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Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

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Trauma and Violence: What Is Trauma and Its Effects?

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SAMHSA addresses the impact of trauma on individuals, families, and communities as a behavioral health concern that requires a healing and recovery process.

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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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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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Trauma can affect everybody differently. So you might recognise some of the experiences listed on this page. But you might also have experiences or reactions that aren't mentioned here.

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Feelings of self-blame

People who go through trauma sometimes feel as if they are to blame. This can cause very strong feelings of shame or guilt, even though it wasn't your fault.

Reasons for feeling self-blame include the following:

It can be one way your mind tries to make sense of what has happened, and to avoid overwhelming feelings ofanger,griefor betrayal.

It's how you've survived in an unsafe or stressful situation, such as living with someone who's harmed you.

You wish you could have done something differently at the time, even though you couldn't have.

Someone else blamed you for what happened or acted like it was your fault.

You were made to feel responsible for someone else's actions, even though they had power over you (this is sometimes called 'transfer of responsibility').

Even though self-blame can be very hard to cope with, it can be a way your mind tries to protect you, so it might take time and support to be able to start feeling differently. You might feel confused or overwhelmed if someone else says it wasn't your fault, although hearing this can also be a relief.

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Feelings of self-blame People who go through trauma sometimes feel as if they are to blame. This can cause very strong feelings of shame or guilt, even though it wasn't your fault. Reasons for feeling self-blame include the following: It can be one way your mind tries to make sense of what has happened, and to avoid overwhelming feelings ofanger,griefor betrayal.

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Trauma is a psychological response to an event or series of events that cause physical, emotional, and/or mental harm. The effects of trauma can be short- or long-term, and severity can vary depending on the individual. Research shows us that trauma can affect everyone differently. There are several trauma types to know about. Read on to learn about each of them.

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What Are the Different Types of Trauma?

When we think of psychological trauma, we often think of a single event that causes great harm or pain. However, different types of traumas can occur throughout our lives. Trauma isn't limited to physical events; it can also be emotional or psychological in nature. Some common trauma symptoms can include:

Flashbacks or intrusive memories of the traumatic event

Nightmares about the event

Avoidance of people, places, things, or situations that remind you of the event

Feeling numb or disconnected from others

Difficulty concentrating

Irritability

Hypervigilance

Confusion

Exhaustion

Agitation

Sadness

Anxiety

Dissociation

Chronic pain

Difficulty sleeping

Angry outbursts

Depression

Substance abuse

Self-harming behaviors

Suicidal thoughts or attempts

Believing the world is a dangerous place and that you can't trust anyone

Feeling unable to experience pleasure

"Trauma can be caused by various situations ranging from natural disasters to abuse, vehicle accidents, and more."
- Talkspace therapist Ashley Ertel, LCSW, BCD, C-DBT

While most people are familiar with the concept of trauma, many are unaware of the different types of trauma that exist. Trauma can be classified as acute, chronic, or complex.

1. Acute trauma

Acute trauma is a psychological trauma that occurs in response to a single, highly stressful event. For example, it can come after experiencing a natural disaster, seeing a bad car accident, or witnessing violence. Acute trauma can lead to long-term mental health problems if not appropriately addressed.

Examples of acute trauma

Acute trauma can come from a single event threatening your life or safety. It can also result from an act of violence against you or after witnessing a traumatic event happening to someone else.

This type of trauma can lead to acute stress disorder (ASD), which is a mental health condition typically appearing within 3 days of a traumatizing event and lasting up to 1 month.

2. Chronic trauma

Chronic trauma is a response to ongoing or repeated traumatic experiences. It differs from acute trauma in this sense, as acute trauma occurs after just one traumatic experience or event.

Examples of chronic trauma

Chronic trauma can result from any of the following:

Physical abuse: Physical abusers often use force to control their victims. They may hit, kick, choke, or throw things at them - the list goes on. It's common for physical abusers to threaten their victims and use fear and intimidation to control them.

Sexual abuse: Sexual abusers often take advantage of people who are weaker than they are. They may be in a position of power over their victim, making it easier for them to coerce or force them into sexual acts. Victims of sexual abuse often suffer from flashbacks, nightmares, anxiety disorders, depression, and post-traumatic stress disorder (PTSD), sometimes even long after the initial event occurred.

Emotional abuse: Emotional abusers try to chip away at self-esteem by putting their victims down constantly or making them feel bad about themselves.

Domestic violence: Domestic violence can cause chronic trauma. It's not always physical abuse either - mental and emotional torture can be just as debilitating. Domestic violence targets every aspect of a person's life to control them. It leaves long-term scars that can be difficult to deal with for years after the abuse has stopped.

Poverty: Growing up in poverty can result in chronic trauma. Children who grow up below the poverty line are more likely to see violence, witness drug use, and not have enough food or adequate shelter. This can lead to lasting effects such as anxiety, depression, PTSD, and more.

3. Complex trauma

Complex trauma is a type of stress similar to generational trauma that can occur when someone experiences multiple, chronic, or prolonged exposure to traumatizing events. It can happen to both children and adults. However, complex traumas like abandonment trauma, for example, are more common among those who experienced abuse or neglect during childhood.

Complex trauma can cause long-term problems with physical and mental health. Forming and maintaining healthy relationships can also be very isolating and challenging.

Examples of complex trauma

Complex trauma can harm mental and physical health due to repeated, continued traumatization. It can be the result of things like:

Childhood abuse or neglect

Domestic violence

Sexual assault

War-related experiences

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The Different Types of Trauma Explained - Talkspace

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When we think of psychological trauma, we often think of a single event that causes great harm or pain. However, different types of traumas can occur throughout our lives. Trauma isn't limited to physical events; it can also be emotional or psychological in nature.

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Preschoolers are very vulnerable to traumatic events.

They will struggle to express their fears or thoughts and will show this through changes in behaviour and how they function.

They will need assistance to make them feel safe and to help them understand the experience.

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Preschoolers may not have the words but will show their distress at traumatic events through changes in behaviour and functioning.

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Understanding the Effects of Childhood Trauma

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Understanding the Effects of Childhood Trauma

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Childhood trauma is an event experienced by a child that evokes fear and is commonly violent, dangerous, or life-threatening.¹

Northwestern University Feinberg School of Medicine. What is child trauma?.

Also sometimes referred to as adverse childhood experiences or ACEs, there are many different experiences that can lead to trauma. Unfortunately, it is all too common. An estimated 46% of children experience trauma at some point in their young lives.²

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Childhood trauma involve aversive, distressing experiences that can affect a child's ability to function and cope. Unfortunately, it is all too common. An estimated 46% of children experience trauma at some point in their young lives.

While kids are resilient, they're not made of stone. Adults often say things like, 'They were so young when that happened, they won't even remember it as an adult.' However, it is important to recognize that childhood trauma can have a lifelong effect.

"As children's brains develop, they are learning how safe or unsafe the world is through their experiences," says psychotherapist Yolanda Renteria, LPC. "A child has to develop a way to protect itself from what it deems unsafe; the ways in which a child protects itself shape their adult personality."

Because of this, it's important to recognize when a child may need professional help for dealing with their trauma. Early intervention can also prevent the ongoing effects of the trauma into adulthood.

What Is Childhood Trauma?

Childhood trauma is an event experienced by a child that evokes fear and is commonly violent, dangerous, or life-threatening. Also sometimes referred to as adverse childhood experiences or ACEs, there are many different experiences that can lead to trauma.

Physical or sexual abuse, for example, can be traumatic for children. One-time events like a car accident, natural disaster (like a hurricane), the loss of a loved one, or a major medical incident can take a psychological toll on children as well.

Ongoing stress, such as living in a dangerous neighborhood or being the target of bullying, can also be traumatic for a child-even if it just feels like daily life to an adult.

Childhood trauma doesn't even have to involve experiences that occur directly to the child. Watching a loved one endure a major health issue, for instance, can be extremely traumatic for children. Violent media can have this effect too.

Childhood Trauma and PTSD

As many as 15% of girls and 6% of boys develop post-traumatic stress disorder (PTSD) following a traumatic event. Children with PTSD may re-experience the trauma in their minds over and over again. They might also avoid anything that reminds them of the trauma or re-enact the trauma in their play.

Sometimes children believe that they missed warning signs predicting the traumatic event. In an effort to prevent future traumas, they become hypervigilant in looking for signs that something bad is going to happen again.

Children with PTSD may also:

Act younger than they are (such as by sucking their thumb)

Experience trouble focusing

Feel more depressed or anxious

Find it difficult to be affectionate with others

Have increased anger and aggression

Have issues in school

Have trouble sleeping

Lose interest in activities they once enjoyed

Lose touch with reality

Seem detached, numb, or non-responsive

Worry about dying young

Even children who don't develop PTSD may still exhibit emotional and behavioral issues following a traumatic experience. Here are some things to watch for during the weeks and months after an upsetting event:

Anger issues

Attention problems

Changes in appetite

Development of new fears

Increased concerns about death or safety

Irritability

Loss of interest in normal activities

Problems sleeping

Sadness

School refusal

Somatic complaints like headaches and stomachaches

Impacts of Childhood Trauma

Traumatic events can affect how a child's brain develops, which can have lifelong consequences for them physically, mentally, and socially.

Physical Health Impacts

When a child experiences a traumatic event, it can impair their physical development. The stress can impair the development of their immune and central nervous systems, making it harder to achieve their full potential.

Specifically, it notes that exposure to repeated trauma increases a child's risk of developing:

A 2019 review of 134 different research-based articles adds that exposure to adverse experiences as children increases the risk of developing several different conditions-such as autoimmune diseases, pulmonary disease, cardiovascular disease, and cancer-in adulthood, as well as increasing levels of pain.

Mental Health Impacts

Childhood trauma can also have an impact on mental health. Psychological effects of traumatic experiences can include:

Children exposed to complex traumas may even become disassociated. Dissociation involves separating themselves from the experience mentally. They might imagine that they are outside of their bodies and watching it from somewhere else or they may lose memory of the experience, resulting in memory gaps.

Research published in Psychiatric Times further notes that the prevalence of suicide attempts is significantly higher in adults who experienced traumas such as physical abuse, sexual abuse, and parental domestic violence as a child.

Relationship Impacts

A child's relationship with their caregivers-whether they be parents, grandparents, or other familial or non-familial adults-is vital to their emotional and physical health. The attachment children have with their caregivers can help them learn to trust others, manage emotions, and positively interact with the world around them.

When a child experiences a trauma that teaches them that they cannot trust or rely on that caregiver, they're likely to believe that the world around them is a scary place and people are dangerous. This lesson makes it incredibly difficult to form relationships throughout their childhood and into their adult years.

Children who experience trauma are also likely to struggle with romantic relationships in adulthood. A 2017 study in the Journal of Family Psychology found that spouses with a history of child abuse tend to have less satisfying marriages, even when still in the newlywed phase.

Renteria notes that the lasting effects of trauma often depend on the nature and severity of the event. In some cases, it may lead to feelings of anxiety or avoidance coping that some partners may find frustrating or confusion.

Yolanda Renteria, LPC

She also explains that some common relationship struggles that can stem from such trauma include:

Difficulty trusting

Being physically and verbally distant

Defensiveness

Difficulty being vulnerable

Difficulty giving their partner the benefit of the doubt

Difficulty with communication skills

Difficulty seeing their partner as their ally

Other Impacts

Sometimes the impact of childhood trauma extends beyond physical or mental health and relationships. For instance, some studies have connected adverse childhood experiences with an increased risk of becoming a criminal offender by the age of 35, oftentimes committing offenses that are serious and violent.

Additional impacts can include:

Being easily "set off" and having more intense reactions

Engaging in high-risk behaviors (such as driving at high speeds or unsafe sex)

Inability to plan ahead or prepare for the future

Increased risk of self-harm

Lack of impulse control

Low self-esteem

Trouble problem-solving or reasoning

Children experiencing traumatic events may also have a reduced ability to parent their own kids later in life.

Untreated Childhood Trauma

How to Help Children Who Have Experienced Trauma

Social support can be key to reducing the impact trauma has on a child, even as far as reducing their risk of suicidal ideation. Here are some ways to support a child after an upsetting event:

Encourage the child to talk about their feelings and validate their emotions.

Help them understand that they are not at fault.

Answer their questions honestly.

Reassure the child that you'll do everything you can to keep them safe.

Stick to a daily routine as much as possible.

Be patient as each child recovers at their own pace.

Depending on the child's age and needs, they may be referred for services such as cognitive behavioral therapy, play therapy, or family therapy. In some cases, such as when there is a diagnosis of PTSD, medication may also be an option to help treat their symptoms.

How to Heal From Your Own Childhood Trauma

If you experienced trauma as a child and still have some healing to do, there are several actions you can take to help you better cope. Among them are:

Talking to a mental health professional can also help you start to heal. Therapeutic options may include a number of trauma-informed therapies, such as cognitive processing therapy (CPT), trauma-focused cognitive behavioral therapy (TF-CBT), eye movement desensitization and reprocessing (EMDR), and acceptance and commitment therapy (ACT), among others.

You may also want to reach out to reputable organizations able to help childhood trauma survivors. The Disaster Distress Helpline offered by the Substance Abuse and Mental Health Services Administration (SAMHSA) is one option. If you prefer to communicate via text, the Crisis Text Line is another.

A Word From Verywell

While it's normal to have some level of distress following a traumatic event, it's not out of the question that children can return to a healthy state of functioning-and some kids are less affected by their circumstances than others.

If childhood trauma has created negative effects, it is never too late to get help. Whether you've adopted a teenager who was abused over a decade ago or you've never received help for the traumatic experiences you endured 40 years ago, trauma treatment can still be effective and beneficial.

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The effects of childhood trauma can be debilitating and last a lifetime without early intervention. Here's how to recognize the signs of trauma and get help.

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When upsetting things happen to a child, their parents and teachers will try to help them work through their distress or grief in a healthy way. Most will rebound without suffering long-term effects. But some children are more at risk for experiencing long-term pain. These kids include those who have lost a close friend and those who learned about an event or loss in a very upsetting way.

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In the wake of a disturbing event or tragic loss in the lives of children, we know parents and teachers will do their best to help kids cope with their grief and anxiety in a healthy way. We have provided some tips on how best to engage kids in a calm and supportive dialog about their feelings-it's certainly not easy to do, but it can make a big difference to kids.

Still, some children are more at risk than others for suffering long-term effects from an upsetting event, including those who have lost close friends or classmates and those who might have learned about the event or loss in a particularly emotional and upsetting way.

How a child experiences an event and how it's handled by those around him have an effect on how traumatizing it can be, notes Child Mind Institute psychologist Jerry Bubrick, PhD. When families come upon news accidentally, parents can be caught off guard and respond in a highly emotional way that can impact children. Television coverage and shocking newspaper headlines can also amplify the impact of a disturbing event or loss.

So even as you try to soothe and comfort children, it is important to recognize the signs of unhealthy coping that would suggest a visit with a professional might be needed. In extreme cases, children can develop post-traumatic stress disorder, but even less extreme PTSD-like symptoms can interfere with a child's life and happiness. Here are some signs to look for and things to keep in mind.

"Everyone grieves at a different pace," Dr. Bubrick says, and an immediate reaction-or lack of one-is not really an indicator of how a child will cope with the loss. "If a child seems to be coping well now, they might still have a poor reaction later," he says. "Or it could also just be a sign that they're handling it well." So while we want to help our children as much as possible immediately after the event, a lasting and hurtful response usually won't be evident until 3 or 6 months later.

Increased thinking about death and safety

One common sign of PTSD or a PTSD-like reaction is what Dr. Bubrick calls a "hyper-focus on mortality or death." And while some kids become notably morbid and fascinated by death, others will develop an obsession with their own safety and the safety of those close to them. In the case of a fire or another disaster, their thoughts might return with disturbing regularity to the possibility of a fire in their own home, or of the earthquake or flood happening where they live.

Problems with sleeping, eating, anger, and attention

Some of the symptoms of trauma in children (and adults) closely mimic depression, including too much or too little sleep, loss of appetite or overeating, unexplained irritability and anger, and problems focusing on projects, school work, and conversation. Sometimes the symptoms appear more like an anxiety disorder-obsessive or pervasive worry, difficulty separating from parents.

A year after a tragic event, we tend to look back, take stock, and memorialize those whose lives were lost. But as Dr. Bubrick observes, there are other anniversaries connected to children's lives that could have unexpected consequences for them- the birthdays of friends or classmates who died, for instance. Children "could be basically OK between now and then, maybe with some rocky periods," he says. "And then around the time of the birthday, they could have more symptoms. It's a trigger."

When an event is connected to school, such as the loss of classmates or violence at school itself, an unhealthy reaction could take the form of avoiding school. As Dr. Bubrick points out, school is "where the most reminders of the kids' deaths will be." While episodes of depression, heightened anxiety, trouble sleeping, and a fixation on the accident may be transient, avoiding school is a clear sign that something is wrong. "For the most part, everyone is going to experience some form of those things, altogether or in pieces," says Dr. Bubrick. "But if, over time, it's not really lifting and it's continuing, it may result in school refusal altogether. At that point we definitely know the child needs help."

You should also know that stress and trauma can manifest differently in girls and boys. Although this is by no means definitive, boys often react more quickly and with more irritation and anger, while girls can have delayed reactions that are more internal.

Frequently Asked Questions

What are the signs of trauma in a child?

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Signs of Trauma in Children - Child Mind Institute

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What to watch for in the weeks and months after an upsetting event - signs of trauma in children and how to begin to address the issue.

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Parents do everything they can to protect their children. But sadly, many kids have gone through trauma.

A trauma is any event that is deeply upsetting, scary, or harmful. Things like abuse, violence, accidents, or natural disasters can be traumas. Becoming homeless, losing a parent, or a serious illness can be traumas too

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Parents do everything they can to protect their children. But sadly, many kids have gone through trauma.

A trauma is any event that is deeply upsetting, scary, or harmful. Things like abuse, violence, accidents, or natural disasters can be traumas. Becoming homeless, losing a parent, or a serious illness can be traumas too.

Traumas are serious events that cause kids to fear for their life or safety.

After a trauma, the emotional effects can last a long time. It can be hard to move on. For some kids, trauma can lead to post-traumatic stress disorder (PTSD).

But kids can recover after trauma. There is therapy that can help. Kids also need extra support and comfort from parents.

How Does Trauma Affect Kids?

Trauma affects a child's sense of safety and trust. After a trauma, kids can still feel tense or scared. Some feel alone, sad, angry, or guilty. They may think they are to blame for what happened to them. For some kids, there's a loss of self-esteem or dignity. For some, there's deep grief.

Trauma also can affect a child's mood, behavior, or sleep. Some kids become depressed. They might act grumpy or seem sad. Some get in trouble more often, or do worse in school. Some have new fears, or trouble sleeping. Some have upsetting memories, called flashbacks. Often, kids avoid things that remind them of what they've been through.

After a trauma, some kids share how they feel. But other kids keep things to themselves. They may try to hide how they feel, or try to push it out of their minds. They may think others expect them to "get over it." Some just don't have words for their feelings. For any of these reasons, a parent might not know what their child is going through.

How Does Therapy Help Kids Heal After a Trauma?

Therapy gives kids a way to safely share their feelings, tell their story, and get support. In therapy, kids learn to talk about what they've been through. They learn coping and calming skills. They learn to adjust the way they think and feel about the trauma. Slowly, they learn to face things they used to avoid. Therapy helps kids find their own courage and gain confidence.

Child therapy for trauma is called trauma-focused cognitive-behavioral therapy (or TF-CBT). Therapy includes talk, play, and learning activities that heal trauma.

TF-CBT helps parents too. It's natural for parents to feel upset about what their child has been through. In therapy, parents get the support they need. They get advice on how to help their child at home.

In TF-CBT, parents can play a big role in their child's healing. They are coached to listen in ways that help their child open up, talk, and feel close. They help their child practice coping skills at home. They share in the good feelings as their child makes progress.

How Can I Find Therapy for My Child?

Talk to your child's doctor. Let them know what your child has been through. Your child's doctor cares about your child's mental health too.

Ask your child's doctor to refer you to a trained child therapist who can help. You might need to take your child to therapy once a week for a few months. But you'll see progress along the way.

How Can I Give My Child the Extra Support They Need?

After a trauma, kids need your support and comfort more than ever. Be sure to:

Spend time with your child. Do things that are soothing, relaxing, or fun. Cook together, take a walk, play, read, make art, or sing. Try to do this every day, even if it's only for a few minutes.

Parent with patience and warmth. Use kind words. Give praise when your child is doing well or trying hard. Let your child know you're proud of them. Be patient when they make a mistake. Show them how to try again.

Show love. Use hugs, smiles, words, and caring actions to show your love. Use soothing words and offer comfort when your child is upset.

Have soothing routines. Take a few minutes at bedtime (or any time) to read a story, snuggle together, or sing to your young child. For older kids, make it a routine to give a good night hug, along with a few minutes to talk, listen, or laugh together. Those extra few minutes with you can help your child feel calm, safe, and relaxed.

These may seem like small things - things you already do. But giving extra support and time keeps your child feeling loved and close to you. After a trauma, that closeness matters more than ever.

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Helping Your Child Heal After Trauma (for Parents) - Nemours KidsHealth

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Kids can recover after trauma with help from therapy and extra support and comfort from parents.

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Trauma-informed care shifts the focus from “What’s wrong with you?” to “What happened to you?” A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient’s life situation — past and present — in order to provide effective health care services with a healing orientation. Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. It can also help reduce avoidable care and excess costs for both the health care and social service sectors.

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There are a number of benefits to using a trauma-informed approach, not only for patients but also for providers and staff. Many patients with trauma have difficulty maintaining healthy, open relationships with a health care provider. For patients, trauma-informed care offers the opportunity to engage more fully in their health care, develop a trusting relationship with their provider, and improve long-term health outcomes. Trauma-informed care can also help reduce burnout among health care providers, potentially reducing staff turnover.

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Learn about how trauma-informed care shifts the focus from "What's wrong with you?" to "What happened to you?"

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Addressing Trauma: Support and Resources for Young Children

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Addressing Trauma: Support and Resources for Young Children

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When events such as parental incarceration, family separation, abuse or neglect, the illness or death of a parent, or natural disasters occur early in life, they weigh on children emotionally and physically.

Young children can quickly absorb information, environments, love and trauma. Constant and excessive exposure to toxic stress can rewire the developing brains of young children and trigger constant stress responses — fight, flight or freeze.

Not every young child suffers traumatic stress after a distressing event, but for those who do, trauma can profoundly affect their well-being and development.

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Home Children of all ages can experience the impact of trauma. When events such as parental incarceration, family separation, abuse or neglect, the illness or death of a parent or sibling, or natural disasters occur early in life, they weigh on children both emotionally and physically.

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A traumatic event is a frightening, dangerous, or violent event that poses a threat to a child’s life or bodily integrity. Witnessing a traumatic event that threatens life or physical security of a loved one can also be traumatic. This is particularly important for young children as their sense of safety depends on the perceived safety of their attachment figures.

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The National Child Traumatic Stress Network

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Children who suffer from child traumatic stress are those who have been exposed to one or more traumas over the course of their lives and develop reactions that persist and affect their daily lives after the events have ended.

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When a child feels intensely threatened by an event he or she is involved in or witnesses, we call that event a trauma. There is a range of traumatic events or trauma types to which children and adolescents can be exposed.

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The National Child Traumatic Stress Network

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When a child feels intensely threatened by an event he or she is involved in or witnesses, we call that event a trauma. There is a range of traumatic events or trauma types to which children and adolescents can be exposed.

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There are 10 types of childhood trauma measured in the Adverse Childhood Experience Test.  Each type of trauma that you mark as Yes counts as one.

It’s important to remember is that the Adverse Childhood Experience (ACE) score is meant as a guideline only and does not take into consideration the positive relationships throughout your childhood.

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Online ACE Test - Adverse Childhood Experience Test

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Discover the lasting effects of childhood traumas with the online Adverse Childhood Experience Test. Free online ACE test with no personal information required.

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Addressing Trauma: Support and Resources for Young Children

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Addressing Trauma: Support and Resources for Young Children

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When events such as parental incarceration, family separation, abuse or neglect, the illness or death of a parent, or natural disasters occur early in life, they weigh on children emotionally and physically.

Young children can quickly absorb information, environments, love and trauma. Constant and excessive exposure to toxic stress can rewire the developing brains of young children and trigger constant stress responses — fight, flight or freeze.

Not every young child suffers traumatic stress after a distressing event, but for those who do, trauma can profoundly affect their well-being and development.

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Home Children of all ages can experience the impact of trauma. When events such as parental incarceration, family separation, abuse or neglect, the illness or death of a parent or sibling, or natural disasters occur early in life, they weigh on children both emotionally and physically.

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National Center for Mental Health Promotion and Youth Violence Prevention

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National Center for Mental Health Promotion and Youth Violence Prevention

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It is important for schools, communities, parents, caregivers, and all those serving children and families

to understand the full extent of trauma on young children, school-aged kids, and adolescents. With this

knowledge, Safe Schools/Healthy Students (SS/HS) project directors (PDs) can work with school and

community leaders to help children cope with trauma and develop the skills they need to succeed in

school and in life.

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The word “trauma” literally means wound, shock, or injury. Psychological trauma is a person’s experience of emotional distress resulting from an event that overwhelms the capacity to emotionally digest it. The precipitating event may be a one-time occurrence or a series of occurrences perceived as seriously harmful or life-threatening to oneself or loved ones. People process experiences differently, and not everyone has the same reaction to any event; what one person experiences as trauma may not cause distress for another.

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Trauma is a person's emotional response to a distressing experience. Few people can go through life without encountering some kind of trauma. Unlike ordinary hardships, traumatic events tend to be sudden and unpredictable, involve a serious threat to life-like bodily injury or death-and feel beyond a person's control.

