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Undoing the harm of childhood trauma and adversity | UCSF Department of Psychiatry

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Undoing the harm of childhood trauma and adversity | UCSF Department of Psychiatry

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Adversity experienced during a person's childhood has far-reaching consequences.

Years of research have shown that trauma and adverse events in childhood can put a person at an elevated risk for a wide range of physical and mental health problems across their life span. But the scope and significance of that impact - and how to reverse it - is just beginning to come into focus.

The number of children under the age of 18 who have experienced trauma and are at risk for health problems is staggering: About two-thirds of kids have experienced at least one major traumatic event in their lives and one-third have experienced two or more, according to a 2007 study.

The idea that adversity increases the risk of disease later in life is generally acknowledged in the medical community, said Tom Boyce, MD, a professor of pediatrics and psychiatry at UC San Francisco who began studying psychological stress as a disease risk factor in children nearly 40 years ago. Now health professionals and researchers are working to understand the psychological and biological connections between adverse events and trauma on health - and what to do to interrupt those effects.

Connecting adverse events, health effects

Nearly two decades ago, the connection between adverse childhood experiences (ACEs) and long-lasting health effects was thrust into the spotlight when the Adverse Childhood Experiences Study was published. It examined seven categories of adverse experiences - such as childhood maltreatment, parent criminal behavior and domestic violence - in 17,000 adult Kaiser Permanente members in Southern California.

Findings in the study showed strong correlations between early-life adversity and risk factors for several of the leading causes of death in adults, including depression, diabetes and heart disease.

While that pivotal ACE study laid the groundwork for connecting the association of childhood adversity with many leading causes of morbidity and mortality, the number and scope of ACEs and their health impacts have expanded since then. ACEs now include detrimental experiences and trauma such as abuse, neglect, parental death or divorce, or an environment of racism or violence.

As more research is done, more evidence surfaces about the harmful effects of ACEs. For example, a new study shows that a person who experienced persistent poverty in young adulthood had lower cognitive scores later in life than a person who had never been in poverty. Another study showed that childhood adversity increases the odds of shorter telomeres, which have been linked to an increased risk of non-communicable illnesses in adulthood, such as cardiovascular disease and cancer.

The impacts from such hardships and trauma also have now been shown to go beyond correlations to diseases. ACEs have been shown repeatedly to predict a wide range of risky health behaviors, such as smoking or other substance abuse.

The more traumatic or adverse events children have, the higher the risk for negative health effects and mental health issues that can continue well into adulthood.

"Children do not outgrow the impact of ACEs," said Alicia Lieberman, PhD, a professor of psychiatry who leads one of 25 National Child Traumatic Stress Network centers at Zuckerberg San Francisco General Hospital and Trauma Center. "On the contrary, when children are exposed to multiple ACEs, the effect increases such that children get worse over time rather than better - unless we change the conditions."

Mechanisms of transmitting ACEs effects

For children, ACEs from unhealed parents could be passed on through a dual-pronged influence: from the environment a parent creates for a child and, researchers are discovering, in biology.

"We now understand that effects of adversity exposure can begin immediately when an organism is conceived and begins to develop," said Nicole Bush, PhD, an associate professor of psychiatry and pediatrics who is determined to uncover the mechanisms of how early-life adversity affects chronic disease in humans.

Maternal stress hormones appear to program fetal development, she said, and beyond that, a mother's own early childhood adversity can affect her biology throughout her life, which she carries into her pregnancy.

Bush and Lieberman have joined forces in the CTRP-Health study at the UCSF Child Trauma Research Program (CTRP) to examine the biological systems implicated in traumatic stress and their response to Lieberman's child-parent interventions. In mothers and their children, Bush and colleagues are searching for biological markers of adversity in the telomeres at the ends of chromosomes, the immune system and other physiological stress response systems.

"People tend to blame a child for having a 'bad attitude' or behavior problems," Bush said. She hopes to demonstrate that those issues are related to trauma and that an intensive intervention might fix a biological problem, for example by correcting a dysregulated immune system, which could reverse a range of biological, behavioral and psychological problems.

"You can't blame a kid for having a dysregulated immune system," she said. "Findings like this would start taking away some of the blame and start making it a larger societal issue that we need to address."

Tools to address impact of trauma

Prevention of adverse events in the first place would be ideal, said Boyce, and many nationwide efforts to reduce ACEs are geared in that direction. "But we are a long way from preventing one of the most chronic and pernicious stressors, which is simply not having enough money or resources such as food or shelter to take care of the needs of the family," he said.

In the real world where children are presenting with depression or anxiety or behavior problems due to ACEs, Boyce said there is an arsenal of clinical interventions that are simple but very effective in helping kids recover, primarily by supporting parents and giving them strategies to deal with trauma and stress.

"What is lacking is a general awareness that we have the tools available to us to address the impact of trauma in adults that lead to ACEs in children and poor health outcomes in adulthood," said Edward Machtinger, MD, a professor of medicine who, as director of the Women's HIV Program at UCSF, sees the long-term effects of childhood adversity on his adult patients. In his clinic, they are using trauma-informed methods to more effectively treat depression, substance use, chronic pain and other conditions that predispose parents exposing their children to ACEs.

Lieberman, who is a UCSF professor of psychiatry, has created an assessment and treatment program to decrease the impact of ACEs on children's physical and mental health. After an initial assessment with a child experienced interpersonal trauma and his or her primary caretaker, Lieberman's team at CTRP offers a treatment a treatment plan tailored to the needs of each family, which can include forms of psychotherapy, crisis intervention and practical assistance for living situations.

