress mobilizes an individual's physical and psychological resources to perform more effectively in combat, reactions to the stress may persist long after the actual danger has ended. As with other traumas, the nature of the event(s), the reactions of others, and the survivor's psychological history and resources affect the likelihood and severity of CSR. With combat veterans, this translates to the number, intensity, and duration of threat factors; the social support of peers in the veterans' unit; the emotional and cognitive resilience of the service members; and the quality of military leadership. CSR can vary from manageable and mild to debilitating and severe. Common, less severe symptoms of CSR include tension, hypervigilance, sleep problems, anger, and difficulty concentrating. If left untreated, CSR can lead to PTSD.

Common causes of CSR are events such as a direct attack from insurgent small arms fire or a military convoy being hit by an improvised explosive device, but combat stressors encompass a diverse array of traumatizing events, such as seeing grave injuries, watching others die, and making on-the-spot decisions in ambiguous conditions (e.g., having to determine whether a vehicle speeding toward a military checkpoint contains insurgents with explosives or a family traveling to another area). Such circumstances can lead to combat stress. Military personnel also serve in noncombat positions (e.g., healthcare and administrative roles), and personnel filling these supportive roles can be exposed to combat situations by proximity or by witnessing their results.

Advice to Counselors: Understanding the Nature of Combat Stress

Several sources of information are available to help counselors deepen their understanding of combat stress and postdeployment adjustment. Friedman (2006) explains how a prolonged combat-ready stance, which is adaptive in a war zone, becomes hypervigilance and overprotectiveness at home. He makes the point that the "mutual interdependence, trust, and affection" (p. 587) that are so necessarily a part of a combat unit are different from relationships with family members and colleagues in a civilian workplace. This complicates the transition to civilian life. Wheels Down: Adjusting to Life After Deployment ( Moore & Kennedy, 2011) provides practical advice for military service members, including inactive or active duty personnel and veterans, in transitioning from the theater to home.

The following are just a few of the many resources and reports focused on combat-related psychological and stress issues:

Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery ( Tanielian & Jaycox, 2008)

On Killing ( Grossman, 1995), an indepth analysis of the psychological dynamics of combat

Haunted by Combat ( Paulson & Krippner, 2007), which contains specific chapters on Reserve and National Guard troops and female veterans

Specific Trauma-Related Psychological Disorders

Part of the definition of trauma is that the individual responds with intense fear, helplessness, or horror. Beyond that, in both the short term and the long term, trauma comprises a range of reactions from normal (e.g., being unable to concentrate, feeling sad, having trouble sleeping) to warranting a diagnosis of a trauma-related mental disorder. Most people who experience trauma have no long-lasting disabling effects; their coping skills and the support of those around them are sufficient to help them overcome their difficulties, and their ability to function on a daily basis over time is unimpaired. For others, though, the symptoms of trauma are more severe and last longer. The most common diagnoses associated with trauma are PTSD and ASD, but trauma is also associated with the onset of other mental disorders-particularly substance use disorders, mood disorders, various anxiety disorders, and personality disorders. Trauma also typically exacerbates symptoms of preexisting disorders, and, for people who are predisposed to a mental disorder, trauma can precipitate its onset. Mental disorders can occur almost simultaneously with trauma exposure or manifest sometime thereafter.

Acute Stress Disorder

ASD represents a normal response to stress. Symptoms develop within 4 weeks of the trauma and can cause significant levels of distress. Most individuals who have acute stress reactions never develop further impairment or PTSD. Acute stress disorder is highly associated with the experience of one specific trauma rather than the experience of long-term exposure to chronic traumatic stress. Diagnostic criteria are presented in Exhibit 1.3-3.

The primary presentation of an individual with an acute stress reaction is often that of someone who appears overwhelmed by the traumatic experience. The need to talk about the experience can lead the client to seem self-centered and unconcerned about the needs of others. He or she may need to describe, in repetitive detail, what happened, or may seem obsessed with trying to understand what happened in an effort to make sense of the experience. The client is often hypervigilant and avoids circumstances that are reminders of the trauma. For instance, someone who was in a serious car crash in heavy traffic can become anxious and avoid riding in a car or driving in traffic for a finite time afterward. Partial amnesia for the trauma often accompanies ASD, and the individual may repetitively question others to fill in details. People with ASD symptoms sometimes seek assurance from others that the event happened in the way they remember, that they are not "going crazy" or "losing it," and that they could not have prevented the event. The next case illustration demonstrates the time-limited nature of ASD.

Differences between ASD and PTSD

It is important to consider the differences between ASD and PTSD when forming a diagnostic impression. The primary difference is the amount of time the symptoms have been present. ASD resolves 2 days to 4 weeks after an event, whereas PTSD continues beyond the 4-week period. The diagnosis of ASD can change to a diagnosis of PTSD if the condition is noted within the first 4 weeks after the event, but the symptoms persist past 4 weeks.

ASD also differs from PTSD in that the ASD diagnosis requires 9 out of 14 symptoms from five categories, including intrusion, negative mood, dissociation, avoidance, and arousal. These symptoms can occur at the time of the trauma or in the following month. Studies indicate that dissociation at the time of trauma is a good predictor of subsequent PTSD, so the inclusion of dissociative symptoms makes it more likely that those who develop ASD will later be diagnosed with PTSD ( Bryant & Harvey, 2000). Additionally, ASD is a transient disorder, meaning that it is present in a person's life for a relatively short time and then passes. In contrast, PTSD typically becomes a primary feature of an individual's life. Over a lengthy period, PTSD can have profound effects on clients' perceptions of safety, their sense of hope for the future, their relationships with others, their physical health, the appearance of psychiatric symptoms, and their patterns of substance use and abuse.

There are common symptoms between PTSD and ASD, and untreated ASD is a possible predisposing factor to PTSD, but it is unknown whether most people with ASD are likely to develop PTSD. There is some suggestion that, as with PTSD, ASD is more prevalent in women than in men ( Bryant & Harvey, 2003). However, many people with PTSD do not have a diagnosis or recall a history of acute stress symptoms before seeking treatment for or receiving a diagnosis of PTSD.

Case Illustration: Sheila

Two months ago, Sheila, a 55-year-old married woman, experienced a tornado in her home town. In the previous year, she had addressed a long-time marijuana use problem with the help of a treatment program and had been abstinent for about 6 months. Sheila was proud of her abstinence; it was something she wanted to continue. She regarded it as a mark of personal maturity; it improved her relationship with her husband, and their business had flourished as a result of her abstinence.

During the tornado, an employee reported that Sheila had become very agitated and had grabbed her assistant to drag him under a large table for cover. Sheila repeatedly yelled to her assistant that they were going to die. Following the storm, Sheila could not remember certain details of her behavior during the event. Furthermore, Sheila said that after the storm, she felt numb, as if she was floating out of her body and could watch herself from the outside. She stated that nothing felt real and it was all like a dream.

Following the tornado, Sheila experienced emotional numbness and detachment, even from people close to her, for about 2 weeks. The symptoms slowly decreased in intensity but still disrupted her life. Sheila reported experiencing disjointed or unconnected images and dreams of the storm that made no real sense to her. She was unwilling to return to the building where she had been during the storm, despite having maintained a business at this location for 15 years. In addition, she began smoking marijuana again because it helped her sleep. She had been very irritable and had uncharacteristic angry outbursts toward her husband, children, and other family members.

As a result of her earlier contact with a treatment program, Sheila returned to that program and engaged in psychoeducational, supportive counseling focused on her acute stress reaction. She regained abstinence from marijuana and returned shortly to a normal level of functioning. Her symptoms slowly diminished over a period of 3 weeks. With the help of her counselor, she came to understand the link between the trauma and her relapse, regained support from her spouse, and again felt in control of her life.

Effective interventions for ASD can significantly reduce the possibility of the subsequent development of PTSD. Effective treatment of ASD can also reduce the incidence of other co-occurring problems, such as depression, anxiety, dissociative disorders, and compulsive behaviors ( Bryant & Harvey, 2000). Intervention for ASD also helps the individual develop coping skills that can effectively prevent the recurrence of ASD after later traumas.

Although predictive science for ASD and PTSD will continue to evolve, both disorders are associated with increased substance use and mental disorders and increased risk of relapse; therefore, effective screening for ASD and PTSD is important for all clients with these disorders. Individuals in early recovery-lacking well-practiced coping skills, lacking environmental supports, and already operating at high levels of anxiety-are particularly susceptible to ASD. Events that would not normally be disabling can produce symptoms of intense helplessness and fear, numbing and depersonalization, disabling anxiety, and an inability to handle normal life events. Counselors should be able to recognize ASD and treat it rather than attributing the symptoms to a client's lack of motivation to change, being "dry drunk" (for those in substance abuse recovery), or being manipulative.

Posttraumatic Stress Disorder

The trauma-related disorder that receives the greatest attention is PTSD; it is the most commonly diagnosed trauma-related disorder, and its symptoms can be quite debilitating over time. Nonetheless, it is important to remember that PTSD symptoms are represented in a number of other mental illnesses, including major depressive disorder (MDD), anxiety disorders, and psychotic disorders ( Foa et al., 2006). The DSM-5 ( APA, 2013a) identifies four symptom clusters for PTSD: presence of intrusion symptoms, persistent avoidance of stimuli, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity. Individuals must have been exposed to actual or threatened death, serious injury, or sexual violence, and the symptoms must produce significant distress and impairment for more than 4 weeks ( Exhibit 1.3-4).

Case Illustration: Michael

Michael is a 62-year-old Vietnam veteran. He is a divorced father of two children and has four grandchildren. Both of his parents were dependent on alcohol. He describes his childhood as isolated. His father physically and psychologically abused him (e.g., he was beaten with a switch until he had welts on his legs, back, and buttocks). By age 10, his parents regarded him as incorrigible and sent him to a reformatory school for 6 months. By age 15, he was using marijuana, hallucinogens, and alcohol and was frequently truant from school.

At age 19, Michael was drafted and sent to Vietnam, where he witnessed the deaths of six American military personnel. In one incident, the soldier he was next to in a bunker was shot. Michael felt helpless as he talked to this soldier, who was still conscious. In Vietnam, Michael increased his use of both alcohol and marijuana. On his return to the United States, Michael continued to drink and use marijuana. He reenlisted in the military for another tour of duty.

His life stabilized in his early 30s, as he had a steady job, supportive friends, and a relatively stable family life. However, he divorced in his late 30s. Shortly thereafter, he married a second time, but that marriage ended in divorce as well. He was chronically anxious and depressed and had insomnia and frequent nightmares. He periodically binged on alcohol. He complained of feeling empty, had suicidal ideation, and frequently stated that he lacked purpose in his life.

In the 1980s, Michael received several years of mental health treatment for dysthymia. He was hospitalized twice and received 1 year of outpatient psychotherapy. In the mid-1990s, he returned to outpatient treatment for similar symptoms and was diagnosed with PTSD and dysthymia. He no longer used marijuana and rarely drank. He reported that he didn't like how alcohol or other substances made him feel anymore-he felt out of control with his emotions when he used them. Michael reported symptoms of hyperarousal, intrusion (intrusive memories, nightmares, and preoccupying thoughts about Vietnam), and avoidance (isolating himself from others and feeling "numb"). He reported that these symptoms seemed to relate to his childhood abuse and his experiences in Vietnam. In treatment, he expressed relief that he now understood the connection between his symptoms and his history.

Certain characteristics make people more susceptible to PTSD, including one's unique personal vulnerabilities at the time of the traumatic exposure, the support (or lack of support) received from others at the time of the trauma and at the onset of trauma-related symptoms, and the way others in the person's environment gauge the nature of the traumatic event ( Brewin, Andrews, & Valentine, 2000).

People with PTSD often present varying clinical profiles and histories. They can experience symptoms that are activated by environmental triggers and then recede for a period of time. Some people with PTSD who show mostly psychiatric symptoms (particularly depression and anxiety) are misdiagnosed and go untreated for their primary condition. For many people, the trauma experience and diagnosis are obscured by co-occurring substance use disorder symptoms. The important feature of PTSD is that the disorder becomes an orienting feature of the individual's life. How well the person can work, with whom he or she associates, the nature of close and intimate relationships, the ability to have fun and rejuvenate, and the way in which an individual goes about confronting and solving problems in life are all affected by the client's trauma experiences and his or her struggle to recover.

Posttraumatic stress disorder: Timing of symptoms

Although symptoms of PTSD usually begin within 3 months of a trauma in adulthood, there can be a delay of months or even years before symptoms appear for some people. Some people may have minimal symptoms after a trauma but then experience a crisis later in life. Trauma symptoms can appear suddenly, even without conscious memory of the original trauma or without any overt provocation. Survivors of abuse in childhood can have a delayed response triggered by something that happens to them as adults. For example, seeing a movie about child abuse can trigger symptoms related to the trauma. Other triggers include returning to the scene of the trauma, being reminded of it in some other way, or noting the anniversary of an event. Likewise, combat veterans and survivors of community-wide disasters may seem to be coping well shortly after a trauma, only to have symptoms emerge later when their life situations seem to have stabilized. Some clients in substance abuse recovery only begin to experience trauma symptoms when they maintain abstinence for some time. As individuals decrease tension-reducing or self-medicating behaviors, trauma memories and symptoms can emerge.

Advice to Counselors: Helping Clients With Delayed Trauma Responses

Clients who are experiencing a delayed trauma response can benefit if you help them to:

Create an environment that allows acknowledgment of the traumatic event(s).

Discuss their initial recall or first suspicion that they were having a traumatic response.

Become educated on delayed trauma responses.

Draw a connection between the trauma and presenting trauma-related symptoms.

Create a safe environment.

Explore their support systems and fortify them as needed.

Understand that triggers can precede traumatic stress reactions, including delayed responses to trauma.

Develop coping strategies to navigate and manage symptoms.

Culture and posttraumatic stress

Although research is limited across cultures, PTSD has been observed in Southeast Asian, South American, Middle Eastern, and Native American survivors ( Osterman & de Jong, 2007; Wilson & Tang, 2007). As Stamm and Friedman (2000) point out, however, simply observing PTSD does not mean that it is the "best conceptual tool for characterizing post-traumatic distress among non-Western individuals" (p. 73). In fact, many trauma-related symptoms from other cultures do not fit the DSM-5 criteria. These include somatic and psychological symptoms and beliefs about the origins and nature of traumatic events. Moreover, religious and spiritual beliefs can affect how a survivor experiences a traumatic event and whether he or she reports the distress. For example, in societies where attitudes toward karma and the glorification of war veterans are predominant, it is harder for war veterans to come forward and disclose that they are emotionally overwhelmed or struggling. It would be perceived as inappropriate and possibly demoralizing to focus on the emotional distress that he or she still bears. (For a review of cultural competence in treating trauma, refer to Brown, 2008.)

Methods for measuring PTSD are also culturally specific. As part of a project begun in 1972, the World Health Organization (WHO) and the National Institutes of Health (NIH) embarked on a joint study to test the cross-cultural applicability of classification systems for various diagnoses. WHO and NIH identified apparently universal factors of psychological disorders and developed specific instruments to measure them. These instruments, the Composite International Diagnostic Interview and the Schedules for Clinical Assessment in Neuropsychiatry, include certain criteria from the DSM (Fourth Edition, Text Revision; APA, 2000a) as well as criteria from the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10; Exhibit 1.3-5).