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A traumatic event is a scary, dangerous, or violent event. An event can be traumatic when we face or witness an immediate threat to ourselves or to a loved one, and it is often followed by serious injury or harm (NCTSN Parents and Caregivers Website). When this happens it can cause emotions such as fear, loss, or distress.  Sometimes people experience these types of strong negative emotions in reaction to the experience or because the person may not have the ability to protect or stop the event from happening. Reactions to a traumatic event can also have lasting effects on the individual’s daily functioning including possible changes in a child’s mental, physical, social, emotional, and/or spiritual health (See traumatic stress below for more information).

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Center for Child Trauma Assessment and Service Planning

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What are Traumatic Events?

A ( traumatic event is a scary, dangerous, or violent event. An event can be traumatic when we face or witness an immediate threat to ourselves or to a loved one, and it is often followed by serious injury or harm NCTSN Parents and Caregivers Website). When this happens it can cause emotions such as fear, loss, or distress. Sometimes people experience these types of strong negative emotions in reaction to the experience or because the person may not have the ability to protect or stop the event from happening. Reactions to a traumatic event can also have lasting effects on the individual's daily functioning including possible changes in a child's mental, physical, social, emotional, and/or spiritual health (See traumatic stress below for more information).

The image below illustrates some potentially traumatic events. This is not a comprehensive or complete list. Your child or a child you know may have experienced something that is not on this list, but the event could still qualify as or feel traumatic. But remember, not all events may be considered traumatic for each individual.

For this list and more information about traumatic events check out the NCTSN's Resources for Parents and Caregivers webpage. Additionally, for more detailed descriptions of different traumatic events, click check out the NCTSN's Definitions of Different Trauma Types document.

While many of the examples listed above may be more easily thought of or identified as traumatic, other events might be less obvious when thinking about the potential of traumatic impact. For example, many families might need to relocate due to job changes, financial hardship, or military involvement. While these are fairly common occurrences for some families, they could have a lasting traumatic impact. It is also important to remember that all youth in foster care, independent of why they might have entered foster care, have experienced changes in caregivers and living situations, and it is important to take into consideration how these events may have made an impact.

What are ACEs?

Another term that you may hear a clinician use when referring to difficult or scary experiences is Adverse Childhood Experiences or ACEs. The ACE study is an ongoing research study that explores the relationship between childhood trauma experience and long-term medical health and social consequences. Results show that approximately 65% of children experience at least 1 adverse event during their childhood and that nearly 40% of children experience at least 2 or more ACEs.This study further has repeatedly found that the greater number of ACEs a child has been exposed to, the greater he/she is at risk for developing physical and mental health problems throughout their lifespan (e.g. heart and lung disease, alcoholism, risk for initimate partner violence, drug use, poor academic or work performance, depression, suicide) ACEs include many traumatic experiences, but are broader in nature. The original ACEs study included the following 10 adverse childhood experiences

1. Physical abuse

2. Sexual abuse

3. Emotional abuse

4. Physical neglect

5. Emotional neglect

6. Mother treated violently

7. Household substance abuse

8. Household mental illness

9. Parental separation or divorce

10. Incarcerated household member

Since the original study, the list has expanded to include additional types of adverse experiences. For more information about ACEs, please visit acestudy.org.

What Is Child Traumatic Stress?

If your child has reactions that impact his/her daily life after a traumatic event, these responses are called child traumatic stress. These reactions may show up in different ways, such as changes in your child's behavior (such as more being irritable, withdrawn, or acting younger than his/her age), difficulties in interactions with others, problems or changes in sleeping or eating patterns, or school performance. The National Child Traumatic Stress Network (NCTSN) states, "Child traumatic stress occurs when children and adolescents are exposed to traumatic events or traumatic situations that overwhelm their ability to cope."

When these stress symptoms develop, they happen automatically (i.e., are not in your child's conscious control) as your child attempts to manage negative emotions (like fear) that emerges in response to memories of the event. The difficulties or stress symptoms can present immediately or show up later. They may also continue for days, weeks, or months after the traumatic experience and/or may resurface at different periods throughout a young person's life. Some children may be more susceptible to developing traumatic stress reactions than others.To learn more about this click here: http://www.nctsn.org/resources/audiences/parents-caregivers .

Signs and Symptoms of Traumatic Stress

When your child experiences traumatic stress, he or she may act in an uncharacteristic or not typical way for him or her. These reactions may continue for days, weeks, or months after the traumatic experience. They also could emerge weeks or months after the event took place. Remember these are normal reactions to your child having survived an overwhelming life experience.

The signs and symptoms of traumatic stress look different in each child and at different ages. Below is a diagram to help family members understand traumatic stress symptoms by age. Diagram recreated from the Understanding Trauma webpage within NCTSN's Resources for Parents and Caregivers website.

If your child has experienced a traumatic event and/or if you recognize any concerning symptoms or behaviors, you are not alone. Don't hesitate to ask for help. Click on the "What is Trauma Therapy?" tab to learn more about healing options for your child, your family, and you.

THE "THREE E's" OF TRAUMA

Another way to understand and define trauma may be by remembering the "Three E's of Trauma," developed by the Substance Abuse and Mental Health Administration (SAMHSA). The "Three E's of Trauma" are: Event, Experience, and Effect.

The "Event" refers to the threat or actual experience of harm which may occur once or multiple times to your child. Some events may include abuse, neglect, death of a loved one, or bullying.

Caregiver Pause and Reflect: Did an event take place in my child's life?

The "Experience" refers to your child's unique perception of the event described above - remember, an event that is scary or overwhelming to one child might not be for another child. In this domain, you are looking to understand your child's potential experience or perception of the event. Some feelings that your child might experience include shame, isolation, betrayal, fear, etc.

Caregiver Pause and Reflect: How might my child feel about the event that occurred? Could my child be experiencing any of the emotions listed above or any other negative feelings? What could the event mean to him or her? Could the event have changed the way my child feels about the world, others, or about him or herself?

The "Effect" refers to the impact the event and experience has upon your child. The impact can be short-term or long-term and it may come on immediately or show up later. The effect and experience of the event might result in new or increased problems in social or family relationships, changes in sleep, eating,or mood, and difficulties thinking, concentrating, and/or expressing emotions.

Caregiver Pause and Reflect: How has my child changed after the event and in what ways? Does my child exhibit any of the examples listed in the chart above? Or have you noticed any other changes?

For more information on the Three E's of Trauma, click HERE.

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A ( traumatic event is a scary, dangerous, or violent event. An event can be traumatic when we face or witness an immediate threat to ourselves or to a loved one, and it is often followed by serious injury or harm NCTSN Parents and Caregivers Website).

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Adverse childhood experiences (ACEs) can have a lasting impact on your health and well-being. The negative experiences of childhood trauma can affect your growth and development. They can lead to physical, mental and behavioral health problems. ACEs can also decrease your life expectancy. But with treatment, you can still lead a fulfilling life.

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Adverse Childhood Experiences (ACEs) & Childhood Trauma

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Adverse childhood experiences (ACEs) are traumatic events that happen between the ages of 1 and 17. ACEs affect a person’s overall health.

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Helping Children and Adolescents Cope With Traumatic Events

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Helping Children and Adolescents Cope With Traumatic Events

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Every year, children and adolescents experience disasters and other traumatic events. Family, friends, and trusted adults play an essential role in helping youth cope with these experiences.

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National Institute of Mental Health (NIMH)

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Helping Children and Adolescents Cope With Traumatic Events

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This fact sheet presents information on how children and adolescents respond to traumatic events, and what family, friends, and trusted adults can do to help.

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The Kids Are Not All Right: How Trauma Affects Development

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The Kids Are Not All Right: How Trauma Affects Development

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Most Americans are familiar with the concept of Post-Traumatic Stress Disorder (PTSD) as a condition affecting veterans or those exposed to terrible violence. In fact, PTSD has grown out of conditions informally referred to as “war neurosis” or “shell shock”.  What is less well known is that many children are coming out of their childhoods with similar conditions that fit the clinical profile of PTSD. Growing up in environments with instability, abuse, neglect, and impoverishment can create stress and trauma that look like PTSD and affect development. Trauma is so prevalent among children, clinicians have proposed a new term to attempt to explain it: Developmental Trauma Disorder.

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The Kids Are Not All Right: How Trauma Affects Development - Focus for Health

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Developmental Trauma Disorder is a new phrase used for children growing up with seriously adverse symptoms, like those seen in combat veterans with PTSD.

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How to Support Students Who Have Experienced Trauma

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How to Support Students Who Have Experienced Trauma

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The effects of childhood trauma often manifest in the classroom in the form of disruptive student behavior. So how is a new educator to bridge the gap between expectation and reality?

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When you think of your first year teaching, you probably imagine a group of bright young minds, looking forward to school. But behind those eager faces, some students may be experiencing trauma- induced stress and fear. Almost half of America's youth have had at least one traumatic childhood experience, according to data from the National Survey of Children's Health, with that number rising to 55 percent for youth older than 12.

The effects of childhood trauma often manifest in the classroom in the form of disruptive student behavior. So how is a new educator to bridge the gap between expectation and reality?

It's important to understand how trauma affects the brain and behavior. Scientists tell us that a child's brain physically changes after experiencing poverty, eviction, or hunger, or after witnessing violence at home or in the community. The brain adapts for survival under the worst conditions. As a result, these young people will frequently exhibit "fight, flight, or freeze" responses to stress.

Living in a constant, fear-activated state of hyper-awareness means these students can be quick to rage. They can be perceived as defiant, disrespectful, or overly aggressive, explains Illinois special education teacher Kathi Ritchie. 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.'"

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

Use calming colors, more subdued lighting, and sensory tools, such as stress balls, that help students regulate their emotions. Create a "cool-down" corner where students

can take a break and self-soothe. Thoughtful breathing or mindfulness exercises also can be helpful.

Use predictable and consistent classroom routines: first breakfast, then seat work, followed by circle time. Give advance warning of any changes.

Ask students to repeat verbal instructions and use visual cues, including more written instructions or visual prompts for multi-step directions-like a sticky note on a desk. The brains of some traumatized students are ill-adapted for language development or memory retention.

These cues and prompts help alert the student to move on to the next task.

Be flexible. The work of a trauma-informed educator isn't about using a special "trauma curriculum," it's about giv- ing students the support they need to access your regular curriculum, says John Snelgrove, head of guidance services for Brockton Public Schools in Massachusetts. This includes implementing restorative practices that allow students to examine their behavior and make amends.

NEA offers toolkits, information, and other resources to help educators support students who have experienced trauma at nea.org/trauma-informed.

"What educators need to know is that they can adapt, too," says Deb Stevens, director of instructional advo- cacy for the Delaware State Education Association. With professional training, educators can reduce the impact of traumatic experiences and help foster learning. "You must believe you can make a difference," she says.

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How to Support Students Who Have Experienced Trauma: A Guide for Aspiring Educators | NEA

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The effects of childhood trauma often manifest in the classroom in the form of disruptive student behavior. So how is a new educator to bridge the gap between expectation and reality?

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WHAT TRAUMA CAN LOOK LIKE IN THE CLASSROOM (AND SCHOOL)

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WHAT TRAUMA CAN LOOK LIKE IN THE CLASSROOM (AND SCHOOL)

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CHILDREN EXPOSED TO TRAUMA STRUGGLE TO:  Accurately perceive-safety (over perceive danger)  Self-regulate (attention, behavior, emotion)  Hold a self image that includes the belief that they matter  Succeed academically and or socially at schoo

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Back to School Child Trauma Guide: Tips for Parents and Caregivers

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Back to School Child Trauma Guide: Tips for Parents and Caregivers

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Children who have experienced violence or abuse may carry trauma into every aspect of their lives. Trauma can profoundly disrupt a child’s life, especially when they experience it in their younger formative years. Childhood trauma can turn even the smallest surprises or changes into overwhelming challenges, which can make preparing to return to school tough.

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Back to School Child Trauma Guide: Tips for Parents and Caregivers

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If your child experienced trauma and is going back to school, read these expert tips for supporting traumatized children for back to school.

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Classroom Strategies to Support Students Experiencing Trauma

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Classroom Strategies to Support Students Experiencing Trauma

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Schools are uniquely positioned to provide students with academic and social-emotional supports that can address many of the potential impacts and symptoms of trauma. Many students spend most of their time at school and school staff consistently and frequently interact with students. These interactions enable school staff to be aware of and sensitive to students' needs in the context of the surrounding community and their family life. Importantly, safe, engaging, and supportive learning environments, as well as healthy and supportive relationships with caring adults, can serve as potential protective factors that buffer against the negative impacts of trauma and stress. ⁵

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Classroom Strategies to Support Students Experiencing Trauma | IES

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Students are facing increased stressors and trauma stemming from the consequences of the opioid epidemic, racial injustices, and the recent COVID-19 pandemic which are contributing to a range of negative social-emotional, behavioral, and academic outcomes in school performance. Schools are uniquely positioned to provide students with academic and social-emotional supports that can address many of the potential impacts and symptoms of trauma. This blog discusses trauma-informed strategies and…

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For many kids who suffer from trauma, it’s not one event. Often, it’s ongoing abuse or neglect. This could be violence at home or in their neighborhood. For some, it’s not having a place to sleep. Trauma affects the way kids act in classrooms. Children who’ve gone through trauma are good at hiding pain. Instead, it comes through in ways that look like misbehavior or even ADHD.

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How Trauma Affects Kids in School - Child Mind Institute

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Learn how trauma from ongoing neglect, abuse, homelessness or violence causes children to have problems with learning and behavior. How to help these kids.

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Provides school administrators, teachers, staff, and concerned parents with basic information about working with traumatized children in the school system.

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The National Child Traumatic Stress Network

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Provides school administrators, teachers, staff, and concerned parents with basic information about working with traumatized children in the school system.

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Teaching Teachers to Respond to Trauma in the Classroom

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Teaching Teachers to Respond to Trauma in the Classroom

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First Steps in Creating a Trauma-Informed School Culture

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Trauma can have significant and lasting effects on students. This PD Café will help you learn how to recognize the signs of trauma, better understand the causes of trauma, and take steps to establish social and emotional safety in your classroom.

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Responding to Trauma in Your Classroom

Bad Behavior or Reacting to Trauma?

Think of a student who challenges you. Have you observed any of these behaviors in that student?

Excessive anger

Unusual startle reactions

Loss of appetite

Extreme fatigue

Physical or verbal aggression

Regular tardiness or absence from class

Perfectionistic, controlling or anxious behavior

Difficulty concentrating

Frequent headaches or stomachaches

Low self-confidence

Irritability

Clinginess

Trouble making friends

Self-harm or suicidal ideation

Hoarding

Risky behaviors (including drug or alcohol abuse or sexual acting out)

Panic attacks

Extreme self-reliance

Running away

Defiance

Alienation from peers

If you've observed even some of these behaviors (or other troubling symptoms), you may have a student who is directly or indirectly experiencing trauma. Trauma can be defined as the reaction to a shocking or painful event or series of negative events. Some traumas require immediate intervention and court-mandated reporting; others go by unmarked. Regardless of whether or not you are aware of the details, there are things you can do to mitigate the effects of trauma for individual students and for all students in your classroom.
Source: Mental Health Connection of Tarrant County
What Causes Trauma?

Trauma affects the ways individuals feel, think and behave. It influences self-perception as well as beliefs about other people and the world.

Though this list is not exhaustive, traumatic experiences can include:

Medical crises

Accidents or injuries (like a house fire or car collision that threatens the student's safety)

Bullying or harassment

Family separation (due to incarceration, deployment, divorce, foster placement or death)

Natural disaster

Abuse (emotional, physical or sexual)

Neglect

Observation of domestic, community or school violence

Substance abuse

Mental illness

Terrorism and war

Instability due to being unhoused

Poverty

Overt discrimination or constant microaggressions

Refugee or undocumented status

More students may suffer trauma-or suffer more trauma-than you can see or know. Trauma is difficult to assess and identify; it's also specific to the individual. An event that may traumatize one person may not traumatize another person. Moreover, the same event may lead to different trauma symptoms in different people.
Source: The National Child Traumatic Stress Network
Responding to Trauma

Proactively applying trauma-informed classroom strategies benefits all students. Students respond positively when educators get to know their individual circumstances, affirm their identities and cultivate empathy in the classroom. Here are some ideas to consider incorporating in your teaching practice:

Establish social and emotional safety in your classroom.

Social and emotional safety is the cornerstone of positive classroom outcomes. Research shows that students need to feel both physically and emotionally safe to learn. Students experiencing trauma, including bias, bullying and social isolation, are more likely to feel unsafe.
Strategies

Classroom contracts

Explicit anti-bullying or community-building curricula

Timely interventions in conflicts and hurtful exchanges

Teaching and modeling of empathy and active listening skills

Create a behavior-management plan that focuses on positive reinforcement.

Discipline and behavior management are central to classroom culture and often present unique challenges for students responding to traumatic events or experiences. Foster compassion for and among your students. Focus on praising students for appropriate classroom behavior, not on punishment.
Strategies

Implement student-generated agreements and contracts

Adopt "zero indifference" (NOT zero-tolerance) policies

Seek out training in restorative justice techniques

Explore stress-management strategies to diffuse tense situations and help students process feelings in the moment

Give students opportunities to demonstrate their strengths

Increase your self-awareness and trauma competency.

Increase your knowledge about trauma and how it may manifest for your students. Remember, students respond to trauma in different ways, and their responses may be influenced by cultural traditions, religious beliefs or familial relationships. Connect with students and their families to identify resources and services that can inform how best to support students who experience trauma.
Strategies

Seek professional development on working with specific identity groups

Share support resources with other educators

Connect with community organizations

Engage in ongoing self-assessment and reflection on your trauma responsiveness

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Trauma can have significant and lasting effects on students. This PD Café will help you learn how to recognize the signs of trauma, better understand the causes of trauma, and take steps to establish social and emotional safety in your classroom.

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Responding to Trauma-Related Behaviors in Early Childhood Settings

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Responding to Trauma-Related Behaviors in Early Childhood Settings

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When young children have experienced trauma, it affects their behavior and interactions in the classroom. How can early childhood teachers and caregivers respond to trauma-related behaviors in order to best support children’s needs? In this video, experts discuss how the organization of the brain affects children's response to trauma and discuss regulatory and relational strategies that are most effective at supporting children demonstrating trauma-related behaviors. The experts caution against using behavioral strategies for children who have experienced trauma.

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CECE Early Childhood Videos at Eastern CT State U.

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Responding to Trauma-Related Behaviors in Early Childhood Settings

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A Practitioner’s Guide to  Educating Traumatized Children

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A Practitioner’s Guide to  Educating Traumatized Children

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The rates at which children in the United States are traumatized due to abuse, neglect, poverty, and violence have been studied for more than three decades—and unfortunately, they have not changed a great deal over the years. According to Mental Health Connection of Tarrant County (2013) and National Child Traumatic Stress Network (n.d.)

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Attachment Disorders are psychiatric illnesses that can develop in young children who have problems in emotional attachments to others. Parents, caregivers, or physicians may notice that a child has problems with emotional attachment as early as their first birthday. Often, a parent brings an infant or very young child to the doctor with one or more of the following concerns:

severe colic and/or feeding difficulties

failure to gain weight

detached and unresponsive behavior

difficulty being comforted

preoccupied and/or defiant behavior

inhibition or hesitancy in social interactions

being too close with strangers

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Attachment Disorders are psychiatric illnesses that can develop in young children who have problems in emotional attachments to others.

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Attachment Issues in Children: Causes, Symptoms, Treatment

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Attachment Issues in Children: Causes, Symptoms, Treatment

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Attachment problems can affect your child’s development, relationships, and overall well-being. But as a parent, there are ways to overcome insecure attachment and set your child up for success.

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Attachment Issues and Attachment Disorders in Children

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Attachment problems can affect your child’s development, relationships, and overall well-being. Here’s how to overcome insecure attachment.

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Psychobiology of Attachment and Trauma—Some General Remarks From a Clinical Perspective

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Psychobiology of Attachment and Trauma—Some General Remarks From a Clinical Perspective

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Attachment refers to a psychobiological principle that is deeply rooted in evolutionary development; it is thought to contribute a major advantage in the survival of the social group. Within individual development it indicates a primary motivational system that guides the initial transactions between mother and baby and furthermore mediates affective attunement and regulation.

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Psychobiology of Attachment and Trauma—Some General Remarks From a Clinical Perspective

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Attachment refers to a psychobiological principle that is deeply rooted in evolutionary development; it is thought to contribute a major advantage in the survival of the social group. Within individual development it indicates a primary motivational…

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Attachment is a clinical term used to describe "a lasting psychological connectedness between human beings” (Bowlby, 1997)¹. In particular, attachment theory highlights the importance of a child’s emotional bond with their primary caregivers. Disruption to or loss of this bond can affect a child emotionally and psychologically into adulthood, and have an impact on their future relationships.

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Introduction

What is attachment theory and why is it important?

Attachment is a clinical term used to describe "a lasting psychological connectedness between human beings" (Bowlby, 1997). In particular, attachment theory highlights the importance of a child's emotional bond with their primary caregivers. Disruption to or loss of this bond can affect a child emotionally and psychologically into adulthood, and have an impact on their future relationships.

Only specially trained and qualified professionals should assess a child's attachment style. However, it's important for all adults working with children to understand what attachment is and know how to help parents and carers become attuned to their child's needs. You might do this by working with them directly, or by signposting families to other appropriate services. In the long term, this can help improve wellbeing and provide positive outcomes for both the child and their caregivers.

Understanding attachment in the early years

Children can form attachments with more than one caregiver, but the bond with the people who have provided close care from early infancy is the most important and enduring (Bowlby, 1997).

It's important that parents and carers are attuned and responsive to their baby's needs and are able to provide appropriate care. This includes recognising if their baby is hungry, feeling unwell or in need of closeness and affection (Howe, 2011).

Forming an attachment is something that develops over time for a child, but parents and carers can start to form an emotional bond with their child before they are born. Sometimes a parent or carer may have difficulty forming this bond, for example if they are experiencing mental health issues or don't have an effective support network.

On this page, you'll find information on:

why attachment is important

how children develop attachment

attachment issues, insecure and secure attachment and behaviours to look out for

how trauma can affect attachment

how you can support parents and carers to develop a bond with their child.

Need specific information?

Our information specialists are here to help you find research, guidance and best practice.

References

Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Howe, David (2011) Attachment across the lifecourse: a brief introduction. Basingstoke: Palgrave Macmillan.

Stages of attachment

Stages of attachment

The first two years of a child's life are the most critical for forming attachments (Prior and Glaser, 2006).

During this period, children develop an 'internal working model' that shapes the way they view relationships and operate socially. This can affect their sense of trust in others, self-worth and their confidence interacting with others (Bowlby, 1997).

When are attachments formed?

Attachments are formed in different ways during the phases of a child's development.

Antenatal (before birth)

During the antenatal period, parents and carers can form a bond with their child. Any bonds formed before birth can have a positive impact on the relationship between babies and their caregivers once the child is born (Condon and Corkindale, 1997).

Birth until 6 weeks

This is sometimes referred to as the pre-attachment phase because the baby doesn't appear to show an attachment to any specific caregiver. However, parents and carers who provide a nurturing environment and are responsive to their babies needs can lay the foundation for secure attachments to form (Bowlby, 1997).

6 weeks until 6-8 months

During this stage of their development, a baby might start to show a preference for their primary and secondary caregivers (often the mother and father).

6-8 months until 18 months-2 years

During this period a child begins to show a strong attachment to their primary caregivers. Babies start to develop separation anxiety during this phase and can become upset when their caregiver leaves, even for short periods (Bowlby, 1997).

18 months - 2 years onwards

At this point children are likely to become less dependent on their primary caregiver, particularly if they feel secure and confident the caregiver will return and be responsive in times of need (Bowlby, 1997).

References

Prior, V. and Glaser, D. (2006) Understanding attachment and attachment disorders: theory, evidence and practice. London: Jessica Kingsley. Condon, J. T. and Corkindale, C. (1997)
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.

The correlates of antenatal attachment in pregnant women. British Journal of Medical Psychology. Cambridge University Press, 70 (4): 359-372. Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.

Types of attachment

Types of attachment

A child's need for attachment is part of the process of seeking safety and security from their caregiver.

What does secure attachment look like?

In secure caregiver-child relationships, the caregiver is usually sensitive and tuned in to the child's needs. They are able to provide care that is predictably loving, responsive and consistent.

Young children who have formed a secure attachment to their caregiver may display the following patterns of behaviour during times of stress or exploration:

proximity maintenance - wanting to be near their primary caregiver

safe haven - returning to their primary caregiver for comfort and safety if they feel afraid or threatened

secure base - treating their primary caregiver as a base of security from which they can explore the surrounding environment. The child feels safe in the knowledge that they can return to their secure base when needed

separation distress - experiencing anxiety in the absence of their primary caregiver. They are upset when their caregiver leaves, but happy to see them and easily comforted when they return

Benefits of secure attachment

When caregivers react sensitively to ease their child's distress and help them regulate their emotions, it has a positive impact on the child's neurological, physiological and psychosocial development (Howe, 2011).

Children with secure attachments are more likely to develop emotional intelligence, good social skills and robust mental health (Howe, 2011).

Effects of insecure attachment

Not receiving comfort and security in the early years can have a negative effect on children's neurological, psychological, emotional and physical development and functioning (Newman, 2015).

Babies and young children who have attachment issues may be more likely to develop behavioural problems such as attention deficit hyperactivity disorder (ADHD) or conduct disorder (Fearon et al, 2010).

Children who have attachment issues can have difficulty forming healthy relationships when they grow up. This may be because their experiences have taught them to believe that other people are unreliable or untrustworthy (Bowlby, 1997).

Adults with attachment issues are at a higher risk of entering into volatile relationships and having poor parenting skills, behavioural difficulties and mental health problems (Howe, 2011).
> Find out more about how trauma affects child brain development
Further reading

Take a look at our reading list on child attachment.
> View the reading list on the NSPCC Library catalogue

Attachment issues

Attachment issues

Factors affecting attachment

Some circumstances can make it more challenging for a child and their caregivers to form a pattern of secure attachment. These may include:

abuse, maltreatment and trauma experienced by the parent or child

parental mental health difficulties

parental substance misuse

the child having multiple care placements

parents being separated from their baby just after birth, for example if the baby is receiving neonatal care

stress such as having a low income, being a single parent, or being a young parent

bereavement or loss of another caregiver that a child had an attachment with

Signs that a child may have attachment issues

Children's behaviour can be influenced by a wide range of circumstances and emotions.