Her model has been disseminated in 35 states and five countries.

"When we are able to intervene early to protect children from the impact of ACEs, the effects are amazing," she said. "They change the developmental trajectory of the child and ensure that their current illnesses do not become chronic."

Focusing on children and adults

While early intervention is imperative in cases where children are experiencing ACEs, Boyce said that one of the best things health professionals can do is give parents and children the opportunity to discuss traumatic events in their lives. "It helps both parents and kids immensely to just talk about this," Boyce said.

Machtinger contends that treating ACEs requires a focus on adults - the children who grew up with unresolved early life trauma who then may transmit ACEs to their own children through abuse, neglect or a dysfunctional home environment.

"At UCSF, we are at the forefront of innovating ways to address trauma as the primary underlying factor in the illnesses of our adult patients," he said.

Machtinger is leading a series of studies implementing and evaluating a trauma-focused care model for dealing with the impact of lifelong abuse. The model incorporates several proven strategies, including creating a safe supportive clinical environment, empowering patients, and combating their social isolation and screening and treatment for post-traumatic stress disorder, chronic pain, substance abuse and mental illness.

"If you want to interrupt ACEs, you have to help the adults heal," he said.

In recognition that parents who have unresolved ACEs will have their parenting skills affected, Lieberman's treatment helps heal both children experiencing adversity and the children's parents or caretakers. Called Child-Parent Psychotherapy, the technique brings the two together to alleviate impact of ACEs on the child by helping the parent become a better protector for the child.

After treatment, not only are the physical and mental health indicators much better for the child, but they are much improved for the parent as well.

In an imperfect world where children do experience stress and trauma, a bit of good news is that there considerable evidence of great variation between children in their responses to stress and adversity.

"I feel tremendously encouraged by research being done at UCSF and elsewhere to determine the factors that contribute to a child's resilience," Boyce said. Good parenting, a good diet, social support and strong communities are likely candidates. "But we already know that supporting young families and children - financially, psychologically and educationally - really helps with prevention of these stress-related disorders."

About UCSF Psychiatry

The UCSF Department of Psychiatry and the Langley Porter Psychiatric Institute are among the nation's foremost resources in the fields of child, adolescent, adult, and geriatric mental health. Together they constitute one of the largest departments in the UCSF School of Medicine and the UCSF Weill Institute for Neurosciences, with a mission focused on research (basic, translational, clinical), teaching, patient care, and public service.

UCSF Psychiatry conducts its clinical, educational, and research efforts at a variety of locations in Northern California, including UCSF campuses at Parnassus Heights, Mission Bay, and Laurel Heights, the UCSF Medical Center at Mt. Zion, Zuckerberg San Francisco General Hospital and Trauma Center, the San Francisco VA Health Care System, and UCSF Fresno.

About the UCSF Weill Institute for Neurosciences

The UCSF Weill Institute for Neurosciences, established by the extraordinary generosity of Joan and Sanford I. "Sandy" Weill, brings together world-class researchers with top-ranked physicians to solve some of the most complex challenges in the human brain.

The UCSF Weill Institute leverages UCSF's unrivaled bench-to-bedside excellence in the neurosciences. It unites three UCSF departments-Neurology, Psychiatry, and Neurological Surgery-that are highly esteemed for both patient care and research, as well as the Neuroscience Graduate Program, a cross-disciplinary alliance of nearly 100 UCSF faculty members from 15 basic-science departments, as well as the UCSF Institute for Neurodegenerative Diseases, a multidisciplinary research center focused on finding effective treatments for Alzheimer's disease, frontotemporal dementia, Parkinson's disease, and other neurodegenerative disorders.

About UCSF

UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children's Hospital San Francisco, and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.

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Undoing the harm of childhood trauma and adversity

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Adversity experienced during a person's childhood has far-reaching consequences. Years of research have shown that trauma and adverse events in childhood can put a person at an elevated risk for a wide range of physical and mental health problems across their life span.

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PTSD, or Posttraumatic Stress Disorder, is a psychiatric disorder that can occur following the experience or witnessing of a life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or physical or sexual assault in adult or childhood. Most survivors of trauma return to normal given a little time.

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Facts and Figures | National Child Traumatic Stress Network - Child Trauma Home

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Facts and Figures | National Child Traumatic Stress Network - Child Trauma Home

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The National Child Traumatic Stress Network

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The following resources on child trauma were developed by the NCTSN.

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Research has shown that children are particularly vulnerable to trauma because of their rapidly developing brain. During traumatic experiences, a child's brain is in heightened state of stress and fear-related hormones are activated. Although, stress is a normal part of life, when a child is exposed to chronic trauma, like abuse or neglect, the child's brain remains in this heightened pattern.

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Childhood trauma’s devastating impact on health | News | Harvard T.H. Chan School of Public Health

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Childhood trauma’s devastating impact on health | News | Harvard T.H. Chan School of Public Health

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Exposure to trauma during childhood can dramatically increase people's risk for 7 out of 10 of the leading causes of death in the U.S.-including high blood pressure, heart disease, and cancer -and it's crucial to address this public health crisis, according to Harvard Chan alumna Nadine Burke Harris, MPH '02.

In an impassioned TED talk, Burke Harris, a California pediatrician, cites research that links early adversity-such as physical or emotional abuse or neglect, parental mental illness or substance abuse, or domestic violence-to a host of serious health problems. She noted that such "toxic stress" can cause changes in the brain and the hormonal system. In particular, the repeated activation of the "fight-or-flight" response in children can lead to serious health problems over time.

