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The Brain State Model describes three distinct brain–body states that shape behavior in both children and adults: Survival, Emotional, and Executive. It emphasizes that internal states precede outward behavior, so to guide behavior change, one must first work on feelings and physiological responses. The model stresses that adults need to develop awareness and skills to move themselves (and help children) from Survival or Emotional states into the Executive state. Key supports for doing that are creating safety, building connection, and engaging in problem‑solving.

- The Survival State is rooted in the primal brain (brain stem) and asks, “Am I safe?” When someone is in this state, they respond with fight, flight, or freeze—thinking is minimal and defensive behavior predominates.

- The Emotional State involves the limbic system and asks, “Am I loved?” This state limits perspective-taking, often triggering reactive, automatic responses based on past conditioning rather than mindful choice.

- The Executive State centers in the prefrontal lobes; it asks, “What can I learn?” This is the optimal state for problem‑solving, calm awareness, learning, setting goals, and making wise choices. In this state, thoughts and feelings are integrated, and one responds rather than reacts.

Relevance:

Understanding the Brain State Model is crucial for child educators because it highlights how children's behavior is directly linked to their brain state, specifically, whether they are operating from the survival brain or the thinking (executive) brain. When children are in a state of fear, stress, or emotional overwhelm, their survival brain takes over, limiting their ability to reason, follow instructions, or learn. In contrast, the thinking brain enables problem-solving, empathy, and self-regulation, skills that are essential for academic and social success. Educators who recognize these states can respond with empathy and appropriate strategies to help children shift out of reactive modes and back into a calm, learning-ready state. This understanding empowers teachers to address the root causes of behavior rather than just reacting to symptoms, fostering healthier classroom environments and more effective teaching.

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A multidisciplinary approach based on three distinct brain-body states in adults and children that drive behavior.

Conscious Discipline's Brain State Model

Conscious Discipline empowers us to be conscious of brain-body states in ourselves and children. It then provides us with the practical skills we need to manage our thoughts, feeling and actions.

With this ability to self-regulate, we are then able to teach children to do the same. By doing this, we help children who are physically aggressive (survival state) or verbally aggressive (emotional state) become more integrated so they can learn and use problem-solving skills (executive state). When we understand the brain state model, we can clearly see the importance of building our homes, schools and businesses on the core principles of safety, connection and problem-solving.

Survival State asks the question, "Am I safe?"

The only way to soothe the survival state is through the creation of safety.

In a survival state where we feel triggered by threat, these skills are flight, fight or surrender. We can't think clearly when a tiger is chasing us. In the modern world, the tiger may be a disrespectful child, but our brain's evolutionary skill set is the same: fight, flight or surrender.

Emotional State asks the question "Am I loved?"

The only way to soothe an upset emotional state is through the creation of connection.

Emotional State is our response to upset - and can only be soothed through connection. An upset emotional state is triggered by the world not going our way. It limits our ability to see from another's point of view. This upset, unconscious state keeps us on autopilot so our words and tone match those of key authority figures from our childhood. We revert to disciplining the same ways we were disciplined, even if we know these behaviors to be ineffective or hurtful.

Executive State asks the question, "What can I learn?"

The Executive State is the optimal state of problem-solving and learning.

Conscious Discipline empowers us to be conscious of brain-body states in ourselves and children. It then provides us with the practical skills we need to manage our thoughts, feeling and actions. With this ability to self-regulate, we are able to teach children to do the same. By doing this, we help children who are physically aggressive (survival state) or verbally aggressive (emotional state) become more integrated so they can learn and use problem-solving skills (executive state). When we understand the brain state model, we can clearly see the importance of building our homes, schools and businesses on the core principles of safety, connection and problem-solving.

Executive State is the optimal state for problem-solving and learning. As we learn to regulate and integrate our internal state to be one of relaxed alertness, we are able access our own brilliance. We are empowered to change and make wise choices. An integrated executive state frees us from past conditioning, attunes us to the feelings and experiences of others, enables us to remain focused enough to set and achieve goals, and allows us to consciously respond instead of automatically react to life events.

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A multidisciplinary approach based on three distinct brain-body states in adults and children that drive behavior. Conscious Discipline's Brain State Model Conscious Discipline empowers us to be conscious of brain-body states in ourselves and children. It then provides us with the practical skills we need to manage our thoughts, feeling and actions.

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This article explores how trauma impacts the brain and body. It emphasizes that many responses survivors have, such as freezing, dissociating, or struggling to recall details, are natural, involuntary survival mechanisms rather than conscious choices. When a person experiences trauma, their brain activates fear circuitry that can override the rational, decision-making part of the brain, known as the cortex. This can lead to automatic responses like fight, flight, freeze, or collapse, and may also cause memory fragmentation or emotional numbness. The article aims to dispel myths that blame survivors for their reactions during or after an assault, helping both survivors and those around them understand that these behaviors are deeply rooted in neurobiology.

Relevance:

This article provides helpful information to readers regarding why people with trauma have specific reactions of instincts. It explains the impact trauma has on brain development and supports the actions and reactions that people with trauma have in response to triggering events.

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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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This video explains how trauma and PTSD cause structural and functional changes in the brain, affecting emotions, memory, behavior, and the nervous system in lasting ways, but also highlights that healing and recovery are possible, emphasizing neuroplasticity, which is the idea that the brain can rewire itself through therapy, mindfulness, writing, body‑based interventions like yoga, and other practices, helping restore safety, calm, and control.

Relevance:

This video explains how trauma affects the brain, causing areas such as the amygdala to become more reactive, the hippocampus to become less effective at processing memories, and the prefrontal cortex to become weaker at controlling emotions and thinking clearly. In a classroom setting, this helps teachers understand that some student behaviors, such as trouble focusing, emotional outbursts, or shutting down, may be signs of a trauma response, not misbehavior. By creating a calm, predictable environment and using simple tools like mindfulness or movement breaks, educators can help students feel safer, regulate their emotions, and stay engaged in learning.

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Neurobiological Development in the Context of Childhood Trauma

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Neurobiological Development in the Context of Childhood Trauma

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This article examines how early traumatic experiences can alter brain development, particularly affecting areas involved in memory, emotional regulation, and stress response. It discusses how trauma can disrupt the functions of the hippocampus, prefrontal cortex, and amygdala, leading to difficulties in processing and recalling traumatic events, as well as heightened fear responses, also highlighting the significance of genetic factors, which can influence an individual's vulnerability to trauma and the development of post-traumatic stress disorder. Overall, the article emphasizes the complex interplay between biological, environmental, and genetic factors in shaping the neurobiological outcomes of childhood trauma.

Relevance:

This article explains how childhood trauma can alter brain development, especially in areas like the hippocampus, amygdala, and prefrontal cortex, which are critical for memory, emotional regulation, and stress response. It also highlights how chronic trauma disrupts the body’s stress system, leading to lasting changes in brain function and increased vulnerability to conditions like PTSD. Understanding these biological impacts helps educators recognize that trauma can affect students’ behavior, attention, and emotional control. In a classroom setting, this knowledge can guide teachers to create supportive, predictable environments and use trauma-informed strategies, such as offering emotional regulation tools and being sensitive to stress triggers, to better meet the needs of students affected by trauma and promote their learning and well-being.

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. Author manuscript; available in PMC: 2019 Mar 21.

Published in final edited form as: Clin Psychol (New York). 2017 May 20;24(2):111-124. doi: 10.1111/cpsp.12198

Abstract

Neurobiological systems may be particularly susceptible to deleterious impact of childhood trauma, and the impact of childhood trauma on development and subsequent functional outcomes across the lifespan has been well-documented. The current review addresses the neurobiological impact of exposure to interpersonal trauma in childhood in the context of executive function, emotion regulation, and dissociation/interoceptive awareness. Subsequent risk for PTSD and depression is also discussed. The pathway of risk from childhood trauma to these cognitive, emotional, and psychiatric outcomes is addressed in terms of potential structural and functional alterations within the hippocampus, prefrontal cortex, and amygdala resulting from chronic or repeated activation of the hypothalamic-pituitary-adrenal (HPA) axis and its interaction with and influence on genetic and epigenetic processes during sensitive periods of development. Implications for practice are discussed.

Keywords: childhood trauma, childhood maltreatment, dissociation, executive function, emotion regulation, neurobiology

Neurobiological Development in the Context of Childhood Adversity

For this review, with regard to childhood stressful and traumatic experiences, we focus on findings related to childhood exposure to interpersonal trauma because, relative to non-interpersonal trauma, interpersonal trauma may be more likely to recur across development and to present in multiple forms ( Masten & Wright, 1998) such that children are often exposed to multiple types of abuse and/or neglect (i.e., physical, sexual, emotional abuse, and/or physical and emotional neglect; Finkelhor, Turner, Ormrod, & Hamby, 2009), as well as to witnessed family violence ( Zolotor, Theodore, Coyne-Beasley, & Runyan, 2007). Because children are likely to spend a large majority of their time during the first several years of life with family or other caregivers, exposure to violence, abuse, or neglect in a primary setting, such as the home, may promote persistent fear and anticipation of recurrence and, thus, represent just the kind of stressor that can profoundly alter neurobiological development ( Tarullo & Gunnar, 2006).

Therefore, the current review considers the impact of childhood interpersonal trauma, as a form of chronic stress exposure, on neurobiological development. We address the impact of chronic stress exposure on neurobiological development during childhood, in part through the potential roles of repeated activation of the physiological stress response system, environmental influence on gene expression, and specific sensitive periods of development. Given the broad-reaching impact of trauma on development (i.e., multifinality), we focus not only on the impact of childhood trauma on neurobiological development with respect to risk for specific diagnoses (e.g., depression, PTSD), but also on the impacts on three areas of functioning that cut across diagnoses: 1) executive function 2) emotion regulation, and 3) dissociation/interoceptive awareness.

Overview of the Neurobiological Impact of Childhood Trauma

Exposure to childhood trauma can impact brain development over time, leading to changes in the structure and function of multiple stress-sensitive areas, including the hippocampus, prefrontal cortex (PFC), and the amygdala ( Cerqueira, Mailliet, Almeida, Jay, & Sousa, 2007; Stevens et al., 2013; Tomoda et al., 2009; van Harmelen et al., 2014). Under normal neurobiological conditions, the hippocampus receives input regarding perceptual information ("who and what") and binds it to contextual information ("when and where"), and the PFC facilitates future recollection of and attributions about that information ("why") ( Ranganath, 2010). The PFC also modulates amygdala activity via inhibitory mechanisms ( Banks, Eddy, Angstadt, Nathan, & Phan, 2007) and communicates with the hippocampus to promote the consolidation of emotional and perceptual information ( Kajiwara, Takashima, Mimura, Witter, & Iijima, 2003). Under adverse neurobiological conditions, such as those shaped by frequent or enduring trauma, the individual and connected functions of the hippocampus, PFC, and amygdala can be impacted in ways that not only facilitate inappropriate associations among perceptual, contextual, and attributional information about traumatic events ( Acheson, Gresack, & Risbrough, 2012), but also diminish capacity for consciously managing recollections of the events and moderating fear responses to the recollections. ( Stevens et al., 2013). Importantly, the pathways from chronic stress exposure during childhood to these differences in brain region structure, function, and connectivity are potentially many, and chief among them is the pathway through the stress response system.

Chronic fear, whether in response to actual or anticipated threat, can lead to repeated activation of the physiological stress response system, the hypothalamic-pituitary-adrenal (HPA) axis, altering the regulation of glucocorticoids, such as cortisol ( Tarullo & Gunnar, 2006; Trickett, Noll, Susman, Shenk, & Putnam, 2010). Childhood trauma is associated with HPA axis upregulation (i.e., elevated baseline cortisol, as well as greater increase and slower decline of cortisol following stress-exposure; Tarullo & Gunnar, 2006). At elevated levels or with repeated exposure, cortisol is thought to have neurotoxic effects, particularly early in development ( Lupien et al., 2016). Notably, however, lower cortisol levels and attenuated cortisol reactivity (i.e., HPA axis downregulation) are observed in some individuals exposed to childhood trauma, and the onset of downregulation is typically during adolescence ( Trickett et al., 2010). Downregulation of the HPA axis follows a period of chronic upregulation and may be the result of increased glucocorticoid receptor sensitivity leading to blunted stress reactivity and lower baseline cortisol levels, potentially as a compensatory strategy. Nevertheless, upregulation and associated neurobiological differences likely precede and persist beyond the onset of downregulation ( Slattery, Grieve, Ames, Armstrong, & Essex, 2013).

The impact of HPA axis dysfunction on the neurobiology of childhood trauma may be better understood when considered in the context of genetic and epigenetic processes that influence and are influenced by glucocorticoid exposure. Although a more complete consideration is beyond the scope of this review (see Sharma, Powers, Bradley, & Ressler, 2016, and Heim & Binder, 2012), a particularly relevant area of research is the study of gene-environment (G × E) interactions of the FKBP5 gene with childhood adversity. FKBP5 is a gene that contributes to the regulation of glucocorticoid receptor sensitivity, and risk variants of FKBP5 polymorphisms are associated with reduced receptor sensitivity, which can lead to diminished HPA axis negative feedback (i.e., slower "off-switch" for the stress response) and subsequent maintenance of glucocorticoids in the absence of threat ( Dias, Maddox, Klengal, &Ressler, 2015). Sustained elevations of glucocorticoids may interfere with neurotrophic gene expression and protein synthesis across the brain, but particularly within the hippocampus and PFC, resulting in reduced neurogenesis and neuroplasticity in, as well as degraded connectivity between, the two regions ( Cerqueira et al., 2007; Daskalakis, De Kloet, Yehuda, Malaspina, & Kranz, 2015). There is now substantial evidence of an interaction between FKBP5 polymorphisms and early childhood maltreatment in predicting adult PTSD symptoms ( Binder et al., 2008; Boscarino et al., 2012; Xie et al., 2010). This effect is not driven by total trauma exposure and appears directly related to childhood exposure, suggesting a developmental window in which FKBP5-mediated cellular interactions have lasting effects on neurobiology that increase the risk of developing PTSD in adulthood. G × E interactions of childhood trauma and FKBP5 polymorphisms also predict adult risk for other psychopathology, including depression and psychosis ( Appel et al., 2011; Collip et al., 2013; Zimmerman et al., 2011), and there is emerging evidence of a similar G × E effect of FKBP5 polymorphisms and childhood maltreatment on adult executive function ( Green et al., 2015; Lovallo et al., 2015).

In addition to G × E interactions, there appears to be an important role of epigenetic mechanisms, such as DNA methylation, in understanding how childhood trauma leads to neurobiological changes and subsequent development of psychopathology ( Heim and Binder, 2012; McGowen et al., 2009). For example, in a sample of low-income, primarily African American adults with high levels of trauma exposure across the lifespan, Klengel et al. (2013) found evidence that epigenetic mechanisms mediated the G × E effect of early life trauma and FKBP5 on the development of PTSD and depression symptoms in adulthood. Epigenetic changes in the form of differential transcriptional activation of FKBP5 by glucocorticoid receptor activation in the presence of childhood abuse may enhance FKBP5 responsiveness, leading to both long-term changes in the body's stress response system and alterations of neuronal circuits, resulting in higher risk for trauma-associated psychiatric disorders in adults. Similar to G × E effects, the effects on DNA methylation in this study were observed only for childhood trauma exposure, further highlighting the potential impact of traumatic events occurring in early development.

To fully understand the impact of childhood trauma on neurobiological development, the timing of the trauma exposure, as well as its chronicity across the course of development, should be taken into account. Foundational to the idea that childhood trauma can impact neurobiological development is the observation in human and non-human studies of sensitive periods of brain development marked by enhanced plasticity during which experience is inordinately influential to neurogenesis, synaptic growth, and organization of neural circuits ( Heim & Binder, 2012; Knudsen, 2004). Thus, exposure to stress during these sensitive periods has the potential to alter the neurobiological landscape in powerful and lasting ways ( Knudsen, 2004). Trauma occurring during early, sensitive periods of development can increase risk for psychological, behavioral, and neurocognitive problems across the lifespan. ( Cowell, Cicchetti, Rogosch, & Toth, 2015; Dunn et al., 2017; Enlow, Egeland, Blood, Wright, & Wright, 2012)

In addition to broader neurobiological sensitivity during periods of early development, specific brain regions mature at unequal pace, affording differential, timing-dependent impacts of environmental input across development. If childhood trauma exposure acts through sensitive periods to impact neurobiological changes, timing-dependent effects on brain regions should be observed for relevant developmental periods. Recent research has provided some support for this idea showing age-dependent impacts of childhood environment, including trauma and abuse, on amygdala, hippocampal, and PFC volume (e.g., Pechtel, Lyons-Ruth, Anderson, & Teicher, 2014; Andersen et al., 2008; Rao et al., 2010). Although brain regions mature at unequal pace, regional development is anything but independent. Brain regions are structurally and functionally connected such that regions may facilitate or inhibit activity in other regions. Environmental input during sensitive periods may not only interfere with the normative development of one specific region, but also the nature of its relationship to other regions ( Knudsen, 2004). The hippocampus, PFC, and amygdala are part of a network of connected regions ( Tottenham & Sheridan, 2010), chronic stress reduces connectivity within this network ( Cerqueira et al., 2007), and reduced connectivity is associated with deficits across multiple domains ( Cerqueira et al., 2007; Opitz & Friederici, 2003; Wendelken & Bunge, 2010; Stevens et al., 2013). Thus, even if a particular brain region, such as the PFC, is most vulnerable during a sensitive period later in development, its connectivity to regions, such as the hippocampus, with earlier sensitive periods may introduce opportunity for stressful or traumatic experiences earlier in development to nevertheless degrade both the structure and the function of that later-peaking brain region ( Cerqueira et al., 2007).

Taken together, these findings suggest that childhood trauma can alter neurobiological development, particularly within the hippocampus, PFC, and amygdala, and this may occur at least in part as a result of the chronic or repeated activation of the physiological stress response system acting together with genetic and epigenetic processes during sensitive periods of development. These neurobiological changes can, in turn, influence a number of critical cognitive and emotional processes (i.e., executive function, emotion regulation, and that, when disturbed, may represent transdiagnostic risk factors for trauma-related psychopathology, such as PTSD and depression.

Impact of Childhood Trauma on Executive Function

Executive function refers to a set of processes, supported largely by the PFC, that facilitate awareness of and adaptation to internal and external stimuli and goals, thus promoting flexible, context-appropriate, and goal-oriented emotional and behavioral responses ( Miyake et al., 2000). Executive function comprises working memory (i.e., holding onto and actively manipulating multiple mental representations), cognitive flexibility (i.e., inhibiting previously learned responses to meet new demand), inhibitory control (i.e., inhibiting overlearned or automatic responses), and the ability to form abstract concepts. Exposure to childhood trauma is associated with relative impairments in each these processes ( Cowell et al. 2015; DePrince, Weinzierl, & Combs, 2009; Gould et al., 2012; Kavanaugh & Holler, 2014; Nikulina & Widom, 2013; Nolin & Ethier, 2007; Skowron, Cipriano-Essel, Gatzke-Kopp, Teti, & Ammerman, 2014; Spann et al., 2012), and such impairment is associated with increased risk for PTSD and depression ( Aupperle, Melrose, Stein, & Paulus, 2012; Joormann, 2010).

Impact of Childhood Trauma on Emotion Regulation

Emotion regulation refers to a broad set of strategies to manage cognitive, behavioral, and physiological responses to emotion ( Cole, Martin, & Dennis, 2004) and encompasses a number of components, including awareness, understanding, and acceptance of emotional experiences ( Gratz & Roemer, 2004). Developmental research points to an important impact of trauma on children's emotional awareness, understanding, and regulation ( Shields, Ryan, & Cicchetti, 2001; Shipman, Zeman, Penza, & Champion, 2000), which are typically developed in part through interactions with parents and other supportive adults ( Bariola, Gullone, Hughes, 2011; Parke, 1994). Because exposure to childhood maltreatment often includes abuse or neglect from a primary caregiver or the presence of violence within the home, children are less likely to be exposed to modeling of appropriate emotional labeling, expression, and regulation behaviors often modeled by primary caregivers and may therefore develop deficits in appropriate emotion regulation.

In addition to the potential absence or scarcity of appropriate models, emotion regulation may also be diminished in the context of childhood trauma due to its partial reliance on executive function-itself diminished by childhood trauma. Executive function contributes to emotion regulation by controlling the contents of working memory to prevent excessive attention to negative thoughts or stimuli ( Joormann, 2010), shifting to new coping strategies when old ones are no longer effective ( Gilliom, Shaw, Beck, Schonberg, & Lukon, 2002), and inhibiting automatic emotional, behavioral, or cognitive responses that do not fit the situation or one's goals ( Carlson & Wang, 2007), such as during cognitive reappraisal ( Goldin, McRae, Ramel, & Gross, 2008).

Emotion dysregulation is considered a transdiagnostic risk factor for a broad range of psychiatric morbidity ( Werner & Gross, 2010), including PTSD and depression ( Bradley et al., 2011a), and exposure to childhood trauma is associated with emotion regulation deficits across the lifespan ( Cloitre, Miranda, Stovall-McClough, & Han, 2005; Kim & Cicchetti, 2010; McLaughlin, Peverill, Gold, Alves, & Sheridan, 2015; Powers, Etkin, Gyurak, Bradley, & Jovanovic, 2015). Similar to executive function, emotion regulation is most impacted by trauma that occurs early and often ( Kim & Cicchetti, 2010). Associated deficits are diverse and may present as attentional bias to negative or threatening stimuli, trouble recognizing emotions in the self or others, and difficulty effectively modulating or reappraising distress ( McLaughlin et al., 2015; Pollak, 2008; Tottenham et al., 2010).

Neuroimaging studies demonstrate an association of emotion regulation and childhood trauma in terms of both neurobiological structure and function and behavioral strategies. In a study of institutionally-raised children, Tottenham et al. (2010) found that prolonged placement was associated with increased attention to negatively-valenced stimuli, as well as with enlarged amygdala, a finding which could represent potential for a relative disadvantage of the PFC in modulating amygdala. For example, in a study of adolescents with histories of childhood maltreatment, McLaughlin et al. (2015) also found a bias toward negatively-valenced stimuli and, relative to non-maltreated adolescences, greater recruitment of the PFC during cognitive reappraisal to achieve comparable reduction of amygdala activity. In this study, both maltreated and non-maltreated adolescents were able to demonstrate emotion regulation ability via amygdala modulation, but maltreated adolescents expended more executive resources to so regulate, which could decrease the availability of those resources for regulating subsequent distress ( Muraven & Baumeister, 2000). It is possible, therefore, for some individuals to present with a pattern of apparent emotion regulation-perhaps even overregulation-followed by depletion of regulatory resources. Efforts to overregulate may be associated with aspects of dissociation.

Impact of Childhood Trauma on Dissociation and Interoceptive Awareness

Notably, individuals with histories of childhood trauma often report depersonalized dissociation, or feeling disconnected from their own bodies ( Simeon, Guralnik, Knutelska, Hollander, & Schmeidler, 2001) and, paradoxically, often have high incidences of chronic somatic disorders and concerns (Friedrich & Shafer, 1994; McFarlane, Atchison, Rafalowicz, & Papay, 1994). Given these findings, it is not surprising that dissociation has been linked to impairments in interoception, or awareness of somatic states. For some individuals exposed to trauma-particularly abuse-attending to their current physiological state can evoke trauma-related reminders and subsequent distress and is thus avoided ( Lanius et al., 2010).

Opportunities for Intervention

Limitations

Second, the potential causes of childhood trauma-related changes to neurobiological development presented in the current review are by no means exhaustive. For example, this review does not address the impacts of poverty or racism, both of which have been shown to exert pernicious influence on neurobiological development ( Blair & Raver, 2012; Chae et al., 2014). Children living in poverty are confronted with distressed and less responsive caregivers, and may also be at increased risk of experiencing maltreatment ( Blair & Raver, 2012; Brooks-Gunn, Schneider, & Waldfogel, 2013). Furthermore, African-American and Hispanic children are disproportionately impacted by poverty ( Macartney, 2011), and compared to all other racial/ethnic groups, African-American children are more likely to be exposed to violence ( Goldmann et al., 2011) and to demonstrate dysregulated HPA axis functioning in infancy, childhood, and adulthood ( Blair et al., 2011; Kuzawa & Sweet, 2009). Although outside the scope of this review, these findings highlight the troubling intersection of poverty and racism with trauma that must not be ignored when addressing the role of childhood trauma in adult functioning.

In addition, this review does not address all physiological sequelae of childhood trauma that may impact neurobiological development. For example, inflammation is elevated across development for individuals exposed to childhood trauma ( Coelho, Viola, Walss-Bass, Brietzke, & Grassi-Oliveira, 2014), increasing risk to physical and mental health and contributing additional influence to neurobiological development ( Hagberg & Mallard, 2005). Finally, this review does not address potential intergenerational effects of trauma on neurobiological development. Elevated cortisol levels in utero are associated with long-term relative deficits in neurocognitive ability ( LeWinn et al., 2009), and childhood trauma may also interfere with later parenting behavior ( Smith, Cross, Winkler, Jovanovic, & Bradley, 2014), potentially creating adverse conditions in the next generation. Certainly, consideration of intergenerational effects is important for better understanding the individual effects in broader context.

Conclusion

Childhood trauma, particularly if experienced early and often, is associated with neurobiological changes that may influence important processes, such as executive function and emotion regulation, as well as increase risk for dissociation and trauma-related disorders, such as PTSD and depression. This neurocognitive, emotion regulation, and psychiatric risk may result from cascading changes to neurobiology facilitated by chronic HPA axis reactivity and interaction with genetic and epigenetic processes during sensitive periods in development in ways that ultimately interfere with the structure, function, and functional connectively of the hippocampus, PFC, and amygdala and limit resilience to future stressors.

Acknowledgments

We thank the Grady Trauma Project research staff and coordinators, Angelo Brown, Allen W. Graham, and Rebecca Roffman, as well as the nurses in the Clinical Research Network of Grady Health Systems. Funding from the National Institute of Child Health and Human Development (HD018264), and the National Institute of Mental Health (MH100122-01, MH071537, and MH102890) supported this work. The contents of this manuscript do not reflect the views of the Department of Veterans Affairs or the United States Government

Footnotes

Conflicts of Interest: We have no conflicts of interest to declare

Contributor Information

Dorthie Cross, Department of Psychology, Georgia Southern University.

Negar Fani, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine.

Abigail Powers, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine.

Bekh Bradley, Department of Psychiatry and Behavioral Sciences, Emory University School of MedicineAtlanta VA Medical Center.

References

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Neurobiological Development in the Context of Childhood Trauma

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Neurobiological systems may be particularly susceptible to deleterious impact of childhood trauma, and the impact of childhood trauma on development and subsequent functional outcomes across the lifespan has been well-documented. The current review ...

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Context:

The CDC's page on Adverse Childhood Experiences (ACEs) outlines how traumatic events during childhood, such as abuse, neglect, or household dysfunction, can have lasting effects on health and well-being. ACEs are common, with approximately 64% of adults in the U.S. reporting at least one ACE before age 18. These experiences can lead to increased risks of chronic health conditions, mental illness, substance misuse, and reduced educational and occupational achievement. However, ACEs are preventable through strategies that promote safe, stable, nurturing relationships and environments. The CDC emphasizes the importance of community involvement, supportive policies, and accessible resources to prevent and mitigate the impact of ACEs.

Relevance:

Understanding the impact of ACEs helps educators recognize that some student challenges stem from trauma-related changes in the brain rather than willful misbehavior. In the classroom, this awareness supports creating safe, stable, and nurturing environments that help students feel secure. Teachers can apply trauma-informed practices by fostering positive relationships, offering emotional support, and using consistent routines to reduce stress and improve students’ ability to learn and thrive.

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Overview of adverse childhood experiences, the latest data, and CDC’s approach to prevention.

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In her TED Talk, "How Childhood Trauma Affects Health Across a Lifetime," Dr. Nadine Burke Harris explains how early traumatic experiences, such as abuse, neglect, or living with a parent struggling with mental illness or substance abuse, can have lasting effects on an individual's health. She discusses the Adverse Childhood Experiences (ACE) Study, which found a strong correlation between childhood trauma and various health problems, including heart disease, lung cancer, and depression. Dr. Burke Harris emphasizes the importance of recognizing and addressing childhood trauma to improve long-term health outcomes.

Relevance:

This TED Talk underscores how early adverse experiences can disrupt the development of the brain and body's stress response systems. Understanding these effects can help educators and healthcare professionals better support individuals who have experienced trauma. In a classroom setting, this knowledge can be applied by implementing trauma-informed practices. Educators can create a safe and supportive environment, recognize signs of trauma, and provide appropriate interventions to help students cope with the effects of their experiences. By fostering a nurturing atmosphere, teachers can mitigate the impact of trauma on learning and overall well-being.

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How childhood trauma affects health across a lifetime

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Childhood trauma isn’t something you just get over as you grow up. Pediatrician Nadine Burke Harris explains that the repeated stress of abuse, neglect and parents struggling with mental health or substance abuse issues has real, tangible effects on the development of the brain. This unfolds across a lifetime, to the point where those who’ve experienced high levels of trauma are at triple the risk for heart disease and lung cancer. An impassioned plea for pediatric medicine to confront the prevention and treatment of trauma, head-on.

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The SAMHSA webpage on child trauma outlines how traumatic experiences, such as abuse, neglect, or exposure to violence, can significantly impact a child's development and well-being. These experiences can lead to a range of emotional, behavioral, and physical health issues, affecting the child's ability to learn, form relationships, and function in daily life. The page emphasizes the importance of early identification and intervention, highlighting strategies like trauma-informed care and evidence-based treatments to support affected children and their families.

Relevance:

This article explains how early adverse experiences can disrupt brain development and stress response systems, leading to lasting effects on mental and physical health. Understanding these impacts is crucial for educators, caregivers, and healthcare providers in recognizing and addressing the needs of children affected by trauma.

In a classroom setting, this knowledge can be applied by implementing trauma-informed practices that create a safe and supportive environment for all students. Educators can be trained to recognize signs of trauma, respond with empathy, and adjust teaching methods to accommodate the needs of affected students. Additionally, fostering positive relationships and providing consistent routines can help mitigate the effects of trauma and promote resilience in students.

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Children are among the most vulnerable after traumatic events or disasters. Traumatic stress occurs when a child (0-18 years) feels intensely threatened by an event they experience or witness. Young people often need time and emotional support to feel secure again after experiencing trauma or a disaster. Their reactions are influenced by how parents, relatives, teachers, and caregivers respond. These individuals provide comfort and stability, and play a vital role by maintaining normal routines or establishing new ones after a crisis. With proper caregiving and access to trauma-informed services, many children recover and thrive.

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The Impacts of Childhood Trauma on Social Development 

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The Impacts of Childhood Trauma on Social Development 

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This article discusses how early traumatic experiences, such as abuse, neglect, or exposure to violence, can significantly affect a child's social and emotional development. Trauma can lead to difficulties in forming secure attachments, which are crucial for healthy relationships and emotional regulation. Children may exhibit behaviors like aggression, withdrawal, or defiance as coping mechanisms. The article emphasizes the importance of understanding these behaviors within the context of trauma and highlights the need for supportive interventions to help children heal and develop healthy social skills.

Relevance:

The article underscores how early adverse experiences can disrupt brain development and affect emotional and social functioning. Recognizing the signs of trauma and understanding its impact on development can guide educators, caregivers, and healthcare providers in offering appropriate support and interventions. In a classroom setting, this knowledge can be applied by creating a safe and supportive environment that fosters trust and emotional security. Educators can implement trauma-informed practices, such as establishing consistent routines, offering emotional support, and teaching social-emotional skills, to help students affected by trauma build resilience and improve their social development.

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Morgan Pospisil, M.A., NCC

The implications of trauma during adolescence can alter social and emotional development. Research identifies a child's exposure to traumatic events can create ripple effects throughout an individual's lifespan. This begins as early as infancy with the introduction to trust versus mistrust. Depending on whether or not a child has a secure attachment with their primary caregiver, will influence the trajectory of how they navigate the next developmental crisis of autonomy versus shame.
Reaction to Trauma
A child's reaction to trauma may appear differently than what is expected. This depends heavily on their developmental stage and personality. With my younger clients that have encountered trauma one recurrent theme among all of them is personalization. Children are trying to identify their place in the world so it is natural for egocentrism to take place. However, this can lead a child to the assumption that they are culpable for the trauma. If a child is exposed to trauma during an earlier development stage, they may adopt magical thinking as a way to dissociate from the traumatic experience. Another common reaction is externalizing behavior. Externalization can include defiance, outbursts of anger, and physical aggression.
Taking a Look at Erikson's Eight Stages of Development
Erikson, a developmental psychologist and psychoanalyst, theorized that development is based on their ego identity throughout their lifespan. The eight stages of development include:

Infancy - Basic trust versus mistrust

Toddler - Autonomy versus shame and doubt

Preschool-age - Initiative versus guilt

School-age - Industry versus inferiority

Adolescence - Identity versus identity confusion

Young adulthood - Intimacy versus isolation

Middle age - Generativity versus stagnation‌

Older adulthood - Integrity versus despair

Understanding the Impact of Trauma at Any Age
When hearing words like PTSD, anxiety, grief, or depression it may be difficult to conceptualize children encountering these symptoms. In using the developmental model, the overall impact of a traumatic experience can be better understood. It is helpful to understand what area of development is addressed when using a trauma focused modality. Narrowing the focus to early childhood and adolescence, maladaptation could include tantrum-related behaviors. When viewing the behavior as a child's form of communication, problematic behavior or inappropriate behavior could be an indicator of a stress reaction.
Parenting a Child Who has Experienced Trauma
There is a proverb "it takes a village to raise a child." This means establishing an environment that can include the support of extended family, teachers, coaches, and therapists. As a parent or caregiver, it may feel invasive to involve others when it comes to raising a child. However, the way I describe treatment to parents is through the lens of a child learning curriculum at school or engaging in a sport. Therapy is intended to help your child heal and grow. Additionally, providing a healthy routine creates a sense of safety and stabilization within your home environment. It can be tough when your child is reactive, but remember using parenting tactics like time-in as well as use of soothing words help to emphasize a nurturing environment.

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The Impacts of Childhood Trauma on Social Development - Centerstone

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Morgan Pospisil, M.A., NCC The implications of trauma during adolescence can alter social and emotional development. Research identifies a child's

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Supporting Brain Development in Traumatized Children and Youth

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Supporting Brain Development in Traumatized Children and Youth

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This bulletin outlines how early exposure to trauma, such as abuse or neglect, can disrupt healthy brain development in children. It explains that trauma can impair areas of the brain responsible for learning, memory, and emotional regulation, leading to difficulties like attention problems, learning disabilities, and emotional dysregulation. The document emphasizes the importance of early intervention and trauma-informed care to support affected children and promote healthy brain development.

Relevance:

The text highlights how adverse experiences can alter brain structure and function, affecting cognitive and emotional development. Understanding these impacts is crucial for educators, caregivers, and healthcare providers in recognizing and addressing the needs of children affected by trauma. In a classroom setting, this knowledge can be applied by implementing trauma-informed practices that create a safe and supportive environment for all students. Educators can be trained to recognize signs of trauma, respond with empathy, and adjust teaching methods to accommodate the needs of affected students. Additionally, fostering positive relationships and providing consistent routines can help mitigate the effects of trauma and promote resilience in students.

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Supporting Students Who Have Experienced Trauma

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Supporting Students Who Have Experienced Trauma

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This video emphasizes the importance of understanding how trauma impacts students' learning and behavior. It highlights that trauma can affect brain development, leading to difficulties in attention, memory, and emotional regulation. It advocates for trauma-informed practices in schools, such as creating safe and supportive environments, building strong relationships, and implementing strategies that promote resilience. By recognizing and addressing the effects of trauma, educators can better support affected students and foster an environment conducive to learning and growth.

Relevance:

The video explains how trauma affects brain development, particularly areas involved in attention, memory, and emotional regulation. These changes can make it harder for students who have experienced trauma to focus, control their emotions, and process information. Understanding this helps educators see that some challenging behaviors are linked to brain changes caused by trauma rather than intentional misbehavior. In the classroom, this knowledge encourages teachers to create safe, supportive environments with consistent routines and strong relationships. Applying trauma-informed strategies—like allowing breaks, using calming techniques, and teaching self-regulation skills—can help students manage their emotions, improve focus, and engage more fully in learning.

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Research@Work: Supporting Students Who Have Experienced Trauma

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This article emphasizes the importance of understanding and addressing trauma in early childhood education. It highlights how experiences such as abuse, neglect, and domestic violence can significantly impact a child's behavior, emotional regulation, and learning abilities. The article provides strategies for educators to create supportive and responsive classroom environments that acknowledge the effects of trauma. These strategies include building strong, trusting relationships with students, establishing predictable routines, and implementing practices that promote emotional safety and resilience. By adopting a trauma-sensitive approach, educators can better support the developmental needs of all children, particularly those affected by adverse experiences.

Relevance:

This article acknowledges how traumatic experiences affect brain development, particularly areas involved in emotional regulation, stress response, and learning. Trauma can disrupt a child’s ability to focus, manage emotions, and feel safe, all of which are linked to changes in the brain’s structure and function. Understanding these neurological impacts helps educators recognize that children’s challenging behaviors may be trauma responses rather than intentional actions. In the classroom, this knowledge supports creating trauma-sensitive environments by building trusting relationships, establishing consistent routines, and fostering emotional safety. Applying these trauma-informed strategies helps children regulate their emotions, feel secure, and engage more effectively in learning.

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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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The article explains that complex trauma refers to the damage caused by repeated, chronic interpersonal stressors, especially during childhood, such as abuse, neglect, or living amid violence, where caregivers either harm the child or fail to protect them. Because these traumas occur over time and often involve people the child depends on, they interfere deeply with a child’s sense of safety, trust, attachment, emotional regulation, behavior, and cognition. The article also emphasizes specific symptoms, including disorganization, dissociation, difficulties with relationships, low self‑esteem, and trouble in school. Treatment typically focuses on helping the child form secure attachments with reliable adults, building self‑regulation and competence, and providing consistent caring responses from both clinicians and other important adults to help the child heal.

Relevance:

The article defines how repeated and prolonged interpersonal trauma, particularly involving caregivers, can deeply impact a child's development. It explains that children who experience complex trauma often struggle with trust, emotional regulation, behavior, learning, and relationships, all of which play a critical role in their success in educational environments. For childhood educators, understanding complex trauma is essential because many affected children may not display obvious signs of distress but instead show disruptive behavior, withdrawal, or learning difficulties. Recognizing that these behaviors may be rooted in trauma, not defiance or laziness, allows educators to respond with empathy, patience, and appropriate support strategies. By fostering a safe, consistent, and nurturing environment, educators can play a vital role in helping traumatized children feel secure, build resilience, and succeed academically and socially.

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When people think of trauma, they often imagine a specific, distinct experience - a frightening accident, a natural disaster, or an experience of violence. And it's true that going through any very upsetting or life-threatening experience (or watching a loved one do so) can lead to post-traumatic stress disorder (PTSD) and other mental health challenges.

But trauma experts increasingly recognize that there's another form of trauma that involves prolonged, repeated experiences and symptoms that often look different from PTSD. This is most commonly known as complex trauma.

Children who have gone through complex trauma often experience profound challenges as a result, and their symptoms are frequently misunderstood. Knowing the signs of complex trauma and understanding how it affects kids can go a long way toward getting them the support they need.

Complex trauma isn't a diagnosis, but rather a concept that describes how chronic upsetting and dangerous experiences impact people, especially children.

"It's a more fundamental change," says Jamie Howard, PhD, a clinical psychologist and the director of the Trauma and Resilience Service at the Child Mind Institute. "A typical trauma might really shake up your schema of how the world works. With complex trauma, it affects how the schema is developed in the first place."

Complex trauma generally stems from chronic, interpersonal negative experiences such as abuse, neglect, or violence in the child's home or community. Because parents or caregivers are often the ones harming the child in situations like these, the child doesn't have the chance to develop a sense of safety and trust in adults. That disruption of the child's core sense of attachment to caregivers is a key element of complex trauma.

"Any kind of trauma can disrupt trust," Dr. Howard says. "But with complex trauma, you don't necessarily develop an ability to trust people in general."

The evidence base for complex trauma is growing, with research indicating that children who have been through trauma that is ongoing and interpersonal in nature tend to have more intense symptoms and behavioral challenges than those who have experienced other forms of trauma.

The development of the concept of complex trauma began several decades ago, when clinicians working with people who had experienced ongoing traumatic events (such as survivors of child abuse) noticed that these people's symptoms were often more varied than the symptoms of PTSD. This distinct set of symptoms became known as "complex PTSD" (CPTSD) and later evolved into a proposed diagnosis termed "developmental trauma disorder" (DTD).

The ideas of complex trauma and DTD developed in large part through the work of the clinician and author Bessel van der Kolk, MD. DTD is not included as a distinct disorder in the most recent diagnostic manual that clinicians use, the DSM-5. But some of the updated PTSD symptoms in the DMS-5 were influenced by the research of Dr. van der Kolk and his colleagues.

To some extent, the symptoms of complex trauma overlap with the symptoms of PTSD. For instance, kids who have experienced complex trauma may experience flashbacks, nightmares, and feelings of emotional numbness.

But with complex trauma, the symptoms are more pervasive. Kids' behavior can look completely unpredictable. "Their lives have been so chaotic that they haven't found a coherent way to organize the world," says Dr. Howard. "And so they look physically and emotionally disorganized and dysregulated. They're not sitting still, they're moving around, they're sort of jumpy. They're a little bit like a live wire."

Children who have experienced complex trauma frequently meet the criteria for a range of different DSM-5 disorders, but there is currently no one diagnosis that captures their typical symptom profile.

However, experts agree that the following symptoms are generally associated with complex trauma:

Challenges with attachment and relationships

Difficulty regulating emotions and behavior

Challenges related to attention span and other cognitive abilities

Dissociation from reality

Low self-esteem

Overall negative outlook on the world

Dr. Howard notes that being in loud, chaotic environments can quickly get overstimulating for kids who have been through complex trauma. "This is when kids start to look like they have ADHD," she says. "Or they might look like they have a severe mental health disorder because their ability to regulate their physiological responses and make sense of the environment is so compromised." Complex trauma is also known to interfere with learning and frequently leads to challenges with behavior and focus at school.

There's no definitive list of the kinds of experiences that can lead to complex trauma. That said, experts generally agree that the events underlying complex trauma usually meet the following criteria:

They are severely negative, such as abuse, neglect, or violence.

They take place over an extended period of time.

They affect the child's ability to relate to others and build trusting relationships with caregivers and other authority figures.