Indicators that a baby or toddler might not have a secure attachment with their caregiver will emerge as a pattern of behaviour over time, particularly during moments of stress or exploration. This pattern might include:

being fearful or avoidant of a parent or carer

becoming extremely distressed when their carer leaves them, even for a short amount of time

rejecting their caregiver's efforts to calm, soothe, and connect with them

not seeming to notice or care when their caregiver leaves the room or when they return

being passive or non-responsive to their carer

seeming to be depressed or angry

not being interested in playing with toys or exploring their environment

As children with attachment issues get older, these behaviour patterns might evolve. As well as being evident during times of stress, some behaviours may start to become obvious at other times. These may include the child:

finding it difficult to ask for help

struggling to form positive relationships with adults and peers

struggling to concentrate

struggling to calm themselves down

both demanding and rejecting attention or support at the same time

becoming quickly or disproportionately angry or upset, at times with no clear triggers

appearing withdrawn or disengaged from activities

daydreaming, being hyperactive or constantly fidgeting or moving

(Mentally Healthy Schools, 2020).

If you think a child may have attachment issues, you should refer them to a suitably trained health and social care professional for a full assessment. You should follow your organisation's procedures to make a health and social care referral, or contact your local authority children's social care services.

References

Bowlby, John (1989) The making and breaking of affectional bonds. London: Routledge. Mentally Healthy Schools (2020)
Howe, David (2011) Attachment across the lifecourse: a brief introduction. Basingstoke: Palgrave Macmillan.
Attachment and child development. [Accessed 09/11/2020].

Trauma and attachment

Trauma and attachment

The signs of attachment issues can be similar to indicators that a child is experiencing other challenges, such as:

This means it's important to consider everything that's going on in a child's life and make sure they and their family are provided with appropriate support.

Think about all your previous experiences with the child and their caregivers, to help you build a clear picture of their relationships and recognise any concerning patterns of behaviour.

The impact of trauma and attachment

Children who have experienced abuse, neglect and trauma might develop coping strategies that can make it more complicated to recognise attachment issues.

For example, one sign of secure attachment is that children see their caregiver as a secure base to explore from. But children who have experienced neglect, for example, might display independent behaviour in order to protect themselves from the emotional pain of not having their needs met (Marvin et al, 2002).

It is also possible for a child to develop an attachment to someone who is maltreating them (Blizard & Bluhm, 1994).

As well as affecting attachment, experiencing trauma can have an impact on a child's brain development. Children might need extra support to help strengthen the architecture of their brain.
> Find out more about how trauma affects child brain development
What to do if you're worried that a child is experiencing or at risk of abuse or neglect
If a child is in immediate danger, call the police on 999.
If you're worried about a child but they are not in immediate danger, you should share your concerns.

Follow your organisation's child protection procedures without delay. These should provide clear guidelines on the steps you need to take if a child discloses abuse. They will state who in your organisation has responsibility for safeguarding or child protection and who you should report your concerns to.

Contact your local child protection services. Their contact details can be found on the website for the local authority the child lives in.

Contact the police. They will assess the situation and take the appropriate action to protect the child.

Contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk. Our child protection specialists will talk through your concerns with you, give you expert advice and take action to protect the child as appropriate. This may include making a referral to the local authority.

> Find out more about recognising and responding to abuse
If your organisation doesn't have a clear safeguarding procedure or you're concerned about how child protection issues are being handled in your own, or another, organisation, contact the Whistleblowing Advice Line to discuss your concerns.
> Find out about the Whistleblowing Advice Line on the NSPCC website
When you're not sure

The NSPCC Helpline can help when you're not sure if a situation needs a safeguarding response. Our child protection specialists are here to support you whether you're seeking advice, sharing concerns about a child, or looking for reassurance.

Whatever the need, reason or feeling, you can contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk

Our trained professionals will talk through your concerns with you. Depending on what you share, our experts will talk you through which local services can help, advise you on next steps, or make referrals to children's services and the police.
> Find out more about how the NSPCC Helpline can support you

Supporting children and families

Supporting children and families

Building positive relationships

It's important for anyone who works with children and families to support parents and carers in building positive relationships with their child. Having positive interaction and play with caregivers can help a child's brain to develop healthily.
> See our early years resources which you can share with parents and caregivers
Video feedback programmes can also be used by specially trained social care professionals to help caregivers improve their interactions with their child. This involves caregivers being filmed when they are interacting with their child and then watching the recording with a trained practitioner, who gives them feedback and helps them build on their strengths.

Support for parents and carers

If parents are struggling with their own issues, it may make it harder for them to bond with their child and provide consistant and responsive care. They may have:

experienced abuse of trauma themselves

drug and/or alcohol dependencies

mental health issues.

> Find out more about parental mental health > Learn more about parental substance misuse
Services for children and families

The NSPCC has many services that children and families can be referred to, from supporting parents and carers in taking care of their children to preventing sexual abuse and overcoming abuse.

Our services might be suitable for children and families you are working with:

Pregnancy in Mind helps parents who are at risk of or experiencing mild to moderate anxiety and depression during pregnancy. The service helps build parents' capacity to provide sensitive, responsive care to their babies and keep these skills developed postnatally and as their children develop
Browse for more services
Further reading

Take a look at our reading list about child attachment interventions, support and treatment.
> View the list on the NSPCC Library catalogue
Supporting children's mental health

Children with attachment issues may have problems expressing or controlling their emotions and forming positive relationships, which might affect their mental health.

It's important to make sure children and young people have access to mental health support.
> Find out more about child mental health > See the NSPCC's advice for parents and carers on how to support their child's mental health
Childline

If a child or young person needs confidential help and advice you can always direct them to Childline. Calls to 0800 1111 are free and children can also contact Childline online. Children under the age of 12 can be directed to the Childline Kids website.

We also have a series of posters and wallet cards you can download for free. These can be printed and displayed in your setting to encourage children to contact Childline if they need to talk.

Introduction

What is attachment theory and why is it important?

Attachment is a clinical term used to describe "a lasting psychological connectedness between human beings" (Bowlby, 1997). In particular, attachment theory highlights the importance of a child's emotional bond with their primary caregivers. Disruption to or loss of this bond can affect a child emotionally and psychologically into adulthood, and have an impact on their future relationships.

Only specially trained and qualified professionals should assess a child's attachment style. However, it's important for all adults working with children to understand what attachment is and know how to help parents and carers become attuned to their child's needs. You might do this by working with them directly, or by signposting families to other appropriate services. In the long term, this can help improve wellbeing and provide positive outcomes for both the child and their caregivers.

Understanding attachment in the early years

Children can form attachments with more than one caregiver, but the bond with the people who have provided close care from early infancy is the most important and enduring (Bowlby, 1997).

It's important that parents and carers are attuned and responsive to their baby's needs and are able to provide appropriate care. This includes recognising if their baby is hungry, feeling unwell or in need of closeness and affection (Howe, 2011).

Forming an attachment is something that develops over time for a child, but parents and carers can start to form an emotional bond with their child before they are born. Sometimes a parent or carer may have difficulty forming this bond, for example if they are experiencing mental health issues or don't have an effective support network.

On this page, you'll find information on:

why attachment is important

how children develop attachment

attachment issues, insecure and secure attachment and behaviours to look out for

how trauma can affect attachment

how you can support parents and carers to develop a bond with their child.

Need specific information?

Our information specialists are here to help you find research, guidance and best practice.

References

Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Howe, David (2011) Attachment across the lifecourse: a brief introduction. Basingstoke: Palgrave Macmillan.

Stages of attachment

Stages of attachment

The first two years of a child's life are the most critical for forming attachments (Prior and Glaser, 2006).

During this period, children develop an 'internal working model' that shapes the way they view relationships and operate socially. This can affect their sense of trust in others, self-worth and their confidence interacting with others (Bowlby, 1997).

When are attachments formed?

Attachments are formed in different ways during the phases of a child's development.

Antenatal (before birth)

During the antenatal period, parents and carers can form a bond with their child. Any bonds formed before birth can have a positive impact on the relationship between babies and their caregivers once the child is born (Condon and Corkindale, 1997).

Birth until 6 weeks

This is sometimes referred to as the pre-attachment phase because the baby doesn't appear to show an attachment to any specific caregiver. However, parents and carers who provide a nurturing environment and are responsive to their babies needs can lay the foundation for secure attachments to form (Bowlby, 1997).

6 weeks until 6-8 months

During this stage of their development, a baby might start to show a preference for their primary and secondary caregivers (often the mother and father).

6-8 months until 18 months-2 years

During this period a child begins to show a strong attachment to their primary caregivers. Babies start to develop separation anxiety during this phase and can become upset when their caregiver leaves, even for short periods (Bowlby, 1997).

18 months - 2 years onwards

At this point children are likely to become less dependent on their primary caregiver, particularly if they feel secure and confident the caregiver will return and be responsive in times of need (Bowlby, 1997).

References

Prior, V. and Glaser, D. (2006) Understanding attachment and attachment disorders: theory, evidence and practice. London: Jessica Kingsley. Condon, J. T. and Corkindale, C. (1997)
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.

The correlates of antenatal attachment in pregnant women. British Journal of Medical Psychology. Cambridge University Press, 70 (4): 359-372. Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.

Types of attachment

Types of attachment

A child's need for attachment is part of the process of seeking safety and security from their caregiver.

What does secure attachment look like?

In secure caregiver-child relationships, the caregiver is usually sensitive and tuned in to the child's needs. They are able to provide care that is predictably loving, responsive and consistent.

Young children who have formed a secure attachment to their caregiver may display the following patterns of behaviour during times of stress or exploration:

proximity maintenance - wanting to be near their primary caregiver

safe haven - returning to their primary caregiver for comfort and safety if they feel afraid or threatened

secure base - treating their primary caregiver as a base of security from which they can explore the surrounding environment. The child feels safe in the knowledge that they can return to their secure base when needed

separation distress - experiencing anxiety in the absence of their primary caregiver. They are upset when their caregiver leaves, but happy to see them and easily comforted when they return

Benefits of secure attachment

When caregivers react sensitively to ease their child's distress and help them regulate their emotions, it has a positive impact on the child's neurological, physiological and psychosocial development (Howe, 2011).

Children with secure attachments are more likely to develop emotional intelligence, good social skills and robust mental health (Howe, 2011).

Effects of insecure attachment

Not receiving comfort and security in the early years can have a negative effect on children's neurological, psychological, emotional and physical development and functioning (Newman, 2015).

Babies and young children who have attachment issues may be more likely to develop behavioural problems such as attention deficit hyperactivity disorder (ADHD) or conduct disorder (Fearon et al, 2010).

Children who have attachment issues can have difficulty forming healthy relationships when they grow up. This may be because their experiences have taught them to believe that other people are unreliable or untrustworthy (Bowlby, 1997).

Adults with attachment issues are at a higher risk of entering into volatile relationships and having poor parenting skills, behavioural difficulties and mental health problems (Howe, 2011).
> Find out more about how trauma affects child brain development
Further reading

Take a look at our reading list on child attachment.
> View the reading list on the NSPCC Library catalogue

Attachment issues

Attachment issues

Factors affecting attachment

Some circumstances can make it more challenging for a child and their caregivers to form a pattern of secure attachment. These may include:

abuse, maltreatment and trauma experienced by the parent or child

parental mental health difficulties

parental substance misuse

the child having multiple care placements

parents being separated from their baby just after birth, for example if the baby is receiving neonatal care

stress such as having a low income, being a single parent, or being a young parent

bereavement or loss of another caregiver that a child had an attachment with

Signs that a child may have attachment issues

Children's behaviour can be influenced by a wide range of circumstances and emotions.

Indicators that a baby or toddler might not have a secure attachment with their caregiver will emerge as a pattern of behaviour over time, particularly during moments of stress or exploration. This pattern might include:

being fearful or avoidant of a parent or carer

becoming extremely distressed when their carer leaves them, even for a short amount of time

rejecting their caregiver's efforts to calm, soothe, and connect with them

not seeming to notice or care when their caregiver leaves the room or when they return

being passive or non-responsive to their carer

seeming to be depressed or angry

not being interested in playing with toys or exploring their environment

As children with attachment issues get older, these behaviour patterns might evolve. As well as being evident during times of stress, some behaviours may start to become obvious at other times. These may include the child:

finding it difficult to ask for help

struggling to form positive relationships with adults and peers

struggling to concentrate

struggling to calm themselves down

both demanding and rejecting attention or support at the same time

becoming quickly or disproportionately angry or upset, at times with no clear triggers

appearing withdrawn or disengaged from activities

daydreaming, being hyperactive or constantly fidgeting or moving

(Mentally Healthy Schools, 2020).

If you think a child may have attachment issues, you should refer them to a suitably trained health and social care professional for a full assessment. You should follow your organisation's procedures to make a health and social care referral, or contact your local authority children's social care services.

References

Bowlby, John (1989) The making and breaking of affectional bonds. London: Routledge. Mentally Healthy Schools (2020)
Howe, David (2011) Attachment across the lifecourse: a brief introduction. Basingstoke: Palgrave Macmillan.
Attachment and child development. [Accessed 09/11/2020].

Trauma and attachment

Trauma and attachment

The signs of attachment issues can be similar to indicators that a child is experiencing other challenges, such as:

This means it's important to consider everything that's going on in a child's life and make sure they and their family are provided with appropriate support.

Think about all your previous experiences with the child and their caregivers, to help you build a clear picture of their relationships and recognise any concerning patterns of behaviour.

The impact of trauma and attachment

Children who have experienced abuse, neglect and trauma might develop coping strategies that can make it more complicated to recognise attachment issues.

For example, one sign of secure attachment is that children see their caregiver as a secure base to explore from. But children who have experienced neglect, for example, might display independent behaviour in order to protect themselves from the emotional pain of not having their needs met (Marvin et al, 2002).

It is also possible for a child to develop an attachment to someone who is maltreating them (Blizard & Bluhm, 1994).

As well as affecting attachment, experiencing trauma can have an impact on a child's brain development. Children might need extra support to help strengthen the architecture of their brain.
> Find out more about how trauma affects child brain development
What to do if you're worried that a child is experiencing or at risk of abuse or neglect
If a child is in immediate danger, call the police on 999.
If you're worried about a child but they are not in immediate danger, you should share your concerns.

Follow your organisation's child protection procedures without delay. These should provide clear guidelines on the steps you need to take if a child discloses abuse. They will state who in your organisation has responsibility for safeguarding or child protection and who you should report your concerns to.

Contact your local child protection services. Their contact details can be found on the website for the local authority the child lives in.

Contact the police. They will assess the situation and take the appropriate action to protect the child.

Contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk. Our child protection specialists will talk through your concerns with you, give you expert advice and take action to protect the child as appropriate. This may include making a referral to the local authority.

> Find out more about recognising and responding to abuse
If your organisation doesn't have a clear safeguarding procedure or you're concerned about how child protection issues are being handled in your own, or another, organisation, contact the Whistleblowing Advice Line to discuss your concerns.
> Find out about the Whistleblowing Advice Line on the NSPCC website
When you're not sure

The NSPCC Helpline can help when you're not sure if a situation needs a safeguarding response. Our child protection specialists are here to support you whether you're seeking advice, sharing concerns about a child, or looking for reassurance.

Whatever the need, reason or feeling, you can contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk

Our trained professionals will talk through your concerns with you. Depending on what you share, our experts will talk you through which local services can help, advise you on next steps, or make referrals to children's services and the police.
> Find out more about how the NSPCC Helpline can support you

Supporting children and families

Supporting children and families

Building positive relationships

It's important for anyone who works with children and families to support parents and carers in building positive relationships with their child. Having positive interaction and play with caregivers can help a child's brain to develop healthily.
> See our early years resources which you can share with parents and caregivers
Video feedback programmes can also be used by specially trained social care professionals to help caregivers improve their interactions with their child. This involves caregivers being filmed when they are interacting with their child and then watching the recording with a trained practitioner, who gives them feedback and helps them build on their strengths.

Support for parents and carers

If parents are struggling with their own issues, it may make it harder for them to bond with their child and provide consistant and responsive care. They may have:

experienced abuse of trauma themselves

drug and/or alcohol dependencies

mental health issues.

> Find out more about parental mental health > Learn more about parental substance misuse
Services for children and families

The NSPCC has many services that children and families can be referred to, from supporting parents and carers in taking care of their children to preventing sexual abuse and overcoming abuse.

Our services might be suitable for children and families you are working with:

Pregnancy in Mind helps parents who are at risk of or experiencing mild to moderate anxiety and depression during pregnancy. The service helps build parents' capacity to provide sensitive, responsive care to their babies and keep these skills developed postnatally and as their children develop
Browse for more services
Further reading

Take a look at our reading list about child attachment interventions, support and treatment.
> View the list on the NSPCC Library catalogue
Supporting children's mental health

Children with attachment issues may have problems expressing or controlling their emotions and forming positive relationships, which might affect their mental health.

It's important to make sure children and young people have access to mental health support.
> Find out more about child mental health > See the NSPCC's advice for parents and carers on how to support their child's mental health
Childline

If a child or young person needs confidential help and advice you can always direct them to Childline. Calls to 0800 1111 are free and children can also contact Childline online. Children under the age of 12 can be directed to the Childline Kids website.

We also have a series of posters and wallet cards you can download for free. These can be printed and displayed in your setting to encourage children to contact Childline if they need to talk.

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Attachment and child development | NSPCC Learning

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Explains why attachment is important as well as the different stages. Includes information on types of attachment, attachment issues and the effect of trauma.

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As an infant, every time we cry, reach out for our caregivers, or seek comfort from them, we develop an understanding of ourselves, others, and the world. We call this bond “attachment,” and it can have a long-lasting impact on our lives.

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Adoption Triad (2019, October). Attachment and Developmental Stages Throughout Childhood. Child Welfare.

Andersen, T. E., Ravn, S. L., Manniche, C., & O'Neill, S. (2018). The impact of attachment insecurity on pain and pain behaviors in experimental pain. Journal of Psychosomatic Research, 111, 127-132.

Andriopoulou, P. (2021). Healing attachment trauma in adult psychotherapy: The role of limited reparenting. European Journal of Psychotherapy & Counselling, 23(4), 468-482.

Cassioli, E., Rossi, E., Vizzotto, C., Malinconi, V., Vignozzi, L., Ricca, V., & Castellini, G. (2022). Avoidant Attachment Style Moderates the Recovery of Healthy Sexuality in Women With Anorexia Nervosa Treated With Enhanced Cognitive Behavior Therapy (CBT-E): A 2-Year Follow-Up Study. The journal of sexual medicine, 19(2), 347-355.

Collins, N. L., & Feeney, B. C. (2004). Working Models of Attachment Shape Perceptions of Social Support: Evidence From Experimental and Observational Studies. Journal of Personality and Social Psychology, 87(3), 363-383.

Dagnino, P., Pérez, C., Gómez, A., Gloger, S., & Krause, M. (2017). Depression and Attachment: How do Personality Styles and Social Support Influence This Relation?. Research in psychotherapy (Milano), 20(1), 237.

Fearon, P., Bakermans-Kranenburg, M. J., Van IJzendoorn, M., Lapsley, A., & Roisman, G. I. (2010). The Significance of Insecure attachment and Disorganization in the Development of Children's Externalizing Behavior: A Meta-Analytic Study. Child Development, 81(2), 435-456.

Lahousen, T., Unterrainer, H. F., & Kapfhammer, H. P. (2019). Psychobiology of Attachment and Trauma-Some General Remarks From a Clinical Perspective. Frontiers in psychiatry, 10, 914.

Malekpour, M. (2007). Effects of attachment on early and later development. British Journal of Developmental Disabilities, 53(105,Pt2), 81-95.

Rees C. (2007). Childhood attachment. The British journal of general practice: the journal of the Royal College of General Practitioners, 57(544), 920-922.

Romeo, A., Tesio, V., Castelnuovo, G., & Castelli, L. (2017). Attachment Style and Chronic Pain: Toward an Interpersonal Model of Pain. Frontiers in psychology, 8, 284.

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.

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Attachment Trauma: What is it? - Attachment Project

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What are the signs and how do we heal from attachment trauma? Read the article now to discover the ins and outs of attachment trauma.

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Interventions for attachment and traumatic stress issues in young children

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Interventions for attachment and traumatic stress issues in young children

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Although mental health professionals acknowledge that clinical issues often look different in young children, treatment practices continue to rely heavily on adult literature. These mostly miniaturized forms of adult treatment are often scaled down using more basic language and vocabulary, but they still depend on discovering ways to encourage the verbal communication of children. Furthermore, major deficiencies exist in the mental health care delivery system for children. General neglect and fragmentation of services create obstacles to effective service provision for this population.

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Interventions for attachment and traumatic stress issues in young children

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With their emphasis on human development, prevention, ecosystems and wellness, counselors are well-positioned to address the unique service needs of the pediatric population.

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The Attachment & Trauma Network, a 2016 Angel in Adoption® Recipient “Trauma-Informed “Trailblazer” has been the VOICE for traumatized children and their families since 1995. Through our mission of Support – Education – Advocacy, we seek to improve the lives of children impacted by early childhood trauma, abuse and neglect, and prenatal exposures in their families, schools and communities. We believe that trauma-informed, attachment-focused therapy and teaching parents therapeutic parenting strategies are significant factors in helping our children overcome their early traumas and build resiliency and healthy relationships. We believe that trauma-informed schools are the best educational environment for all children, but especially the significant population of children impacted by Adverse Childhood Experiences (ACEs).

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The VOICE for Traumatized Children and families - Attachment and Trauma Network

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Attachment & Trauma Network (ATN) the VOICE for traumatized children through our mission Empowering Trauma-Informed Families, Schools, and Communities.

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Trauma, PTSD, and Attachment in Infants and Young Children

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Trauma, PTSD, and Attachment in Infants and Young Children

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Decades ago, little was known about what PTSD looked like in infants and young children. Today, we know that trauma and maltreatment can have grave impact on the very young. In addition, we know the importance of the early child-caregiver attachment to a child's development. This page discusses epidemiology, diagnosis, and treatment of trauma-related problems in infants and young children, with a special focus on the role of attachment.

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Erin R. Barnett, PhD and Jessica Hamblen, PhD

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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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Developmental Trauma Disorder: A Legacy of Attachment Trauma in Victimized Children

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Developmental Trauma Disorder: A Legacy of Attachment Trauma in Victimized Children

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Developmental trauma disorder (DTD) and posttraumatic stress disorder (PTSD) have been found to have both shared and unique traumatic antecedents. The present study was an independent replication, with the DTD Structured Interview and the Traumatic Events Screening Instrument administered to 271 children in mental health treatment in six U.S. sites. On an unadjusted basis, DTD (27.3% prevalence, N = 74) and PTSD (40.2% prevalence, N = 109) both were associated with traumatic physical assault or abuse, family violence, emotional abuse, caregiver separation or impairment, and polyvictimization

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Developmental Trauma Disorder: A Legacy of Attachment Trauma in Victimized Children

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Developmental trauma disorder (DTD) and posttraumatic stress disorder (PTSD) have been found to have both shared and unique traumatic antecedents. The present study was an independent replication, with the DTD Structured Interview and the Traumatic…

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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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When someone experiences a traumatic event or experiences extreme fear, brain chemistry is altered and the brain begins to function differently--this is called the "Fear Circuity" and it is a protective mechanism which we all have inside of us.  The neurobiology of trauma--essentially the effects of trauma on the brain--is important to understand because it helps break down common misconceptions and victim-blaming about gender-based violence and it helps survivors to understand their experience and the aftermath in a new way.  We encourage you to watch the video below by Dr. Jim Hopper and read through the information on this page to learn more!

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Neurobiology of Trauma helps to explain many of the common behaviors and experiences of survivors of gender-based violence. Having an understanding of how trauma affects the brain helps to dismantle common misconceptions and victim-blaming statements about sexual violence. Please read the Myth vs Fact document below to learn more!

Key Concepts

The prefrontal cortex is the decision-making/choice-making part of the brain; it's the part of the brain responsible for rational thinking, planning effective responses, remembering important information, etc. When a person is experiencing a traumatic event or experiencing extreme fear, their " Fear Circuitry" may kick in and the prefrontal cortex begins to function less effectively. This means that in the midst of trauma, a person may not be able to think through the situation and make decisions such as calling for help. It is not a matter of choice--their brain is in survival mode and the fear circuitry is bypassing their prefrontal cortex entirely.

Many people are familiar with the concept of "fight or flight," but research shows that there is a third response called " freeze." A common example is a deer in the headlights, and humans have this same fear response--in fact, freezing is the most common reaction to trauma or fear, rather than fighting back or running away.

In addition to freezing, some survivors may experience extreme survival reflexes such tonic immobility or collapsed immobility. If you've ever seen a possum go limp when it is scared, you are familiar with this brain response. Going limp, feeling "sleepy" or passing out, or being completely unable to move or speak are survival mechanisms hard-wired into our brains--even apex predators like sharks have these responses! It is not a sign of weakness, nor is it a choice the person is making.

Survivors may also experience dissociation, which is a survival reflex where someone may feel disconnected from their body or may go into " auto-pilot" mode. In auto-pilot mode, a person is not using their prefrontal cortex to make decisions, but is instead relying upon habitual modes of being. Habitual responses are rooted in socialization--for example, women are socialized to be polite and pleasing, to "save face" or placate. This means that during an assault, a person might engage in sexual acts, say polite things, even smile, but they are not consenting; they are actually experiencing extreme fear and their brain is operating on auto-pilot as a survival mechanism.