Burke Harris saw firsthand the impact of trauma on her young patients in Bayview-Hunters Point, one of the poorest, most underserved neighborhoods in San Francisco. But she said the problem occurs among children across the economic and social spectrum. She called for an increased focus on preventing childhood exposure to trauma and on developing effective treatments when it does occur.

"This is treatable. This is beatable. The single most important thing that we need today is the courage to look this problem in the face and say, 'this is real, and this is all of us,' " she said.

Watch Nadine Burke Harris' TED talk: How childhood trauma affects health across a lifetime
Learn more
Chronic stress takes a toll on the young (Harvard Chan School news)

The Toxic Stress of Early Childhood Adversity (Forum webcast)

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Childhood trauma's devastating impact on health

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Exposure to trauma during childhood can dramatically increase people's risk for 7 out of 10 of the leading causes of death in the U.S.-including high blood pressure, heart disease, and cancer -and it's crucial to address this public health crisis, according to Harvard Chan alumna Nadine Burke Harris, MPH '02.

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Welcome to Temple Grandin's Official Autism Website

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Welcome to Temple Grandin's Official Autism Website

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Dr. Grandin did not talk until she was three and a half years old. She was fortunate to get early speech therapy. Her teachers also taught her how to wait and take turns when playing board games. She was mainstreamed into a normal kindergarten at age five. Oliver Sacks wrote in the forward of Thinking in Pictures that her first book Emergence: Labeled Autistic was "unprecedented because there had never before been an inside narrative of autism." Dr. Sacks profiled Dr. Grandin in his best selling book Anthropologist on Mars.

Dr. Grandin became a prominent author and speaker on both autism and animal behavior. Today she is a professor of Animal Science at Colorado State University. She also has a successful career consulting on both livestock handling equipment design and animal welfare. She has been featured on NPR (National Public Radio) and a BBC Special - "The Woman Who Thinks Like a Cow". She has also appeared on National TV shows such as Larry King Live, 20/20, Sixty Minutes, Fox and Friends, and she has a 2010 TED talk. Articles about Dr. Grandin have appeared in Time Magazine, New York Times, Discover Magazine, Forbes and USA Today. HBO made an Emmy Award winning movie about her life and she was inducted into the American Academy of Arts and Sciences in 2016.

When she was young, she was considered weird and teased and bullied in high school. The only place she had friends was activities where there was a shared interest such as horses, electronics, or model rockets. Mr. Carlock, her science teacher, was an important mentor who encouraged her interest in science. When she had a new goal of becoming a scientist, she had a reason for studying. Today half the cattle in the United States are handled in facilities she has designed.

In 2013, the American Psychiatric Association revised the diagnostic criteria for autism. This greatly broadened the spectrum. It now ranges from brilliant scientists, artists, and musicians to an individual who cannot dress himself or herself. Over the years, the diagnostic criteria have kept changing. It is not precise like a lab test for strep throat. Labels such as autism, ADHD, sensory processing disorder or learning disability are often applied to the same child. In older children with no speech delay, the diagnosis sometimes switches back and forth between autism and ADHD.

"One of the problems today is for a kid to get any special services in school, they have to have a label. The problem with autism is you've got a spectrum that ranges from Einstein to someone with no language and intellectual disability," said Grandin. "Steve Jobs was probably mildly on the autistic spectrum. Basically, you've probably known people who were geeky and socially awkward but very smart. When does geeks and nerds became autism? That's a gray area. Half the people in Silicon Valley probably have autism."

As the number of children diagnosed with autism continues to rise nationally, Grandin is sharing her message about the disorder and "differently-abled brains" with packed houses. At the heart of that message is this: Rigid academic and social expectations could wind up stifling a mind that, while it might struggle to conjugate a verb, could one day take us to distant stars.

"Parents get so worried about the deficits that they don't build up the strengths, but those skills could turn into a job," said Grandin, who addresses scientific advances in understanding autism in her newest book, "The Autistic Brain: Thinking Across the Spectrum." These kids often have uneven skills. We need to be a lot more flexible about things. Don't hold these math geniuses back. You're going to have to give them special ed in reading because that tends to be the pattern, but let them go ahead in math."

Early diagnosis can lead to early intervention and access to special education programs, and, while crucial for children with speech delay, also means a permanent label that ultimately could impede progress, and the healthy development of a child's identity. There are other situations where an autism diagnosis is helpful for an older person who is having problems with relationships. It can give them great insight, and enable them to improve relationships.

Have High, But Reasonable Expectations

A label can also impact parental expectations, a major source of therapeutic momentum for children. A parent with a diagnosed autistic child might be reluctant to teach practical social skills that are outside the child's comfort zone, such as ordering food at a lunch counter. You have to stretch these kids just outside their comfort zone to help them develop. Give them choices of "stretching" activities such as you can do Boy Scouts or robotics.

"It hurts because they don't have enough expectations for the kids. I see too many kids who are smart and did well in school, but they're not getting a job because when they were young, they didn't learn any work skills," Grandin said. "They've got no life skills. The parents thinks, 'Oh, poor Tommy. He has autism so he doesn't have to learn things like shopping." Grandin was raised by her mother in the 1950's, a time when social skills were "pounded into every single child," she said. "Children in my generation, when they were teenagers, they had jobs and learned how to work. I cleaned horse stalls. When I was 8 years old, my mother made me be a party hostess - shake hands, take coats, etc. In the 1950's, social skills were taught in a much more rigid way so kids who were mildly autistic were forced to learn them. It hurts the autistic much more than it does the normal kids to not have these skills formally taught."