Complex trauma and complex traumatic stress

When individuals experience multiple traumas, prolonged and repeated trauma during childhood, or repetitive trauma in the context of significant interpersonal relationships, their reactions to trauma have unique characteristics ( Herman, 1992). This unique constellation of reactions, called complex traumatic stress, is not recognized diagnostically in the DSM-5, but theoretical discussions and research have begun to highlight the similarities and differences in symptoms of posttraumatic stress versus complex traumatic stress ( Courtois & Ford, 2009). Often, the symptoms generated from complex trauma do not fully match PTSD criteria and exceed the severity of PTSD. Overall, literature reflects that PTSD criteria or subthreshold symptoms do not fully account for the persistent and more impairing clinical presentation of complex trauma. Even though current research in the study of traumatology is prolific, it is still in the early stages of development. The idea that there may be more diagnostic variations or subtypes is forthcoming, and this will likely pave the way for more client-matching interventions to better serve those individuals who have been repeatedly exposed to multiple, early childhood, and/or interpersonal traumas.

Other Trauma-Related and Co-Occurring Disorders

The symptoms of PTSD and other mental disorders overlap considerably; these disorders often coexist and in clude mood, anxiety, substance use, and personality disorders. Thus, it's common for trauma survivors to be underdiagnosed or misdiagnosed. If they have not been identified as trauma survivors, their psychological distress is often not associated with previous trauma, and/or they are diagnosed with a disorder that marginally matches their presenting symptoms and psychological sequelae of trauma. The following sections present a brief overview of some mental disorders that can result from (or be worsened by) traumatic stress. PTSD is not the only diagnosis related to trauma nor its only psychological consequence; trauma can broadly influence mental and physical health in clients who already have behavioral health disorders.

The term " co-occurring disorders " refers to cases when a person has one or more mental disorders as well as one or more substance use disorders (including substance abuse). Co-occurring disorders are common among individuals who have a history of trauma and are seeking help.

Advice to Counselors: Universal Screening and Assessment

Only people specifically trained and licensed in mental health assessment should make diagnoses; trauma can result in complicated cases, and many symptoms can be present, whether or not they meet full diagnostic criteria for a specific disorder. Only a trained assessor can distinguish accurately among various symptoms and in the presence of co-occurring disorders. However, behavioral health professionals without specific assessment training can still serve an important role in screening for possible mental disorders using established screening tools ( CSAT, 2005c; see also Chapter 4 of this TIP). In agencies and clinics, it is critical to provide such screenings systematically-for each client-as PTSD and other co-occurring disorders are typically under diagnosed or misdiagnosed.

People With Mental Disorders

MDD is the most common co-occurring disorder in people who have experienced trauma and are diagnosed with PTSD. A well-established causal relationship exists between stressful events and depression, and a prior history of MDD is predictive of PTSD after exposure to major trauma ( Foa et al., 2006).

Many survivors with severe mental disorders function fairly well following trauma, including disasters, as long as essential services aren't interrupted. For others, additional mental health supports may be necessary. For more information, see Responding to the Needs of People With Serious and Persistent Mental Illness in Times of Major Disaster ( Center for Mental Health Services, 1996).

Co-occurrence is also linked with greater impairment and more severe symptoms of both disorders, and the person is less likely to experience remission of symptoms within 6 months.

Generalized anxiety, obsessive-compulsive, and other anxiety disorders are also associated with PTSD. PTSD may exacerbate anxiety disorder symptoms, but it is also likely that preexisting anxiety symptoms and anxiety disorders increase vulnerability to PTSD. Preexisting anxiety primes survivors for greater hyperarousal and distress. Other disorders, such as personality and somatization disorders, are also associated with trauma, but the history of trauma is often overlooked as a significant factor or necessary target in treatment.

The relationship between PTSD and other disorders is complex. More research is now examining the multiple potential pathways among PTSD and other disorders and how various sequences affect clinical presentation. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( CSAT, 2005c), is valuable in understanding the relationship of substance use to other mental disorders.

People With Substance Use Disorders

There is clearly a correlation between trauma (including individual, group, or mass trauma) and substance use as well as the presence of posttraumatic stress (and other trauma-related disorders) and substance use disorders. Alcohol and drug use can be, for some, an effort to manage traumatic stress and specific PTSD symptoms. Likewise, people with substance use disorders are at higher risk of developing PTSD than people who do not abuse substances. Counselors working with trauma survivors or clients who have substance use disorders have to be particularly aware of the possibility of the other disorder arising.

Co-Occurring PTSD and Other Mental Disorders

Individuals with PTSD often have at least one additional diagnosis of a mental disorder.

The presence of other disorders typically worsens and prolongs the course of PTSD and complicates clinical assessment, diagnosis, and treatment.

The most common co-occurring disorders, in addition to substance use disorders, include mood disorders, various anxiety disorders, eating disorders, and personality disorders.

Exposure to early, severe, and chronic trauma is linked to more complex symptoms, including impulse control deficits, greater difficulty in emotional regulation and establishing stable relationships, and disruptions in consciousness, memory, identity, and/or perception of the environment ( Dom, De, Hulstijn, & Sabbe, 2007; Waldrop, Back, Verduin, & Brady, 2007).

Certain diagnostic groups and at-risk populations (e.g., people with developmental disabilities, people who are homeless or incarcerated) are more susceptible to trauma exposure and to developing PTSD if exposed but less likely to receive appropriate diagnosis and treatment.

Given the prevalence of traumatic events in clients who present for substance abuse treatment, counselors should assess all clients for possible trauma-related disorders.

Timeframe: PTSD and the onset of substance use disorders

Knowing whether substance abuse or PTSD came first informs whether a causal relationship exists, but learning this requires thorough assessment of clients and access to complete data on PTSD; substance use, abuse, and dependence; and the onset of each. Much current research focuses solely on the age of onset of substance use (not abuse), so determining causal relationships can be difficult. The relationship between PTSD and substance use disorders is thought to be bidirectional and cyclical: substance use increases trauma risk, and exposure to trauma escalates substance use to manage trauma-related symptoms. Three other causal pathways described by Chilcoat and Breslau's seminal work ( 1998) further explain the relationship between PTSD and substance use disorders:

1. The "self-medication" hypothesis suggests that clients with PTSD use substances to manage PTSD symptoms (e.g., intrusive memories, physical arousal). Substances such as alcohol, cocaine, barbiturates, opioids, and amphetamines are frequently abused in attempts to relieve or numb emotional pain or to forget the event.

2. The "high-risk" hypothesis states that drug and alcohol use places people who use substances in high-risk situations that increase their chances of being exposed to events that lead to PTSD.

3. The "susceptibility" hypothesis suggests that people who use substances are more susceptible to developing PTSD after exposure to trauma than people who do not. Increased vulnerability may result from failure to develop effective stress management strategies, changes in brain chemistry, or damage to neurophysiological systems due to extensive substance use.

PTSD and substance abuse treatment

PTSD can limit progress in substance abuse recovery, increase the potential for relapse, and complicate a client's ability to achieve success in various life areas. Each disorder can mask or hide the symptoms of the other, and both need to be assessed and treated if the individual is to have a full recovery. There is a risk of misinterpreting trauma-related symptoms in substance abuse treatment settings. For example, avoidance symptoms in an individual with PTSD can be misinterpreted as lack of motivation or unwillingness to engage in substance abuse treatment; a counselor's efforts to address substance abuse-related behaviors in early recovery can likewise provoke an exaggerated response from a trauma survivor who has profound traumatic experiences of being trapped and controlled. Exhibit 1.3-6 lists important facts about PTSD and substance use disorders for counselors.

Case Illustration: Maria

Maria is a 31-year-old woman diagnosed with PTSD and alcohol dependence. From ages 8 to 12, she was sexually abused by an uncle. Maria never told anyone about the abuse for fear that she would not be believed. Her uncle remains close to the family, and Maria still sees him on certain holidays. When she came in for treatment, she described her emotions and thoughts as out of control. Maria often experiences intrusive memories of the abuse, which at times can be vivid and unrelenting. She cannot predict when the thoughts will come; efforts to distract herself from them do not always work. She often drinks in response to these thoughts or his presence, as she has found that alcohol can dull her level of distress. Maria also has difficulty falling asleep and is often awakened by nightmares. She does not usually remember the dreams, but she wakes up feeling frightened and alert and cannot go back to sleep.

Maria tries to avoid family gatherings but often feels pressured to go. Whenever she sees her uncle, she feels intense panic and anger but says she can usually "hold it together" if she avoids him. Afterward, however, she describes being overtaken by these feelings and unable to calm down. She also describes feeling physically ill and shaky. At these times, she often isolates herself, stays in her apartment, and drinks steadily for several days. Maria also reports distress pertaining to her relationship with her boyfriend. In the beginning of their relationship, she found him comforting and enjoyed his affection, but more recently, she has begun to feel anxious and unsettled around him. Maria tries to avoid sex with him, but she sometimes gives in for fear of losing the relationship. She finds it easier to have sex with him when she is drunk, but she often experiences strong feelings of dread and disgust reminiscent of her abuse. Maria feels guilty and confused about these feelings.

Sleep, PTSD, and substance use

Many people have trouble getting to sleep and/or staying asleep after a traumatic event; consequently, some have a drink or two to help them fall asleep. Unfortunately, any initially helpful effects are likely not only to wane quickly, but also to incur a negative rebound effect. When someone uses a substance before going to bed, "sleep becomes lighter and more easily disrupted," and rapid eye movement sleep (REM) "increases, with an associated increase in dreams and nightmares," as the effects wear off ( Auerbach, 2003, p. 1185).

People with alcohol dependence report multiple types of sleep disturbances over time, and it is not unusual for clients to report that they cannot fall asleep without first having a drink. Both REM and slow wave sleep are reduced in clients with alcohol dependence, which is also associated with an increase in the amount of time it takes before sleep occurs, decreased overall sleep time, more nightmares, and reduced sleep efficiency. Sleep during withdrawal is "frequently marked by severe insomnia and sleep fragmentation...a loss of restful sleep and feelings of daytime fatigue. Nightmares and vivid dreams are not uncommon" ( Auerbach, 2003, pp. 1185-1186).

Confounding changes in the biology of sleep that occur in clients with PTSD and substance use disorders often add to the problems of recovery. Sleep can fail to return to normal for months or even years after abstinence, and the persistence of sleep disruptions appears related to the likelihood of relapse. Of particular clinical importance is the vicious cycle that can also begin during "slips"; relapse initially improves sleep, but continued drinking leads to sleep disruption. This cycle of initial reduction of an unpleasant symptom, which only ends up exacerbating the process as a whole, can take place for clients with PTSD as well as for clients with substance use disorders. There are effective cognitive-behavioral therapies and nonaddictive pharmacological interventions for sleep difficulties.

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Trauma-informed care (TIC) involves a broad understanding of traumatic stress reactions and common responses to trauma. Providers need to understand how trauma can affect treatment presentation, engagement, and the outcome of behavioral health services. This chapter examines common experiences survivors may encounter immediately following or long after a traumatic experience.

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When you experience a traumatic event, it's common to have an emotional reaction. Such stress reactions are normal and not weakness. Most people recover in time. Learn about stress reactions and problems that occur after trauma.

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Common Reactions After Trauma

Available en Español

When you experience a traumatic event, it's common to have an emotional reaction. Such stress reactions are normal and not weakness. Most people recover in time. Learn about stress reactions and problems that occur after trauma.

Reading time: minutes

What Are Common Reactions to Trauma?

All kinds of trauma create stress reactions. People often say that their first feeling is relief to be alive after a traumatic event. This may be followed by stress, fear and anger. Trauma may also lead people to find they are unable to stop thinking about what happened. Traumatic events can create a high level of arousal-or feeling alert or "on guard"-as well, which causes people to react strongly to sounds and sights around them.

If you understand what is happening when you or someone you know reacts to a traumatic event, you may be less fearful and better able to cope. Reactions are common for anyone, even Service members and Veterans, or disaster rescue and relief workers, who have been trained to respond to crises.

Here are some common reactions to trauma:

Losing hope for the future

Feeling distant (detached) or losing a sense of concern about others

Being unable to concentrate or make decisions

Feeling jumpy and getting startled easily at sudden noises

Feeling on guard and alert all the time

Having dreams and memories that upset you

Having problems at work or school

Avoiding people, places and things related to the event

You may also experience more physical reactions such as:

Stomach upset and trouble eating

Trouble sleeping and feeling very tired

Pounding heart, rapid breathing, feeling shaky

Sweating

Severe headache if thinking of the event

Not keeping up with exercise, diet, safe sex or-regular health care

Smoking more, using alcohol or drugs more, or eating too much

Having your ongoing medical problems get worse

You may have more emotional troubles such as:

Feeling nervous, helpless, fearful, sad

Feeling shocked, numb, or not able to feel love or joy

Being irritable or having angry outbursts

Getting easily upset or agitated

Blaming yourself or having negative views of oneself or the world

Being unable to trust others, getting into fights, or being trying to control everything

Being withdrawn, feeling rejected, or abandoned

Feeling detached, not wanting intimacy

Recovery From Stress Reactions

Turn to your family and friends when you are ready to talk. They are your personal support system. Recovery is an ongoing gradual process. Don't look to be "cured" all of a sudden or assume that you will forget what happened. Most people will recover from trauma naturally. If your stress reactions are getting in the way of your relationships, work or other important activities, you may want to talk to a counselor or your doctor. Good treatments are available.

Common Problems That Can Occur After a Trauma

Posttraumatic Stress Disorder (PTSD). PTSD is a condition that can develop after you have gone through a life-threatening event. If you have PTSD, you may have trouble keeping yourself from thinking over and over about what happened to you. You may try to avoid people and places that remind you of the trauma. You may feel numb. Lastly, if you have PTSD, you might find that you have trouble relaxing. You may startle easily, and you may feel on guard most of the time.

Depression. Depression involves feeling down or sad more days than not. If you are depressed, you may lose interest in activities that you used to enjoy or find fun. You may feel low in energy and be overly tired. You may feel hopeless or in despair, and you may think that things will never get better. Depression is more likely when you have had losses such as the death of close friends. If you are depressed, at times you might think about hurting yourself. For this reason, getting help for depression is very important.

Self-blame, guilt and shame. Sometimes in trying to make sense of a traumatic event, you may blame yourself. You may think you are to blame for bad things that happened, or for surviving when others didn't. You may feel guilty for what you did or did not do. Remember, we all tend to be our own worst critics.

Suicidal thoughts. Trauma and loss can lead someone who is depressed to think about self-harm. If you have thoughts of suicide, talk to someone. If you think someone you know may be thinking about suicide, ask them. You will NOT put the idea in their head. If you or someone you care about is thinking about suicide:

Call the Suicide and Crisis Lifeline at 988 or visit 988lifeline.org.

If you are a Veteran, or you are concerned about one, call 988 and press 1 to speak with a responder trained to help Veterans. Visit the Veterans Crisis Line.

You can also call a counselor or doctor; or dial 911 for emergency response services (like police or an ambulance).

Anger or aggressive behavior. Trauma is related to anger in many ways. After a trauma, you might think that what happened to you was unfair or unjust. You might not understand why the event happened and why it happened to you. These thoughts can result in intense anger. Anger is a natural and healthy emotion, but strong feelings of anger and aggressive behavior can cause problems with family, friends or co-workers. If you become violent when angry, it makes the situation worse. Violence can lead to injury, and there may be legal outcomes.

Alcohol or drug abuse. Drinking or "self-medicating" with drugs is a common, and unhealthy, way of coping with upsetting events. You may drink too much or use drugs to numb yourself and to try to deal with difficult thoughts, feelings and memories related to the trauma. While using alcohol or drugs may offer a quick solution, it can lead to more problems. If someone close to you begins to lose control of drinking or drug use, try to get them to see a health care provider about managing their drinking or drug use.

Summing It All Up

Right after a trauma, almost every survivor will find it hard to stop thinking about what happened. Stress reactions-such as fear, anxiety, jumpiness, upsetting memories, and efforts to avoid reminders-will gradually decrease over time for most people.