Memories are encoded differently during a traumatic event. The brain does not encode memories in chronological order, there are gaps in memory, and whatever the "fear circuitry" in the brain focused attention on during the assault is more likely to be encoded into memory than periphery details. For example, a survivor may have a very clear memory of the smell of the perpetrator's cologne, but not have any memory of what the room looked like. Contextual information (e.g., the layout of a room) and time‐sequence information (e.g., the order in which sexual acts occurred) are often poorly encoded. Again, this is not a conscious choice a survivor is making about what to focus on or remember during an assault; it is a common impact on the brain when the "fear circuitry" survival response kicks in.

These are all based in normal brain processes that occur during extremely
stressful and traumatic situations. They can happen to police officers, soldiers - anyone who is attacked or fears for their life.

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Information about how trauma impacts the brain of victims and survivors, both during and after a traumatic event.

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An emotional trauma may induce a cascade of neurobiological events that have long-lasting consequences even altered gene expression. Early abuse and neglect can deregulate the child's developing neurobiological system by reducing its resistance to stressful events, leading to later problems of emotional regulation. Children who have been subjected to physical or emotional abuse tend to pay more attention to signs that contain anger and are hypersensitive to threat. Scar hypothesis and the theories of behavioural sensitization or electrophysiological kindling suggest that emotional traumas may leave traces that persist even after remission of depression, and render individuals vulnerable to the onset of new episodes, even under the influence of only moderate psychosocial stress. Unfavorable early social experiences, such as emotional abuse or institutionalization can affect the structure and function of the prefrontal cortex.

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Neurobiology of emotional trauma - PubMed

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An emotional trauma may induce a cascade of neurobiological events that have long-lasting consequences even altered gene expression. Early abuse and neglect can deregulate the child’s developing neurobiological system by reducing its resistance to stressful events, leading to later problems of emoti …

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The body keeps the score: The neurobiological profile of traumatized adolescents

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The body keeps the score: The neurobiological profile of traumatized adolescents

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Trauma-related disorders are debilitating psychiatric conditions that affect people who have directly or indirectly witnessed adversities. Experiencing multiple types of traumas appears to be common during childhood, and even more so during adolescence. Dramatic brain/body transformations occurring during adolescence may provide a highly responsive substrate to external stimuli and lead to trauma-related vulnerability conditions, such as internalizing (anxiety, depression, anhedonia, withdrawal) and externalizing (aggression, delinquency, conduct disorders) problems. Analyzing relations among neuronal, endocrine, immune, and biochemical signatures of trauma and internalizing and externalizing behaviors, including the role of personality traits in shaping these conducts, this review highlights that the marked effects of traumatic experience on the brain/body involve changes at nearly every level of analysis, from brain structure, function and connectivity to endocrine and immune systems, from gene expression (including in the gut) to the development of personality.

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The Neuroscience of Trauma: Understanding Psychological Wounds Through the Lens of Neurophysiology

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The Neuroscience of Trauma: Understanding Psychological Wounds Through the Lens of Neurophysiology

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Trauma becomes embedded in the brain, mind and body. It directs our behavior, shapes our social habits and profoundly informs the ways we navigate the world. An inner injury, trauma imprints itself into our neurobiology, leaving a footprint in the nervous system. Rather than an event, trauma is what happens inside of us—it is a fracturing of the self that manifests in the form of disintegrated neural patterning. Lack of self-regulatory capacity lies at the heart of this disintegration, which shows up as chaos and/or rigidity in our relational and neural functioning. During a traumatic stress response, the brain and other nervous systems mobilize neurophysiological processes to cope with the stressor. Prolonged activation of brain regions involved in the stress response and an ongoing release of neurochemicals associated with trauma reorganize the brain-mind-body system, resulting in a compromised ability to prepare for and adapt in the face of stress, adversity and daily challenges.

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Trauma becomes embedded in the brain, mind and body. It directs our behavior, shapes our social habits and profoundly informs the ways we navigate the world. An inner injury, trauma imprints itself into our neurobiology, leaving a footprint in the nervous system. Rather than an event, trauma is what happens inside of us-it is a fracturing of the self that manifests in the form of disintegrated neural patterning. Lack of self-regulatory capacity lies at the heart of this disintegration, which shows up as chaos and/or rigidity in our relational and neural functioning. During a traumatic stress response, the brain and other nervous systems mobilize neurophysiological processes to cope with the stressor. Prolonged activation of brain regions involved in the stress response and an ongoing release of neurochemicals associated with trauma reorganize the brain-mind-body system, resulting in a compromised ability to prepare for and adapt in the face of stress, adversity and daily challenges.

This workshop provides a definition of trauma from an Integrative NeuroSomatic® perspective, which emphasizes the nature of trauma as being an internal wound that impacts multiple biological systems involved in human development. Findings from an array of scientific fields, including contemporary neuroscience, mind-body research, traumatology, polyvagal theory and epigenetics will be shared. Tools for helping people who have histories of developmental and complex trauma use safety and neuroplasticity to rewire their nervous systems, upgrade internal models and enhance neural integration for higher levels of self-regulation will be explored.
Learning Objectives:

Define trauma from a neurophysiological perspective

Describe the role of the central nervous system, autonomic nervous system, and the HPA axis in the formation and navigation of trauma narratives

Examine integrative approaches for helping people begin the process of healing inner wounds

Apply a neuroscience-informed tool for working with people who have suffered trauma

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The Neuroscience of Trauma: Understanding Psychological Wounds Through the Lens of Neurophysiology | Continuing and Professional Education | Human Services

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Trauma becomes embedded in the brain, mind and body. It directs our behavior, shapes our social habits and profoundly informs the ways we navigate the world. An inner injury, trauma imprints itself into our neurobiology, leaving a footprint in the nervous system. Rather than an event, trauma is what happens inside of us—it is a fracturing of the self that manifests in the form of disintegrated neural patterning. Lack of self-regulatory capacity lies at the heart of this disintegration, which shows up as chaos and/or rigidity in our relational and neural functioning. During a traumatic stress response, the brain and other nervous systems mobilize neurophysiological processes to cope with the stressor. Prolonged activation of brain regions involved in the stress response and an ongoing release of neurochemicals associated with trauma reorganize the brain-mind-body system, resulting in a compromised ability to prepare for and adapt in the face of stress, adversity and daily challenges.

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Trauma on the Brain: The Neurobiological Effects of PTSD

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Trauma on the Brain: The Neurobiological Effects of PTSD

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The neurobiological effects of PTSD can vary based on personal touch. PTSD is caused by extreme trauma and is seen most in women. Research shows that long term experience of traumatic stress has drastic impacts on specific structures of the brain, like the prefrontal cortex. These disruptions can affect the ability to regulate emotion, learn, and form new memories. It is treatable. Daisy attended the University of San Francisco and received her degree in Psychology and minor in Neuroscience. Currently, she runs her family’s ranch and cares for her hoard of animals. She’s applying to Psychology and Behavioral Neuroscience PhD programs this fall and plans to research genetics, neural basis of emotion, and psychopathology. This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at https://www.ted.com/tedx

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Trauma on the Brain: The Neurobiological Effects of PTSD | Daisy Payton | TEDxMeritAcademy

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The Neurobiology & Phenotypes of Trauma And It's Implications for Clinical Practice

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The Neurobiology & Phenotypes of Trauma And It's Implications for Clinical Practice

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In this video, we unravel the intricate world of PTSD phenotypes, exploring the neurobiology of trauma and its implications for clinical practice. Discover the key brain centers involved, from the threat-focused amygdala to the emotional hub of the anterior cingulate cortex. Learn how individualized treatment plans can be crafted based on the recognition of different phenotypes. Ready to delve into the complexities of PTSD?

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The Neurobiology & Phenotypes of Trauma And It's Implications for Clinical Practice

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The Neurobiology of Trauma and Trauma-Informed Response

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The Neurobiology of Trauma and Trauma-Informed Response

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This is a very informative slideshow about the neurobiology of trauma.

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Researchers reveal how trauma changes the brain

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Researchers reveal how trauma changes the brain

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Exposure to trauma can be life-changing – and researchers are learning more about how traumatic events may physically change our brains. But these changes are not happening because of physical injury, rather our brain appears to rewire itself after these experiences. Understanding the mechanisms involved in these changes and how the brain learns about an environment and predicts threats and safety is a focus of the ZVR Lab at the Del Monte Institute for Neuroscience at the University of Rochester, which is led by assistant professor Benjamin Suarez- Jimenez, Ph.D.

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Exposure to trauma can be life-changing - and researchers are learning more about how traumatic events may physically change our brains. But these changes are not happening because of physical injury, rather our brain appears to rewire itself after these experiences. Understanding the mechanisms involved in these changes and how the brain learns about an environment and predicts threats and safety is a focus of the ZVR Lab at the Del Monte Institute for Neuroscience at the University of Rochester, which is led by assistant professor Benjamin Suarez- Jimenez, Ph.D.

"We are learning more about how people exposed to trauma learn to distinguish between what is safe and what is not. Their brain is giving us insight into what might be going awry in specific mechanisms that are impacted by trauma exposure, especially when emotion is involved," said Suarez-Jimenez, who began this work as a post-doctoral fellow in the lab of Yuval Neria, Ph.D., professor at Columbia University Irving Medical Center.

Their research, recently published in Communications Biology, identified changes in the salience network - a mechanism in the brain used for learning and survival - in people exposed to trauma (with and without psychopathologies, including PTSD, depression, and anxiety). Using fMRI, the researchers recorded activity in the brains of participants as they looked at different-sized circles - only one size was associated with a small shock (or threat). Along with the changes in the salience network, researchers found another difference - this one within the trauma-exposed resilient group. They found the brains of people exposed to trauma without psychopathologies were compensating for changes in their brain processes by engaging the executive control network - one of the dominate networks of the brain.

"Knowing what to look for in the brain when someone is exposed to trauma could significantly advance treatments," said Suarez-Jimenez, a co-first author with Xi Zhu, PhD, Assistant Professor of Clinical Neurobiology at Columbia, of this paper. "In this case, we know where a change is happening in the brain and how some people can work around that change. It is a marker of resilience."

Adding the element of emotion

The possibility of threat can change how someone exposed to trauma reacts - researchers found this is the case in people with post-traumatic stress disorder (PTSD), as described in a recent study in Depression & Anxiety. Suarez-Jimenez, his fellow co-authors, and senior author Neria found patients with PTSD can complete the same task as someone without exposure to trauma when no emotion is involved. However, when emotion invoked by a threat was added to a similar task, those with PTSD had more difficulty distinguishing between the differences.

The team used the same methods as the other experiment - different circle sizes with one size linked to a threat in the form of a shock. Using fMRI, researchers observed people with PTSD had less signaling between the hippocampus - an area of the brain responsible for emotion and memory - and the salience network - a mechanism used for learning and survival. They also detected less signaling between the amygdala (another area linked to emotion) and the default mode network (an area of the brain that activates when someone is not focused on the outside world). These findings reflect a person with PTSD's inability to effectively distinguish differences between the circles.

"This tells us that patients with PTSD have issues discriminating only when there is an emotional component. In this case, aversive; we still need to confirm if this is true for other emotions like sadness, disgust, happiness, etc.," said Suarez-Jimenez. "So, it might be that in the real-world emotions overload their cognitive ability to discriminate between safety, danger, or reward. It overgeneralizes towards danger."

"Taken together, findings from both papers, coming out of a NIMH funded study aiming to uncover neural and behavioral mechanisms of trauma, PTSD and resilience, help to extend our knowledge about the effect of trauma on the brain," said Neria, lead PI on this study. "PTSD is driven by remarkable dysfunction in brain areas vital to fear processing and response. My lab at Columbia and the Dr. Suarez-Jimenez lab at Rochester are committed to advance neurobiological research that will serve the purpose of development new and better treatments that can effectively target aberrant fear circuits."

Suarez-Jimenez will continue exploring the brain mechanisms and the different emotions associated with them by using more real-life situations with the help of virtual reality in his lab. He wants to understand if these mechanisms and changes are specific to a threat and if they expand to context-related processes.

Additional authors include co-first authors John Keefe, Ph.D., of Albert Einstein College of Medicine and Xi Zhu, Ph.D., of Columbia University Irving Medical Center, Amit Lazarov, Ph.D., of Columbia University Irving Medical Center, Ariel Durosky of the University of Tulsa, Oklahoma, Sara Such of the University of Pennsylvania, Caroline Marohasy of the University of Washington, Seattle, and Shmuel Lissek of the University of Minnesota, Minneapolis. The research was supported by the National Institute of Mental Health.

Additional authors on the Communications Biology paper include co-first author Xi Zhu, Ph.D., Amit Lazarov, Ph.D., Scott Small, M.D., of Columbia University Irving Medical Center, Ariel Durosky of the University of Tulsa, Oklahoma, Sara Such of the University of Pennsylvania, Caroline Marohasy of the University of Washington, Seattle, Tor Wager, Ph.D., of Dartmouth College, Martin Lindquist, Ph.D. of Johns Hopkins, and Shmuel Lissek, Ph.D., of the University of Minnesota. The research was supported by the National Institute of Mental Health.

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Researchers reveal how trauma changes the brain

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Researchers have found exposure to traumatic events may physically change the brain, including the mechanism used for learning and survival. These findings could significantly advance future treatments.

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The Neurobiology of Trauma: Webinar Series

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The Neurobiology of Trauma: Webinar Series

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In this three-part webinar, psychology professor Dr. Rebecca Campbell explains the neurobiology of sexual assault trauma. The presentations discuss the body and brain response to trauma, implications for improved response to sexual assault, how victims behave during and after an assault, how trauma affects memory formation and recall during and immediately after an assault, and application of knowledge of the body and brain response to trauma in cold case investigations and victim notification.

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SAKI Toolkit: The Neurobiology of Trauma: Webinar Series

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This three-part series by Dr. Rebecca Campbell explains the body/brain reactions to trauma and implications for improved response to sexual assault.

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The Neurobiology of Trauma-Dr. Arielle Schwartz

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The Neurobiology of Trauma-Dr. Arielle Schwartz

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The neurobiology of trauma guides effective healing and recovery. Unresolved PTSD can leave you feeling both overwhelmed and shut down and it is beneficial to know not only why this is happening but how to most effectively respond.

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The Neurobiology of Trauma | Dr. Arielle Schwartz

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This post will help you go beyond fight and flight with an understanding of the neurobiology of trauma to inform you about symptoms and guide treatment…

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Trauma-informed Interventions in Early Childhood Education and Care Settings: A Scoping Review

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Trauma-informed Interventions in Early Childhood Education and Care Settings: A Scoping Review

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Trauma in early childhood is a significant public health concern. Early Childhood Education and Care (ECEC) services are uniquely positioned to buffer the negative impact of early childhood trauma on children. This scoping review synthesized studies evaluating trauma-informed interventions in ECEC settings through a systematic search of four relevant online databases (PsycINFO, Medline, ERIC, A+ Education).

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Trauma-informed Interventions in Early Childhood Education and Care Settings: A Scoping Review

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Trauma in early childhood is a significant public health concern. Early Childhood Education and Care (ECEC) services are uniquely positioned to buffer the negative impact of early childhood trauma on children. This scoping review synthesized studies…

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Trauma-Informed Classroom in Early Childhood Education

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Trauma-Informed Classroom in Early Childhood Education

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In early childhood education, creating a safe and nurturing environment is crucial for supporting young children's holistic development. However, many children may have experienced trauma or adverse life events that can impact their well-being and ability to learn. As educators, it is essential to understand the effects of trauma and implement strategies to create trauma-informed classrooms.

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The importance of trauma-informed care in early childhood education cannot be overstated. Trauma-informed care prevents further trauma by creating a safe and supportive environment for children who have experienced trauma. It improves educational outcomes and fosters social-emotional development when implemented effectively. You also promote resilience in children by helping them develop skills to cope with and overcome adversity when you integrate it into classroom management.

However, many early childhood education providers are unfamiliar with trauma-informed care or how to implement it effectively. This leads to missed opportunities to support children who have experienced trauma and help them thrive.

This article looks closely at trauma-informed care and how to apply it in early childhood education. It provides tips and strategies for creating a trauma-informed classroom that meets the needs of young children.

What is a trauma-informed classroom?

A trauma-informed classroom is a safe and supportive environment for children who have been through serious events in their life. It's designed to meet the unique needs of children and promote their social-emotional development and healing.

What is trauma-informed care?

Trauma-informed care is a strengths-based approach that considers the unique needs of children who have experienced trauma. It focuses on creating a safe and supportive environment and building resilience .

Trauma-informed caretaking practices take into account the child's individual experience of trauma and its effects on their development. Caretakers must be attuned to the child's needs and responsive to their behaviors.

However, not all children who have experienced trauma will exhibit the same behaviors or need the same level of support. Therefore, it's essential for caretakers to be familiar with the signs and symptoms of trauma and thus adapt their approach to meet the child's individual needs.

Here are the components of trauma-informed care:

Safety: A trauma-informed environment is physically and emotionally safe for children. It's free from any violence or threat of violence.

Support: It's supportive and nurturing. Children feel cared for and respected.

Resiliency: It helps children develop skills to cope with and overcome adverse childhood experiences.

Principles of trauma-informed care

Trauma-informed care is based on principles designed to meet the unique needs of children who have experienced trauma. When integrated into early childhood education, they have the potential to improve educational outcomes and foster social-emotional development.

Below we review the guiding principles to a trauma-informed approach :

Safety

Physical and emotional safety is paramount to a trauma-informed approach. Achieving safety requires understanding the effects of trauma on children and families and implementing policies and practices that address safety concerns.

For children to feel safe, they need to be in an effective and positive learning environment. As an educator, you can implement specific behavior management strategies like developing clear behavior guidelines and following a consistent daily routine that will create a structured setting for your children to focus on learning. Also, things like managing transitions carefully will help to minimize stress and anxiety in your classroom.

Trustworthiness and transparency

Children who have experienced trauma need to feel that they can trust the adults in their lives, requiring adults to be transparent in their actions and intentions.

Building trust begins with developing relationships with children and families based on mutual respect. Then, keep your word, follow through on promises, and avoid surprises. Also, be open to feedback and willing to adjust your plans based on what you learn.

Peer support

Peer support, or the inclusion of others who have similar lived experiences and understanding of trauma, are key in promoting healing and recovery. For example, family members of children that have experienced traumatic events, can offer valuable support.

Collaboration and mutuality

Educators must work collaboratively with children, families, and other professionals when appropriate. This requires good communication and a shared understanding of the child's needs.

Empowerment, voice and choice

Educators should strive to empower children and families by providing them with the knowledge and resources they need to make decisions about their lives. Give children choices, such as what toy to play with or what snack to have, whenever possible and respect their preferences.

Encourage children and families to advocate for themselves. Help them identify their strengths and build on them. Also, connect them with community resources that help them meet their needs.

Cultural, historical, and gender issues

It's essential to understand the unique experiences of different groups of people and be aware of their historical trauma. This includes respecting children and families' cultural and spiritual beliefs and working to actively move past stereotypes and biases.

When working with children and families from diverse backgrounds, be aware of potential language barriers and have access to interpreters when needed. Also, be familiar with the unique customs and traditions of different cultures.

Some families may want to incorporate their religious beliefs into their care, and others may not want to discuss religion. Respect the wishes of families and avoid imposing your own beliefs on them.

Why is trauma-informed care important?

Children who have faced trauma often have difficulty in school and may struggle to keep up with their peers. Trauma-informed care helps these children with the support they need to succeed. When implemented correctly, it leads to several benefits.

First, trauma-informed care fosters social-emotional development . It provides a safe and supportive environment where children can feel free to express themselves. A comfortable and secure child is more likely to develop positive relationships with others.

Second, trauma-informed care promotes resilience in children by helping them develop skills to cope with and overcome adversity. Children who have gone through traumatic experiences often feel helpless and hopeless, and some even develop mental health problems such as anxiety and depression. But with proper support, they can learn to deal with their experiences in a healthy way and develop the strength to overcome them.

It can also deter future trauma. Children who have been through traumatic experiences are more likely to experience them again in adulthood. Trauma-informed care works to break this cycle as it's a preventative approach. By giving children the tools and resources they need to deal with adversity, they're more likely to avoid future trauma - or at least be better equipped to deal with it.

Lastly, it improves educational outcomes. Children who have experienced trauma may have difficulty concentrating and may fall behind in their studies. Such children need extra support in the classroom to be successful. Trauma-informed care provides all children with the necessary emotional and social support to succeed academically.

How to practice trauma-informed care

A trauma-informed classroom focuses on the whole child and considers their unique identity along with their physical, social, emotional, and cognitive needs.

A trauma-informed classroom must also utilize developmentally appropriate practices that considers each child's individual needs and their social and cultural contents to create an engaging learning experience.

To further support your children's growth and development at each stage, download our list of activity ideas promoting language, sensory, social-emotional, cognitive, and physical development.

Follow these tips to create a trauma-informed classroom:

Use positive reinforcement

Trauma may cause children to feel unworthy or incapable of being good. Positive reinforcement encourages desired behaviors by providing positive affirmations, praise, or rewards after the behavior is displayed. Help children feel good about themselves and their accomplishments by providing plenty of positive reinforcement, such as verbal praise, stickers, or small toys.

Avoid using punishments

Punishments can trigger feelings of shame, fear, powerlessness, and bad memories in children who have experienced trauma. Instead, use logical and natural consequences related to the child's behavior. For example, if a child hits another child, the child might have to take a break from playing with other children for a few minutes. While logical and natural consequences aren't always easy to come up with, they're more effective in the long run than punishment.

Create a safe and supportive environment

Children need to feel safe to learn. A safe learning environment is one where there is no physical or emotional harm. To create a safe environment:

Avoid yelling or using offensive language

Be aware of your body language and tone of voice

Be consistent with rules and expectations

Build trust

Building trusting relationships with children and helping them to develop positive relationships with their peers is essential for creating a trauma-informed classroom. Promote trust and relationships by:

Showing genuine interest in each child

Listening to children without judgment

Respecting each child's confidentiality

Being available to talk when a child wants to talk

Enhance coping skills

To deal with difficult emotions and experiences, childcare providers should support the development of children's coping skills. For example, provide opportunities for expression through art, music, dance, or play. Teach children how to identify and label their emotions, helping them understand that it's normal to feel a range of emotions, and showing them healthy ways to cope with and express their feelings.

Help children regulate their emotions

When children feel overwhelmed by emotions, they may act out negatively. For example, a child with difficulty regulating emotions might yell, have tantrums, hit or bite others, or disrupt the class.

Here's what to do to help a child regulate their emotions:

Teach breathing exercises or other relaxation techniques

Use calming words and phrases such as, "It's okay," "Take a deep breath," or "Count to 10"

Offer physical comforts such as a hug, back rub, or hand to hold

Promote physical activity and healthy eating

Physical activity and healthy eating can help control stress and promote positive mental health. Incorporate physical activity into the daily routine, and provide nutritious snacks and meals.

Promote healthy communication

Help children learn how to express themselves in a healthy way. For example, teach them to use words to describe their feelings, demonstrate assertive communication skills, and model respectful communication.

Encourage a sense of belonging

Trauma may cause children to feel disconnected from others. Group work, cooperative games, and circle time help children feel more connected to their classmates and teachers. Promote a sense of belonging by making each child feel valued and respected. Also, show warmth, empathy, and understanding-let children know you care about them.

Be aware of your triggers

As a childcare provider, be aware of your triggers. A trigger sets off an adverse reaction in you, such as sights, smells, sounds, or memories. When you're aware of your triggers, you take steps to avoid them or manage them in a way that doesn't negatively affect the children in your care.

Seek out professional help

If you're feeling overwhelmed or having difficulty implementing trauma-informed practices, seek professional help. Many resources are available to childcare providers, including books, websites, and training programs. Find a resource that is right for you and your particular needs.

Trauma-informed care training

The training for early childhood educators is designed to help you understand what trauma is, how it impacts children and families, and what you do to create a trauma-informed environment in your early childhood program. Consider an accredited program that offers the flexibility to complete the training at your own pace and schedule.

Here is a list of some recommended programs:

Conclusion

A trauma-informed classroom increases safety and security, improves academic outcomes, and creates a more positive school climate for all children. When implemented correctly, a trauma-informed approach mitigates trauma's effects and builds resilience in children.

As a childcare provider, you can make a positive difference in the lives of the children in your care by creating a trauma-informed classroom. With proper knowledge and support, you'll help children heal from their experiences and build the skills they need to thrive.

Remember that every child is different and will respond to a trauma-informed classroom in their own way. Be patient, flexible, and prepared to adjust your approach as needed. With time, patience, and care, you can create a safe and supportive environment that meets the needs of all the children in your care.
Brightwheel is the complete solution for early education providers, enabling you to streamline your center's operations and build a stand-out reputation. Brightwheel connects the most critical aspects of running your center-including sign in and out, parent communications, tuition billing, and licensing and compliance-in one easy-to-use tool, along with providing best-in-class customer support and coaching. Brightwheel is trusted by thousands of early education centers and millions of parents. Learn more atmybrightwheel.com.

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Trauma-Informed Classroom in Early Childhood Education

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Learn about creating a trauma-informed classroom to foster social-emotional development, increase safety and security, and improve academic outcomes for children.

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Four-year-old Alex is in his first year of preschool. He loves his teachers and is always excited to come to school, yet his teachers describe his behavior as “out of control.” At times he screams, curses at his classmates and teachers, and destroys classroom materials and other children’s artwork—all seemingly without cause. Unbeknownst to his teachers, Alex has been witnessing domestic violence and experiencing physical abuse since birth. Furthermore, Alex’s mom works the night shift and his dad works the day shift at the same 24-hour diner. Because of his parents’ schedules, there are times when Alex wakes in the morning and finds himself home alone.

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Many early childhood educators are likely to encounter young children who have experienced trauma on a daily basis.

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Trauma-Informed Care in the Early Childhood Education Classroom

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Trauma-Informed Care in the Early Childhood Education Classroom

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Trauma can significantly impact a child’s physical and emotional well-being, making trauma-informed care in the classroom a critical component of early education. Trauma-informed care creates a safe, supportive environment and helps meet students’ unique social and emotional development needs.

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Trauma-Informed Care in the Early Childhood Education Classroom

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Trauma has a significant impact on a child's physical and emotional well-being, making trauma-informed care a key part of early education.