"In my generation, paper routes taught important working skills. Today, parents should set up jobs a child can do in the neighborhood such as walking dogs for the neighbors. Younger children can do volunteer jobs outside the home such as being an usher at a house of worship or community center. This will teach both discipline and responsibility. It improved my self esteem to be recognized for doing a job well."

"The skills that people with autism bring to the table should be nurtured for their benefit and society's." Grandin said. "And, if a cure for autism were found, she would choose to stay just the way she is.

"I like the really logical way that I think. I'm totally logical. In fact, it kind of blows my mind how irrational human beings are," She said. "If you totally get rid of autism, you'd have nobody to fix your computer in the future."

Educating Students with Different Kinds of Minds

If algebra had been required course for college graduation in 1967, there would be no Temple Grandin. At least, no Temple Grandin as the world knows her today - professor, inventor, best-selling author, and rock star in the seemingly divergent fields of animal science and autism education. "I probably would have been a handyman, fixing toilets at some apartment building somewhere," said Grandin. "I can't do algebra. It makes no sense. Why does algebra have to be the gateway to all other mathematics?"

The abstract concepts in algebra present a common stumbling block for many with an autism spectrum disorder, dyslexia, or other learning problems. Many of the kids would do well if geometry was substituted for algebra. For autistic and photo-realistic visual thinkers, such as Grandin, understanding comes from being able to see and work through a concept in images, creating what is in effect, a virtual reality program that plays out in the brain. In this manner, Grandin, who didn't speak until she was almost 4, conceptualized down to minute details her design for a humane livestock restraint system now used on nearly half to the cattle in the U.S.

Fortunately, the academic trend in the late 1960's was finite math, a course Grandin passed with the help of tutors and devoted study, satisfying her college math requirement. She went on to earn a bachelor's degree in psychology and both masters and doctoral degrees in animal science. For the past two decades, she's been a professor at Colorado State University.

In her book, The Autistic Brain, she presents research findings that definitely show three types of specialized thinking. They are the photo realistic visual thinkers who think the way I do, math/pattern thinkers and word thinkers. Children who think differently will often thrive if they have more hands-on activities. Parents need to work with the schools to make sure that elementary school children have art, music, theater, sewing, woodworking, computer programs, and cooking . These classes teach important career skills and provide opportunities for students to have social interactions with their peers. Older students need to have access to career related classes such as welding, auto mechanics, and computer science.

There is a huge shortage of skilled mechanics. When I worked in construction installing my systems, I worked with many talented mechanics and metal fabricators. Some of them may have been on the milder end of the autism spectrum. These people were brilliant and they built very complicated things. Skilled trades are not for everybody on the spectrum. I estimate that a skilled trade would be a good choice for 25% of fully verbal people with ASD. When I look back on a long career, some of the best days of my life were out at a construction site. It was so much fun to talk about building things.

- 1 in 68 U.S. children has been identified with an autism spectrum disorder (ASD).
- ASD in 4.5 times more common in boys (1 in 42) and in girls (1 in 189).
- About 1 in 6 children in the U.S. had a developmental disability 2006-2008.

This covers a wide range of developmental problems ranging from mild to severe.

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Welcome to Temple Grandin's Official Autism Website

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Dr. Grandin did not talk until she was three and a half years old. She was fortunate to get early speech therapy. Her teachers also taught her how to wait and take turns when playing board games. She was mainstreamed into a normal kindergarten at age five.

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Learning to Cope With a Mind’s Taunting Voices - NYTimes.com

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Learning to Cope With a Mind’s Taunting Voices - NYTimes.com

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Families and Trauma | National Child Traumatic Stress Network - Child Trauma Home

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Families and Trauma | National Child Traumatic Stress Network - Child Trauma Home

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Families and Trauma | National Child Traumatic Stress Network - Child Trauma Home

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The Families and Trauma webpage is for providers who want to know more about the impact of trauma on families and are looking for family-centered resources. At the heart of family-centered services is respect for the strengths families develop and draw on when living through adversity.

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The toll of childhood trauma - Counseling Today

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The toll of childhood trauma - Counseling Today

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Mention the word trauma to Americans in the 21st century, and their thoughts are likely to turn to images of terrorism, war, natural disasters and a seemingly continual stream of school shootings. The horrific scenes at Newtown and Columbine still dominate public consciousness, particularly when our society discusses child trauma. While those events make headlines, however, counseling professionals say the most pervasive traumatic threat to children is found not in big events or stranger danger, but in chronic and systemic violence that happens in or close to the home.

This kind of ongoing trauma, much of which takes place out of public view, leaves deep scars that can cause a lifetime of emotional, mental, physical and social dysfunction if left untreated. Research shows that chronic, complex trauma can even rewire a child's brain, leading to cognitive and developmental issues.