"Complex trauma doesn't have to be physical abuse, but the reason attachment is so affected is because it usually is perpetrated by, or not able to be stopped by, a child's primary caregiver," Dr. Howard says. "And that's what makes it so fundamentally disruptive: the primary caregiver isn't able to provide consistency and safety to the child."

Dr. Howard notes that this kind of disruption can also occur when a parent isn't the one causing the trauma. For instance, kids who are exposed to a lot of community violence might develop complex trauma because their caregivers aren't able to protect them from those dangers, no matter how much they want to.

There isn't yet conclusive evidence about whether certain populations of children are more likely to experience complex trauma. But, says Dr. Howard, "usually this happens in the context of low resources and environments that are stressful overall," which means that children in low-income families may be at greater risk.

Complex trauma can be challenging to treat because, unlike the kind of traumatic event that is typical of PTSD, chronic traumatic experiences may be ongoing even as the child is getting treatment. And most of the research behind evidence-based treatments for trauma symptoms in children is focused on PTSD.

That said, it's still very important for kids dealing with complex trauma to get treatment. The leading treatment for PTSD in children is called trauma-focused cognitive behavioral therapy (TF-CBT), and there is a growing body of research about adapting it for use with complex trauma.

There is also a treatment model known as the ARC Framework that is designed specifically for children who have experienced complex trauma. ARC stands for attachment, self-regulation, and competency, and it focuses on the following goals:

Attachment: Fostering strong connections between kids and their caregivers and creating a safe, supportive environment in which the family can recover from trauma.

Self-regulation: Helping kids learn to identify, express, and manage their emotions.

Competency: Supporting kids' self-esteem and sense of competence, as well as key developmental tasks like executive functions and social skills.

Dr. Howard notes that building a child's secure attachment to trusted adults is at the core of any treatment for complex trauma. "Trauma treatment doesn't involve the abusive parent, if there is one," she says. "To develop an attachment, you need someone who's going to be relatively consistently responsive." This might be another biological parent, a foster parent, a grandparent, or any other reliable caregiver. "What kids need is to form an ability to trust people in this world, to be able to predict how people will respond to them, and have it be appropriate and healthy."

Dr. Howard also points out that when kids don't already have a trustworthy adult in their lives, forming a strong relationship with a trained professional like a therapist or social worker can be another way to rebuild their sense of attachment.

For a child who's dealing with complex trauma, any reliable support from a caring adult can make a big difference. If you're an educator, clinician, or other consistent presence in a child's life, there are ways you can help them even if you're not involved in their formal treatment.

"The first thing is to always take a benign interpretation," says Dr. Howard. "Sometimes we infer adult thinking, we apply it to kids. But these kids aren't trying to push your buttons. They're having a physiological response."

It's helpful to stay as calm as possible and to take steps to avoid retraumatizing the child. "You have to be a little more thoughtful in how you approach them," Dr. Howard advises. "Don't get too physically close to them because they're going to think you're going to hurt them."

She also recommends keeping your tone of voice neutral, even if you do need to set a boundary or establish a consequence for the child's behavior. "If you snap at a child who hasn't been traumatized, it's not going to totally rattle them," she said. "But if you start to raise your voice and look angry at a child who's been multiply traumatized, they don't know what's going to happen. It's like they might duck and cover."

Overall, says Dr. Howard, it's important to try to remember why kids who have been through complex trauma behave in ways that can look confusing and frustrating. "They're doing this because the world is hard to make sense of, and so they're reactive. It's best met with calm, consistent respect to help them to overcome what they've been through."

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What Is Complex Trauma? - Child Mind Institute

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When people think of trauma, they often imagine a specific, distinct experience - a frightening accident, a natural disaster, or an experience of violence. And it's true that going through any very upsetting or life-threatening experience (or watching a loved one do so) can lead to post-traumatic stress disorder (PTSD) and other mental health challenges.

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Complex Trauma: What is is and how does it affect people?

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Complex Trauma: What is is and how does it affect people?

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The article defines complex trauma as exposure to multiple, often related traumatic experiences, especially those that begin in early childhood, are recurrent or ongoing, and are inflicted by people who are supposed to care for or protect the child. The text also points out how complex trauma’s effects are widespread: altering brain development, changing stress responses, affecting self‑image, behavior, and relationships over time. It challenges the tendency in some diagnostic or medical contexts to split trauma exposure and outcomes into separate categories, arguing instead that they are part of one indivisible phenomenon.

Relevance:

The article emphasizes not just traumatic events themselves, but also how deeply those experiences shape a person’s development, especially when the trauma begins in childhood and is caused by caregivers. It highlights that behaviors often labeled as “difficult” or “disruptive” are frequently survival strategies developed in response to chronic, relational trauma. For childhood educators, this understanding is crucial. Children affected by complex trauma may struggle with trust, regulation, learning, and relationships, not because they are defiant or disinterested, but because their nervous systems have adapted to survive in unsafe environments. Recognizing these patterns allows educators to shift from punishment to support, creating classrooms that foster emotional safety, stability, and healing. Educators who understand complex trauma can play a vital role in helping students rebuild a sense of safety and connection, foundations that are essential for both learning and personal growth.

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Unresolved trauma can leave people feeling hopeless and ashamed. Sometimes for years. Often for decades. Occasionally, and tragically, for a lifetime.

When the assigned diagnoses, treatments or medications keep failing to work, most people cannot help but begin to suspect that they may be incurable, that s omething is really wrong with them. Many take matters into their own hands, seeking desperate measures to feel alive, to quiet the pain, the self-loathing, and the terror, or simply to disappear.

Desperate measures often bring additional complications and unwanted consequences, and are recognized by the outside world solely for the risk they entail, the irresponsibility they convey, and the destruction they bring.

In time, many come to believe that they must be to blame for how much they hurt, for how messed up their lives have become. They come to understand that the monster is real, and that it is inside of them. That it is them.

Defining Complex Trauma

Complex Trauma is distinct from the multitude of other terms that exist to describe types of trauma exposure or manifestations of posttraumatic disturbance.

Complex Trauma is defined as the exposure to multiple, often interrelated forms of traumatic experiences AND the difficulties that arise as a result of adapting to or surviving these experiences.

The adverse experiences encapsulated by Complex Trauma typically begin in early childhood, are longstanding or recurrent, and are inflicted by others. Most often they are perpetrated within a person's formative attachment relationships. Sometimes they are compounded by patterns of risk and dysfunction afflicting generations of families. Frequently, they intersect with structural and institutional forms of violence and oppression that beset certain peoples and communities, particularly those holding minority status within a given society.

The outcomes associated with Complex Trauma span a wide range of psychiatric diagnoses and misdiagnoses, functional impairments, and evolving educational, vocational, relational and health problems.

As illustrated by the above graphic representation of terms used to describe trauma exposure and outcomes, Complex Trauma is the most encompassing of these terms. Importantly, it is the sole clinical construct that considers traumatic experiences and posttraumatic adaptations to be elements of a singular phenomenon.

The Brontasaurus in the Basement

Historically minimized, misunderstood, and misdiagnosed, complex trauma, if not overlooked entirely, has often been assumed to be adequately covered by pre-existing diagnoses. Consequently, in research studies and treatment settings alike, it is not uncommon for people to be assigned to as many as eight "comorbid" psychiatric diagnoses in attempt to account for the array of neurobiological effects and survival adaptations exhibited by youth and adults whose lives have been impacted by complex trauma.

The Complex Trauma Framework

The complex trauma framework recognizes that a survivor's presentation cannot be understood in isolation, but rather must be considered in the context of that person's tremendous effort to manage and adapt to significant life adversity.
"Complex trauma" provides a strength-based, survival driven reframe of trauma, shifting the focus from "what's wrong with you?" to "what happened to you?"
A complex trauma reframe takes many factors into account, including:

reexamination of an individual's behaviors
for example: aggression, self-harm, lying, giving up on oneself

interpersonal difficulties
for example: pushing healthy and safe people away, continually repeating past mistakes in relationships

identity and self-image
for example: self-hatred, identity confusion, fragmented sense of self

psychiatric diagnoses
for example: eating, addictive, and attentional disorders

From a complex trauma perspective, all of these difficulties can be viewed -- partially or completely on a case by case basis -- as adaptive strategies to survive overwhelming experiences and prepare for ongoing threat in a hostile world.

What the Research Tells Us

In fact, prolonged or severe exposure to interpersonal trauma-- particularly when onset begins in early life within the child's primary caregiving relationships or living situation-- has unequivocally been established through both neuroscientific and clinical research to cause fundamental changes to:

brain development,

neurochemistry,

physiological stress response, and

associated alterations in identity, behavior and relationships as part of the person's efforts to endure, escape, and make sense of these experiences.

Deepening one's understanding of complex trauma requires an appreciation of how inextricably intertwined trauma exposure and trauma adaptation are in the complex trauma construct.

Beginning with the 2003 release of the National Child Traumatic Stress Network's formative White Paper on Complex Trauma, Dr. Joseph Spinazzola and his colleagues offered the first comprehensive conceptualization of complex trauma. As defined by these scholars, researchers and therapists, complex trauma is acknowledged to be a dual problem of both exposure to adverse life experiences -- particular those occurring in the context of primary caregiving relationships and beginning during childhood - and adaptation to these life experiences in the form of immediate effects and long-term consequences.

More recently, research by Dr. Rachel Wamser-Nanney at the University of Missouri-St. Louis has been instrumental in empirically validating the concept of complex trauma, and in illuminating potential gender and ethnic differences in complex trauma exposure and outcome.

Unearthing the Brontosaurus in the Basement

Despite being embraced by numerous international psychological associations and many multidisciplinary and clinical service-oriented networks and organization in the United States, some American medical associations and academically oriented research societies have opposed the notion of complex trauma precisely because of its complexity, and with it, its inability to fit neatly into pre-established boxes:

Is complex trauma a type of traumatic event or experience?

Or is it the outcome of exposure to these experiences?

Our vantage point is that the problem lies in this faulty insistence upon binary answers to a multidimensional problem. Complex trauma is the Brontosaurus in the basement. Closing one's eyes and insisting that it is does not exist will not stop the cracks in the foundation of outdated medical and diagnostic paradigms from spreading.

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Complex Trauma: What is it and how does it affect people?

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Unresolved trauma can leave people feeling hopeless and ashamed. Sometimes for years. Often for decades. Occasionally, and tragically, for a lifetime. When the assigned diagnoses, treatments or medications keep failing to work, most people cannot help but begin to suspect that they may be incurable, that s omething is really wrong with them.

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Physical abuse, according to NCTSN, refers to acts by a parent or caregiver that result in bodily injury to a child or adolescent. This includes things like bruises, welts, cuts, broken bones, or muscle sprains. These injuries may even result unintentionally, depending on legal definitions that differ by state. The effects of physical abuse can be long‑lasting and are particularly harmful when the people who should be protecting the child are the ones causing harm, as that undermines the child’s sense of safety and trust. Interventions described include efforts to reduce risk, provide treatment for traumatic stress, create safe caregiving environments, and help with recovery through psychosocial and therapeutic supports.

Relevance:

The article emphasizes how physical abuse, especially when repeated or occurring within caregiving relationships, is a common source of chronic traumatic stress in children. When a trusted adult causes physical harm, it not only creates fear and injury but also disrupts the child's sense of safety, attachment, and emotional stability. For childhood educators, understanding this is essential because children who have experienced physical abuse may not always show visible injuries, but they often display signs of trauma through behavior. These behaviors can be misunderstood as defiance or laziness unless seen through a trauma-informed lens. By recognizing the signs of physical abuse and its emotional impacts, educators are better equipped to respond with empathy, structure, and support, creating a safe space that can help restore trust and facilitate healing. Additionally, being trauma-informed helps educators follow appropriate protocols for reporting and collaborating with caregivers or support services.

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The National Child Traumatic Stress Network

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The impact of physical abuse on a child's life can be far-reaching. It is especially devastating when a parent, the person a child depends on for protection and safety, becomes a danger.

The interventions below are among those that are being used by NCTSN members to help children who have been, or are at risk of becoming, victims of physical abuse.

The following resources on Physical Abuse were developed by the NCTSN.

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The impact of physical abuse on a child's life can be far-reaching. It is especially devastating when a parent, the person a child depends on for protection and safety, becomes a danger. The interventions below are among those that are being used by NCTSN members to help children who have been, or are at risk of becoming, victims of physical abuse.

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The article on emotional abuse defines it as a form of abuse where a child is repeatedly made to feel worthless, unloved, or scared. Emotional abuse can include constant rejection, hostility, teasing, bullying, yelling, criticism, and exposure to family violence. The impacts of emotional abuse are just as harmful as physical abuse. Emotional abuse is particularly damaging to a child’s self-esteem and emotional well-being. It can lead to a range of emotional, psychological, and physical problems, including mental health disorders, difficulty forming relationships, developmental delays, and suicidal thoughts. Recognizing the signs of emotional abuse and understanding its impacts are crucial for childhood educators to provide appropriate support and interventions for affected children.

Relevance:

The article emphasizes how emotional abuse can profoundly damage a child’s sense of safety, self-worth, and ability to regulate emotions. These effects are central to complex trauma, which arises from repeated interpersonal harm, especially in early development. For childhood educators, recognizing emotional abuse is crucial because its impacts may manifest as anxiety, withdrawal, behavioral challenges, or difficulties forming healthy relationships. Understanding these signs through a trauma-informed lens allows educators to respond with empathy and appropriate support rather than punishment. This awareness helps create a safe and nurturing learning environment, promoting healing and resilience for children affected by complex trauma.

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The impacts of emotional abuse are just as harmful as physical abuse. How can you help?

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This article explains that neglect is known as the ongoing failure to meet a child's basic physical and psychological needs, and it is the most common form of child abuse. Children who experience neglect may be left hungry, dirty, or without proper clothing, shelter, supervision, or healthcare. This can put them in danger and have long-term effects on their physical and mental well-being. Neglect can be difficult to spot, but there are four broad types: physical neglect, educational neglect, emotional neglect, and medical neglect. Recognizing the signs of neglect is crucial, as it can lead to serious and lasting harm if not addressed.

Relevance:

The article explains that neglect, whether physical, emotional, educational, or medical, involves the chronic failure to meet a child’s basic needs, often by those who are supposed to provide care and protection. This ongoing lack of support and safety undermines a child’s development, attachment, and sense of security, which are core issues in complex trauma. For childhood educators, understanding neglect is vital because its effects can show up as difficulties with attention, emotional regulation, social skills, and learning, behaviors that might be misunderstood without awareness of the child’s background. By recognizing signs of neglect and responding with empathy and consistent support, educators can help create a stable, nurturing environment that fosters healing and resilience, and also connect children with necessary resources and interventions to address their needs.

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The article on childhood sexual abuse highlights the profound impact such trauma can have on children and families. It defines child sexual abuse as any sexual contact between an adult and a child, including touching, fondling, or exposure to sexual materials. The article emphasizes that the majority of abuse cases involve someone the child knows, such as a family member or close acquaintance. Long-term effects on victims can include guilt, shame, depression, substance abuse, and difficulties in relationships. Treatment approaches often combine victim advocacy with family systems therapy, aiming to address all levels of vulnerability and prevent future abuse. The article underscores the importance of therapy in helping families heal and establish safeguards to protect future generations.

Relevance:

Sexual abuse, especially when perpetrated by someone known and trusted, can cause deep, long-lasting trauma that affects multiple areas of a child’s emotional, social, and cognitive development. This type of abuse often contributes to complex trauma, as it typically involves repeated violations of safety and trust during critical developmental periods. For childhood educators, understanding the impact of childhood sexual abuse is essential because affected children may exhibit behaviors such as withdrawal, aggression, difficulties in forming relationships, or trouble concentrating in class. Recognizing these signs and responding with trauma-informed care allows educators to provide a safe and supportive environment that fosters healing and resilience. Moreover, educators play a key role in identifying abuse, collaborating with families and professionals, and advocating for the child’s well-being and protection.

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What are the treatment goals?

The essential goal of any family sex abuse treatment program is the immediate cessation of all forms of abuse within the family. This goal will take precedence over all others and may determine the structure of therapy and the timing of interventions. For example, if the child is at risk for further abuse because the abusing family member denies the abuse, then removal of the abusive family member would be in order.

Another over-arching goal is that the family's vulnerabilities to abuse must be reduced so that there is little if any likelihood of future abuse in the family. This educational material will help the family establish new boundaries and rituals to heal from past abuse and to prevent future abuse from occurring.

Finally, healing of the victim is an important treatment goal. Helping the child feel safe again and work through the trauma they experienced will be the main goals of their individual therapy. Research has shown that going through the therapy process is helpful in preventing or minimizing long term effects from happening. Also, important in building resilience is building a strong support group and feeling empowered to prevent further abuse.

Who is involved in a treatment plan?

Many treatment plans include a therapeutic team with the family and all professionals involved with their case. Building this team with the family offers them a sense of power and control. The team meets regularly to discuss treatment planning, progress and, eventually, termination. Having everyone "on the same page" throughout treatment eases the entire therapeutic experience.

Creating and maintaining hope

There are few problems that can leave a family feeling more hopeless than sexual abuse. Hope emerges from the basic belief in the goodness of people, and their ability to change. Most treatment programs have as their foundation a belief that families can and, with help and hard work, eradicate sexual abuse from their family. Hope that they are breaking the cycle of abuse can inspire a family to make the necessary changes towards a healthier future.

Stages of treatment

Most family therapy programs which treat sexual abuse are offered in the following stages:

Stage 1: Creating a Context for Change. In Stage 1, a context of safety and hopefulness is created. The family members commit to work toward change. A collaborative relationship between client and professionals is built to assess the problem and determine the therapeutic goals. A detailed treatment plan is determined between professionals and consumers. Stage 2: Challenging Old Patterns and Expanding New Alternatives. The family is encouraged to creatively challenge problematic thoughts, feelings, and behaviors which are no longer useful, giving way to more adaptive healthier alternatives. Therapeutic interventions are designed based on the family's strengths. During Stage 2, family members may actively participate in group, individual, family, or couple sessions Stage 3: Consolidation. In this stage, the family consolidates the positive, adaptive new behaviors they have made so that they will sustain. The family prepares for future situations and plans how to continue to make adaptive choices to ensure that no further abuse takes place in their life or future generations of their family.

Restoration versus retribution

One of the most controversial differences between the traditional child advocacy and systemic approaches to treating child sexual abuse is the role of family intervention and whether a family can be reunited. Retribution in therapy means designing treatment to punish the behavior. This may include forbidding contact among some family members during therapy, threatening the removal of children for excessively long periods of time, and operating under the belief that sexually abusive behavior is impossible to eradicate.

Restorative therapy is geared to create change within the family, by encouraging healthy, non-abusive family systems. The underlying view is that people are basically good, and that this goodness can be restored to encourage strong, positive-valued, abuse-free interactions. This restoration does not necessarily mean reunification; rather it means the restoring of some type of safe, non-abusive relationships.

These contexts include larger systemic vulnerability factors, such as a family living in a cultural system that may offer tacit approval of sexuality within the family; family system vulnerabilities, such as extreme enmeshment leading to social isolation; and individual vulnerability factors, such as specific paraphilia on the part of the abusing family member.

Utilization of cognitive-behavioral and psycho-educational strategies

Cognitive-Behavioral strategies help instruct the family on new ways of thinking about their lives. This can include breaking old thought patterns of how life is and inserting new ways of thinking that lead to a healthier life. Breaking bad habits and barriers to healthy thoughts is a way to recover from past abuse and maintain a new way of thinking.

Psycho-Educational strategies help the family learn information so they can prevent abuse from happening in the future, as well as new parenting techniques so they can have better connection in the family unit.

The family learns to recognize the repetitive and dysfunctional patterns that might characterize their family and which may make them more vulnerable to abuse. Once these are recognized, the family learns ways to disrupt these patterns and establish new, healthier interactions. This process is taught throughout therapy in individual, family and group sessions.

Strength-based and solution-focused interventions

Strength-Based interventions focus on what is strong in the family. Solution-Focused interventions pay attention to what is working well for the family and decides how the family can do more of that. Both interventions believe that the family knows what will work best for them and allows them to work with the therapist to decide what they can achieve.

Families and their members are seen as competent, complex, human beings rather than as mere "labels," such as "offender" or "victim." Most interventions are framed in a strength-based, resiliency manner. Family members are encouraged to engage in behaviors that build on their strengths and interests, and at the same time preclude abuse.

Safe therapeutic environment

When a family begins therapy, they want to feel safe and comfortable. What ensures a safe therapeutic environment includes confidentiality within the family and sometimes between family members. The therapist should maintain a nonjudgmental stance when working with the family where the offender is a part of the family. The parents should not be made to feel as if they are at fault for the abuse.

If the child victim isn't ready for their parents to know certain facts and details, they have the right to decide when to share that information with their parents. This is an example of how the therapist can work with the child to feel empowered during therapy.

Another example of a safe environment is one where the family is safe from approach by the perpetrator while attending therapy sessions. Also, the family records are confidential as well as their actual sessions. The family must feel that they are protected or they will not be able to progress through their treatment.

A consistent and specific focus on safety is maintained. There is a strong emphasis for the establishment of strong and appropriate boundaries, which in turn will provide a sense of safety for the child victim and family. These boundaries can include who they share their information with, who they allow into their inner circle, and how they communicate with each other. Family rules are an important part of this safety net that extends beyond therapy and into their lives.

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There are indisputable long-term negative effects to child sexual abuse for many, if not most, victims. Such problems as eating disorders, substances abuse disorders, and sexual dysfunction. Some of the most common consequences are: guilt, shame, re-victimization, diminished self-esteem, depression, relationship difficulties, and/or other types of dissociative disorders. This does not mean every child who has experienced abuse will necessarily experience symptoms. However, there is ample evidence that sexual abuse is damaging and warrants intensive and specialized intervention to stop the abuse and aid in recovery. Even compliant victims who believe they have consented to the sexual contact are likely to be negatively affected since children must trust and rely on adults, and those older than them to keep them safe. Being asked to participate in activities that are inappropriate for their age/stage of development is a violation of their trust & well-being, even if they comply.

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Context:

The article outlines common signs that children may have experienced trauma, which can manifest in emotional, behavioral, and physical changes. These signs include persistent grief, fascination with death, heightened safety concerns, sleep disturbances, changes in appetite, irritability, difficulty concentrating, and avoidance behaviors such as refusing to attend school. The article emphasizes that while some children may show immediate reactions, others might exhibit delayed responses, with symptoms emerging months after the traumatic event. It also notes that boys and girls may display different reactions; boys often show more immediate anger or irritability, while girls may internalize their feelings. Recognizing these signs is crucial for parents, caregivers, and educators to provide appropriate support and seek professional help when necessary.

Relevance:

The article highlights the wide range of emotional, behavioral, and physical symptoms that children exposed to chronic or repeated trauma may exhibit. Complex trauma often involves ongoing stressors that affect a child’s ability to regulate emotions, concentrate, and feel safe. For childhood educators, understanding these signs is crucial because many children may not openly communicate their trauma but instead express it through changes in behavior or learning difficulties. Recognizing these symptoms allows educators to respond with sensitivity, create supportive and predictable environments, and collaborate with caregivers and mental health professionals to address the child’s needs effectively, promoting healing and academic success.

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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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This article provides a comprehensive guide to recognizing trauma in young children, emphasizing that trauma manifests differently based on age, developmental stage, and individual circumstances. Trauma can disrupt various developmental domains, including attachment, physical development, and emotional regulation, leading to challenges such as trust issues, hypersensitivity, and emotional instability. Early identification and intervention through professional therapy, such as Trauma-Focused Cognitive Behavioral Therapy or Eye Movement Desensitization and Reprocessing, are crucial for effective recovery. The article also emphasizes the importance of timely recognition and appropriate treatment to support children's healing and development.

Relevance:

This article highlights how trauma in young children can present in varied and age-specific ways, which is crucial for understanding complex trauma. The article emphasizes how complex trauma often impacts multiple areas of a child’s development, including emotional regulation, attachment, and behavior. For child educators, this information is vital because they are often among the first adults outside the family to observe signs of trauma in children. Recognizing symptoms early allows educators to provide appropriate support, create trauma-sensitive learning environments, and collaborate with caregivers and professionals to ensure timely intervention. This understanding helps prevent misinterpretation of trauma-related behaviors as mere misbehavior and promotes better emotional and educational outcomes for affected children.

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How to Spot Trauma in Young Children | Child Focus

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Trauma manifests itself in children in a variety of ways. It depends on the child, the issue they are facing, their age and developmental level, as well as other social and genetic factors

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The article defines trauma as any event that is deeply upsetting, scary, or harmful, such as abuse, violence, accidents, or natural disasters. The emotional effects of trauma can last a long time and may include feelings of fear, sadness, anger, or guilt, as well as changes in mood, behavior, or sleep patterns. Therapy, specifically trauma-focused cognitive-behavioral therapy (TF-CBT), is recommended to help children process their experiences, learn coping skills, and rebuild trust. Parental support is also crucial; spending quality time together, showing love and patience, and maintaining soothing routines can help children feel safe and supported during their recovery.

Relevance:

This article addresses how deeply upsetting and ongoing traumatic experiences, such as abuse, violence, or repeated adversity, can have lasting emotional and behavioral effects on children. Complex trauma often involves multiple traumatic events over time, leading to challenges in emotional regulation, trust, and coping skills, which the article highlights through the need for trauma-focused therapy and supportive care. For child educators, understanding this information is crucial because they play a key role in recognizing trauma symptoms in children and providing a stable, nurturing environment. Knowing how trauma affects behavior and emotions helps educators respond with patience, create safe spaces, and collaborate with families and mental health professionals to support a child’s healing and development effectively.

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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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The Paradox of Trauma-Informed Care: Vicky Kelly TED Talk 

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The Paradox of Trauma-Informed Care: Vicky Kelly TED Talk 

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The TED Talk by Vicky Kelly explains that Trauma-informed care is an approach that recognizes the widespread impact of trauma and understands the signs and symptoms in individuals, integrating this knowledge into policies, practices, and interactions to avoid re-traumatization. It emphasizes creating safe, supportive environments that foster trust, empowerment, and collaboration, while prioritizing a person’s emotional and physical safety. Kelly emphasizes that this approach is especially important because trauma can profoundly affect a person’s behavior, relationships, and ability to learn or heal. By adopting trauma-informed care, professionals, whether in education, healthcare, or social services, can respond with greater empathy and effectiveness, helping individuals feel understood and supported on their path to recovery.

Relevance:

Trauma-informed care is crucial for childhood educators to understand because many children in their classrooms may have experienced trauma that affects how they think, feel, and behave. Understanding trauma helps educators recognize that challenging behaviors might be responses to past trauma rather than intentional misbehavior. This awareness encourages teachers to respond with empathy, patience, and support rather than punishment. By creating a safe and nurturing environment, trauma-informed educators can help children feel secure, build trust, and develop the emotional skills needed to succeed both socially and academically. Ultimately, trauma-informed care enables educators to better support children’s healing and learning, fostering healthier development and improving overall classroom dynamics.

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The paradox of trauma-informed care | Vicky Kelly | TEDxWilmington

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The article defines attachment trauma as a relational trauma that results when a child’s primary caregiver fails to reliably respond to the child’s emotional needs, either overtly (neglect, abuse, death, domestic violence) or covertly (emotional unavailability, inconsistent affection, poor boundaries, parentification, etc.). This disruption in the caregiver–child bond leads to insecure attachment styles, including avoidant, anxious, and disorganized. The consequences show up in childhood as difficulties with emotion regulation, developmental delays, problems in friendships, aggressive or uncooperative behavior, and later in life as mental health struggles, self‐sabotage, trouble with intimacy, hypervigilance, etc. Finally, the article discusses pathways to healing, including therapy (especially attachment- or trauma-informed care), forming healthy and safe relationships, and learning emotional regulation skills.

Relevance:

The information discussed in the article is important because attachment is foundational, and early caregiver-child bonds set up core beliefs regarding safety, trust, and how one relates to others. If that bond is disrupted, the child's internal working model of relationships, self, and the world becomes unstable. Attachment trauma also has considerable long-term effects that carry beyond childhood, including affected emotional regulation, mental health, relational capacity, identity, etc. As child educators, understanding attachment trauma and its effects is important, as educators are often among the first outside the family to notice signs. Recognizing signs as potentially being related to attachment trauma, rather than just "bad behavior," allows earlier, more compassionate interventions. Having a good understanding also allows educators the capacity to create safe, attuned environments that promote resiliency and healing, as well as give educators the proper knowledge needed to support families and help provide external resources.

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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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Context:

The article emphasizes that attachment is a primary motivational and regulatory system deeply rooted in our evolutionary biology, which organizes early caregiver–infant interaction, affective attunement, and regulation. The article focuses on how the attachment pattern formed in infancy becomes an implicit template through which future interpersonal relationships, empathy, and mentalization. When early caregiving is disrupted through neglect, emotional unavailability, or trauma, these processes are compromised.

Relevance:

The information from the article highlights how early caregiving experiences shape a child’s brain development, emotional regulation, stress response, and capacity for relationships. Attachment is not only an emotional experience but a biological and psychological process that influences how children learn to trust, manage emotions, and interact with the world. When a child experiences trauma in their early attachment relationships, such as neglect, emotional inconsistency, or abuse, this can disrupt the development of secure attachment, leading to long-term difficulties with behavior, self-regulation, and mental health. For early childhood educators, understanding this is crucial because many challenging behaviors in the classroom may stem from underlying attachment trauma rather than intentional defiance or poor discipline. Educators are in a unique position to provide consistent, responsive, and emotionally safe environments that support healing and development. By recognizing the signs of attachment-related struggles and responding with empathy, structure, and emotional support, educators can play a key role in building resilience and helping children develop healthier relational patterns. This knowledge also allows for more effective collaboration with families and professionals, ensuring that children receive the early interventions they need.

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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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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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Context:

The article describes how infants and very young children are especially vulnerable to the effects of maltreatment, neglect, or exposure to traumatic events. Attachment to a caregiver is presented as fundamental, and children are biologically driven to form attachments. Secure attachment with a responsive, sensitive caregiver helps build emotional regulation, trust, social cognition, self‑organization, and gives the young child a “felt sense of security.” When attachment relationships are disrupted by maltreatment, caregiver role issues, caregiver trauma, or inconsistent responses, children are more likely to suffer persistent traumatic stress, difficulty coping, and delays or disruptions in development. The article also reviews interventions, including recognizing signs of poor attachment or trauma early, using relationship‑based interventions such as Child‑Parent Psychotherapy (CPP), supporting caregivers to become more emotionally sensitive and attuned, and helping repair attachment damage through therapy, developmental guidance, and play.

Relevance:

This information emphasizes how early experiences can significantly shape a child's emotional and psychological development. A secure attachment with a sensitive, consistent caregiver acts as a protective factor, helping children regulate emotions, develop trust, and build a foundation for future relationships. When these attachments are disrupted or inconsistent, due to neglect, caregiver trauma, or maltreatment, children may struggle to cope and may experience long-term developmental challenges. For early childhood educators, this understanding is essential because they often interact closely with children during critical stages of development and are in a key position to observe early signs of trauma or attachment difficulties. Educators who are aware of these dynamics can respond with empathy, consistency, and trauma-informed strategies that foster emotional safety, support healthy relationships, and promote resilience in children who have experienced early adversity.

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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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Attachment Theory: How Childhood Affects Relationships 

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Attachment Theory: How Childhood Affects Relationships 

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This video explains the four different attachment styles —secure, anxious, avoidant, and disorganized —and how these styles develop and shape your relationships. These styles develop in early childhood based on the consistency, responsiveness, and emotional availability of primary caregivers. Secure attachment forms when caregivers are consistently nurturing and responsive, leading children to feel safe, trust others, and form healthy, stable relationships as adults. Anxious attachment arises from inconsistent caregiving, making individuals feel unsure about others’ availability, often resulting in clinginess, fear of abandonment, and emotional dependency in relationships. Avoidant attachment develops when caregivers are emotionally distant or rejecting, causing individuals to suppress emotional needs, avoid closeness, and struggle with intimacy. Disorganized attachment, often linked to trauma or abuse, leads to confusion, fear, and unpredictable behaviors in relationships, as individuals may both seek and fear closeness. The video highlights how these early patterns influence the way people interact with others, manage conflict, express emotions, and perceive intimacy throughout their lives.

Relevance:

The four attachment styles reflect how early relationships with caregivers, especially in the context of consistency, neglect, or trauma, shape a child's emotional development and future relationships. Children who have experienced trauma or inconsistent caregiving are more likely to develop insecure attachment styles, which can manifest in the classroom as behavioral challenges, difficulty trusting adults, emotional dysregulation, or social withdrawal. For child educators, this knowledge is essential because it shifts the perspective from seeing these behaviors as intentional misbehavior to recognizing them as coping mechanisms rooted in early experiences. It equips educators to respond with empathy, provide stability, set healthy boundaries, and support emotional development.

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Attachment theory: How Childhood Affects Relationships

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Attachment Theory in Psychology Explained

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Attachment Theory in Psychology Explained

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Context:

The article outlines John Bowlby’s foundational ideas about attachment, positing that humans have an innate drive to form emotional bonds with primary caregivers, which serve as a “secure base” from which children can explore the world and to which they can return when distressed. It describes how the caregiver’s availability and responsiveness foster a child’s internal working models, which guide expectations and interactions across the lifespan. Mary Ainsworth’s Strange Situation is presented as a key experimental method for classifying infants’ attachment styles based on how children respond to separation and reunion episodes. The article further discusses how attachment develops in stages, how secure attachment supports healthy exploration and autonomy, and how early attachment patterns can influence later relationships and behavior. It also offers a critical evaluation, noting cultural considerations, the role of temperament, and the danger of oversimplifying or misunderstanding attachment concepts in practice.

Relevance:

This article highlights how early emotional bonds between children and their caregivers form the foundation for social, emotional, and psychological development and explains that when caregivers are consistently responsive and sensitive to a child’s needs, a secure attachment develops, fostering a child’s confidence, emotional regulation, and ability to form healthy relationships. In contrast, when caregiving is inconsistent, neglectful, or frightening, children may develop insecure or disorganized attachment styles, which can lead to difficulties with trust, behavior, and emotional well-being, especially if early experiences involve trauma. For early childhood educators, understanding this is crucial because the classroom often becomes an extension of the child’s relational world. Educators can support secure attachment by offering predictable routines, emotionally attuned interactions, and safe environments. They are also in a key position to recognize signs of attachment-related distress and refer children for appropriate support. By understanding the principles of attachment theory, educators can more effectively respond to children’s emotional and behavioral needs and help build resilience in those who have experienced trauma or insecure early relationships.

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Attachment can be defined as a deep and enduring emotional bond between two people in which each seeks closeness and feels more secure when in the presence of the attachment figure.

The initial and perhaps most crucial emotional bond forms between infants and their primary caregivers.

Distinct behaviors characterize attachment in children and adults, such as seeking closeness with the attachment figure when distressed or threatened (Bowlby, 1969).

John Bowlby

Attachment theory in psychology finds its roots in the pioneering work of John Bowlby (1958). During the 1930s, Bowlby was a psychiatrist at a Child Guidance Clinic in London, treating numerous emotionally troubled children.

His experiences there underscored the significance of a child's relationship with their mother in shaping their social, emotional, and cognitive development.

It molded his understanding of the connection between early separations from the mother and subsequent maladjustment, leading him to develop his attachment theory.

The attachment bond isn't coincidental. Its primary purpose is to ensure the survival of the vulnerable infant, requiring the constant presence of a caregiver (Bowlby, 1973, 1980).

Viewed from this lens, attachment emerges as an evolutionary concept. The behavior of seeking proximity is universally observed across cultures (Van Ijzendoorn & Sagi-Schwartz, 2008).

Bowlby (1988) contended that the drive for proximity arises from an interconnected set of behavioral systems that collectively shape behavior. These include the attachment, caregiving, and exploratory behavioral systems.

Attachment Behavioral System

The attachment behavioral system concerns the tendency of an individual to seek security during times of stress (Mikulincer & Shaver, 2003), which can be internal (i.e., hunger, fatigue, illness) or from external features of the environment, such as threatening stimuli (Bowlby, 1988).

The more extreme the stress, the more intense the attachment system activation. The attachment system is most readily activated during the first five years of life, a period characterized by high levels of vulnerability and dependence.

Once the attachment system is activated, the infant is motivated to seek proximity to significant others (attachment figures) to protect themselves from physical or emotional harm (Bowlby, 1969).

If this goal is achieved, the infant develops feelings of safety and security, and their attachment system becomes deactivated. The infant will call upon a range of attachment behaviors with the goal of attaining proximity to the attachment figure.

Bowlby (1988) suggests the attachment behavioral system remains important throughout life and will also motivate adults to seek proximity in times of stress during adulthood.

Caregiving System

The attachment figure is viewed as a 'safe haven', and their role is to correspondingly alter their level of responsiveness to deactivate the infant's attachment system by promoting feelings of security.

George and Solomon (1996) call this reciprocal response of the attachment figure to the infant's attachment system the 'caregiving' system.

Bowlby (1969) posits that the caregiving system exists to provide protection and support to others in need of assistance, through providing sensitive and responsive care.

The caregiving system is activated when an individual expresses a need for support or their attachment system is activated, and is deactivated when the care recipient appears to be in a secure state (Shaver & Mikulincer, 2006).

Once activated, the caregiver may utilize a variety of behavioral strategies intended to improve the other person's well-being, re-establishing their felt security, and facilitating their coping efforts.

Caregiving strategies include validating a person's worries, providing physical closeness and affection, and communicating that a person is loved and valued (Mikulincer & Shaver, 2007).

In addition to attachment behaviors, the caregiving system can support exploratory behaviors (Feeney, 2004).

The Importance of Early Emotional Bonds

Attachment behavior in adults toward the child includes responding sensitively and appropriately to the child's needs. Such behavior appears universal across cultures.

Attachments are most likely to form with those who responded accurately to the baby's signals, not the person they spent more time with. Schaffer and Emerson called this sensitive responsiveness.

Reciprocity is the mutual, two-way interaction between an infant and caregiver, where both respond to each other's signals, such as when a baby's smile evokes a smile in return. This interaction is vital for a child's development, establishing their foundational trust and shaping future relationships and learning.

Exploratory Behavioral System

When infants feel safe and secure, and their attachment system is deactivated, their energy can be devoted to what Bowlby (1969) refers to as the exploratory behavioral system.

The exploratory behavioral system refers to behaviors that drive the organism to interact with the environment in a bid to inspect it, manipulate it, and master it (Mikulincer & Shaver, 2007).

According to Bowlby (1969), the exploratory system is activated by novelty and is terminated when a person exhibits a sense of competence and familiarity with their environment. From this perspective, attachment figures can also be seen as a 'secure base' which infants use to explore their social world (Ainsworth, Blehar, Waters, & Wall, 1978).

The more assured the infant is in the availability of their attachment figure in times of stress, the more likely they will interact with others and their environment. Thus attachment, far from interfering with exploration, is viewed as nurturing exploration.

Caregivers who provide a secure base allow infants to become autonomous, inquisitive, and experimental. Children who lack a secure base find their attachment system keeps overriding their attempts to be autonomous and to competently interact with their social environment.

This, in turn, can impair and harm a child's social, emotional, and cognitive development (Bowlby, 1980). Of course, not all attachment figures become a secure base, and this function is based on the responsiveness of their caregiver towards the infant (Ainsworth & Wittig, 1969).

Ainsworth et al. proposed the interconnecting between attachment and exploratory systems are adaptive as they ensure a balance between protection and exploration of the social and physical environment.

Ainsworth's Strange Situation

Mary Ainsworth and her colleagues discovered three major patterns that infants attach to their primary caregivers ("mother figures") from their Strange Situation Procedure (Ainsworth et al., 1978).

The study recruited four different samples of infants at around one year of age, and engaged them in the Strange Situation procedure, roughly described below:

An infant was put into an unfamiliar environment with his or her mother and was free to explore the environment; a stranger entered the room and gradually approached the infant; the mother then left the room, returning after the infant spent some time alone with the stranger.

Ainsworth and colleagues observed how comfortable each infant was physically farther away from the mother in an unfamiliar environment, how each infant interacted with the stranger, and how each infant greeted the mother upon her return.

Based on the observations, they sorted the infants into three groups: secure, anxious, and avoidant.

Attachment Styles

Attachment styles refer to the particular way in which an individual relates to other people. The style of attachment is formed at the very beginning of life, and once established, it is a style that stays with you and plays out today in how you relate in intimate relationships and in how you parent your children.

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

Secure Attachment

Bowlby (1988) described secure attachment as the capacity to connect well and securely in relationships with others while also having the capacity for autonomous action as situationally appropriate.

Secure attachment is characterized by trust, an adaptive response to being abandoned, and the belief that one is worthy of love.

An infant with a secure attachment is characterized as actively seeking and maintaining proximity with the mother, especially during the reunion episode. The infant may or may not be friendly with the stranger, but always shows more interest in interacting with the mother.

Additionally, during the same situation the infant tended to be slightly distressed during separation from the mother, but the infant rarely cried.

Ainsworth and colleagues interpreted infants who were securely attached to their mothers, showed less anxiousness and more positive attitudes toward the relationship, and were likely because they believed in their mothers' responsiveness towards their needs.

Anxious (Ambivalent) Attachment

Anxious attachment (also called ambivalent) relationships are characterized by a concern that others will not reciprocate one's desire for intimacy. This is

caused when an infant learns that their caregiver or parent is unreliable and does not consistently provide responsive care towards their needs.

An anxiously attached infant is characterized as being somewhat ambivalent (and resistant) to the mother. The infant often demonstrated signs of resisting interactions with the mother, especially during the strange situation reunion episode.

However, once contact with the mother was gained, the infant also showed strong intentions to maintain such contact. Overall, ambivalent infants often displayed maladaptive behaviors throughout the Strange Situation.

Ainsworth and colleagues found ambivalent infants to be anxious and unconfident about their mothers' responsiveness, and their mothers were observed to lack "the fine sense of timing" in responding to the infants' needs.

As adults, those with an anxious preoccupied attachment style are overly concerned with the uncertainty of a relationship. They hold a negative working model of self and a positive working model of others.

Avoidant Attachment

Children with avoidant attachment styles tend to avoid interaction with the caregiver, and show no distress during separation. This may be because the parent has ignored attempts to be intimate, and the child may internalize the belief that they cannot depend on this or any other relationship.

An infant with an avoidant attachment was characterized as displaying little to no tendency to seek proximity with the mother.

The infant often showed no distress during separation from the mother, interacted with the stranger similarly to how he or she would interact with the mother, and showed slight signs of avoidance (turning away, avoiding eye contact, etc.) when reunited with the mother.

Ainsworth and colleagues interpreted infants' avoidance behaviors as a defensive mechanism against the mothers' own rejecting behaviors, such as being uncomfortable with physical contact or being more easily angered by the infants.