Use your personal support systems, family and friends, when you are ready to talk. Or, be a support for someone you care about who has been through a trauma. Recovery is an ongoing gradual process that takes time. Don't look for a quick "cure" or assume that you will forget what happened. Most people will recover from trauma on their own. If your emotional reactions are getting in the way of your relationships, work or other important activities, you may want to talk to a counselor or your doctor. Good treatments are available.

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Available en Español When you experience a traumatic event, it's common to have an emotional reaction. Such stress reactions are normal and not weakness. Most people recover in time. Learn about stress reactions and problems that occur after trauma. Reading time: minutes All kinds of trauma create stress reactions.

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The impact of childhood trauma on children's wellbeing and adult behavior

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The impact of childhood trauma on children's wellbeing and adult behavior

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This article looks at the impact of childhood trauma on children's wellbeing and adult behavior from the perspective of 9 clinical professionals in Ireland. It exhibits how physical, sexual and emotional abuse disrupts one's life through analyzing coping strategies and behaviors adopted by childhood trauma victims following adversity exposure.

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Abstract

Background

This article looks at the impact of childhood trauma on children's wellbeing and adult behavior from the perspective of 9 clinical professionals in Ireland. It exhibits how physical, sexual and emotional abuse disrupts one's life through analyzing coping strategies and behaviors adopted by childhood trauma victims following adversity exposure.

Objectives

To examine if coping mechanisms such as denial, self- isolation, drug and alcohol abuse are associated with childhood trauma survivors. Correspondingly, this research investigates if symptoms related to depression and anxiety, sleep disturbance and low self-esteem are consequences of childhood trauma. The final objective explores possible correlations between resilience capacity and social class background. Upon this selection, the authors acknowledge that consequences and post-trauma symptoms can vary depending on numerous factors, including the type of abuse endured by victims.

Methods

Participants were recruited through convenience selection and snowball sampling. Individuals worked in social care, counselling, psychotherapy, psychology and support work. Seven females and two males participated in recorded semi-structured interviews. Six interviews were carried out via phone call and three were conducted face-to-face. Participants shared experiences about their client-based interactions. Participants were assigned a pseudonym to protect their identity.

Results

Within this study, childhood trauma survivors present alcohol and drug dependency issues, deny the negative impact their adversities have on their wellbeing (especially if it was inflicted by their parents), and construct a false self-image to cope rather than self-isolate. Early onset of trauma may contrive a low self-esteem and depression and anxiety can surface due to feelings of inadequacy. Sleep disturbance did not appear as a consequence of childhood trauma in this study. Social class was not an influential factor in mediating the type of traumatic experiences faced by individuals from different backgrounds. Financial circumstances did however, present as significant in impacting support-service availability. Interventions, treatment plans and social support emerged as crucial in enhancing resilience levels, reversing the onset of problematic behavior and psychiatric conditions.

Conclusion

Childhood trauma victims exhibit low self-esteem, and experience depression and anxiety. Some deny their trauma history, while others create a false self-image and engage in alcohol and drug misuse in attempts to prevent their traumatic experiences from impacting their life. Early interventions may reduce trauma symptoms alongside sufficient and customized treatment strategies.

Data for reference

Interview questions can be accessed via Zenodo: 10.5281/zenodo.4639706.

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The impact of childhood trauma on children's wellbeing and adult behavior

# data[].attributes.attachment_link.description
This article looks at the impact of childhood trauma on children's wellbeing and adult behavior from the perspective of 9 clinical professionals in Ireland. It exhibits how physical, sexual and emotional abuse disrupts one's life through analyzing coping strategies and behaviors adopted by childhood trauma victims following adversity exposure.

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Trauma and Behavior Part 1: "How Trauma Affects the Brain"

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Trauma and Behavior Part 1: "How Trauma Affects the Brain"

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Educational Specialist Laura Phipps describes the effect of trauma on the brain, and what this often looks like in terms of children's behavior.

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Trauma and Behavior Part 1: "How Trauma Affects the Brain"

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The Impact of Trauma on Learning Part 2: Classroom Behavior

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The Impact of Trauma on Learning Part 2: Classroom Behavior

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For many children who have experienced traumatic events, the school setting can feel like a battleground in which their assumptions of the world as a dangerous place sabotage their ability to remain calm and regulate their behavior in the classroom. Unfortunately, many of these children develop behavioral coping mechanisms in an effort to feel safe and in control, yet these behaviors can frustrate educators and evoke exasperated reprisals, reactions that both strengthen the child’s expectations of confrontation and danger and reinforce a negative self-image.

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The Impact of Trauma on Learning Part 2: Classroom Behavior

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Most people who go through traumatic events may have a hard time adjusting and coping for a short time. But with time and by taking good care of themselves, they usually get better. If the symptoms get worse, last for months or years, and affect their ability to function daily, they may have PTSD.

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Overview

Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.

Most people who go through traumatic events may have temporary difficulty adjusting and coping, but with time and good self-care, they usually get better. If the symptoms get worse, last for months or even years, and interfere with your day-to-day functioning, you may have PTSD.

Getting effective treatment after PTSD symptoms develop can be critical to reduce symptoms and improve function.

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Symptoms

Post-traumatic stress disorder symptoms may start within one month of a traumatic event, but sometimes symptoms may not appear until years after the event. These symptoms cause significant problems in social or work situations and in relationships. They can also interfere with your ability to go about your normal daily tasks.

PTSD symptoms are generally grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. Symptoms can vary over time or vary from person to person.
Intrusive memories
Symptoms of intrusive memories may include:

Recurrent, unwanted distressing memories of the traumatic event

Reliving the traumatic event as if it were happening again (flashbacks)

Upsetting dreams or nightmares about the traumatic event

Severe emotional distress or physical reactions to something that reminds you of the traumatic event

Avoidance
Symptoms of avoidance may include:

Trying to avoid thinking or talking about the traumatic event

Avoiding places, activities or people that remind you of the traumatic event

Negative changes in thinking and mood
Symptoms of negative changes in thinking and mood may include:

Negative thoughts about yourself, other people or the world

Hopelessness about the future

Memory problems, including not remembering important aspects of the traumatic event

Difficulty maintaining close relationships

Feeling detached from family and friends

Lack of interest in activities you once enjoyed

Difficulty experiencing positive emotions

Feeling emotionally numb

Changes in physical and emotional reactions
Symptoms of changes in physical and emotional reactions (also called arousal symptoms) may include:

Being easily startled or frightened

Always being on guard for danger

Self-destructive behavior, such as drinking too much or driving too fast

Trouble sleeping

Trouble concentrating

Irritability, angry outbursts or aggressive behavior

Overwhelming guilt or shame

For children 6 years old and younger, signs and symptoms may also include:

Re-enacting the traumatic event or aspects of the traumatic event through play

Frightening dreams that may or may not include aspects of the traumatic event

Intensity of symptoms
PTSD symptoms can vary in intensity over time. You may have more PTSD symptoms when you're stressed in general, or when you come across reminders of what you went through. For example, you may hear a car backfire and relive combat experiences. Or you may see a report on the news about a sexual assault and feel overcome by memories of your own assault.
When to see a doctor
If you have disturbing thoughts and feelings about a traumatic event for more than a month, if they're severe, or if you feel you're having trouble getting your life back under control, talk to your doctor or a mental health professional. Getting treatment as soon as possible can help prevent PTSD symptoms from getting worse.
If you have suicidal thoughts
If you or someone you know has suicidal thoughts, get help right away through one or more of these resources:

Reach out to a close friend or loved one.

Contact a minister, a spiritual leader or someone in your faith community.

Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat. Services are free and confidential.

Make an appointment with your doctor or a mental health professional.

When to get emergency help
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.

If you know someone who's in danger of attempting suicide or has made a suicide attempt, make sure someone stays with that person to keep him or her safe. Call 911 or your local emergency number immediately. Or, if you can do so safely, take the person to the nearest hospital emergency room.

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Causes

You can develop post-traumatic stress disorder when you go through, see or learn about an event involving actual or threatened death, serious injury or sexual violation.

Doctors aren't sure why some people get PTSD. As with most mental health problems, PTSD is probably caused by a complex mix of:

Stressful experiences, including the amount and severity of trauma you've gone through in your life

Inherited mental health risks, such as a family history of anxiety and depression

Inherited features of your personality - often called your temperament

The way your brain regulates the chemicals and hormones your body releases in response to stress

Risk factors

People of all ages can have post-traumatic stress disorder. However, some factors may make you more likely to develop PTSD after a traumatic event, such as:

Experiencing intense or long-lasting trauma

Having experienced other trauma earlier in life, such as childhood abuse

Having a job that increases your risk of being exposed to traumatic events, such as military personnel and first responders

Having other mental health problems, such as anxiety or depression

Having problems with substance misuse, such as excess drinking or drug use

Lacking a good support system of family and friends

Having blood relatives with mental health problems, including anxiety or depression

Kinds of traumatic events
The most common events leading to the development of PTSD include:

Combat exposure

Childhood physical abuse

Sexual violence

Physical assault

Being threatened with a weapon

An accident

Many other traumatic events also can lead to PTSD, such as fire, natural disaster, mugging, robbery, plane crash, torture, kidnapping, life-threatening medical diagnosis, terrorist attack, and other extreme or life-threatening events.

Complications

Post-traumatic stress disorder can disrupt your whole life - your job, your relationships, your health and your enjoyment of everyday activities.

Having PTSD may also increase your risk of other mental health problems, such as:

Depression and anxiety

Issues with drugs or alcohol use

Eating disorders

Suicidal thoughts and actions

Prevention

After surviving a traumatic event, many people have PTSD-like symptoms at first, such as being unable to stop thinking about what's happened. Fear, anxiety, anger, depression, guilt - all are common reactions to trauma. However, the majority of people exposed to trauma do not develop long-term post-traumatic stress disorder.

Getting timely help and support may prevent normal stress reactions from getting worse and developing into PTSD. This may mean turning to family and friends who will listen and offer comfort. It may mean seeking out a mental health professional for a brief course of therapy. Some people may also find it helpful to turn to their faith community.

Support from others also may help prevent you from turning to unhealthy coping methods, such as misuse of alcohol or drugs.

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Post-traumatic stress disorder (PTSD) - Symptoms and causes

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Post-traumatic stress disorder (PTSD) is a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety.

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Trauma focused CBT for children with co-occurring trauma and behavior problems

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Trauma focused CBT for children with co-occurring trauma and behavior problems

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Traumatized children commonly have behavioral problems that therapists must effectively evaluate and manage in the context of providing trauma-focused treatment. This manuscript describes practical strategies for managing behavior problems in the context of trauma-focused evidence-based treatment (EBT) using a commonly implemented EBT for traumatized children.

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Abstract

Objective

Childhood trauma impacts multiple domains of functioning including behavior. Traumatized children commonly have behavioral problems that therapists must effectively evaluate and manage in the context of providing trauma-focused treatment. This manuscript describes practical strategies for managing behavior problems in the context of trauma-focused evidence-based treatment (EBT) using a commonly implemented EBT for traumatized children.

Methods

The empirical literature is reviewed and practical strategies are described for conducting trauma- and behavioral-focused assessments; engaging families in trauma- and behavioral-focused treatment; treatment-planning that includes a balance of both trauma and behavioral foci; managing ongoing behavioral problems in the context of providing trauma-focused treatment; managing behavioral crises ("crises of the week"); addressing overwhelming family or social problems; and steps for knowledge transfer.

Results

Trauma-focused EBT that integrate behavioral management strategies can effectively manage the behavioral regulation problems that commonly occur in traumatized children.

Conclusions

Addressing trauma-related behavioral problems is an important part of trauma-focused treatment and is feasible to do in the context of using common trauma-focused EBT.

Practice implications

Integrating effective behavioral interventions into trauma-focused EBT is essential due to the common nature of behavioral regulation difficulties in traumatized children.

View full text

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Trauma focused CBT for children with co-occurring trauma and behavior problems

# data[].attributes.attachment_link.description
Childhood trauma impacts multiple domains of functioning including behavior. Traumatized children commonly have behavioral problems that therapists must effectively evaluate and manage in the context of providing trauma-focused treatment. This manuscript describes practical strategies for managing behavior problems in the context of trauma-focused evidence-based treatment (EBT) using a commonly implemented EBT for traumatized children.

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The relation between trauma exposure and prosocial behavior.

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The relation between trauma exposure and prosocial behavior.

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purpose of this study was to assess the relation between trauma exposure and prosocial behavior. Undergraduate students (N = 1,528) completed online measures of prosocial behavior (both daily helping behavior and volunteering), lifetime trauma exposure, and 5 other known correlates (i.e., empathy, agreeableness, religiosity, extraversion, and gender) of prosocial behavior

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Cognitive and Behavioral Responses to Trauma

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Cognitive and Behavioral Responses to Trauma

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highlight the importance of the study of responses to different traumatic stressors in order to identify cognitive mechanisms and behaviors activated by trauma. Such phenomena may be important to our understanding of the effects of traumatic stress and their acute and long-term health outcomes.

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Childhood trauma: its relationship to Behavioral and psychiatric disorders

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Childhood trauma: its relationship to Behavioral and psychiatric disorders

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It is important to understand the relation ships among family violence, child maltreatment, and psychiatric and behavioral disorders in order to prevent, assess, and treat these very serious social problems. This study demonstrates a strong level of comorbidity among these problems.

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Understanding Intergenerational Trauma and Its Effects on Mental Health

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Understanding Intergenerational Trauma and Its Effects on Mental Health

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This article is about how trauma can be passed down from one generation to the next, the five things that can happen when you experience intergenerational trauma, and the strategies that can stop the cycle.

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Intergenerational Trauma: What You Need To Know

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Intergenerational trauma is passed from one generation to the next. Learn how it is defined, what causes it, and how people with this type of trauma can get support.

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Intergenerational trauma refers to the apparent transmission of trauma between generations of a family. People who experienced adverse childhood experiences growing up, or who survived historical disasters or traumas, may pass the effects of those traumas on to their children or grandchildren, through their genes, their behavior, or both, leaving the next generation susceptible to anxiety, depression, hypervigilance, and other emotional and mental health concerns.

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Intergenerational trauma refers to the apparent transmission of trauma between generations of a family. People who experienced adverse childhood experiences growing up, or who survived historical disasters or traumas, may pass the effects of those traumas on to their children or grandchildren, through their genes, their behavior, or both, leaving the next generation susceptible to anxiety, depression, hypervigilance, and other emotional and mental health concerns.

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Addressing Historical, Intergenerational, and Chronic Trauma: Impacts on Children, Families, and Communities

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Addressing Historical, Intergenerational, and Chronic Trauma: Impacts on Children, Families, and Communities

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This focuses on the generations of families who have ongoing experiences of historical, intergenerational, and chronic trauma, particularly tribal populations and communities of color.

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Addressing Historical, Intergenerational, and Chronic Trauma: Impacts on Children, Families, and Communities

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The next workshop session focused on the generations of families who have ongoing experiences of historical, intergenerational, and chronic trauma, particularly tribal populations and communities of color. Harolyn Belcher, Kennedy Krieger Institute, and Jennifer Tyson, U.S. Department of Justice, co-moderated the panel. Presenters were Teresa Brockie, School of Nursing at The Johns Hopkins University; Emily Haozous, University of New Mexico College of Nursing; and Reggie Moore, Office of Violence Prevention, Milwaukee Health Department. Each shared research and firsthand accounts to provide a better understanding of how addressing trauma can improve health equity.

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Understanding Intergenerational Trauma and Its Effects

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Understanding Intergenerational Trauma and Its Effects

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Trauma passed down through generations can ripple through multiple areas of life, not just for the survivors, but also for descendants not yet born at the time of the original trauma.

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Traumatic experiences can take many forms.

You might, for instance, find yourself facing long-term emotional distress after discovering a partner's infidelity, losing your sibling in a car accident, or coping with the sudden illness and death of a beloved pet.