The good news is that counselors in all areas of practice - in schools, agencies, shelters, clinics, private practice and elsewhere - can and are working with children and, when possible, their parents to stop the cycle of violence, or at least to mitigate its effects.
Behind closed doors
The number of children exposed to violence in the United States is staggering. According to the National Survey of Children's Exposure to Violence (NatSCEV), funded by the U.S. Department of Justice and the Centers for Disease Control and Prevention (CDC) and carried out by the University of New Hampshire's Crimes against Children Research Center, more than 60 percent of children surveyed had been exposed to direct or indirect violence during the 12 months prior to the survey. Nearly half - 46.3 percent - had been assaulted at least once in the past year, meaning they had experienced one or more of the following: any physical assault, assault with a weapon, assault with injury, attempted assault, attempted or completed kidnapping, assault by a brother or sister, assault by another child or adolescent, nonsexual genital assault, dating violence, bias attacks or threats. One in 10 had experienced some form of maltreatment, which includes nonsexual physical abuse, psychological or emotional abuse, child neglect and custodial interference. Other CDC research indicates that 1 in 4 girls and 1 in 6 boys are victims of sexual abuse. However, many experts emphasize that due to the stigma involved, sexual abuse is underreported.

Significant exposure to violence and trauma can also lead to illness later in life. From 1995-1997, the CDC, in collaboration with Kaiser Permanente, collected detailed medical information from 17,000 patients at Kaiser's Health Appraisal Clinic in San Diego. These patients also answered detailed questions about childhood experiences of abuse, neglect and family dysfunction. The initial study, Adverse Childhood Experiences, as well as more than 50 studies since using the same population, found that adult survivors of childhood abuse are more likely to develop chronic conditions and diseases such as heart disease, obesity, cancer, chronic obstructive pulmonary disease and liver disease. They are also more likely to engage in risky health behaviors such as smoking and drug and alcohol abuse. In addition, adult survivors of child abuse may have autobiographical memory problems; exhibit increased problems with depression, anxiety and other mental illnesses; and struggle with suicidal tendencies.

NatSCEV data, collected between January and May 2008, indicate that one in 10 children surveyed experienced five or more incidents of direct violence. It is this kind of ongoing abuse that can cause polyvictimization, or what many researchers call complex trauma - repeated exposure to traumatic events over time and often at the hands of caregivers or other loved ones.

"This cumulative trauma has much more serious effects than a single event," says David Lawson, a licensed professional counselor (LPC) and licensed marriage and family therapist in Nacogdoches, Texas, who has worked with victims and perpetrators of sexual and domestic abuse since the 1980s. Because the abuse is ongoing, it disrupts a child's sense of security, safety and self and alters the way he or she sees others, explains Lawson, an American Counseling Association member who is also a researcher and professor in the school psychology and counseling program at Stephen F. Austin State University in Nacogdoches.

"In childhood, attachments are still forming, and abuse can shatter this developing ability," says Jennifer Baggerly, an ACA member, LPC and play therapist who studies child trauma intervention. "It can also distort their forming personality and the way they interact with people as a whole." This distortion can cause the child to believe that the world is an unsafe place and that people aren't trustworthy, adds Baggerly, an associate professor and chair of the Department of Counseling and Human Services at the University of North Texas at Dallas.

That pattern of uncertainty and instability can cause cognitive distortion, dissociation and problems with emotional self-regulation and relationship formation, and even alter a child's brain structure, notes Lawson, the author of Family Violence: Explanations and Evidence-Based Clinical Practice, published by ACA in 2013.

"Children get stuck in flight or fight," adds Baggerly. "Everything is a threat, so instead of strengthening the prefrontal cortex, the brain operates more from the limbic system, which causes them to be more hypervigilant."

Because they are almost constantly on alert, these children and adolescents most of the time use what Lawson calls their "survival brain" instead of their "learning brain." Childhood and adolescence are periods in which the brain is developing rapidly and crucial cognitive skills are being learned. If children and adolescents spend too much time in survival mode, they are not accessing areas in the brain that are responsible for learning developmentally appropriate cognitive skills and laying down the neural pathways that are critical to future learning.

"As the child gets older, this chronic hypervigilance - and the overload of cortisol that comes with it - completely remaps the brain and just stifles development," says Gail Roaten, president-elect of the Association for Child and Adolescent Counseling, a division of ACA. "You see them lose ground cognitively, especially in their ability to learn."
Support and stability
Traumatized children's problems with cognition, learning, self-regulation and development can last a lifetime, making it more likely that they will continue the cycle of abuse in their relationships, abuse drugs and alcohol, have trouble finding and keeping jobs or end up in the criminal justice system. Adults who were traumatized as children also are much more likely to face a host of physical and mental health problems.

The situation is far from hopeless, however. Counseling interventions for trauma can make a dramatic difference, and the earlier a child starts receiving therapy, the better. A variety of techniques have proved to be effective, but interventions are most successful when a supportive environment is created, Lawson emphasizes. Whenever possible, a parent or parents should be participants in a child's therapy (as long as they are not the perpetrators of the abuse), and if not the biological parents, then foster parents or grandparents.

"I try to bring in whoever can help build a support system for the child," Lawson says, "because an hour a week [of counseling] is woefully inadequate, and I need to have them able to take what they learn in therapy into the home."

In many cases, parents or caregivers need help learning how to support the abused child emotionally, he says. When parents come to sessions with their children, the counselor can help the parents learn not just the best way to support the child in therapy, but also how to strengthen their parenting skills.

"We really emphasize connection," Lawson says. "Once they [abused children] have attachment, they may be ready to tell parents about their abuse and may just blurt it out at home. I try to prepare parents to listen to the child. If the parents are not comfortable addressing this [topic], I have them at least write down what the child says and then use that as a therapeutic prompt."

In sessions, Lawson guides parents, teaching them how to interact and better bond with children who have been traumatized. Some parents and caregivers have never really learned how to play with their children, he says.