Disorganized (Fearful) Attachment

Main and Solomon (1986) discovered that a sizable proportion of infants did not fit into secure, anxious, or avoidant, based on their behaviors in the Strange Situation experiment. They categorized these infants as having a disorganized attachment type.

Disorganized attachment is classified by children who display sequences of behaviors that lack readily observable goals or intentions, including obviously contradictory behaviors or stilling/freezing of movements.

Main and Solomon found that the parents of disorganized infants often had unresolved attachment-related traumas, which caused the parents to display either frightened or frightening behaviors, resulting in the disorganized infants being confused or forcing them to rely on someone they were afraid of at the same time.

Stages of Attachment

Rudolph Schaffer and Peggy Emerson (1964) investigated if attachment develops through a series of stages by studying 60 babies at monthly intervals for the first 18 months of life (this is known as a longitudinal study).

The children were all studied in their own homes, and a regular pattern was identified in the development of attachment.

The babies were visited monthly for approximately one year, their interactions with their carers were observed, and carers were interviewed.

A diary was kept by the mother to examine the evidence for the development of attachment. Three measures were recorded:

* Stranger Anxiety - response to arrival of a stranger.

* Separation Anxiety - distress level when separated from carer, degree of comfort needed on return.

* Social Referencing - degree that child looks at carer to check how they should respond to something new (secure base).

They discovered that baby's attachments develop in the following sequence:

Very young infants are asocial in that many kinds of stimuli, both social and non-social, produce a favorable reaction, such as a smile.

Indiscriminate Attachments (6 weeks to 7 months)

Infants indiscriminately enjoy human company; most babies respond equally to any caregiver. They get upset when an individual ceases to interact with them.

From 3 months, infants smile more at familiar faces and can be easily comfortable by a regular caregiver.

Specific Attachment (7 - 9 months)

Special preference for a single attachment figure. The baby looks to particular people for security, comfort, and protection. It shows fear of strangers (stranger fear) and unhappiness when separated from a special person ( separation anxiety).

Some babies show stranger fear and separation anxiety much more frequently and intensely than others; nevertheless, they are seen as evidence that the baby has formed an attachment. This has usually developed by one year of age.

Multiple Attachment (10 months and onwards)

Many of the babies from the Schaffer and Emerson study had multiple attachments by 10 months old, including attachments to mothers, fathers, grandparents, siblings, and neighbors.

The baby becomes increasingly independent and forms several attachments. By 18 months, the majority of infants have formed multiple attachments.

The multiple attachments formed by most infants vary in their strength and importance to the infant. Attachments are often structured in a hierarchy, whereby an infant may have formed three attachments, but one may be stronger than the other two, and one may be the weakest.

The results of the study indicated that attachments were most likely to form with those who responded accurately to the baby's signals, not the person they spent more time with. Schaffer and Emerson called this sensitive responsiveness.

Intensely attached infants had mothers who responded quickly to their demands and, interacted with their child. Infants who were weakly attached had mothers who failed to interact.

The Lasting Impact of Early Attachment

According to Bowlby's theory (1988), when we form our primary attachment, we also make a mental representation of what a relationship is (internal working model), which we then use for all other relationships in the future i.e., friendships, working, and romantic relationships.

The different attachment styles may be viewed as internal working models of "relationships" that evolved from event experiences (Main, Kaplan, & Cassidy, 1985).

This would suggest that early interactions with caregivers could not only shape how an infant understood and behaved in relationships (as exemplified by infant attachment styles), but that such impact could be carried forward into adult attachment.

According to Bowlby (1969) later relationships are likely to be a continuation of early attachment styles (secure and insecure) because the behavior of the infant's primary attachment figure promotes an internal working model of relationships which leads the infant to expect the same in later relationships.

In other words, there will be continuity between early attachment experiences and later relationships. This is known as the continuity hypothesis.

In humans, attachment does not conclude in infancy, or even childhood, but instead is active throughout the lifespan, with individuals gaining comfort from both physical and mental representations of significant others (Bowlby, 1969).

It is through an individual's internal working model that childhood patterns of attachment are carried forward across the life cycle into adolescence and adulthood.

The notion of security is still an important one; however, the growing emergence of autonomy is also significant as the attachment system in adults is less likely to be activated due to them being able to tolerate higher levels of distress compared to children.

During adulthood, new attachment bonds are formed which may become a significant source of support during periods of distress, or during periods of goal achievement and exploration.

Researchers have proposed that working models are interconnected within a complex hierarchical structure (Bowlby, 1980; Bretherton, 1985, 1990; Collins & Read, 1994; Main, Kaplan, & Cassidy, 1985).

For example, the highest level model comprises beliefs and expectations across all types of relationship, and lower level models hold general rules about specific relations, such as romantic or parental, underpinned by models specific to events within a relationship with a single person.

The existence of multiple mental models is supported by evidence which demonstrates considerable within-person variability in the expectations and beliefs that people hold about the self and others (Baldwin & Fehr, 1995).

Furthermore, although specific models of attachment relationships are positively associated with more overarching general working models, the correlations are small to moderate (less than .40), indicating that they comprised distinct beliefs regarding the self and significant others (Cozzarelli, Hoekstra, & Bylsma, 2000).

Likely, general mental models indicate a typical appraisal of the self and others across relationships, and relationship-specific beliefs about the self and one's partner would plausibly represent only a part of these generalized beliefs.

Key Takeaways

Attachment is defined as a "lasting psychological connectedness between human beings" (Bowlby, 1969, p. 194), and may be considered interchangeable with concepts such as "affectional bond" and "emotional bond."

Attachment is characterized by specific behaviors in children, such as seeking proximity to the attachment figure when upset or threatened (Bowlby, 1969).

Attachment theory explains how the parent-child relationship emerges and influences subsequent development.

A person's first attachment is often established with the primary caregiver during infancy. However, it must be noted that attachment is not unique to infant-caregiver relationships but may also be present in other social relationships.

Attachments of various kinds are formed through the repeated act of "attachment behaviors" or "attachment transactions," a continuing process of seeking and maintaining a certain level of proximity to another specified individual (Bowlby, 1969).

Because caregivers vary in sensitivity and responsiveness, not all infants attach to caregivers in the same way.

References

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

Ainsworth, M. D. S. (1973). The development of infant-mother attachment. In B. Cardwell & H. Ricciuti (Eds.), Review of child development research (Vol. 3, pp. 1-94) Chicago: University of Chicago Press.

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

Ainsworth, M. D. S. (1991). Attachments and other affectional bonds across the life cycle. In C . M. Parkes, J. Stevenson-Hinde, & P. Marris (Eds.), Attachment across the life cycle (pp. 33-51). London: Routledge.

Ainsworth. M. D. S., & Wittig, B. A. (1969) Attachment and exploratory behaviour of one-year-olds in a strange situation. In: B. M. Foss (Ed.) Determinants of infant behaviour, IV. London: Methuen, p. 111-136.

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

Bowlby J. (1969). Attachment. Attachment and loss: Vol. 1. Loss. New York: Basic Books.

Bowlby, J., and Robertson, J. (1952). A two-year-old goes to the hospital. Proceedings
of the Royal Society of Medicine, 46, 425-427.

Bowlby, J. (1973). Attachment and loss, Vol. 2: Separation. New York: Basic Books.

Bowlby, J. (1980). Attachment and loss, Vol. 3: Loss, sadness and depression. New York: Basic Books.

Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books.

Dollard, J. & Miller, N.E. (1950). Personality and psychotherapy. New York: McGraw-Hill.

Feeney, B. C. (2004). A secure base: responsive support of goal strivings and exploration in adult intimate relationships. Journal of Personality and Social Psychology, 87(5), 631.

George, C., & Solomon, J. (1996). Representational models of relationships: Links between caregiving and attachment. Infant Mental Health Journal, 17(3), 198-216.

Harlow, H. F. & Zimmermann, R. R. (1958). The development of affective responsiveness in infant monkeys. Proceedings of the American Philosophical Society, 102, 501 -509.

Mikulincer, M., & Shaver, P. R. (2003). The attachment behavioral system in adulthood: Activation, psychodynamics, and interpersonal processes. Advances in Experimental Social Psychology, 35, 53-152.

Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change. New York: Guilford Press.

Prior, V., & Glaser, D. (2006). Understanding attachment and attachment disorders: Theory, evidence and practice. Jessica Kingsley Publishers.

Schaffer, H. R., & Emerson, P. E. (1964). The development of social attachments in infancy. Monographs of the Society for Research in Child Development, 1-77.

Shaver, P. R., & Mikulincer, M. (2006). Attachment theory, individual psychodynamics, and relationship functioning. The Cambridge handbook of personal relationships, 251-271.

Van Ijzendoorn, M. H., & Sagi-Schwartz, A. (2008). Cross-cultural patterns of attachment: Universal and contextual dimensions. In J. Cassidy & P. Shaver (Eds) Handbook of Attachment: Theory, Research and Clinical Applications (pp. 880-905). New York: Guildford Press.

FAQs

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Attachment Theory In Psychology Explained

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Attachment can be defined as a deep and enduring emotional bond between two people in which each seeks closeness and feels more secure when in the presence of the attachment figure.

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Attachment and Resilience: The Power of One-Dr. Erica Liu Wollin 

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Attachment and Resilience: The Power of One-Dr. Erica Liu Wollin 

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Context:

In her TEDx Talk, Dr. Erica Liu Wollin shares her personal journey and insights about how early attachment disruptions, especially when a child comes from an institutional or unstable background, can profoundly shape emotional and relational development, but also how resilience can be cultivated with the caring presence of just one person. She describes adopting a daughter from an orphanage and observing how behaviors like intense emotion, withdrawal, or surprise upon reunions exposed deep survival responses learned early in life. Wollin argues that though early trauma can “wire” the brain toward expecting threat, neural plasticity allows for healing over time through consistent, attuned care. She emphasizes that caregivers, educators, or even someone who truly attunes to the child and validates their inner world can make a critical difference in helping that child reclaim trust, safety, and relational strength.

Relevance:

Dr. Erica Wollin highlights how early relational wounds, often caused by neglect, institutional care, or loss, can shape a child’s brain, behaviors, and expectations of others. However, it also offers hope: healing is possible through consistent, attuned, and safe relationships, even if just with one caring adult. This message is critically important for child educators to understand because they often serve as key attachment figures, especially for children with disrupted or traumatic pasts. Educators who recognize the signs of attachment trauma and respond with patience, empathy, and reliability can play a powerful role in a child’s recovery and growth. Wollin’s message empowers educators to see their relationships with students not just as academic support, but as opportunities to build trust, co-regulate emotions, and foster resilience—proving that one safe, responsive adult can change the course of a child’s life.

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Attachment and resilience -- the power of one: Dr. Erica Liu Wollin at TEDxHongKong 2013

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Attachment Theory in the Classroom: Guidance for Teachers

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Attachment Theory in the Classroom: Guidance for Teachers

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Context:

The article explains that a student’s attachment history, the quality of their early bonds with caregivers, can powerfully shape how they behave, learn, and relate in school. It lays out how secure, anxious, avoidant, and disorganized attachment styles may manifest in classroom behavior. For instance, anxiously attached students may cling, struggle with transitions, or seek attention, and avoidant students may isolate themselves or resist help; disorganized students may act unpredictably or aggressively. The article also emphasizes that understanding these patterns enables teachers to tailor responses, using reassurance, routines, indirect support, comfort objects, firm boundaries, and consistent communication, rather than simply punishing misbehavior, to better reach and support every student.

Relevance:

The article explains how attachment patterns are often deeply shaped by early experiences of trauma or stress, such as neglect, abuse, or inconsistent caregiving. Trauma can disrupt a child’s ability to form secure attachments, leading to behaviors in the classroom that might seem challenging or “problematic” but are actually expressions of unmet emotional needs or survival strategies. When educators understand attachment and trauma, they can recognize that difficult behaviors often signal a child’s internal struggles rather than willful misbehavior. Instead of reacting punitively, teachers who understand attachment can create a safe, predictable environment that helps children feel secure, builds trust, and fosters emotional regulation. This can improve not only behavior but also learning outcomes, social relationships, and overall well-being. Ultimately, this knowledge equips educators to be trauma-informed responders who contribute to healing and resilience, rather than unintentionally exacerbating a child’s sense of insecurity or distress.

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Attachment Theory in the Classroom: Guidance for Teachers

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Understand the impact of attachment theory in the classroom and how recognizing students’ attachment styles can help educators!

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Attachment Issues and Attachment Disorders in Children

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Attachment Issues and Attachment Disorders in Children

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Context:

The article explains how attachment issues in children arise when the emotional bond between a child and their primary caregiver is disrupted or inadequately formed. This bond is crucial for healthy emotional development, and its absence can lead to difficulties in expressing emotions, building trust, and forming relationships. Such issues may manifest as behavioral problems, including withdrawal, aggression, or defiance. The causes are varied, encompassing neglect, inconsistent caregiving, trauma, or separation from caregivers. While some children may exhibit mild attachment issues, others might develop more severe conditions like Reactive Attachment Disorder (RAD) or Disinhibited Social Engagement Disorder (DSED), both of which are often linked to early life trauma or instability. Early intervention is vital, and strategies such as consistent caregiving, establishing predictable routines, and seeking professional therapy can significantly improve outcomes for affected children.

Relevance:

This information is highly relevant in the context of attachment and trauma because it highlights how early disruptions in the child-caregiver bond, due to neglect, inconsistency, trauma, or separation, can profoundly affect a child’s emotional development, behavior, and ability to form healthy relationships. For child educators, understanding these dynamics is crucial because they often serve as secondary attachment figures in children's lives. Recognizing signs of attachment issues allows educators to respond with empathy, patience, and appropriate support, rather than frustration or misunderstanding. This understanding helps create a safe, predictable, and nurturing learning environment that can foster healing and resilience.

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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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Context:

This article discusses Reactive Attachment Disorder (RAD), which is a serious condition in which infants or young children fail to form healthy emotional bonds with caregivers, often due to neglect or inconsistent caregiving. Symptoms typically emerge in infancy and may include unexplained withdrawal, fear, sadness, irritability, lack of seeking comfort, and failure to engage in social interactions. The disorder is most commonly associated with environments where children's basic emotional and physical needs are unmet. Risk factors include institutional living, frequent changes in caregivers, and parental mental health issues. Without intervention, RAD can lead to long-term complications affecting relationships, behavior, and mental health. Treatment focuses on creating a stable, nurturing environment and may involve caregiver education and counseling.

Relevance:

Reactive Attachment Disorder (RAD) directly results from early disruptions in the caregiver-child relationship, often caused by neglect, inconsistent caregiving, or trauma. Understanding RAD helps child educators recognize that some children’s challenging behaviors, such as withdrawal, fear, or difficulty forming relationships, are not just behavioral issues but stem from deep emotional wounds tied to attachment trauma. For educators, this awareness is vital to responding with sensitivity and appropriate support rather than frustration or punishment. It highlights the importance of creating a stable, nurturing, and predictable environment that can help these children feel safe and gradually build trust. Additionally, educators play a key role in early identification and referral for professional help, which can improve the child’s long-term emotional and social development.

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Overview

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

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

Products & Services

Symptoms

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

Signs and symptoms may include:

Unexplained withdrawal, fear, sadness or irritability

Sad and listless appearance

Not seeking comfort or showing no response when comfort is given

Failure to smile

Watching others closely but not engaging in social interaction

Failing to ask for support or assistance

Failure to reach out when picked up

No interest in playing peekaboo or other interactive games

When to see a doctor

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

Causes

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

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

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

Risk factors

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

Live in a children's home or other institution

Frequently change foster homes or caregivers

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

Have prolonged separation from parents or other caregivers due to hospitalization

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

Complications

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

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

Prevention

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

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

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

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

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

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

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Reactive attachment disorder - Symptoms and causes

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

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Disinhibited Social Engagement Disorder (DSED)

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Disinhibited Social Engagement Disorder (DSED)

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Context:

The article discusses Disinhibited Social Engagement Disorder (DSED), which is an attachment disorder in which children display overly friendly and inappropriate behaviors toward strangers, such as hugging, talking, or wandering off with unfamiliar adults without hesitation. This lack of social boundaries often stems from early childhood neglect, inconsistent caregiving, or institutional care, leading to difficulties in forming secure attachments. Symptoms may include ignoring personal space, asking personal questions, and forming shallow relationships. While DSED is rare in the general population, it is more prevalent among children with a history of institutional living. Early intervention, including consistent caregiving, setting clear social boundaries, and professional therapy, can help children develop healthier attachment patterns and improve their social interactions.

Relevance:

This information about Disinhibited Social Engagement Disorder (DSED) shows how early experiences of neglect, inconsistent caregiving, or institutional care can disrupt a child’s ability to form healthy, secure attachments. Children with DSED often struggle with social boundaries and may behave in overly familiar or risky ways with strangers, reflecting deep attachment trauma. For child educators, understanding DSED is crucial because these behaviors can be misunderstood as simply being overly friendly or attention-seeking, rather than signs of emotional distress and trauma. Recognizing DSED helps educators respond with appropriate care, set clear and consistent boundaries, and provide a safe, stable environment that promotes healthy social development. This knowledge also allows educators to collaborate with caregivers and professionals to support the child’s emotional healing and social skills, ultimately fostering better outcomes in both the classroom and the child’s broader life.

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Disinhibited Social Engagement Disorder (DSED) - HelpGuide.org

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Parenting a child who's over-friendly with strangers can be challenging. But there are ways to mange the symptoms of this attachment disorder.

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The NCBI “Learning, Recalling, and Thinking” chapter explores how the brain supports cognition and memory at both structural and functional levels. It describes how learning and memory depend on physical changes in neurons, such as strengthening synapses, forming new connections, and gene expression, that underlie long‑term memory. It also explains how the brain maintains internal representations of the world to guide behavior and thought processes. The chapter also emphasizes the role of neurotransmitters and the prefrontal cortex in working memory, attention, and higher-order thinking, showing how chemical signaling influences cognitive function.

Relevance:

This chapter explains the neurological processes that allow for learning, memory, and higher-order thinking; functions that are only accessible when a child is in a calm, regulated state. When a child is in survival mode, due to stress or fear, the brain prioritizes immediate safety over cognitive functions like reasoning, reflection, and problem-solving. The chapter also highlights how learning depends on the brain’s ability to form and strengthen neural connections, especially in areas like the prefrontal cortex, which is responsible for executive functions and is largely offline during stress. For child educators, understanding this is important for creating an emotionally safe, supportive environment that enables children to access their thinking brain. Without this foundation, even the best instruction may be ineffective, as the child’s brain isn't in a state to learn.

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The brain regulates an array of functions necessary to survival: the action of our five senses, the continuous monitoring of the spatial surround, contraction and relaxation of the digestive muscles, the rhythms of breathing and a regular heartbeat. As the vital functions maintain their steady course without our conscious exertion, we are accustomed to consider the brain as preeminently the organ of thought. The brain houses our mind and our memories, and we rely on its information-processing capacities when we set out to learn something new.

But where in the brain can we locate memory or thought itself? Chapter 7 offered some clues about the ways scientific investigation-from the molecular level to studies of the alert, behaving animal-has begun to define in physical terms an abstract quality such as "attention." Similar techniques and approaches are being applied to other mental functions, too, even those as seemingly intangible as learning, remembering, or thinking about the outside world.

Learning and memory, which for many years were considered central problems in psychology, the social sciences, and philosophy, have recently assumed greater importance in the area of neurobiology, itself a confluence of several lines of investigation.

Neuroscientific interest in learning and memory has recently increased for two reasons, according to psychiatrist Eric Kandel, a senior scientist in the Howard Hughes Medical Institute at Columbia University. One reason is the proposal of cellular mechanisms that account for a basic kind of learning and long-term memory. The model was first identified in the relatively simple nervous systems of the marine snail and the crayfish, but it appears to hold good in the hippocampus of vertebrates as well, where it also may be associated with the formation of long-term memories.

The second reason for a new interest in learning and memory is the evidence accumulating to suggest that mechanisms involved in the structural change in the nervous system that accompanies learning may strongly resemble certain important steps in the nervous system's development. In other words, the sorts of adjustments among synapses that account for learning may be the same as the "fine-tuning" that occurs while the maturing system is assuming its unique elaborated form. Thus, the biological changes that accompany learning may be seen-in a very schematic way-as an old process put to a new use, or as a specialized way in which the brain continues to "grow" after maturation.

A Molecular Account Of Long-Term Memory

Eric Kandel is best known for his work on the physical basis of learning and memory in the marine snail Aplysia. This animal, simple as its nervous system is (most of its 20,000 neurons have been identified by number), nevertheless provides an excellent model for the study of learning and memory, through its "gill withdrawal" reflex. When Aplysia perceives something touching its skin, it quickly withdraws both the siphon (a respiratory organ) and the gill, much as a person withdraws a hand from a hot stove without thinking about it. Although this withdrawal is a reflex, it is not completely hard-wired but can be modified by various forms of learning. One such form is sensitization, in which the animal becomes aware of a threatening factor in the environment and to protect itself learns to augment its reflex. The augmented version of the withdrawal reflex can also be maintained in short-term or long-term memory, depending on whether researchers administer the noxious stimulus (the negative reinforcement) only once or twice, or many times within a short period. The two forms of memory can be distinguished not only by their duration-the difference between minutes and days-but also at a molecular level, because it is possible to treat the snail with a chemical compound that interferes with long-term memory but leaves short-term memory unimpaired.

A major set of elements in this reflex are sensory neurons in the siphon skin, which perceive the stimulus; motor neurons in the gill, which contract the muscle and cause the gill to withdraw; and "facilitating neurons," or interneurons, which act on the sensory neurons to enhance their effect. The role of these facilitating neurons has recently become clearer, thanks to observations made from cell cultures, at the simplest level possible: the neurons themselves. A single sensory neuron and a single motor neuron, when implanted in a glass dish with a suitable nourishing culture, form functional interconnections. When a facilitating neuron is added or the cells are exposed to serotonin (the transmitter released by the facilitating neuron), the connection between the sensory and the motor neuron becomes stronger. The connection can last in this enhanced form for more than a day, even up to several weeks, and apparently includes some process of genetic transcription, or expression of part of the nerve cell's DNA.

This genetic transcription produces two results that set long-term memory apart from short-term memory. One is a sort of extension of a short-term effect, in which the potassium channels in the sensory neuron membrane remain closed for a longer time, while the calcium channels remain open. The net effect is that the sensory neuron is more easily excited and releases more neurotransmitter, which in turn activates the motor neuron more strongly. Actually, this effect can be produced on a short-term basis by increased levels of the second-messenger compound cyclic AMP; but after transcription, it is no longer dependent on such a factor and persists even without it. The effect can be disrupted, however, by inhibitors of protein synthesis and RNA synthesis. This constraint establishes that the recording of long-term memories involves not simply a momentary release of neurotransmitters but actual gene expression, with the synthesis of new proteins in the nerve cells themselves.

The new protein products that are synthesized-for example, under the stimulus of a repeated threatening signal-do more than merely reduce the dependence of the sensory neurons on serotonin or cyclic AMP for their activation. As a second transcription event, they induce new growth in certain parts of the sensory neurons themselves. These neurons develop many more presynaptic terminals, the structures through which they release neurotransmitter to the motor neurons; in addition, the number and the surface area of active zones in each presynaptic terminal increase, as does the total number of vesicles, the storage containers for the neurotransmitter. Thus, gene expression appears to build long-term memory out of several effective components, which come together in a formidable array: increased excitability of the sensory neurons, with the protein kinase continuing to work on its own to keep calcium channels open, allowing calcium ions in and more neurotransmitter out; more synapses for conveying signals between sensory and motor neurons; greater numbers of active zones in the synapses; and greater quantities of neurotransmitter contained in the active zones, ready for release. No wonder that memories built of such stuff tend to last awhile.

For closer study, the Kandel laboratory has replicated in cell culture the same conditions that in the living animal lead to protein synthesis and neuronal growth: a motor neuron, a sensory neuron (injected with a fluorescent dye to make imaging possible afterward), and exposure to serotonin repeated four or five times. The results are clear: within several hours, the main axon of the sensory neuron shows an increase in the number of synapses. Exposing the neurons to the second messenger cyclic AMP produces a similar result. But regardless of whether the facilitating compound is the neurotransmitter or the second messenger, neuronal growth occurs only if a target-a motor neuron-is also present.

The necessary presence of a target was the first similarity that Kandel and his collaborators noticed between the processes of structural change that accompany long-term memory, or learning, and those of development. The observation fit in well, too, with an earlier finding: the fine axonal branches of a sensory neuron in isolation adhere together in fat bundles, but on first contact with a motor neuron the branches tend to separate, each potentially to form its own synapse with the motor neuron. Here, at a mechanical level, is the explanation for a disassembly process that is required prior to the marked increase in synapses that takes place in the presence of serotonin. But in long-term memory, as in development, the presence of the target is necessary-a feature that makes for plasticity, or the all-important ability to change in response to the environment.

To study this learning-related plasticity at the molecular level, Kandel's research group is looking at the proteins that change in level when exposed to serotonin or cyclic AMP (or, in the living animal, to a noxious stimulus). Of the 15 proteins that change, 10 show an increase and 5 show a decrease. The reactions are transient: the levels go up, or down, and back again quite quickly.

Most interesting, in the investigators' view, are the proteins whose response is to decrease in level. Is there a way in which producing less of something can figure in a growth process? At a molecular level, the answer can be yes, if the something is an inhibitory factor of some kind. Such an answer may apply in this case, because four of these proteins that have been identified by genetic sequencing turn out to be none other than cell-adhesion molecules of the immunoglobulin type, first discovered by the research team of Gerald Edelman at Rockefeller University.

During development, the proteins apparently play a fundamental role; at least one of them is present at the very first stages, when the fertilized egg begins to divide. In the adult, however, these four proteins appear only in the nervous system, in both sensory and motor neurons. An interesting effect of these cell-adhesion proteins can be demonstrated on an isolated sensory neuron: if an antibody is added that blocks the cell-adhesion effect, the axonal filaments of the neuron start to come apart from their thick bundle and to separate out. The effect is similar to what happens when a sensory neuron is exposed to serotonin in the presence of a target, a motor neuron. This suggests that cell-adhesion molecules can indeed act as an inhibiting factor in particular circumstances. What they inhibit, apparently, is the growth and proliferation of signal-transmitting elements on the axons of sensory neurons.

By this reasoning, the effect of the cell-adhesion molecules would have to be held in abeyance at some point, to allow the sensory neurons to strengthen and increase their synaptic connections with the motor neurons. Perhaps there is even an innate tendency for some neurons, when they are near other target neurons, always to have their axons branching and proliferating, always to be seeking to form more synapses. (Indeed, during development, as discussed in Chapter 6, the brain actually forms a great many more synapses than can ever be functional during the animal's lifetime.) The inhibitory action of the cell-adhesion molecules may thus be a crucial factor that keeps neuronal growth somewhat under control, and the temporary inhibition of cell-adhesion molecules in favor of long-term memory may be a single, notable exception to this form of containment. Of course, these results come from painstakingly close study of very simple nervous systems. The degree to which such findings can be extrapolated to the brains of primates, for example, which are many times more complex and which follow different patterns of development, is a matter of lively discussion among researchers in various specialized areas of neuroscience.

One striking aspect of such a system is the ingeniously high level of what, in a person, might be called thriftiness-the degree to which the same materials or biological processes are used and reused, but in novel contexts and to different ends. The protein kinase described earlier, which is dependent on cyclic AMP, appears in many other systems of the body and has various effects; but only in the nervous system, in relation to learning, does it play a role in long-term activation. Likewise, cell-adhesion molecules-better known to researchers for their general role in development-play a rather specialized part in the adult nervous system.

Just as intriguing, from a different perspective, is the evidence for significant common ground between biological mechanisms of learning and the early development of the organism: not only the common use of cell-adhesion proteins (although in different ways) but also the fact that growth in both contexts requires a target. Even the finding that a neurotransmitter such as serotonin is not restricted to moment-by-moment signaling but can actually be a factor that initiates neuronal growth in the case of long-term memory adds to an impression of the two contexts conjoining, with neurotransmitters sometimes acting as growth factors.

The World In The Front Of The Brain

Short-term and long-term memory are not the only forms in which the brain stores information. All the time that the five senses are operating, the brain is assembling and sorting perceptions of the outside world, directing some to conscious attention and collecting others into a set of perpetually updated mental representations. Although we may seldom be aware of the full extent of these mental representations, or examine them directly, nevertheless, they hold great importance for our thought processes and our ability to carry out the simplest planned action or predictive step, even something as elementary as following a fast-moving target with our eyes. These mental representations are the data on which we base cognition-our thoughts, ideas, and abstract mental processes.

Animals, too, form complex mental representations of the world, which are shaped by their own brain structure and ecological requirements. For instance, information gathered through the sense of smell undoubtedly plays a much larger role in the mental representations of a dog than in those of a bird, which relies much more on its excellent vision (both in detail and in color) to help it recognize its kin, observe the territories of its rivals, and seek out food and mates. With such differences taken into account, the study of mental representation in animals can help scientists explain similar processes in humans, particularly if the neurobiology of the animal is also under study or is well known from earlier research.

Mental representation in the monkey, in the form of short-term or working memory, has actually been studied for more than 50 years. The earliest experiments were carried out as delayed-response tests: the monkey was shown a morsel of food being placed in one of two food wells and after a short delay had to open the correct one to claim the food as a reward. The reason for the delay was to force the monkey to rely on an internal mental representation rather than on immediate stimulation-that is, what it saw taking place at that moment. In the rhesus monkey, the area of the brain known to be important for this task is the prefrontal cortex; and in humans, too, homologous areas in the frontal region of the cortex, just behind the forehead, are sites of activity for tasks that test working memory.

Present-day research of this kind with monkeys uses a computer monitor. In such experiments, the animal directs its gaze to the center of the screen. While it keeps its attention fixed on the central spot, a visual target (a light) flashes briefly (for half a second) somewhere else on the screen. The monkey's task (which requires some months of training) is to keep its eyes fixed on the central spot as long as it is lit, and then, when the central spot has been switched off, to move its eyes to the place where the visual target had flashed some seconds before. Clearly, the test calls for working memory: the chances of turning one's eyes to the correct site by a lucky guess are slight, and since the visual target can appear anywhere at all on the screen, in any sequence-not simply location A alternating with location B-there is no possible way to ''prepare" the correct response beforehand. A monkey that is practiced in this task can perform with a high degree of accuracy; but when a portion of its principal sulcus is removed by surgery, an animal that was previously proficient performs with no more than 50 percent accuracy.

Given this sharp drop in performance, what is the nature of the deficit in the monkey's brain after surgery? Patricia Goldman-Rakic, who directs such investigations at Yale University Medical School, explains that it can be considered a "hole" in the memory-not in vision or in the ability to move the eyes. These faculties show up unimpaired in tests in which the visual target is left on (so that the monkey simply moves its eyes to the target at the appropriate time). Only the ability to guide the response by a mental image (memory) is missing.

Another complementary way of investigating the same topic is to record electrical activity from the brain during a working memory task. The ideal record in terms of clarity and precision is one obtained from a single neuron, by means of extremely fine microelectrodes. Recordings of this kind have become possible only in the past decade or so; those from Goodman-Rack's laboratory show several very interesting things. First, the neuron under study, in the prefrontal cortex, holds to a steady level of activity when the target light appears. But it increases its activity sharply once the target light is switched off and shows sustained activity during the delay, the interval over which a memory of the target must be maintained. Finally, the neuron's activity rather abruptly returns to a baseline level when the monkey begins its response-that is, when it moves its eyes to the site where the target had been. The neuron thus shows a high level of activity only during the time required to keep the correct spot "in mind" until the moment arrives to respond actively.

A second point of interest from these recordings is that the neurons of this region in the prefrontal cortex each tend to remember one precise location on the screen-and no others. For example, one neuron would respond accurately for targets at a 270-degree rotation from the center but would remain unresponsive to all other locations; another neuron would respond only to targets at a 90-degree rotation. In an analogy with the visual system, the neurons form a "memory field" in much the same way that nerve cells of the occipital lobe form a visual field. The memory field even shows the same cross-brain pattern that is traced by many signals: neurons oriented to the memory of stimuli that appeared in the right visual field predominate in the left hemisphere, and those oriented to the memory of stimuli presented in the left visual field predominate in the right hemisphere.

In Goodman-Rack's words, memory is an added-on feature of the representation system for visual space. Bearing out this interpretation are recordings from trials during which monkeys that were usually accurate made a mistake in their response, moving their eyes to the wrong place. The electrical data show that the particular neurons for that location were not highly active during the delay period, and so they failed to sustain the mental representation.

According to a current view, these neurons are organized in modules rather like the ocular dominance columns of the visual system. Several lines of research have established that the principal sulcus receives a great deal of its information about the outside world from the parietal cortex, which specializes in visual spatial information (as discussed in Chapter 7). The nerve tracts that project from the parietal lobe do in fact form a pattern of columns in the prefrontal cortex that alternates with columns for incoming signals from other regions. As in the visual system, each column is about half a millimeter wide.

These mental representations in the prefrontal cortex are too limited to be directly responsible for an animal's complex behavior. Goldman-Rakic and her colleagues believe that this representational knowledge does guide behavior in collaboration with other areas-particularly the parietal cortex-and that the larger network very probably represents the neural circuitry underlying spatial cognition in monkeys. Different parts of the network, and the connections among them, must be analyzed separately before the ensemble can be well understood as a network. A broad assortment of psychological studies have shown that when people are asked to perform any cognitive task, the prefrontal cortex invariably is activated; what remains to be discerned is which particular subdivisions of the area (visual or auditory or other) are involved. Increasingly specific testing, anatomical examination, and medical imaging of animals and human subjects are the tools that can provide this kind of information.

Meanwhile, noninvasive medical imaging of humans offers opportunities for the direct simultaneous study of physiology and mental functioning. In addition to NMR and PET scans, electroencephalographic studies can be quite useful, recording electrical activity at the scalp with great temporal precision. Recent EEG studies have shown that when a subject performs cognitive or judgment tasks that require keeping something in mind over a short period, a number of areas in the prefrontal cortex are active. When, on occasion, the subject makes an error, it appears that the network as a whole was not engaged.

Neurotransmitters And The Information System

In addition to the information-processing circuits arranged in neuronal modules and in columns of incoming nerve tracts, the brain is replete with other systems of input. In the prefrontal cortex, for example, nerve fibers containing the neurotransmitter dopamine are found in especially high concentration, and researchers have wondered for some time what role dopamine might play in prefrontal circuits of information. The evidence gathered on this point over the past few years has begun to make clear the enormous extent to which dopamine shapes not only our physical functioning in the world but also our ability to process new information, to associate ideas effectively, and even to maintain a sense of well-being in balance with realistic perceptions.

In the human prefrontal cortex, the nerve fibers containing dopamine are not scattered evenly throughout the six cerebral cell layers but are concentrated in the outermost layers and the deep layers-that is, in layers 1, 5, and 6-and are less densely distributed in the middle layers. The cell bodies of these neurons are located relatively far away in the ventral tegmental area, a portion of the brainstem; they preferentially project their fibers to the frontal and prefrontal cortex. In addition, researchers have identified at least two distinct kinds of receptor sites for dopamine, and each has its own pattern in the layers of the cortex. The preponderance of the D-1 receptor fairly matches that of the dopamine-containing fibers: very high in the outermost layers and also considerable in the deep layers. The D-2 receptor, by contrast, shows a lower concentration throughout, with just a mild peak in layer 5.

In a test to see whether interference with the D-1 receptors would have any effect on cognitive function, Goldman-Rakic's research team injected a compound that blocks the D-1 receptor sites in the prefrontal cortex of monkeys trained in the delayed-response test described earlier. About 20 minutes after the injection, the animals showed an impairment of working memory, moving their eyes to the wrong location when the trial included a delay; but they responded correctly in a "sensory-guided" version of the task, in which the target light was left on as a guide. The D-1 receptors thus appear to be implicated in the efficiency of working memory.

A chemical compound developed for use in research that selectively stains neurons in the cerebral cortex bearing D-1 receptor sites has provided the Yale research team with an interesting lead. These neurons have been identified as pyramidal cells, the large principal cells that are the main element of cerebral cortex layer 6. The axons of these cells carry signals to another region-in this case, the thalamus (which plays an important role in the control of movement and forms part of the limbic system).

It appears from electron-microscopy studies that the dopamine receptors on these cells may modulate excitatory synapses, possibly from other pyramidal cells in the same or another region. Therefore, since dopamine acts directly on the output neurons of the prefrontal cortex-which are involved in processing, sorting, and assembling information about the outside world-the dopamine circuits can be considered a physical pathway by which this neurotransmitter can influence cognitive function. With each neuron bearing millions of spines on which dopamine synapses may act, a mechanism of this kind can have a pervasive effect, and even a slight deficiency or excess of dopamine could powerfully alter the ability of many neurons to integrate information from other regions of the brain. Goldman-Rakic and her colleagues are looking closely at the identified dopamine synapses to understand more precisely the mechanism by which dopamine may affect cognition.

The prefrontal cortex, with its importance for cognition, shows a form of dysfunction when tested in patients suffering from schizophrenia. (An often disabling mental illness, schizophrenia interferes with the capacity for logical thought and greatly disturbs the emotions and social behavior; see Chapter 4 for a discussion of current theories about the importance of dopamine levels in schizophrenia.) In experiments calling for cognitive tasks, which normally require the participation of the prefrontal cortex, schizophrenic patients show significantly lower rates of activity in this region of the brain. This does not mean that a disorder as complex and varied in form as schizophrenia can be explained as a simple failure of one part of the brain-particularly since the prefrontal cortex is known to be so richly interconnected with many other regions. But the findings that indicate a less active prefrontal cortex, which have been replicated in numerous studies, fit in well with other evidence suggesting that some dysfunction in a network of areas, including the prefrontal cortex, is implicated in schizophrenia.

Studies are under way to probe the state of working memory in schizophrenic patients as a way of learning more about the normal and impaired functioning of the prefrontal cortex. Meanwhile, rhesus monkeys treated in such a way as to mimic some of the deficits characteristic of schizophrenia are also being tested for working memory, thereby allowing more direct study of the neurobiology involved. One of the behavioral deficits that has been experimentally produced in monkeys is the inability to track a fast-moving target with the eyes. The deficit is not based in the visual or motor system; this much is clear, because the monkeys remain able to track targets moving more slowly. Instead, the problem seems to be cognitive, an inability to predict where the target will be in the next fraction of a second. This predictive aspect of eye movements, which falters in schizophrenic patients and in the experimentally treated animals, may well draw on the type of mental representations that the prefrontal cortex is largely occupied in assembling. The research being conducted in animals and humans is mutually helpful, offering the prospect over the next decade of significant advances in a neuroscientific account of the workings of the prefrontal cortex-including a cellular explanation of this area's memory functions. A view shared currently by Goldman-Rakic and many colleagues is that the main function of this greatly enlarged part of the brain, so recently evolved in the primate line, is to guide behavior by means of mental representations of stimuli, rather than by the stimuli themselves. Over the course of primate evolution, the advantages of this mode of mental functioning would have been considerable, greatly expanding the animal's options for varied and complex behavior.

What Kind Of Computer Is This?

The types of mental representation discussed above, such as the continuous monitoring of the spatial surround by the parietal lobes, illustrate a vital point that is often overlooked when comparisons are made between the human brain and the computer. The fact is that the human brain-or the brain of many other animals-is solving quite difficult computational problems at every moment, just in seeing, recognizing a voice, or moving in a coordinated fashion on four limbs, or two limbs, or two wings. Most of these problems are so complex that they have yet to be formulated in explicit terms by computer scientists, which is why machines that can perceive and move and communicate as animals do-and perform all these functions at once-are still largely the stuff of science fiction.

If computers are not really brains, what does it mean to call the brain a kind of computer? Terrence J. Sejnowski, whose work at the Salk Institute for Biological Studies in San Diego focuses on computer models of cognition and brain structure, answers this question by pointing to a simple device designed to do one thing optimally, and one thing only: play tic-tac-toe. This "computer," built from electronic Tinkertoys at MIT's Artificial Intelligence Laboratory, is programmed with every possible position in the game. (These have been reduced, through mathematical operations that apply the principle of symmetry, to a subset of about 48.) The positions, each with its one optimal response, are encoded as the computer's memory. When presented with a particular position, the computer matches it to one in its subset and produces the correct response. By contrast, a digital computer would meet the challenge with a set of programmed instructions that it would run through recursively at each move to arrive at the optimal response.

The MIT device does not carry out a string of calculations or algorithms, the kind of task we generally think of a computer performing; instead, what it offers is essentially a "look-up table," with the correct answer precomputed and readily available. To obtain swift access to that answer, however, one must present a problem that exactly matches one of the problems originally encoded in the computer's memory. Beyond that pre-encoded set, the computer cannot provide any correct answer-or even a partial answer-unlike a digital computer, which can be reprogrammed for new problems because of its more general mode of operation. Still, within the realm of its pre-encoded problems and responses, the "look-up table" is extremely fast and effective.

This kind of device, however, requires a great deal of memory, since every significant aspect of each pre-encoded problem must be specified if the match is to be accurate. For the game of tic-tac-toe this is manageable; for chess, with its 10 40 possible game positions, or for real-life contexts in which the rules are less clear, it is impossible, at least at present. As a practical device, the look-up table is strictly limited. However, the principle of precomputing certain responses and being able to retrieve them with minimal additional effort appears to Sejnowski and others in his field as a likely clue to some of the workings of the brain. True, the abundant memory required by a look-up table was extremely expensive in the first computers and still poses a practical challenge today. But if the amount of memory were tremendously expanded, it would be possible to store many more solutions-in other words, to address many more and different kinds of problems.

It is hardly a revelation at this point that the human brain exhibits just such a tremendous capacity to store information. With somewhere between a hundred billion and a trillion neurons, the human brain already looks fairly impressive-but what really expands its storage capacity far beyond anything we can yet envision on an engineer's drawing board is the brain's proliferation of synapses. Each neuron contains several thousand points at which signals can be transmitted. Even if the brain were to store information at the low average rate of one bit per synapse (in terms comparable to a digital code, the synapse would be either active or inactive), the structure as a whole could still build up vast stores of memory, on the order of 10 14 bits. Meanwhile, today's most advanced supercomputers command a memory of about 10 9 bits. The human brain, to use Sejnowski's phrase, is memory-rich by comparison.

Of course, organization is crucial to managing such a vast resource, and the brain exhibits this feature at several levels, as discussed throughout this book. Research conducted on the simpler nervous system of invertebrates, as well as on nonhuman primates, other vertebrates, and humans, has indicated how learning brings about structural changes in nerve cells and how the neurons in turn form regions, which take part in networks. The networks are organized into distributed systems, which collaborate with other systems, both sensory and associative, to produce the total working effect.

