6. vii
FOREWORD
Learn your theories as well as you can, but put them aside
when you touch the miracle of the living soul.
—Carl Jung
Whatever our age, certain moments embed themselves in our
memories. I still clearly remember my first day on the job,
decades ago, working as a bona fide child welfare profession-
al. After earning my master’s degree, I was of the opinion that my grad-
uate training was ample preparation to make a serious dent in solving
the problems facing American families. I would be in for a rude awak-
ening, but at that time, I was eager to begin. I can do this, I thought.
I arrived to work early on my first day and watched staff wander in
with cups of coffee and bagged sandwiches. I remember wearing a dark
suit and carefully ironed white blouse, accessorized with a grin and the
desire to please. Waiting in the main lobby to report to my new super-
visor, I was absent of worry or apprehension without the slightest
awareness of how far I would have to travel in my profession to under-
stand how complex child advocacy can be.
My job as a juvenile probation counselor was heavy on the role of
counselor rather than officer. In 1977, this was a big deal for a small
county in Ohio. At that time societal norms leaned more toward the
title of officer. But my boss, a part-time farmer with a down-to-earth
manner and a feeling for the work, had convinced the very conserva-
tive community leaders to support a newer progressive approach to
helping challenged kids.
Looking back, I recognize that on more than one occasion I may
have been a tad naive during this time. For example, I practically
7. Working with Traumatized Childrenviii
choked when a police officer presented me with one of my 17-year-old
clients after picking her up for prostitution at the local watering hole.
I had unwittingly supported her desire to fulfill her current career goal
by extending her curfew so that she could visit her sick “daddy.” I
remember trying to wrap my mind around this girl’s behavior without
giving much thought to the fact that there had been an awful lot that
had transpired in her life leading up to trading sex for money.
I was eventually hired upstairs (literally—the juvenile center where
I had been working was located in the basement of the building) to be
the social worker for adolescent girls who were adjudicated dependent
and living in the county residential homes. These early work experi-
ences were my introduction to not only recognizing that child and
family advocacy can be a tough job, but that there was something more
behind my young clients’ behavior like running away at the most
unusual moments.
Their out-of-home environments, on the surface, appeared safe
enough. Those in our profession thought that warm food and a clean
bedroom was a good start in placing young and often troubled clients
on the right track. In those days social work had more to do with super-
imposing its own brand of values onto troubled children. In addition, I
was also one of those “helpers” that erroneously believed that role-
modeling kindness and consistency was enough to tackle problems.
The kids, on the other hand, didn’t get the memo. In some instances
my good intentions helped, but more frequently they didn’t come close
to addressing the underlying causes behind the problems. The majori-
ty of kids in care had sufficient trauma backgrounds to impact their
coping capacities and rendered them helpless, at the whim of their
hypersensitive arousal systems. They were also prone to physical prob-
lems such as colds, headaches, and stomach or breathing disorders—
just about any ailment that reflected impaired immune systems.
The older kids’ issues were often chalked up to being teenagers. After
raising a teenager of my own and learning about the neural science
behind the adolescent brain, I believe there is some truth to that.
However, these youth exhibited psychological and physical extremes
8. such as cutting themselves, exaggerated mood swings, and massive
fears. I helplessly stood by and watched when they were immobilized
by panic attacks or became excessively violent. Many of their fears and
behaviors surfaced within seconds.
I spent the early years of my career in search of the perfect
trauma antidote. Back then, I perseverated on why, after all my well-
intentioned caring, many of my young trauma clients continued to
experience overwhelming fear, panic attacks, rages, and oppositional
behaviors. In the late 1970s the brain’s relationship to toxic stress, and
the attending fallout from traumatic human experiences, was just
beginning to be understood.
Then a wonderful thing occurred. Interventions to help traumatized
children, youth, and their families turned a corner when neural research
came into the picture. With the help of neural imaging technologies
and important studies published by dedicated neural researchers, I
began to understand the connection between horrific experience and
disrupted brain-body function. Since then it’s been my mission to
merge neural science and frontline social work together and bring it
into focus for those who work with traumatized children and adults.
This book was first written over 20 years ago for frontline workers,
administrators, court and law enforcement officials, educators, volun-
teers, and just about anyone who works to support traumatized chil-
dren. In this third edition of the book there is more to share.