At the same time, he notes that learning positive interaction skills is not just about the fun stuff. Parents and caregivers also need to know how to effectively discipline the child. "Many times when parents find out that their child has been abused, they are hesitant to discipline or correct behavior because they feel sorry for them," he says. "Or they come down too hard."

Lawson encourages parents to use time-outs, to not respond when a child is acting out with attention-getting behavior and to not use corporal punishment.

In the absence of parents or other supportive adults, the counselor may become the stabilizing adult in a traumatized child's life. Although the counselor is not with the child as often as a parent or caregiver would be, just having someone who is concerned and will listen to whatever the child wants to say can be enough for an abused child to start to heal, Lawson says, even if he or she never chooses to talk about the abuse. He notes that even in the absence of other supportive figures, the therapeutic bond between counselor and child can help in decreasing hyperarousal.

Counselors need to know that although it may seem best to address the child's trauma right away, establishing and cementing the therapeutic relationship must come first, Lawson says. The child needs to feel safe and supported - even if it is only in the counselor's office - before he or she can begin to process the trauma.

"You're trying to get them in a safe place if possible, or at least a predictable place," Lawson says. "Then we can start teaching them how to cope [with the trauma] without lashing out or
avoiding it."

Abused children do not know how to cope with what they are experiencing, Lawson says. It is common for children who are traumatized to lash out in anger when stressed and to feel that the best way to establish some sort of stability in their lives is to try to control everything. They may be moody, irritable or withdrawn. Abused children may also bully and hit other children or turn their anger on themselves and engage in self-abusive behaviors such as cutting.

Once a child feels supported, the counselor can also begin to teach the child how to self-soothe. Lawson guides traumatized children in using calming techniques such as diaphragmatic breathing or grounding themselves by focusing on something external such as the ticking of the clock or the texture of their clothes. "The point is to experience emotions in a safe place and cut out bad coping behaviors," he says.
Safety first
Jennifer Foster, an assistant professor in the Department of Counselor Education and Counseling Psychology at Western Michigan University, studies child sexual abuse. Much of her research has involved listening to the narratives of abuse victims and how they perceive what has happened to them. Although these children display myriad reactions and emotions, Foster says two themes are always prominent: fear and safety.

"Child victims of sexual abuse often view the world as unsafe and are likely to enter counseling with unresolved fears," Foster says. "They need help from their counselor to learn how to cope with their fears."

"Although adults often see disclosure as a positive thing that will put an end to the abuse, for many children it is embarrassing and frightening, especially for those who feel at fault for their abuse and believe they will be blamed or, worse, not believed," says Foster, who studied the experiences of sexually abused children for her dissertation.

Several counseling interventions are designed to help sexually abused children regain a sense of safety. One is called the "safe place technique," in which a counselor guides the child in visualizing and vividly describing an imaginary safe place.

"The counselor may say, 'Close your eyes and picture a special place where you feel completely safe,'" Foster explains. "This can be followed by specific questions to capture additional details such as: What do you see? What do you hear? What do you feel? What are you doing in your safe place? The details are recorded by the counselor and used to create a script."

Once the safe place has been established, the child can return to it mentally anytime he or she feels stressed or scared, Foster says.

Another intervention called the "comfort kit," developed by Liana Lowenstein, helps children who engage in nonsuicidal self-injury to learn self-soothing strategies, says Foster. "Counselors help children brainstorm and create a list of items that bring them comfort and make them feel better," she explains. "Although the process is guided by the counselor, children are the ones who choose what will go inside their box or bag."

Foster says children commonly include items such as a blanket, music, a favorite stuffed animal, written or recorded guided imagery, a stress ball, a list of relaxation activities, bubbles (for deep breathing exercises), a favorite book, a picture of a caring person or special place, a journal and pen, art supplies and a list of self-affirmations.

Foster is also a proponent of bibliotherapy. "Children's books about sexual abuse can introduce child victims to others who have had similar experiences, which may lead to decreased feelings of isolation and normalize their trauma-related symptoms," she says.

Books can also provide comfort, offer coping suggestions and teach kids important lessons such as that the abuse is not their fault, Foster adds.

Because fear is a predominant issue for child victims of sexual abuse, Foster also recommends stories that specifically address feeling afraid. Her suggestions include Once Upon a Time: Therapeutic Stories That Teach and Heal by Nancy Davis and A Terrible Thing Happened: A Story for Children Who Have Witnessed Violence or Trauma by Margaret Holmes. To help older adolescents explore their memories and feelings connected to sexual abuse, Foster recommends The Secret: Art & Healing from Sexual Abuse by Francie Lyshak-Stelzer. Foster notes that the author's artwork is particularly effective at capturing fear and the myriad other feelings generated by abuse.
Finding relief through play
Play therapy is one of the most commonly used interventions with children, particularly those who have suffered complex trauma, meaning they have experienced long-term (and often multiple types of) abuse, says Roaten, an LPC who works with traumatized children in clinics and schools, and an associate professor at Hardin-Simmons University in Abilene, Texas.

Most therapeutic playrooms feature a fairly specific set of toys that might include an art center, play dough, a Bobo doll (an inflatable plastic doll modeled after the inflatable clown used in Alfred Bandura's seminal study on children and aggression), a dollhouse with miniature people, animal figures, toy weapons, costumes and a sandbox. These toys and activities help children to act out their experiences in a safe and less negative manner, Roaten says. For instance, she recounts treating one child who "would just attack and slash the doll where the penis was. She was a victim of sexual abuse."