Memory itself is organized so as to take advantage of these many levels of information: it appears to be arranged along associative paths, by the principle of contiguity. That is, the brain associates bits of information in such a way that we can recall items either on their own or by being "reminded" of them by a cue. The name of an acquaintance may come to mind when needed, or we may search for it under one heading or another: the name sounded like that of another friend, or the person looked like a former co-worker, or the meeting took place at the lunch following a difficult business negotiation. Considering the brain in purely physical terms, researchers have suggested that another form of contiguity may apply as well, that is, the simple proximity that builds up into maps. It may be that neurons close enough to one another to be activated together keep some trace of that contiguity as part of their bit of information.

Just what the memory-forming mechanisms might be, at a physiological level, has long puzzled psychologists as well as neurobiologists. Evidence of several kinds is gathering, however, in support of a model first suggested in 1949 by Donald Hebb, that a memory forms as a result of at least two kinds of activity taking place at a synapse simultaneously. The activities would have to include both the preand postsynaptic elements, the neuron transmitting the signal and the one receiving it. Hebb reasoned that the strength of the signal received in the postsynaptic cell would depend on the interaction of many details-the amount of transmitter released, the presence or absence of neuromodulators that affect the postsynaptic cell's excitability, the number of receptor sites on the receiving cell, and other such variables. Whatever the specifics, the underlying principle would be that information is stored as a result of two or more biochemical factors coming together in time, at the same instant, and in space, at the same synapse.

Physical evidence that indirectly supports this model has come recently from Eric Kandel's work with Aplysia. Hebb postulated two active elements (the pre- and postsynaptic terminals), but the nervous system in the marine snail appears to include a third element, the facilitating neuron that enhances the excitability of the sensory neuron. The Hebbian principle still applies, however, to the extent that the variables have to meet in time and space at a synapse.

In mammals, an example that conforms even better to the Hebbian model is found in part of the hippocampus of rats. The particular area, designated CA-3, contains about half a million neurons with recurrent connections-in other words, many of their axons lead back into the same population of neurons. Some axons also lead into the adjacent area CA-1. At the synapses in this area, both among CA-3 cells and between CA-3 and CA-1 cells, the neurotransmitter glutamate is released. It binds to two types of receptors: at one type of receptor site the glutamate slightly lowers the excitability threshold of the neuron, but at the other the binding of glutamate does not in itself affect the cell. Another simultaneous event is required: depolarization of the receiving cell, perhaps by other synapses. When this occurs together with the binding of glutamate, the cell membrane becomes momentarily permeable to ions-particularly calcium ions, which are important for bringing about persistent changes in the structure of the cell.

This receptor system illustrates the principle of contiguity outlined by Hebb: the binding of glutamate to a particular kind of receptor site and the depolarization of the postsynaptic cell must occur simultaneously, or at least within the same 20 to 50 thousandths of a second, for calcium ions to enter the cell and induce structural changes.

Assembling A Brain In The Laboratory

Hebbian synapses have also been demonstrated in another kind of laboratory, where computer scientists and engineers have built them into a computer chip. The device is a simple one, with only 16 synapses, but it performs Hebbian learning quite efficiently, at the rate of a million times per second. Newer chips have already been developed to represent more realistic neurons, with many thousands of synapses; and technology to represent the connections between such neurons will make the assembly of something more nearly resembling a working brain a little easier to envision. Such a device will have to combine analog signals, like those propagated within neurons, and digital signals, the off or on impulses transmitted from one neuron to another. It will not be simply a larger, or even an unbelievably faster, version of today's familiar computer.

An artificial brain of this kind could be invaluable for further research along two main lines. For one, it could be set to work on some of the more difficult problems in an emerging field that might be called "artificial perception": problems of computer vision and of speech recognition that can be delineated by current devices but that cannot be resolved by them in a practical way. For a second main line of research, this kind of artificial brain can offer an advanced testing ground for neuroscientists' ideas about how the brain functions. Theoretical models of memory, in particular, cannot be tested adequately on a digital computer simulation of a few hundred model neurons, because the living brain works on such an enormously larger scale. But a computerized circuit of several million model neurons, with information circulating in real time, could yield a whole new order of information about such circuits in the living animal.

The field of artificial perception already boasts chips developed at the California Institute of Technology that are capable of much of the sensory processing performed just outside the brain by the retina, for example, and by the cochlea, the spiral passage of the inner ear whose hair cells respond to vibrations by sending impulses to the auditory nerve. Now in development as well are chips to simulate some of the functions of the visual cortex; others, with some of the memory-storing capacity of the hippocampus, are being scaled up, closer to the dimensions of a living system.

But more time and knowledge are needed to produce a device that can successfully mimic the information processing of the five senses and of short-term and long-term memory, and that can, moreover, integrate these systems into a unit that functions as a whole with respect to the outside world. This is not to say that progress has not occurred: early computers of the 1950s carried out only a few thousand instructions per second (a speed matched by today's pocket calculators), whereas the fastest of the supercomputers in use today can perform billions of operations per second. Still, this rate of processing, at 10 9 or so operations per second, is far from that of the human brain, in which an estimated 10 14 synapses are each active about 10 times per second-giving a total of 10 15 operations per second.

An interesting constraint that confronts computer designers who work with the current top speeds is the simple, unchanging limitation posed by the speed of light. Signals simply cannot be transmitted faster than about 1 foot per billionth of a second (10⁻⁹, the speed of light); to achieve the effect of speeds higher than this, the computer must be reduced in size to less than a cubic foot. This reduction is made possible by duplicating the central processor many times, even thousands of times, within the same computer, so that signals have less distance to travel. Even so, extrapolating from the recent rate of increase and from today's highest known speeds of computer processing, Terrence Sejnowski estimates that an artificial device approximating the human brain cannot be expected before at least the year 2015.

This prediction should not be considered discouraging-far from it. For such a project to be within sight at all is the clearest possible sign of the progress of neuroscience, gaining impetus as it does from an increasing number of fields that are related in some way to its investigations. Now not only the biological sciences, medicine, biochemistry, pharmacology, and psychology have an interest in improving our understanding of the brain's functioning; the computer sciences, physics, and mathematics also contribute to such models and stand to gain much from their continued exploration and testing. And along the way toward the assembly of a fully functioning artificial brain, it should become increasingly possible to construct devices that satisfactorily replicate some of the principles at work in the human brain. Although the devices probably would not resemble a brain in their material form any more than an airplane resembles a bird, they will be successful if they can show some of the brain's operating principles adapted to their own form, just as an airplane carries out, in mechanical translation, some of the aerodynamic principles of natural flight.

The Benefits Of An Artificial Brain

Of course, the brain cannot ever be completely characterized in terms of a computer because in addition to all its computing faculties it possesses the properties of a biological organ in a living system. But, points out Gerald Edelman of the Neurosciences Institute at Rockefeller University, computers can indeed do something that, until recently, only a brain could do: they can carry out logical functions. Today, a computer can address any challenge or problem that can be described in a logical formula. This still leaves unexplored vast areas of human experience, such as perception; but as described earlier in this chapter, computer and mathematical modeling on one side, and more detailed neurobiological examination on the other side, are making inroads in this area too.

Edelman and his colleagues have used an approach they call synthetic neural modeling to build an automaton that is able to explore its environment by simulated vision and touch; moreover, it can categorize objects on the basis of its perceptions, and its responses draw on previous experiences with similar objects. Darwin III (the third generation of its kind) is a robot whose nervous system is built of about 50,000 cells of different types. The signals transmitted at its approximately 640,000 synaptic junctions enable Darwin III to control the functioning of its one eye and its multijointed arm. In analogy with the way living brains enter the world, Darwin III has no specific information built into its systems about the objects it may encounter in its environment. The nervous system is pre-encoded only to the extent that the devices for perception are made to detect certain features, such as light or movement or rough texture.

An important principle of Darwin III's nervous system is that the strength of the synaptic connections can increase selectively with greater activity when that activity leads to an adaptive end. What is ''adaptive" for Darwin III is defined by arbitrary values built into its programming. For example, the built-in principle that light is "better" than no light serves to direct and refine the system's eye movements toward a target. Just as in living neurons, the enhanced connection provides a stronger response the next time that particular neural pathway is active.

This selective strengthening of connections is reminiscent of the competition among synapses in the developing brain (as discussed in Chapter 6). Together with the ability to categorize, it means that the system can produce behaviors that we commonly call "recognition," for instance, or "association." At present, Darwin III can turn its head to track a moving object with its eye; it can extend its arm to trace the contours of an object; and, alternatively, if the stimulus is noxious, it can swat the object away. In all these responses the system shows increasing accuracy with practice, as the relevant synapses are strengthened. Eventually, such a system should be able to teach itself to apply both visual and motor abilities to a complex task-for instance, distinguishing a particular object or kind of object, and picking it out with the arm from among many others.

Although Darwin III cannot represent the nervous system of living animals in a highly detailed way, its synapses and circuits provide a much-needed testing ground for ideas about what takes place inside the real thing that makes those 3 pounds of semisoft tissue the most complex information-processing system ever known. Perhaps computers can never be brains in the full sense of serving as the nervous center of a biological system, but they can be designed with increasing success to carry out some of the functions that are routinely managed by a living brain. Gerald Edelman, like Terrence Sejnowski, believes that the prospects for building more complex "perception machines" are good-and the benefits in both intellectual and economic terms will be enormous. Most important of all would be the expanded opportunities for an understanding of higher brain functions-those that make us human-to be gained by using the computer not so much as a model of the brain, but as a tool for exploring it.

Acknowledgments

Chapter 8 is based on presentations by Gerald Edelman, Patricia Goldman-Rakic, Eric Kandel, and Terrence Sejnowski.

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The brain regulates an array of functions necessary to survival: the action of our five senses, the continuous monitoring of the spatial surround, contraction and relaxation of the digestive muscles, the rhythms of breathing and a regular heartbeat.

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The Neuroscience Behind the Emotional Brain and the Thinking Brain

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The Neuroscience Behind the Emotional Brain and the Thinking Brain

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The article explains the difference between the emotional brain and the thinking brain. The emotional brain controls our automatic reactions, especially when we feel scared or stressed, helping us to survive, but it can also completely take over our thoughts and make it hard to think clearly. The thinking brain, on the other hand, helps us reason, reflect, and make thoughtful decisions. When we’re calm, these two parts work together well. But during stress or trauma, the emotional brain can block the thinking brain, making it hard to learn or act wisely. The article suggests that using mindfulness and self-awareness can help shift control back to the thinking brain so we can respond more calmly and thoughtfully.

Relevance:

The article explains how a child's brain functions differently depending on whether they are in a thinking state or a survival state. When a child feels unsafe, stressed, or overwhelmed, their emotional brain takes over, triggering automatic reactions like outbursts or withdrawal. In this state, the thinking brain, which is responsible for learning, reasoning, and self-control, is essentially offline. For educators, understanding this is crucial because it means that children cannot access higher-level thinking or learn effectively until they feel emotionally and physically safe. By recognizing the signs of emotional brain dominance and responding with empathy, regulation strategies, and support, educators can help students return to a calm state where meaningful learning and growth can happen.

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Can you talk about the neuroscience behind the emotional brain and the thinking brain? originally appeared on Answer by Karena Kilcoyne, who is a former criminal defense attorney, turned wellness expert and author of Rise Above The Story: Free Yourself from Past Trauma and Create the Life You Want, on Quora : the place to gain and share knowledge, empowering people to learn from others and better understand the world.
Learning the science of what your brain does in the presence of trauma was a powerful part of my healing journey. The brain is so complex-so I keep it really simple in my book Rise Above the Story because I want people to understand the basics of what their brain does when it experiences trauma and how it protects them. First and foremost, the brain prioritizes survival. Not love, not connection, not success. Survival. That's the default setting.
This question originally appeared on - the place to gain and share knowledge, empowering people to learn from others and better understand the world.
I want everyone to lean into this with me. In my distillation of the science, there are two parts to the brain--the emotional brain and the thinking brain.

The "emotional brain" is where the reptilian and limbic parts reside on autopilot. There's no real thinking going on here. It's all automatic (think breathing, heartbeat, body temperature). It's all about survival in this part of the brain. When we we're in danger or experience trauma, our emotional brain shifts into survival mode and initiates the fight or flight response. Our body is then flooded with cortisol, adrenaline, and cytokines.

Then there's what I call the "thinking brain." This is the cortex, frontal cortex, and prefrontal cortex This is where we house thinking and reasoning. This is where our conscious mind and self-awareness exist. This is where we find compassion and empathy.

In normal brain formation, these two parts of the brain are integrated and they work together to process information. But here's where things can go awry. When we're exposed to trauma or ongoing trauma and don't process the emotions around it, our emotional brain sets out on a course to keep us "safe." It doesn't want us to get hurt again, so it creates fear loops in our mind. It doesn't send information to the thinking brain. Instead, it goes ROGUE. It floods us with fear and limitation. We don't trust. We're skeptical. We live a small life. We don't take risks. We think we're worthless and that no one could ever love us.

It takes mindfulness and self-awareness to shift out of emotional brain subconscious storytelling and into thinking brain conscious processing. That's where we need to get if we want to heal. In this space of conscious, self-awareness we will find compassion and empathy for ourselves, which will give way to unconditional self-love.

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The Neuroscience Behind The Emotional Brain And The Thinking Brain

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Can you talk about the neuroscience behind the emotional brain and the thinking brain? Answer by Karena Kilcoyne, Author

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Survival Mode: What is it and What to do About it

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Survival Mode: What is it and What to do About it

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The article defines survival mode as a prolonged state in which the body’s stress systems become dysregulated, meaning one is overactive relative to the other. When someone is in survival mode, they may experience persistent stress, difficulty making decisions, memory problems, trouble relaxing or sleeping, mood swings, dissociation, low motivation, and erratic eating or self-care habits. The article recommends several steps to emerge from "survival mode," including acknowledging the state, practicing self‑compassion, engaging in physical and mental self‑care, building structure and small wins into daily life, reducing stress triggers, reaching out for social support, and, if needed, working with a mental health professional.

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The article explains how chronic stress can keep both adults and children stuck in survival mode, where the brain focuses on immediate safety rather than learning, reflection, or decision-making. In this state, the thinking brain, which is responsible for focus, reasoning, and emotional regulation, is largely shut down, and behavior is driven by automatic reactions like fear, withdrawal, or aggression. For child educators, recognizing the signs of survival mode is essential, as students in this state are not being "difficult"; they are dysregulated and unable to access their full cognitive abilities. Understanding this helps educators respond with patience, structure, and support rather than punishment, creating classroom environments that promote safety, connection, and a return to the thinking brain, where meaningful learning can happen.

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Survival Mode: What Is It And What To Do About it

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Survival mode arises as a result of great stress and it’s all too common in modern-day life. Here, we explain what it is and what to do about survival mode.

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Understanding Trauma: Learning Brain vs. Survival Brain

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Understanding Trauma: Learning Brain vs. Survival Brain

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In the video "Understanding Trauma: Learning Brain vs Survival Brain," Jacob Ham explains how trauma affects the brain's ability to learn and process information. He contrasts the learning brain, which is open, curious, and receptive to new information, with the survival brain, which is focused on immediate threats and often shuts down higher cognitive functions. Ham emphasizes that when individuals are in survival mode, due to trauma or stress, their learning capacity diminishes, making it challenging to engage in educational or developmental activities. He advocates for creating safe, supportive environments that help individuals feel secure, thereby enabling them to shift from survival mode back to a learning state, where they can process information and grow effectively.

Relevance:

The video explains how trauma can trap children in a survival brain state, where their focus is on immediate safety rather than learning or thinking. When the survival brain is activated, the thinking brain, responsible for reasoning, problem-solving, and self-regulation, is less accessible, making it difficult for children to absorb new information or manage emotions. For child educators, understanding this distinction is crucial because it highlights the need to create safe, predictable, and supportive environments that help children feel secure enough to shift out of survival mode and engage their thinking brain. This awareness encourages trauma-informed teaching practices that prioritize emotional safety as a foundation for academic success and healthy development.

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Understanding Trauma: Learning Brain vs Survival Brain

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Learning Brain vs. Survival Brain: What's the Difference?

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Learning Brain vs. Survival Brain: What's the Difference?

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The article contrasts two brain modes being the learning brain, which is open, curious, flexible, and able to absorb new information, and the survival brain, which is triggered by stress, threat, or trauma and becomes defensive, closed, and focused on safety. In learning mode, neural pathways are more receptive to growth and change, while in survival mode, the brain prioritizes defense over growth, making learning and decision‑making harder. The article emphasizes that chronic stress or past trauma can push someone into prolonged survival mode, reducing the capacity to shift back into learning mode. To help the brain return to learning mode, the article suggests practices like relaxation, good rest, reducing stressors, and engaging in pleasurable, enriching activities.

Relevance:

The article shows how the brain functions differently depending on whether it is in a thinking state or a survival state. When a child feels safe, calm, and supported, their brain is in learning mode and is open to new ideas, able to focus, and ready to grow. But when a child is stressed, overwhelmed, or threatened, their brain shifts into survival mode, which blocks access to higher thinking skills and makes learning nearly impossible. For child educators, understanding this is vital because it highlights that behavior often reflects a brain state, not a child’s character or willingness to learn. By creating safe, supportive, and predictable environments, educators can help shift children out of survival mode and into learning mode, making emotional regulation a foundation, not a barrier, for academic and social development.

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If you've ever noticed that the more stressed you get, the more difficult everyday tasks become, then you've experienced the difference between learning brain and survival brain. On the whole, the subject is a bit more complex than how easily you can or can't tie your shoes or remember where your keys are, but those little things are more based on our state of being than many people realize.

At any given moment while we're awake, our brain is existing in learning mode or survival mode. For optimum health, wellness, and happiness, learning mode is the goal. Ahead, we'll examine what the two brain states involve, what causes survival brain, and the steps you can take to move from survival back to learning.

What Is Learning Brain?

A learning brain is one that is able to take in new information. It also means that you're able to perform daily tasks that you're accustomed to without much issue, and that you likely don't find those tasks stressful or frustrating.

If you're currently experiencing a healthy life without anything major going on, such as mental health challenges or trauma, chances are you're in learning brain mode. This means that the idea of something new might be exciting for you, and that you probably feel open to new ideas. In short, a learning brain is one that is capable of, and often eager for, learning.

What Is Survival Brain?

Survival brain is what happens when you feel mentally and/or emotionally overwhelmed and you're unable to process new ideas. Additionally, you may find basic everyday tasks that otherwise would feel easy for you to be more complicated or difficult.

Let's look at the various causes of survival brain.

Causes of Survival Brain

Anything that overwhelms you can be a cause for entering a state of survival brain. However, there are some common occurrences that are most likely to lead to shifting into survival brain mode. Let's look at what those are.

Chronic Stress

Our brains are built and designed to handle stress, but they can hit a point where stress has gone on for too long to enable them to function fully. There can be lasting neurological problems caused by excessive stress. One study notes that stress can cause an imbalance in the parts of your brain controlling cognition, decision making, anxiety and mood, which can affect those behaviors and behavioral states.

This means that stress reduces your ability to do simple things like make decisions or stay in a moderate mood. That's not your fault, but rather, a biological function. So it makes good sense that you also can't learn new things when in a stressed state for a long time.

When you experience trauma, just surviving from one moment to the next can feel like an impossible job. Just like chronic stress, trauma can change your brain for the worse, making you unable to do all you did prior to the event.

Your body produces cortisol, a stress hormone, in response to a traumatic occurrence, so the result on your brain from trauma is similar to that from chronic stress. One study describes it well in stating that "during a traumatic experience, the reptilian brain takes control, shifting the body into reactive mode. Shutting down all non-essential body and mind processes, the brain stem orchestrates survival mode." Trauma can also lead to PTSD, which we will discuss next.

Suffering a traumatic event is bad enough, but often the trauma isn't over just because the event has ended. Post traumatic stress disorder, a psychiatric disorder involving extreme distress and disruption of daily living that happens after exposure to a traumatic event, is common for people who have undergone trauma, and while for some it resolves quickly, for others it can take a long time. Think of PTSD as a different version of chronic stress, one in which the stress is centered around a specific event.

How to Shift From Survival Brain to Learning Brain

Now that you understand what causes survival brain, you are probably interested in discovering how to make the shift back to learning brain so that you can enjoy life more and be receptive to new ideas. Thankfully, it can be an easier process that you might think! There are many ways to move your brain into learning mode. Let's review them.

Soothe Your Nervous System

Anything that relaxes you can help you be less stressed, and being less stressed can help you move out of survival brain mode. When you have chronic stress or PTSD, your amygdala is on overdrive.

Soothing your nervous system helps to stop that, which in turn will make you feel better. Yoga and meditation can be useful to calm one's nervous system, as can exercise. Any bodily movement that feels good to you, even simple stretching exercises, are useful.

Address Sources of Stress

There's no way to recover from the effects of chronic stress if you are still experiencing them. You can't get out of survival mode when your brain feels that survival is iffy and needs to be focused on.

It's important to address your sources of stress and assess if there are any that you can remove from your life. This may take time. For example, if your source of chronic stress is a job you don't enjoy or a partner who isn't kind to you, you can't necessarily remove either from your life without a plan to move forward with.

Address Trauma and PTSD

If you have recently experienced trauma, or if you have PTSD, it's vital to make sure you get the help you need to get past the traumatic event. If you don't, you can get stuck for months or years in survival mode-but by addressing the trauma, you'll become able to move forward from it.

When you do, you'll see that you become open again to new experiences and ideas. There are many ways to address trauma and PTSD, from speaking about it with friends and family to professional help. Therapy, either individual or group, can be highly beneficial in resolving PTSD.

It may sound mundane, but rest is incredibly important for us to be functional as people. Moving from learning brain to survival brain is a sign from your body that rest is needed, and it can definitely help you move back into learning brain mode.

Your nervous system will have time to calm down, your brain will have time to recharge and process the information of recent events, and your overall spirit can feel renewed just by you taking some time off. Rest can involve you doing anything calm and peaceful, from reading a book or watching tv to napping or taking a bath.

Pursue Joyful Activities

Giving your body a boost of happy chemicals like dopamine is an excellent way to calm your system and your brain. Anything that feels joyful for you and produces feelings you enjoy counts for this one!

Doing one of those activities with one or more people you enjoy will only enhance the effects.

A Word From Verywell

At much as you might desire the shift from survival brain to learning brain, know that this process can take some time and, at times, additional professional assistance. Don't be afraid to seek help from a professional if you are having difficulties or feel like things are too overwhelming for you right now.

Adopting multiple helpful practices may speed up the process, but be patient with yourself and remember that healing is never instantaneous. It's a process, and our brains can recover in amazing ways when we give them time and self-care.

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Learning Brain vs. Survival Brain: What's the Difference?

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"Learning brain" is your brain in its calm, natural state, where you are open to new information; "survival brain" is what happens when stress or trauma move you into a state of survival mode.

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This article describes how living in survival mode compresses one’s mental, emotional, and physical bandwidth to only what’s necessary to get through the moment. It points out that in this state, the thinking brain dims, and the survival brain brightens. Meaning that decision‑making, planning, learning, and emotional regulation become much harder. The article lists signs of survival mode (e.g., brain fog, irritability, fatigue, avoidance) and recommends steps like pausing, restoring basic needs, building safety, doing small achievable goals, and seeking support to help shift out of survival mode into a more balanced, thriving state.

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The article explains how being in survival mode limits access to the thinking brain, making it difficult to learn, focus, plan, or manage emotions. When the brain prioritizes immediate safety and survival, the logical and rational parts responsible for decision-making and problem-solving are suppressed. For child educators, this is critical to understand because students who appear disengaged, anxious, or reactive may not be choosing to behave that way; they may be stuck in survival mode. Recognizing the signs and supporting students through calm, structured, and emotionally safe environments can help shift them back into their thinking brains, where meaningful learning and positive behavior become possible.

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Living in survival mode feels like treading water—you’re keeping afloat but expending all your energy just to stay in place…

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A Caregiver's Guide: Supporting Children in Fight/Flight Mode

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A Caregiver's Guide: Supporting Children in Fight/Flight Mode

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The article explains how, when children become upset, their brains shift into a fight/flight mode, meaning they can’t listen or reason until they’ve calmed down. The guide emphasizes that caregivers should first recognize the triggers, examples including hunger or overstimulation. Before escalation, caregivers can intervene by acknowledging the child’s feelings, offering a break with a choice of calming strategies (deep breathing, counting, etc.), and even modeling those strategies together. During an episode, it is important for caregivers to remain calm, speak softly, guide the child to a safe, quiet space, reduce sensory overload, and help them gradually regulate. After the event, caregivers should debrief in a nonjudgmental way by discussing what happened, what coping strategies helped, and planning better responses for next time.

Relevance:

The article highlights how, when children enter fight/flight (survival) mode, their thinking brain shuts down, making it impossible for them to process instructions, regulate emotions, or engage in learning. Understanding this helps child educators recognize that challenging behaviors are often a sign that a child’s survival brain has taken over, not simply misbehavior. By identifying triggers early, responding with calm and supportive strategies, and helping children regulate their emotions, educators can guide students back into their thinking brain, where reasoning, problem-solving, and learning can occur. This knowledge encourages patience and empathy, fostering safer, more effective learning environments that prioritize emotional safety as the foundation for academic success.

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A Caregiver's Guide: Supporting Children in Fight/Flight Mode - Connect the Dots Pediatric Therapy

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Learn about different strategies to help your child when they are responding to a situation in flight or flight mode.

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The article from Brown University Health introduces Conscious Discipline as a social-emotional learning program developed by Dr. Becky Bailey. It emphasizes that parents, caregivers, and educators must first learn to manage their own emotions before they can effectively teach children to do the same. The program is grounded in brain research, focusing on moving from unconscious, reactive states to more aware, solution-driven responses. By modeling emotional regulation and understanding, adults can help children recognize and manage their own feelings, leading to improved behavior and resilience. Ultimately, Conscious Discipline aims to foster connection and safety, creating an environment where children feel secure enough to learn and grow.

Relevance:

The article explains that Conscious Discipline is based on the idea that adults, and by extension children, need to move from survival-driven, reactive states into calm, thoughtful states where the thinking brain can function effectively. For child educators, understanding this helps them recognize that children’s challenging behaviors often come from being stuck in survival mode, where emotions run high and reasoning is shut down. By first managing their own emotional responses and creating safe, connected environments, educators model and teach children how to regulate their feelings, shift out of survival mode, and access their thinking brain. This foundation is crucial for supporting social-emotional growth, effective learning, and positive behavior in the classroom.

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What is Conscious Discipline? | Brown University Health

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Parents, caregivers and teachers serve as role models for children. This is especially true when it comes to managing emotions and understanding feelings. But…

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Wiring the Brain for Success: Dr. Becky Bailey TEDx

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Wiring the Brain for Success: Dr. Becky Bailey TEDx

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In her TEDx talk, Wiring the Brain for Success, Dr. Becky Bailey, creator of Conscious Discipline, delves into the neuroscience of behavior, emphasizing that the brain's development is influenced by the environments and relationships children experience. She explains that when adults model emotional regulation and create safe, connected environments, they can help children develop the neural pathways necessary for self-regulation and success. Dr. Bailey advocates for shifting from traditional discipline methods to approaches that foster connection and understanding, thereby supporting the development of the thinking brain over the survival brain. This approach not only enhances children's ability to learn and thrive but also promotes resilience and emotional intelligence. Her insights underscore the importance of adults' roles in shaping children's brain development through conscious, compassionate interactions.

Relevance:

Dr. Becky Bailey highlights how children's brain development, especially the growth of the thinking brain responsible for self-regulation and problem-solving, is deeply shaped by the emotional safety and connections they experience. When adults create supportive, calm environments and model emotional regulation, they help children move out of the reactive survival brain state and into a state where learning and resilience can flourish. For child educators, understanding this enables the ability to build strong relationships and foster emotional safety as foundational to effective teaching. It shifts the focus from punishment to connection, enabling educators to better support children’s cognitive and emotional growth, ultimately helping them succeed both academically and socially.

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Dr. Becky Bailey at TEDx - Wiring the Brain for Success

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The article explains how neglect is a form of child abuse characterized by a persistent failure to meet a child’s basic needs, such as food, hygiene, clothing, shelter, supervision, education, or medical care, which can place the child in danger and impair their physical and psychological development. There are four broad types of neglect: physical neglect, educational neglect, emotional neglect, and medical neglect, each reflecting different ways a child’s needs may go ignored. Signs can include poor appearance or hygiene, health and developmental problems, housing or family issues, and behavioral changes. Neglect can have lasting effects, including impaired brain development, risk‑taking behavior, difficulties forming healthy relationships, and mental health challenges.

Relevance:

The article outlines how unmet basic needs, such as food, safety, emotional care, and medical attention, can severely harm a child’s development. Neglect is not always immediately visible but can lead to long-term emotional, cognitive, and physical trauma, which often manifests as behavioral problems, learning difficulties, or emotional withdrawal. For child educators, understanding the signs and impact of neglect is critical because they are in a key position to notice early warning signs. Their awareness allows for timely intervention, support, and referrals to safeguarding services, which can significantly improve a child’s well-being and future outcomes. Moreover, trauma-informed educators can create safe, stable, and nurturing learning environments that help mitigate the effects of neglect and support the child’s recovery and resilience.

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Discover our advice on identifying and responding to child neglect. Understand signs, impacts, and ways to support or report to safeguard children.

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The article explains that, in Michigan, child abuse includes nonaccidental physical or mental harm, sexual abuse, or exploitation by a parent, guardian, or caregiver. Neglect is the failure to provide necessary care, such as food, shelter, or medical attention, or placing a child at risk by not acting on known dangers. The law also defines serious abuse or neglect as causing severe injury or risk, and it requires certain individuals to report suspected cases.

Relevance:

This information is relevant because it defines what legally constitutes neglect and abuse, which are major causes of trauma in children. Understanding these definitions helps child educators recognize when a child's well-being is at risk, even if signs are subtle. Since educators are often among the first adults outside the home to observe a child regularly, they play a vital role in early identification and reporting. Being informed allows them to take appropriate action, support the child emotionally and academically, and help prevent further harm or trauma.

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The NCBI / New Directions in Child Abuse and Neglect Research chapter describes how abuse and neglect can cause far‑reaching, multi‑dimensional harm across biological, cognitive, psychological, social, and behavioral systems. Early neglect or abuse can dysregulate stress systems, alter brain structures, and impair executive functions, learning, memory, and emotion regulation. Children affected often struggle with attachment, peer relationships, internalizing or externalizing symptoms, and academic underachievement. However, outcomes vary depending on severity, timing, chronicity, and protective factors, and interventions in childhood or later life can moderate or reverse many of these harmful effects.

Relevance:

This information is highly relevant because it shows how neglect and trauma can deeply affect a child’s brain development, emotional regulation, behavior, and ability to learn. For child educators, understanding these effects is crucial—they may see signs like difficulty concentrating, emotional outbursts, anxiety, or poor peer relationships, which are often rooted in early trauma. Recognizing these behaviors as potential responses to neglect (rather than simply "misbehavior") enables educators to respond with empathy, adjust their approach, and connect students with the necessary support. This trauma-informed perspective helps create safer, more supportive learning environments that can significantly improve outcomes for affected children.

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Since the 1993 National Research Council (NRC) report on child abuse and neglect was issued, dramatic advances have been made in understanding the causes and consequences of child abuse and neglect, including advances in the neural, genomic, behavioral, psychologic, and social sciences. These advances have begun to inform the scientific literature, offering new insights into the neural and biological processes associated with child abuse and neglect and in some cases, shedding light on the mechanisms that mediate the behavioral sequelae that characterize children who have been abused and neglected. Research also has expanded understanding of the physical and behavioral health, academic, and economic consequences of child abuse and neglect. Knowledge of sensitive periods-the idea that for those aspects of brain development that are dependent on experience, there are stages in which the normal course of development is more susceptible to disruption from experiential perturbations-also has increased exponentially. In addition, research has begun to explore differences in individual susceptibility to the adverse outcomes associated with child abuse and neglect and to uncover the factors that protect some children from the deleterious consequences explored throughout this chapter. An important message is that factors relating to the individual child and to the familial and social contexts in which the child lives, as well as the severity, chronicity, and timing of abuse and neglect experiences, all conspire to impact, to varying degrees, the neural, biological, and behavioral sequelae of abuse and neglect.

This chapter begins by exploring background topics that are important to an understanding of research on the consequences of child abuse and neglect, including an ecological framework and methodological attributes of studies in this field. Next is a review of the research surrounding specific outcomes across the neurobiological, cognitive, psychosocial, behavioral, and health domains, many of which can be seen in childhood, adolescence, and adulthood. The chapter then examines outcomes that are specific to adolescence and adulthood, reviews factors that contribute to individual differences in outcomes, and considers the economic burden of child abuse and neglect. The final section presents conclusions.

CASCADING CONSEQUENCES

Newborns are almost fully dependent upon parents to help them regulate physiology and behavior. Under optimal conditions, parents buffer young children from stress and serve as "co-regulators" of behavior and physiology ( Hertsgaard et al., 1995; Hofer, 1994, 2006). Over time, children raised by such parents gradually assume these regulatory capacities. They typically enter school well regulated behaviorally, emotionally, and physiologically; thus, being prepared for the tasks of learning to read, write, and interact with peers.

For some children, parents cannot fill these roles as buffer and co-regulator effectively. When children have caregivers who cannot buffer them from stress or who cannot serve as co-regulators, they are vulnerable to the vicissitudes of a challenging environment. Although children can cope effectively with mild or moderate stress when supported by a caregiver, conditions that exceed their capacities to cope adaptively often result in problematic short- or long-term consequences.

Studies conducted with some nonhuman primate species and rodents have shown that the young are dependent on the parent for help in regulating behavior and physiology ( Moriceau et al., 2010). Thus, young infants are dependent on parents fulfilling the functions of carrying, holding, and feeding. The period of physical immaturity and dependence lasts an extended time in humans. Even beyond the point at which young children are physically dependent, they remain psychologically dependent throughout childhood and adolescence. Thus, inadequate or abusive care can have considerable consequences in terms of children's health and social, psychological, cognitive, and brain development.

Children who have experienced abuse and neglect are therefore at increased risk for a number of problematic developmental, health, and mental health outcomes, including learning problems (e.g., problems with inattention and deficits in executive functions), problems relating to peers (e.g., peer rejection), internalizing symptoms (e.g., depression, anxiety), externalizing symptoms (e.g., oppositional defiant disorder, conduct disorder, aggression), and posttraumatic stress disorder (PTSD). As adults, these children continue to show increased risk for psychiatric disorders, substance use, serious medical illnesses, and lower economic productivity.

This chapter highlights research supporting the association between these outcomes, among others, and experiences of child abuse and neglect. The potential dramatic and pervasive consequences of child abuse and neglect underscore the need for research to illuminate the myriad pathways by which these ill effects manifest in order to guide treatment and intervention efforts. However, it is important to note at the outset that not all abused and neglected children experience problematic outcomes. As discussed in the section on individual differences later in this chapter, a body of research is devoted to uncovering the factors that distinguish children who do not experience problematic outcomes despite facing significant adversity in the form of abuse or neglect. Further, as discussed in Chapter 6, the past two decades have seen substantial growth in proven models for treatment of the consequences of child abuse and neglect, indicating that these effects are potentially reversible and that there is opportunity to intervene throughout the life course.

BACKGROUND

Several key concepts need to be considered in attempting to understand potential pathways that lead from abuse and neglect to the various consequences discussed in this chapter and the context in which those consequences manifest. First, positive and negative influences found among individual child characteristics, within the family environment, and in the child's broader social context all interact to predict outcomes related to child abuse and neglect. Second, child abuse and neglect occur in the context of a child's brain development, and their potential effects on developing brain structures can help explain the onset of certain negative outcomes. Finally, abused and neglected children often are exposed to multiple stressors in addition to experiences of abuse and neglect, and potential consequences may manifest at different points in a child's development. Therefore, the most rigorous research on this topic attempts to account for the many factors that may be confounded with abuse or neglect.

Ecological Framework

Since 1993, transactional-bioecological or ecological models have guided attempts to conceptualize the relative contributions of risk and protective factors to children's developmental outcomes, particularly in relation to child abuse and neglect ( Belsky, 1993; Cicchetti and Lynch, 1993; Cicchetti and Toth, 1998). Versions of this approach consider the development of the child in the context of the broader social environment in which he or she functions, within the context of a family; in turn, children and families are embedded in a larger social system that includes communities, neighborhoods, and cultures. The assumption underlying these models is that behavior is complex, and development is multiply determined by characteristics of the individual, parents and family, and neighborhood and/or community and their interactions.

Ontogenic development-Reflects factors within the individual that influence the achievement of competence and adaptation.

Microsystem-Defined as the "immediate context" (i.e., the family) in which the child experiences abuse or neglect, including the bidirectional influence of parent and child characteristics and other relationships (such as marriage) that may impact parent-child interactions directly or indirectly.

Exosystem-The exo- and macrosystemic levels reflect social or cultural forces that contribute to and maintain abuse or neglect. The exosystem encompasses the effects of broader societal systems (e.g., employment, neighborhoods) on parent and child functioning.

Macrosystem-Mirrors temporally driven, sociocultural ideologies (e.g., cultural views of corporal punishment), or a "larger cultural fabric," that inevitably shape functioning at all other levels. It is represented by social attitudes (such as attitudes toward violence or the value of children).

The model is based on the fact that a child's multiple ecologies influence one another, affecting the child's development. Thus, the combined influence of the individual, family, community, and larger culture affect the child's developmental outcomes. Parent, child, and environmental characteristics combine to shape the probabilistic course of the development of abused and neglected children.

At higher, more distal levels of the ecology, risk factors increase the likelihood of child maltreatment. These environmental systems also influence what takes place at more proximal ecological levels, such as when risk and protective factors determine the presence or absence of maltreatment within the family environment. Overall, concurrent risk factors at the various ecological levels (e.g., cultural sanction of violence, community violence, low socioeconomic status, loss of job, divorce, parental substance abuse, maladaptation, and/or child psychopathology) act to increase or decrease the likelihood that abuse will occur.

The manner in which children handle the challenges associated with maltreatment is seen in their own ontogenic development, which shapes their ultimate adaptation or maladaptation. Although the overall pattern is that risk factors outweigh protective factors, there are infinite permutations of these risk variables across and within each level of the ecology, providing multiple pathways to the sequelae of child abuse and neglect.

Types of Evidence

Many studies of the consequences of abuse and neglect have been conducted with methodologies ranging from prospective to retrospective designs, from observational measures to self-report, and from experimental to case-controlled designs to no-control designs. The strongest conclusions could be reached with experimental designs whereby children would be randomly assigned to different abusive or neglectful experiences; however, this is obviously neither desirable nor possible.

Nonhuman studies involving primates and other species have allowed experimental assessment of different rearing conditions that may parallel human conditions of neglect and abuse (e.g., Sanchez, 2006; Suomi, 1997). One salient human study involved random assignment of children abandoned to institutions to high-quality foster care (a randomized controlled trial of foster care as an alternative to institutional care) ( Nelson, 2007). In this prospective, longitudinal study, known as the Bucharest Early Intervention Project, 136 children abandoned at or around the time of birth and then placed in state-run institutions were extensively studied when they ranged in age from 6 to 31 months (mean age = 21 months), as was a sample of 72 never-institutionalized children who lived with their families in the greater Bucharest community. Following the baseline assessment, half of the institutionalized children were randomly assigned to a high-quality foster care program that the investigators created, financed, and maintained, and half were randomly assigned to remain in care as usual (institutional care). These children were followed extensively through age 12 (for discussion, see Fox et al., 2013; Nelson et al., 2007a, b; Zeanah et al., 2003). Although at first glance it may not be obvious why the study of children reared in institutions is relevant to a report on child abuse and neglect, institutional care, which affects as many as 8 million children around the world, can involve an extreme and specific form of neglect-broad-spectrum psychosocial deprivation. Therefore, neglectful institutional care settings can serve as a model system for understanding the effects of neglect on brain development. The neglect experienced by children in such settings should not serve as a proxy for the type of neglect experienced by noninstitutionalized children in the United States, who are more likely to experience neglect in such domains as food, shelter, clothing, or medical care rather than broad-spectrum psychosocial deprivation. Nevertheless, this study can provide important insight into the effects of neglect on behavioral and neurological development because of its randomized, controlled, and longitudinal nature.

The discussion in this chapter necessarily relies primarily (although not exclusively) on the strongest nonexperimental studies conducted. These studies involve longitudinal prospective designs, which assess child abuse and neglect objectively at the time of occurrence and assess outcomes longitudinally. A good example is the study of Widom and colleagues (1999), which followed a large cohort of abused and neglected children and a matched comparison sample from childhood into adulthood. Other examples include the studies of Johnson and colleagues (1999, 2000), Noll and colleagues (2007), and Jonson-Reidz and colleagues (2012). Retrospective designs that ask participants to recall whether abuse and neglect were experienced are more troublesome because recall of child abuse and neglect can be affected by a variety of factors and open to a number of potential biases ( Briere, 1992; Offer et al., 2000; Ross, 1989; Widom, 1988). Results of studies based on treatment samples of adults who experienced maltreatment as children may be potentially biased because not all victims of child abuse and neglect seek treatment as adults, and because people who do seek treatment may have higher rates of problems than people who do not seek treatment ( Widom et al., 2007a). When participants are asked to report on conditions such as current depression and previous history of child abuse and neglect, the added problem of shared method variance arises. On the other hand, use of official records raises the problem of underreporting ( Gilbert et al., 2009a).

The federal government has supported an effort, launched since the 1993 NRC report was issued-the National Survey of Child and Adolescent Well-Being (NSCAW)-to expand understanding of the consequences of child abuse and neglect. This study includes use of multiple data sources and record reviews, as well as interviews with children and youth who have experienced child abuse and neglect, their caretakers, and child welfare workers. Several of its findings are discussed in Chapter 5.

This chapter contains an extensive review of the more recent biologically based studies of child abuse and neglect because of the important advances that have been made in this area. To the extent possible, the discussion relies on findings from studies characterized by the greatest methodological rigor.

Finding: Risk factors that co-occur with child abuse and neglect, such as poverty, prenatal substance exposure, and parent psychopathology, can confound attempts to draw causal inferences about the specific consequences of abuse and neglect for children's functioning. These factors need to be controlled for in studies seeking to identify the specific consequences of child abuse and neglect.