When I first wrote this book, neural research was rapidly revealing
connections between physical and psychological environments that
included their impact on the growing and not so growing human
brain. My intention was to synthesize this newer information and write
a trauma informational guide for child advocates without science
backgrounds. I also wanted to make the book practical and relevant,
but to take care not to give the green light to people in the front lines
to diagnose, treat, or otherwise suggest medical therapies. (That job is
left to licensed and trained mental health professionals.)
Putting this new information into the language of a reality check
for my colleagues was my intention. (Like in parenting, a check-in with
ixA Handbook for Healing
9. a reliable source can go a long way in helping us feel as though we’re not
entirely crazy.) It was important to translate trauma research into prac-
tical application. And like its predecessors, this edition is also intended
for that audience: professionals and volunteers working with and refer-
ring support services for traumatized children, youth, and caregivers.
I explain recent neuroscience research that has more clearly articu-
lated functional brain changes following a traumatic experience.
Trauma-informed care is further discussed in the first chapter as an
enlightened and common sense approach to working with trauma-
tized children.
Overviews of the Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood, Revised (DC:
0-3R) diagnosing manual, along with the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) and the
International Classification of Diseases (ICD-10 and ICD-11), are pro-
vided. In addition, the impact of physical, verbal, and cyber bullying
on children is expanded.
While simple and easy-to-follow exercises to soothe and calm chil-
dren remain within this edition of the book, additional interventions
are discussed based upon recent research. Interventions to help facili-
tate trauma recovery vary depending upon the age, needs, and severi-
ty of trauma experienced, so they are explained in terms of early and
middle childhood and adolescence. (However, we must not forget that
young adults even into their 20s remain impressionable and that their
brains continue to grow as well.) These interventions do not require a
graduate degree or mental health license to execute—just responsible,
mindful connection with kids and caregivers. In other words, they
aren’t rocket science, and with the help of trauma-informed care they
can be effective in supporting kids to become actively aware of, under-
stand, and learn how to cope with their posttrauma challenges.
The chapter on growing up traumatized and later choosing to work
with young trauma survivors has been expanded as well. It remains an
important chapter because unless child advocates spend time in per-
sonal growth exercises to deal with their own trauma-related conditions,
Working with Traumatized Childrenx
10. or receive enlightened mentoring and supervision, they can inadver-
tently inject their trauma symptomatology into their work. I think of
it as the “do not shoot yourself in the foot” chapter.
After a while “she/he” can be tedious to read, so “she” and “he” are
used alternately throughout the book. The names of all children in this
book have been changed to protect their privacy.
What will the next 10 years reveal about trauma and its impact on
human beings? Currently there are national trauma initiatives such as
the National Child Traumatic Stress Network as well as ongoing
research to address trending policies, procedures, and ultimately treat-
ment. Undoubtedly we will continue to be enlightened. Perhaps, the
fallout from trauma will be nonexistent because there will be a med-
ical antidote.
In the end, while neuroscience has greatly enlightened our profes-
sion, passion, authenticity, and intention remain three more subjective
but overwhelmingly positive child advocacy traits that underpin our
work. I’ve learned through time that these character attributes set the
stage for meaningful connections with our children.
This book is meant to be your reference and guide. It will provide
you with insight into how traumatic experiences affect mind and body
functioning and what you can do to foster safety and healing in chil-
dren. Take from it what works for you. What matters most is the work.
Does it bring you pleasure? Does it sustain your soul?
Working to heal traumatized children and their families makes a
difference in the overall quality of life on Earth. And, to all of you who
make that difference, thank you.
xiA Handbook for Healing
11. xiii
GRATITUDE
T
eamwork is behind any published work, and it was certainly
behind this book. All three editions would not have happened
if Child Welfare League of America leaders felt there was no
value in educating child advocates about childhood trauma. For this
edition, thank you to Christine James-Brown, President and CEO of
CWLA, for advocating for this edition and continuing to raise the bar
for CWLA members. Thank you to Emily Shenk Flory, my great editor,
for cleaning up my work and asking the important questions. It’s
always easy to work with you. And thank you to Marlene Saulsbury, art
director at CWLA, for creating a beautiful cover and being so encour-
aging. In addition, Julie Brite at CWLA has been a great help with
webinars and has been there since my first edition was published.
My dear friends gave invaluable advice. Thank you to Meg Trigg for
reading and rereading chapters, Christine Armbrecht for your kind
review, Lynn Thomas for checking facts, and Joe Hege, my best friend
and husband, for your continuing support. Finally, I want to share
immense gratitude for my grandchildren, Eleanor and Tristan Mirgeaux.