In some cases, Roaten says, children just "play through," processing their trauma entirely through play without needing to talk to the play therapist.

In many instances, Baggerly says, traumatized children act out things they aren't able to verbalize. She once treated a 6-year-old who didn't speak for about 10 sessions because the girl had a severe case of internalized anxiety and depression. But as the girl played, she would express her rage by taking a gun and shooting the Bobo doll in the head, stomach and groin area. Baggerly took this cue as a chance to ask the child about the anger and hurt she was feeling.

Catherine Tucker, a licensed mental health counselor who works with traumatized children in her role as a counselor supervisor and consultant, uses a child and family therapy called Theraplay, which was developed by the Theraplay Institute in the 1960s. "Theraplay works on a four-dimensional model: structure, nurture, engagement and challenge," says Tucker, an associate professor in the college of education at Indiana State University.

Theraplay builds and enhances attachment, self-esteem, trust in others and engagement through participation in simple games. The idea is that the four dimensions - structure, nurture, engagement and challenge - are needed by children for healthy emotional and psychological development. The "play" in Theraplay is built around activities that teach participants what the elements of those dimensions are. Ideally, children engage in Theraplay with their parents or caregivers. Participating together teaches skills to parents or caregivers who don't know how to provide the four dimensions, while enhancing the bond with the child. In the absence of parents or caregivers - whether because they are abusive or because they cannot or do not want to participate - the counselor plays directly with the child so the child can still learn how to interact in an emotionally healthy way.

The games and activities are simple - suitable for children as young as 1, yet still engaging for older children - and include things such as blowing bubbles, playing with stuffed animals, cotton ball hockey, cotton ball wars and newspaper basketball. The activities teach parenting skills and also help traumatized children with affect regulation, impulse control, feeling safe and not feeling like they have to be in control of the world, Tucker says. She notes that, oftentimes, kids who have suffered trauma feel like they have to be in charge either because a parent is abusive or simply doesn't know how to provide a sense of security or stability, or because the child's sense of control is being undermined by the abuse he or she experienced at the hands of another adult or peer.
Finding help at school
Counselors who are treating traumatized children should tap all available resources to help these clients, Lawson says, working not only with caregivers or other relatives but also with the child's school. School counselors may be a source of additional one-on-one counseling for the child, or they could get the child involved in group activities with other children who are trauma victims or with children who share common interests such as music, sports or art, Lawson says. These peer networks provide abused children additional sources of support and can also teach them how to interact with people - something that many abused and isolated children have never learned to do.

Perpetrators of abuse seek to control and isolate their victims. An abusive parent has the power to cut off or severely limit a child's healthy interactions with people outside of the circle of abuse. "[These] kids often didn't learn social skills because they are kept away from other people," Lawson says.

Abuse is often part of a viciously long-lived cycle, handed down from generation to generation, Lawson adds. Parents who were abused as children often grow up to abuse their own children. Even if parents with an abusive background are not abusive themselves, they may still carry on other dysfunctional behaviors, he says.

"You may have three or four generations of people [who] have a very skewed view of how to interact with people," he says. "So they never learn how to interact with others. You have to help [these children] connect with other sources."

School counselors also can play important roles as advocates and educators. Many people - including teachers and administrators - do not understand that many children who act out are doing so because they have been or are being abused, Tucker asserts.

"School counselors can really make a difference by making sure that kids get evaluated instead of just automatically disciplined," Tucker says.

"So many boys end up in the criminal justice system because they were physically acting out in response to trauma," she adds.

School counselors can also help abused and traumatized children learn how to help themselves, says Elsa Leggett, an ACA member, associate professor of counseling at the University of Houston-Victoria and president of the Association for Child and Adolescent Counseling.

"Talk to kids about safety plans," Leggett urges. "Ask them, 'When abusive things are going on at home, where do you go? How do you know when things are getting dangerous?'"

The most important thing that all practicing counselors can do to address childhood trauma is to ask questions, Lawson says. Children - and sometimes adults who were traumatized as children - don't always recognize what they've experienced as abuse, so rather than asking "have you been abused?" Lawson instructs his students to pose questions such as "has anyone ever hit you?" and "has anyone ever touched you in a way that made you feel uncomfortable?"

ACA member Cynthia Miller is an assistant professor of counseling at South University in Richmond, Virginia, and an LPC who has worked with incarcerated women. She has seen the kind of positive change that can occur when people get the help they need, but she has also witnessed the pattern of incarceration, addiction and institutionalization that can become entrenched in generation after generation.

"If you want to decrease the amount of money we spend on treating people with substance abuse or incarceration," Miller says, "address child abuse."
Caring for children during a disaster
Although ongoing trauma causes the biggest and longest-lasting kind of damage, one-time events can also create problems that linger. It is particularly important for children to receive timely counseling intervention, experts say.

"Typically, most children will have short-term responses to a disaster that include five basic realms," Baggerly says. These realms are:

Physical: Symptoms include headache or stomachache

Thought process: Children exhibit confusion and inattention

Emotional: Children are scared and sad

Behavioral: Children might become very withdrawn or clingy, or may start sucking their thumb or wetting the bed again

Spiritual/worldview: Children may question their beliefs about God and the world

(For more information about typical trauma responses and recommended interventions, see "Children's trauma responses and intervention guidelines" below.)

"Typically these [responses] don't last long," Baggerly says, "but that depends on the kind of support kids get in the immediate aftermath."