Yet certain types of trauma can have a far more profound impact. Major, large-scale traumatic events often don't affect only those who survive them. The toll of these experiences can reverberate across generations.

Experts refer to this as intergenerational trauma, or secondary traumatization. You might also come across the term historical trauma, which describes intergenerational trauma that stems from oppression related to culture, race, or ethnicity.

Trauma passed down through generations can ripple through multiple areas of life, not just for the survivors, but also for descendants not yet born at the time of the original trauma.

Intergenerational trauma might affect:

Though intergenerational trauma can have deep, complex, and far-reaching effects, it's possible to heal - not to mention minimize your chances of continuing the cycle.

You'll find more details on intergenerational trauma below, including key signs, causes, and tips for getting support.

Researchers first began to explore intergenerational trauma after observing its effects on the children and grandchildren of Holocaust survivors and Japanese Americans forced into internment camps during World War II.

This list doesn't include all potential causes of trauma. But if your parents or grandparents experienced any adverse events, especially throughout childhood, the aftereffects may linger within the family dynamic.

suggests that adverse childhood experiences (ACEs), typically defined as abuse, neglect, and parental mental health conditions, can have a profound effect on emotional, mental, and physical health, explains Giovanna Torres, MSW, LSWAIC, a therapist in the Seattle area.

Torres, who specializes in working with first-generation individuals to address intergenerational trauma through the use of relational and somatic therapy, goes on to say that traumatization can stem from abuse or neglect both in and out of the home.

"Historical context is everything," she says. "You might not be someone who considers yourself a victim of trauma. But what is the history of your parents, grandparents, and relatives' people, within the United States or abroad? Did they experience discrimination or abuse on a larger scale that impeded their well-being?"

It's not always easy to recognize intergenerational trauma, since many of the signs also characterize mental health conditions like depression and post-traumatic stress disorder (PTSD).

What's more, the signs and symptoms of trauma can also vary widely from person to person and family to family.

"Some people become so accustomed to living with the impact of generational trauma in a family that accepts it as 'normal,' the trauma becomes normalized and symptoms appear 'normal' to them," says Canh Tran, LICSW, a trauma therapist in Seattle, WA.

"Our families, society, and culture shape our environment, so this is key," says Tran. He goes on to explain that this normalization of trauma symptoms can lead you to begin accepting it as "normal" yourself.

Some common signs and symptoms might include:

dissociation and depersonalization, or a sense of disconnection and detachment from your body and feelings

emotional numbness, or difficulty experiencing and expressing emotions

difficulty connecting with others, establishing trust, and forming relationships

feelings of isolation and withdrawal

feelings of shame, guilt, or low self-esteem

a sense of helplessness or vulnerability

difficulty establishing personal identity

trouble regulating your mood and emotions

a tendency to avoid certain people, places, or things

substance use, especially to help manage mood or emotional symptoms

nightmares

intrusive thoughts

a diminished sense of security and safety in everyday life

feelings of anxiety and depression

a heightened response to stress

thoughts of suicide, death, or dying

Signs of traumatization can also show up for the members of your family who lived through the initial trauma. They might:

have difficulty discussing the trauma, or deny it outright

minimize the traumatic experience ("It wasn't so bad. Other people had it worse.")

have trouble expressing emotions and communicating

use alcohol and other substances to numb or cope with unwanted feelings

raise their voice or become angry easily

have either an overly harsh or mostly uninvolved parenting style

These patterns can appear in your own behavior, though you might not always consciously recognize these effects.

Examples to consider

Maybe you've always witnessed family members using alcohol to:

navigate tense situations

ease uncomfortable emotions

destress after a difficult day

It's only natural you might find yourself turning to alcohol for the same reasons, simply because your family modeled that behavior.

Or, perhaps no one in your family shares their feelings or shows love and approval. You might never learn how to share emotions and affection - but this might not feel unusual, since that's what you learned growing up.

Maybe your parents remained distant or detached, even when you did try to show your love or earn their approval. As a result, you might:

begin to feel unsafe expressing your feelings to others

consistently fear rejection

avoid forming attachments and becoming close to others

On the other hand, when you have some awareness of the impact of your family's trauma, you might resolve to do things differently but end up erring on the side of overcompensation.

If you grew up in a household where you had little money for basic necessities, much less toys and outings, you might indulge your own child by:

frequently taking them to restaurants

going on expensive trips and vacations

buying them everything they ask for (and plenty of things they don't ask for)

Or perhaps your parents' inability to express love felt so devastating that you constantly tell your partner and children how much you love them - to the point where it leaves them a little uncomfortable.

The key to understanding intergenerational trauma lies in the nature of trauma responses themselves.

When you experience a traumatic or stressful event, your brain and body work to protect you through one of four main responses:

fight, or standing up to the threat

flight, or fleeing from the threat

freeze, or stopping in your tracks and waiting to determine the best response

fawn, or attempting to soothe and appease the source of the threat

Repeated or ongoing exposure to trauma - whether that means you continue to face the same trauma, or different traumas again and again - can leave you "stuck" in this response. Your body wants you to get through the event safely, so it remains on guard for danger.

But this state of hypervigilance, or constant high alert for possible threats, can have some pretty big consequences. It can have a long lasting impact on your overall physical and mental health and well-being, for one. But it can also affect your very biology by triggering changes in the expression of certain genes.

The role of epigenetics

Research in a field known as epigenetics explores the ways these heritable changes to DNA affect the activity and function of your genes. These changes don't alter the sequence of the nucleotides in your DNA. In other words, they don't change the DNA molecule itself, but they can alter which genes activate and deactivate.

Where does the "intergenerational" aspect come in? Well, some of these changes don't just modify your genes. They lie in your genetic code and shape the genes you eventually pass on to your children.

In short, you don't have to experience any direct threat to your health and safety. Your genes carry the knowledge of what your parents, grandparents, and great-grandparents lived through, regardless.

Other factors

Of course, other effects of trauma can also play a major role.

It helps to remember that people respond to trauma in different ways. They can then teach those responses, consciously or unconsciously, to their own children.

For instance, if your grandmother experienced abuse and neglect from one parent, she might have learned to:

suppress her own needs and desires

avoid drawing attention to herself

do whatever she could to keep that parent happy

apologize immediately when encountering disapproval from someone else

She might have passed on those behaviors and responses when she became a parent, whether her partner was abusive or not. Your mother, then, learned to avoid upsetting her father or asking for things she wanted. As you grew up, you learned similar behaviors from your mother.

Trauma can also affect how you communicate.

A parent who suppresses the memory of painful experiences by refusing to talk to them can inadvertently teach you to bottle up unwanted or distressing emotions. When you reach adulthood, you might have a hard time communicating your feelings or talking about unpleasant situations.

Here's why hiding or brushing off your emotions generally doesn't help.

Trauma, whether you experience it directly or vicariously, can show up in many areas of daily life.

According to Tran, you might:

find it hard to get out of bed, no matter how much sleep you get

have trouble sleeping, or be afraid to sleep, because you're having nightmares

notice your old ways of coping no longer work effectively

use substances to numb discomfort and pain

notice increased rage, anger, irritability, sadness, grief, and loneliness, when before you never really felt or processed emotions

don't feel anything at all because you're so disconnected from yourself

find yourself ruminating frequently on critical, demanding, and shaming thoughts

experience physical symptoms like headaches, migraine, stomachaches, hot body temperature, and shakiness

As a result of these symptoms, you might begin to avoid your family and friends, have trouble at school or work, or find it difficult to even leave your house.

These effects can persist, but they might also subside and return over time. Eventually, they can begin to affect your day-to-day function, quality of life, and relationships with others.

"Relationships shape the quality of our lives. When our relationship with others and ourselves begin to disconnect and weaken to the point of isolation and withdrawal, this can be a sign to seek help," Tran emphasizes.

Environmental and relational experiences in early childhood can affect lifelong learning, memory, emotions, and behavior. Epigenetic changes can also play a part in a number of health and mental health conditions, including:

"Essentially, chronic or ongoing stress can change brain development and affect how the body responds to stress," Tran says.

Once you begin to recognize the signs of intergenerational trauma in your own life and behavior, you might wonder what steps you can take to keep history from repeating itself.

Acknowledging the signs and symptoms is an important place to start. Once you name and accept these experiences, you can begin addressing them.

"It's crucial to tend to emotional ailments just as you would a physical wound. The task can be daunting, but the outcome can offer a tremendous amount of relief," Torres says.

If you're working through intergenerational trauma, connecting with a mental health professional can have benefit.

A trauma-informed therapist can help you begin to heal by:

listening to your experiences

sharing insight into trauma responses

offering guidance with identifying possible coping skills and sources of support

Here's how to find the right therapist for you.

Therapy that doesn't address intergenerational trauma directly can still teach helpful skills, including strategies for communicating, processing emotions, and navigating relationship challenges. But when therapy doesn't explore your personal history, it may not prove as effective for healing trauma.

"A trauma-informed and resilience lens is crucial," Tran emphasizes. "It's moving from, 'What's wrong with you?' to 'What happened to you?' to 'How have you learned to survive?' and eventually 'What can we do to support your healing moving forward?'"

Beyond therapy

"Intergenerational trauma must also account for socio-environmental-political-cultural contexts such as racism, poverty, sexism, and xenophobia," Tran says.

"Therapy is only one way, but not the only way to heal from the impacts and legacies of trauma," he explains. "Reconnecting to your cultural wisdoms and knowledge is one step. What did your grandparents do to heal? What about your great-grandparents?"

He offers examples like:

song

dance and other movement

storytelling, art, and writing

religion and spirituality

other healing methods like reiki, qi gong, acupuncture, bodywork, massage, and healing circles

Both Torres and Tran emphasize the importance of including trusted loved ones, support groups, or supportive professionals in your healing work.

For more insight and guidance on steps forward, Tran recommends:

You may not be able to rewrite your genes or change your past, but you can certainly take steps to address your personal response to trauma and begin to heal.

If you can navigate distressing and unwanted experiences in more productive ways, you can later share these important skills with any children you have.

Even if financial barriers keep you from accessing mental health support, you still have options, including:

In search of tips for finding the right culturally competent therapist? Our guide can help.
Crystal Raypole writes for Healthline and Psych Central. Her fields of interest include Japanese translation, cooking, natural sciences, sex positivity, and mental health, along with books, books, and more books. In particular, she's committed to helping decrease stigma around mental health issues. She lives in Washington with her son and a lovably recalcitrant cat.

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Intergenerational Trauma: What It Is and How to Heal

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Traumatic experiences can take many forms. You might, for instance, find yourself facing long-term emotional distress after discovering a partner's infidelity, losing your sibling in a car accident, or coping with the sudden illness and death of a beloved pet. Yet certain types of trauma can have a far more profound impact.

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Someone who has experienced trauma might struggle to feel calm in situations that are objectively safe due to anxiety that another traumatic event will occur. When this occurs, the trauma response can be harmful rather than adaptive.

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Intergenerational trauma refers to trauma that is passed from a trauma survivor to their descendants. Read to learn more.

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Intergenerational Trauma: How Trauma Can Be Inherited

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Intergenerational Trauma: How Trauma Can Be Inherited

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This article helps to understand intergenerational trauma, the symptoms to look out for, and how you, the parent, and your child can help yourselves and future generations.

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Intergenerational Trauma: How Trauma Can Be Inherited

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Learn about intergenerational trauma, its symptoms, and how to break the cycle and heal from inherited trauma.

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Protective factors in intergenerational trauma: A mixed methods investigation of the role of holistic well-being and parental empowerment by parents’ gender

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Protective factors in intergenerational trauma: A mixed methods investigation of the role of holistic well-being and parental empowerment by parents’ gender

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Parents who have experienced trauma often experience symptoms and challenges that impact their children as well, potentially resulting in intergenerational trauma transmission. To help address intergenerational trauma, better understanding of strengths-based and holistic protective factors, as well as the interplay of gender and protective factors, can inform empowering interventions to support parents. This study used a convergent mixed methods design to explore the role of parents’ holistic well-being and parental empowerment in intergenerational trauma, with subsequent analysis of gender and fathers’ lived experiences

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Intergenerational trauma is associated with expression alterations in glucocorticoid- and immune-related genes

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Intergenerational trauma is associated with expression alterations in glucocorticoid- and immune-related genes

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Offspring of trauma survivors are more likely to develop PTSD, mood, and anxiety disorders and demonstrate endocrine and molecular alterations compared to controls. This study reports the association between parental Holocaust exposure and genome-wide gene expression in peripheral blood mononuclear cells (PBMC) from 77 Holocaust survivor offspring and 15 comparison subjects.

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Intergenerational trauma is associated with expression alterations in glucocorticoid- and immune-related genes - Neuropsychopharmacology

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Neuropsychopharmacology - Intergenerational trauma is associated with expression alterations in glucocorticoid- and immune-related genes

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A cultural framework for generational trauma

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A cultural framework for generational trauma

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In this article, they define intergenerational trauma as any traumatic experiences survived or actions perpetrated on communities or individuals that contribute to enduring biopsychosocial changes, including adverse repercussions for survivors or abusers, and direct, indirect or vicarious implications for their children and grandchildren, both within a culture and across cultures.

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A cultural framework for generational trauma

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With the right clinical framework, counselors can help clients identify and process the complex experiences of intergenerational trauma.

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Intergenerational trauma is when the original traumatic experience is transferred from parents to children, and then grandchildren and so on. This is thought to be a result of learnt behaviour and alternations to internal workings with biological changes in the body due to stress

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With trauma, a person fears for their own safety or the safety of a loved one. It can be anything from a loss of a parent, to experiencing or witnessing an assault, to being in a car accident.

Trauma can lead to PTSD (Post-traumatic stress disorder), a condition that requires professional treatment. The key sign of PTSD is that the person has difficulty doing the day-to-day things that they had done prior to a traumatic event.

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Childhood trauma can lead to physical and mental struggles later in life

Some people assume we forget or outgrow trauma. But the truth is, if someone experiences trauma as a child, it can lead to physical and mental struggles that affect their entire life.

Thomas O'Connor, director of the Wynne Center for Family Research at the University of Rochester Medical Center, and Kristen Holderle, UR Medicine's Clinic Director of the HEAL Collaborative, share the ways in which trauma affects the brain and body, how PTSD and trauma are related, and suggestions for healing.

What is the difference between trauma and PTSD?

With trauma, a person fears for their own safety or the safety of a loved one. It can be anything from a loss of a parent, to experiencing or witnessing an assault, to being in a car accident.

Trauma can lead to PTSD (Post-traumatic stress disorder), a condition that requires professional treatment. The key sign of PTSD is that the person has difficulty doing the day-to-day things that they had done prior to a traumatic event.

Symptoms of PTSD can include:

Flashbacks

Distressing intrusive thoughts

Avoiding things that remind you of the trauma

Feeling jumpy

Difficulty concentrating

Shutting down emotionally

Lack of interest in things you enjoyed before

Not everyone will experience a traumatic event the same (even those exposed to the same traumatic event may respond differently), and a traumatic event does not necessarily lead to PTSD.

"It's normal to react deeply to a stressful event," says Holderle. "If you're having a hard time, that doesn't mean something is wrong with you. It's important to normalize big feelings and big reactions."

Several factors can determine if experiencing a trauma will become a bigger problem and require help.

How can childhood trauma impact adulthood?

The impact of childhood trauma on life as an adult can depend on the environment in which the person was raised, how they coped with the trauma and supports that were available, and when in life the trauma occurred.

To determine risks of developing mental illness, addiction, and other conditions, it is now common to ask about past traumatic events using measures like the ACE (Adverse Childhood Experience). The higher a person's ACE score, the more likely it is that they will have negative physical or mental health outcomes.