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What Is Trauma-Informed Care in Early Childhood Education? 

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What Is Trauma-Informed Care in Early Childhood Education? 

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Trauma is complex and can have long-lasting impacts on young children. By implementing trauma-informed practices to address the impact of trauma, educators can help children build resilience and foster safe and supportive learning environments.

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What Is Trauma-Informed Care in Early Childhood Education? | Action for Children

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Discover how trauma-informed care in early childhood education supports children’s resilience, learning, and emotional well-being. Learn key strategies to create trauma-sensitive classrooms and join Action for Children’s virtual Trauma-Informed Care Conference with Nationwide Children’s Hospital.

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Trauma-Informed Practices in Early Childhood Education

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Trauma-Informed Practices in Early Childhood Education

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Trauma early in life can significantly impair children’s development, mental health, and learning, placing them at risk for poor mental and physical health problems throughout life. Young children experience trauma more often, and are more vulnerable to its harmful eects, than older children. Early childhood education (ECE) programs regularly work with traumatized children and their families, often without adequate training in trauma-informed care (TIC). Implementing TIC in ECE can increase the chances that young traumatized children recover, thrive, and enter kindergarten ready to learn. This article discusses specific approaches to TIC in ECE and related implications for the field.

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Developmentally Informed Trauma Practices in Early Childhood

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Developmentally Informed Trauma Practices in Early Childhood

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Traumatic experiences in childhood can have long-term impacts on a child’s outcomes and overall well-being. Developmentally Informed Trauma Practices (DITP) from WestEd helps infant–family and early childhood workforces develop an increased understanding of the risks and impact of trauma on infants, toddlers, young children, and their families with strategies they can use to better serve them.

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Developmentally-Informed Trauma Practices in Early Childhood (WestEd DITP)

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Learn how to support young children who may have experienced trauma in order to support their health, healing, resilience, and well-being.

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Trauma-Informed Practices in Early Childhood

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Trauma-Informed Practices in Early Childhood

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Introduction • Trauma-informed systems • Development, learning, adversity The teachers as an agent of change • Teacher-student co-regulation • Self-regulated learning • Early learning standards in the context of trauma- informed practices The Trauma Sensitive Pedagogy (TSP) • TSP SMART-TI tools

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Considerations for Trauma-Informed Child Care and Early Education Systems

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Considerations for Trauma-Informed Child Care and Early Education Systems

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Trauma can affect everyone in a child care and early education (CCEE) system—young children, their families, and CCEE providers.i, ii A growing body of evidence shows that young children are particularly vulnerable to events that threaten their safety or the safety of their parents and caregivers.iii Because young children may respond differently to traumatic experiences than older children and may be unable to talk directly about their experiences, the potential effects of trauma on young children can be overlooked. Young children affected by trauma may have challenges regulating their behavior and emotions and may rely heavily on families and other adults, including their CCEE providers, for co-regulation of emotions and a sense of safety. Parents, caregivers, and CCEE providers may be affected by caring for young children experiencing traumatic stress or may experience their own trauma, which can affect their capacity to support young children in CCEE. Parents and caregivers may similarly be affected into adulthood by unresolved trauma from their own childhood, which can affect their engagement in CCEE and the parent-child relationship.iv

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Considerations for Trauma-Informed Child Care and Early Education Systems

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Discover an overview of trauma and its impact on child care and early education (CCEE), actionable steps to ensure providers use trauma-informed approaches, and guidance for addressing the needs of young children, parents/caregivers, and CCEE providers.

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Implementing Trauma-Informed Practices in Early Childhood Education

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Implementing Trauma-Informed Practices in Early Childhood Education

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Early childhood is a critical time for brain development, and trauma during this period can significantly impact a child’s growth, mental health, and learning. Young children are more vulnerable to trauma’s effects, and early childhood education (ECE) programs often work with traumatized children and families without sufficient training in trauma-informed care (TIC). By integrating TIC, ECE programs can help children recover, thrive, and be ready for kindergarten.

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Implementing Trauma-Informed Practices in Early Childhood Education | Parents as Teachers Illinois State Office

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Early childhood is a critical time for brain development, and trauma during this period can significantly impact a child’s growth, mental health, and l…

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Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms

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Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms

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This paper reviews the research evidence concerning the intergenerational transmission of trauma effects and the possible role of epigenetic mechanisms in this transmission. Two broad categories of epigenetically mediated effects are highlighted. The first involves developmentally programmed effects. These can result from the influence of the offspring's early environmental exposures, including postnatal maternal care as well as in utero exposure reflecting maternal stress during pregnancy.

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Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms

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This paper reviews the research evidence concerning the intergenerational transmission of trauma effects and the possible role of epigenetic mechanisms in this transmission. Two broad categories of epigenetically mediated effects are highlighted.…

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Treatment and Coping for Intergenerational Trauma

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Treatment and Coping for Intergenerational Trauma

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Intergenerational trauma refers to trauma that is passed from a trauma survivor to their descendants. It can also be referred to as transgenerational or multigenerational trauma.

People experiencing intergenerational trauma may experience symptoms, reactions, patterns, and emotional and psychological effects from trauma experienced by previous generations (not limited to just parents or grandparents).

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Intergenerational trauma refers to trauma that is passed from a trauma survivor to their descendants. It can also be referred to as transgenerational or multigenerational trauma.

People experiencing intergenerational trauma may experience symptoms, reactions, patterns, and emotional and psychological effects from trauma experienced by previous generations (not limited to just parents or grandparents).

What Is a Trauma Response?

Humans have survived for thousands of years by evolving the ability to adapt. If you live with chronic stress or have lived through a traumatic event, certain responses activate to help you survive-these are known as trauma responses.

Although these responses are helpful for short-term survival, being in that "survival mode" headspace is harmful to both physical and mental health in the long term. When your brain learns the adaptive behavior necessary to keep yourself and your family safe/alive, these adaptations may be passed on to future generations and can be challenging to un-learn.

Remaining in "survival mode" can limit one's ability to thrive, as living in survival mode is founded in response to fear/trauma/scarcity. Thriving is possible when there is a developed sense and lived experience of safety and security, which people suffering from intergenerational trauma may not have a model/cellular knowing or foundation for.

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.

For example, someone may have grown up in a household where there were generations of yelling and shouting at their children in anger, stemming from a place of unresolved trauma and pain. In order to understand intergenerational trauma, it is important to acknowledge the impact of what the parents/grandparents/great-grandparents/ancestors/etc. survived that resulted in their yelling or shouting.

This may have been because yelling or shouting was adaptive behavior for survival or they had their own parents yell at them because those parents and those before them didn't have the tools, energy, modeling, support, or space to speak kindly/gently/lovingly to their children due to constant stressors and the trauma of historical oppression/struggle.

The impact of intergenerational trauma in this case would be descendants continuing to shout/scream at their own children, from a place of unresolved intergenerational trauma/stress.

What Does Intergenerational Trauma Look Like?

Those affected by intergenerational trauma might experience symptoms similar to that of post-traumatic stress disorder (PTSD), including hypervigilance, anxiety, and mood dysregulation.

However, because the individual did not directly experience the trauma themselves, they will not experience flashbacks or intrusive memories. They experience trauma symptoms and trauma responses from events that did not occur to them; rather, the response is inherited genetically.

Because stress responses are linked to more physical health issues, intergenerational trauma can also manifest as medical issues including heart disease, stroke, or early death.

What Causes Intergenerational Trauma?

Intergenerational trauma occurs when the effects of trauma are passed down between generations. This can occur if a parent experienced abuse as a child or Adverse Childhood Experiences (ACEs), and the cycle of trauma and abuse impacts their parenting.

Intergenerational trauma can also be the result of oppression, including racial trauma or other systemic oppression. The effects of intergenerational trauma have been documented in descendants of refugees, residential schools, and Holocaust survivors, demonstrating that this type of trauma continues to impact populations for generations after a collective traumatic event has occurred.

Genetics and Intergenerational Trauma

Although research differs and a definitive number is not presently known, it is estimated that human beings have more than 25,000 genes present in our DNA.The way that our genetic material manifests in our bodies, or the way that our genes determine everything from how we look to what diseases we may be predisposed to, is called epigenetics.

Some genes are dormant when we are born but activate based on our environment. This is one way that we adapt to our environment and survive.

When someone experiences trauma, their DNA responds by activating genes to help them survive the stressful time. Genes that prime us for things like a fight, flight, freeze, or fawn response will activate to help us be ready for future dangerous situations. We then pass these genes onto our offspring in order to prepare them for possible traumatic events.

Our genetics do a great job of keeping us safe even if this does not mean keeping us happy. When genes are primed for stressful or traumatic events, they respond with greater resilience to those events, but this constant state of anticipating danger is stressful. The trade-off of being constantly prepared to keep us safe increases our body's stress levels and impacts our mental and physical health over time.

If your parents or grandparents experienced trauma, their DNA coded itself to have a survival response that helped them get through those events, which then passed down through generations. This "survival mode" remains encoded and passed down for multiple generations in the absence of additional trauma.

Our genetics do a great job of keeping us safe even if this does not mean keeping us happy. When genes are primed for stressful or traumatic events, they respond with greater resilience to those events, but this constant state of anticipating danger is stressful.

Treatment and Coping for Intergenerational Trauma

As noted above, intergenerational trauma persists for multiple generations if additional trauma is not present. However, research shows that children of parents with higher ACEs scores are at higher risk for their own adverse childhood experiences.

If you experience intergenerational trauma, trauma-informed interventions and therapy treatment can help you cope with your own symptoms, understand the impact of intergenerational trauma, and equip you with tools to help change deeply embedded patterns and heal yourself and generations after you.

Even if you do not have your own memories of the trauma, a trauma-informed approach to care can help you manage your body's physiological response to intergenerational trauma.

There are many resources available to those dealing with trauma, both personal and intergenerational. Recognizing trauma symptoms, even if they are inherited rather than related to a personal trauma, is vital in coping and seeking support for intergenerational trauma.

Even if you do not have your own memories of the trauma, a trauma-informed approach to care can help you manage your body's physiological response to intergenerational trauma.

Healing Intergenerational Trauma

Because intergenerational trauma is inherited across generations, it can be fully healed by creating an environment where additional trauma does not occur for multiple generations. It can be healed even in the context of continuing stressors with the tools, inner resources, and support needed to care for symptoms and heal the root cause of the intergenerational trauma on physical/somatic, emotional, mental, cellular, and ancestral levels.

Support and resources for trauma survivors and those living with intergenerational trauma are essential for preventing future traumas.

This means both providing education about trauma, trauma responses, and intergenerational trauma to providers, teachers, and parents, as well as addressing systemic issues that perpetuate trauma in minoritized populations.

It also means acknowledging how intergenerational trauma impacts those who have not personally experienced a traumatic event. This understanding is the first step in treating intergenerational trauma in individuals as well as preventing future intergenerational trauma.

Press Play for Advice on Healing Intergenerational Trauma

This episode of The Verywell Mind Podcast, featuring Holistic Psychologist Mariel Buqué, shares how you can stop the cycle of intergenerational trauma. Click below to listen now.

Keep in Mind

If you are experiencing the effects of intergenerational trauma, please know that therapy can be a helpful tool to help you overcome and navigate trauma responses. A therapist can also teach you healthy coping mechanisms that you can employ if you encounter a trigger. Please remember that you are not alone and that there's no shame in reaching out to a professional.

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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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the transmission of trauma or its legacy, in the form of a psychological consequence of an injury or attack, poverty, and so forth, from the generation experiencing the trauma to subsequent generations. The transference of this effect is believed to be epigenetic—that is, the transmission affects the chemical marker for a gene rather than the gene itself. The trauma experienced by the older generation is translated into a genetic adaptation that can be passed on to successive generations. The trauma reactions vary by generation but often include shame, increased anxiety and guilt, a heightened sense of vulnerability and helplessness, low self-esteem, depression, suicidality, substance abuse, dissociation, hypervigilance, intrusive thoughts, difficulty with relationships and attachment to others, difficulty in regulating aggression, and extreme reactivity to stress.

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A trusted reference in the field of psychology, offering more than 25,000 clear and authoritative entries.

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If you have ancestors or older relatives who went through a very distressing or oppressive event, their emotional and behavioral reactions could ripple through the generations of your family and affect you. This is called intergenerational trauma. You might also hear it called generational trauma, historical trauma, or multigenerational trauma.

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Intergenerational trauma, or generational trauma, happens when the trauma of an earlier generation gets passed down. Learn more about what causes it and what to do about it.

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Breaking the Cycle of Generational Trauma | Candice Jones | TEDxLSSC

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Breaking the Cycle of Generational Trauma | Candice Jones | TEDxLSSC

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This talk focusses on how trauma can impact individuals medically, emotionally, and mentally as well as how it can be passed down from one generation to the next. Dr. Jones addresses the steps necessary for identifying and breaking the cycle of trauma within families for health and wholeness. Candice W. Jones, MD, FAAP is a board-certified physician practicing as a general pediatrician in Orlando, FL. A former National Health Service Corps Scholar and spokesperson for the American Academy of Pediatrics, Dr. Candice is committed to the health and well-being of underserved children and adolescents impacted. She is an award-winning author, speaker, podcaster working with various charitable organizations and initiatives and to promote wellness in the community. This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at https://www.ted.com/tedx

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Breaking the Cycle of  Generational Trauma | Candice Jones | TEDxLSSC

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Inherited Pain: The Science of Generational Trauma

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Inherited Pain: The Science of Generational Trauma

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Some experiences are so powerful, they shape not only our lives, but also those of our children and grandchildren. This intergenerational transmission of deep stress is known as generational trauma.

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Inherited Pain: The Science of Generational Trauma

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If people don’t have the opportunity to heal from trauma, they may unknowingly pass it on to others through their behaviour. Their children may experience difficulties with attachment, disconnection from their extended families and culture and high levels of stress from family and community members who are dealing with the impacts of trauma. This can create developmental issues for children, who are particularly susceptible to distress at a young age. This creates a cycle of trauma, where the impact is passed from one generation to the next.

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Transgenerational trauma or intergenerational trauma is the psychological and physiological effects that the trauma experienced by people has on subsequent generations in that group. The primary mode of transmission is the shared family environment of the infant causing psychological, behavioral and social changes in the individual.

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Transgenerational trauma is the psychological and physiological effects that the trauma experienced by people has on subsequent generations in that group. The primary modes of transmission are the uterine environment during pregnancy causing epigenetic changes in the developing embryo, and the share…

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Intergenerational Trauma: Assessment in Biological Mothers and Preschool Children

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Intergenerational Trauma: Assessment in Biological Mothers and Preschool Children

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Childhood trauma can lead to lifelong detrimental outcomes. Intergenerational trauma should be considered when supporting healthy parent–child relationships. Research is needed on intergenerational trauma in relation to children’s negative life event exposure, which could compound intergenerational trauma. We examined the prevalence of and relations between mother and child traumas in a sample of 88 biological mothers and their preschool-aged children. We coded child negative life events to examine those related to intergenerational trauma. Results showed that mother traumas and child negative life events were positively associated; subtypes of mothers’ traumas (abuse, neglect) and high trauma levels were associated with higher numbers of child negative life events, including those tied to parent trauma. It is necessary to consider how childhood trauma in adults and children is measured, and what analyses can reveal about the intergenerational context, especially considering compounding current, stressful world events.

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Intergenerational Trauma: Assessment in Biological Mothers and Preschool Children

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Childhood trauma can lead to lifelong detrimental outcomes. Intergenerational trauma should be considered when supporting healthy parent–child relationships. Research is needed on intergenerational trauma in relation to children’s negative life…

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Understanding Intergenerational Trauma: Its Impact and Legacy

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Understanding Intergenerational Trauma: Its Impact and Legacy

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Explore the rising topic of intergenerational trauma. This video dives into how unresolved familial trauma can manifest biologically and psychologically across generations, leaving lasting effects that shape our lives today. Discover the complexities and implications of this crucial subject

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Understanding Intergenerational Trauma: Its Impact and Legacy

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Effective Mental Health Treatment for Young Children and their Families

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Effective Mental Health Treatment for Young Children and their Families

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Years of research and clinical expertise have resulted in effective treatments for infant and early childhood mental health disorders. Here’s how interventions work to build positive and attuned caregiving skills, teach problem-solving and coping strategies, and enhance support systems.

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Effective Mental Health Treatment for Young Children and their Families

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Years of research and clinical expertise have resulted in effective treatments for infant and early childhood mental health disorders. Here’s how interventions work to build positive and attuned caregiving skills, teach problem-solving and coping strategies, and enhance support systems. This is excerpted from the third blog post in a three-part series exploring the mental health needs of very young children. Click […]

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Child Counseling Techniques & Therapy Activities for Kids

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Child Counseling Techniques & Therapy Activities for Kids

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Child therapy helps address emotional & behavioral challenges, promoting a child’s overall development & wellbeing.

Techniques like play therapy, art therapy & family involvement create a supportive environment for expression & healing.

Early intervention in therapy fosters resilience & equips children with coping skills for future challenges.

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Child Therapy: 19 Counseling Techniques & Kids’ Activities

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What is child therapy? How does it differ from regular therapy?

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Since the 1930s, play therapy has been used to help clients deal with mental, physical, and emotional disorders. In-play therapy, play therapists use well-structured games and activities to help their clients get more comfortable and open up.

Playing is natural, and during play therapy, the clients, especially children, let down their guard and open up to issues they might be holding back or undergoing either at school or home. For example, a child might not talk about bullying in school. However, if a role play technique is used during the sessions, the child will impersonate the bully. Therapists are then able to make their diagnosis and help the child overcome such occurrences.

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25 Play Therapy Techniques | Core Wellness

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25 Play Therapy Techniques | Core Wellness

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Recommending Evidence-based Interventions for Young Children and their Families

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Recommending Evidence-based Interventions for Young Children and their Families

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When considering therapeutic intervention for young children and their families affected by trauma, there are interventions that have an established evidence-base. These interventions have been listed by The National Child Traumatic Stress Network (NCTSN), indicating the treatment developer, the intended age group, the level of evidence, and a brief description of the focus and design of the intervention. Below is an alphabetical list of those evidence-based interventions that are designated as appropriate for young children — birth through 5 — and their families or caregivers

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Recommending Evidence-based Interventions for Young Children and their Families | The Center of Excellence (CoE) for Infant and Early Childhood Mental Health Consultation (IECMHC)

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Interventions for Young Children’s Mental Health: A Review of Reviews

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Interventions for Young Children’s Mental Health: A Review of Reviews

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To determine the efficacy of intervention programs for young children (4–9 years) with emerging mental health needs, we conducted a review of meta-analytic and systematic reviews of the intervention literature. Of 41,061 abstracts identified and 15,076 screened, 152 review articles met the inclusion criteria. We reviewed interventions across multiple disciplines targeting: (1) general mental health concerns; (2) internalizing symptoms; (3) externalizing symptoms; (4) anxiety; (5) depression; (6) trauma; (7) symptoms of attention-deficit/hyperactivity disorder; and (8) mental health concerns associated with autism spectrum disorder. Substantial evidence was found for the efficacy of behavioral and cognitive behavioral interventions for general mental health concerns, externalizing symptoms (generally, as well as ADHD, conduct, and other behavioral symptoms) and internalizing symptoms (generally, as well as anxiety) aged 4–9 years. Emerging evidence was identified for interventions targeting trauma symptoms, depression symptoms, and social, emotional and behavioral symptoms in autism spectrum disorder in children aged 4–9 years. Currently there is only limited emerging evidence regarding non-behavioral or non-cognitive behavioral interventions for programs targeting children ages 4–9 years where the aim is to deliver an evidence-based program to improve child social, emotional and/or behavioral functioning. Given the recent rises in mental health needs reported in children, targeted behavioral-and/or cognitive behavior therapy-based interventions should be made widely available to children (and their families) who experience elevated symptoms.

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Interventions for Young Children’s Mental Health: A Review of Reviews

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To determine the efficacy of intervention programs for young children (4–9 years) with emerging mental health needs, we conducted a review of meta-analytic and systematic reviews of the intervention literature. Of 41,061 abstracts identified and…

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Treating Children's Mental Health with Therapy

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Treating Children's Mental Health with Therapy

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Mental, emotional, and behavioral disorders in childhood can cause long-term problems that may affect the health and well-being of children, families, and communities. Treating a child's mental health problems as soon as possible can help children reduce problems at home, in school, and in forming friendships. It can also help with healthy development into adulthood.

The first step is to arrange a comprehensive evaluation of your child's mental health with a mental health provider to figure out a diagnosis and what type of treatments might work best. Psychological therapy is a key component to improving mental health. Depending on the type and severity of the problem, psychological therapy for children may be used in combination with medication.

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Treating Children’s Mental Health with Therapy

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Treating children’s mental health problems can help reduce problems at home and in school.

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We identified therapies according to 10 different therapeutic approaches, as summarised below. Detailed descriptions of each approach are also provided.

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Cognitive-behavioural therapies:

Systemic interventions:

Psychoeducation

Group work with children

Psychotherapy (unspecified)

Counselling

Peer mentoring

Intensive service models:

Activity-based therapies

Cognitive-behavioural therapies

Cognitive-behavioural therapies are a group of interventions that draw on a number of theories of learning, both to account for, and address a range of, emotional, psychological and behavioural problems. They have a wide application, ranging from addressing health and mental health problems to more interpersonal and social problems, such as social skills deficits and delinquency. As such, they have considerable relevance to the problems associated with child maltreatment. Before describing the core features of a cognitive-behavioural approach, we briefly describe the therapeutic approaches associated with earlier behavioural and social learning theories, as these continue to form important components of complex cognitive-behavioural interventions.

Behavioural therapies

The earliest interventions were essentially behavioural, drawing on operant (instrumental) and classical (respondent) conditioning paradigms of learning, associated, respectively, with BF Skinner and I Pavlov. Operant conditioning focuses on how behaviour changes with changes in the environment, as when a child's antisocial behaviour increases as a result of adult attention (reinforcement). Classical conditioning focuses on associative learning, whereby a person learns to respond in a particular way (e.g. becoming anxious) to a neutral stimulus (e.g. a place) by dint of the pairing of the neutral stimulus with a traumatic event (e.g. sexual assault, humiliation).

Although now rarely viewed as adequate conceptualisations of human behaviour, operant and classical conditioning continue to inform the interventions required to address complex social and psychological problems, such as those associated with child maltreatment. Strategies drawing on both operant and classical conditioning are used in psychosocial treatments. The most commonly used classical or respondent-based technique is relaxation training. Children are trained to relax in the face of a hitherto stressful stimulus (e.g. a memory of sexual abuse) either as a way of neutralising the impact of the stimulus (where it forms part of an exposure therapy) or as the means of providing an opportunity to practise other ways of coping, such as 'reframing' (locating the responsibility for the maltreatment with the perpetrator rather than blaming themselves; practising positive self-talk). Some of the included studies evaluate a purely respondent approach to anxiety management. Operant techniques, such as differential reinforcement (essentially ensuring unwanted behaviour is not reinforced and positively reinforcing prosocial or wanted behaviour) form an important part of interventions that are designed to address the behavioural problems that are often associated with maltreatment, particularly for younger infants and children.

Modelling and skills training

Social learning theory, recognises that we are not simply the product of our environments: we do not simply respond to stimuli - we interpret them. What we think influences what we do and how we respond to other people and events, and our experiences lead us to expect certain outcomes from certain courses of action under certain circumstances. Furthermore, a large proportion of our behavioural repertoire (e.g. our social skills, our ability to problem solve) comes not from simple respondent or operant processes, but by learning from others. We learn how to do things and how to behave by watching other people or via processes of vicarious learning (e.g. by books or verbal instruction). Reinforcement will play a part in determining whether or not we adopt or use certain responses, and some may find it difficult to manage particular situations if they have not had the opportunity to develop the appropriate skills, including social skills. Social learning theory informs our understanding of how certain forms of maltreatment may be associated with the certain outcomes, for example in understanding how witnessing intimate partner violence can exert a 'modelling effect' on children, particularly boys, which - in the absence of opportunities to learn alternate ways of managing conflict or frustration (for example) - can lead to intergenerational cycles of violence. The understanding of the importance of modelling and behaviour rehearsal (with feedback and positive reinforcement) is used to inform a number of psychosocial therapies that aim to help individuals find more adaptive ways of responding to situations.

Cognitive-behavioural therapies

In contrast with traditional learning theory, cognitive theories afford the mind a central role in understanding behaviour, and in developing interventions designed to address psychosocial problems. Unlike the behaviour therapies, which emerged from laboratory-based experiments, cognitive therapies developed from clinical practice, largely in the field of depression, and thus predated the empirical data that have subsequently accrued. For example, Beck 1979 argued that depression resulted from the reciprocal interaction of three things: a negative way of viewing oneself, one's situation and one's prospects ( cognitive triad), rigid ways of thinking about the world ( schema) that often develop early in life or based on the interpretation of prior experience, and which result in negative, automatic thoughts, and biased and erroneous thinking ( faulty information processing). It is thought that children who have experienced maltreatment may well develop unhelpful ways of thinking about themselves, their situation and their prospects, which may cause them difficulties or prevent them overcoming associated problems. For example, children who have been maltreated may well blame themselves for what has happened to them; they may have internalised a negative self-image; they may have 'learned' that nothing they do can bring about a sought-after outcome (to be loved, thought well of), resulting in poor self-efficacy or indeed depression. Many of the psychosocial interventions designed to address the problems experienced by maltreated children are concerned to influence these cognitive sequelae. Cognitive-behavioural therapies seek to do so quite directly by helping individuals to identify maladaptive beliefs and ways of thinking, to challenge them (reality testing) and to replace them with more realistic and positive ways of thinking.