Ultimately, the purpose of any counseling intervention after a traumatic event is to reduce or eliminate a child's anxiety and stress, Baggerly asserts. She attempts to do that by "resetting" the child and connecting him or her to coping strategies.

"They need caring family and community support," Baggerly says, "but if it is a huge disaster, then parents and teachers are equally traumatized, so they are not able to give support to kids. That's when you need to bring people from outside."

Some children are at greater risk than others, Baggerly says. "Kids who don't have supportive family [and] who already have anxiety or have some type of developmental disability often will have ongoing symptoms that go longer than 30 days," she explains. "Counselors need to triage to find out who is at most risk."

During her roughly dozen years of experience working with chronic trauma and disasters, Baggerly has developed an integrated approach that she calls disaster response play therapy. The approach uses a trauma-informed philosophy in which counselors train parents and teachers in typical and atypical reactions to disasters so they can screen children and determine which ones need more help, she explains. "We also normalize typical symptoms, provide psychoeducation that informs kids about the impact of disasters, teach them coping strategies and provide them with child-centered play therapy."

Baggerly usually begins by gathering a group of children and talking with them about rebuilding the community. She also encourages children to use expressive arts or drama to communicate their feelings.

"The other part of what we do is facilitate connection and conversation between kids and parents," Baggerly says. "We may start out with Theraplay and do structured activities, such as holding hands or singing 'Row, Row, Row Your Boat.' The point is to have them [parents and children] looking at each other so that the mirror neurons can be engaged."

Baggerly also educates parents on activities they can do at home with their children. She refers them to an online workbook, "After the Storm," which has scales of 1 to 10 or a thermometer that kids can fill in to indicate how much stress they are feeling.

Roaten often does volunteer trauma work and provided on-site support in the wake of the April 2013 fertilizer plant explosion in West, Texas, that killed 15 people, injured more than 150 and caused extensive damage to buildings and property.

"One girl, a seventh-grader, had been standing outside in a neighborhood with a view of the plant and observed the explosion itself," Roaten says. "So she had that image in her head and it would not go away. I taught her some deep breathing and progressive relaxation and did some guided imagery about her favorite place to be.

"When that picture came up in her mind, she could breathe, relax and go to her good place. By the fourth day I was there, she was no longer seeing the image."

Roaten uses expressive therapy for children who aren't very verbal or who don't have the vocabulary to talk about their feelings. She brings a sand tray with miniatures of fences, people and buildings. She then allows children (and even adults) to set up scenarios or vignettes that help them express and act out what they are feeling.

"I might say something like, 'Create your world before [Hurricane] Katrina; then create your world after Katrina," Roaten explains.

Roaten also uses trauma-focused cognitive behavior therapy to help children and adolescents learn coping skills.

"You teach them about trauma and its impact on them," she explains. "Then you teach them relaxation and breathing skills. Once you get them to be able to self-soothe, relax and be calm, you can help them deal with pictures or scenarios that come up. You help them change the story - what they are telling themselves and what that means - which helps them work through the trauma a little bit at a time."

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Children's trauma responses and intervention guidelines Preschool through 2nd grade Typical trauma responses:

Believes death is reversible

Magical thinking

Intense but brief grief responses

Worries others will die

Separation anxiety

Avoidance

Regressive symptoms

Fear of the dark

Reenactment through traumatic play

Intervention guidelines:

Give simple, concrete explanations as needed

Provide physical closeness

Allow expression through play

Read storybooks such as A Terrible Thing Happened, Brave Bart, Don't Pop Your Cork on Monday

3rd through 6th grade Typical trauma responses:

Asks a lot of questions

Begins to understand that death is permanent

Worries about own death

Increased fighting and aggression

Hyperactivity and inattentiveness

Withdrawal from friends

Reenactment though traumatic play

Intervention guidelines:

Give clear, accurate explanations

Allow expression through art, play or journaling

Read storybooks

Middle school Typical trauma responses:

Physical symptoms such as headaches and stomachaches

Wide range of emotions

More verbal but still needs physical outlet

Arguments and fighting

Moodiness

Intervention guidelines:

Be accepting of moodiness

Be supportive and discuss when they are ready

Groups with structured activities or games

High school Typical trauma responses:

Understands death is irreversible but believe it won't happen to them

Depression

Risk-taking behaviors

Lack of concentration

Decline in responsible behavior

Apathy

Rebellion at home or school

Intervention guidelines:

Listen

Encourage expression of feelings

Groups with guiding questions and projects

Source: "Systematic Trauma Interventions for Children: A 10-Step Protocol," by Jennifer Baggerly in Terrorism, Trauma and Tragedies: A Counselor's Guide to Preparing and Responding, third edition, American Counseling Association Foundation, 201

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ACA Traumatology Interest Network
Counselors and counselors-in-training who have an interest in providing counseling services to trauma- or disaster-affected individuals and communities should consider joining the ACA Traumatology Interest Network. Network participants share insights, experiences, new plans and advances in trauma counseling services. For more information on joining the interest network, go to counseling.org/aca-community/aca-groups/interest-networks.

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To contact individuals interviewed for this article, email:

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

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The toll of childhood trauma - Counseling Today

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Mention the word trauma to Americans in the 21st century, and their thoughts are likely to turn to images of terrorism, war, natural disasters and a seemingly continual stream of school shootings. The horrific scenes at Newtown and Columbine still dominate public consciousness, particularly when our society discusses child trauma.