"The studies suggest that this happens because early trauma affects stress response," Holderle says. "Your flight or fight response, your neurodevelopment, gets off track. It suggests that if you can intervene early, when someone has a childhood traumatic event, it could have a huge lasting impact on their life."

The earlier the intervention, the greater chance that treatment can help, especially for trauma early in childhood.

When a person develops behaviors to deal with an early childhood trauma, changing those habits later in life can be more difficult.

Can trauma impact physical health?

Yes. In addition to affecting mental health and coping mechanisms, trauma has been proven to affect physical health as well.

"Research has shown that the experience of trauma not only influences our thinking and behavioral patterns, but also our biology," says O'Connor. "Trauma influences our stress response system and may be associated with compromised immunity and poor cardiovascular health."

URMC scientists are also investigating how the effects of trauma may be passed on, such as the ways biological changes caused by trauma affect health in pregnancy. They are also exploring epigenetics, the study of how behavior and environment can affect the way genes work.

What can help with healing?

If someone you care about has experienced trauma, it can help to offer a listening ear and encourage that person to talk about, rather than avoid, the event.

"Sometimes trauma happens, and people feel scared to talk about it because they don't want to make it worse," says Holderle. "It's important to talk about. You might not be able to fix things, and that's okay."

Therapy can help a person make sense of the experience and move forward.

The type of therapy recommended will vary, but could include:

Trauma-focused cognitive behavioral therapy

Cognitive processing therapy

Written expressive therapy

Most therapists will focus on helping individuals separate themselves from the traumatic experience.

"A lot of the work we do is trying to help people even before the story that they make of the trauma is solidified," says Holderle. "We try to help with the narrative. We can't change our past, but we can change our relationship to it."

University of Rochester Medicine Mental Health Treatment

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Some people assume we forget or outgrow trauma. But the truth is, if someone experiences trauma as a child, it can lead to physical and mental struggles that affect their entire life.

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Childhood Trauma in Adults: Signs & How to Deal with It

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Childhood Trauma in Adults: Signs & How to Deal with It

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Childhood trauma doesn’t go away just because you grow up. There can be a long-term impact on mental health, relationships, and sense of self-worth. Fortunately, knowing the symptoms of childhood trauma in adults, the effect it can have, and how to treat it can help you heal from a painful past. Keep reading to learn more about childhood trauma in adults.

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Childhood Trauma in Adults: Signs & How to Deal — Talkspace

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Uncover the lasting effects and symptoms of childhood trauma in adults. Learn more about recognizing the signs and finding pathways to healing childhood trauma.

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Adult survivors of childhood trauma: Complex trauma, complex needs

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Adult survivors of childhood trauma: Complex trauma, complex needs

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Childhood trauma is common and can have profound consequences throughout a person’s life. Adult survivors of childhood abuse pose a number of challenges for general practitioners (GPs). The diagnosis of their medical and psychiatric illnesses is complex; the therapeutic relationship can be both delicate and critical to recovery; and the treatments are varied, often expensive and frequently inaccessible.

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Childhood trauma is common ¹ and can have profound consequences throughout a person's life (Box 1). ²⁻⁴ Although the total prevalence of childhood mistreatment is difficult to measure, it may be as high as 28%. ⁵ Trauma is more common in women ² and in population groups that have a higher incidence of cumulative or intergenerational trauma, such as refugees or Aboriginal and Torres Strait Islander communities. 6,7 The impact of childhood abuse is significant, comprising approximately 2% of the total disease burden. ² Cumulative trauma, where there are multiple adverse childhood experiences, leads to poorer health outcomes. ⁸

Box 1. What is childhood trauma, and how common is it?

Adverse childhood experiences (ACEs) is the term used to describe all types of abuse, neglect, and other potentially traumatic experiences that occur to people under the age of 18 years.

ACEs have been linked to risky health behaviours, chronic health conditions, low life potential and early death.

As the number of ACEs increases, so does the risk for these outcomes. The presence of ACEs does not mean that a child will experience poor outcomes.

The definition of child abuse and neglect can be found on the Centers for Disease Control website ( www.cdc.gov/violenceprevention/pdf/CM_Surveillance-a.pdf).

The definition of and diagnostic requirements for complex post-traumatic stress disorder (PTSD) can be found on the International Classification of Diseases website ( https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/585833559).

Note that complex PTSD is a new diagnosis in the International Classification of Diseases, 11th Revision, and was endorsed by the member nations of the World Health Organization in May 2019, due to come into effect from 1 January 2022.

Prevalence of childhood trauma
A systematic review of Australian research estimates prevalence rates of childhood sexual abuse are approximately 8.6%, physical abuse 8.9%, emotional abuse 8.7% and childhood neglect 2.4%. ²

Multiple forms of trauma can occur, and cumulative trauma is more damaging than single-episode trauma. ³ Trauma may or may not be deliberate: a young child with leukaemia may experience hospitalisations as deeply traumatic despite no intent to harm on the part of the caregivers. Not all trauma is mistreatment.

General practice management of adult survivors of childhood trauma

Adult survivors of childhood abuse pose a number of challenges for general practitioners (GPs): the diagnosis of their medical and psychiatric illnesses is complex; ⁹ the therapeutic relationship can be both delicate and critical to recovery; ¹⁰ and the treatments available are varied, often expensive and frequently inaccessible. 11,12 Medicare Benefits Schedule rebates favour short consultations, and this makes mental healthcare in general practice financially difficult. ¹³ Given the prevalence of childhood trauma, many GPs will have their own trauma histories, which complicates the therapeutic relationship. ¹⁴ Vicarious trauma is common, ⁹ and GPs frequently feel unsupported and uncertain about how best to manage the distress that can be associated with trauma. ¹⁵ Many GPs may still be developing their capacity to 'sit with uncertainty' and to support a patient in distress without attempting to 'fix the problem'. ¹⁶ The combination of these factors means that it may be difficult to manage such a sensitive and traumatic issue appropriately.

It can be challenging for survivors of childhood trauma to directly disclose; it may take up to decades for some to do so, if they do so at all. ¹⁷ Instead, patients may present with conscious or subconscious manifestations of distress: somatic, psychiatric, psychological or social. These consultations require listening to both the overt distress and the 'underneath story' of trauma and recovery. The following are typical symptoms for adult survivors of childhood trauma (Table 1). Figure 1 summarises the features of complex post-traumatic stress disorder (PTSD), one diagnostic formulation for the consequences of childhood abuse. 18,19

Table 1. Common symptomatology seen in survivors of childhood trauma linked to intervention

Somatic symptoms
Medically unexplained symptoms

Syndromes such as irritable bowel syndrome, chronic fatigue and fibromyalgia

Chronic pain

Consequences of maladaptive coping (eg substance abuse, eating disorders)

May be associated with strong emotional states

Validation of the patient's physical distress and appropriate investigation

Psychoeducation regarding the psychological awareness of the link between symptoms and situation

Emotional dysregulation
Irritability and chronic hyperarousal

Recurrent or chronic suicidal ideation
Self-harm

Maladaptive coping strategies (eg addictions, eating disorders)

Distress regulation*

Psychoeducation regarding the psychological awareness of the link between distress and situation

Interpersonal instability
Re-enacting unhelpful relationships from the past (eg becoming abusive themselves, or partnering with an abusive partner)

Poor parenting skills

Modelling of appropriate attachment
Offering a stable and supportive therapeutic relationship

Avoidance
Gaps in the history-taking or the story
Diversion or distraction associated with a specific theme

Behaviours associated with avoidance. These may include substance use, eating disorders or disruptive behaviours. Avoidant behaviours may also be traditionally considered as 'positive' behaviours until they become maladaptive. An example could include distraction into work rather than addressing the issues most triggering the emotional distress.

Validation and acknowledgement of the patient's distress and what they have been able to achieve

Supportive therapy to build on other resiliences

Exposure therapy, once the patient is ready

Note: If a person is using avoidance as a coping mechanism, they may be feeling too overwhelmed at this point of time. Go slow. Engaging the patient may require identification of what they are avoiding; drawing links between the distress and current management style (avoidance); and exploration of alternatives. This should be patient centred, or otherwise risks alienating the patient.

Re-experiencing and dissociation
Post-traumatic stress disorder symptoms, including nightmares, flashbacks and re-experiencing

Flashbacks may be predominantly emotional (ie feeling acutely distressed, anxious or fearful for no apparent reason and with no obvious narrative)

Dissociation, where survivors lose track of time and place, or have an intense experience of depersonalisation or derealisation

Distress regulation

Exposure therapy

Disorders of memory
Fragmented memories from childhood

Psychoeducation

Distress regulation

Shame
Poor sense of self, including beliefs that they are fundamentally defective, toxic or worthless

Establishment of values and appropriate
goal setting †

*Further ways to manage distress regulation are considered in Box 2. Asking difficult questions - Identifying a person's strengths and supports.
†Achieving a sense of purpose or meaning is an important aspect of self-actualisation. This concept is known by various names in different forms of psychotherapy. For example, in cognitive behavioural therapy, it can be called 'schema therapy'. In acceptance and commitment therapy, it can be the 'values' and 'goal setting' arms of therapy. The goal of psychodynamic therapy is for the patient come to an understanding of their sense of purpose or meaning through exploration of their self-belief within a consistent, respectful and empathic therapeutic relationship. Self-actualisation and changing belief settings may only be possible once other needs, such as safety and security, are met.

Figure 1. A model of complex post-traumatic stress disorder with potential general practice interventions18,19 Click here to enlarge Adapted from the International Society for Traumatic Stress Studies guidelines and the World Health Organization's International Classification of Diseases, 11th Revision
Somatic symptoms

There is increasing understanding of the neurobiological changes apparent in survivors of childhood abuse, 20-22 and there is also increasing understanding of the somatic consequences of chronic stress. ²³ For these reasons, it is important to explore trauma histories in patients with complex and chronic illness, particularly when illnesses are ill-defined or contain mixed emotional and physical symptoms. 21,24,25 Presentations of somatic symptoms are outlined in Table 1.

Emotional dysregulation

Survivors may find it more difficult to regulate their emotions when they are under stress ²⁶ or re-experiencing a sense of powerlessness. Because of the intensity of their emotional experience, and the poor sense of self that often follows childhood trauma, these patients may have recurrent or chronic suicidal ideation and self-harm. 7,21 Children who grow up in abusive families often have little opportunity to learn healthy emotional coping skills and may learn to manage strong emotions in unhelpful ways (Box 2).

Box 2. Asking difficult questions

As a result of the disordered memory associated with childhood trauma, it can be challenging to ask appropriate questions. Many adults who have experienced severe trauma will not remember or recognise their childhood as abusive.

Asking difficult questions about adverse childhood experiences

Useful questions include:

'Was your home a safe and secure place?'

'What were you like as a young child?' (Children who have been abused often have a highly negative self-image of themselves, such as 'My mother said I was born angry' or 'I was ugly and everyone said I was stupid'.)

'Were you asked to keep any secrets as a child?'

'What happened when you were punished as a child?'

'Did anything happen to you in childhood that hurt you?'

'Did anything happen around you that made you feel unsafe?'

'Was there someone you could turn to when life was difficult?'

Identifying a person's strengths and supports

What coping strategies have they found helpful in the past?

If the coping strategies are maladaptive (eg substance abuse, food restriction/purging, self-harm or other risky behaviour), then explore further until a coping strategy that is less maladaptive has been identified.

Potential coping strategies include lifestyle factors (sleep, exercise, diet), distraction, connection with others, pursuing meaning and purpose in life (eg meaningful work, volunteering, advocacy, caring for others), creative pursuits and various forms of therapy.

Whom have they found helpful in the past?

Troubleshooting involves the following types of questions:

At times when support can be variable, what factors have made the support more helpful?

At times when there are limited personal supports, what professional supports have been helpful in the past?

If the patient does not think the supports (personal and/or professional) have been helpful in the past, what type of support do they need now? The aim is to help them construct a list that is specific and achievable. This may take some time; trust will develop slowly.

Identifying a person's strengths and supports can assist the person with emotional dysregulation to identify coping strategies that are more helpful.

Interpersonal instability

Interpersonal difficulties can arise as a result of disordered attachment and modelling of relationships. 7,27 Symptoms may be more predominant at important life events such as marriage, pregnancy and childbirth. When abuse occurs within the family, or in another trusted group of adults (eg school, religious institution, sporting club), the trauma is compounded by betrayal of trust. 28,29 In betrayal trauma, symptoms are more likely to be severe, and survivors often lose their capacity to detect unsafe behaviours into adulthood. ³⁰ For this reason, they are more likely to stay in unsafe relationships.

Disorders of memory

There is evidence that children who experience trauma have fragmentation of their memories of childhood. ³¹ Disorders of memory can make understanding and validating trauma extremely difficult. When taking a history, it is important to respect this fragmentation. The goal is not to reconstruct the facts but to understand and manage the consequences. Most survivors will be able to articulate that childhood was distressing, even if they cannot give a clear narrative of their childhood experience. This is most common in patients who experienced trauma at a very young age (ie younger than five years of age). ³² It is more likely that patients will be unable to articulate their distress the younger they were when exposed, and the more prolonged and persistent their experience, particularly if their experience occurred in the absence of other positive childhood experiences and attachment figures. Dissociation can still occur even if the event occurs after adolescence, especially the more significant the intrusiveness of the event, and if there is a pronounced experience of helplessness.

Re-experiencing and dissociation

PTSD is common in patients with a history of childhood trauma. However, when trauma occurs in childhood, the flashbacks may well be experienced as a flood of emotion, disconnected from the narrative in which the trauma originally arose. ²⁷ This is partly due to fragmentation of memory. 31,33 As a result, survivors may struggle to identify triggers, and so may misinterpret re-experiencing as panic attacks or hallucinations. Re-experiencing (Table 1) may be predominantly emotional (feeling acutely distressed, anxious or fearful for no apparent reason and with no obvious narrative) or somatic (medically unexplained symptoms; syndromes such as irritable bowel syndrome, chronic fatigue and fibromyalgia; chronic pain; consequences of maladaptive coping such as substance abuse, eating disorders). Avoidance of the feelings or sensations may create a sense of being disembodied or distant from the experience (dissociation). Many people will find this experience difficult to talk about or describe, so it will require careful supportive questioning (Box 2) to elicit these experiences if this information is crucial to recovery.

Avoidance

Adults may also carry coping strategies that were helpful in childhood into adulthood, including avoidance or the tendency to dissociate during stress. 26,34 Intense somatic and emotional symptoms and a sense of loss of control over these sensations are understandably feelings that the person often seeks to avoid. This can become even more confusing when there is cognitive impairment or triggers are perceived to be unpredictable. At an unconscious level, the person may not be able to identify the emotional distress occuring and may report dissociative symptoms. There is high comorbidity with complex PTSD and substance use, and there is evidence for managing the complex PTSD and substance use concurrently. ³⁵

The person may seek to avoid the unpleasant experiences by rerouting their sense of chaos to something they feel they can control; this can give rise to unhelpful behaviours such as comorbid eating disorders. ³⁶ Alternatively, they may redirect to productive actions and be extremely successful in other aspects of life. Avoidance may be the only defence the person has developed to cope with the unpleasant experiences they have had. Box 2 explores how to ask about this and build on alternative ways of coping.

Shame

One of the most painful symptoms of early childhood trauma is a pervasive sense of shame. ²⁷ A healthy sense of self is established early in childhood and developed through constant reinforcement by significant attachment figures in a child's life. If a child is abused at a young age, they tend to believe they deserve it. This may be reinforced if the abuser implies the trauma is the child's fault or if the child is not believed by other family members. This pervasive sense of shame can be difficult to shift; it is not unusual for a survivor to be valued, successful and respected but still carry a deep burden of shame.