Trauma-focused cognitive-behavioural therapy

Trauma-focused CBT (TF-CBT) is a manualised intervention developed by Cohen, Mannarino and Deblinger. TF-CBT directly addresses traumatic symptoms, alongside other components that are typical of CBT interventions, such as coping skill training and symptom management, cognitive restructuring and gradual exposure. However, key differences are a greater focus on graded exposure, creating an appropriate account of the trauma [a trauma narrative (TN)] and cognitive processing of experiences. This focus builds on findings from research that support a model of trauma in which traumatic memories and related symptoms are maintained by cognitive biases and avoidance strategies. The TN component aims to address this in order to reduce symptomology and process traumatic memories. TF-CBT combines joint child-parent sessions and individual sessions for both child and non-offending parents. Parent involvement provides opportunities to address misperceptions and to validate parental reactions to their child's traumatic experiences, to train parents to support their child's therapeutic work and to provide a supportive environment at home (e.g. the studies by Cohen et al., and Cohen and Mannarino).

Eye movement desensitisation and reprocessing

We identified two controlled studies (both randomised trials) of EMDR. EMDR is a manualised intervention developed by Shapiro et al. Because its core features combine strategies from the learning theories outlines above, we have included it in the group of cognitive-behavioural interventions. EMDR involves the identification and processing of traumatic memories using bilateral stimulation, desensitisation through imaginal exposure, and challenging and replacing maladaptive beliefs about the trauma. The information processing model suggests that this helps to process traumatic memories into long-term memory, thereby reducing trauma-related symptoms, such as hypervigilance, as well as replacing unhelpful beliefs, related to the trauma, with more adaptive ones.

Relationship-based interventions

Attachment-orientated Interventions

Attachment describes an infant's strong disposition 'to seek proximity to and contact with a specific figure and to do so in certain situations, notably when . . . frightened, tired, or ill'. It is a behavioural system that is a product of human evolution, designed to trigger protection in the face of perceived danger and to alleviate its associated response, fear. Most infants develop an attachment to their primary carers, and, for most infants, the relationship with the mother is the first intimate relationship in which they engage. From these attachment relationships children start to form a sense of who they are, what they can expect from others, and what behaviour it is useful or dangerous to engage in. Infants whose primary carer provides sensitive and responsive care develop what is called a secure attachment. Carer sensitivity and responsiveness to their infant's needs helps to 'shape their physiological regulation and biobehavioral patterns of response' (p. 624), and, as infants develop a secure attachment (sometime towards the end of their first year), they use that attachment and associated feelings as a secure base from which to explore their worlds.

Emotional and physical neglect or abuse, and exposure to violence, can result in insecure attachments or sometimes disorganised attachments, which, if unresolved, will contribute to a wide range of problems in later development, including poor socioemotional development, self-regulation difficulties, maladaptive behaviour, sleep disturbance, language delays, poor peer relationships, school underachievement, and psychopathology and delinquency in later life.,, It has also been associated with a disturbed hypothalamic-pituitary-adrenal axis, which is important for self-regulation and stress management. Disorganised attachment styles develop when children are emotionally and physically depending on someone who is also a source of fear and anxiety. Unsurprisingly, disorganised attachments styles are prevalent among children living in families in which there is child maltreatment, parental depression, parental history of loss or trauma, parental dissociation, parental frightening behaviour or marital discord. The cascade of negative outcomes associated with a disturbed attachment has been referred to as 'toxic stress'.

There is a sizeable literature focused on interventions that are designed to promote maternal sensitivity and responsiveness (see van Ijzendoorn et al.). In this review, we included only those interventions that specifically focused on families when maltreatment was deemed to be an issue. Although these interventions might arguably also be viewed as secondary prevention (and therefore not appropriate for this review), the nature of attachment is such that interventions designed to promote secure attachments inevitably focus on the primary caregiver. Given the significant impact on subsequent development, these interventions were judged to meet the inclusion criteria of a psychosocial intervention dealing with the adverse consequences of maltreatment for children.

Attachment interventions generally involve caregiver-infant sessions, and aim to enhance parental sensitivity to emotional and behavioural cues in order to improve a child's attachment security (e.g. Moss et al.). This may involve child development training, parenting skills, coping strategies, developing social support networks, enhancing the caregiver's capacity to provide safety, child-caregiver joint narrative of trauma experiences, addressing negative maternal representational models in the parent-child interaction, providing a corrective emotional experience for caregivers or addressing a caregiver's own attachment difficulties stemming from childhood.,,⁻ In attachment-based interventions, the focus of the intervention is not the caregiver or the child but rather the caregiver-child relationship. This relationship is used as a vehicle to address a child's emotional, cognitive and social functioning difficulties. ⁻

Attachment and biobehavioral catch-up

Attachment and Biobehavioral Catch-up (ABC) is informed by both attachment theory and neurobiology., ABC focuses specifically on disorganised attachment styles, which are associated with frightening or frightened parental behaviour rather than purely a lack of attunement or insensitivity by the parent. This form of attachment has been found to mediate disrupted maternal behaviour and children's behavioural difficulties and dysregulation. Children's behavioural level and biobehavioural level dysregulation is characterised by externalising behaviour problems, conduct difficulties and disrupted cortisol patterns (which are associated with stress reactivity).,

Attachment and Biobehavioral Catch-up (ABC) is a manualised didactic intervention which was designed to decrease parental frightening behaviour and increase parental sensitivity. In contrast with more general attachment-based interventions, the focus of ABC is on parental behaviour change rather than changing parental internal representations. The aim of the intervention is to help children learn self-regulatory skills by changing the way parents interpret their children's behaviour, over-riding their own issues that interfere with their caregiving and providing an enabling environment for developing self-regulation skills.,

Parent-child interaction therapy

Parent-child interaction therapy (PCIT) was developed by Sheila Eyberg. PCIT draws on the work of Diana Baumrind (on parenting styles), as well as attachment theory and learning theory. In its original form it was designed to help parents to establish a secure and nurturing relationships with their child, and enhance prosocial behaviour while decreasing undesirable behaviour. Unlike parent training, PCIT involves in vivo child-parent dyadic sessions in which parents are taught behaviour management techniques, often being coached through a one-way mirror. To an extent, PCIT resembles a behavioural version of play therapy [Children's Depression Inventory (CDI)] and behavioural parent training (parent-directed interaction).

Most studies of PCIT seek to minimise the risk of maltreatment or future maltreatment and secure children's well-being by promoting nurturing parenting and reducing those parental practices that have been linked to maltreatment and attachment disorders, such as inappropriate discipline, coercive cycles of behaviour and negative communication.,

Dyadic developmental psychotherapy

Dyadic developmental psychotherapy (DDP) is designed to address the impairments associated with attachment disorders and complex childhood trauma., The intervention uses the child-therapist relationship to establish a relational context in which the child can learn how to engage with, and benefit from, relationships with others. The therapist seeks to establish a relationship that mirrors the general principles characteristic of parent-child relationships that facilitate secure attachments, for example attunement, reflecting back to the child his/her subjective experiences (including the trauma s/he has experienced) and helping him/her to make sense of these 'with acceptance, curiosity and empathy'. In the same way that attachments develop as a result of experience (preverbally), DDP emphasises the importance of healing experiences. In order to benefit from DDP, children need to be in a safe and secure environment (at home or in substitute care) and parents (or carers) are active participants in the therapy, either being with the child in the sessions or watching the therapy through a one-way mirror.

Child-parent psychotherapy

Child-parent psychotherapy (CPP) is a home-based, manualised intervention provided on a weekly basis for 1 year by trained master's level therapists. It is described as a 'supportive, non-directive, and nondidactic' intervention that 'includes developmental guidance based on the mother's concerns' (p. 794). When children are aged ≤ 1 year, this therapy is referred to as Infant-Parent Psychotherapy; when they are older, the intervention is called, alternately, Pre-School Parent Psychotherapy or Toddler-Parent Psychotherapy.

Parenting interventions

In general, parent training interventions aim to change unhelpful or maladaptive parenting practices in order to improve child development and well-being. As such, most parenting programmes that address maltreatment are concerned with secondary prevention, but we found three studies,, with a specific focus on improving outcomes for children who have been exposed to maltreatment, and these studies were included. One study evaluated the effectiveness of a parenting programmes designed to help foster parents and parents to co-parent children in foster care, with a view to ameliorating the child behaviour problems associated with, and return the children to, the care of their biological parents. A second assessed the impact of training maltreating mothers in elaborative and supportive reminiscing about positive and negative everyday past events with young children, as a means of addressing multiple sequelae of maltreatment. The third specifically examined the impact of the Webster-Stratton IY programme on children's autonomy, as well as positive parenting, recognising that autonomy is an important subjective state and a critical behaviour acquired in the early years, and which is related to the quality of parenting.

Systemic interventions

Systems theory posits that individuals are embedded in, and influenced by, a number of interacting systems, including - most importantly - the family. Within systems theory, the problems affecting an individual are conceptualised as a function of the relationships and patterns of interaction that surround him or her, with the resulting implication that effective interventions necessitate locating individual problems within that context and - in many circumstances - directing intervention at the family, rather than simply the individual. Systemic analyses can also be applied to other social systems, such as wider family networks, groups or organisations. Given the inclusion criteria, systemic interventions were included only when they directly focused on ameliorating the consequences of maltreatment for the children in the family (as opposed to halting it and creating a supportive family system that was capable of promoting optimal child development).

Systemic family therapy

There are many forms of FT, most of which are informed primarily by structural family systems theory and drawing on a wide range of techniques from other interventions, such as CBT. This can make assessing its effectiveness quite challenging, as some forms of therapy are essentially systems-focused cognitive-behavioural interventions.

Multisystemic therapy

Multisystemic therapy (MST) is a short-term, multifaceted intervention for children and young people with serous psychosocial and behavioural problems. It differs from FT in that it includes a combination of multiple systems in the treatment focus, such as family, peers, school, neighbourhood or community. Consistent with social ecological theories of human development, this broader focus is based on the view of the programme developers - that children's difficulties are caused and maintained by multiple factors within these systems and their interaction. The intervention therefore focuses on identifying and targeting these factors in order to reduce symptoms and distress, and promote health.

Group work with children

Group psychotherapies (or therapeutic groups) are interventions in which the group format is central. The group itself is deemed to be 'therapeutic', providing a number of essential components, such as a feeling of universality, reducing isolation, extending social networks, social skills practice, healthy relationship building and normalising.

The interventions' group content includes psychoeducation, as well as skills training and experiential learning. This may include assertiveness training, narrative therapeutic activities, such as storytelling or body image and self-esteem enhancement. Many of these interventions are based on social learning theory.

Psychotherapy/counselling

Common to all psychotherapeutic interventions that address individual, familial and community-level issues, is a non-judgemental, insight-orientated approach with a strong focus on the therapeutic alliance and dynamic relational processes with therapists or group members. Using these processes to work through past and current relationships, losses and disruptions, is thought to address underlying psychological processes in relation to traumatisation and to enable long-term change. Many the studies we identified provided only very general descriptions of these talking-based therapies (such as 'psychotherapy' or 'counselling'), often with little or no information on the underpinning theory of the approach used.

Intensive service provision

Treatment foster care

Enhanced Foster Care is designed specifically to meet the developmental, social and emotional needs of children in foster care with particularly challenging behaviour. A multidisciplinary team works with specially trained foster parents to reduce behavioural difficulties, increase regulatory abilities and increase a young person's secure attachment-related behaviour through a consistent and predictable environment. It involves high rates of positive reinforcement for desirable behaviours, clear limit setting, 24-hour crisis intervention for foster parents, support groups for foster parents, group therapeutic support for children and FT for relationships with biological family.

Therapeutic residential/day care

Like milieu therapy, therapeutic residential care entails creating a nurturing, stable and consistent environment and a predictable routine for children and young people who need specialist help, and whose problems make it difficult to provide that help in any other way. Indeed, for some maltreated children their experiences of maltreatment, combined with adverse care experiences, may mean they cannot be managed in substitute home-based care settings, such as adoption and fostering. A variety of specific interventions are used in the therapeutic residential care studies included in this review, among which are therapeutic parenting, life story work, trauma-focused psychological therapy, addressing cognitive distortions, improving impulse control, social skills training, risk management, sex education and behaviour modification, as well as preparation for independence for older adolescents.

Therapeutic day programmes aim to meet the developmental needs of children in terms of fine motor, language, and social and emotional skills. Therapeutic day programmes are held in classroom environments and usually run intensively over numerous full days per week. The programmes can include milieu therapy (see below), developmentally appropriate play and activities, structured interaction, individual and parent counselling, and education services, within a psychologically safe environment that is consistent and predictable.,,,

Milieu therapy is a therapeutically planned approach to a residential or day-care environment that is designed to provide a safe environment in which adults can assist children to address the consequences of maltreatment. Safety, containment, structure, support, involvement and validation are key therapeutic activities. Like therapeutic communities (the terms are sometimes used interchangeably), the aim is to provide a safe, nurturing environment that can engage the 'whole child' in processes of psychological change. Through multiple and repeated experiences that are carefully controlled (safe), children can learn about their behaviour and how to discuss distressing feelings and find alternative ways of expressing these. They can develop their self-esteem, learn to trust others, and learn to negotiate relationships and to acquire problem-solving skills. Milieu therapy draws on a range of theoretical frameworks, including attachment theory and object relations theory. Staff use their understanding of transference and countertransference to identify how a child's feelings and behaviour towards others reflect those with parents, siblings and significant others in their lives, and use this to facilitate change.

Co-ordinated care

Co-ordinated care refers to interventions designed to provide a single point of entry to services, combined with a seamless system of service delivery. It has much in common with initiatives designed to improve interagency working. It is designed to address some of the weaknesses that are inherent in a reliance solely on case management.

Activity-based therapies

Arts therapy

Children who have been maltreated can find it difficult to verbalise their experience, and may feel intimidated by the therapeutic environment and overwhelmed by the verbalisation of abuse experiences. Using a variety of media - such as paint, clay, photos, poems, storytelling or music - arts-based therapies are thought to help facilitate the non-verbal and verbal expression of thoughts, feelings and life narratives. In this way, arts can provide a non-verbal medium for therapeutic communication and cognitive processing for children for whom verbal forms of therapy are not possible. It can help to bridge the gap between the internal world and the limitations of verbal language, particularly in latency age children, and provide a mode of communication for children who are unwilling or unable to talk about what has happened to them.

Play/activity interventions

Play or activity interventions, depending on the age of the target population, are based on the premise that play and activity are vital for healthy development. Play therapy views play as a 'natural medium in which children express themselves' (p. 28). It therefore provides a way to communicate complex ideas that would be otherwise difficult, through verbal means and helps children make sense of their internal and external worlds. Furthermore, deficits in imaginative play have been observed in children who have experienced maltreatment that have been negatively associated with positive affect, peer interaction and problem-solving. Activity-based interventions, such as sports or game based interventions, view activity as an appropriate medium for adolescents because it is more enjoyable than one-to-one office-based therapy, requires the development of social skills and peer relations, has physiological benefits through physical exercise and requires cognitive skills, such as impulse inhibition and planning.

Interventions included under this category are those identified by the author as imaginative play training, challenge/initiative games and the sports-based intervention 'Do the Good'.

Animal therapy

Animal therapy (or animal-assisted therapy) uses animals as part of the therapeutic process. Animals (from dogs through to horses) are used to assist with the therapeutic process and strengthen treatment strategies. They are thought to aid the therapeutic environment through the provision of warmth, acceptance, empathy and unconditional love. Animal therapy is based on research that has found that the presence of animals has improved the communication skills of children participating in therapy, lowered anxiety while undergoing therapy and improved motivation for therapy, as well providing opportunities to teach boundaries and appropriate touch in maltreated populations.

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Cognitive-behavioural therapies: Systemic interventions: Psychoeducation Group work with children Psychotherapy (unspecified) Counselling Peer mentoring Intensive service models: Activity-based therapies Cognitive-behavioural therapies are a group of interventions that draw on a number of theories of learning, both to account for, and address a range of, emotional, psychological and behavioural problems. They have a wide application, ranging from addressing health and mental health problems to more interpersonal and social problems, such as social skills deficits and delinquency.

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In Child Centered Play Therapy, children are able to express themselves in developmentally appropriate ways through play, toys and art. Play is the natural expression and communication of young children. Children are able to communicate thoughts, experiences and emotions in ways that they may not be ready or able to verbalize in traditional “talk therapy.” Playing out experiences is self-healing and organizes experiences and feelings, much the same as verbal communication does for adults. As children express their inner feelings through therapeutic play, they feel better and learn new coping skills to regulate their emotions and behavior.

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Therapeutic Approaches | Children’s Counseling Center

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The Children’s Counseling Center uses a wide array of therapeutic approaches to offer developmentally appropriate, individualized, play-based counseling for your child.

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Understanding Behavioral Therapies for Children: Finding the Right Fit

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Understanding Behavioral Therapies for Children: Finding the Right Fit

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Understanding behavioral therapies for your child can feel overwhelming, but finding the right approach is crucial for their development. In this webinar, Dr. Nancy Carnevale, Kelsey Cameron, BCBA, and Lee Turner, LPC, explore evidence-based therapies, including Applied Behavior Analysis (ABA), Parent Behavior Management Training (PMT), Cognitive Behavioral Therapy (CBT), and exposure techniques. Learn how these therapies address conditions like autism, ADHD, anxiety, and disruptive behaviors. Discover practical strategies for reinforcing positive behaviors and improving family dynamics. Watch now to gain expert insights into behavioral interventions and therapy options tailored to your child’s needs!

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Understanding Behavioral Therapies for Children: Finding the Right Fit

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Teaching Effective Coping Skills to Deal with Life's Struggles

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Teaching Effective Coping Skills to Deal with Life's Struggles

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25% of adults and 20% of youth 13-18 experience Mental Illness.
100% of adults and youth experience Mental Health!

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Teaching Effective Coping Skills to Deal with Life’s Struggles | Coping Kids

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Teaching Effective Coping Skills to Deal with Life’s Struggles. Coping Kids offers a free Mental Health Workbook for kids!

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Developmental trauma: Conceptual framework, associated risks and comorbidities, and evaluation and treatment

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Developmental trauma: Conceptual framework, associated risks and comorbidities, and evaluation and treatment

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Children exposed to adverse childhood experiences (ACEs) and pervasive interpersonal traumas may go on to develop PTSD and, in most cases, will further undergo a significant shift in their developmental trajectory. This paper examines contemporary research on Developmental Trauma (DT), which is inextricably linked to disruptions in social cognition, physiological and behavioral regulation, and parent-child attachments. Developmental trauma associated with early experiences of abuse or neglect leads to multi-faceted and longstanding consequences and underscores critical periods of development, complex stress-mediated adaptations, and multilevel, trans-theoretical influences in the diagnostic formulation and treatment of traumatized children, adolescents, and adults. Psychological and medical correlates of Developmental Trauma Disorder are considered, and directions for future research are discussed.

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Developmental trauma: Conceptual framework, associated risks and comorbidities, and evaluation and treatment

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Children exposed to adverse childhood experiences (ACEs) and pervasive interpersonal traumas may go on to develop PTSD and, in most cases, will further undergo a significant shift in their developmental trajectory. This paper examines contemporary…

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Substantial theoretical, empirical, and clinical work examines trauma as it relates to individual victims and perpetrators. As trauma professionals, it is necessary to acknowledge facets of institutions, cultures, and communities that contribute to trauma and subsequent outcomes. Systemic trauma-contextual features of environments and institutions that give rise to trauma, maintain it, and impact posttraumatic responses-provides a framework for considering the full range of traumatic phenomena. The current issue of the Journal of Trauma & Dissociation is composed of articles that incorporate systemic approaches to trauma. This perspective extends conceptualizations of trauma to consider the influence of environments such as schools and universities, churches and other religious institutions, the military, workplace settings, hospitals, jails, and prisons; agencies and systems such as police, foster care, immigration, federal assistance, disaster management, and the media; conflicts involving war, torture, terrorism, and refugees; dynamics of racism, sexism, discrimination, bullying, and homophobia; and issues pertaining to conceptualizations, measurement, methodology, teaching, and intervention. Although it may be challenging to expand psychological and psychiatric paradigms of trauma, a systemic trauma perspective is necessary on both scientific and ethical grounds. Furthermore, a systemic trauma perspective reflects current approaches in the fields of global health, nursing, social work, and human rights. Empirical investigations and intervention science informed by this paradigm have the potential to advance scientific inquiry, lower the incidence of a broader range of traumatic experiences, and help to alleviate personal and societal suffering.

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Substantial theoretical, empirical, and clinical work examines trauma as it relates to individual victims and perpetrators. As trauma professionals, it is necessary to acknowledge facets of institutions, cultures, and communities that contribute to trauma and subsequent outcomes. Systemic trauma-con …

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Systemic Oppression and Trauma: Why Healing-centered, Two-generation Approaches are Crucial to Poverty Alleviation

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Systemic Oppression and Trauma: Why Healing-centered, Two-generation Approaches are Crucial to Poverty Alleviation

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Systemic racism and discrimination are forms of systemic oppression found to be root causes of poverty and hunger in the United States. Systemic racism is a form of violence that places or keeps people of color in conditions of hunger and poverty through the structural withholding of resources and opportunities, hyper-surveillance, and unjust incarceration inflicted on racialized individuals and communities. Racial discrimination consists of interpersonal and individual interventions with a person’s physical, emotional, economic, or social wellbeing because of biases against someone’s race, often in by way of access to public space, employment, housing, and healthcare. Both systemic racism and discrimination create conditions of economic insecurity that then exacerbate and foster a cycle of poor health and exposure to violence stemming from this systemic trauma. Many health professionals and policy advocates have called for approaches that seek to address, remediate, and prevent individualized trauma.

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Systemic Oppression and Trauma: Why Healing-centered, Two-generation Approaches are Crucial to Poverty Alleviation - Center for Hunger Free Communities

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Trauma-Informed Care: Understanding the Impact of Systemic Trauma

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Trauma-Informed Care: Understanding the Impact of Systemic Trauma

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Trauma-informed care is a critical aspect of providing support to children in foster care. However, it is not just individual traumatic experiences that impact children in foster care. Systemic trauma, such as racism and poverty, can also have a significant impact on a child's development and well-being. At Anthony's Villa, we are committed to providing trauma-informed care that takes into account the impact of systemic trauma on the children in our care.

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Trauma-Informed Care: Understanding the Impact of Systemic Trauma

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Trauma-informed care is a critical aspect of providing support to children in foster care. However, it is not just individual traumatic experiences that impact children in foster care. Systemic trauma, such as racism and poverty, can also have a significant impact on a child’s development and well-being. At Anthony’s Villa, we are committed to providing trauma-informed care that takes into account the impact of systemic trauma on the children in our care.Systemic trauma refers to the impact of s

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Trauma can significantly alter how an individual engages with the world around them for the foreseeable future. I often use the analogy of a child’s experience with a hot stove when discussing the impact of trauma: Generally, when a child gets burned by a hot stove, their relationship with that stove is altered. Where they may have been curious previously, they are now cautious and maybe even avoidant. If anyone gets near the stove, the child makes sure to warn them “Hot! Be careful!” The same protective mechanisms are at play when a person experiences trauma and the long-term mental health effects often encompass the general internal message of “Hot! Be careful!”

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NBCC | National Board for Certified Counselors & Affiliates

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Systemic Trauma in Foster Care: Understanding the Impact Beyond Intervention 

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Systemic Trauma in Foster Care: Understanding the Impact Beyond Intervention 

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It was the middle of the night, and police lights cast a flickering glow outside a home in crisis. Two elementary-aged children, hastily packing their belongings into a bag, were about to be taken into emergency custody. Their mother and her boyfriend sat in the back of a patrol car nearby.

The children, confused and frightened, were placed into the backseat of a social worker’s car, unsure of where they were going. The placement team was actively working to find an available home for them—if one could be found that night. Though the social worker reassured them they would be safe, the reality was stark: they had known this adult for less than an hour and were being asked to trust a stranger to take them to an unfamiliar place.

For thousands of children in the child welfare system, this scenario is not uncommon. In cases of domestic violence, substance abuse, neglect, or physical harm, state intervention is necessary to ensure a child’s safety. However, what is often overlooked is the secondary trauma that occurs within the foster care system itself—an experience known as systemic trauma.

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It was the middle of the night, and police lights cast a flickering glow outside a home in crisis. Two elementary-aged children, hastily packing their belongings into a bag, were about to be taken into emergency custody. Their mother and her boyfriend sat in the back of a patrol car nearby.

The children, confused and frightened, were placed into the backseat of a social worker's car, unsure of where they were going. The placement team was actively working to find an available home for them-if one could be found that night. Though the social worker reassured them they would be safe, the reality was stark: they had known this adult for less than an hour and were being asked to trust a stranger to take them to an unfamiliar place.

For thousands of children in the child welfare system, this scenario is not uncommon. In cases of domestic violence, substance abuse, neglect, or physical harm, state intervention is necessary to ensure a child's safety. However, what is often overlooked is the secondary trauma that occurs within the foster care system itself-an experience known as systemic trauma.

What is often overlooked is the secondary trauma that occurs within the foster care system itself-an experience known as systemic trauma.

The Hidden Trauma of the Foster Care Process

The removal of a child from their home is rarely straightforward. Even when intervention is essential, the process itself can be deeply traumatic. According to the National Child Traumatic Stress Network ( NCTSN), children in foster care often experience complex trauma, a term that describes both their experiences before entering the system and the distress caused by separation, instability, and uncertainty once in care.

Children placed into protective custody may experience:

Being escorted from their homes by law enforcement and social workers, which can be intimidating, particularly for children who already associate police presence with negative experiences.

Uncertainty about where they will sleep that night-whether in a foster home, a group home, or a temporary shelter.

Separation from siblings, which is common when agencies struggle to place multiple children together due to age gaps or a lack of available foster homes.

Disruptions to schooling, leading to concerns about falling behind academically or losing social connections.

Feelings of guilt or responsibility, especially if they have acted as caregivers for younger siblings or have been conditioned to protect a parent from harm.

Research from the Administration for Children and Families (ACF) highlights that both acute and chronic stress, such as the upheaval caused by foster care placement, can significantly impact a child's ability to develop self-regulation skills-the foundational ability to manage emotions, behaviors, and social interactions. Children who experience repeated disruptions in caregiving relationships, as is common in foster care, may struggle with heightened anxiety, withdrawal, and difficulty forming secure attachments due to an overactive stress-response system.