NEUROBIOLOGICAL OUTCOMES

An adequate caregiver is needed to support developing brain architecture and the developing ability to regulate behavior, emotions, and physiology for young children. When children experience abuse or neglect, such development can be compromised. The effects of abuse and neglect are seen especially in brain regions that are dependent on environmental input for optimal development, and on aspects of functioning especially susceptible to environmental input. Early in development, infants are completely reliant on input from their caregivers for help in regulating arousal, neuroendocrine functioning, temperature, and other basic functions. With time and with successful experiences in co-regulation, children increasingly take over these functions themselves. Abuse and neglect represent the absence of adequate input (as in the case of neglect) or the presence of threatening input (as in the case of abuse), either of which can compromise development. The following sections present a review of evidence with respect to key neurobiological systems that are altered as a result of abuse and neglect early in life: the hypothalamic-pituitary-adrenal (HPA) axis of the stress response system; the amygdala, involved in emotion processing and emotion regulation; the hippocampus, involved in learning and memory; the corpus callosum, involved in integrating functions between hemispheres; and the prefrontal cortex, involved in higher-order cognitive functions. The discussion begins, however, with a brief overview of brain development.

Overview of Neurobiological Development

The Construction of the Brain

Brain development begins just a few weeks after conception, starting with the construction of the neural tube. This is followed by the generation of different classes of brain cells-neurons and glia. Once formed, these immature neurons begin their migratory phase (generally away from the ventricular zone, which is their point of origin) to build the cerebral cortex. Much of cell migration is completed by the end of the second trimester of pregnancy, eventually leading to the construction of the six-layered cerebral cortex. After these immature cells have migrated to their target destination, they can differentiate; that is, they develop cell bodies and processes (axons and dendrites). Once processes have been formed, synapses begin to form; synapses are the connections between neurons that allow for the transmission of signals across the synaptic cleft, which is the small space that exists between two adjacent brain cells, generally between a dendrite and an axon. The synapse permits one neuron to communicate with another, and eventually, entire circuits are built, followed by neural networks (i.e., organized units). Finally, some axons in the brain develop a coating called myelin that speeds the flow of information along the length of the axon. Sensory and motor pathways begin to myelinate during the last trimester of pregnancy, whereas association areas of the brain, particularly the prefrontal cortex, continue to myelinate through the second decade of life. Neural elements (e.g., axons) that are coated with myelin are referred to as white matter, whereas most of the rest of the brain is referred to as grey matter.

Many aspects of brain development (particularly those that occur before birth) fall under genetic control (although some are affected by experience-prenatal exposure to neurotoxins such as alcohol being but one example). After birth, however, much of brain development becomes dependent on experience. For example, although the generation of synapses-which are massively overproduced early in development-is largely under genetic control, the pruning of synapses-which occurs primarily after birth-is largely under experiential control. Thus the prefrontal cortex of the 1-year-old child has many more synapses than the adult brain, but over the next one to two decades, these synapses are pruned back to adult numbers, based largely on experience ( Nelson et al., 2011).

Neural Plasticity and Sensitive Periods

Many aspects of brain development depend on experiences occurring during particular time periods, often the first few years of life. These so-called sensitive or critical periods represent vital inflection points in the course of development, such that if specific experiences fail to occur within some narrow window of time (or the wrong experiences occur), development can go awry. This leads to the concept that plasticity "cuts both ways," meaning that if the child is exposed to good experiences, the brain benefits, but if the child is exposed to bad experiences or inadequate input, the brain may suffer ( Nelson et al., 2011). Prenatally, an example of a bad experience is exposure to neurotoxins such as alcohol or drugs of abuse. An example of a good experience is access to good nutrition, including the many micronutrients that facilitate brain development (e.g., iron, zinc). Postnatally, the topic of this report represents examples of bad experience (i.e., abuse and neglect). Conversely, examples of good experiences include providing a child with consistent, sensitive caregiving; a nurturing home in general; and adequate stimulation.

The Time Course of Development

In general, most sensory systems develop early in life; thus the ability to see and to discriminate and recognize faces and speech sounds come on line in the first months and years of life, based on appropriate experiences occurring during that time window (e.g., exposure to faces, to speech). This is not surprising given how vitally important these functions are to subsequent development (e.g., language is not learned until children can discriminate the basic units of sound, such as one consonant from another). Critical to the discussion in this chapter, however, is that the functions subserved by some other regions of the brain, most notably the prefrontal cortex-executive control, planning, cognitive flexibility, emotion regulation-have a much more protracted course of development for the simple reason that both synaptogenesis and myelination of these cortical regions do not mature until mid- to late adolescence, perhaps even a bit later. As a result, the sensitive period for prefrontal cortical functions may be far more prolonged than is the case for sensory functions, extending well into the adolescent period. One example of the differential time course of different brain regions, and perhaps their corresponding sensitive periods, is illustrated in Figure 4-1.

These concepts are important to the study of the neurobiological toll of early childhood abuse and neglect because children who experience considerable adversity early in life may be exposed to environments/experiences that the species has not come to expect (such as abusive caregivers) or worse, environments that are largely lacking in key experiences (i.e., neglect). In both cases, when the expectable environment is violated by either gross alterations in the type of care received or a complete lack of care, subsequent development can be seriously derailed.

Hypothalamic-Pituitary-Adrenocortial (HPA) Axis and Biological Regulation

Glucocorticoids also serve an important role in maintaining circadian patterns of daily activity, such as waking up, sleeping, and energy regulation ( Gunnar and Cheatham, 2003). Diurnal species, including humans, have a diurnal pattern of cortisol production that enhances the likelihood of being awake at the same time in the day. In humans, diurnal cortisol levels peak about 30 minutes after waking up, decrease sharply by mid-morning, and continue to decrease gradually until bedtime ( Gunnar and Donzella, 2002). The higher morning values of cortisol reflect greater metabolism of glucose early in the day, providing energy for the day's activities.

The HPA axis is highly sensitive to the effects of early experiences. Diurnal effects typically have been examined as wake-up values and bedtime values because those time points allow assessments of change from nearly the highest reliable waking time point (with 30 minutes post wake-up being the highest) to the lowest waking time point. Daytime values are affected by a number of factors, such as exercise, naps, and travel to work ( Larson et al., 1991; Watamura et al., 2002). The most consistent findings involve flatter, more blunted patterns of diurnal regulation among abused or neglected children relative to low-risk children ( Bernard et al., 2010; Bruce et al., 2009; Dozier et al., 2006; Fisher et al., 2007; Gunnar and Vazquez, 2001). Similar flattened diurnal rhythms have been found in institutionalized children ( Bruce et al., 2000; Carlson and Earls, 1997). Flattened diurnal cortisol patterns may reflect down-regulation of HPA axis activity following earlier hyperactivation ( Carpenter et al., 2009; Fries et al., 2005).

There is as yet no compelling empirical evidence among humans that high levels of cortisol result from abuse or neglect and persist long enough to affect brain development adversely, leaving these arguments speculative. Nonetheless, the evidence is compelling that the HPA axis is perturbed in many cases, and perturbations are associated with a range of health and mental health problems ( McEwen, 1998; Yehuda et al., 2002).

Amygdala

The amygdala performs a primary role in the formation and storage of memories associated with emotional events. The amygdala undergoes rapid development within the first several years of life and is particularly susceptible to early adversity (e.g., Chareyron et al., 2012). Relative to low-risk children, abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety, and emotional reactivity ( Ellis et al., 2004; Kaplow and Widom, 2007; Tottenham et al., 2009; van Ijzendoorn and Juffer, 2006; Zeanah et al., 2009) and deficits in emotional processing ( Dalgeish et al., 2001; Pollak et al., 2000; Vorria et al., 2006). Figure 4-2 illustrates structures in the medial temporal lobe critically involved in emotion (amygdala) and learning and memory (hippocampus).

Functional magnetic resonance imaging (fMRI) studies have shown that early adversity leads to a sensitized amygdala. Relative to comparison children, previously institutionalized children showed heightened amygdala activity in response to fearful faces compared with neutral faces ( Tottenham et al., 2011). Similarly, Maheu and colleagues (2010) found that children with a history of abuse or neglect showed greater activation of the left amygdala in response to fearful and angry relative to neutral faces.

Hippocampus, Learning, and Memory

The hippocampus (see Figure 4-2) plays an important role in learning and memory ( Andersen et al., 2007; Ghetti et al., 2010; Otto and Eichenbaum, 1992) and, like the amygdala, matures rapidly over the first months and years of life ( Lavenex et al., 2007). The hippocampus appears to be particularly susceptible to stress early in life ( Gould and Tanapat, 1999; Sapolsky et al., 1990) and plays a role in modulating the response of the HPA axis to stressors, as binding of cortisol to hippocampal receptors serves to turn off the HPA axis response ( Kim and Yoon, 1998). Damage to the hippocampus due to abuse or neglect can have negative consequences for its roles in regulation of the stress response system and in memory formulation ( de Quervain et al., 1998; Sheridan et al., 2012).

Prefrontal Cortex and Executive Functions

The prefrontal cortex (see Figure 4-2) is responsible for a variety of higher-order "executive" functions ( Miller and Cohen, 2001). The development of the prefrontal cortex is protracted, extending from birth into the third decade of life ( Gogtay et al., 2004; Rubia et al., 2006; Sowell et al., 2003). Prefrontal systems are especially sensitive to experiences of early adversity ( Hart and Rubia, 2012; McLaughlin et al., 2010).

Consistent with these findings among abused and neglected children, previously institutionalized children and adolescents have been found to demonstrate disruptions in the prefrontal network that is associated with inhibitory control. For example, Mueller and colleagues (2010) found that children with a history of neglect or institutional care showed greater activation in several regions of the prefrontal cortex (e.g., left inferior frontal cortex, anterior cingulate cortex) during response inhibition trials of a go/no-go task compared with children without a history of neglect. Similar findings have been reported by McDermott and colleagues (2012) and Loman and colleagues (2009) among currently and previously institutionalized children.

Corpus Callosum

Influence of Early Profound Neglect on Brain Electrical Activity

The influence of profound neglect early in life has been examined using electroencephalography (EEG) and event-related potentials (ERPs).

Electroencephalography

At follow-up, as a group, children assigned to foster care did not differ from the care-as-usual group ( Marshall et al., 2008). However, the subset of children placed in foster care before 2 years of age showed EEG activity that more closely resembled that of the never-institutionalized group than the care-as-usual group. Overall, then, "institutionalization led to dramatic reductions in brain activity (as reflected in the EEG), whereas placement in foster care before 2 years of age led to a more normal pattern of EEG activity" ( Nelson et al., 2011, p. 139). This last finding was replicated when the children were 8 years old ( Vanderwert et al., 2010). Specifically, previously institutionalized children placed in foster care before about 2 years of age had patterns of brain activity that resembled those of never-institutionalized children, whereas children placed in foster care after 2 years of age had patterns of brain activity that resembled those of children randomly assigned to institutional care.

Event-Related Potentials

Finding: Across human and nonhuman primate studies, perturbations to the HPA system often are seen to be associated with child abuse and neglect. The findings are complex, moderated by a number of factors and seen at some ages and not others. Further, the perturbations sometimes are reflected in atypically high production of cortisol across either basal or reactive contexts and sometimes in atypically low production. Recent work in epigenetics suggests that this may well be an area of future inquiry into the mechanisms whereby abuse or neglect alters gene expression and, in turn, behavior.

Finding: Abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety and emotional reactivity, and deficits in emotional processing. Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect; however, fMRI studies have shown that early adversity leads to a sensitized amygdala.

Finding: Despite mixed evidence regarding structural changes in the prefrontal cortex, a number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and associated brain regions, often affecting inhibitory control.

Finding: Examination of patterns of brain electrical activity in institutionalized children suggests that extreme forms of neglect are associated with a maturational delay or deficit in cortical development.

COGNITIVE, PSYCHOSOCIAL, AND BEHAVIORAL OUTCOMES

Cognitive Development

There is a long history of research exploring the effects of child abuse and neglect on cognitive development. Studies have examined executive functioning and attention, as well as academic achievement.

Executive Functioning and Attention

As discussed earlier, some studies have found that child abuse and neglect have effects on the prefrontal cortex, a brain structure centrally involved in executive functioning. Executive functioning refers to higher-order cognitive processes that aid in the monitoring and control of emotions and behavior ( Lewis-Morrarty et al., 2012). Included among executive functions are "holding information in working memory, inhibiting impulses, planning, sustaining attention amid distraction, and flexibly shifting attention to achieve goals" ( Lewis-Morrarty et al., 2012, p. 2). Executive functioning abilities develop rapidly between the ages of 3 and 6 years, but continue to develop through at least the second decade of life.

Children who experience abuse and neglect appear to be especially at risk for deficits in executive functioning, which have implications for behavioral regulation. Extreme neglect, as seen in institutional care, has been related to executive functioning in a number of studies conducted by the Bucharest Early Intervention Project team ( McDermott et al., 2012). For example, McDermott and colleagues (2012) found that children who were randomly assigned to foster care showed better performance on an executive functioning task (i.e., a go/no-go task requiring inhibitory control) than children who were randomly assigned to treatment as usual. The assessments of executive functioning were conducted when children were 8 years old. Similar findings among comparably aged internationally adopted children (with histories of institutionalization) have been reported (e.g., Loman et al., 2013). These findings suggest that extreme forms of neglect may interfere with the development of executive functioning.

A number of studies have found evidence that children who experience abuse and neglect show deficits in executive functioning and attention ( Arseneault et al., 2011; De Bellis et al., 2009; Fisher et al., 2011; Lewis et al., 2007; Spann et al., 2012). Pears and colleagues (2008) found that abuse and neglect were associated with generally lower cognitive functioning among preschoolers. Lewis and colleagues (2007) found that 4-year-old children who had experienced abuse or neglect and were in foster care showed poorer inhibitory control on a Stroop-like task relative to comparison children, despite similar levels of performance on a control task. Spann and colleagues (2012) found that physical abuse and neglect were associated with diminished cognitive flexibility on the Wisconsin Card Sorting Task among adolescents.

Academic Achievement

Abuse and neglect increase children's risk for experiencing academic problems. Several studies suggest that abuse versus neglect matters, with neglect being especially predictive of academic underachievement ( Briere et al., 1996; Jonson-Reid et al., 2004; Nikulina et al., 2011). Other studies failed to find differences between abuse and neglect, with both predicting achievement problems (e.g., Barnett et al., 1996; Crozier and Barth, 2005; Eckenrode et al., 1993; Jaffee and Gallop, 2007; Kurtz et al., 1993; Leiter and Johnsen, 1997). On balance, the evidence suggests that both abuse and neglect are predictive of academic problems. Perez and Widom (1994) found that child abuse and neglect had a significant impact on reading ability, IQ scores, and academic achievement. For example, 42 percent of abused and neglected children completed high school, compared with two-thirds of the matched comparison group without histories of abuse and neglect. The average IQ score for the abused and neglected children was about one standard deviation below the average for the control group; this association was significant after controlling for age, race, gender, and social class ( Perez and Widom, 1994). Using NSCAW data, Jaffee and Maikovich-Fong (2011) found that chronically abused or neglected children had lower IQ scores than situationally abused or neglected children. The effect of chronic abuse or neglect on IQ scores remained significant after controlling for the effects of caregiver educational level on IQ. Leiter and Johnsen (1997) found that effects of abuse and neglect on school performance were cumulative, with more episodes of abuse and neglect being associated with poorer outcomes. Abuse and neglect predicted entry into special education after controlling for early medical conditions ( Jonson-Reid et al., 2004). Jonson-Reid and colleagues (2004) found that 24 percent of the abused and neglected children entered special education, compared with 14 percent of those with no record of abuse or neglect. Further, every additional report of abuse or neglect before the age of 8 led to an increase of 7 percent in entry into special education. Thompson and colleagues (2012) found that expectations of future academic success were adversely affected by previous experiences of abuse and neglect, with these expectations having powerful self-fulfilling possibilities ( Ross and Hill, 2002).

Psychosocial and Behavioral Outcomes

Given that child abuse and neglect are social experiences that undermine the ability to trust in caregivers, either because caregivers are frightening (as in cases of abuse) or because they fail to protect or provide care (as in cases of neglect), it makes sense that children who experience abuse and neglect are at risk for interpersonal problems. At the most proximal level, problems are seen in children's ability to form trusting attachments to their parents. But not surprisingly, the effects also are seen in such areas as children's processing of emotion (e.g., overly vigilant of angry faces), their attributions of others' intent (e.g., assuming that intentions are malevolent when they are ambiguous), and difficulties with peers (e.g., being the victim or perpetrator of bullying or violence). Problems also are seen in internalizing symptoms, such as anxiety and depression, and externalizing symptoms, such as conduct disorder and substance use.

Attachment

Children develop secure attachments to parents who are responsive to them when they are distressed ( Ainsworth, 1978). Children typically develop insecure (avoidant or resistant) attachments when parents are unresponsive or inconsistent in responsiveness, but not frightening or bizarre (e.g., Lyons-Ruth et al., 1993; Schuengel et al., 1998). Secure, avoidant, and resistant attachments are referred to as organized attachment strategies because they are organized around the caregiver's availability and provide a child a template for dealing with distress. On the other hand, disorganized attachment represents a breakdown in or a lack of strategy for dealing with distress when in the parent's presence ( Main and Solomon, 1990). Disorganized attachments are the most problematic in terms of outcomes for children. Relative to organized attachment, disorganized attachment is most predictive of long-term problems, especially externalizing symptoms ( Fearon et al., 2010). Fearon and colleagues (2010) found strong evidence for a link between disorganized attachment and later externalizing symptoms through a meta-analysis of 34 studies involving 3,778 participants.

Child abuse and neglect are predictive of disorganized attachment, as well as insecure attachment more generally. A meta-analysis conducted by Cyr and colleagues (2010) included the 10 studies that have examined attachment quality with samples of children who have experienced abuse and neglect. The effect size was large for both disorganized and insecure attachment. Although abuse was more strongly related to disorganized attachment and neglect to insecure attachment, both abuse and neglect were associated with both types of attachment. These results are consistent with theory and with other empirical findings suggesting that when parents are either frightening or unavailable, children fail to develop a secure attachment to them. Nonetheless, the effects of having more than five socioeconomic risk factors were comparable to those of child abuse and neglect, indicating that multiple challenges to parental functioning had significant effects on attachment regardless of whether these effects were seen in child abuse and neglect.

In early childhood, abused or neglected children may develop attachment disorders resulting from and following pathogenic care that inhibits a young child's ability to form selective attachments ( Hornor, 2008). Childhood attachment disorders are phenomena distinct from insecure, disorganized, or nonexistent attachment types; they have been redefined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) to include two distinct disorders: reactive attachment disorder and disinhibited social engagement disorder ( APA, 2013a, b). Reactive attachment disorder involves inhibited or emotionally withdrawn behavior, including rarely seeking and responding to comforting; it results from a lack of or incompletely formed selective attachments to adult caregivers ( APA, 2013a). Disinhibited social engagement disorder is marked by a pattern of overly familiar behavior with strangers; it may occur even in children with established or secure attachments. Previously, each attachment disorder was considered the inhibited or disinhibited type of reactive attachment disorder, respectively.

Zeanah and colleagues (2004) studied the prevalence of attachment disorders among 94 toddlers in foster care whose abuse or neglect cases had been substantiated and who were enrolled in an intervention program; they found that the prevalence of attachment disorders reached 38-40 percent. Lyons-Ruth and colleagues (2009) examined socially indiscriminate attachment behavior in a sample of mother-child dyads that included pairs referred to a clinical service because of problematic caregiving and comparison pairs matched on socioeconomic status. They found that 18-month-olds displayed socially indiscriminate attachment behavior only if they had a history of abuse or neglect, or their mother had a history of psychiatric hospitalizations. Both disorders also have been identified in children exposed to neglectful institutional care in Romania who were later adopted into middle-class families in the United Kingdom ( Smyke et al., 2002; Zeanah et al., 2002), although the disinhibited type of reactive attachment disorder (as defined in DSM-IV) has been found to be much more prevalent than the inhibited type ( O'Connor et al., 2003). Furthermore, findings from the Bucharest Early Intervention Project study indicate that the inhibited type of reactive attachment disorder declined significantly once institutionalized children were placed in foster care, but the disinhibited type proved more persistent ( Smyke et al., 2002; Zeanah and Gleason, 2010).

Emotion Regulation

Infants have limited capacities to regulate their own emotions and are dependent on caregivers to help them deal effectively with distress ( Tronick, 1989). Indeed, infants and young children are highly attuned and responsive to their parents' emotions and use parental emotional signals to guide their behavior ( Klinnert et al., 1983; Malatesta and Izard, 1984). The scaffolding important for the development of emotion regulation is challenged in abusing or neglecting families. When children feel upset or distressed, parents' availability and soothing presence can help them feel that they can cope with the strong negative affect, such that they are able to develop autonomous and effective means of regulating emotions over time. When children regulate their emotions well, they react to challenge with flexible and socially acceptable responses ( Cole et al., 1994; Kim and Cicchetti, 2010). Abused and neglected children, however, may not have such scaffolding experiences. It is likely that abused and neglected children experience not only a lack of modeling and support and an absence of positive affect but also harsh, inconsistent, and insensitive parenting ( Shipman and Zeman, 2001). In the case of abuse, parents often respond in threatening or unpredictable ways to children's distress ( Milner, 2000). In the case of neglect, parents may be unresponsive or nonempathic. As a result of either response, children are at risk of failing to develop effective strategies for regulating emotions ( Cicchetti et al., 1995; Kim and Cicchetti, 2010; Rogosch et al., 1995).

An initial, key task in regulating emotions is processing of cues. Studies have examined differences among children who have experienced abuse and neglect in how readily they identify angry, sad, and happy faces ( Pollak and Sinha, 2002; Pollak and Tolley-Schell, 2003; Pollak et al., 2000; Shackman et al., 2007). Pollak and Sinha (2002) found that the threshold for detecting anger in the face was lower among abused than nonabused children; there were no differences in processing happy faces. Thus, these children appear to have a bias toward angry faces rather than a general deficit in processing faces. Pollak and Sinha (2002) point out that it is useful to identify emotions in others based on less than full information. Abused children's bias toward attributing angry or sad affect may be adaptive when living with parents whose anger may be an important threat cue ( Belsky et al., 2012); nonetheless, it comes at the cost of assuming hostile intent too readily under benign conditions, leading to aggressive responses that would not have been evoked had attributions been different ( Dodge et al., 1995). Neglected children, on the other hand, generally are not as good as nonneglected children at identifying facial expressions, showing a general deficit ( Pollak et al., 2000).

Peer Relations

Children's relationships with their peers are critical to their sense of well-being. Abused and neglected children have problematic peer relations at disproportionately high rates ( Kim and Cicchetti, 2010), as do children with a history of institutional care ( Almas et al., 2012). Chronicity of child abuse and neglect predict peer relations, as reported by teachers, at age 8 ( Graham et al., 2010). Problematic emotion regulation ( Shields and Cicchetti, 2001) and higher levels of aggression and withdrawal ( Rogosch et al., 1995) found in abused and neglected children can become apparent to peers when frustrations and challenges arise in school and playground environments.

Externalizing Problems

Externalizing behavior refers to problem behaviors that are manifested externally (rather than internally, as in the case of depression and anxiety). Findings from several studies indicate that children who have experienced abuse and neglect are at greater risk for a number of externalizing behaviors, including conduct disorders, aggression, and delinquency ( Lansford et al., 2002, 2009; Lynch and Cicchetti, 1998; Stouthamer-Loeber et al., 2001; Thornberry et al., 2010).

Oppositional defiant disorder and conduct disorder Studies have reported significant associations between a history of childhood abuse or neglect and various conduct problems, including those classified as oppositional defiant disorder or conduct disorder. Oppositional defiant disorder is indicated by a frequent or persistent pattern of angry or irritable mood, argumentative or defiant behavior, and vindictiveness ( APA, 2013a). Its symptoms usually first appear during early childhood, and it often precedes conduct disorder, anxiety disorders, or major depressive disorder. Conduct disorder is indicated by a repetitive or persistent pattern of behavior that violates the basic rights of others or major societal norms or rules, including aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules ( APA, 2013a). Conduct disorder can begin in childhood or adolescence; however, childhood-onset conduct disorder is more often preceded by oppositional defiant disorder, more persistent into adulthood, and more likely to include aggressive behavior than adolescence-onset conduct disorder. Both disorders also frequently co-occur with ADHD.

In a study using a community sample, Dodge and colleagues (1995) found that children who were physically abused before age 5 were 4 times more likely than nonabused children to display externalizing conduct problems in grade 3 and 4. Likewise, Kaplan and colleagues (1998) found that adolescents (aged 12-18) with substantiated cases of physical abuse were more likely to display conduct disorder or oppositional defiant disorder at the time of the study (odds ratio = 5.98) than the matched nonabused comparison group. Fergusson and colleagues (2008) found that childhood sexual abuse was associated with higher rates of conduct disorder in young adulthood. Furthermore, they found that childhood physical abuse was not associated with conduct disorder when sexual abuse was included in the model. Additional environmental and individual factors that interact with abuse or neglect to increase the likelihood of conduct disorder or oppositional defiant disorder include exposure to parental divorce ( Afifi et al., 2009), interparental violence ( Boden et al., 2010), and community violence ( McCabe et al., 2005), as well as gender, with males more likely to display conduct disorder ( Boden et al., 2010).

Aggression Manly and colleagues (2001) found that children who had experienced severe emotional abuse only as infants or severe physical abuse only as toddlers were more aggressive and showed more externalizing symptoms as school-aged children than children without a history of abuse or neglect. The severity of abuse experienced predicted aggressiveness and externalizing symptoms in middle childhood. Although abuse experienced only in early childhood had lasting effects, abuse experienced beyond early childhood also had effects on aggression and externalizing symptoms, and the most problematic effects were seen for children subjected to chronic, severe abuse ( Manly et al., 2001). Rogosch and colleagues (1995) found that physically abused children showed both aggressive behaviors and social withdrawal during peer interactions. Along these lines, abused and neglected children were disproportionately likely to be both bullies and victims of aggression, effects that were mediated by emotion dysregulation ( Shields and Cicchetti, 2001). At odds with these findings, Kotch and colleagues (2008) found that children who experienced neglect in their first 2 years of life showed more aggression toward peers at ages 4, 6, and 8 relative to children without a history of abuse or neglect. Indeed, in that study, other subgroups (children who were abused or who were neglected at older ages) did not show an increased likelihood of aggression.

Internalizing Problems

Internalizing problems-problems that are manifested internally-include symptoms of depression and anxiety. Child abuse and neglect have been found to put children at increased risk of internalizing symptoms from early childhood through adolescence and adulthood ( Dubowitz et al., 2002; Thornberry et al., 2001; Widom et al., 2007a).

Dubowitz and colleagues (2002) found that neglect was associated with internalizing problems for 3- and 5-year-old children. Swanston and colleagues (1997) found that sexually abused children had a significantly higher average score on depression measures than a control group just 5 years after the abuse occurred, after adjusting for individual differences in age and sex, as well as contextual factors such as socioeconomic status, family functioning, mother's mental health, and number of negative life events. Trickett and colleagues (2001) found that a sample of sexually abused girls had significantly higher rates of self-reported depression than a comparison group of nonabused females. At follow-up, approximately 7 years later, rates of depression were found to be significantly higher among the sexually abused group, excluding a subset whose experience of abuse was characterized chiefly by multiple perpetrators and a relatively short duration.

The heightened risk of depression extends beyond childhood to adolescence and adulthood. Multiple studies have found clear links between child abuse and neglect and depression in adolescence (e.g., Fergusson et al., 2008; Heneghan et al., 2013; Lansford et al., 2002). Brown and colleagues (1999) found that child abuse and neglect were associated with a nearly threefold increase in the rate of depression in adolescence, although this risk was diminished after controlling for other adverse conditions. Gilbert and colleagues (2009b) cite a body of studies reporting adjusted odds ratios ranging from 1.3 to 2.4 for depression after childhood among those subjected to abuse and neglect as children. Among adults, Brown and colleagues (1999) found that the increased risk of depression associated with child abuse and neglect remained when other factors were covaried, consistent with findings that more than one-third of abused or neglected children show symptoms of major depressive disorder by their late 20s ( Gilbert et al., 2009b). Likewise, Widom and colleagues (2007a) followed a group of individuals who had experienced abuse and/or neglect in childhood and a matched comparison group into young adulthood and found that experiencing childhood physical abuse and multiple types of abuse increased the lifetime risk for a diagnosis of major depressive disorder.

Dissociation

Child abuse and neglect have been associated with dissociation among both preschool-aged and elementary-aged children ( Hulette et al., 2008, 2011; Macfie et al., 2001), as well as among adults ( van Ikzendoorn and Schuengel, 1996). The existence of a subgroup of PTSD patients with high levels of dissociation has been demonstrated in clinical ( Lanius et al., 2013; Putnam, 1997), psychophysiological ( Griffin et al., 1997), neuroimaging ( Lanius et al., 2013), and epidemiological ( Stein et al., 2013) research. As a result, DSM-V is adding a dissociative subtype to the PTSD diagnosis ( Spiegel et al., 2011 a) (see the discussion of PTSD on p. 139).

High scores on dissociation measures have proven to be a predictor of externalizing behavior in children ( Kisiel and Lyons, 2001; Shapiro et al., 2012; Yates et al., 2008). In adults, high levels of dissociation are associated with refractoriness to standard treatments for a number of psychiatric conditions, as well as increased comorbidity ( Jans et al., 2008; Kleindienst et al., 2011; Wolf et al., 2012; Zanarini et al., 2011).

A meta-analysis of 55 studies ( Cyr et al., 2010) links abuse with disorganized attachment. Grienenberger and colleagues (2005) found that mothers who engaged in disrupted affective communication with their infants at 4 months (as measured using the AMBIANCE scale) were more likely to have toddlers who were classified as disorganized at 14 months. In turn, disorganized attachment at 14 months predicted high dissociation scores at age 20 years ( Lyons-Ruth, 2008). Disorganized attachment assessed during the child's second year predicted elevated levels of self-reported dissociation in mid-adolescence (age 16 years) ( Carlson, 1998) and early adulthood (age 19) ( Ogawa et al., 1997).

Based on findings from the Minnesota Mother-Child Project, Egeland and Susman-Stillman (1996) propose that dissociation may act as a mediator of child abuse across generations. In a longitudinal study of sexually abused girls followed into parenthood, Kim and colleagues (2010) found that increased dissociation, together with a history of self-reported punitive parenting as a child, predicted whether a mother would parent her own children in a harsh and punitive manner. Thus, a tentative generational loop can be hypothesized in which harsh and abusive parenting increases the risk for higher levels of dissociation in childhood and adolescence, which in turn increases the risk for impulsive behavior and harsh parenting of offspring. Further research, especially with a longitudinal design, is warranted to determine whether this hypothesized generational pattern of transmission represents an early opportunity for prevention of abuse in the next generation.

Posttraumatic Stress Disorder

A number of prospective and retrospective studies have found elevated rates of PTSD among individuals with a history of abuse and neglect ( Chen et al., 2010; Kearney et al., 2010; Tolin and Foa, 2006; Weich et al., 2009; Widom, 1999). Numerous studies have found that PTSD was preceded by abuse and neglect; links with sexual abuse were especially strong ( Chen et al., 2010; Gregg and Parks, 1995; Kendall-Tackett et al., 1993; Tolin and Foa, 2006; Weich et al., 2009; Widom, 1999). Kearney and colleagues (2010) report PTSD rates of 20-50 percent among youth who had been sexually abused, 50 percent among youth who had been physically abused, and 33-50 percent among youth who had experienced neglect combined with exposure to domestic violence. Kolko (2010) found that nearly 20 percent of youth in out-of-home care showed posttraumatic symptoms. Widom (1999) found increased risk for PTSD among adults who had experienced abuse and neglect as children, with 23 percent of those who had been sexually abused, 19 percent of those who had been physically abused, and 17 percent of those who had been neglected meeting criteria for PTSD at age 29, compared with 10 percent of the comparison group.

Personality Disorders

Finding: Abuse and neglect have profound effects on selected aspects of children's cognitive development. Although many attempts have been made to disentangle the effects of abuse and neglect, the balance of findings suggests that severe neglect may interfere with the development of executive functioning, and both neglect and abuse increase the risk for attention regulation problems and ADHD, lower IQ, and poorer school performance.

Finding: As a result of abusive or neglectful responses from caregivers, children have a difficult time developing organized and secure attachments. As a result, abused and neglected children are at higher risk for the development of attachment disorders, particularly disinhibited social engagement disorder.

Finding: Abused and neglected children often fail to develop effective strategies for emotion regulation, partly as a result of differences in processing of emotional cues. Difficulties with emotion regulation can lead to further problems, including externalizing and internalizing problems and challenges in peer relations.

Finding: Children who experience abuse or neglect have been found to be at higher risk for the development of externalizing behavior problems, including oppositional defiant disorder, conduct disorder, and aggressive behaviors. Abused and neglected children also have been found to be at increased risk for internalizing problems, particularly depression, in childhood, adolescence, and adulthood.

Finding: Among preschool- and elementary school-aged children, as well as adults, a history of childhood abuse and neglect has been associated with dissociation, which increases the risk for externalizing behavior in childhood and resistance to treatment for psychiatric conditions later in life. It has been suggested that dissociation may act as a mediator of harsh or abusive parenting across generations, although this hypothesis requires further research.

Finding: A number of studies have found elevated rates of PTSD among individuals with a history of abuse and neglect. PTSD has been associated with physical, cognitive, psychological, social, and behavioral problems among youth who were abused or neglected in childhood.

HEALTH OUTCOMES

Child abuse and neglect have effects on a number of health outcomes, from growth to illness to obesity. Connections have been found between problematic neurobiological outcomes of child abuse and neglect and health. One plausible mechanism for these effects relates to the purported frequent or chronic activation of the HPA axis. As discussed previously, the HPA axis is designed for responding in crises.

Growth and Motor Development

Illness

In a longitudinal prospective study, childhood abuse and neglect predicted health indices among middle-aged adults ( Widom et al., 2012). Both physical abuse and neglect predicted hemoglobin A1C (a biomarker for diabetes) and albumin (a biomarker for liver and kidney function); physical abuse uniquely predicted malnutrition and blood urea nitrogen (a marker for kidney function); neglect uniquely predicted poor peak airflow; and sexual abuse uniquely predicted hepatitis C ( Widom et al., 2012).

Obesity

Finding: Experiences of child abuse and neglect have effects on many health outcomes, including risks for long-term chronic and debilitating diseases and, in extreme cases, stunted growth.

ADOLESCENT AND ADULT OUTCOMES

While a number of the consequences of child abuse and neglect discussed previously in this chapter can be present across childhood, adolescence, and adulthood, this section focuses on behavioral outcomes that manifest specifically in either adolescence or adulthood.

Delinquency and Violence

Alcohol and Substance Use

Suicide Attempts

Sexual Behavior

Studies have investigated the association between child abuse and neglect and several aspects of sexual behavior, including early sexual initiation and sexual risk behavior, teen pregnancy, and prostitution and the risk for commercial sexual exploitation of children and adults.

Early Sexual Initiation and Sexual Risk Behavior

Children who experience abuse and neglect may initiate sexual activity at earlier ages than other children ( Lodico and DiClemente, 1994; Noll et al., 2003; Springs and Friedrich, 1992; Wilson and Widom, 2008). In addition, there is limited evidence of an association between child abuse and neglect and increased risky sexual behaviors ( Jones et al., 2010; Senn et al., 2008). This association has been studied most frequently for sexual abuse; however, Jones and colleagues (2010) found that physical and emotional abuse, but not neglect, contributed to risky behaviors over and above the effects of sexual abuse. Trickett and colleagues (2011) undertook one of the most extensive longitudinal studies of developmental outcomes for female victims of sexual abuse. The majority had experienced severe sexual abuse, defined by the type of abuse (with vaginal and anal penetrative abuse seen as most severe), the length of time over which the abuse occurred, and the relationship of the abuser to the victim. In addition to earlier initiation of sexual activity among women who had been sexually abused in childhood, the authors found less use of birth control ( Noll et al., 2003). For both abused and nonabused women, having a large number of male peers in childhood networks was associated with a lack of birth control use in adolescence ( Trickett et al., 2011). For abused females, however, having high-quality relationships with male peers and nonpeers in childhood was associated with greater birth control use in adolescence; in the comparison group, this association was not found.

Teen Pregnancy

Evidence linking childhood sexual abuse and increased risk for teen pregnancy has been mixed. Trickett and colleagues (2011) found that severely sexually abused females reported significantly higher rates of teen pregnancy and teen motherhood than nonabused females (abused = 39 percent, nonabused = 15 percent). In a meta-analysis of previously published studies of sequelae of child sexual abuse, Noll and colleagues (2009) found an increased risk for early pregnancy among girls who had been sexually abused. In contrast, using a prospective cohort design that followed children with documented cases of abuse and neglect into young adulthood, Widom and Kuhns (1996) found no evidence that childhood sexual abuse was a significant risk factor for multiple early sexual partners or teenage pregnancy.

Prostitution and Risk for Commercial Sexual Exploitation of Children and Adults

While an important topic, evidence that child abuse and neglect increase the risk for commercial sexual exploitation of children is very limited and comes primarily from retrospective studies of sexually exploited youth. Some older studies have reported that experiences of childhood sexual abuse influenced the decision of young women to become involved in commercial sex work ( Bagley and Young, 1987; Silbert and Pines, 1983). A comprehensive look at those issues will be presented in a forthcoming Institute of Medicine report from the Committee on Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States.

Finding: Experiences of abuse and neglect in childhood have a large effect on delinquency, violence, and suicide attempts in adolescence and adulthood.

Finding: Adolescents and adults with a history of child abuse and neglect have higher rates of alcohol abuse and alcoholism than those without a history of abuse and neglect, although this relationship has been found most frequently in women.

Finding: Children who experience abuse and neglect may initiate sexual activity at earlier ages than comparison groups. Childhood sexual abuse also has been found to be associated with heightened risks for a range of adverse outcomes related to sexual risk-taking behaviors.

Finding: Studies seeking an association between child abuse and neglect and teen pregnancy or adult prostitution have reported mixed results.

INDIVIDUAL DIFFERENCES IN OUTCOMES

This chapter has presented extensive evidence that children who are abused or neglected, as a group, are at increased risk for a variety of problematic outcomes. However, not all children who experience abuse or neglect experience these negative consequences. Not surprisingly (given what is known about typical development), children vary in the outcomes they experience even when exposed to the same type of abuse or neglect, with outcomes ranging from the most problematic to functioning well across domains. As discussed earlier in this chapter, an ecological-transactional model is helpful for understanding outcomes related to abuse and neglect as influenced by the interplay of risk and protective factors that occur at multiple levels of a child's ecology. Through examination of compensatory resources in children and their environment, an ecological-transactional framework can aid in understanding children who exhibit resilient outcomes despite having been abused or neglected ( Cicchetti and Toth, 2009; Luthar et al., 2000). Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. However, neither a child's individual strengths nor the surrounding environment alone can predict resilient outcomes. As noted by Jaffee and colleagues (2007, p. 233), "the fit between the child and the environment is the best predictor of children's psychological well-being." The following sections describe research examining explanatory factors for differences in outcomes related to child abuse and neglect.

Characteristics of Abuse or Neglect Experiences

Resilience

The concept of resilience serves as a useful lens for evaluating the differing outcomes of children exposed to abuse and neglect. By examining factors that contribute to whether children experience maladaptive outcomes in response to abuse or neglect, researchers can gain a better understanding of how better to prevent and treat these consequences. While resilience has been defined in various ways, it can be understood as "a good outcome in spite of high risk, sustained competence under stress, and recovery from trauma" ( McGloin and Widom, 2001, p. 1022).

Results from a study of adults who were the subjects of substantiated cases of child abuse or neglect as children indicate that 22 percent of abused and neglected individuals met the criteria for resilience, which required successful functioning in 6 of 8 domains ( McGloin and Widom, 2001). A study by Collishaw and colleagues (2007) examined resilience to adult psychopathology within a representative community sample, finding that 44 percent of adults who reported abuse during childhood reported no psychiatric problems in adulthood and demonstrated positive adaptation in other domains.

Protective factors supporting resilience have been examined at the levels of the individual, family, and social environment, with resilience being measured in childhood, adolescence, and early adulthood. In a review of protective factors for resilience following child abuse and neglect, Afifi and Macmillan (2011) identify three protective factors that are best supported by findings from longitudinal and cross-sectional studies: a stable family environment, supportive familial relationships, and personality traits that support social skills.

Gene x Environment Interactions

Historically, those working in the field of child abuse and neglect were unable to examine whether such adverse experiences interacted with biological risk or protective factors (e.g., so-called risk or protective genes)-specifically, whether experience interacted with underlying genetics. This situation has changed over the past 20 years as advances in molecular genetics have enabled a search for gene x environment (GxE) interactions. A number of such interactions have been studied in the last several decades in relation to early adversity generally and child abuse and neglect in particular. Critics of these approaches charge, among other things, that examining single gene and single environment combinations in interactions capitalizes on chance. In addition, some experts in genetics argue that the action of any single gene is likely to be very small, and to detect its effects will likely require very large sample sizes. Nonetheless, some GxE findings have emerged as robust and apparently replicable.

The 5-HTT gene is perhaps at the top of this list. This gene regulates reuptake of serotonin (a neurotransmitter that has various functions, including regulation of mood and sleep and some cognitive functions, such as memory and learning) at the synaptic cleft. The gene has long and short allelic variants that confer differential reuptake efficiency. Rodent, nonhuman primate, and human studies (e.g., Caspi et al., 2003) have shown that two alleles confer advantage among animals raised in stressful environments. Caspi and colleagues (2003) found that adults who had experienced stressful life events as children were more likely to have a major depressive disorder if they had one or two short alleles. Those who had two long alleles were no more likely to develop depression than individuals who had not experienced stressful life events.

Finding: Not all children who experience abuse or neglect show problematic outcomes. Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. These factors, along with risks and stressors at each level, interact with one another to predict resilient outcomes.

Finding: There is a positive association between the number of risk factors for abuse and neglect to which a child is exposed and the likelihood of experiencing adverse outcomes.

Finding: The timing, chronicity, and severity of child abuse and neglect, as well as the context in which they occur, have been shown to impact the associated outcomes.

ECONOMIC BURDEN

Although the total costs of child abuse and neglect are difficult to gauge because much abuse is unreported ( Waters et al., 2004), a number of studies over the last few decades have attempted to document the economic burden of child abuse and neglect on society ( Corso and Fertig, 2010; Fang et al., 2012; Wang and Holton, 2007; Waters et al., 2004). Economic burden or economic impact analyses typically quantify burden by aggregating the direct medical expenditures resulting from a condition, the direct nonmedical expenditures associated with a condition, and the subsequent indirect losses in productivity potential for society. These analyses often are called cost of illness/injury analyses.