Diagnosis

Given the complexity of symptomatology experienced by survivors, many will have acquired a raft of diagnoses, including depression, anxiety, panic disorder, psychosis and borderline personality disorder. This is confusing for patients and their GPs. However, symptoms can be clustered together to form a unifying diagnosis of complex PTSD, now listed in the International Classification of Diseases, 11th Revision (ICD-11). ¹⁹ This type of PTSD is 'complex' because of the developmental consequences of early trauma; a child is developing their core sense of self, learned behaviour, expectations of relationships and neurological system, and all this is disrupted by trauma.

It is important to note the crossover of borderline personality disorder and complex PTSD. Many patients with complex PTSD will have previously been diagnosed with borderline personality disorder and experienced the stigma associated. ³⁷ There is increasing awareness of the role of trauma underlying the pathophysiology of symptoms for those people, and thus the change to the diagnosis of complex PTSD. There have also been marked changes in the classification of personality disorder in ICD-11, but not yet in the Diagnostic and Statistical Manual of Mental Disorders, from categorical to dimensional descriptors. ICD-11 now focuses on the severity of personality disorder rather than on the type of personality dysfunction. ³⁸ This can then be further classified by traits. Consequently, a person with complex PTSD may have severe personality disorder or no personality disorder, where they have persistent feelings of shame or poor self-worth that do not affect functioning.

Managing complex PTSD: The story underneath

Disclosure of the trauma story underneath is more likely if the consultation is undertaken in an empathic, non-judgemental style. ³⁹ However, trauma can also affect consultation dynamics. There may be normalisation in groups where complex PTSD is prevalent, and other organisational barriers such as language and access to services. In people of Aboriginal and Torres Strait Islander background, previous stigmatisation and trauma by people in authority may negatively affect trust within the clinician relationship. This becomes more significant when issues of child safety and potential removal are raised. ⁴⁰ Many of these patients struggle with emotional dysregulation and poor interpersonal skills, so they can be defensive, angry and even abusive themselves. This can trigger a strong emotional reaction in their clinicians. ⁴¹ For self-care, and for the benefit of the therapeutic relationship, it is important that health practitioners are mindful of and carefully manage their own emotional responses.

Recovery requires rehabilitation of the sense of self. This involves not only sharing an understanding of how trauma affects the mind and body, but also the experience of empathy, respect, validation and compassion: what Rogers called 'unconditional positive regard'. ⁴² GPs are uniquely placed to provide this reparative relationship, demonstrating to patients that they are worthy of time, respect and empathy.

Time is a significant barrier in general practice, and GPs may consciously or unconsciously avoid starting the conversation for fear of the 'Pandora's box': 43,44 opening up trauma they feel unable to manage. Clinicians may also carry assumptions about their patients, particularly if the patient seems to be high functioning. Patients can have significant psychological disability and still appear quite high functioning: some patients manage their trauma by overachieving in the workplace.

When to intervene

Intervention is helpful if there is functional impairment or significant distress and the patient is ready to address this. Common presentations that may guide intervention styles are summarised in Box 3.

Box 3. Common presentations of complex post-traumatic stress disorder that inform intervention style

The informative patient

The informative patient may be more psychologically aware of the link between their symptomatology and complex post-traumatic stress disorder. They may be 'matter of fact' and report in explicit detail.

There is a risk of 'emotional backlash', where the retelling of the story may
be re-traumatising.

The focus of intervention is prioritisation of issues to allow this to guide timeframes for each intervention.

The distressed patient

Maladaptive coping styles in response to the distress are predominant.

The aim of treatment is for the patient to establish the link between their trauma and symptoms. It is critical that the health practitioner acknowledges the trauma and validates the patient's experience.

The focus of intervention is on emotional regulation and distress tolerance.

The avoidant patient

The avoidant patient may present with unrelated matters, often frequently. Queries are often met with topic change. In this situation, it is important for the general practitioner to progress slowly.

It is important for practitioners to identify that the patient is distressed by something and offer them support. Avoidant patients can be understood as 'emotional pre-contemplators': they may not be ready to address their trauma with a health practitioner, and need gentle, persistent support to feel safe to disclose.

The focus of intervention is on psychological awareness and distress tolerance.

Figure 2 considers a stepwise approach that outlines how these presentations may inform management.

Therapies used for complex PTSD

Psychotherapies for the management of complex PTSD that are supported by evidence include modified cognitive behavioural therapies such as dialectical behaviour therapy and some psychodynamic therapies (Figure 2). ⁴⁵ For many patients with complex PTSD, particularly in rural and remote contexts, the GP may provide the only supportive relationship they have. ⁴⁶ GPs can enhance positive supports and promote resilience ⁴⁷ while providing a long-term, empathic therapeutic relationship. Supportive therapies include art, yoga, exercise, community engagement, music and behavioural activation.

Figure 2. Roadmap to recovery: A flowchart for the management of adult survivors of childhood trauma. Click here to enlarge
Medications such as selective serotonin re-uptake inhibitors, antipsychotics and sedatives can target distress regulation. People experiencing significant psychological distress often request pharmacotherapy, but the greater the distress, the more likely there may be anxiety associated with the medication and its reported side effects. Therefore, patients may need considerable support when initiating or changing medication.

How to select the right therapy

It can seem overwhelming to manage patients with PTSD when multiple issues are present and when management options are uncertain. Focusing therapy on the predominant issues presenting at the time engages the person in their own care plan (Figure 1). Needs can constantly change. It is better to foster empowerment through small successes than overwhelm with failures. Comorbidity is common and should be considered in the therapy paradigm.

Therapy should be guided by the individual's values, capacity and needs. When there are multiple issues occurring, a model such as Maslow's hierarchy can help with prioritisation. Physiological needs are more critical than self-actualisation, so addressing core beliefs and values may need to be delayed until the patient has safe shelter and food security. Targeted management options are discussed in Figures 1 and 2.

Recovery includes addressing social and environmental circumstances, as well as fostering connectedness, self-compassion and a sense of purpose or meaning. A recovery journey may result in a greater number of adaptive strategies, but it may also include poor choices or unhealthy relationships. As part of risk management, it is appropriate to voice when unsafe behaviours occur. However, if the patient has capacity to choose, then decisions are ultimately their own. By being open and non-judgemental, GPs can encourage patients to be more open to reconsidering their choices in the future.

Implications for practice

There is increasing awareness of the role of GPs in the care of a person who has experienced childhood adversity. GPs can be effective and facilitate recovery-orientated, trauma-focused care, even when local services are limited.

Key principles include listening and engaging to understand why the person is presenting in this way and approaching care in a targeted and collaborative approach. This can alleviate emotional distress for the person, GP and care team.

To ensure long-standing continuity of care and ongoing therapeutic alliance, the clinician must also ensure that their own care needs are met, even while caring for others. While it can be rewarding working with survivors of trauma towards recovery, it can also be complex and challenging, especially in a practice with limited other supports and services. Much of this article has discussed factors within the GP-patient interaction that can enhance the recovery journey and therapeutic relationship. The organisational team that surrounds the care team, including the interactions and support of the non-clinical team, will also have an impact on the recovery journey. The non-clinical (and clinical) support team may benefit from additional guidance relating to the principles discussed in this article. Scheduling more frequent regular appointments of appropriate duration, particularly during crisis periods, may allow the patient to hold their emotional distress until the next scheduled appointment, reducing the frequency of 'unanticipated crisis'. There will be times when personal resources will be stretched. At this time, support is available through doctors' health and advisory services, which are available in each Australian state and territory and outlined in the Resources section of this article. As part of ongoing personal care, it is important that GPs have the space and time for activities that foster wellbeing, including personal reflection. This can include mentor or peer support groups, formal or informal. This may need to be deliberately scheduled or structured, especially as resources become stretched and there are greater competing demands. Balint groups are peer support groups that focus on the clinical relationship. ⁴⁸ They can be run locally or by teleconference.

GPs can make a difference in the recovery journeys of patients with complex PTSD. Improved understanding and facilitation of the recovery journey can decrease the emotional distress of all involved in that recovery journey, including the patient and healthcare provider.

Resources

The Royal Australian College of General Practitioners. Abuse and violence: Working with our patients in general practice. 4th edn. East Melbourne, Vic: RACGP, 2014. Available at www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/white-book

Marel C, Mills KL, Kingston R, et al. Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings. 2nd edn. Sydney: Centre of Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales, 2016. Available at https://extranet.who.int/ncdccs/Data/AUS_B9_Comorbidity-Guidelines-2016.pdf

Blue Knot Foundation: National Centre for Complex Trauma. Available at www.blueknot.org.au

Project Air: A Personality Disorders Strategy. Strategy for personality disorders. Wollongong, NSW: University of Wollongong, 2019. Available at www.projectairstrategy.org

1800RESPECT: National Sexual Assault, Domestic Family Violence Counselling Service. Greenway, ACT: DSS, 2016. Available at www.1800Respect.org.au

Balint Society of Australia & New Zealand. Peer support groups can be run locally or by teleconference. Available at www.balintaustralianewzealand.org

DRS4DRS. Doctors' health and advisory services exist for doctors and medical students, available in each Australian state and territory. Barton, ACT: Doctors' Health Services, 2019. Available at www.drs4drs.com.au/getting-help

Australasian Doctors' Health Network. St Leonards, NSW: Doctors Health Advisory Service, 2020. Available at www.adhn.org.au

References

1. Stoltenborgh M, Bakermans-Kranenburg MJ, Alink LRA, van Ijzendoorn MH. The prevalence of child maltreatment across the globe: Review of a series of meta-analyses. Child Abuse Review 2015;24(1):37-50. doi: 10.1002/car.2353. Search PubMed

2. Moore SE, Scott JG, Ferrari AJ, et al. Burden attributable to child maltreatment in Australia. Child Abuse Negl 2015;48:208-20. doi: 10.1016/j.chiabu.2015.05.006. Search PubMed

3. Kezelman C, Hossack N, Stavropoulos P, Burley P. The cost of unresolved childhood trauma and abuse in adults in Australia. Milsons Point, NSW: Blue Knot Foundation, 2015. Search PubMed

4. Royal Commission into Institutional Child Sexual Abuse. Final Report. Barton, ACT: Royal Commission into Institutional Child Sexual Abuse, 2017. Search PubMed

5. Child Family Community Australia. The prevalence of child abuse and neglect. Southbank, Vic: Australian Institute of Family Studies, 2017. Search PubMed

6. Atkinson J. Trauma trails, recreating song lines: The transgenerational effects of trauma in Indigenous Australia. North Melbourne, Vic: Spinifex Press, 2002. Search PubMed

7. Kirmayer LJ, Lemelson R, Barad M. Understanding trauma: Integrating biological, clinical, and cultural perspectives. Cambridge: Cambridge University Press, 2007. Search PubMed

8. Felitti VJ, Anda RF, Nordenberg D, et al. REPRINT OF: Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. Am J Prev Med 2019;56(6):774-86. doi: 10.1016/j.amepre.2019.04.001. Search PubMed

9. Hensel JM, Ruiz C, Finney C, Dewa CS. Meta-analysis of risk factors for secondary traumatic stress in therapeutic work with trauma victims. J Trauma Stress 2015;28(2):83-91. doi: 10.1002/jts.21998. Search PubMed

10. Liotti G. Trauma, dissociation, and disorganized attachment: Three strands of a single braid. Psychotherapy (Chic) 2004;41(4):472-86. doi: 10.1037/0033-3204.41.4.472. Search PubMed

11. Rosenberg SP, Hickie IB. The runaway giant: Ten years of the Better Access program. Med J Aust 2019;210(7):299-301.e1. doi: 10.5694/mja2.50068. Search PubMed

12. Meadows GN, Enticott JC, Inder B, Russell GM, Gurr R. Better access to mental health care and the failure of the Medicare principle of universality. Med J Aust 2015;202(4):190-94. doi: 10.5694/mja14.00330. Search PubMed

13. Hutton C, Gunn J. Do longer consultations improve the management of psychological problems in general practice? A systematic literature review. BMC Health Serv Res 2007;7:71. doi: 10.1186/1472-6963-7-71. Search PubMed

14. Zerubavel N, Wright MO. The dilemma of the wounded healer. Psychotherapy (Chic) 2012;49(4):482-91. doi: 10.1037/a0027824. Search PubMed

15. Coles J, Dartnall E, Astbury J. 'Preventing the pain' when working with family and sexual violence in primary care. Int J Family Med 2013;2013:198578. doi: 10.1155/2013/198578. Search PubMed

16. Stone L. Reframing chaos - A qualitative study of GPs managing patients with medically unexplained symptoms. Aust Fam Physician 2013;42(7):501-02. Search PubMed

17. Lee A, Coles J, Lee S, Kulkarni J. Women survivors of child abuse - Don't ask, don't tell. Aust Fam Physician 2012;41(11):903-06. Search PubMed

18. International Society for Traumatic Stress Studies Guidelines Committee. ISTSS guidelines position paper on complex PTSD in adults. Oakbrook Terrace, IL: International Society for Traumatic Stress Studies, 2019. Search PubMed

19. World Health Organization. International Classification of Diseases, 11th Revision (ICD-11). Geneva: World Health Organization, 2019. Available at www.who.int/classifications/icd/en [Accessed 17 January 2020]. Search PubMed

20. Lu S, Gao W, Wei Z, et al. Intrinsic brain abnormalities in young healthy adults with childhood trauma: A resting-state functional magnetic resonance imaging study of regional homogeneity and functional connectivity. Aust N Z J Psychiatry 2017;51(6):614-23. doi: 10.1177/0004867416671415. Search PubMed

21. Van der Kolk BA. The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Penguin Books, 2015. Search PubMed

22. Kreidler M, Kurzawa C. Trauma spectrum disorders: Clinical imperatives. J Psychosoc Nurs Ment Health Serv 2009;47(11):26-33. doi: 10.3928/02793695-20090930-02. Search PubMed

23. Baumeister D, Akhtar R, Ciufolini S, Pariante CM, Mondelli V. Childhood trauma and adulthood inflammation: A meta-analysis of peripheral C-reactive protein, interleukin-6 and tumour necrosis factor-α. Mol Psychiatry 2016;21(5):642-49. doi: 10.1038/mp.2015.67. Search PubMed

24. Van der Kolk BA. Assessment and treatment of complex PTSD. In: Yehuda R, editor. Treating trauma survivors with PTSD. Washington, DC: American Psychiatric Publishing, 2002; p. 127-56. Search PubMed

25. Van der Kolk BA, McFarlane AC, Weisaeth L. Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press, 2007. Search PubMed

26. Herman JL. Trauma and recovery: The aftermath of violence - From domestic abuse to political terror: New York: Basic Books, 2015. Search PubMed

27. Fisher J. Healing the fragmented selves of trauma survivors: Overcoming internal self-alienation. New York: Routledge, 2017. Search PubMed

28. Birrell P, Freyd J. Blind to betrayal: Why we fool ourselves we aren't being fooled. Hoboken, NJ: John Wiley & Sons, 2013. Search PubMed

29. Smith CP, Freyd JJ. Institutional betrayal. Am Psychol 2014;69(6):575-87. doi: 10.1037/a0037564. Search PubMed

30. Birrell PJ, Freyd JJ. Betrayal trauma: Relational models of harm and healing. J Trauma Pract 2006;5(1):49-63. doi: 10.1300/J189v05n01_04. Search PubMed

31. Levine PA. Trauma and memory: Brain and body in a search for the living past: A practical guide for understanding and working with traumatic memory. Berkeley, CA: North Atlantic Books, 2015. Search PubMed

32. Vonderlin R, Kleindienst N, Alpers GW, Bohus M, Lyssenko L, Schmahl C. Dissociation in victims of childhood abuse or neglect: A meta-analytic review. Psychol Med 2018;48(15):2467-76. doi: 10.1017/S0033291718000740. Search PubMed