These early disruptions can have long-term consequences. ACF research suggests that prolonged exposure to chronic stressors, such as housing instability and caregiver turnover, can alter brain development, making it more difficult for foster youth to build healthy relationships, regulate emotions, and adapt to new environments. Without consistent, trauma-informed support, these effects can extend into adulthood, increasing the risk of mental health challenges, homelessness, and difficulty maintaining employment or long-term connections.

Understanding these developmental challenges is essential for foster agencies, caregivers, and advocates, who play a critical role in providing stability, emotional regulation strategies, and nurturing environments that help mitigate the impact of systemic trauma. By fostering predictability, security, and emotional support, caregivers can help youth develop resilience and rebuild trust in their relationships and future stability.

Addressing Systemic Trauma in Foster Care

While some level of distress is inevitable, intentional support and trauma-informed care can help lessen the impact of systemic trauma. Foster agencies, caregivers, and social workers play an integral role in minimizing unnecessary hardship.

1. Prioritizing Stable, Supportive Placements

When children entering care have a safe, welcoming home ready for them, it can make an enormous difference. Research from the American Academy of Pediatrics (AAP) shows that placement stability is one of the most significant factors in long-term emotional well-being for foster youth. Multiple moves within the system only compound trauma.

2. Keeping Sibling Groups Together Whenever Possible

Sibling bonds often provide the strongest sense of stability for children in care. Studies from the Journal of Child and Family Studies indicate that siblings placed together in foster care experience fewer behavioral challenges and higher overall emotional well-being than those separated. Whenever possible, agencies work to place siblings together or maintain frequent, meaningful contact.

3. Encouraging Trauma-Informed Foster Parenting

Foster parents serve as the frontline caregivers in the lives of children recovering from trauma. By providing predictability, emotional validation, and patient caregiving, foster families create environments where children feel safe enough to heal. Trauma-informed parenting training helps caregivers understand the neurobiological effects of trauma and how to support children through fear-based reactions, anxiety, and attachment difficulties.

4. Supporting Reunification Efforts When Safe and Possible

Reunification with biological parents remains the primary goal of foster care, provided it can be achieved safely and in the best interest of the child. According to data from the Administration for Children and Families (ACF), approximately 50-54% of children in California's foster care system are reunified with their families each year. Successful reunification often requires comprehensive support, including mental health services, substance abuse treatment, and parenting education, to ensure that families can provide a stable and nurturing environment upon reunification.

Without proper resources, children may experience emotional fragmentation, struggling to adjust as they navigate between placements and biological family relationships. A well-supported reunification process-one that prioritizes trauma-informed care, parent-child bonding, and long-term stability-can help reduce reentry into the foster care system and promote healthy family reunification outcomes. Foster agencies, caregivers, and social workers play a key role in ensuring that families receive the tools and support necessary to make reunification a lasting success.

The Role of Foster Parents & Community Support

At the heart of these efforts are foster families-individuals who open their homes and hearts to provide temporary refuge and long-term impact. The presence of a stable, nurturing adult in a child's life can mean the difference between prolonged distress and a chance to rebuild a sense of security.

Foster parents offer:

A soft place to land when everything feels uncertain.

Consistency, even when a child's emotions are overwhelming.

Encouragement for reunification, recognizing that a child's strongest bond may still be with their biological parents.

Advocacy for the child's needs, whether in school, therapy, or social services.

Even for those who are not able to foster, there are countless ways to support the well-being of foster youth-from mentorship programs and volunteer opportunities to donations that support housing, education, and mental health resources.

The work being done at Orangewood Foundation's foster family agency, Youth Connected Program (YCP), and partner agencies across Orange County is a testament to the belief that no child should have to navigate trauma alone. Through safe placements, dedicated foster families, and trauma-informed advocacy, the goal is not just intervention but healing and hope.

For more information on how to become a foster parent, volunteer, or support foster youth in need, contact [email protected].

Reducing Systemic Trauma, Rebuilding Trust in Foster Care

The trauma experienced before foster care is undeniable, but the trauma experienced within the system does not have to be inevitable. By acknowledging systemic trauma and actively working to reduce its impact, foster agencies, caregivers, and advocates can ensure that children in care receive more than just protection-they receive the stability, healing, and hope they deserve.

The trauma experienced before foster care is undeniable, but the trauma experienced within the system does not have to be inevitable.

At YCP and Orangewood Foundation, the mission remains clear: to walk alongside foster youth with compassion, consistency, and unwavering support-no matter how difficult the road ahead may be.

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Supportive Solutions to Systemic Trauma in Foster Care

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Systemic trauma in foster care can have lasting effects. Discover how intentional, trauma-informed support helps foster youth heal and thrive beyond the system.

# data[].attributes.headline
The systemic impact of traumatized children.

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The systemic impact of traumatized children.

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The purpose of this chapter is to provide an overview of the systemic effects that occur when a child has been traumatized. The chapter begins with a general description of childhood trauma, followed by (a) the individual subsystem effects on the child and (b) the family system effects, including the parent-child subsystem, the sibling subsystem, and the extended family subsystem. While it certainly is necessary to recognize the significant negative effects of childhood trauma, it also is important to identify the resilience factors that protect many children from the long-term effects of trauma. The chapter addresses those resilience factors and concludes with implications for future research which address the systemic effects of traumatized children. (PsycInfo Database Record (c) 2025 APA, all rights reserved)

# data[].attributes.attachment_link.title
The systemic impact of traumatized children.

# data[].attributes.attachment_link.description
The purpose of this chapter is to provide an overview of the systemic effects that occur when a child has been traumatized. The chapter begins with a general description of childhood trauma, followed by (a) the individual subsystem effects on the child and (b) the family system effects, including the parent-child subsystem, the sibling subsystem, and the extended family subsystem. While it certainly is necessary to recognize the significant negative effects of childhood trauma, it also is important to identify the resilience factors that protect many children from the long-term effects of trauma. The chapter addresses those resilience factors and concludes with implications for future research which address the systemic effects of traumatized children. (PsycInfo Database Record (c) 2025 APA, all rights reserved)

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What Are the Long-Term Effects of Systemic Trauma on Communities?

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What Are the Long-Term Effects of Systemic Trauma on Communities?

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Systemic traumaMeaning → Systemic trauma is the harm created and maintained by institutions and cultural norms, impacting individuals and hindering a sustainable future. , often stemming from historical oppression, ongoing discrimination, or widespread violence, leaves deep scars on communities. Understanding its long-term effects is the first step towards healing and building resilient societies. These effects are far-reaching, touching everything from individual mental health to the economic stability of a region.

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What Are the Long-Term Effects of Systemic Trauma on Communities? → Question

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Systemic trauma’s effects are far-reaching, impacting mental health, social cohesion, and economic stability, often across generations. → Question

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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.

# data[].attributes.attachment_link.title
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.

# data[].attributes.body
Practices and procedures implemented by institutions or their leaders that directly or indirectly cause psychological, emotional, economic, spiritual, physical or sexual harm to particular individuals or specific groups of people. Perpetuates inequality, injustice, marginalization, exploitation and oppression of certain individuals or groups through such means as denial of opportunities, exclusionary tactics, preferential advancement of individuals or groups granted majority status, disenfranchisement, forced displacement, isolation, or separation from family, resources or other supports. Typically effects those assigned minority status in a given context or society based upon factors including race, ethnicity, citizenship, social class, age, gender, sexual orientation, religion, and disability. Empowered by and often stemming directly from structural violence.

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Practices and procedures implemented by institutions or their leaders that directly or indirectly cause psychological, emotional, economic, spiritual, physical or sexual harm to particular individu…

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Strong resilience and protective factors likely play a role in safeguarding the mental health of communities of color despite the numerous barriers they face.

Protective factors can improve mental health and suicide prevention efforts for all Coloradans, especially those of color who have been disproportionately affected by COVID-19. Harnessing these factors can also address long-standing systemic barriers to care.

Health care providers, community leaders, and policymakers play a role in integrating protective factors that will build resilience, promote good mental health, and reduce disparities throughout the communities they serve.

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Resilience and Protective Factors | Colorado Health Institute

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Avenues to Improving Mental Health and Reducing Health Disparities

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Protective Factors Associated With Post-traumatic Outcomes in Individuals With Experiences of Psychosis

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Protective Factors Associated With Post-traumatic Outcomes in Individuals With Experiences of Psychosis

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Trauma and trauma-specific mental health difficulties (e.g., post-traumatic stress disorder) are highly prevalent in people with psychosis. However, not everyone develops post-traumatic symptoms, and some people even experience post-traumatic growth (PTG) following trauma. It is important to identify which protective factors are associated with less severe trauma symptoms and/or positive outcomes to inform the development and implementation of interventions fostering these variables. Eighty-five patients with experiences of psychosis took part in a cross-sectional study. They were administered questionnaires measuring exposure to traumatic events, symptoms of PTSD and complex PTSD and potential protective factors assumed to be associated with lower vulnerability for post-traumatic symptoms and higher post-traumatic growth (trait resilience, secure attachment, social support, adaptive coping, optimism, general self-efficacy). Multiple hierarchical regression showed that some of these protective factors, in particular optimism, were associated with lower post-traumatic symptoms, explaining 21% of the variance in complex PTSD symptoms and 16% of the variance in PTSD symptoms.

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Abstract

Trauma and trauma-specific mental health difficulties (e.g., post-traumatic stress disorder) are highly prevalent in people with psychosis. However, not everyone develops post-traumatic symptoms, and some people even experience post-traumatic growth (PTG) following trauma. It is important to identify which protective factors are associated with less severe trauma symptoms and/or positive outcomes to inform the development and implementation of interventions fostering these variables. Eighty-five patients with experiences of psychosis took part in a cross-sectional study. They were administered questionnaires measuring exposure to traumatic events, symptoms of PTSD and complex PTSD and potential protective factors assumed to be associated with lower vulnerability for post-traumatic symptoms and higher post-traumatic growth (trait resilience, secure attachment, social support, adaptive coping, optimism, general self-efficacy). Multiple hierarchical regression showed that some of these protective factors, in particular optimism, were associated with lower post-traumatic symptoms, explaining 21% of the variance in complex PTSD symptoms and 16% of the variance in PTSD symptoms. However, the hypothesized protective factors, in particular resilience and adaptive coping, explained a considerably larger proportion of variance in PTG (44%). Our results suggest that whilst these variables provide only moderate protection from the vulnerability to experience post-traumatic stress, they may play an important role in allowing people to find meaning despite multiple traumas and subsequently lead more fulfilling lives. Therapies targeting the emotional and psychological consequences of trauma in people with psychosis might benefit from the integration of intervention strategies to enhance these additional psychological protective factors, which in turn may lead to positive treatment outcomes beyond the mere reduction of post-traumatic stress symptoms.

Keywords: post-traumatic growth, resilience, PTSD, post-traumatic stress disorder, psychosis, trauma, CPTSD, PTG

Introduction

Trauma and trauma-related conditions such as post-traumatic stress disorder (PTSD) are highly prevalent among people with psychosis ( 1- 3). Different relationships have been suggested to exist between trauma, PTSD, and psychosis. Trauma exposure, especially during childhood, can increase vulnerability to psychotic disorders or psychotic-like experiences such as delusions, hallucinations, disorganized thinking, and abnormal behavior ( 4- 6). Furthermore, due to the phenomenological similarity between post-traumatic stress symptoms and specific symptoms of psychosis (e.g., flashbacks and hallucinatory experiences), it has been suggested that psychosis and PTSD could be part of the same spectrum of responses to traumatic events. The way these intrusive experiences are labeled determines the diagnostic interpretation of these symptoms as either a function of psychosis or PTSD ( 7, 8). Finally, psychotic symptoms or related experiences can be so distressing that they cause symptoms of PTSD-an idea captured with the term psychosis-related PTSD ( 9, 10).

PTSD is not the only adverse outcome that could follow exposure to traumatic events. In addition to PTSD, the International Classification of Diseases 11th edition manual (ICD-11) proposed the distinct diagnosis of complex PTSD (CPTSD), which is supported by an increasing number of studies ( 11, 12). CPTSD comprises both the core PTSD symptoms (re-experiencing, avoidance, and sense of threat), plus three additional symptom clusters collectively referred to as "Disturbances in Self Organization" (DSO) ( 13). These comprise affective dysregulation (i.e., difficulties in regulating emotions, which can manifest in heightened emotional arousal or feeling of numbness and dissociation), negative self-concept (i.e., persistent negative views of the self and extremely negative self-evaluations) and disturbed relationships (i.e., difficulties with developing and maintaining interpersonal relationships, which can result in feeling distant from others) ( 11). Despite the recognition of the co-occurrence of psychotic symptoms and CPTSD ( 14), the increasing evidence in support of the ICD-11 CPTSD diagnosis, and research suggesting that psychological constructs consistent with the DSO may be important mediators of the association between trauma and psychosis ( 15), research specifically focusing on CPTSD in psychosis is still lacking ( 3, 16).

While PTSD and CPTSD are two recognized negative outcomes that can follow a traumatic experience, research has shown the existence of protective factors that might instead lead to more positive outcomes. These outcomes refer to circumstances when individuals can use their social and personal characteristics to remain immune to the effects of trauma, to "bounce back" to previous levels of adjustment or to prosper and experience post-traumatic growth (PTG) ( 17). PTG is described as a positive change that people experience after a traumatic event, to the point of developing beyond their previous level of psychological functioning in certain areas of their lives ( 18). Furthermore, numerous meta-analyses and systematic reviews have been carried out to understand which factors seem to favor different positive outcomes following trauma in non-clinical populations. Social support ( 19- 21), adaptive coping ( 21, 22), optimism ( 23, 24), trait resilience ( 25), self-efficacy ( 26, 27) and secure attachment ( 28, 29) are among the factors that seem to be more consistently associated to these positive post-traumatic outcomes.

Some research has been conducted on protective factors from trauma in people with psychosis, and PTG and its underpinnings are being increasingly investigated among service users ( 30). However, this has not been done as extensively as in other populations and never looking at numerous protective factors within the context of one study. When protective factors such as secure attachment were investigated, they were usually studied in association with their influence on psychotic symptoms [e.g., ( 31)]. In the rare instances where studies looked specifically at trauma and trauma-related responses in psychosis, research found that trait resilience ( 32) and adaptive coping ( 33) mediated the relationship between trauma and psychotic-like experiences, and that social support protected against the effects of trauma ( 34). To address the paucity of research on the topic, this present study investigated commonly recognized protective factors (social support, adaptive coping, optimism, trait resilience, self-efficacy and secure attachment) for three different post-traumatic outcomes in a sample of people with experiences of psychosis. First, we examined what protective factors were associated to different posttraumatic outcomes (PTSD, DSO and PTG), and then if these factors moderated the relationship between potentially traumatic life events and post-traumatic outcomes. It was hypothesized that: (1) participants with higher scores on the protective factors scales will report less severe symptoms of PTSD and DSO; (2) participants with higher scores on the protective factors scales will report higher scores on the PTG scale; (3) the protective factors will moderate the relationship between the amount of adverse event and PTSD and DSO symptoms severity.

Materials and Methods

Participants

Eighty-five participants were recruited from inpatient and outpatient services and from a list of eligible participants who had previously given consent to be contacted for research purposes by researchers at the authors' institution. Recruitment took place across five NHS Trusts in the North-West of England. Participants were considered eligible if they were: (1) aged 16 or above; (2) able to provide informed consent; (3) experiencing psychosis (e.g., having a diagnosis of schizophrenia) as confirmed with their mental health professional.

Measures

A brief self-report demographic questionnaire was used to collect data on participants' gender, age, nationality, ethnicity, legal status, level of education, employment status, present mental health illnesses and treatment history.

The Brief Coping Orientation to Problems Experienced inventory [Brief-COPE; ( 42)] is a 28-item self-report multidimensional inventory assessing 14 different forms of copying, each comprised of 2 items. Participants indicate whether they employed certain coping strategies based on a 4-point Likert scale ranging from "I haven't been doing this at all (1)" to "I've been doing this a lot (4)." Studies have grouped the original 14 coping scales into various overarching subscales. For this study, we used the adaptive coping subscale, which has been previously used in the psychosis literature ( 33, 43). Adaptive coping included active coping, planning, use of emotional support, use of instrumental support, positive reframing, religion, and humor items. The internal consistency in the present sample was good, with Cronbach's α = 0.78.

Procedure

After receiving NHS and Health Research Authority ethics approval (reference number: 18/NW/0469), participants were recruited between May 2019 and December 2019. Testing took place in locations convenient to participants, including the participants' homes, hospitals, community mental health centers, and university premises. After providing informed written consent, participants were asked to complete the demographic form, the PANSS clinical interview and the battery of research questionnaires. Participants were then fully debriefed and received £10 as a thank you for participating.

Data Analysis

Established procedures to identify multivariate outliers (combination of unusual scores on at least two variables) ( 50) found no evidence of influential cases in this dataset. As our variables were not normally distributed, non-parametric correlational analyses (Spearman's ρ) were carried out to examine the bivariate associations between the number of adverse life events, protective factors (adaptive coping, trait resilience, social support, secure attachment, optimism and general self-efficacy) and the outcome variables (PTSD, DSO and PTG). Following bivariate analyses, three multiple hierarchical regression models were conducted to examine whether protective factors predicted each of the post-traumatic outcomes (PTSD, DSO and PTG), and to investigate any increment in variation accounted for the addition of potential confounders (PANSS total, age, gender, and ethnicity). As PTSD and DSO were not normally distributed, the regression models including these dependent variables were bootstrapped. All regression analyses met the assumption of absence of multicollinearity (as confirmed by inspection of collinearity diagnostics, including variance inflation factor and tolerance statistics) and the assumption of normality of residuals. PROCESS (Model 1), a macro for SPSS, was then used to carry out an analysis to investigate if any of the protective factors moderated the relationship between the number of adverse events and outcome variables. All statistical analyses were carried out using SPSS version 25.

Results

Sample Characteristics

Demographic and descriptive measures for the current sample are displayed in Table 1. In summary, 60 participants were males and 25 were females, with a mean age of 44. Most of our participants had a diagnosis of schizophrenia (78%), followed by affective psychosis (14%) and psychosis NOS (8%). More than half of the participants reported clinically relevant post-traumatic symptoms on the ITQ (64%), with 13% meeting criteria for a diagnosis of PTSD, 29% meeting criteria for a diagnosis of CPTSD, and 22% meeting criteria for DSO symptoms (but not CPTSD).

All participants reported at least two different traumas and three participants reported up to seventeen different traumas out of the twenty included in the TALE. During childhood, 46% reported to have felt unsafe, unloved or unimportant, 31% reported to have experienced sexual abuse, and 20% reported to have gone thirsty, hungry or not have had a safe place to stay. Participants also reported to have often experienced potentially traumatic and highly distressing psychosis-related life events, with 85% reporting to have felt in danger or distress because of psychosis-related experiences, 62% reporting to have experienced a threatening or upsetting contact with mental health services, and 44% reporting acting in a way that put them or someone else in danger or that was strange or embarrassing.

Correlational Analyses

Non-parametric correlational analyses are reported in Table 2. In partial support of our hypothesis, some but not all the protective factors were associated with less severe symptoms of PTSD and DSO. Optimism was associated with lower PTSD scores, whereas resilience, optimism and self-efficacy were associated with lower DSO scores. Contrary to predictions, adaptive coping was associated with higher PTSD symptoms. To better understand this unexpected association, we carried out additional correlation analyses considering the specific subscales of the adaptive coping measure and PTSD, and we found that planning ( r = 0.409, p < 0.001), positive reframing ( r = 0.220, p = 0.043) and religion ( r = 0.254, p = 0.019) were the only subscales positively related to PTSD scores. In partial support of our hypothesis, participants with higher scores on some of the protective factor scales reported higher scores on the PTGI scale. PTG had a significant positive association with adaptive coping, resilience, optimism, and general self-efficacy. Contrary to predictions, secure attachment was not correlated with any post-traumatic outcome. The correlational analysis also showed a relationship between the number of potentially traumatic events as reported in the TALE, and PTSD and DSO. However, no association was found between number of traumatic events and PTG.

Regression Analyses

Three separate hierarchical regressions were carried out with post-traumatic outcomes (PTSD, DSO and PTG) as the dependent variables while controlling for psychotic symptoms (PANSS Total) and demographic variables (age, gender, and ethnicity) ( Table 3). The first hierarchical regression was carried out with PTSD as the dependent variable. After entering all the protective factors (adaptive coping, resilience, social support, secure attachment, optimism and GSE) in the first step of the analysis, the model explained 16% of the variance in the PTSD outcome [ F(6, 78) = 3.74, p = 0.003, R ² = 0.22, = 0.16]. The inclusion of psychotic symptoms in the second step did not significantly improve the prediction of PTSD ( R ² = 0.23, significance of R ² change p = 0.35). In step three, the demographic variables did not contribute to the prediction of PTSD (respectively R ² = 0.24, significance of R ² change p = 0.96). Throughout the three steps of the regression, adaptive coping and optimism remained significant. Adaptive coping was positively associated with PTSD symptoms (I: β = 0.383, p = 0.001; II: β = 0.351, p = 0.003; III: β = 0.356, p = 0.004), while optimism was negatively associated with PTSD symptoms (I: β = −0.380, p = 0.006; II: β = −0.363, p = 0.010; III: β = −0.353, p = 0.015).

A second regression model was estimated with DSO as the dependent variable. When entering the protective factors in step one, this model explained 21% of variance [ F(6, 78) = 4.79, p < 0.001, R ² = 0.27, = 0.21]. The inclusion of PANSS total in step two ( R ² = 0.29, significance of R ² change p = 0.18) and of gender, age and ethnicity in step three ( R ² = 0.31, significance of R ² change p = 0.48) did not significantly improve the prediction of DSO. Optimism was the only variable significantly associated with lower DSO symptoms across the three steps of the analysis (I: β = −0.400, p = 0.003; II: β = −0.376, p = 0.005; III: β = −0.355, p = 0.010).

The last hierarchical regression was conducted with PTG as the dependent variable, and in step one the model explained 44% of the variance [ F(6, 78) = 12.00, p < 0.001, R ² = 0.48, = 0.44]. In step one, resilience (β = 0.559, p < 0.001) and adaptive coping (β = 0.223, p = 0.015) predicted higher PTG scores. Adding PANSS total in step two significantly improved the prediction of PTG ( R ² = 0.51, significance of R ² change p = 0.03). In step two adaptive coping (β = 0.281, p = 0.003) and resilience (β = 0.562, p < 0.001) were still significant predictors; furthermore, it was found that PANSS total was negatively associated with growth (β = −0.193, p = 0.032). Step three also showed a small significant improvement in the prediction of PTG ( R ² = 0.57, significance of R ² change p = 0.03). Adaptive coping (β = 0.320, p = 0.001) and resilience (β = 0.513, p = 0.001) remained significant in step three, whereas PANSS was no longer a significant predictor. Age predicted lower PTG scores (β = −0.244, p = 0.004).

Moderation Analysis

A series of moderation analyses were carried out using PROCESS (Model 1) to investigate if any of the protective factors moderated the relationship between the number of adverse life events and post-traumatic outcomes. The results of the analyses (shown in Appendix A) revealed that none of the interaction terms were significant.

Discussion

This study investigated potential protective factors (social support, adaptive coping, optimism, trait resilience, self-efficacy, and secure attachment) and their relationship with post-traumatic outcomes (PTSD, DSO and PTG) in a sample of people experiencing psychosis. We hypothesized that the potential protective factors would be associated with less severe trauma symptoms and higher levels of PTG. We also hypothesized that the protective factors would moderate the relationship between number of adverse life events and post-traumatic outcomes. Correlational analyses showed that PTSD was negatively associated with optimism, DSO was negatively associated with resilience, optimism and general self-efficacy and PTG had a significant positive association with adaptive coping, resilience, optimism and general self-efficacy. Regression analyses carried out for each post-traumatic outcome while controlling for psychotic symptoms and demographic variables showed that adaptive coping predicted higher PTSD symptoms, that optimism negatively predicted both PTSD and DSO symptoms and that resilience and adaptive coping predicted higher PTG. The series of moderation analyses found that none of the protective factors moderated the relationship between adverse life events and PTSD and DSO symptoms.

Our results, in line with previous studies, indicated that participants had experienced multiple traumas and reported high rates of post-traumatic symptoms, with 13% of the sample meeting possible criteria for PTSD and 28% meeting criteria for CPTSD. Twenty-two percent of the sample presented potentially clinically significant DSO scores, despite not meeting criteria for CPTSD. Considering the high levels of DSO symptoms in this sample (across people meeting CPTSD criteria and not), our results suggest that people with psychosis might be more likely to experience complex trauma and particularly prone to develop DSO symptoms, thus supporting the need for more research on complex trauma and psychosis ( 3). It is also worth noting that most participants reported "psychosis-related traumas" (85% reported being scared by symptoms, 44% reported behaving in dangerous or embarrassing ways and 62% reported being upset from a contact with a mental health service). These results are consistent with previous studies highlighting high rates of psychosis-related trauma and associated post-traumatic stress in psychosis ( 9, 10). Despite the high rates of psychosis-related trauma, none of these events could be used as index traumas in this study (i.e., the event participants selected when reporting levels of traumatic stress on the ITQ scale). This was because in all cases these traumas were still ongoing and, as the authors of the TALE suggest, it would have been difficult to use ongoing events as a clear anchor for a post-traumatic symptoms assessment ( 35). Not being able to use psychosis-related traumas highlights the difficulty of assessing PR-PTSD using current PTSD diagnostic tools and suggesting that rates of PTSD and DSO symptoms may be even higher in people experiencing psychosis. It is worth noting that the TALE was developed for clinical purposes, and although it is a highly acceptable measure for people with psychosis, it does not instruct on how to consider the impact of recurrent or ongoing traumatic experiences. The measure, however, has great potential and might be a more sensible way to approach future research about trauma in psychosis, compared to trauma measures that do not capture elements that are specific for this population (i.e., PR-PTSD) ( 35).