Examples of direct medical expenditures include inpatient and outpatient hospital care, mental health care, medical transport required in the event of an emergency, medications and medical devices, and the medical treatment of chronic conditions resulting from the abuse. Multiple studies since the 1993 NRC report was issued have assessed the direct medical costs associated with child abuse and neglect ( Brown et al., 2011), particularly the inpatient costs associated with severe abuse ( Courtney, 1999; Evasovich et al., 1998; Irazuzta et al., 1997; Libby et al., 2003; New and Berliner, 2000; Rovi et al., 2004).

Direct nonmedical expenditures include use of the child welfare system, law enforcement, and the criminal justice system. Studies have included nonmedical costs in their assessment of the economic burden of child abuse and neglect ( Staudt, 2003; Zagar et al., 2009).

Productivity losses include the child's missing school or performing at subpar levels in school because of the abuse, parents missing work or performing at subpar levels at work because of the abuse situation or having to deal with child welfare and criminal justice services, and permanent losses in lifetime productivity potential because of premature death. Productivity losses and economic well-being have been incorporated into a number of analyses of the economic burden of child abuse and neglect ( Brown et al., 2011; Corso and Fertig, 2010; Corso et al., 2011; Currie and Widom, 2010; Fang et al., 2012).

Gelles and Perlman (2012) estimate that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion each year-$33.3 billion in direct costs and $46.9 billion in indirect costs. An analysis by the Centers for Disease Control and Prevention found that the average lifetime cost of a case of nonfatal child abuse and neglect is $210,012 in 2010 dollars, most of this total ($144,360) due to lost productivity but also encompassing the costs of child and adult health care, child welfare, criminal justice, and special education ( Fang et al., 2012). The average lifetime cost of a case of fatal child abuse and neglect is $1.27 million, due mainly to loss of productivity.

Currie and Widom (2010) found that adults who had experienced abuse and neglect in childhood had lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect. A higher percentage of adults who had been abused or neglected as children worked in menial, semiskilled positions at age 29 compared with adults who had not been abused or neglected-62 versus 45 percent, respectively. More of the abused and neglected group has been unemployed at some point during the previous 5 years (41 versus 58 percent, respectively). And fewer of those from the abused or neglected group were currently employed or had a bank account, owned a car, or owned their home. Larger effects were seen for women than for men.

Analyses of the economic burden of child abuse and neglect could be strengthened by greater transparency in the study methods, including a full accounting of all cost categories that may be impacted by abuse and neglect and transparency in the unit cost estimates for each cost category, as well as a methodologically sound choice of study design for estimating economic burden ( Corso and Fertig, 2010; Corso and Lutzker, 2006; Fang et al., 2012). Several approaches could be taken to estimate economic burden, each of which has advantages and disadvantages that could potentially result in overestimating or underestimating the true economic cost of child abuse and neglect. Options include using cross-sectional data to compare the medical costs for an abused/neglected population compared with a nonabused/nonneglected population, including only those health care costs that can be explicitly linked to diagnosis-specific health care utilization (and costs) through the use of diagnosis and external cause codes used in inpatient settings, and supplementing either of these two approaches by including the costs of the fraction of other health conditions attributed to child abuse and neglect.

Finding: Although the total costs of child abuse and neglect are difficult to gauge, a number of studies have attempted to document the economic burden of child abuse and neglect on society, including such measures as direct medical and nonmedical expenditures and productivity losses. One study estimates that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion annually ( Gelles and Perlman, 2012).

Finding: Some studies have shown that adults who experienced abuse and neglect in childhood have lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect.

CONCLUSIONS

Child abuse and neglect appear to influence the course of development by altering many elements of biological, cognitive, psychosocial, and behavioral development; in other words, child abuse and neglect "get under the skin" ( Hertzman and Boyce, 2010) to have a profound and often lasting impact on development. Brain development is affected, as is the ability to make decisions as carefully as one's peers, or executive functioning; the ability to regulate physiology, behavior, and emotions is impaired; and the trajectory toward more problematic outcomes is impacted. Effects are seen across domains, with the interplay across brain and behavioral systems being particularly striking.

Risk and protective factors across multiple levels of a child's ecology interact to influence outcomes related to child abuse and neglect. Factors that influence resilience across these domains are important to an understanding of how to protect children from the adverse outcomes discussed in this chapter. Evidence suggests that the timing, chronicity, and severity of the abuse or neglect matter in terms of outcomes. The more times children experience abuse or neglect, the worse are the outcomes ( Jonson-Reid et al., 2012). As Jonson-Reid and colleagues (2012) point out, it is not enough to know whether an event happened; one must also know how ongoing the problem is. The committee sees as hopeful the evidence that changing environments can change brain development, health, and behavioral outcomes. There is a window of opportunity, with developmental tasks becoming increasingly more challenging to negotiate with continued abuse and neglect over time.

Future research in this area needs to focus on disentangling the effects of child abuse and neglect from those of other conditions. There is a need to explore beneath the surface to understand the behavioral, neurobiological, social, and environmental mechanisms that mediate the association between exposure to abuse and neglect and their behavioral and neurobiological sequelae.

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Fox NA, Nelson CA III, Zeanah CH Jr. Families and child health. Landale NS, McHale SM, Booth A, editors. New York: Springer; 2013. pp. 33-41. (The effects of early severe psychosocial deprivation on children's cognitive and social development: Lessons from the Bucharest Early Intervention Project).

Gelles RJ, Perlman S. Estimated annual cost of child abuse and neglect. Chicago: Prevent Child Abuse America; 2012.

Kitterle FL. Hemispheric communication: Mechanisms and models. Hillsdale, NJ: Lawrence Erlbaum Associates; 1995.

Klinnert M, Campos J, Sorce J, Emde R, Svejda M. Emotion: Theory, research and experience. Kellerman RPH, editor. New York: Academic Press; 1983. pp. 57-86. (Emotions as behavior regulators in infancy: Social referencing in infancy).

Lanius R, Miller M, Wolf E, Brand B, Frewen P, Vermetten E, Spiegel D. Dissociative subtype of PTSD. Washington, DC: U.S. Department of Veterans Affairs; 2013.

Malatesta CZ, Izard CE. The psychobiology of affective development. Fox NA, Davidson RJ, editors. Hillsdale, NJ: Psychology Press; 1984. pp. 161-206. (The ontogenesis of human social signals: From biological imperative to symbol utilization).

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Nelson CA III, Zeanah CH, Fox NA. Adolescent psychopathology and the developing brain: Integrating brain and prevention science. Romer D, Walker EF, editors. New York: Oxford University Press; 2007a. pp. 197-215. (The effects of early deprivation on brain-behavioral development: The Bucharest Early Intervention Project).

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Putnam FW. Dissociation in children and adolescents: A developmental perspective. New York: Guilford Press; 1997.

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Waters H, Hyder A, Rajkotia Y, Basu S, Rehwinkel JA, Butchart A. The economic dimensions of interpersonal violence. Geneva: Department of Injuries and Violence Prevention, World Health Organization; 2004.

Widom CS. Childhood victimization: Early adversity and subsequent psychopathology. Adversity, Stress, and Psychopathology. 1998:81-95.

Widom CS, Maxfield MG. An update on the "cycle of violence.". Washington, DC: U.S. Department of Justice, Office of Justice Programs, National Institute of Justice; 2001.

Zeanah CH, Gleason MM. Reactive attachment disorder: A review for DSM-V. Washington, DC: APA; 2010.

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Since the 1993 National Research Council (NRC) report on child abuse and neglect was issued, dramatic advances have been made in understanding the causes and consequences of child abuse and neglect, including advances in the neural, genomic, behavioral, psychologic, and social sciences.

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Long-Term Effects of Child Abuse and Neglect

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Long-Term Effects of Child Abuse and Neglect

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Context:

The page explains that child abuse and neglect can lead to toxic stress, which damages brain development by overstimulating survival systems and under‑developing areas responsible for emotion, reasoning, and self‑regulation. Over time, the effects manifest in poor academic performance, behavioral issues, mental and physical health disorders, and higher risk behaviors. The harms also ripple outward, burdening healthcare, education, and the criminal justice systems, and reducing community well-being and economic productivity.

Relevance:

This information is relevant because it shows how neglect and abuse create toxic stress that disrupts brain development and leads to long-term emotional, behavioral, and physical health problems, which are core aspects of childhood trauma. For child educators, understanding these impacts is essential because they often observe the early signs, such as learning difficulties, aggression, withdrawal, or poor emotional control. Recognizing these behaviors as possible trauma responses, not simply discipline issues, enables educators to respond with empathy, adapt their teaching strategies, and seek appropriate support. This knowledge helps create safe, nurturing environments that promote healing and learning.

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Positive Childhood Alliance North Carolina

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Long-Term Effects of Child Abuse & Neglect | Positive Childhood Alliance NC

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Child abuse & neglect have long-term effects on the child and the community. Read about the ACE Study that uncovered the impact of childhood experiences.

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Neuropsychological Findings in Childhood Neglect and their Relationships to Pediatric PTSD

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Neuropsychological Findings in Childhood Neglect and their Relationships to Pediatric PTSD

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Context:

The article reports that children who have experienced neglect show significantly lower scores on IQ, academic achievement, and neurocognitive domains compared to non‑neglected peers. The study also found that those neglected children who additionally met criteria for PTSD performed worse, especially on memory for faces and visual planning tasks, and that higher levels of PTSD symptoms and more maltreatment exposure were correlated with poorer cognitive outcomes. The findings suggest that neglect, often accompanied by trauma, has measurable, deleterious effects on brain function and learning even when physical injury is absent.

Relevance:

This information is relevant because it shows that childhood neglect, especially when paired with trauma like PTSD, can significantly impair a child’s cognitive abilities, including memory, attention, language, and executive function. These deficits directly affect a child’s ability to learn and succeed in school. For child educators, understanding this connection is vital because they may be the first to notice academic struggles or unusual behaviors that stem from underlying trauma. Recognizing these as possible signs of neglect allows educators to respond with appropriate support, adjust expectations, and advocate for interventions, helping to improve both educational and emotional outcomes for affected children.

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Neuropsychological Findings in Childhood Neglect and their Relationships to Pediatric PTSD

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Although child neglect is the most prevalent form of child maltreatment, the neurocognitive effects of neglect is understudied. We examined IQ, reading, mathematics, and neurocognitive domains of fine-motor skills, language, visual-spatial,…

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How Might Abuse and Neglect Adversely Impact a Child or Young Person's Mental Health?

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How Might Abuse and Neglect Adversely Impact a Child or Young Person's Mental Health?

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Context:

The video explains that abuse and neglect can profoundly affect a young person's mental health, influencing their thoughts, emotions, and behaviors across various areas of life, such as school, relationships, and home. Severe trauma can lead to difficulties in emotional regulation, flashbacks, and heightened fight, flight, or freeze responses. Research shows that adverse childhood experiences, including abuse, significantly impact mental health and well-being into adulthood, often causing anxiety, depression, attachment disorders, and sometimes self-harm or suicidal thoughts if untreated. Early intervention is crucial to help children feel safe enough to disclose abuse and reduce long-term harm. While trauma can deeply affect the brain, additional factors like bullying or discrimination can compound its impact. However, there is hope: with timely support and intervention, the negative effects can be mitigated, showing that recovery and resilience are possible for those affected.

Relevance:

The video highlights the deep and lasting effects these experiences can have on a young person's mental health, development, and behavior. Understanding the impact helps child educators recognize signs of distress, emotional struggles, or behavioral changes that might stem from abuse or neglect. It also emphasizes the importance of early intervention to prevent long-term harm and supports creating a safe, supportive environment where children feel comfortable disclosing their experiences. For child educators, knowing this is crucial because they often spend significant time with children and can be key in identifying issues early, responding sensitively, and connecting children to the help they need, ultimately promoting better outcomes for the child’s mental health and overall well-being.

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How might abuse & neglect adversely impact a child or young person’s mental health? | NSPCC Learning

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Context:

The Harvard “Guide to Neglect” emphasizes that consistent, responsive caregiving is foundational to healthy brain development and lifelong well‑being. Chronic neglect, or the persistent absence of emotional and physical responsiveness, disrupts brain architecture, undermines learning, emotional regulation, and relationship capacities, often causing more widespread developmental damage than abuse despite receiving less attention in policy and practice. The guide argues for preventive policies and practices that promote stable, nurturing environments and reliable caregiving to buffer children from the long‑term risks associated with neglect.

Relevance:

This information is relevant because it highlights that neglect, especially when persistent, can cause deep and lasting damage to a child’s brain development, emotional health, and ability to form trusting relationships, often more so than abuse. For child educators, understanding this helps them recognize that children struggling with attention, emotional regulation, or social connections may be experiencing the effects of neglect-related trauma. This awareness is crucial for creating supportive, stable classroom environments and for advocating early interventions that provide the consistent care and emotional responsiveness these children need to heal and thrive.

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Center on the Developing Child at Harvard University

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A Guide to Neglect - Center on the Developing Child at Harvard University

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The absence of responsive relationships can negatively impact a young child’s development and well-being, underscoring the importance of safe, stable developmental environments.

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Supporting Maltreated Children: Countering the Effects of Neglect and Abuse

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Supporting Maltreated Children: Countering the Effects of Neglect and Abuse

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Context:

The article emphasizes the profound impact of early neglect and abuse on children's brain development, attachment, and behavior. It explains how chronic neglect can disrupt the development of emotional and social capacities, leading to difficulties in forming meaningful relationships. The piece also highlights how abuse can trigger a persistent fear state in the brain, resulting in hyper-vigilance, anxiety, and behavioral impulsivity. Despite these challenges, the article offers hope, noting that with consistent, responsive caregiving, children can begin to heal and develop healthier relationships and behaviors.

Relevance:

For child educators, understanding these insights is crucial. Recognizing that behaviors such as aggression, withdrawal, or difficulty concentrating may stem from early trauma rather than intentional misbehavior allows educators to respond with empathy and appropriate support. By creating a stable and nurturing environment, educators can play a pivotal role in helping maltreated children heal and thrive academically and socially.

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Supporting Maltreated Children: Countering the Effects of Neglect and Abuse - Families Rising

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By Bruce D. Perry, M.D., Ph.D. http://childtrauma.org/ This article was […]

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The Role of Educators in Child Abuse & Neglect Prevention

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The Role of Educators in Child Abuse & Neglect Prevention

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The Kempe Foundation's article underscores the critical position educators hold in identifying and addressing child maltreatment. Educators, often spending significant time with children, are well-placed to observe behavioral, emotional, and physical changes that may indicate abuse or neglect. By creating a safe and supportive classroom environment, educators can encourage children to disclose concerns. Additionally, they can guide and support families by sharing strategies that promote positive parenting and prevent maltreatment.

Relevance:

This information is relevant because educators are often the first adults outside the family to notice signs of neglect and trauma in children. Their role in observing changes in behavior, emotions, or physical health is crucial for early identification and prevention of abuse and neglect. Understanding this responsibility empowers educators to create safe, supportive environments where children feel comfortable sharing their experiences. It also equips them with strategies to support families and implement trauma-informed practices, ultimately helping to reduce the impact of trauma and promote healing. For child educators, this knowledge is essential to protect vulnerable children and foster their well-being and academic success.

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A report created by the Child Welfare Information Gateway states, "Dealing with child abuse and neglect is, in fact, a community effort. As leaders in their communities, educators are often in an ideal position to initiate this type of teamwork."

As some children spend most of their day with educators, the role of the teacher can be extremely important in mitigating child abuse & neglect. Here are some of the ways educators contribute to the safety of children and families:
Recognizing signs of abuse
The Role of Educators in Preventing and Responding to Child Abuse and Neglect Report by the Child Welfare Information Gateway states, "Educators are in an excellent position to notice behavioral indicators. As trained observers, they are sensitive to the range of behaviors exhibited by children at various developmental stages, and they are quick to notice behaviors that fall outside this range."

Since educators spend so much time with children, they can better notice physical, emotional, and behavioral changes. They can also talk to other educators that the child has interacted with to gain a better understanding of the child's usual behavior and any changes that may have occurred.

Resources such as the Child Welfare Training System (CWTS) - an advanced adult learning system for child welfare workers, other professionals, foster parents and mandatory reporters - can also help teachers learn more about recognizing signs of abuse.
Creating a safe environment
Educators also have the opportunity to create a safe environment in their classrooms and schools that allow children to feel comfortable to confide in them about potential abuse.

This allows children to feel safe in the school environment, opening them up to adults they can trust and talk to.
Supporting parents, caregivers, and family members
Because educators also interact with caregivers, they are in a position to advise parents on at-home strategies that can prevent child abuse and neglect. The CDC states that one of the protective factors that help prevent child abuse is "Families with strong social support networks and stable, positive relationships with the people around them."

By building relationships with families, educators can have an opinion in protecting the children around them.
Working alongside supportive school programs
Educator training and school programs that aid in preventing child abuse is fundamental to a child's support system. One example of educators working alongside support programs is the Trauma-Responsive Implementation and Practice (TRIP) program at The Kempe Center. The TRIP program integrates, enhances and implements trauma-responsive and culturally appropriate practices for parents, educators and others to help mitigate the impact of trauma. The program provides direct evidence-based clinical services to children and families, facilitates trainings for professionals across the human service fields and offers implementation guidance for child, youth and family-serving agencies.

Programs such as TRIP provide additional support to schools and educators to better advocate for child and family safety.
Educating themselves, and their students, on disparities
As we've talked about in our "Talking to your children about race, inequality, and diversity" blog post, educating oneself, and children, about disparities in society can also help society better understand the world around them.

Building a classroom or school environment that respects all experiences can allow children to feel safer, and more trusting of educators. The article "Five Activities to Promote Diversity in the Classroom" by Purdue University Global states, "It's up to teachers to help students explore cultures that differ from their own. "It's important for us all to honor our differences," says Weaver. "And as the adults in the classroom, teachers have to model what that looks like for our children."

Racial disparities still exist within child welfare. By helping children and parents alike understand this, educators are also introducing their community to the ways inequality might play a part in child abuse and neglect, reporting, and family experiences.

Most of all, by teaching this type of material, teachers can also take a deep delve into their own biases, which will allow them to take action to be better educators, and guides, for children and families.

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The Role of Educators in Child Abuse & Neglect Prevention - The Kempe Foundation

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A report created by the Child Welfare Information Gateway states, "Dealing with child abuse and neglect is, in fact, a community effort. As leaders in their communities, educators are often in an ideal position to initiate this type of teamwork." As some children spend most of their day with educators, the role of the [...]

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Classroom Strategies to Support Students

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Classroom Strategies to Support Students

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Context:

The article explains that supporting students who have experienced trauma requires a compassionate, structured, and proactive approach, as trauma can significantly affect their emotional, cognitive, and behavioral development. Educators need to recognize trauma symptoms such as headaches, difficulty concentrating, withdrawal, mood swings, and changes in communication to respond appropriately. Effective classroom strategies include creating safe and predictable environments with consistent routines and clear expectations, building positive relationships through regular check-ins and calm interactions, and using “in the moment” techniques like teaching self-regulation and validating emotions. After incidents, providing opportunities for reflection through journaling or art and following up with students helps reinforce support. Additionally, school-wide efforts such as staff training, engaging families and communities, and reviewing policies ensure a cohesive trauma-informed approach that fosters healing and academic success.

Relevance:

Children who experience these often struggle with emotional regulation, concentration, and behavior in the classroom due to the lasting impact of their adverse experiences. For child educators, understanding trauma symptoms and implementing trauma-informed strategies is crucial to creating a safe, predictable, and supportive learning environment. This knowledge helps educators respond with empathy rather than frustration, reducing re-traumatization and promoting healing. By recognizing and addressing the unique needs of trauma-affected students, educators can improve both their academic success and emotional well-being.

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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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Parental Divorce or Seperation and Children's Mental Health 

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Parental Divorce or Seperation and Children's Mental Health 

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Context:

The article reviews evidence linking parental divorce or separation to children’s mental health outcomes, acknowledging that while many children adjust well, on average, divorce is associated with increased risks of problems such as lower academic performance, conduct issues, substance use, depressed mood, and risky sexual behavior. Children of separated parents face a cascade of interrelated stressors, such as reduced parental resources, increased interparental conflict, less effective parenting, and diminished contact with one parent, that mediate much of the observed risk. The authors emphasize that although controlling for confounds reduces the strength of the association, it does not eliminate it, thus consistent with a partially causal interpretation. They also point out that moderating factors influence how children are affected, and call for more rigorous evaluation of interventions aimed at mitigating the negative effects of family instability.

Relevance:

The article highlights how divorce or separation can negatively affect childhood development through increased conflict, reduced parental support, and emotional stress, leading to issues like lower academic performance and behavioral problems. This is important for educators to understand, as they play a key role in recognizing these signs, offering support, and creating a stable learning environment. Being informed helps teachers respond with empathy and provide the right interventions to support a child’s well-being and development.

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Parental divorce or separation and children’s mental health

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An increasing number of children across the world experience family instability due to divorce/separation and the consequences of non‐marital childbearing/cohabitation1.

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The Impact of Divorce: All Children Only Get One Childhood

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The Impact of Divorce: All Children Only Get One Childhood

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The article emphasizes that when parents divorce, children often become inadvertent victims of adult conflict, even though divorce is ultimately a decision for the adults to manage. It argues that during the legal and emotional unraveling of a marriage, children’s needs can be overlooked as parents focus on their own hurt, anger, or logistical concerns. The authors warn that aggressive legal battles and parental antagonism can leave long‑term psychological scars on children, affecting trust, emotional security, and future relationships. To minimize damage, they suggest a set of guiding principles for divorcing parents: avoid speaking ill of one another to the children, refrain from making the children confidants, be truthful, treat one another civilly, keep the children informed, validate the children’s feelings, and prioritize the children’s interests above parental grievances.

Relevance:

This information is highly relevant to understanding how divorce or separation can affect childhood development, as it highlights the emotional impact of parental conflict on children. When children are caught in the middle of adult disputes, it can lead to lasting issues with trust, emotional security, and relationships, all of which can disrupt healthy development. For educators, this is important because they are in a position to notice emotional or behavioral changes in students. Understanding the effects of divorce enables educators to respond with sensitivity, offer appropriate support, and collaborate with families or counselors to ensure the child’s needs are met during a challenging time.

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The Impact Of Divorce: All Children Only Get One Childhood

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The Clay Center for Young Healthy Minds at Mass General Hospital is a free, online educational resource that educates parents and other caregivers.

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The Impact of Family Structure on the Health of Children: Effects of Divorce

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The Impact of Family Structure on the Health of Children: Effects of Divorce

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Context:

The article argues that children who live with their married, biological parents generally display better physical, emotional, and academic outcomes compared to children from divorced or single‑parent households. It reviews evidence showing that divorce often leads to losses in income, time with both parents, emotional security, and educational support, which can contribute to increased behavioral problems, diminished health, and lower achievement. The author concludes that, barring situations involving severe domestic violence, maintaining stable marriages may better support children’s well-being, and encourages pediatricians and policymakers to promote policies that bolster family stability.

Relevance:

This information is relevant because it highlights how divorce or separation can negatively affect multiple areas of a child's development, such as emotionally, physically, and academically, mainly due to reduced stability, parental involvement, and resources. These challenges can lead to behavioral issues and lower school performance. For child educators, understanding these effects is important because they are often the first to notice signs of distress in students. Being aware allows educators to respond with empathy, provide appropriate support, and collaborate with families or school counselors to help students stay on track during difficult transitions.

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Abstract

Nearly three decades of research evaluating the impact of family structure on the health and well-being of children demonstrates that children living with their married, biological parents consistently have better physical, emotional, and academic well-being. Pediatricians and society should promote the family structure that has the best chance of producing healthy children. The best scientific literature to date suggests that, with the exception of parents faced with unresolvable marital violence, children fare better when parents work at maintaining the marriage. Consequently, society should make every effort to support healthy marriages and to discourage married couples from divorcing.

Keywords: Divorce, Children, Emotional well being, Society

Epidemiology

The demographics of families are changing, and with that, the philosophical underpinnings of relationships are also changing. Many young adults feel marriage is old-fashioned and confining, and that open cohabitating relationships provide a healthier option that is more conducive to personal development. If a relationship does not provide personal happiness, parents often believe that their children will adapt to new family relationships so that divorce or separation will have few long-term, adverse consequences. These beliefs have led to marriage occurring later, women having fewer children and doing so later in life, single mothers giving birth to many of our children, more parents cohabitating, and fewer children living with their married, biologic parents.

In 1960, the average age of a woman's first marriage was 20.3 years; that of men was 22.8 years. But by 2010, that changed so that the median age at first marriage was 25.8 years for women and 28.3 years for men ( Copen et al. 2012). In 1960, the rate of marriage for women was 76.5 per 10,000, but this had decreased to 37.4 per 10,000 by 2008. The birth rate for the United States is now so low that it is below replacement rate, and 41 percent of all births in 2009 were to unmarried women. Nearly one in five births to women in their thirties was non-marital in 2007, compared with one in seven in 2002.

Children's lives track with these statistics. In 1970, 84 percent of children lived with their married biologic parents, whereas by 2009, only 60 percent did so. In 2009, only 29 percent of African-American children lived with their married biologic parents, while 50 percent were living in single-mother homes. Furthermore, 58 percent of Hispanic children lived with married biologic parents, while 25 percent were living in single-mother homes. Importantly, a recent Harvard study on single-parent families revealed that the most prominent factor preventing many children from upward mobility is living with a single parent ( Chetty et al. 2014).

In addition, the number of couples who choose to cohabit rather than marry has increased dramatically, with 4.9 million cohabiting couples in 2002, versus just 500,000 in 1970 ( U.S. Census Bureau 2003). Half of the unmarried births are to mothers who are in cohabitating relationships, and seven in ten children of cohabitating couples will experience parental separation. The dissolution rate of cohabitating couples is four times higher than married couples who did not cohabitate before marriage ( Osborne, Manning, and Stock 2007).

The Centers for Disease Control stopped gathering complete data on the number of children affected by divorce in 1988, and at that time more than one million children were affected ( Cohen 2002). Since then, the incidence of divorce has continued to climb, and according to the 2009 American Community Survey, only 45.8 percent of children reach age 17 years while still living with their biologic parents who were married before or around the time of the child's birth ( Fagan and Zill 2011). The majority of divorces affect younger children since 72 percent of divorces occur during the first 14 years of marriage. Because a high percentage of divorced adults remarry, and 40 percent of these remarriages also end in divorce, children may be subjected to multiple family realignments ( Cohen 2002).

The precipitating causes of divorce have also changed over time. Prior to no-fault divorce laws, the legal procedures for obtaining a divorce were often difficult and expensive, so that only the most dysfunctional marriages ended in divorce. Children who are removed from the most dysfunctional environments are more likely to do better after the divorce. However, with the introduction of no-fault divorce laws, it is likely that the child has not experienced severe levels of parental discord, so the divorce has more adverse effects on the child. One study seems to conclude that the majority of more recent divorces were not preceded by an extended period of marital conflict ( Amato and Booth 1997 as quoted in Amato 2001).

Divorce and parental separation are damaging to children, families, the economy, and society as a whole, and this paper outlines these adverse effects. While recognizing that not all children or parents will experience every negative consequence listed below, given the seriousness of these adverse outcomes and the magnitude of the issue, it is important that pediatricians support public policies that promote the health and preservation of the child's biologic family.

Evaluating the Literature

When evaluating the scientific research on the effects of divorce on children and parents, it is important to consider all of the factors affecting the outcome, including family dynamics, children's temperaments and ages at the time of divorce, and family socioeconomic status, as well as any behavioral or academic concerns present prior to divorce. Some adverse effects noted in the literature after divorce are actually diminished when controlled for their presence prior to divorce. It is also important to note that violence in a home is never acceptable and can have serious adverse effects on children's behavior, development, academic success, and future health.

Effects of Divorce on Children

Each child and each family are obviously unique, with different strengths and weaknesses, different personalities and temperaments, and varying degrees of social, emotional, and economic resources, as well as differing family situations prior to divorce. Despite these differences, divorce has been shown to diminish a child's future competence in all areas of life, including family relationships, education, emotional well-being, and future earning power. One review of the literature conducted in the United Kingdom found that "although children are at increased risk of adverse outcomes following family breakdown and that negative outcomes can persist into adulthood, the difference between children from intact and non-intact families is a small one, and the majority of children will not be adversely affected in the long-term" ( Mooney, Oliver, and Smith 2009). There is much research, however, that offers evidence to the contrary.

Two large meta-analyses, one reported in 1991 and the other reported ten years later in 2001, showed that "children with divorced parents continued to score significantly lower on measures of academic achievement, conduct, psychological adjustment, self-concept, and social relations" ( Amato and Keith 1991; Amato and Booth 1997 as quoted in Amato 2001).

This research demonstrates that, when a child experiences parental divorce, there are significant losses that must be acknowledged.

The child may lose time with each parent

1.
Parents must adjust to their own losses as well as to their new role as a divorced parent. Thus, parents may not have as much emotional strength and time to invest in parenting, i.e., the parents experience a "moratorium on parenting."

2.
Although laws are gradually changing, most children spend more time with one custodial parent and obviously have less time with each parent overall.

3.
For most children, this means much less time spent with their fathers.

4.
The child may also spend less time with their mother as she may need to work longer hours to support the family.

The child may lose economic security

1.

Custodial mothers experience the loss of 25-50 percent of their pre-divorce income.

a. Women who divorced in the past 12 months were more likely to receive public assistance than divorced men (23% versus 15%) ( U.S. Census Bureau 2011).

b. Even five years after the divorce, mothers who remain single have only risen to 94 percent of their pre-divorce income, while continuously married couples have increased their income.

2.
Only 50 percent of custodial mothers have child support agreements, and 25 percent of mothers who have been granted support receive no payments.

3.
Custodial fathers also experience financial loss; although they tend to recover financially more quickly and rarely receive child support.

4.
Loss of income may lead to increased work time for parents, as well as a change in residence.

5.

Children living with single mothers are much more likely to live in poverty than children living with both married parents ( Edwards 2014).

a. In 2009, children living with a divorced parent were more likely to live in a household below the poverty level (28%) compared with other children (19%) ( U.S. Census Bureau 2011).

6.

Unmarried women are more likely to remain in poverty compared with married individuals and unmarried men ( Edwards 2014).

a. Approximately 32.2 percent of people in single-mother families in poverty during the first two months of 2009 continued to be in poverty for 36 months. In contrast, only 18.7 percent of people in married-couple families in poverty during this same time remained in poverty for 36 months.

7.

Children living with single parents are less likely to experience upward financial mobility.

a. The fraction of children living in single-parent households is the strongest negative correlate of upward income mobility according to one study ( Chetty et al. 2014).

b. The percentage of married families in a community also contributes to future upward economic mobility of all children in the community ( Chetty et al. 2014).

The child may lose emotional security (Amato and Afifi 2006)

The child may have decreased social and psychological maturation

The child may change his or her outlook on sexual behavior

4.
Boys similarly have earlier sexual debut and higher rates of sexually transmitted disease when they have experienced divorce in their family.

7.
The children of divorced parents are two to three times more likely to cohabit and to do so at younger ages (Amato and Booth 1997, 112, as quoted in Fagan and Churchill 2012, 26).

The child may lose his/her religious faith and practice (Myers 1996)

The child may lose cognitive and academic stimulation

The child may be less physically healthy

The child may have a higher risk of emotional distress

Effects of Divorce on Parents

Parents who divorce also experience adverse effects on their physical, emotional, and financial well-being, which may also in turn affect their children.

Married (male/female) people are more likely to have better physical health

5.

Married men live longer than men who never married.

a. In the Framingham Offspring Study, married men had a 46 percent lower rate of dying from cardiovascular disease than unmarried men ( Goodwin et al. 1987).

Married (male/female) people are more likely to have higher incomes

Married women are more likely to be physically safer than divorced or separated women

Married individuals are more likely to be involved in their community

Divorce may have adverse long-term emotional effects for parents

One study demonstrated that those who were unhappy in their marriage when first surveyed, but remained married, were likely to have an improved relationship and be happier five years later than those who divorced ( Wallerstein and Blakeslee 2004, 45).

Effects of Divorce on Society

Divorce adversely affects society by

1.
Diminishing the child's future competence.

2.
Weakening the family structure.

3.
Contributing to early sexual experimentation leading to increased costs for society.

4.
Adversely affecting religious practice-divorce diminishes the frequency of religious worship.

5.
Diminishing a child's learning capacity and educational attainment.

6.
Reducing the household income.

8.
Increasing risk for school suspensions, "Persons in Need of Supervision" status, binge drinking, and marijuana use ( Demuth and Brown 2004; Eckenrode, Mrcynyszyn, and Evans 2008; Osborne, Manning, and Stock 2007).

9.
Increasing emotional and mental health risks, including suicide.

Studies have attempted to estimate the financial cost of divorce to the United States, with most recent estimates reaching $33.3 billion per year, and with adolescent pregnancy costing at least $7 billion ( Schramm 2003).

Conclusion

There are clearly negative long-term consequences of divorce-children, parents, and society all suffer. Wallerstein's long-term study shows that many children never have full "recovery" as each special event, holiday, or celebration reminds the child of his/her loss. Given these tremendous costs borne by all individuals affected by divorce, as well as the costs to society, it is the responsibility of physicians-especially pediatricians, who care for children in the context of their families-to advocate for public health policies that promote marriage and decrease the likelihood of divorce.

Acknowledgements

The American College of Pediatricians is a national organization of pediatricians and other healthcare professionals dedicated to the health and well-being of children. Formed in 2002, the College is committed to fulfilling its mission by producing sound policy, based on the best available research, to assist parents and to influence society in the endeavor of child rearing. Membership is open to qualifying healthcare professionals who share the College's Mission, Vision and Values. The home office is in Gainesville, Florida, the website is http://www.acpeds.org and the office telephone number is 888-376-1877.

Biography

Dr. Jane Anderson is a Clinical Professor of Pediatrics at the University of California, San Francisco, where she practiced for 33 years until her retirement in November, 2012. She continues there as a volunteer faculty member. She has authored numerous articles on general pediatric topics, has presented lectures on adolescent brain development and parenting in both the US and China, and has received teaching awards from medical students and pediatric residents, including the 2014 Volunteer Faculty Teaching Award from the pediatric residents at the University of California, San Francisco. Dr. Anderson provided testimony on behalf of Alaska's parental notification law demonstrating in her testimony that parental notification is in the best interest of adolescents, and the judge upheld the law.

She has been married to her husband, Karl, for 39 years, and has four children. She participates annually in short-term medical missions trips with Medical Servants International, and is on the Board of Directors of the National Physician Center. She has been a member of the American College of Pediatricians since 2002 and currently serves on its Board.

References

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4. ChildStats.gov. 2013. America's Children: Key National Indicators of Well-Being, 2013: Emotional and Behavioral Difficulties (2013) http://www.childstats.gov/americaschildren/health3.asp.

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6. Edwards A.N. 2014 Dynamics of Economic Well-being: Poverty, 2009-2001: Household Economic Studies (2014) United States Census Bureau Web Site. http://www.census.gov/prod/2014pubs/p70-137.pdf .

7. Ellis B.J., Bates J.E., Dodge K.A., Fergusson D.M., Horwood L.J., Pettit G.S., and Woodward L.. 2003. Does father absence place daughters at special risk for early sexual activity and teenage pregnancy? Child Dev 74: 810-1. [DOI] [PMC free article] [PubMed] [Google Scholar]

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13. US Census Bureau. 2003. "Unmarried-Couple Households, by Presence of Children: 1960 to Present," Table UC-1, June 12, 2003.

14. US Census Bureau. 2011. Divorce Rates Highest in the South, Lowest in the Northeast, Census Bureau Reports United States Census Bureau Web Site. http://www.census.gov/newsroom/releases/archives/marital_status_living_arrangements/cb11-144.html.

Articles from The Linacre Quarterly are provided here courtesy of SAGE Publications

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The impact of family structure on the health of children: Effects of divorce

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Nearly three decades of research evaluating the impact of family structure on the health and well-being of children demonstrates that children living with their married, biological parents consistently have better physical, emotional, and academic ...

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The Impact of Divorce on Children: Tamara D. Afifi TEDX

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The Impact of Divorce on Children: Tamara D. Afifi TEDX

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Context:

In her TEDx talk, "The Impact of Divorce on Children," Dr. Tamara D. Afifi discusses how parental divorce affects children's emotional and psychological well-being. She emphasizes that while divorce can be distressing, the level of parental conflict during and after the separation plays a crucial role in determining the extent of the impact on children. High levels of conflict can lead to increased stress and emotional difficulties for children, whereas lower conflict levels can mitigate these effects. Dr. Afifi also highlights the importance of maintaining healthy communication between parents and providing children with consistent support to help them navigate the challenges of divorce.

Relevance:

For child educators, understanding these dynamics is essential. Recognizing the signs of emotional distress related to parental separation allows educators to offer appropriate support and create a stable environment for affected students. By fostering open communication and collaborating with families, educators can play a pivotal role in helping children cope with the changes and maintain their academic and emotional development.

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The impact of divorce on children: Tamara D. Afifi at TEDxUCSB

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Does Shared Parenting Help or Hurt Children in High-Conflict Divorced Families? 

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Does Shared Parenting Help or Hurt Children in High-Conflict Divorced Families? 

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Context:

The paper reviews existing research on whether shared parenting is beneficial or harmful in cases of high interparental conflict. It finds that in long‑term, high‑conflict settings, greater shared parenting is sometimes associated with poorer child adjustment, though that association is weaker or absent when conflict is assessed nearer to the time of divorce. Gender differences emerge in some studies. However, the quality of parenting by one or both parents often acts as a buffer, as high parenting quality can mitigate negative effects even when conflict is high. The authors emphasize that decisions about shared parenting in high‑conflict cases should carefully weigh the severity and nature of conflict, the exposure of children to conflict, and each parent’s capacity for high‑quality parenting.

Relevance:

This information is relevant because it shows that shared parenting after divorce can have mixed effects on childhood development, especially when parents are in high conflict. While shared time with both parents is often seen as beneficial, ongoing conflict can harm children emotionally and behaviorally; however, when at least one parent provides consistent, warm, and supportive care, it can help protect children from these negative effects. For educators, this is important because they may observe the impact of these family dynamics in the classroom. Understanding the role of conflict and parenting quality helps educators better support students, recognize when additional help is needed, and communicate more effectively with families navigating divorce.

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. Author manuscript; available in PMC: 2021 Mar 23.

Abstract

Despite a recent shift in the allocation of parenting time arrangements following divorce, there is no clear consensus regarding the effects of shared parenting on children's adjustment in high conflict families. We propose key questions and methodological options to increase the ability of results from well-designed empirical studies to inform practice and policy. We review eleven studies of the relations between parenting time and quality of parenting with children's adjustment in high conflict divorced families. Despite heterogeneity of the methods used across the studies some tentative conclusions can be made based on findings across multiple studies. Higher levels of shared parenting were related to poorer child adjustment in samples with high conflict many years following the divorce, but typically not in samples that assessed conflict during the divorcing process or in the two or three years following the divorce. There is also evidence that the effects of shared parenting on child adjustment in the presence of high conflict differs by gender, and that high quality of parenting by at least one parent is associated with better child adjustment in high conflict divorces. Implications for policy and practice are discussed as well as directions for research to strengthen the knowledge base to inform policy.

Keywords: Interparental Conflict, Parenting Time, Parenting Quality, Fathers, Youth Adjustment, Shared Parenting

Over the past several decades, there has been a significant shift in the allocation of parenting time following divorce, such that fathers are receiving more parenting time than ever before ( Meyer, Cancian, & Cook, 2017). Reasons for this cultural shift in parenting time include increases in women's participation in the workforce, legislation encouraging shared parenting arrangements, changing attitudes about the benefits of father involvement in children's upbringing ( Lamb, 2012) and changes in what is considered a fair distribution of parenting time following divorce ( Braver, Ellman, Votruba & Fabricius, 2011). As shared parenting arrangements have become more widely accepted, changes in court practices have followed, either by holding a presumption for shared parenting ( Fabricius, Aarons, Akins & Assini, 2017) or by imposing shared parenting on families that cannot reach a voluntary agreement on a parenting plan ( Smart, 2004). Although there is broad agreement that shared parenting is generally associated with better child adjustment following divorce (Braver, 2017), there is disagreement about whether this generalization holds under conditions of high interparental conflict ( Nielsen, 2017; Smyth, McIntosh, Emery, & Howarth, 2016).

Over the past two decades, three groups have made recommendations related to shared parenting, including optimal parenting arrangements in the context of high interparental conflict. In 1997, a group sponsored by the National Institute of Child Health and Human Development ( Lamb, Sternberg, & Thompson, 1997) emphasized the importance of both parents staying involved following separation or divorce and recognized the need to protect children from an ongoing pattern of violence between parents but did not provide special recommendations for parenting arrangements when high levels of non-violent conflict were present. In 2013, a group sponsored by the Association of Family and Conciliation Courts advocated for a balance of the needs to maintain family relationships following divorce and protect children from exposure to high levels of interparental conflict ( Pruett & DiFonzo, 2014). This group of judges, lawyers, mental health professionals, and social scientists proposed that decisions should be made on a case-by-case basis for families with high levels of conflict. Their report cautioned against using research findings uniformly, particularly in high conflict cases, and instead advocated that research should inform lines of inquiry and variables to consider when assessing families during custody evaluations. They reached no consensus on shared parenting for young children. A third group reached consensus that shared parenting was appropriate for families with young children ( Warshak, 2014, with 110 endorsements from researchers and practitioners). The report considered the special case of high conflict families (i.e., families who litigate custody or show conflict in their interactions) and supported the consideration of shared parenting arrangements even in families with high levels of interparental conflict. This group suggested that courts heavily weigh their assessment of the quality of parenting in both parents and consider ways to improve transitions between parents and reduce conflict, rather than dismiss the option of shared parenting arrangements in cases of high interparental conflict.

Despite the considerable attention that the issue has received, there continues to be conflicting recommendations from prominent social scientists about whether shared parenting is likely to be in the best interest of children in divorced families when there is a high level of interparental conflict ( Nielsen, 2017; Smyth et al., 2016). Further, it remains unclear how much quality of parenting should be considered. Many have argued that it is important to consider quality of parenting when deciding on parenting time arrangements in high conflict divorces because quality of parenting is more strongly associated with child adjustment than parenting time per se ( Adamsons & Johnson, 2013).

Critical Questions for the Scientific Community

For the scientific community to better inform policy recommendations for parenting time in families with high interparental conflict, there are three critical questions that need to be addressed:

1. Is shared parenting time associated with better child adjustment when there are high levels of interparental conflict?

2. Is the quality of mothers' and fathers' parenting associated with better child adjustment when there is high interparental conflict?

3. Do shared parenting time and quality of parenting interact to influence child adjustment in high conflict families?

Before reviewing the studies that have addressed these questions we will discuss how interparental conflict, parenting quality, and parenting time have been defined and measured in the literature.