33. Platt MG, Luoma JB, Freyd JJ. Shame and dissociation in survivors of high and low betrayal trauma. J Aggress Maltreat Trauma 2017;26(1):34-49. doi: 10.1080/10926771.2016.1228020. Search PubMed

34. Herman JL. Shattered shame states and their repair. Shattered states: Disorganised attachment and its repair. 2012:157-70. Search PubMed

35. Najavits LM, Hien D. Helping vulnerable populations: A comprehensive review of the treatment outcome literature on substance use disorder and PTSD. J Clin Psychol 2013;69(5):433-79. doi: 10.1002/jclp.21980. Search PubMed

36. Sommer JL, Mota N, El-Gabalawy R. Maladaptive eating in posttraumatic stress disorder: A population-based examination of typologies and medical condition correlates. J Trauma Stress 2018;31(5):708-18. doi: 10.1002/jts.22323. Search PubMed

37. Cloitre M, Garvert DW, Weiss B, Carlson EB, Bryant RA. Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. Eur J Psychotraumatol 2014;5(1):250-97. doi: 10.3402/ejpt.v5.25097. Search PubMed

38. Bach B, First MB. Application of the ICD-11 classification of personality disorders. BMC Psychiatry 2018;18(1):351. doi: 10.1186/s12888-018-1908-3. Search PubMed

39. The Royal Australian College of General Practitioners. Abuse and violence: Working with our patients in general practice. 4th edn. East Melbourne, Vic: RACGP, 2014. Search PubMed

40. Purdie N, Dudgeon P, Walker R. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. Canberra: Department of Health and Ageing, 2010. Search PubMed

41. Dalenberg CJ. Maintaining the safe and effective therapeutic relationship in the context of distrust and anger: Countertransference and complex trauma. Psychotherapy (Chic) 2004;41(4):438-47. doi: 10.1037/0033-3204.41.4.438. Search PubMed

42. Rogers CR. A theory of therapy, personality, and interpersonal relationships: As developed in the client-centered framework. New York: McGraw-Hill, 1959. Search PubMed

43. Cushman R. Getting beyond 'pandora-phobia'. Fam Syst Health 2014;32(1):130-32. doi: 10.1037/fsh0000025. Search PubMed

44. Townsend JM. One last question: Opening Pandora's box? Ann Fam Med 2009;7(2):176-77. doi: 10.1370/afm.948. Search PubMed

45. Ehring T, Welboren R, Morina N, Wicherts JM, Freitag J, Emmelkamp PM. Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clin Psychol Rev 2014;34(8):645-57. doi: 10.1016/j.cpr.2014.10.004. Search PubMed

46. Kezelman C, Hossack N, Stavropoulos P, Burley P. The cost of unresolved childhood trauma and abuse in adults in Australia. Sydney: Adults Surviving Child Abuse and Pegasus Economics, 2015. Search PubMed

47. Poole JC, Dobson KS, Pusch D. Childhood adversity and adult depression: The protective role of psychological resilience. Child Abuse Negl 2017;64:89-100. doi: 10.1016/j.chiabu.2016.12.012. Search PubMed

48. Benson J, Magraith K. Compassion fatigue and burnout: The role of Balint groups. Aust Fam Physician 2005;34(6):497-98. Search PubMed

# data[].attributes.attachment_link.description
Childhood trauma is common 1 and can have profound consequences throughout a person's life (Box 1). 2-4 Although the total prevalence of childhood mistreatment is difficult to measure, it may be as high as 28%.

# data[].attributes.headline
Childhood Trauma & Its Lifelong Impact: 12 Resources

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Childhood Trauma & Its Lifelong Impact: 12 Resources

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Childhood trauma can significantly impact mental & emotional development, leading to challenges in behavior & relationships.

Healing from trauma involves creating a safe environment, fostering trust & promoting open communication for emotional recovery.

Professional support & therapeutic interventions are vital in helping children & adults process trauma & build resilience.

# data[].attributes.attachment_link.title
Childhood Trauma & Its Lifelong Impact: 12 Resources

# data[].attributes.attachment_link.description
By better understanding childhood trauma, therapists can recognize its signs and guide clients on a path toward healing and resilience.

# data[].attributes.headline
The Impact of Childhood Trauma on Adult Functioning

# data[].attributes.subject
The Impact of Childhood Trauma on Adult Functioning

# data[].attributes.body
The effects of childhood trauma are often longstanding and chronic. Adult survivors of complex childhood trauma can struggle with processing what they survived in childhood, which can lead to a host of emotional, psychological, and physical symptoms. Equally common are histories of toxic romantic relationships, poor choices in friends, and patterns of self-sabotage based on shame and guilt for what they survived.

# data[].attributes.attachment_link.title
The Impact of Childhood Trauma on Adult Functioning

# data[].attributes.attachment_link.description
Adult survivors of complex childhood trauma can struggle with processing what they survived which can lead to a host of emotional, psychological, and physical symptoms.

# data[].attributes.body
The developing brain learns through experience what is safe or unsafe and how to deal with the world’s challenges. When a child experiences traumatic events, the effects on their neurology and emotional well-being can last longer than the event itself.

In the United States, 63.9% of adults can recall adverse childhood experiences (ACEs)–the formal term for a potentially traumatic childhood event, such as child abuse or neglect. More than 17% can recall four or more childhood traumatic experiences.¹ With so many people who are childhood trauma survivors, it’s essential to understand and recognize how it affects a person’s everyday life in adulthood.

This post details eight common symptoms of childhood trauma, and what traumatized adults need to begin healing.

# data[].attributes.attachment_link.readable_text
The developing brain learns through experience what is safe or unsafe and how to deal with the world's challenges. When a child experiences traumatic events, the effects on their neurology and emotional well-being can last longer than the event itself.

In the United States, 63.9% of adults can recall adverse childhood experiences (ACEs)-the formal term for a potentially traumatic childhood event, such as child abuse or neglect. More than 17% can recall four or more childhood traumatic experiences. ¹ With so many people who are childhood trauma survivors, it's essential to understand and recognize how it affects a person's everyday life in adulthood.

This post details eight common symptoms of childhood trauma, and what traumatized adults need to begin healing.

Children need a safe environment and trusted adults to help them learn self-soothing and emotional regulation. Because survivors of childhood trauma experienced disruptions in this aspect of development, they often struggle to process intense feelings and have difficulty calming down.

Childhood trauma victims are often unable to name their emotions or work through them. Some have the default response of internalizing, directing those feelings inward with emotional or physical self-harm. Others externalize their reactions, "acting out" against the world even long after the childhood trauma. ²

One of the most common signs of childhood trauma is an inability to maintain healthy relationships. Mistreatment, neglect and violence teach children that family members are not the secure base they should be, and those lessons lead to insecure or disorganized attachment styles. ³

Relationship-related childhood trauma symptoms can range from "chasing" people in a desperate bid for connection to pushing people away for fear of closeness. ⁴

When a child experiences a traumatic event, their brain may learn to protect itself by disconnecting from reality. This disconnection allows the mind to escape when the body cannot. Clinicians refer to this trauma response as "dissociation."

For some survivors of complex trauma, dissociation becomes a go-to coping mechanism. Seeking to escape emotional numbness and detach from traumatic childhood memories, they detach from reality. ⁵

Experts have linked repeated dissociation with repressed memories, which some clinicians refer to as dissociative amnesia. The nervous system "seals off" an early traumatic memory, though some adult survivors recover those memories of childhood trauma. ⁶

Not all survivors who dissociate will have repressed childhood memories. Some use dissociation to escape memories of traumatic events and the associated chronic stress, often as an alternative to constructive coping. ⁷

Mental health disorders are pervasive among childhood trauma survivors. Like post-traumatic stress disorder, anxiety disorders are particularly prevalent, as the traumatized childhood brain has learned to fear a world that should be safe.

This heightened sensitivity can present in various ways, from panic attacks to generalized anxiety disorder. ⁸ Studies show that survivors of early emotional trauma are 1.9 to 3.6 times more likely to develop anxiety disorders in adulthood, with social anxiety symptoms being a particular risk. ⁹

Research also shows that mistreated children are up to 3.73 times more likely to develop depression in adulthood. Survivors are particularly likely to develop severe, chronic and treatment-resistant depression. ¹⁰

Adults with childhood trauma-related anxiety or depression may experience mental and physical symptoms. People with these mental illnesses often describe physical sensations such as low back pain, headaches and digestive disorders. ¹¹ Mood swings are common with both diagnoses. ¹²

Trauma is never a child's fault, yet persistent guilt and shame are common childhood trauma symptoms. Children and adults look back on traumatic experiences and childhood abuse, wondering if they somehow deserved it or could have done more to stop it. ¹³ A child's mind, needing love and protection, cannot accept that their caregivers are dangerous, so these children take the blame on themselves.

Though factually inaccurate, these beliefs often follow a child into adulthood, when ingrained traumatic memories make self-blame part of the person's mental model. Part of healing childhood trauma is learning to accept that the adults, not the child, were in the wrong.

Mistreatment and abuse teach a child that the world is a dangerous place. This perception persists into adult life, making it more difficult for survivors to trust other people.

One study found that survivors of childhood maltreatment perceive others as less trustworthy and more threatening. This reactive mistrust persists even after survivors received positive feedback, suggesting that they have more negative feelings toward others. ¹⁴

Multiple studies have shown that childhood trauma harms physical health. According to the National Center for PTSD, adults who experienced trauma in childhood have more diagnosed medical disorders, including lung and heart disease. ¹⁵

Sleep disturbances are widespread in adults with unresolved trauma. In one study, 33% of adults with traumatic experiences in childhood had trouble falling or staying asleep. ¹⁶

Nightmares are also common signs of childhood trauma in adults. One study theorized that the brain can use dreams to process repressed childhood trauma. The brain uses representations of the traumatic experience to restore the sense of self without forcing the person to face those intrusive memories while awake. ¹⁷

Another theory is that the body becomes more attuned to threats after surviving a childhood trauma. This hypervigilance plays out during sleep, causing a fight-flight-freeze response in the dream. ¹⁸

Studies have shown that childhood trauma survivors have higher rates of addiction and substance abuse than the general population. ¹⁹ Like dissociation, substance use provides a temporary escape from traumatic memories and the chronic stress that many survivors live with. ²⁰

Treatment must address childhood trauma and the addictive disorder to be successful. ²¹ Trauma-informed approaches consider known and repressed trauma while incorporating other mental health considerations, including depression and anxiety.

Yeshiva University's online accredited Master of Social Work (MSW) will help you develop the skills to treat trauma in adults. You'll build the tools you need to practice informed trauma therapy for people at all stages of their healing journeys.

The engaging and culturally aware curriculum in the Wurzweiler School of Social Work will prepare you to treat clients and support their personal growth. Prepare for a dynamic career in the classroom and with hands-on experience working alongside mental health professionals.

Wherever you dream of working, from mental health clinics to online therapy rooms, Yeshiva University's online MSW will help you get there. Build the foundation that will prepare you to master gold-standard trauma treatments, such as exposure therapy, eye movement desensitization and cognitive processing therapy. Learning in the Wurzweiler School of Social Work will be your jumping-off point.

Don't wait to take your mental health care career to the next level. Schedule a call with one of our admissions outreach advisors today.

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The developing brain learns through experience what is safe or unsafe and how to deal with the world's challenges. When a child experiences traumatic events, the effects on their neurology and emotional well-being can last longer than the event itself.

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Understanding the Impact of Childhood Trauma on Adult Relationships

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Understanding the Impact of Childhood Trauma on Adult Relationships

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Childhood trauma can cast a long shadow over a person’s life, affecting how you connect with others well into adulthood. It can make it difficult to navigate conflict, develop an effective communication style, build trust, and overcome fears of vulnerability. Understanding the impact of these experiences is the first step toward breaking their hold on your adult relationships. With the right resources and support, it’s possible to heal from past trauma and create healthier, more fulfilling connections in adulthood.

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The Impact of Childhood Trauma on Adult Relationships

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Learn how childhood trauma affects adult relationships, including the impact and strategies for improving your connections with others.

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How Childhood Trauma Can Carry Into Adulthood

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How Childhood Trauma Can Carry Into Adulthood

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Childhood experiences significantly shape who we become as adults and trauma in these early years can cast a long shadow over our lives. Recognizing its symptoms, even in adulthood, means taking the first steps toward healing.

What constitutes childhood trauma, and how does it manifest into adulthood? Intervention by mental health professionals can help patients explore the most effective strategies for overcoming the impact of childhood trauma.

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How Childhood Trauma Affects Adulthood: The Lifelong Impact

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How Childhood Trauma Affects Adulthood: The Lifelong Impact

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But here’s the thing: you’re not alone. Millions of adults are grappling with the aftermath of childhood trauma every day. And while the journey to healing isn’t always easy, it is possible. In this post, we’ll explore how childhood trauma affects adulthood and what steps you can take to break free from its grip.

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How Childhood Trauma Affects Adulthood: The Lifelong Impact | Counseling Center Group

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Discover how childhood trauma can shape adult mental health, relationships, and coping mechanisms. Learn the long-term effects and paths to healing.

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This article explains what trauma is, what childhood abuse may look like, and how childhood trauma impacts adulthood.

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If you experienced trauma as a child, it's likely that you are or have experienced some amount of post-traumatic stress disorder (PTSD) later in life.

This article explains what trauma is, what childhood abuse may look like, and how childhood trauma impacts adulthood.

What Is Childhood Trauma?

Trauma in childhood not only constitutes physical, emotional, or sexual abuse but exposure to traumatic events as well. These traumatic events could be when children witness natural disasters, or even when they witness violence within their communities.

What Determines a Child's Reaction to Traumatic Events?

Factors that determine a child's reaction to trauma include:

Developmental level: This could mean where the child is age-wise or mentally.

Ethnicity or cultural factors: This can impact what the child views as a normal response to trauma based on what they have seen from people in their communities or families.

Previous exposure to trauma: If a child is more accustomed to traumatic events, it could mean that they adapt by learning to control their reactions.

Available resources: Refers to how socioeconomically connected their family is, as well as their access to their needs on a regular basis.

Preexisting child and family problems: This could dictate how supportive your parents are when you tell them that something traumatic happened, or it could mean that some form of abusive trauma is occurring in your immediate family.

Signs of PTSD in Children

After exposure to any traumatic event, kids tend to express some form of behavioral change. These behaviors are still regularly reported by mental health professionals in their daily practices with adults. These behavioral changes could include:

Sudden new fears: These fears may or may not be related to the traumatic event.

Separation anxiety: Occurs when a child becomes overwhelmed with anxiety if their parents are not around.

Sleep disturbances: This could mean that they start having nightmares or lose the ability to fall asleep quickly.

Sadness: If you notice that you or a loved one is feeling down much more often, it may be a sign that they're coping with a traumatic event.

Losing interest in normal activities: A child may lose interest in things they once enjoyed.

Inability to concentrate: This could be long or short-term and impact things like school, work, or normal activities.

Anger: Unexplained anger, or irritability that doesn't match up to the level of the event, can be a sign of a traumatic event.

Somatic complaints: These can include stomachaches, headaches, or any other physical pains that seem to have no root cause.

It's important to note that many of these symptoms go away with time, however, the risk of PTSD does increase if the child is repeatedly exposed to trauma or has a history of anxiety issues.

While kids may heal, between 3% and 15% of girls and 1% to 6%of boys will develop PTSD.In general, if any of the symptoms listed above appear for longer periods of time, it may be time to consider seeking a therapist that focuses on the treatment of PTSD.

In addition to those symptoms, children who are experiencing PTSD may also exhibit hypervigilance in an effort to look for warning signs to prevent future traumas.

Children suffering from PTSD may also re-experience the trauma or avoid things that may remind them or cause them to remember the trauma.