In our analyses, optimism was consistently associated with lower levels of both PTSD and DSO symptoms, even after controlling for potential confounds. These findings support the results of a recent meta-analysis which found that optimism is associated with lower posttraumatic stress symptoms, possibly because it facilitates positive coping and adaptive response to obstacles ( 51). Longitudinal evidence has also suggested that individuals with high levels of optimism may be less prone to develop post-traumatic symptoms like avoidance and numbing because their optimist beliefs about their ability to cope with threats provide them with higher distress tolerance ( 52). Although the direction of influence between optimism and traumatic responses is still not clear, our results point at the potential importance of optimism as a protective factor from trauma in psychosis, and to the value of increasing it through targeted interventions ( 53). Counterintuitively, we found that adaptive coping predicted higher PTSD scores, despite being previously recognized as an important protective factor from post-traumatic outcomes ( 22), and being measured using a scale widely used with people with psychosis ( 43). Some items of the Brief-COPE (particularly those on the planning subscale i.e. "I've been trying to come up with a strategy about what to do" and "I've been thinking hard about what steps to take") could substantially overlap with important processes involved in the maintenance of post-traumatic difficulties, such as avoidance and rumination, which have been shown to be key factors in the maintenance of PTSD symptoms ( 54). It is worth noting that the religion subscale (i.e., "I've been trying to find comfort in my religion or spiritual beliefs" and "I've been praying or meditating") was also positively associated with PTSD symptom severity. However, the Brief-COPE only assesses to what extent a participant has adopted a specific coping strategy, and not if they benefited from it. It is possible that participants who tried to find comfort in their religion and failed might have felt hopeless, and might have experienced more traumatic symptoms as a consequence. The positive relationship between PTSD and hopelessness is well documented in the literature ( 55). This suggests that well-established measures of coping may not be always suitable in the context of assessing adapting coping in response to trauma. Also, prospective studies investigating the effects of religiosity on PTSD report mixed findings, ranging from no effect on symptoms to either improving or worsening ( 56), resulting in doubts on the effects of religiosity on PTSD.

When we investigated PTG, the results of the correlational and regression analysis showed that resilience and adaptive coping were positively associated with PTG even after controlling for confounds. It is important to note that while resilience and PTG both encompass the idea of thriving in adversity, they are generally regarded as distinct concepts, as resilience refers to positive adaptation despite significant adversity ( 57), while PTG suggests that people become stronger as a consequence of a trauma ( 18). Structural equation models have been used to illustrate that trait resilience is an important predictor of PTG ( 58) and it has been suggested that resilience plays a role in PTG as traumatic experiences may be less traumatic to resilient individuals ( 59). Supporting our findings, structural equation modeling has also shown that higher levels of adaptive coping predicts higher levels of PTG ( 60). As growth can coexist with the negative effects of trauma ( 61), adaptive coping might prove more useful in providing a framework to achieve a sense of control over adversity, which is necessary to experience PTG ( 62), rather than in protecting from traumatic symptoms. The regression analysis for PTG also suggested that the experience of growth might be negatively affected by the severity of psychotic symptoms, supporting the idea that psychotic symptoms are associated with a range of negative long-term functioning outcomes ( 63). Previous research on PTG in military personnel found some evidence that age can predict lower PTG scores ( 64) and suggests that the longer people live, the more likely they might be to experience growth.

Many hypothesized protective factors were not significantly related to any trauma outcomes, suggesting that they may be less important in understanding trauma responses in people with psychosis compared to other samples. Different factors might be more important in predicting trauma outcomes in people with experiences of psychosis, such as the content of voices and unusual beliefs. Furthermore, people with psychosis frequently present risk factors that could potentially interfere with these protective factors. For example, paranoid thoughts and consequent withdrawal from social contact could lead to isolation and prevent people from accessing social support ( 65). In this study, 15% of our participants could not identify anyone to whom they felt close to when completing the MSPSS, and 6% could only think of a member of their care team when asked who they felt they could rely on. Large social networks are important for improving global functioning in schizophrenia ( 66), and particularly having a partner helps lower levels of distress ( 67). In our sample, 22% indicated their romantic partner as their significant other, while 42% chose a family member, 13% chose a friend and 2% chose a religious guide. The relevance of having someone to whom we feel close to is further confirmed by the fact that 22% of our sample indicated "losing a close person" as the most traumatic event they experienced.

Certain protective factors, such as secure attachment, might not have emerged as protective for trauma because they are not very prevalent in people with psychosis. In our sample, 35% agreed to any extent (i.e., mildly, strongly, or very strongly) with the paragraph of the RQ which describes a secure attachment style. These results are not surprising considering that insecure attachment is pervasive in people with psychosis and directly links to psychotic vulnerability especially for paranoia ( 68, 69). Furthermore, secure attachment is associated with good social support ( 70) and a positive view of the self ( 71), both of which might have been lower in our sample, as highlighted by the high levels of DSO symptoms. Having a small sample, along with high levels of isolation, might have prevented social support and secure attachment from being recognized as significant protective factors in our analyses.

The fact that resilience was not found to be consistently protective from trauma is not entirely surprising. While the Connor-Davidson Resilience Scale ( 37) is recognized as a golden standard measure of resilience and is widely used in research, this tool specifically assesses trait resilience, and does not capture more recent conceptualizations that suggest that positive post-traumatic outcomes result from the combination of social and personal characteristics ( 17). Our results corroborate the idea that resilience might be better understood in terms of a collection of variables that allow individuals to successfully manage (i.e., cope with) the consequences of trauma, rather than simply as a trait. The results of the moderation analyses also showed that the hypothesized protective factors did not statistically moderate the association between the number of traumatic events and post-traumatic outcomes. However, we suggest that this might be due to our sample which was relatively small and highly traumatized.

This study has important implications as it suggests that interventions aiming to instill hope and optimism in service users, such as hearing stories of recovery or peer supporters who have recovered, might be used in dealing with post-traumatic symptoms. Such intervention might have the additional benefit of increasing hope in mental health staff, which would eventually benefit service users as positive professional expectancies have been recognized to affect patients' hopefulness ( 72). It is worth noting that most of the investigated protective factors, especially optimism, are already targeted in interventions such as the Cognitive Behavioral Therapy for Psychosis (CBTp), which examines how psychosocial dynamics can reduce the distress associated with the symptoms of psychosis and improve functioning ( 73, 74). There is strong evidence on the efficacy of CBTp ( 75), and our findings serve as a reminder of how this intervention could aim at enhancing some of these factors to ultimately facilitate recovery. Our results could also inform trauma therapies such as Trauma-focused Cognitive Behavior Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR), which not only are safe and effective in improving traumatic symptoms in people with psychosis ( 76, 77), but can improve psychotic symptoms as well ( 78). According to TF-CBT after a patient processed their trauma and associated traumatic losses, they can start rebuilding life by restoring relationships and returning to pursuing one's aspirations ( 79), which relates to the proposed protective factor of social support and self-efficacy. Similarly, phase-based multimodal approaches for the treatment of CPTSD greatly focus on creating new meaning ( 80), which is at the base of the perception of gains necessary to experience growth ( 81). Our findings stress the importance of working on protective factors rather than on risk factors only and highlight the importance of recognizing post-traumatic growth as a viable post-traumatic outcome that clients could be helped to achieve with adequate support. Including the PTGI in routine clinical assessments, discussing growth with clients and focusing advice, resources and effort on supporting growth as well as recovery, would constitute important steps to support patients' wellbeing. Furthermore, clinicians should also explore the presence of DSO symptoms as these might be more relevant to this population in terms of post-traumatic reactions.

This study has some limitations. As our research was cross-sectional in nature, the results cannot be used to define the direction of influence among the variables investigated. The relatively small and heterogeneous sample limits generalisability, and the fact that participants relied on retrospective recall of childhood and adult trauma might have introduced some recall bias. Future research needs to be conducted with larger samples and longitudinal analyses, which would provide a more robust test for the direction of influence between variables. Studies need to account for the possible moderating effect of risk factors, such as levels of isolation, loneliness and medications. Further studies should examine which factors protect from trauma and foster growth in psychosis, investigating variables more specific for this group, such as therapeutic alliance and positive relationship with voices, both related to more positive outcomes in psychosis ( 82, 83).

In conclusion, our results highlight the importance of optimism as a protective factor against negative post-traumatic outcomes such as PTSD and CPTSD. Our findings suggest that protective factors such as resilience and adaptive coping might be less important in terms of protecting against negative outcomes, and more important in terms of enabling people to live a meaningful life despite multiple traumas. By focusing on fostering these protective factors, rather than simply reducing factors involved in the maintenance of distressing symptoms, future interventions may lead to a broader range of positive outcomes for trauma survivors who struggle with psychosis.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by NHS and Health Research Authority Ethics Approval (Reference Number: 18/NW/0469). The patients/participants provided their written informed consent to participate in this study.

Author Contributions

CC was responsible for data collection, data analysis, and drafting the original manuscript. FV and KB supervised CC during all stages of the research. All authors contributed to the design of this study and approved the final manuscript.

Funding

This study was supported by a doctoral research grant from the University of Manchester. The sponsors had no role in the study design, collection, analysis, or interpretation of the data, or the preparation and approval of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors thank Dr. Amy Hardy for offering her support in the early design of this study and Dr. Isabelle Butcher for kindly providing feedback on the final manuscript.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2021.735870/full#supplementary-material

References

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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Articles from Frontiers in Psychiatry are provided here courtesy of Frontiers Media SA

# data[].attributes.attachment_link.title
Protective Factors Associated With Post-traumatic Outcomes in Individuals With Experiences of Psychosis

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Trauma and trauma-specific mental health difficulties (e.g., post-traumatic stress disorder) are highly prevalent in people with psychosis. However, not everyone develops post-traumatic symptoms, and some people even experience post-traumatic growth ...

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How Protective Factors Can Promote Resilience

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How Protective Factors Can Promote Resilience

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According to the National Survey on Drug Use and Health, an estimated 52.9 million people, or 21% of adults ages 18 years or older, experience a mental health or substance use challenge each year. As the COVID-19 pandemic lingers, those numbers are likely to be higher, with roughly three out of four adults reporting that the pandemic has negatively affected their mental health. This means that someone you know may be facing a mental health challenge right now and needs your support more than ever before.

# data[].attributes.attachment_link.title
How Protective Factors Can Promote Resilience

# data[].attributes.attachment_link.description
According to the National Survey on Drug Use and Health, an estimated 52.9 million people, or 21% of adults ages 18 years or older, experience a mental health or substance use challenge each year. As the COVID-19 pandemic lingers, those numbers are likely to be higher, with roughly three out of four adults reporting that ... Read more

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Adverse childhood experiences (ACEs) are not often caused by a single factor. Instead, a combination of factors at the individual, relationship, community, and societal levels can increase or decrease the risk of violence.

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Official websites use .gov

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Many factors can increase or decrease the likelihood of someone experiencing or perpetrating violence.

Risk factors can increase the risk of experiencing or perpetrating violence and protective factors can reduce the risk.

Preventing adverse childhood experiences requires understanding and addressing risk and protective factors.

What are risk and protective factors?

Adverse childhood experiences (ACEs) are not often caused by a single factor. Instead, a combination of factors at the individual, relationship, community, and societal levels can increase or decrease the risk of violence.

Although some risk and protective factors are at the individual and family level, no child or individual is at fault for the ACEs they experience.

Risk factors are characteristics that may increase the likelihood of experiencing adverse childhood experiences. However, they may or may not be direct causes.

Protective factors are characteristics that may decrease the likelihood of experiencing adverse childhood experiences.

Please note the term "caregiver" will be used throughout to refer to parents and those who care for children but may not be biological parents.

Watch the Moving Forward video to learn more about how increasing what protects people from violence and reducing what puts people at risk for it benefits everyone.

Risk factors
Individual and family risk factors Community risk factors

Protective factors
Individual and family protective factors

Children who do well in school.26 27 28 25

Families with strong social support networks and positive relationships with the people around them.24 27 23 32 25

Families where caregivers engage in parental monitoring, supervision, and consistent enforcement of rules.24 27 32 28

Community protective factors

Communities where families have access to economic and financial help.33 34 35 36

References

1. Calvano, C., Engelke, L., Di Bella, J. et al. Families in the COVID-19 pandemic: parental stress, parent mental health and the occurrence of adverse childhood experiences-results of a representative survey in Germany. Eur Child Adolesc Psychiatry (2021). https://doi.org/10.1007/s00787-021-01739-0

2. Khanijahani, A., Sualp, K. Adverse Childhood Experiences, Neighborhood Support, and Internalizing and Externalizing Mental Disorders among 6-17 years old US Children: Evidence from a Population-Based Study. Community Ment Health J 58, 166-178 (2022). https://doi.org/10.1007/s10597-021-00808-7

3. Asmundson. (2019). ACEs : Using Evidence to Advance Research, Practice, Policy, and Intervention.

4. Luther. (2019). Developing a More Culturally Appropriate Approach to Surveying Adverse Childhood Experiences Among Indigenous Peoples in Canada

5. Guo, S., O'Connor, M., Mensah, F., Olsson, C. A., Goldfeld, S., Lacey, R. E., Slopen, N., Thurber, K. A., & Priest, N. (2021). Measuring Positive Childhood Experiences: Testing the structural and predictive validity of the Health Outcomes from Positive Experiences (HOPE) framework. Acad Pediatr. https://doi.org/10.1016/j.acap.2021.11.003

6. Goetschius, L. G., McLoyd, V. C., Hein, T. C., Mitchell, C., Hyde, L. W., & Monk, C. S. (2021). School connectedness as a protective factor against childhood exposure to violence and social deprivation: A longitudinal study of adaptive and maladaptive outcomes. Dev Psychopathol, 1-16. https://doi.org/10.1017/S0954579421001140

7. Bethell, C. D., Garner, A. S., Gombojav, N., Blackwell, C., Heller, L., & Mendelson, T. (2022). Social and Relational Health Risks and Common Mental Health Problems Among US Children: The Mitigating Role of Family Resilience and Connection to Promote Positive Socioemotional and School-Related Outcomes. Child Adolesc Psychiatr Clin N Am, 31(1), 45-70. https://doi.org/10.1016/j.chc.2021.08.001

8. Bellis, M. A., Hughes, K., Ford, K., Madden, H. C. E., Glendinning, F., & Wood, S. (2022). Associations between adverse childhood experiences, attitudes towards COVID-19 restrictions and vaccine hesitancy: a cross-sectional study. BMJ Open, 12(2), e053915. https://doi.org/10.1136/bmjopen-2021-053915

9. Dietz, E. (2017). A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience Model.

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This page outlines the risk and protective factors for adverse childhood experiences.

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Resilience and Risk Factors After Disaster Events

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Resilience and Risk Factors After Disaster Events

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Millions of people have been directly affected by disaster events, which can be natural or human-caused disasters, mass violence, or public health emergencies like disease outbreaks, chemical spills, or radiation emergencies. The vast majority recover from the stress reactions they experience, some survivors will develop psychological disorders such as major depression, generalized anxiety, and posttraumatic stress disorder (PTSD). Many more experience non-specific distress, somatic complaints and other medical health conditions. Risk and resilience (or protective) factors influence the impact of disaster events on affected individuals.

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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 term “protective factors” refers to a set of characteristics that can help reduce the risk of Adverse Childhood Experiences and can increase the health and well-being of children and families. Put more simply, the protective factors are positive elements that have positive effects on children, families and the community as a whole

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Knowing the Protective Factors | Prevent Child Abuse America

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Did you know that there are certain signs to look for that can help prevent abuse or neglect? This Parenting Tip talks about the protective factors, what they mean and how you can identify and strengthen them in your family and community.

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What is resilience? Resilience is the ability of a child to recover and show early and effective adaptation following a potentially traumatic event. What is a traumatic event? Traumatic events, like sexual or physical abuse, witnessing domestic or community violence, or being in a natural disaster, often cause children to have strong, upsetting feelings and can potentially disturb daily life, development, and ability to function. The effect of a traumatic event depends in part on the severity of a child’s experience. All children have some strengths to help them adjust and recover following a traumatic event.

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Development of trauma symptoms following adversity in childhood: The moderating role of protective factors

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Development of trauma symptoms following adversity in childhood: The moderating role of protective factors

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Although the buffering effect of protective factors on children’s outcomes following exposure to adverse childhood experiences has been well documented, research gaps remain as to whether this buffering effect differs based on the type of adversity experienced (i.e., maltreatment versus household dysfunction).

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Resilience after adversity: an umbrella review of adversity protective factors and resilience-promoting interventions

# data[].attributes.subject
Resilience after adversity: an umbrella review of adversity protective factors and resilience-promoting interventions

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Resilience is the dynamic adaptive process of maintaining or recovering mental health from stressors, such as trauma, challenging life circumstances, critical transitions, or physical illnesses. Resilience after adversity can be fostered through protective factors and the implementation of interventions that promote resilience. Hence, it is essential to investigate both protective and vulnerable factors to reduce the negative effects of unfavorable life events and increase resilience through positive risk-response interventions.

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Frontiers | Resilience after adversity: an umbrella review of adversity protective factors and resilience-promoting interventions

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Resilience is the dynamic, adaptive process of maintaining or recovering mental health from stressors. Resilience after adversity can be fostered through pro…

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How to Implement Trauma-informed Care to Build Resilience to Childhood Trauma

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How to Implement Trauma-informed Care to Build Resilience to Childhood Trauma

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Children who are exposed to traumatic life events are at significant risk for developing serious and long-lasting problems across multiple areas of development.[1],[2],[3],[4] However, children are far more likely to exhibit resilience to childhood trauma when child-serving programs, institutions, and service systems understand the impact of childhood trauma, share common ways to talk and think about trauma, and thoroughly integrate effective practices and policies to address it—an approach often referred to as trauma-informed care

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Despite its focus on trauma, TIC is inherently a strengths-based perspective that emphasizes resilience instead of pathology.[50] TIC has been defined and implemented in a number of ways, but the Substance Abuse and Mental Health Services Administration has identified four key elements-the Four Rs (see description of each "R" below)-that can be used broadly across programs, institutions, and services.[51]

Applying TIC to real-world settings begins with a child's first contact with a program, institution, or service system. It requires a comprehensive and multi-pronged effort involving the many adults in children's lives. For example, in a school or afterschool program, TIC means increasing trauma-related knowledge and skills among program facilitators, school administrators, bus drivers, food service workers, classroom assistants, administrative staff, volunteers, teachers, leadership, special education professionals, school social workers and psychologists, families, and anyone else who comes into contact with children. However, increasing trauma knowledge is only one aspect of TIC, which also means that the individuals who care for children must be able to:

1. Realize the widespread nature of childhood trauma and how it impacts the child's emotional, social, behavioral, cognitive, brain, and physical development, as well as their mental health. In addition, adults must be aware of the influence of trauma on family members, first responders, service providers, and others who may experience secondary stress (trauma-related reactions to exposure to another person's traumatic experience).[52],[53] In some instances, adults endure the same traumatic events or circumstances as the child (e.g., a natural disaster, community violence, death of a community member) and may benefit from similar supports.

2. Recognize the symptoms of trauma, including how trauma reactions (i.e., symptoms of posttraumatic stress) vary by gender, age, type of trauma, or setting. In addition, the adults in children's lives must understand that a child's challenging behaviors are normal, self-protective, and adaptive reactions to highly stressful situations, rather than viewing that child as intentionally misbehaving. Children's trauma reactions are understood to be adaptive efforts to protect themselves in response to traumatic events. For example, a child may be hypervigilant to an adult's anger or disapproval because, in the past, he or she experienced physical abuse by a parent. Or, a child may disassociate or daydream as a learned response that enables them to avoid feeling or thinking about a traumatic experience.[54] In addition, TIC means recognizing that trauma may influence a child's engagement in activities and services, interactions with peers and adults, and responsiveness to rules and guidelines.[55]

3. Respond by making necessary adjustments, in their own language and behavior, to the child's environment; and to policies, procedures, and practices to support the child's recovery and resilience to trauma.[56]

4. Resist re-traumatization by actively shaping children's environments to avoid triggers (sounds, sights, smells, objects, places, or people that remind an individual of the original trauma) and protect children from further trauma, which can exacerbate the negative impacts of trauma and interfere with the healing process.[57],[58]

Training and professional development on child trauma is an important first step in TIC. Providing adults (staff, leadership, families, and community partners) with training and professional development on childhood trauma is an important component of implementing TIC.[59] It is essential that adults become aware of the prevalence and impact of trauma, and learn to apply a "trauma lens" (i.e., gain the capacity to view children's difficulties in behavior, learning, and relationships as natural reactions to trauma that warrant understanding and sensitive care).[60] In addition, adults can learn key strategies to manage trauma-related problems in childhood. These include creating environments that feel physically and emotionally safe; teaching children self-regulation, language and communication skills, and how to build healthy relationships; learning each child's trauma triggers and how both the child and adults can limit, anticipate, and cope with them; and supporting the development of healthy attachments with parents and other caregivers, as well as positive relationships with peers. Evaluations of TIC initiatives also indicate that when parents, service providers, and programs share a common language and view of trauma, they are better able to work together to meet children's needs.[61]

Training and professional development opportunities are also important for increasing the capacity of adults to attend to other aspects of TIC, including family engagement; practices that are responsive to culture, gender, and sexual orientation; collaboration with community service providers (e.g., mental health providers who can screen for childhood trauma and provide evidence-based treatment); developing and integrating emergency and crisis response protocols; and establishing trauma-informed policies that support positive youth development despite exposure to trauma. Building capacity and maintaining an ongoing commitment to TIC efforts are critical to sustainability.[62], [63] However, although it is a critical component of TIC, training staff and parents on the impact of childhood trauma is not sufficient and does not in and of itself constitute TIC. TIC must also include comprehensive, ongoing professional development and education for parents, families, school staff, out-of-school program staff, and community service providers on jointly addressing childhood trauma.

Parents and service providers who work with children who experience trauma require self-care to prevent and mitigate the effects of secondary traumatic stress. TIC also means attending to the psychological and physical safety and well-being of the adults who care for children who have experienced trauma.[64], [65] Professionals, parents, and other caregiving adults may suffer secondary traumatic stress (trauma-related reactions to exposure to another person's traumatic experience).[66],[67] Psychoeducation (helping others understand the impact of trauma, both on affected individuals and on their service providers, as well as pathways toward recovery),[68] skills training, high-quality supervision, and self-care (e.g., rest, exercise, social support, mindfulness and other stress reduction activities, engaging in pleasurable activities and hobbies, psychotherapy) are critical to ensuring adult well-being and providing sufficient personal resources to work effectively with children who are exposed to trauma. See Figure 4 for specific strategies recommended by the National Child Traumatic Stress Network to combat secondary traumatic stress and reduce related staff burnout and turnover.[69]

Further research is needed on TIC in child-serving programs, institutions, and systems to develop a sufficient evidence base to inform policy and practice. TIC is a relatively new framework for working with individuals who experience trauma, and the evidence base in support of its effectiveness is in the early stages of development. However, a number of promising TIC initiatives in early care and education, schools, child welfare, and behavioral health have demonstrated improvements in trauma-related knowledge and skills among service providers, foster parents, and family members; reductions in children's posttraumatic stress symptoms and problem behaviors; and increases in children's strengths and protective factors.[70],[71],[72],[73],[74] In addition, a growing number of clinical treatment models-including Trauma-Focused Cognitive Behavioral Therapy,[75],[76] Child-Parent Psychotherapy,[77],[78] Attachment and Biobehavioral Catch-up,[79],[80] and Parent-Child Interaction Therapy,[81],[82] -have undergone rigorous evaluation and shown positive outcomes for children from infancy to late adolescence. However, TIC is not limited to mental health professionals. Each child-serving program, institution, or service system can play a role in TIC, including referral to clinical treatment and follow-up with families.

Conclusion

Trauma-informed programs, institutions, and service systems are critical to promoting and fostering resilience in all children, and particularly those who have experienced trauma. TIC requires comprehensive, multi-pronged support from adults in all aspects of children's lives. It includes increasing adults' knowledge of childhood trauma and helping them recognize the symptoms, as well as giving them the resources to support and refer children who have experienced trauma to appropriate services. Additionally, as programs make their services more trauma-informed, it is important that they promote self-care to prevent or address secondary trauma among adults working with children who have experienced trauma.
Endnotes
[1] De Bellis, M. D. & Zisk, A. (2014). The biological effects of childhood trauma. Child and Adolescent Psychiatric Clinics of North America, 23(2), 185-222.

[2] Enlow, M., Blood, E., & Egeland, B. (2013). Sociodemographic risk, developmental competence, and PTSD symptoms in young children exposed to interpersonal trauma in early life. Journal of Traumatic Stress, 26(6), 686-694.

[3] Lieberman (2004). Traumatic stress and quality of attachment: Reality and internalization in disorders of infant mental health. Infant Mental Health Journal, 25(4), 336-351.

[5] Substance Abuse and Mental Health Services Administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS publication no. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration.

[10] National Survey of Children's Health. (2011/12). Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved June 8, 2018 from www.childhealthdata.org.

[11] U.S Department of Health & Human Services Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. (2019). Child maltreatment 2017. Washington, DC: Children's Bureau. Retrieved June 8, 2018 from https://www.acf.hhs.gov/cb/resource/child-maltreatment-2017

[12] McLaughlin, K. A., Koenen, K. C., Hill, E. D., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Trauma exposure and posttraumatic stress disorder in a US national sample of adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 52, 815-830.

[13] U.S. Department of Health & Human Services Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. (2019).

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# data[].attributes.attachment_link.title
How to Implement Trauma-informed Care to Build Resilience to Childhood Trauma - Child Trends

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Despite its focus on trauma, TIC is inherently a strengths-based perspective that emphasizes resilience instead of pathology.[50] TIC has been defined and implemented in a number of ways, but the Substance Abuse and Mental Health Services Administration has identified four key elements-the Four Rs (see description of each "R" below)-that can be used broadly across programs, institutions, and services.[51] Applying TIC to real-world settings begins with a child's first contact with a program, institution, or service system.