Defining and Measuring Interparental Conflict (IPC).

IPC following divorce has been defined broadly in the literature to include a wide range of factors including anger, unresolved grief, hostile contempt, uncooperative co-parenting, verbal and physical fighting, and legal conflict between the parents ( Nielsen, 2017; Smyth et al., 2016). Previous research and large-scale meta-analyses have documented the negative impact of IPC on a wide range of youth adjustment outcomes including internalizing and externalizing problems, self-esteem, and relationship problems ( Rhoades, 2008). However, the measures of IPC used in the literature differ in their association with child adjustment. For example, Goodman and colleagues found only modest relations among mothers' and fathers' ratings of IPC, "incompetent parenting" by the other parent, and legal conflict (range of r = .24 - .39), and reported that only the measure of mother and father IPC was related to child mental health problems ( Goodman, Bonds, Sandler, & Braver, 2004).

Several factors are important to consider when assessing IPC. First, conflict should be distinguished from domestic violence, which refers to severe emotional and physical abuse that occurs between parents. This distinction has been noted by reviews of the literature on factors that may influence decisions about parenting time arrangements following divorce ( Lamb et al., 1997; Warshak, 2013). Second, it is important to distinguish between high IPC that occurs immediately following separation and during the custody deliberations but declines over time ( Hetherington & Kelly, 2002) and conflict that persists years later. Third, the intensity of IPC can range from verbal disagreements to verbal abuse. Fourth, the IPC may or may not involve, or occur in front of, the children. And fifth, reporter effects are important to consider. Children's exposure to IPC may be best assessed by child report rather than parent report ( Davern, Staiger, & Luk, 2005).

Defining and Measuring Quality of Parenting.

Parenting quality is a broad term that has been applied to several constructs including the quality of the parent-child relationship (e.g., warmth, communication, support, encouragement, closeness), parental involvement in children's activities, and use of effective discipline (e.g., consistency, appropriate consequences, effective monitoring). The combination of a warm parent-child relationship and use of appropriate discipline has been consistently linked with positive child adjustment following divorce ( Adamson & Johnson, 2013; Sandler, Wolchik, Winslow, Mahrer, Moran, & Weinstock, 2012). Reliable and valid measures of the quality of parenting by mother and father have been developed, although sometimes different measures are used for fathers because children have historically lived primarily with their mothers after divorce. For example, many studies use fathers' parenting time and involvement in their children's activities as proxy measures for quality of parenting (see Fabricius, Sokol, Diaz, & Braver, 2012 for review). In contrast, mother's quality of parenting tends to be assessed more directly with measures asking about specific aspects of parenting such as warmth, communication and discipline style.

Defining and Measuring Parenting Time.

Shared parenting is typically defined as living with each parent a minimum of 30% of the time and has been measured by some researchers as a dichotomous variable of "shared" physical residential parenting versus "sole" or "primary" residential parenting. Other researchers report parenting time as a continuous variable, by measuring the number of overnights, or the typical number of days and nights children spend with each parent ( Fabricius et al., 2012).

Theories concerning the effects of parenting time and quality of parenting in high conflict divorced families.

There are competing theories regarding how contact with the parent who has less parenting time predicts child adjustment in high conflict divorces. Because this parent is usually the father, we will refer to this parent as the father in this paper. The "conflict hypothesis" posits that there is an interaction between conflict and parenting time, such that greater amounts of father parenting time is beneficial when conflict is low, but harmful when conflict is high. The theory holds that in high conflict families, more time with father creates more opportunities for children to be exposed to IPC (e.g., Johnston, Kline, & Tschann, 1989) and thus have more adjustment problems (see Nielsen, 2017 for review of evidence concerning this theory). A competing theory posits that in high conflict as well as low conflict divorces more time with the father should predict better child adjustment because it increases the potential benefit of the support the father provides ( Fabricius et al., 2012; Lamb, 2012). We refer to this as the "benefits hypothesis." A further variant of the benefits hypothesis is that, in order to understand the relation between parenting time and child adjustment, the quality of parenting needs to be considered, such that children in high conflict families benefit from shared parenting only when children receive high quality parenting ( Lamb, 2012; Sandler, Wheeler, & Braver, 2013).

Research designs to test the various theories.

Several analytic approaches have been used to test the question of whether the benefits of time or quality of parenting persist even when there is a high level of conflict between the parents following the divorce. One approach compares the relations between parenting time (or parenting quality) of the father and child adjustment, taking into account (or statistically controlling for) the level of IPC. Studies using this approach generally find better adjustment outcomes (mental health and academic) in children with shared parenting or more time with the father (e.g., Buchanan, Maccoby, & Dornbusch, 1996; Gunnoe & Braver, 2001; see Nielsen, 2017 for review). These findings indicate that children benefit from more time with their fathers, even when accounting for the negative effects of IPC. A second approach compares the effect of IPC on child adjustment with the effects of father parenting time or quality of father parenting on child adjustment to determine whether conflict has a stronger negative effect on child adjustment compared to the positive effect of parenting time and/or quality of parenting. Some studies have found that parenting quality is a stronger predictor of positive child adjustment relative to IPC (e.g., Fauber, Forehand, Thomas, & Wierson, 1990). However, neither of these approaches directly addresses the question of how parenting time or quality of parenting is positively or negatively related to child adjustment when there is high IPC.

We propose that researchers design studies that consider the two-way interaction between IPC and parenting time or quality of parenting in predicting child adjustment. This would help to determine whether more father parenting time or a high-quality relationship with the father is likely to help or hurt child adjustment in families with high IPC. A positive relation between father parenting time and child adjustment problems under conditions of high conflict would support the conflict hypothesis. A negative relation would support the benefit hypothesis. In high conflict samples (e.g., families court ordered to high conflict classes), a test of the simple effects of parenting time on child outcomes would be sufficient to test the conflict and benefit hypotheses. These interaction models could also answer more complicated, and as yet unanswered questions. For example, does the effect of father parenting time on child adjustment in high conflict families depend on the quality of his parenting? That is, shared parenting time may be related to better child adjustment for high conflict families when there is high quality parenting, but not when there is low quality parenting. These models can be tested as triple interaction effects, between IPC, parenting time, and parenting quality, although adequate power to detect complex interactive effects requires large sample sizes.

Another approach is to assess the levels of child adjustment problems in families that are characterized by different combinations of parenting time, quality and IPC. An advantage of this approach is that it starts by identifying the different patterns (or profiles) of parenting time, quality and IPC that best characterize the sample being studied and the percentage of families that represent each pattern. For example, although it may be of theoretical interest to understand children's adjustment in families characterized by high father parenting time, low quality parenting, and high IPC, the policy implications of that pattern would differ greatly depending on what percent of families are characterized as having that pattern. A limitation of this approach is that the profiles of most interest to policy makers (e.g., high conflict, shared parenting, high quality of parenting) may not be the ones that best characterize the samples that are studied. Common examples of this approach are latent profile analysis (LPA) and latent class analyses (LCA), both of which allow for inclusion of many variables in the model and create profiles based on common patterns among the participants.

Current empirical evidence of the joint effects of IPC, parenting time, and parenting quality on child adjustment.

We have found eleven studies that examined the joint relations between parenting time, parenting quality, and IPC and child adjustment following divorce using the analytic approaches described above (See appendix available online for a table expanding on the details of these studies). We discuss findings from these studies to systematically address the joint effects of conflict, parenting time, and parenting quality on children's post-divorce adjustment. We first report findings from all studies that report on the associations of parenting time with child adjustment under conditions of high conflict. We then report findings from studies that report on the associations between parenting quality and child adjustment under conditions of high conflict. Finally, we report on studies that report on the joint effects of parenting time and quality under conditions of high conflict.

Question 1: IPC and Parenting Time.

Seven studies analyzed the interactions between father parenting time and IPC in regard to children's adjustment. Significant conflict x parenting time interactions were found in four of the seven studies. In three of these studies, the interaction between parenting time and conflict differed by gender of the child ( Amato & Rezac, 1994; Johnston, Kline, and Tschann, 1989; Vanassche, Sodermans, Matthijs, & Swicegood, 2013). Three other studies did not find a significant interaction between conflict and parenting time ( Fabricius & Luecken, 2007; Gunnoe & Braver, 2001; Kaspiew, Gray, Weston, Moloney, Hand, & Qu, 2009).

Vanassche and colleagues studied mother/father parenting time and IPC in a large representative sample of adolescents of divorced families in Belgium (mean time since divorce = 7.8 years) ( Vanassche et al., 2013). The children in the "joint custody" families were living at least one third of the time with each parent versus those in "primary maternal custody" who lived more than two thirds of the time with the mother. When girls reported high levels of IPC, those in joint custody had significantly higher feelings of depression and marginally lower life satisfaction than girls in primary maternal custody. There was no similar interaction for boys.

A second study also found differences between boys' and girls' outcomes when considering the interaction between IPC and father parenting time ( Amato & Rezac, 1994). There were 725 children between the ages of 5 and 18 in the subsample with divorced parents. "Contact" was broadly defined as anything from phone calls and letters to spending in-person time with the father. In the high conflict families, boys who had the most contact with their fathers had more behavioral problems than boys who had less father contact. Boys had the fewest behavioral problems when father contact was high and parent conflict was low. There was no significant father contact x conflict effect for the girls.

The third study finding differences between boys and girls was conducted roughly four and a half years after the parents' separation ( Johnston et al.,1989). In this study of 100 children ages 1 to 12, all of the parents were considered "high" conflict because they had been court referred for counseling or mediation services. Children who were in the clinically disturbed range using the Total Behavior Problem Score clinical criterion (above the 90%, Achenbach & Edelbrock, 1983) had higher levels of access to the less seen parent. Also, more transitions between parents was associated with clinically disturbed levels of social competence (lower 10%). Probing indicated a gender difference in the relations between contact and children's behavior problems. For boys (but not girls), more access to the less seen parent was associated with lower social competence. For girls (but not boys), greater access to the less seen parent was related to higher behavior problems.

Healy, Malley, and Stewart's study (1990) studied 121 recently separated families (children ages 6 - 12) with primary maternal custody immediately following the divorce and again one year later. There was a significant interaction between "legal" conflict and father parenting time (i.e., visitation regularity and frequency) in predicting mothers' reports of children's behavior problems and children's reports of self-esteem measured concurrently. Regular and frequent visits with the father were related to fewer behavior problems for children in families with high legal conflict. When predicting self-esteem, higher regularity of visits was associated with lower self-esteem when legal conflict was high, but with higher self-esteem when legal conflict was low. In their prospective longitudinal analysis the interaction effects between conflict and father visitation frequency and regularity were not significant in predicting children's self-esteem or behavior problems on year later.

Three studies did not find significant interactions effects between IPC and parenting time in predicting child adjustment. Fabricius and Luecken (2007), in a retrospective longitudinal study of 266 college students with a wide range of time since divorce found that more father parenting time was associated with less feelings of distress surrounding the divorce and more IPC was associated with more feelings of distress. The effects of father parenting time and IPC did not depend on levels of the other factor. Gunnoe and Braver (2001) studied 78 parents of younger children (mean age of approximately 8 years) two years after divorce. They found that children with joint legal custody arrangements had fewer impulsive behavior problems than children with sole maternal custody. This positive effect of father parenting time was not dependent on pre-decree level of IPC. Kaspiew and colleagues (2009) explored the interaction between IPC and parenting time on child adjustment using data from the Longitudinal Study of Separated Families, a large national sample from Australia of 10,000 parents within 26 months of separation. Interparental relationship quality was defined as a categorical variable that delineated friendly/cooperative, distant, and conflictual/fearful parents; several care-time arrangements were examined, including father minority, shared care, mother minority, and no father contact. These researchers found no consistent pattern of significant interaction effects of interparental relationship x care arrangements in predicting child adjustment.

Question 2: IPC and Parenting Quality.

To assess the interactions between conflict and parenting quality, Sandler and colleagues conducted a cross-sectional study with 182 recently divorced families with children between 5 and 12 years old who participated in the "Dads for Life" intervention study ( Sandler, Miles, Cookston, & Braver, 2008). The researchers defined parenting quality as the warmth of children's self-reported relationship separately for mothers and fathers. There was no significant interaction between IPC and either mother warmth or father warmth in predicting children's internalizing or externalizing problems. However, there was a significant three-way interaction in predicting children's internalizing problems. When IPC was high, higher warmth from either the mother or father was associated with lower child internalizing problems when warmth from the other parent was low. Children had the highest levels of internalizing problems when both maternal warmth and paternal warmth were low.

Sandler, Wheeler, and Braver (2013) investigated the relations between quality of mother and father parenting and child mental health problems in a sample of 141 divorced and separating families who were court ordered to attend a class for families with high conflict. The average length of time since separation was five years. Consistent with the effect found by Sandler et al. (2008) for high conflict families, the quality of both father and mother relationships with the children predicted lower child mental health problems when quality of parenting by the other parent was either moderate or low, but not when parenting quality of the other parent was high.

Examining the interaction between father parenting quality (i.e., children's report of closeness) and legal conflict, Healy et al. (1990) found that closeness with the father was not related to child problems when legal conflict was high, but was related to lower child problems when legal conflict was low. This study only assessed the quality of relationship with the father, so they were not able to test whether this effect was further moderated by quality of relationship with the mother.

Question 3: IPC, Parenting Quality, and Parenting Time.

Sandler and colleagues (2013) examined the interaction between father parenting time (i.e., overnights) and parenting quality in predicting child mental health problems in a sample of high conflict divorces. They found a significant interaction between number of overnights and quality of parenting in predicting children's mental health problems, such that higher quality of parenting was only related to lower problems when there was a higher level of time with the child (approximately 30% time). This effect was found for both mother and father parenting time.

In two longitudinal studies, Sandler and colleagues examined the interactions between parental conflict, father parenting time, quality of the father-child relationship and young adults' adjustment across a period of 17 years after the parents' divorce in a sample of 240 families who participated in an intervention for divorced mothers, ( Elam, Sandler, Wolchik & Tein, 2016; Modecki, Hagan, Sandler, and Wolchik, 2014). In these studies, contact with the father included the father writing to or phoning the children, in addition to spending time together in-person. Parents in these studies divorced in the early 1990's when father's typical parenting time after divorce was much lower than in more recent studies. Modecki, Hagan, Sandler, and Wolchik (2014) examined how patterns of IPC, father's parenting quality (i.e., psychosocial support), and father's parenting time (i.e., contact) 6 - 8 years after the divorce (when youth were 15-18 years old), predicted adjustment nine years later (15 - 17 years after the divorce, when youth were 24-27 years old). The authors found three distinct profiles of families: 1) moderate contact, moderate support, and low IPC; 2) low contact, low support, and moderate IPC; and 3) high contact, high support, and high IPC. Young adults whose fathers had moderate contact/moderate support and low IPC had significantly higher academic achievement and marginally lower externalizing problems compared to young adults whose fathers had either the highest or lowest levels of involvement and where there was higher IPC. However, there were no significant differences between the three profiles in how they predicted internalizing problems. These results were interpreted to demonstrate the benefit of a low level of conflict, regardless of the levels of contact or support.

Elam and colleagues ( Elam, Sandler, Wolchik, & Tein, 2016) conducted a similar analysis with the same sample of 240 families, six years earlier. They examined how patterns of IPC, father's parenting quality (i.e., psychosocial support), and father's parenting time (i.e., contact) were associated with children's adjustment problems concurrently (an average of 12 months following the divorce, when children were 9 - 12 years old) and predicted child adjustment problems six years later. Latent profile analyses revealed four profiles: 1) high contact, moderate conflict, moderate support, 2) low contact, moderate conflict, low support, 3) moderate contact, high conflict, moderate support, and 4) moderate contact, low conflict, moderate support. The relations between the various profiles and youth mental health outcomes concurrently and 6 years later differed. In the concurrent analyses, children in the moderate contact, high conflict, and moderate support group had higher levels of internalizing and externalizing problems compared to children in the other profiles. However, in predicting child behavior problems 6 years after the divorce, contact appeared to be the more salient variable, with children in the low contact, low support and moderate conflict group demonstrating higher levels of internalizing and externalizing problems compared to the moderate contact, moderate support, high conflict group, and greater internalizing problems compared to the moderate contact, moderate support and low conflict group. These findings suggest that immediately following the divorce, there is more support for the conflict hypothesis but that over time there is greater support for the benefits hypothesis in predicting children's adjustment.

Limitations of Current Evidence

Differences between the samples on key variables such as time since separation or divorce, parenting or custody arrangement, measurement of constructs (e.g., conflict, parenting time, or quality of parenting), and whether the study was cross-sectional or prospective longitudinal pose limitations in our ability to compare the findings. For example, there is high variability in how parenting time is measured, with some studies dichotomizing samples into full versus shared arrangements, and others measuring any type of father contact (e.g., phone calls, etc.). Thus, it is unclear whether differences across the studies are due to inconsistency in actual effects versus methodological differences. Further, secular trends in the acceptance of shared parenting ( Smart, 2004) may explain differences in findings from studies conducted in the 1980s and those conducted in the 2000's, which inherently have a different distribution of parenting time between mothers and fathers. Another significant limitation is that most samples consist of predominantly non-Hispanic white families. Implications of the findings may not be generalizable to ethnic minority families with different arrangements of family structure and traditions after divorce ( Foster & Kalil, 2007). Also, the reviewed studies do not include infants and toddlers, who may require different parenting time arrangements depending on levels of IPC. Finally, there was not a sufficient sample size of studies to conduct a quantitative analysis to examine the heterogeneity of effect sizes across key variables such as child age or gender, or time since divorce.

Summary of findings from empirical studies

Despite the limited number and heterogeneity of the studies, some tentative conclusions based on the findings can be discerned. First, in the four studies that found that higher father contact was associated with more child problems for high conflict divorced families, conflict was assessed several years after the divorce, and this effect depended on the child's gender in three of the four studies ( Amato & Rezac, 1994; Johnston et al., 1989; Modecki et al., 2015; Vanassche et al., 2013). However, the studies that assessed the interaction between parenting time and IPC more proximally to divorce (either during the divorce or within the first years following), had mixed results. Elam and colleagues (2016) found that the high IPC, high father contact group had higher child problems concurrently, but in contrast, the moderate IPC, low father contact group had more problems six years later. Healy and colleagues (1990) reported that in high IPC families, father parenting time related to lower child behavior problems, but also related to lower self-esteem. Three additional studies did not find a significant interaction between father parenting time and IPC ( Fabricius & Luecken, 2007; Gunnoe & Braver; Kaspiew et al., 2009). Taken together, these nine studies suggest that the positive or negative effects of higher levels of father parenting time in high conflict divorces may depend on whether conflict is assessed more proximally to the divorce (within the first several years) or reflects conflict that persists over a more prolonged period of time.

There is also suggestive evidence that both mother's and father's quality of parenting can be protective in the context of high IPC. Two studies found that in high conflict divorces, higher quality of parenting by either the mother or father was related to lower child adjustment problems when the relationship with the other parent was either poor or moderate, but not when the relationship with the other parent was very good ( Sandler et al., 2008; Sandler et al., 2013). The one study that found that closeness with the father was not significantly related to child problems (i.e., was not protective) when legal conflict was high, did not examine the effect of closeness with the mother ( Healy et al., 1990). It is likely, therefore, that the effect of parenting quality on child adjustment in high conflict families is best understood when considering the parenting by both the mother and father.

Most studies included gender of the child as a control variable, with only three studies including an interaction term to test gender differences in the context of IPC. Gender moderated the effects such that more father parenting time in high conflict families affected boys and girls differently. One study found that when there was high IPC, joint physical custody was associated with higher depressive symptoms for girls, but not for boys ( Vanassche et al., 2013). Another found a negative effect of more father contact on behavior problems for boys when there was high IPC, but not for girls ( Amato & Rezac, 1994). The third study with high conflict families found that boys who had more frequent access with the less seen parent exhibited lower social competence scores but for girls, more frequent access was related to more behavior problems ( Johnston et al., 1989). Given the lack of consistency across findings, it is unclear as to which gender may be more negatively affected.

Implications for court policy and practice concerning post-divorce parenting time.

Some tentative implications can be drawn concerning policy and practice issues facing the family courts. Although four studies found that more contact with the father was associated with more child adjustment problems when there were high levels of chronic, persistent IPC, these studies do not provide guidance for decisions made at the time of the divorce. There is no consistent set of findings that support a policy against shared parenting based on having a conflictual relationship at the time of divorce. Many parents have conflictual relationships when they are separating and in the year that follows, but conflict typically decreases over time, with rates of high conflict dropping from over 50% of families in the initial period after the divorce to about 25% of families several years later ( Hetherington & Kelly, 2002; Fischer, De Graaf, & Kalmijn, 2005). Because IPC is likely to diminish over time in most families, it seems that conflict should not be as heavily weighed as other factors (i.e., parenting quality) when determining parenting arrangement at the time of the divorce.

Although chronic conflict has more serious implications for parenting time arrangements than conflict early in the divorce process, the findings are mute about strategies to promote children's positive adjustment when high conflict persists over time. Given the clear negative implications of chronic IPC for children's adjustment, arrangements that might decrease conflict or children's exposure to conflict would be in the best interest of the children. This might be accomplished by arrangements that minimize the situations where children are most likely to be exposed to the conflict (e.g, exchanges between the parents). If one parent is primarily driving the conflict, reductions in the opportunities for that parent to expose the child to conflict might be considered (e.g., reduced parenting time). In addition, given the association between quality of parenting by either parent and children's adjustment in high conflict divorces, efforts to strengthen and support high quality of parenting may help promote child adjustment. The current evidence provides guidance as to the factors that should be considered in making decisions about parenting time for high conflict divorces. It is critical to consider the nature of the IPC in terms of severity, frequency, child exposure, and the role each parent plays in maintaining the conflict. It is also critical to assess the potential of both parents to provide moderate to high quality parenting in terms of a warm and close relationship with the child. Both fathers and mothers can provide high quality parenting even if there is high conflict and high-quality parenting by either parent can protect children from the deleterious effects of IPC. However, high quality parenting is most likely to be beneficial if children have adequate time with their parent ( Sandler et al., 2013).

It is important to emphasize that these implications are based on current evidence and that the research and practice landscapes are rapidly changing. As more jurisdictions are promoting shared parenting arrangements, there will be more opportunities to learn about the conditions under which these arrangements work well or poorly for children in high conflict divorces. To help inform policy and practice recommendations for parenting time in cases with high IPC, researchers should give priority to three issues. First, given that parenting time decisions are typically made early in the process of divorce, more studies are needed to assess the relations between different patterns of contact and child adjustment in families with high IPC close to the separation and divorce and how this changes over time. Second, studies are needed to identify factors that lead to chronic and persistent conflict several or more years after the divorce. Third, although there are multiple programs that have benefits for divorced families, including mediation ( Holtzworth-Munroe, Beck, & Applegate, 2010), parenting programs (e.g., Wolchik et al. (2013), conflict reduction ( Braver, Sandler, Cohen Hita, & Wheeler, 2016), child coping ( Boring et al., 2015; Pedro-Carroll & Cowen, 1985) and alternative approaches to obtaining a divorce ( Pruett, Insabella, & Gustafson, 2005), more research is needed to identify the best approaches to promote the long-term adjustment of children in high conflict divorced families. Assessing whether they have positive effects on child adjustment in families with high IPC has clear implications for promoting the well-being of children in divorced families with high IPC.

Supplementary Material

Footnotes

The report specifically exempted families with a history of violence or child abuse from its recommendations.

The authors also studied sole custody vs. all other parenting time. We are not including those analyses in this paper because they do not study the minimum criteria for shared parenting.

Although the authors did find gender x parenting time interactions in the overall sample they did not test whether these effects were present for the high conflict divorces.

Contributor Information

Nicole E. Mahrer, University of California, Los Angeles

Karey O'Hara, Arizona State University

Irwin N. Sandler, Arizona State University

Sharlene A. Wolchik, Arizona State University

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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[].attributes.attachment_link.title
Does Shared Parenting Help or Hurt Children in High Conflict Divorced Families?

# data[].attributes.attachment_link.description
Despite a recent shift in the allocation of parenting time arrangements following divorce, there is no clear consensus regarding the effects of shared parenting on children's adjustment in high conflict families. We propose key questions and ...

# data[].attributes.headline
How Custody Arrangements Shape A Child's Mental Health

# data[].attributes.subject
How Custody Arrangements Shape A Child's Mental Health

# data[].attributes.body
Context:

This article discusses how different custody arrangements after divorce can influence a child’s mental health. It explains that joint physical custody tends to be linked with better outcomes, such as higher self‑esteem, fewer emotional problems, and stronger academic performance, compared to sole physical custody, especially when one parent is largely absent. It also emphasizes that the impact varies by age. Crucially, the article warns that the greatest harm comes not necessarily from the custody arrangement itself, but from high parental conflict, including frequent arguments, disparagement, and legal battles can undermine a child’s well‐being. The best outcomes arise when the custody plan is attuned to the child’s needs, both parents remain involved, and conflict is minimized.

Relevance:

This information is relevant because it highlights how custody arrangements after divorce can significantly impact a child’s emotional and academic well-being. Joint custody, with meaningful involvement from both parents, tends to support better development, while high parental conflict, regardless of custody type, can cause the most harm. For educators, understanding these dynamics is important because they often see the effects of family situations on students’ behavior and learning. Knowing the influence of custody and conflict helps educators provide better emotional support, identify children who may need extra help, and collaborate with families to promote stability and well-being in the child’s life.

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Children's Law Center of Central North Carolina

# data[].attributes.attachment_link.title
How Custody Arrangements Shape A Child’s Mental Health — Children’s Law Center of Central North Carolina

# data[].attributes.attachment_link.description
One of the biggest custody debates is whether children do better in joint physical custody, where both parents share time, or sole physical custody, where one parent has primary responsibility for physical custody. Studies overwhelmingly favor joint physical custody, showing that kids in shared arra

# data[].attributes.headline
Child Well-Being in Single Parent Families

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Child Well-Being in Single Parent Families

# data[].attributes.body
Context:

This article highlights that over 23 million children in the U.S., approximately one in three, live in single-parent households. This trend has been influenced by factors such as later marriage ages, declining marriage rates, increasing divorce rates, and a rise in births to unmarried mothers. Among these children, 14.3 million reside in mother-only households, over 6 million live with cohabiting parents, and about 3.5 million are in father-only households. The post also discusses disparities in single-parent family structures across different racial, ethnic, and nativity groups, noting that these differences are often linked to socioeconomic status, systemic inequities, and access to resources. The Foundation emphasizes the importance of understanding these dynamics to support the well-being of children in single-parent families.

Relevance:

This information is relevant because it highlights how the rise in single-parent families, often resulting from divorce or separation, affects a large number of children’s lives, with impacts shaped by economic and social factors. Single-parent households can face challenges like reduced resources and support, which may affect children’s emotional well-being and development. For child educators, understanding these realities is important because it helps them recognize the diverse family backgrounds of their students, the potential challenges these children face, and the need for tailored support. This awareness enables educators to create inclusive, empathetic learning environments and connect families with resources that promote children’s resilience and success.

# data[].attributes.headline
Single Parenting: Impact on Child's Development 

# data[].attributes.subject
Single Parenting: Impact on Child's Development 

# data[].attributes.body
Context:

The article explores how shifting societal norms around family structure, driven by modernization, urbanization, and changing gender roles, have reshaped perceptions of single-parent households. It argues that while older studies largely emphasize the risks of family instability on children’s mental, physical, and psychosocial development, more recent research has begun to highlight resilience and protective factors. The authors note that single parents often face a heavier burden of responsibility, time constraints, social stigma, and limited support, which can impair their capacity to engage fully with their children. Consequently, children in single‑parent families may show poorer academic outcomes, weaker social ties, and more emotional or behavioral difficulties. However, the paper underscores that some children show positive adaptation when protective factors are present. Finally, the authors call for greater attention to fostering resilience and support structures so that children from single-parent households can adjust and thrive.

Relevance:

The article highlights how the breakdown of a two-parent household can lead to emotional, social, and academic challenges for children due to reduced stability, parental involvement, and resources. For child educators, this information is crucial because they are often the first to observe signs of distress or behavioral changes in children affected by family transitions. Understanding the potential impacts of divorce enables educators to respond with empathy, provide appropriate support, and create stable learning environments that promote resilience. Additionally, it helps them avoid stigmatizing single-parent families and instead focus on identifying and reinforcing protective factors that support healthy development.

# data[].attributes.headline
The Impact of Parents Arguing in Front of Kids

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The Impact of Parents Arguing in Front of Kids

# data[].attributes.body
Context:

The article examines how observing parental conflict impacts children, not just when fights concern major issues, but also in everyday disagreements. It emphasizes evidence that frequent, intense arguing between parents is linked to a higher risk of anxiety, depression, behavioral problems, and diminished ability to concentrate at school. Children often internalize parental conflict, feeling distressed or guilty, sometimes blaming themselves or aligning with one parent. The article also highlights how children pick up on parental conflict styles; if parents argue with yelling or name‑calling, kids tend to imitate those patterns. On the brighter side, it suggests ways to reduce the harm: parents can de‑escalate arguments, communicate respectfully, provide reassurance and safety, spend quality family time, and openly talk with children about what’s going on to reduce misunderstanding and emotional burden.

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The article addresses how ongoing parental conflict, often a major factor leading up to or following a separation, can negatively affect a child’s emotional and behavioral development. It shows that the harm to children isn't only caused by the divorce itself but by the conflict surrounding it, especially when it's witnessed directly. Children exposed to frequent or intense arguments may experience anxiety, guilt, and emotional insecurity, which can impact their ability to focus, form healthy relationships, or regulate emotions. For child educators, understanding this is important because it helps them recognize the behavioral or academic challenges that may stem from family conflict at home. It also enables them to create supportive, stable classroom environments, offer emotional reassurance, and collaborate with school counselors or parents to ensure that children affected by such stressors are properly supported in their learning and

# data[].attributes.attachment_link.title
The Impact of Parents Arguing in Front of Kids

# data[].attributes.attachment_link.description
My husband and I had a little argument last week. It wasn’t a big deal, just one of those everyday disagreements. But you know what? Our four-year-old reacted in a surprising way. He saw us arguing and got upset. So upset, in fact, that he pretended to punch my husband. When we asked him what…

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Interparental Conflict, Children's Security With Parents, and Long-Term Risk of Internalizing Problems 

# data[].attributes.subject
Interparental Conflict, Children's Security With Parents, and Long-Term Risk of Internalizing Problems 

# data[].attributes.body
Context:

The article examines the impact of marital conflict and parental discord on children, with particular attention to how exposure to intense, frequent, or unresolved conflict can contribute to children’s emotional distress, behavior problems, and difficulties in social adjustment. It emphasizes the pathways through which conflict affects children, such as negative parenting practices, spillover of stress into the parent–child relationship, and children’s appraisals. The authors also discuss moderating factors, such as temperament, social support, and parents’ conflict resolution skills, that can buffer the effects. Ultimately, the article argues for interventions aimed at reducing destructive conflict, improving parental communication, and enhancing family resilience to mitigate harm to children.

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The article focuses on how exposure to parental conflict, often a precursor or consequence of divorce, can negatively affect child development. It explains that children who witness frequent, intense, or poorly resolved arguments between parents are at increased risk for emotional problems, behavior issues, and difficulties with social relationships. These impacts often persist even after the parents separate, especially if conflict continues. For child educators, this information is essential because it helps them understand the root causes of behavioral or emotional struggles that may appear in the classroom. Recognizing that these issues may stem from family conflict allows educators to respond with empathy, tailor support strategies, and

# data[].attributes.attachment_link.title
Interparental conflict, children’s security with parents, and long-term risk of internalizing problems: A longitudinal study from ages 2 to 10

# data[].attributes.attachment_link.description
Although the negative impact of marital conflict on children has been amply documented, few studies have examined the process of risk in a long-term, longitudinal design. We examined parent–child attachment security as a mechanism that may account…

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Context:

The article emphasizes that trauma doesn’t occur in a vacuum but is deeply shaped by culture, history, race, gender, location, language, and social context. It argues that trauma‑informed systems must recognise the compounded effects of structural inequities and be responsive to the distinctive needs of diverse communities. Cultural awareness, responsiveness, and humility are essential for improving access to and the quality of trauma services — this means reducing service disparities, confronting stigma and social adversity, strengthening families, and supporting positive ethnic identity.

Relevance:

The content highlights how trauma is experienced and expressed differently across cultures, and how factors like racism, historical oppression, and language barriers can compound trauma for children. For child educators, this information is crucial because it helps them understand that a "one-size-fits-all" approach to trauma support may be ineffective, or even harmful. Recognizing the cultural context of a child’s experiences allows educators to respond with greater empathy, relevance, and effectiveness. It also helps build trust with students and families, reduce stigma, and promote healing in ways that affirm the child’s identity and background. Being culturally responsive ensures that trauma-informed care is not just about addressing symptoms, but about truly supporting the whole child respectfully and inclusively.

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The National Child Traumatic Stress Network

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Enhancing cultural competence and encouraging cultural humility are essential to increasing access and improving the standard of care for traumatized children, families, and communities across the

The following resources on Culture and Trauma were developed by the NCTSN.

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Trauma intersects in many different ways with culture, history, race, gender, location, and language. Trauma-informed systems acknowledge the compounding impact of structural inequity and are responsive to the unique needs of diverse communities.

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Social, Cultural, and Other Diversity Issues in the Traumatic Stress Field

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Social, Cultural, and Other Diversity Issues in the Traumatic Stress Field

# data[].attributes.body
Context:

The article explains that trauma doesn't affect everyone the same way; it’s shaped by a person's culture, identity, and life circumstances. Things like race, gender, poverty, disability, or being an immigrant can increase the chances of experiencing trauma and make recovery harder, especially when people face discrimination or lack support. At the same time, cultural values, family, and community can also be sources of strength and healing. The authors stress that professionals working with trauma should not treat everyone the same, but instead understand and respect each person’s background and beliefs. They encourage using trauma approaches that are culturally sensitive and centered on the individual’s lived experience.

Relevance:

This article shows how trauma is deeply influenced by a child’s cultural background, social identity, and life experiences. For child educators, this information is important because it reminds them that trauma doesn’t always look the same in every student, and that some children may carry stress from things like racism, poverty, or immigration challenges. Understanding these layers helps educators avoid misinterpreting behavior and instead respond with empathy and support. By using culturally responsive practices, educators create safer, more inclusive classrooms where all children feel seen, respected, and supported in their healing and learning.

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Social, cultural, and other diversity issues in the traumatic stress field

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This chapter describes how the impact of psychological trauma and posttraumatic stress disorder (PTSD) differ, depending on individual differences and the social and cultural context and culture-specific teachings and resources available to…

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Context:
The article emphasizes that trauma‑informed practices (TIP) are about creating safe, supportive, and caring school environments where students feel secure, understood, and empowered. It lists practical strategies for educators, such as being aware of triggers, showing compassion rather than judgment, giving students space to share their feelings, building trusting relationships, meeting students where they are emotionally, using restorative rather than punitive discipline, and recognising when professional help is needed. It also highlights the importance of supporting educator wellness and training all staff to understand trauma‑informed approaches.

Relevance:

The NEA article on trauma-informed practices emphasizes the need for educators to create environments where all students feel safe, respected, and supported, especially those who have experienced trauma. This aligns with culturally responsive teaching, which recognizes that students' backgrounds, identities, and life experiences shape how they respond to stress and how they heal. For child educators, this is essential knowledge because it encourages them to avoid one-size-fits-all responses to behavior and instead approach each child with empathy, cultural awareness, and flexibility. Understanding trauma through a culturally responsive lens helps educators build stronger, more trusting relationships with students, reduce bias, and foster more inclusive classrooms that support both emotional well-being and academic growth.

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Trauma-Informed Practices (TIP) have been a topic of interest and need for the past several years. Researchers have defined TIP as a set of practices that address the impact of trauma by creating a safe and caring environment. Trauma-informed practices focus on creating a safe school culture, building relationships, and supporting students' self-efficacy. Despite the plethora of research on trauma-informed practices, sometimes research-based practices are disconnected from the daily needs of educators in the field.

Below is a list of common Trauma-Informed practices that educators can implement across all educational settings. This list has been reviewed by a group of educators representing education support professionals, teachers, and specialized instructional support personnel.

Support students from the bus stop to the classroom (and beyond!)
Using trauma-informed practices across all educational spaces can help educators collaborate to support student mental and physical health.Supporting students across settings helps to foster a positive school climate where students feel safe and confident. Be intentional in supporting families and community members in understanding and using trauma-informed practices for long-term student success.

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No matter where you work in our school communities, you can use these practices to create safe and supportive learning environments for all students.

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Context:

The article explains that caring for children who’ve experienced trauma means more than recognizing the event; it means understanding each child and family’s cultural context. It points out that culture influences how trauma is perceived, how distress is expressed, when or it help is sought, and what forms of healing are considered acceptable. The article also outlines key components of culturally‑sensitive, trauma‑informed care, including recognizing cultural variations in trauma responses, building trust and safety in culturally respectful ways, tailoring assessment and intervention to the family’s values and beliefs, and working through the family and community’s existing coping resources.

Relevance:

This article highlights how trauma is experienced and expressed differently depending on a child's cultural background. For child educators, this information is crucial because it encourages them to avoid making assumptions based on their own cultural norms and instead approach each child with curiosity, empathy, and cultural awareness. Understanding that some children may express trauma through physical symptoms, avoid talking about emotions, or rely on family and community for support helps educators respond in more respectful and effective ways. Culturally sensitive, trauma-informed care helps build trust, ensures students feel seen and valued, and supports healing in ways that align with their identity and beliefs. This is essential for creating safe, inclusive classrooms where all children can learn and thrive.

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What is Culturally-Sensitive Trauma-Informed Care?
How does this complement culturally competent health care practice?
As in all pediatric care, Culturally-Sensitive Trauma-Informed Care requires attention to be paid to a child's and family's values and beliefs about health and illness. What's unique is that attention must also be paid to cultural variations in the child's and family's experience of and response to trauma.

Research suggests that although there is a universal biological response to trauma, cultural factors can influence the biopsychosocial experience of trauma and subsequent traumatic stress reactions. Ethnocultural factors play an important role in an individual's vulnerability to, and experience and expression of traumatic stress, as well as one's response to trauma treatment.
What are the key components of Culturally-Sensitive Trauma-Informed Care?
A culturally-sensitive, trauma-informed care provider can help traumatized children and families by:
How do I implement Culturally-Sensitive Trauma Informed Care?
Understanding perceptions of traumatic stress and the role of beliefs:
Research suggests that it is NOT the objective severity of the trauma, but how it is experienced by the child or parent that determines traumatic stress responses.

Cultural differences can exist in the perception and interpretation of the trauma event, the meaning given to the traumatic event and beliefs about control over the event.
Viewed through a cultural lens, a child's or family's subjective perceptions of the trauma experience can sometimes be quite different from a provider's.

For example, some cultures interpret illness and other trauma events as punishment, a test or rite of passage, or a special message.

The way a child or family interprets the meaning of the trauma will influence subsequent distress, reactions, and ways of coping.

Cultural differences can also exist in beliefs about if, when, and how to resolve traumatic stress symptoms, and about help-seeking and utilization of supportive resources outside their community

Remembering that some interpretations may differ from your own, it is best to ask children and families about what the trauma means to them, and incorporate those beliefs into assessment and treatment.

Restoring safety and re-establishing trust:
Trauma erodes a child's or family's sense of physical and emotional safety; promoting trust rebuilds it.

When a trauma occurs, children's and families' global beliefs about safety, vulnerability, responsibility, control, and appropriate ways of coping play a significant role regarding how the trauma impacts them.

Initially, many traumatized children and families can feel physically unsafe and emotionally vulnerable; they may have a difficult time trusting others or accepting help as a result.

Viewed through a cultural lens, some groups are less likely to trust health care providers with the details of the trauma, their symptoms, or treatment recommendations.

In these instances, providers should take a step back to assess how their helping role is perceived. Providers should also try to connect the family with resources they trust - including other types of professionals and traditional healers.

Safety and trust is established not only through words, but through actions.

Providers' cultural awareness and sensitivity help to create provider-patient interactions that build trust and promote optimal patient communication and adherence.

Beyond the words providers choose, some cultures are highly sensitive to nonverbal communication - including eye contact, tone of voice, facial expressions, body language and touch.

Culturally appropriate communication practices have been shown to result in higher levels of perceived trust and increased reporting of information.

Attending to distress:
Significant cultural variations exist in a child's or family's expression of distress.

Pain, fear, worry, or hyperarousal are sometimes expressed somatically. Traumatic stress reactions can be extremely subdued, can appear to be over-magnified, or can even mimic psychotic reactions. Often, family and cultural factors combine to define what is considered an appropriate reaction to illness or trauma.

Some families and cultural groups are less comfortable responding to personal questions about emotional distress. They may think that being distressed means that there is something mentally wrong.

What providers can do:

Provide psychoeducation about common, universal reactions to trauma.

Understand emotional reactions by asking about and responding to specific behaviors (sleep and eating patterns, jitters, etc.).

Listen to and incorporate the child's or family own terms for what they are experiencing into discussions and treatment planning.

Working within and through the family structure:
Some families and cultural groups have distinct customs about who makes decisions and how they are communicated.

These customs may lead to limitations on the child's or other family members' involvement in discussions and decisions.

Incorporating extended family and kinship networks, as well as other types of healing professionals and practices that the child and family view as helpful, may positively impact assessment and treatment.

Considerations in providing Culturally-Sensitive Trauma-Informed Care
What considerations should I keep in mind in providing Culturally-Sensitive Trauma-Informed Care? View RELATIONSHIPS through a Culturally-Sensitive Trauma-Informed lens

Understand your role as a provider within this family's world.

Gain a better understanding of the roles and dynamics within this family.

Consider and facilitate the inclusion of others (extended family, clergy, healers) when treating patients.

View ASSESSMENT through a Culturally-Sensitive Trauma-Informed lens

The manifestation and expression of psychological states differ depending on personal, familial, and cultural beliefs and practices.

Listen to and use the family's own terms during assessment and treatment planning

Trust in / comfort with the provider has been shown to be associated with increases in patient disclosure in some cultural groups.

View TREATMENT through a Culturally-Sensitive Trauma-Informed lens

Healing comes in many different forms; your ideas, beliefs, and values may differ from the family's.

Be sure you have integrated the family's understanding of diagnosis, prognosis, and healing into your treatment planning.

Consider each family's resources and barriers to help-seeking and utilization of supportive services within the community.

Implementing Culturally-Sensitive Trauma- Informed Care with patients
How do I implement Culturally-Sensitive Trauma-Informed Care in my own patient interactions? Culturally-sensitive care begins with the provider

CPTS designed the D-E-F protocol as a practical tool to guide health care providers in implementing trauma-informed pediatric care.