Press Play for Advice On Healing Childhood Wounds

Hosted by Editor-in-Chief and therapist Amy Morin, LCSW, this episode of The Verywell Mind Podcast, featuring award-winning actress Chrissy Metz, shares how to heal childhood trauma, safeguard your mental health, and how to get comfortable when faced with difficult emotions. Click below to listen now.

Follow Now: Apple Podcasts / Spotify / Google Podcasts

Signs of Childhood Trauma in Adults

The effects of childhood trauma can last well into adulthood. Trauma can impact future relationships and lead to other issues like depression and low self-esteem.

Childhood Abuse May Impact Adult Relationships

Experiencing trauma in childhood can impact the way that you form attachments in romantic relationships.

One study asked 911 students (492 female and 419 male) about their experiences with trauma as children.

The students that were surveyed that experienced physical, emotional, or sexual abuse were more likely to exhibit attachment styles that were fearful, preoccupied, and dismissive. It also found that students that did not experience childhood trauma were much more likely to have secure attachment styles into adulthood.

Here's a look at the four attachment styles:

1. Secure: People with secure attachment styles have healthy relationships and good levels of self-esteem.

2. Ambivalent: These attachment styles are reluctant to get too close to people and always worry that their partners are going to leave them.

3. Avoidant: Avoidant attachment styles have problems with intimacy and never let anyone too close for fear of abandonment.

4. Disorganized: These attachment styles sometimes take on parental roles in romantic relationships.

Other Signs of Childhood Trauma in Adults

Exposure to traumatic events can also cause poor self-esteem, depression, self-destructive behavior, and even difficulty trusting others. This can become especially problematic with age, as PTSD and traumatic events from childhood can actually result in adverse health effects in adulthood.

According to a Cleveland Clinic podcast,adults who experienced trauma as kids are much more susceptible to depression and mood disorders, as well as thoughts of suicide. They are also likely to abuse alcohol and other substances. Finally, they are more prone to developing chronic illnesses, like diabetes and heart disease, later in life.

The higher likelihood of developing chronic illness is potentially due to the fact that adults who experienced trauma as children are more likely to engage in high-risk activities like smoking.

This podcast also explained that doctors are researching the possibility that understanding someone's past and their relation to trauma can lead to better treatment that could help in the prevention of these diseases and symptoms. It's even possible that these traumas impacted the brain in a specific way.

Recognizing how the brain has been impacted could lead to advancements in treatment when it comes to therapy and medical intervention.

A Word From Verywell

You are never too old or too far removed to seek help for something that happened when you were a child. Know that you can always start working on yourself and seek help from a therapist. Know that your thoughts and feelings about things that happened to you years ago are just as valid now as they were then, and it is OK if it has taken you a while to get to a point where you are ready to work on it. No matter when you experienced abuse in your life, it is never too late to seek help from a professional.

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Childhood Trauma in Adults: How to Recognize and Heal From It

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If you experienced trauma as a child, it's likely that you are or have experienced some amount of post-traumatic stress disorder (PTSD) later in life. This article explains what trauma is, what childhood abuse may look like, and how childhood trauma impacts adulthood.

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Childhood Trauma: 10 Great Treatments to Help Heal

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Childhood Trauma: 10 Great Treatments to Help Heal

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Experiencing distressing and painful situations as a child can cast a long, dark shadow on our lives. Childhood trauma, whether from physical abuse, sexual abuse, emotional abuse, neglect, or witnessing violence, can have a deep and lasting impact.

Trauma can seep into every part of our being. It can make it challenging to form healthy connections, handle emotions, and increase the risk of mental health issues.

The weight of such experiences can also dramatically increase the chance of addiction in adulthood. But there’s hope. People can overcome addiction and reclaim their lives by recognizing and healing from deep-seated childhood traumas.

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Want to Heal Childhood Trauma? 10 Great Treatments to Recover

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If you are wondering about healing childhood trauma in adults, keep ready to learn the symptoms and a variety of treatment options.

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What’s the Best Childhood Trauma Therapy?

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What’s the Best Childhood Trauma Therapy?

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Childhood trauma — whether that’s adversity, physical or emotional childhood abuse, or another traumatic experience — can leave a lasting impact on a person’s well-being, affecting their relationships, behavior, and mental health. In fact, research shows that childhood trauma can contribute to the development of conditions like anxiety, depression, and post-traumatic stress disorder (PTSD). However, with the right kind of treatment, healing from childhood trauma is possible.

Below, we delve into childhood trauma treatment options, including the best therapy for childhood trauma and other treatments that can help people address childhood trauma (including subconscious or unresolved childhood trauma).

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Childhood trauma can leave a lasting impact on a person's well-being. Here's how to heal.
Learn more about our Clinical Review Process
Ready to start healing?

Childhood trauma - whether that's adversity, physical or emotional childhood abuse, or another traumatic experience - can leave a lasting impact on a person's well-being, affecting their relationships, behavior, and mental health. In fact, research shows that childhood trauma can contribute to the development of conditions like anxiety, depression, and post-traumatic stress disorder (PTSD). However, with the right kind of treatment, healing from childhood trauma is possible.

Below, we delve into childhood trauma treatment options, including the best therapy for childhood trauma and other treatments that can help people address childhood trauma (including subconscious or unresolved childhood trauma).

The best childhood trauma therapy options

Without proper support, childhood trauma can remain in a person's body and continue to affect their mental and physical health. Trauma-related symptoms include difficulty concentrating, sleeping, and eating. As mentioned, trauma has also been linked to anxiety, depression, and PTSD, as well as increased substance use, emergency room admissions, and general feelings of unhappiness.

The most effective treatment for childhood trauma varies depending on individual needs and circumstances. However, some widely recognized and effective therapies for addressing childhood trauma are as follows.

Trauma-focused cognitive behavioral therapy (TF-CBT)

A trauma-specific iteration of cognitive behavioral therapy (CBT), this structured talk therapy aims to help people understand and manage their thoughts, feelings, and behaviors related to a traumatic childhood experience. It often involves techniques such as relaxation skills, cognitive restructuring, and exposure therapy.

Eye movement desensitization and reprocessing (EMDR)

A leading form of trauma therapy, EMDR helps people process traumatic memories by using bilateral stimulation, such as eye movements or tapping, to facilitate the brain's natural healing process. EMDR therapy can be taken to address traumatic childhood experiences, like physical abuse or neglect.

Dialectical behavior therapy (DBT)

DBT is a kind of behavioral therapy that focuses on teaching skills to manage emotions, improve interpersonal relationships, and increase distress tolerance. DBT for trauma can be particularly helpful for people who struggle with emotional dysregulation as a result of childhood trauma.

Play therapy

Especially effective for children, play therapy allows them to express and make sense of their experiences through play and creative expression in a safe and supportive environment. Play therapy can be used by people of all ages.

Attachment-based therapy

Attachment-based therapy is rooted in the understanding that early relationships with caregivers profoundly influence a person's development. For people who have experienced childhood trauma, particularly neglect, abuse, or inconsistent caregiving, these early attachment experiences may have been disrupted or damaged. In attachment-based therapy, a therapist works to address these relational wounds by providing a safe therapeutic environment where clients can explore and make sense of their attachment patterns and experiences.

Somatic experiencing

Somatic experiencing focuses on the body's physical sensations and responses to trauma, helping people release stored tension and regulate their nervous systems. This kind of therapy recognizes that trauma is not just psychological but also physiological, affecting the body's nervous system and somatic (bodily) sensations. During somatic experiencing sessions, a trauma therapist helps clients develop an awareness of their bodily sensations and track how their bodies respond to different thoughts, emotions, and memories. By gently exploring these sensations, clients can gradually release the stored tension from childhood trauma.

How to heal subconscious trauma from childhood

Trauma affects everyone differently, and some people may not even realize when they're carrying trauma from childhood, an experience sometimes referred to as subconscious trauma or unresolved childhood trauma. For example, research shows that trauma can impact the brain's ability to form memories - potentially as a way to cope with the emotional and psychological impact of difficult events. In addition to professional support (like the therapies outlined above), here are three steps you can take to heal subconscious trauma from childhood.

1. Acknowledge the trauma

Trauma relates to a person's understanding of a distressing event and their ability to process and cope with that information. For some people, it's easier to bury the feelings associated with a traumatic experience or pretend that it didn't happen altogether. However, acknowledging your trauma symptoms is one of the first steps in healing. Once you acknowledge a traumatic experience, your triggers, and its impact on your life, you give yourself the power to heal.

2. Process the emotions

Guilt, shame, sadness, confusion, fear, fatigue, embarrassment, denial - there is no right or wrong way to feel after living through a traumatic event. Whatever it is that you feel, take the time to understand how your trauma has impacted your emotional health and well-being. Processing your emotions -especially with a trained mental health professional - creates the necessary room to grow and heal.

3. Be patient

It's important to remember that change doesn't happen overnight. Childhood trauma can have long-term consequences, such as unpredictable emotions, disturbing flashbacks, and strained relationships. If you've experienced trauma, you may also have certain triggers - including smells, sounds, and situations - which can unexpectedly remind you of the traumatic event. Everyone's response to trauma is different, so show yourself patience and compassion as you navigate your unique healing journey.

What causes childhood trauma?

Data shows that more than two-thirds of American children experience a potentially traumatic event by the time they turn 16. A wide range of experiences can cause childhood trauma, but some common causes of trauma in children, teens, and young adults include:

Childhood abuse (including physical, verbal, or sexual abuse)

Neglect (including physical or emotional neglect)

Parental loss or separation (due to substance abuse, divorce, abandonment, or death)

Accidents or disasters

Systemic trauma (also known as historical or intergenerational trauma stemming from racism, poverty, or oppression)

Childhood trauma therapy at Charlie Health

If you or a loved one are struggling with the effects of childhood trauma, Charlie Health is here to help. Charlie Health's virtual Intensive Outpatient Program (IOP) provides more than once-weekly mental health treatment for young people and families dealing with serious mental health conditions, including trauma. Our expert clinicians incorporate evidence-based therapies into individual therapy, family therapy, and group sessions. With this kind of holistic online therapy, managing childhood trauma is possible. Fill out the form below or give us a call to start healing today.

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Childhood Trauma Therapy | Charlie Health

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Childhood trauma has a lasting impact on mental health, but childhood trauma therapy can help people heal. Click here for the best childhood trauma therapy options.

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For many, events that occur during childhood build barriers to happiness later in life. And when you’re still dealing with childhood baggage into adulthood, you start to wonder, “Does childhood trauma ever go away?” Fear not! It truly is possible to create a healthy, safe place where you can thrive.

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Childhood trauma can go away, but most of the time it doesn’t happen without work. At our facility in Nashville, we do the work with you. Call today to get started.

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Healing Childhood Trauma: A Guide to Emotional Recovery and Growth

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Healing Childhood Trauma: A Guide to Emotional Recovery and Growth

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This article will provide comprehensive guidance and practical strategies for individuals seeking to heal from childhood trauma, emphasizing the importance of emotional recovery and growth for overall well-being.

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Good Health Psych | Psychiatric Services for Adults, And Adolescents In NYC

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Healing Childhood Trauma: A Comprehensive Guide

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Discover effective strategies for healing childhood trauma with our comprehensive guide. Explore methods to foster emotional recovery and growth.

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Aside from professional support, it’s crucial to build a network of trusted individuals who can provide emotional support during the healing process. Incorporating self-care practices into your daily routine, like mindfulness, exercise, and journaling, can significantly aid in your recovery. It is important to ensure you are re-filling your cup as you process difficult memories, thoughts, and feelings.

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Healing from childhood trauma involves addressing the emotional, mental, and physical wounds you’ve experienced. Working with a trauma-informed therapist is really important—they can help you accept what happened and grieve its impact. Together, you can process the trauma and develop strategies for dealing with triggers and other related issues. A therapist can also support you

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If you’re living with the emotional and psychological consequences of a traumatic childhood, there is hope. Here are seven ways to heal your childhood trauma and reclaim your life.

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Children are often viewed as highly resilient and able to bounce back from just about any situation, but traumatic experiences in childhood can have severe and long-lasting effects well into adulthood if they are left unresolved. Childhood trauma can result from anything that makes a child feel helpless and disrupts their sense of safety and security, including: sexual, physical or verbal abuse; domestic violence; an unstable or unsafe environment; separation from a parent; neglect; bullying; serious illness; or intrusive medical procedures.

If you're living with the emotional and psychological consequences of a traumatic childhood, there is hope. Here are seven ways to heal your childhood trauma and reclaim your life.

1. Acknowledge and recognize the trauma for what it is. Victims of childhood trauma often spend years minimizing the event or dismissing it by pretending it didn't happen or by succumbing to feelings of guilt or self-blame. The only way you can begin healing is to acknowledge that a traumatic event did occur and that you were not responsible for it.

2. Reclaim control. Feelings of helplessness can carry well over into adulthood and can make you feel and act like a perpetual victim, causing you to make choices based on your past pain. When you're a victim, the past is in control of your present. But when you've conquered your pain, the present is controlled by you. There may always be a battle between past and present, but as long as you're willing to let go of the old defenses and crutches you used as a child to navigate your trauma, you will be able to reclaim control of your life now and heal your pain.

3. Seek support and don't isolate yourself. A natural instinct that many trauma survivors have is to withdraw from others, but this will only make things worse. A big part of the healing process is connecting to other people, so make the effort to maintain your relationships and seek support. Talk to a trusted family member, friend or counselor and consider joining a support group for survivors of childhood trauma.

4. Take care of your health. Your ability to cope with stress will increase if you are healthy. Establish a daily routine that allows you to get plenty of rest, eat a well-balanced diet and exercise regularly. Most importantly, stay away from alcohol and drugs. These might provide temporary relief but will inevitably increase your feelings of depression, anxiety and isolation and can worsen your trauma symptoms.

5. Learn the true meaning of acceptance and letting go. Just because you accept something doesn't mean you're embracing your trauma or that you like it or agree with it. Acceptance means you've decided what you're going to do with it. You can decide to let it rule your life or you can decide to let it go. Letting go doesn't mean "poof!" it's magically gone. Letting go means no longer allowing your bad memories and feelings of a bad childhood to rob yourself of living a good life now.

6. Replace bad habits with good ones. Bad habits can take many forms, like negativity and always mistrusting others, or turning to alcohol or drugs when feelings become too hard to bear. Bad habits can be hard to break, especially when they're used as crutches to help you avoid reliving the pain and trauma of your childhood. A support group or a therapist can help you learn the tools necessary to break your bad habits and replace them with good ones.

7. Be patient with yourself. When you've been seriously hurt as a child you develop out-of-control emotions, hopelessness, defense mechanisms and warped perceptions that are difficult to let go of. It will take a lot of time and hard work to let go of these feelings. Be patient with yourself and honor your progress, no matter how small it may seem. It's the little victories in your recovery that will eventually help you win the battle of healing your childhood trauma.

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Children are often viewed as highly resilient and able to bounce back from just about any situation, but traumatic experiences in childhood can have severe and long-lasting effects well into... Read More

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3 Proven Methods to Heal Trauma and Rewire Your Nervous System

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3 Proven Methods to Heal Trauma and Rewire Your Nervous System

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In this episode, Mel Robbins is making the topic of #trauma easier to understand by taking you step by step through her recent revelation that she was struggling with past trauma. Note: this episode covers sensitive material, including discussion of trauma and sexual assault. If this topic isn’t for you right now – please skip this episode.

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3 Proven Methods to Heal Trauma and Rewire Your Nervous System

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Are you or someone you know going through a difficult time? In this message, we’re learning how to seek healing from trauma. Take some time right now to rest and let God speak to your heart.

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Uncover your trauma score and learn how to move forward with confidence.

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Childhood Trauma Test (ACES Test) – Discover the Impact & Begin Healing

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Do you have childhood trauma? Take our online test to explore how early experiences may impact your life. Gain insights and take the first step toward healing.