The cultural considerations component of the D-E-F protocol helps providers implement trauma informed care in a culturally-sensitive manner that considers a child and family's unique cultural beliefs, values, and practices.

Additional Resources:
The National Child Traumatic Stress Network (NCTSN) website features various resources related to culture and trauma.

The National Center for PTSD (NCPTSD) website features a course module entitled PTSD: General Cross-Cultural Considerations.

Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches: Field Report. Retrieved from www.commonwealthfund.org.

Davidhizar, R. (1999). Assessing culturally diverse pediatric clients. Pediatric Nursing, 25(4), 371-376.

Marsella, A. J., Friedman, M. J., Gerrity, E. T., & Scurfield, R. M. (1996). Ethnocultural aspects of posttraumatic stress disorder: Issues, research, and clinical applications. Washington, D.C.: American Psychological Association.

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Culturally-Sensitive Trauma-Informed Care | Patient Centered Care and Trauma Informed Care for Pediatric Patients - HEALTHCARE TOOLBOX

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How does this complement culturally competent health care practice? As in all pediatric care, Culturally-Sensitive Trauma-Informed Care requires attention to be paid to a child's and family's values and beliefs about health and illness. What's unique is that attention must also be paid to cultural variations in the child's and family's experience of and response to trauma.

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Embedding Culturally Responsive Practices into Trauma-Informed Schools 

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Embedding Culturally Responsive Practices into Trauma-Informed Schools 

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Context:

The article emphasizes the importance of integrating cultural awareness into trauma-informed education to effectively support students affected by trauma. It highlights that trauma-informed practices alone may not fully address the needs of students from diverse cultural backgrounds, as such students may experience trauma differently and have unique coping mechanisms. The article suggests that educators should recognize and respect students' cultural identities, understand the impact of historical and racial trauma, and create inclusive environments that validate diverse experiences. By combining trauma-informed approaches with cultural responsiveness, schools can foster a more supportive and equitable learning environment for all students.

Relevance:

This article stresses that trauma-informed care isn’t enough on its own, and that educators also need to deeply understand and respect students’ cultural backgrounds and experiences. For child educators, this means recognizing that trauma can look different depending on a child’s culture and history, and that healing approaches must be tailored accordingly. This knowledge is important because it helps educators create more inclusive, trusting, and effective learning environments where all students feel understood and supported. Combining cultural responsiveness with trauma-informed practices ensures that children’s unique identities and needs are honored, which is essential for their emotional safety, engagement, and success in school.

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Embedding Culturally Responsive Practices into Trauma-Informed Schools | IES

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Educators can take concrete steps to identify and dismantle racist practices that may exist within schools and contribute to student racial trauma.

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A Trauma-Informed and Culturally Responsive Approach in the Classroom

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A Trauma-Informed and Culturally Responsive Approach in the Classroom

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The chapter from Supporting and Educating Traumatized Students: A Guide for School-Based Professionals explores the intersection of trauma-informed care and culturally responsive teaching. It emphasizes that educators must recognize how cultural backgrounds influence students' responses to trauma and their coping mechanisms. The chapter advocates for integrating cultural awareness into trauma-informed practices to create supportive and inclusive classroom environments. By understanding and respecting students' cultural identities, educators can better address the unique challenges faced by traumatized students, fostering resilience and promoting academic success.

Relevance:

This chapter highlights the need to blend trauma-informed care with cultural awareness in the classroom. For child educators, this means understanding that students’ cultural backgrounds shape how they experience and cope with trauma, which affects how they behave and learn. Knowing this helps educators create supportive, inclusive environments that respect each child’s identity and build resilience. It’s important information because when educators acknowledge and incorporate culture into trauma responses, they can more effectively support students’ emotional well-being and academic success, reducing misunderstandings and fostering trust. This combined approach leads to better outcomes for all students, especially those who have experienced trauma.

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SAMHSA's 9 Steps for Cultural Respnsiveness in Organizations 

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SAMHSA's 9 Steps for Cultural Respnsiveness in Organizations 

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Context:

The video provides an in-depth exploration of how organizations can integrate cultural responsiveness into their trauma-informed practices. Presented by Dr. Scott Giacomucci, the video delves into the significance of understanding identity-based and collective trauma, emphasizing the importance of recognizing microaggressions within group therapy settings. Dr. Giacomucci discusses how organizational identity plays a crucial role in shaping responses to trauma and underscores the necessity for organizations to reflect on their cultural competencies. The chapter also touches upon the application of psychodrama techniques to address identity and oppression, offering a multifaceted approach to culturally responsive trauma care. This resource is valuable for professionals seeking to enhance their understanding and implementation of culturally sensitive practices in trauma-informed care settings.

Relevance:

The video highlights how organizations, including schools, need to actively understand and address the cultural identities and experiences of the people they serve, especially when trauma is involved. For child educators, this means recognizing that students’ cultural backgrounds and collective experiences shape how they respond to trauma and healing. Knowing about microaggressions and the impact of identity helps educators create more inclusive, respectful environments where all students feel safe and supported. This information is important because it encourages educators and schools to reflect on their own cultural awareness and biases, which is key to effectively supporting diverse students who have experienced trauma.

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Phoenix Trauma Center & Dr Scott Giacomucci

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SAMHSA's 9 Steps for Cultural Responsiveness in Organizations (Chapter 10)

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Challenges and Rewards of a Culturally-Informed Approach to Mental Health

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Challenges and Rewards of a Culturally-Informed Approach to Mental Health

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Context:

In her TED Talk, Dr. Jessica Dere emphasizes the profound impact of culture on mental health and the necessity for culturally sensitive practices in clinical settings. Drawing from her own experiences as a person of mixed cultural heritage, Dr. Dere advocates for a stance of "informed curiosity" over expertise, encouraging mental health professionals to approach clients with humility and openness. She highlights that understanding cultural context is crucial, as it shapes how individuals experience and express distress. Dr. Dere also underscores the importance of interdisciplinary learning, such as integrating medical anthropology, to broaden perspectives and challenge assumptions in mental health care. By adopting culturally informed approaches, clinicians can enhance the effectiveness of their interventions and foster more inclusive therapeutic environments.

Relevance:

Dr. Jessica Dere emphasizes the importance of understanding each child’s cultural background when addressing their mental health and trauma. For child educators, this means approaching students with humility, curiosity, and openness rather than assumptions or fixed ideas. Recognizing that culture shapes how children express distress and cope with trauma helps educators respond more effectively and sensitively. This knowledge is vital because it promotes inclusive, supportive environments where students feel understood and respected, ultimately improving their emotional well-being and learning outcomes. It also encourages educators to continually learn and challenge their own biases to better serve diverse students.

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Challenges and Rewards of a culturally-informed approach to mental health | Jessica Dere | TEDxUTSC

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Trauma-Informed Care and Cultural Humility in the Mental Health Care of People From Minoritized Communities

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Trauma-Informed Care and Cultural Humility in the Mental Health Care of People From Minoritized Communities

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Context:

The article emphasizes the necessity of integrating trauma-informed care with cultural humility to effectively address the mental health needs of individuals from minoritized groups. It highlights that trauma is prevalent among these populations and that cultural factors significantly influence how trauma is experienced and expressed. The authors advocate for clinicians to adopt a trauma-informed approach that recognizes the widespread impact of trauma and emphasizes safety, trustworthiness, peer support, and empowerment. Additionally, they stress the importance of cultural humility, which involves a lifelong commitment to self-evaluation and self-critique, recognizing and challenging power imbalances, and developing mutually beneficial partnerships with communities. By combining these frameworks, mental health professionals can provide more effective and equitable care to minoritized individuals, fostering healing and resilience.

Relevance:

This article stresses that effective trauma care for children from minoritized communities requires not only understanding trauma itself but also practicing cultural humility—being open, self-reflective, and aware of power dynamics. For child educators, this means recognizing that students’ cultural backgrounds deeply influence how they experience trauma and healing. It’s important for educators to approach each child with respect, openness, and a willingness to learn about their unique cultural context rather than assuming a one-size-fits-all method. This knowledge helps educators build trust, reduce bias, and create safer, more supportive classrooms that better meet the emotional and educational needs of diverse students, ultimately promoting healing and academic success.

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Trauma-Informed Care and Cultural Humility in the Mental Health Care of People From Minoritized Communities

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The prevalence and impact of trauma constitute a public health crisis that is complicated by the cultural heterogeneity of contemporary society and a higher rate of trauma among individuals from minoritized communities. A trauma-informed care…

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Integrating Culturally Responsive Teaching and Trauma-Informed Practices

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Integrating Culturally Responsive Teaching and Trauma-Informed Practices

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The article explores how integrating culturally responsive teaching with trauma-informed practices can support K–12 students, particularly those from historically marginalized backgrounds who may experience higher rates of trauma. CRT values and incorporates students' diverse cultural backgrounds into teaching methods and curriculum, fostering a sense of belonging and engagement. TIP recognizes and responds to the impact of trauma on students' learning and behavior, emphasizing the creation of safe and supportive environments that foster trust, empowerment, and resilience. By combining CRT and TIP, educators can validate students' lived experiences and provide pathways for healing and academic success, recognizing that addressing both cultural and emotional needs is critical to equitable education.

Relevance:

This article shows how combining culturally responsive teaching with trauma-informed practices creates a powerful way to support students, especially those from marginalized communities who often face both cultural challenges and trauma. For child educators, it’s important to understand that addressing trauma isn’t just about emotional support; it also requires recognizing and valuing students’ cultural identities to help them feel seen, safe, and engaged. Knowing this helps educators build trusting relationships, create inclusive classrooms, and tailor their teaching to meet both the cultural and emotional needs of their students, which leads to better learning outcomes and overall well-being.

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Culturally responsive teaching (CRT) and trauma-informed practices (TIP) are essential, interconnected approaches for supporting K-12 students, especially those from historically marginalized backgrounds who may experience higher rates of trauma.

Trauma-informed practices (TIP) are designed to recognize and respond to the impact of trauma on students' learning and behavior, such as creating communities of support. This approach emphasizes creating a safe and supportive environment that fosters trust, empowerment, and resilience.

By integrating CRT with TIP, educators not only validate students' lived experiences but also provide pathways for healing and academic success, recognizing that addressing both cultural and emotional needs is critical to equitable education.

The Intersection of CRT and TIP

Creating the conditions for culturally responsive teaching and trauma-informed care in K-12 settings is entrenched in three critical elements: recognizing and affirming the cultural backgrounds of students, integrating diverse perspectives into daily classroom learning, and fostering a sense of belonging. To accomplish this, consider trying the following.

1. Create safe spaces. Use seating arrangements that promote inclusiveness (e.g., arrange desks or tables in a circle or U-shape so that students can see each other, which fosters open communication and a sense of community. Alternatively, organize desks or tables into small groups of four to six to allow for collaborative work. Consider providing access to flexible seating options like floor cushions, standing desks, or soft chairs.

Establish norms for respect and active listening. For example, practice listen without interrupting -allow the speaker to share their thoughts fully before responding; use reflection-clarify (paraphrase or ask clarifying questions to ensure understanding and show that you value the speaker's words, such as saying, "So what I'm hearing you say is...").

Create a set of common phrases, visual cues, or reminders that reflect the classroom's values and agreements, while honoring the cultural and linguistic backgrounds of the students (e.g., "Respect each other's ideas"), and create a poster in multiple languages for the classroom. You might also include language frames like "I hear your perspective, and I'd like to add..." to model respectful discourse, encouraging students to use similar phrases in discussions.

2. Get to know your students, and teach them how to get to know one another. Implement regular check-ins to understand students' backgrounds and interests. Using an informal method like exit tickets or a weekly reflection journal, start each week with a survey or a quick one-on-one conversation to learn about students' current interests, current challenges, and any experiences they wish to share.

Foster peer connections and create opportunities for trust-building and celebration of the experiences of the class-for example, organize a "Cultural Sharing Day," when students share something significant from their heritage or personal lives, or have a "Community Circle," where students take turns speaking about their experiences or feelings in a safe, supportive environment.

Encourage collaborative learning and group projects that celebrate diverse perspectives. Create buddy systems for students to support each other emotionally and academically.

3. Integrate prior knowledge and diverse learning materials into the conversation and content. Build opportunities for student discourse that bring students' stories and knowledge forward-for example, think-pair-share: Give students a question or topic related to the lesson. First, they think individually about their response, drawing from their personal experiences and knowledge. Then, they pair up with a classmate to discuss their thoughts. Finally, they share their ideas with the whole class. Modify according to the age/grade levels of your students.

Implement a "cultural sharing" segment-partner with a translator, if needed, and invite students to share aspects of their backgrounds, such as traditions, languages, or family stories, based on comfort levels during a designated time each week or month. They can use various formats-a short presentation, a visual project, or storytelling, depending on their comfort levels.

Guiding with a Trauma-Informed Lens

While you don't need to know the details about a person's trauma to be able to emotionally support them, it's imperative that in working with diverse student populations, you're aware that many of them and their families have been significantly impacted by trauma. Maintaining a trauma-informed lens with language and behavior challenges teachers to do the following:

Collaborate with students to build community, and make sure you feel equipped to provide responsive classroom management.

Establish clear expectations and routines to reduce anxiety, and use positive reinforcement and restorative practices instead of punitive measures. Create a "positive behavior ticket" system to recognize and reward students for desirable behaviors, which they can redeem for small privileges, and/or hold a restorative circle where students discuss the impact of the behavior and collaborate on ways to repair harm. This promotes empathy, accountability, and relationship-building.

Create quiet areas in the classroom where students can go if they feel overwhelmed.

Have flexible options for choosing and presenting assignments or demonstrating proficiency for a performance task. For example, students might demonstrate their understanding by creating a video presentation, writing a traditional essay, designing a visual timeline, or developing a podcast episode. This flexibility lets students leverage their strengths and interests.

Take the time to recognize and understand trauma and its potential triggers.

Learn how to identify signs of trauma in students and understand potential triggers.

Submit a query email to your school leadership, school counselors, social workers, Special Education department, and other school partners to explore how to implement strategies for de-escalation and support.

Promote the understanding and use of emotional regulation skills.

Teach students strategies for managing their emotions, such as deep breathing exercises, mindfulness activities, and reflective journaling.

Incorporate short breaks during lessons for students to practice these techniques.

Utilize trauma-informed language-positive, supportive language-and avoid triggering or stigmatizing terms. This takes time, and you can often take cues from your students. Use language that's nonjudgmental, affirming, and empathetic, while being careful to avoid terms that could trigger shame, fear, or feelings of inadequacy in students. Avoid discussing someone "creating a problem" or being a "problem student." Consider an affirming statement like "I notice you're having a hard time focusing right now; let's work together to find a solution," or "It looks like you're frustrated-how can I help?"

Frame discussions around growth and resilience, as well as a belief in the students' worth. For instance, if there's a discussion about challenges, you could share a personal example and note, "Everyone faces setbacks, but it's how we grow from them that matters. I believe each of you has the strength to overcome difficulties, and your unique experiences help make our class stronger."

Another key part of the work is constructing partnerships with families and community organizations to better understand backgrounds and communication styles. Ideas include hosting events that celebrate cultural diversity and inviting community input about curriculum decisions. Partner with local cultural organizations and families to cohost a "Community Culture Night," where families and community leaders are invited to share their traditions, foods, music, and stories. Leading up to the event, teachers could hold focus groups with families to learn about preferred communication styles and involve them in planning.

Building a school community anchored in culturally responsive teaching and trauma-responsive practices first requires building a culture and climate that encompasses how critical these are for true school improvement. Consistent, sustainable messaging, along with reflective practice around one's own mental health, bias, and lived experiences, is crucial in order to teach and collaborate with diverse student populations.

One step at a time, one story at a time, engaging in this work is as rewarding as it is challenging, but your teaching, as well as your relationships with students and families, will thank you for it.

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Integrating Culturally Responsive Teaching and Trauma-Informed Practices

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These culturally responsive and trauma-informed teaching strategies can help ensure the academic success of all students.

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Child Counseling Techniques and Therapy Activities for Kids 

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Child Counseling Techniques and Therapy Activities for Kids 

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Context:

The article explains that child therapy, also known as child counseling, is a developmentally tailored process that provides children with a safe space and supportive guidance to process their thoughts, emotions, and behaviors, and to develop stronger coping skills, self-esteem, and communication. It outlines a variety of techniques and emphasizes that the choice of method depends on the child’s age, issue, and developmental stage. Importantly, it emphasises early intervention and a strengths-based, forward-oriented approach: therapy isn’t only for addressing trauma or deficits, but also for promoting resilience, positive development, and healthy emotional vocabulary.

Relevance:

Understanding the principles and processes behind therapeutic interventions for children is highly relevant because these approaches directly support a child’s emotional, social, and cognitive development, areas that are critical for learning and overall well-being. For child educators, this knowledge is important because it helps them recognize signs of emotional or behavioral difficulties early on, collaborate effectively with therapists, and create supportive classroom environments that reinforce therapeutic goals. By understanding how interventions such as play therapy, behavioral support, or trauma-informed practices work, educators can respond more empathetically, adapt teaching strategies to individual needs, and contribute to a holistic approach that nurtures both the child’s mental health and academic success.

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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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The article outlines a suite of therapeutic approaches tailored for children and their families, each chosen to match developmental needs, attachment issues, trauma, and emotional or behavioral challenges. These include play-based methods, such as Child-Centered Play Therapy and Parent-Child programs, which are designed to strengthen attachment, regulation, and positive engagement. For children from foster or adoptive situations, or with complex trauma, they offer Dyadic Developmental Psychotherapy, which blends family work, attachment theory, and neuro-trauma understanding. For anxiety or selective mutism, they provide a Cognitive Behavioral Play Therapy that merges CBT principles with age-appropriate play. Finally, for deeper trauma or “stuck” memories, they use Eye Movement Desensitization and Reprocessing to help release frozen emotional responses.

Relevance:

This information explains evidence-based methods, such as play therapy, attachment-based therapy, and cognitive-behavioral approaches, that help children express emotions, build coping skills, and strengthen relationships in ways appropriate to their developmental level. For child educators, understanding these approaches is crucial because emotional and behavioral health significantly impacts learning, attention, and social interaction in the classroom. When educators are aware of how these therapies support a child’s emotional growth and regulation, they can better recognize signs of distress, respond with empathy, and create supportive, trauma-informed environments that promote both academic and personal success.

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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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The Power of Play: How Therapy Turns Toys into Tools for Healing

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The Power of Play: How Therapy Turns Toys into Tools for Healing

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Context:

The article focuses on Child-Centered Play Therapy and explains that it is a developmentally appropriate therapeutic approach for children that uses play as the primary mode of communication. In this therapy, a trained therapist provides a safe, inviting play environment where the child leads their own play with minimal direct intervention; the therapist follows and supports the child’s process, helping the child process experiences, develop emotional regulation, understand relationships, and build self-esteem. This method is especially useful for children who have experienced trauma, loss, anxiety, bullying, or other emotional or behavioral challenges, because it meets children “on their level” and uses their natural medium of play to facilitate healing and growth.

Relevance:

This information demonstrates how play, a child’s natural form of expression, can be used to support emotional healing, self-regulation, and social development. By allowing children to lead their play in a safe, supportive environment, therapists help them process feelings and experiences they may not yet have the words to express. For child educators, understanding this approach is important because it highlights the power of play as both a learning and healing tool. Educators who recognize the emotional messages behind children’s play can respond with greater empathy, create supportive classroom environments, and collaborate more effectively with mental health professionals to foster each child’s emotional and academic growth.

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The Graduate School of Education and Human Development

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The Graduate School of Education and Human Development

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The Power of Play: How Play Therapy Turns Toys into Tools for Healing | The Graduate School of Education and Human Development | The George Washington University

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Learn how play therapy allows children to express their feelings, process experiences, understand emotions, and more. Explore play therapy as a career path.

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Context:

The article provides a concise review of play therapy as an evidence-based intervention for children’s emotional and behavioral difficulties. It discusses the fundamental premise that play is a natural mode of expression for children and thus serves as a vital therapeutic medium. The review outlines different play therapy modalities, highlights the benefits of play therapy, including improved emotional regulation, communication, and behavior, and also notes its limitations, such as dependency on therapist skill and the length of time often required for meaningful change. Additionally, the authors call for more rigorous research to strengthen the empirical base and clarify the mechanisms of action behind play-based interventions.

Relevance:

This information emphasizes how play therapy provides an evidence-based, developmentally appropriate way to help children express emotions, process experiences, and develop coping skills when they may not have the language or maturity to do so verbally. Understanding that play is a child’s natural form of communication helps professionals design interventions that meet children where they are emotionally and cognitively. For child educators, this knowledge is important because it deepens their awareness of the emotional and behavioral meanings behind play and classroom behaviors. It enables them to respond with empathy, recognize when a child may need additional support, and collaborate effectively with counselors or therapists to create a nurturing environment that promotes both emotional well-being and academic growth.

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Play is an essential parameter of children’s growth and expression and this is the reason of why the use of play therapy is considered as fundamental means of preventing and dealing with problems and difficulties presented to children. The aim of…

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Trauma and Play Therapy: Holding Hard Stories

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Trauma and Play Therapy: Holding Hard Stories

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Context:

In her TEDx talk, "Trauma & Play Therapy: Holding Hard Stories," Paris Goodyear-Brown dives into the profound impact of trauma on children and the transformative role of play therapy in their healing process. Drawing from over two decades of experience, she emphasizes the importance of creating a safe, nonjudgmental space where children can express and process their traumatic experiences through play, a natural medium for them. Goodyear-Brown introduces her TraumaPlay model, which integrates developmental neuroscience with therapeutic play techniques to help children reframe and release the emotional charge of their stories. She highlights that by "holding" these difficult narratives with empathy and skill, therapists can guide children toward resilience and recovery. The talk highlights the necessity of specialized training for professionals working with traumatized children and the critical role of supportive environments in fostering healing.

Relevance:

The TEDx talk highlights how trauma can profoundly affect a child’s emotional, behavioral, and cognitive development, and how play therapy provides a safe, natural, and effective way for children to process and express these experiences. By using techniques such as the TraumaPlay model, therapists can help children reframe traumatic memories, regulate emotions, and build resilience in a developmentally appropriate way. For child educators, this information is important because it underscores the role of trauma-informed practices in the classroom. Understanding the impact of trauma and the therapeutic power of play enables educators to recognize signs of distress, respond with empathy, support emotional regulation, and collaborate with mental health professionals to create safe, nurturing environments that promote both learning and healing.

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Trauma & Play Therapy: Holding Hard Stories

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How do children heal from trauma? Play therapy and trauma expert, Paris Goodyear-Brown, takes us on a journey through the stories of children from hard places, the neuroscience of play, and the importance of each of us in bearing witness to the hurt. Graphic images may evoke strong emotions but will reveal the amazing ability of children to tell us what happened and play their way to healing.

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Intergrating Play Therapy Techniques in Child Counseling 

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Intergrating Play Therapy Techniques in Child Counseling 

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Context:

The article outlines how play-based therapy can be effectively woven into counseling practice for children. It emphasizes that counselors need to first assess and plan treatment by observing children’s play to determine the most suitable play-therapy approach. It explains the importance of creating a safe, engaging environment where children feel comfortable engaging in play and involving families and caregivers as partners in the therapeutic process. The article also highlights that these techniques are versatile and can be applied in school settings or clinical practice, for children typically between ages 3 and 11, and across issues such as trauma, anxiety, developmental concerns, or behavior problems. It also stresses the need for specialized training and attention to ethical and cultural sensitivity in choosing toys and activities that reflect children’s backgrounds.

Relevance:

This information demonstrates how play therapy techniques can be intentionally integrated into counseling to support children’s emotional expression, problem-solving, and healing in a developmentally appropriate way. By using play as a medium for communication, counselors can help children process complex emotions, trauma, or behavioral challenges in a safe and supportive environment. For child educators, understanding this approach is important because it highlights the power of play as both a learning and therapeutic tool. Educators who recognize the therapeutic value of play can better identify when students might need emotional support, foster inclusive and empathetic classroom environments, and collaborate effectively with mental health professionals to promote children’s overall well-being and development.

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Integrating Play Therapy Techniques in Child Counseling

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Discover how integrating play therapy techniques in child counseling helps kids express emotions, build coping skills, and foster healthy development.

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Research Shows At-Risk Elementary Students Benefit from Child-Centered Play Therapy 

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Research Shows At-Risk Elementary Students Benefit from Child-Centered Play Therapy 

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Context:

The article describes a school-based research project showing that at-risk elementary students who participated in a year of Child‑Centered Play Therapy exhibited significant improvements in task orientation, behavioral control, assertiveness, and peer/social skills. Using a screening method, children at risk for behavioral or emotional difficulties were identified and received CCPT as a preventive intervention rather than waiting for severe issues to emerge. The findings suggest that CCPT is an effective option for supporting academic success by addressing emotional and social factors early in the school year.

Relevance:

This research demonstrates that Child-Centered Play Therapy can proactively support at-risk students’ emotional, behavioral, and social development, which in turn enhances their ability to succeed academically. By addressing challenges such as task focus, self-control, assertiveness, and peer interactions through play, the child’s natural form of expression, CCPT helps children develop coping skills and emotional regulation before problems escalate. For child educators, this information is important because it highlights the value of early, school-based interventions that integrate therapeutic principles into daily routines. Educators who understand the benefits of play therapy can better recognize students’ emotional needs, support social-emotional learning in the classroom, and collaborate effectively with counselors to foster a positive, developmentally supportive learning environment.

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Research Shows At-Risk Elementary Students Benefit from Child-Centered Play Therapy

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Elementary school students who received child-centered play therapy services over the course of a school year showed significant positive changes, according to data collected by two U of A professors.

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The Effect of Child-Centered Play Therapy on Academic Achievement with Normal Functioning School Children 

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The Effect of Child-Centered Play Therapy on Academic Achievement with Normal Functioning School Children 

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Context:

The article examines the impact of Child-Centered Play Therapy on the academic performance of second-grade students. The study involved 27 students who participated in biweekly 30-minute CCPT sessions over eight weeks, compared to a waitlist control group of 23 students. Results indicated that the students who received CCPT showed a statistically significant improvement in their academic achievement scores, as measured by the Woodcock-Johnson III Total Brief Achievement Score. This suggests that CCPT can be an effective intervention for enhancing academic performance in children without identified disabilities.

Relevance:

This information provides evidence supporting the use of play therapy to improve academic outcomes. For child educators, understanding the benefits of CCPT is crucial, as it explains the importance of addressing emotional and psychological factors that can affect learning. Educators can collaborate with counselors to implement such interventions, creating a more holistic approach to student development that integrates emotional well-being with academic achievement.

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Cognitive Behavioral Therapy (CBT) for Kids: How it Works 

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Cognitive Behavioral Therapy (CBT) for Kids: How it Works 

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Cognitive Behavioral Therapy is an evidence-based therapeutic approach that helps children understand the connection between their thoughts, feelings, and behaviors. By identifying and challenging negative or unhelpful thought patterns, CBT empowers children to develop healthier thinking habits, leading to improved emotional regulation and behavior. This therapy is effective for addressing a range of issues, including anxiety, depression, and behavioral challenges. CBT is typically structured, goal-oriented, and often involves collaboration between the child, parents, and therapists to reinforce skills and strategies learned during sessions. The approach is adaptable to various age groups and can be delivered through individual or group formats, making it a versatile option for supporting children's mental health.

Relevance:

Cognitive Behavioral Therapy provides a structured, evidence-based method for helping children understand the connection between their thoughts, feelings, and behaviors, and for teaching them practical strategies to manage anxiety, depression, or behavioral challenges. By equipping children with skills to identify and challenge unhelpful thinking patterns, CBT supports emotional regulation, problem-solving, and positive behavioral changes. For child educators, this knowledge is important because it helps them recognize cognitive and emotional patterns that may affect learning and classroom behavior, implement supportive strategies, and collaborate effectively with therapists and parents to reinforce skills. Understanding CBT also allows educators to create classroom environments that encourage resilience, self-reflection, and emotional growth alongside academic development

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Cognitive behavioral therapy (CBT) is a type of talk therapy that can help people of all ages, including younger children and teens. CBT focuses on how thoughts and emotions affect behavior. Your child doesn't need to have a diagnosed mental health condition to benefit from CBT.

Therapy usually involves an agreed upon goal and a set number of sessions. The therapist will help your child learn to replace negative thought patterns with more productive ones. Through role-playing and other methods, your child can practice alternate ways of handling stressful situations.

We'll explore what you need to know about CBT for kids, as well as how to find a qualified therapist.

CBT is a form of talk therapy designed to help people recognize unhelpful thoughts and behaviors and learn how to change them. Therapy focuses on the present and the future, rather than on the past.

While CBT isn't designed to "cure" conditions such as ADHD, it can be used to complement other therapies and to help improve specific symptoms.

CBT for kids has practical everyday applications. This therapy can help your child understand the negativity of their thought patterns and learn how to replace them with more positive ones. Discovering new ways of looking at things helps a child learn how to respond differently and improve rather than worsen stressful situations.

This type of therapy can give your child realistic strategies to improve their lives in the here and now. Once these strategies become habit, the new skills can follow them throughout their lives.

CBT can help children learn to control:

Replacing negative reactions with:

improved self-image

new coping mechanisms

problem-solving skills

more self-control

Usually, a parent or caregiver, the child, and a therapist will discuss goals and develop a treatment plan.

CBT involves a structured approach to solving problems in a specified number of sessions. It can be as few as six sessions or as many as 20 or more, depending on the child and the particular goals.

While CBT is a type of talk therapy, it's so much more than talk. The therapist will work to provide tangible ways for your child to take control and empower themselves. They will teach skills that can be put into practice immediately.

Your child can have CBT alone or in combination with medications or any other therapies they might need. The treatment plan can be adapted to meet cultural or regional differences.

CBT techniques

Play therapy. Arts and crafts, dolls and puppets, or role-playing are used to help the child address problems and work out solutions. This can also help keep younger children engaged.

Trauma-focused CBT. This method is used to treat children affected by traumatic events, including natural disasters. The therapist will focus on behavioral and cognitive issues directly related to trauma the child has experienced.

Modeling. The therapist may act out an example of the desired behavior, such as how to respond to a bully, and ask the child to do the same or to demonstrate other examples.

Restructuring. This technique is a way for a child to learn to take a negative thought process and flip it to a better one. For example, "I stink at soccer. I'm a total loser" can become "I'm not the best soccer player, but I'm good at a lot of other things."

Exposure. The therapist slowly exposes the child to the things that trigger anxiety.

Whatever the technique, CBT can be conducted a number of ways, such as:

Individual. Sessions involve only the child and the therapist.

Parent-child. The therapist works with the child and parents together, teaching specific parenting skills so their children make the most of CBT.

Family-based. Sessions can involve parents, siblings, or others who are close to the child.

Group. Includes the child, therapist, and other children who are dealing with the same or similar problems.

Your child doesn't have to have a diagnosed mental health condition to benefit from CBT. But it can be quite effective in dealing with specific conditions, such as:

Attention deficit hyperactivity disorder (ADHD)

Children with ADHD may have a hard time sitting still and may engage in impulsive behaviors. While there are medications to treat this disorder, sometimes they're not the first or only choice of treatment.

Even with medications, some children have persistent symptoms. Research shows that for some teens, adding CBT works better than medication alone.

Anxiety and mood disorders

CBT has been shown to be an effective treatment for children and adolescents with anxiety and mood disorders.

A 2015 review found "substantial support" for CBT as an effective first-line treatment for children with anxiety disorders.

Parents may have a role to play, too. A found that CBT with active parent involvement showed promise as an effective therapy for those ages 3 to 7 with anxiety. The study involved only 37 children, but they showed significant improvement in an average of 8.3 treatment sessions.

Anxiety with autism spectrum disorder

Many adolescents with high functioning autism spectrum disorder have anxiety. In a , a CBT program was designed for preteens with autism spectrum disorders plus clinical anxiety. The program focused on:

exposure

challenging irrational beliefs

behavioral support provided by caregivers

treatment elements specific to autism spectrum disorder

The small study involved only 33 children from 11 to 15 years old. Parents reported a positive effect of CBT on the severity of anxiety symptoms.

Trauma and PTSD

CBT is a first-line treatment for post-traumatic stress disorder (PTSD) in children and adolescents and has been shown to have short-term and long-term benefits.

A 2011 review found significant improvement at an 18-month follow-up and a 4-year follow-up. CBT has been found to be effective for acute and chronic PTSD after a range of traumatic experiences, even for young children.

CBT may also be helpful in treating:

Explaining the idea of CBT to younger children must be done in simple terms. To make things easier, some therapists use worksheets to help children visualize certain concepts.

For example, a worksheet may have drawings with blank thought bubbles for the child to fill out. The therapist may ask the child what the person in the picture is thinking about. Worksheets may include stop signs, to help the child recognize signs that they're about to lose control.

Worksheets can help children and adolescents understand how thoughts, feelings, and actions are connected. Through these worksheets, they can solidify what they've learned. CBT for children may also involve planners, checklists, or a rewards chart to help children remember and complete tasks.

CBT is an evidence-based practice shown to be effective for a variety of issues.

Meta-analyses show that up to of youth treated with CBT for anxiety disorders recover with significant decrease in symptoms following treatment. Follow-up studies of children treated in community mental health clinics show that those recovery rates are likely to continue at 4 years post-treatment.

Studies show that many adolescents with ADHD who received CBT had a significant reduction in symptom severity.

Among children with PTSD who receive individual trauma-focused CBT, there can be a great improvement of symptoms of PTSD, depression, and anxiety. In one , 92 percent of participants no longer met criteria for PTSD after CBT. This gain was still seen at a 6-month follow-up.

While there are many therapists trained in CBT, it's important to look for one who has experience working with children. Here are some things to look for:

Credentials. Look for a licensed counselor, family therapist, clinical social worker, psychologist, or psychiatrist. Licensure indicates a professional has met the legal standards to practice in your state.

Experience. Look for a professional who has worked with children or adolescents.

Transparency. Look for a professional willing to state goals and offer a treatment plan after an initial assessment or session with you and your child.

tips for finding a qualified mental health professional
Here are a few ways to locate mental health professionals with experience in CBT for kids:

Ask your family doctor or pediatrician for a referral to a qualified CBT specialist.

Call local universities, medical school psychiatry departments, or hospitals for referrals.

Ask family and friends who have used CBT.

Ask your insurance company for a list of qualified providers of CBT that are in-network or will be part of your coverage.

Visit these websites for lists of qualified professionals in your area:

CBT can help children understand how thoughts and emotions affect behavior and how changing their thoughts and emotions can change this behavior and the way they feel.

CBT is a safe, effective therapy that can help kids with a wide range of conditions and concerns.

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Cognitive Behavioral Therapy (CBT) for Kids: How It Works

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Cognitive behavioral therapy (CBT) is a type of talk therapy that can help people of all ages, including younger children and teens. CBT focuses on how thoughts and emotions affect behavior. Your child doesn't need to have a diagnosed mental health condition to benefit from CBT.

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DBT: What is Dialectical Behavior Therapy 

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DBT: What is Dialectical Behavior Therapy 

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Dialectical Behavior Therapy is an evidence-based treatment designed to help children and adolescents manage intense emotions, reduce impulsive behaviors, and improve interpersonal relationships. Developed by Dr. Marsha Linehan in the 1970s, DBT integrates principles of cognitive-behavioral therapy with mindfulness and acceptance strategies. The term "dialectical" reflects the balance between accepting one's current emotional state and striving for change. DBT is particularly effective for individuals exhibiting emotional dysregulation, leading to behaviors such as explosive anger, self-harm, or interpersonal conflicts. It has been successfully adapted for various conditions, including depression, anxiety, eating disorders, and substance use disorders. The therapy typically involves individual sessions, skills training groups, and family involvement to reinforce learning and application of skills. DBT's structured approach provides children and adolescents with tools to navigate emotional challenges and build healthier relationships.

Relevance:

Dialectical Behavior Therapy provides structured tools for managing intense emotions, improving self-control, and building healthy interpersonal skills. By teaching children mindfulness, emotional regulation, distress tolerance, and effective communication, DBT addresses behaviors that can interfere with learning, social relationships, and overall well-being. For child educators, understanding DBT is important because it helps them recognize signs of emotional dysregulation or impulsive behaviors in the classroom and respond with strategies that support self-regulation and problem-solving. This knowledge also enables educators to collaborate with mental health professionals and families to reinforce coping skills, creating a safer and more supportive learning environment that fosters both academic and emotional growth.

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If you have a child with psychiatric or behavior problems, there's a good chance you've heard of mindfulness and cognitive behavioral therapy (CBT), two different approaches to helping kids with everything from test anxiety to depression. But there's another very promising therapy that combines elements of both. DBT, or dialectical behavior therapy, is an intensive, highly structured program that's been adapted specifically for adolescents with extreme emotional instability, including self-harm and suicidal ideation.

The "dialectical" in DBT means the therapy works by dealing with two things at once that might seem contradictory: acceptance of feelings (mindfulness) and learning to use thinking to change feelings (CBT). It's basically "'I'm doing the best I can' on the one hand," notes Dr. Alec Miller, professor in the Department of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine " and 'I need to do better.' That's a dialectical truth."

A brief history of DBT

Dialectical behavior therapy was developed by Dr. Marsha Linehan in the 1970s to treat adult borderline personality disorder - a mental illness with symptoms ranging from chronic suicidal thoughts and/or self-harming behaviors to anxiety and depression. These patients were typically thought of as "difficult," if not impossible, to treat. Dr. Linehan redefined the disorder, reframing it as a specific problem of the emotion regulation system that can be addressed with a structured intervention.

People with borderline personality disorder have trouble regulating their moods, which leads to impulsivity and conflict in interpersonal relationships. That, in turn, often leaves them feeling misunderstood by others around them. First, Dr. Linehan tried traditional CBT, which emphasizes using conscious thoughts to confront and change problematic emotions. She was unsuccessful with her patients. So she then tried a much more acceptance-based approach that came out of her meditation and mindfulness practice. This, too, failed.

"So then she had this brilliant epiphany," says Dr. Miller. "Blending the acceptance strategies of mindfulness with the change technologies of CBT to create this dialectical behavior therapy."

How Does DBT Work?

DBT treatment is designed to help with extreme emotional instability, which clinicians call "dysregulation" - the inability to manage intense emotions. Dysregulation leads to impulsive, self-destructive, or self-harming behaviors. The goal of DBT is to teach adolescents techniques to help them understand their emotions without judgment - the mindfulness component - and also to give them skills and techniques to manage those emotions and change behaviors in ways that will make their lives better. But it takes work and commitment.

Related: What Drives Self-Injury and How to Treat It

DBT for adolescents involves individual therapy and group skills training, where parents and teenagers learn together. The feedback from parents, says Dr. Jill Emanuele, a clinical psychologist at the Child Mind Institute, is, "Where have these skills been all my life? I need these skills too." Other components include telephone consultation (patients are encouraged to call their therapists when they feel the urge to self-harm), family therapy, and weekly consultation team meetings where the therapist checks in with other professionals to consult on the case.

What skills does DBT teach?

DBT skills training is very structured; for adolescents, it consists of five modules:

Mindfulness skills: Being present in the moment and understanding the signs of unregulated emotions

Emotion regulation skills: Coping with difficult situations by building pleasant, self-soothing experiences to protect from emotional extremes. "Especially with teenagers," says Dr. Emanuele, "there's a big focus on the physical body: eating properly, getting enough sleep, taking their medicine and avoiding drug use."

Interpersonal effectiveness skills: "It's often interactions with others that are the negative triggers for impulsive behaviors," Dr. Emanuele says. The purpose is to teach adolescents how to interact more effectively with others, and enable them to feel more supported by others.

Distress tolerance skills: "It's being able to recognize urges to do things that would be ineffective, such as hurting themselves or trying to kill themselves" and consciously controlling them, says Dr. Emanuele.

Walking the middle path skill: Kids and parents learn how to validate one another, how to compromise and negotiate, and how to see the other person's side of things. "It has to do with acknowledging multiple truths in the teenagers' and the parents' worldview as opposed to 'I'm right and you're wrong,' " explains Dr. Miller.

What is DBT used to treat in adolescents?

Borderline personality disorder was historically considered something that could not be diagnosed in a person under the age of 18. But many clinicians, including Dr. Emanuele and Dr. Miller, now feel that symptoms of the disorder do develop in some adolescents, and the debilitating roller coaster of extreme emotions that they experience can be effectively treated with DBT.

DBT has also proved effective in treating the emotional instability and severe behavioral symptoms - self-harm and suicidal thoughts or attempts - seen in adolescents with other diagnoses, including:

"DBT," says Dr. Emanuele, "is used to treat adolescents with multiple problems that often include suicidality or self-harming behaviors. The keyword here is multiple."

DBT: An adolescent's perspective

Rachel Monasch did not have it easy as a kid. When she was little her mother's chronic illness kept her in the hospital for long stretches of time. She developed severe anxiety early on in life and had trouble making friends at school. Eventually she developed an eating disorder and at 13 she began to hurt herself. At 15, Rachel says, "I had I guess what you'd call a breakdown. I spent most of the year out of school." Rachel had been in therapy for a long time but it was mostly unstructured talk therapy along with medication. When she began struggling with suicidal thoughts she was hospitalized in an adolescent unit at a hospital that she describes as horrifying and traumatic. "I was assaulted by another patient and they didn't do anything." Rachel says she came out more depressed than when she went in.

Related: Teen Suicides: What Are the Risk Factors?

But then she switched to a therapist who specialized in DBT. That clinician got her enrolled in a 28-day DBT "boot camp" for adolescents that also had an eating disorders program. "We learned and practiced DBT all day, every day, for 28 days," she says. Now, a year later, Rachel is doing very well. She finds some of the tools she learned in DBT more helpful than others, so that's where she focuses her energy. "Distress tolerance, mindfulness, and emotional regulation skills are the big ones for me," she says. "I don't fight with people or even really my parents so the interpersonal effectiveness skills aren't all that helpful to me."

Rachel relies heavily on diary cards - daily logs that track her moods and emotions, what triggered them, how she reacted to them both positively and negatively-and the collection of skills she has come up with to deal with uncomfortable emotions. She has 19 so far. She also does a lot of breathing to center herself.

According to Rachel's dad, "DBT saved her life." But Rachel says it's not quite that simple. "I would say lithium plus DBT and a great therapist saved my life."

Read More:

What to Do if You're Worried About Suicide
What Are the Symptoms of Depression in Teenagers?

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DBT: What Is Dialectical Behavior Therapy?

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If you have a child with psychiatric or behavior problems, there's a good chance you've heard of mindfulness and cognitive behavioral therapy (CBT), two different approaches to helping kids with everything from test anxiety to depression. But there's another very promising therapy that combines elements of both.