12. 1
1
CHILD TRAUMA AND SOCIETY
Fear’s a powerful thing
It’ll turn your heart black you can trust
—Bruce Springsteen, “Devils and Dust”
T
hroughout history there have been few markers that measured
the toll child trauma has had on individuals and society. Children
suffered and struggled to cope with conditions that arose from
a variety of terrifying experiences while they also struggled to grow
and experience normalcy.
Yet, in spite of the fact that history overflows with stories of horrific
events, it has taken a long time for the effects of trauma’s impact to be
recognized and addressed—especially in children. Until fairly recently,
child advocates struggled against this backdrop of societal trauma with
few tools but good intentions to help their clients.
If left untreated, traumatized children grow into adults whose world-
views are shaped through their disrupted relationships, extensive fears,
and irrational thinking. Traumatized parents often mirror these behav-
iors and psychological states for their children. The question remains:
How do these traumatized caregivers create safe havens for their off-
spring when they are forever seeking psychological safety themselves?
13. The merry-go-round of generational trauma continues and enlarges
when entire communities become traumatized. One only has to look
to our country’s tribal and formerly enslaved societies to recognize
the underlying causes behind so many later challenges. But attention
must be paid to the fact that the health and creativity of a communi-
ty is restored through its children and families, and the community
or society that values its children thrives.
In this century,children are not only challenged by poverty,neglect,and
adult abuse; they must also grapple with bullying in schools and online.
These days there are even more trauma contributors with the introduc-
tion of social media and school violence. Child advocates must contend
with traumatized children who have experienced multiple traumas.
Poly-Victimization
In a 2008 study authors Heather A. Turner, David Finkelhor, and
Richard Ormrod sought to document children’s lifetime exposure to
multiple victimization types and examine their association to the extent
of trauma symptomatology (2010). Their study Poly-Victimization in a
National Sample of Children and Youth postulated that most studies of
children’s exposure to violence (leading to trauma) focus on separate,
relatively narrow categories of victimization such as sexual abuse,
physical maltreatment, or bullying. Their study paid more attention to
exposure to multiple forms of victimization, or poly-victimization.
To that end, they conducted telephone interviews between January
and May 2008 with a nationally representative sample of 4,053 chil-
dren aged 2–17 years and their caregivers. They found that exposure to
multiple forms of victimization was common. Almost 66% of the sam-
ple was exposed to more than one type of victimization, 30% experi-
enced fıve or more types, and 10% experienced 11 or more different
forms of victimization in their lifetimes.
Sadly, poly-victims comprise a substantial portion of the children
who would be identifıed by screening for an individual victimization
type, such as sexual assault or witnessing parental violence. Multiple
Working with Traumatized Children2
14. victimization is more highly related to trauma symptoms than experi-
encing repeated victimizations of a single type. The study revealed that
focusing on single forms of victimization is likely to underestimate the
full burden of victimization that children experience in addition to
incorrectly identifying the risk profıles of victims.
Drug and alcohol abuse play a huge role in creating multiple types
of trauma. For example, the recognized study from the National
Center on Addiction and Substance Abuse at Columbia University
(CASA, 2002) validated that children of substance-abusing parents are
the most endangered and vulnerable people in America. This is a chill-
ing reminder that maintaining separate child welfare and substance
abuse silos to treat trauma in children and youth is antiquated.
Jesse
Our society failed Jesse, a poly-victim of trauma who fell through the
cracks of the child protection system. Raised in rural Kentucky, she
was routinely sexually abused after school by an older brother while
her parents were at work. It began when she was seven years old. Her
story of complex trauma grew when she was asked to help a nearby
farmer and was cornered in his barn and sexually molested by him.
Jesse prayed to God to spare her from his repeated rape and misogy-
nistic brutality. To her horror, a few weeks later he died from a sud-
den heart attack. To add to the macabre, Jesse was asked to kiss him
while he was lying in his coffin—a cultural and community norm.
Jesse’s family belonged to a religious sect that required her to
marry at age 18. Fiercely repelled by her new husband, she was forced
to endure painful sex and his violent behavior. Jesse begged for a
divorce, and as a result she was shunned by her family and husband
and turned away from her community.
Seeking comfort, she began communicating long-distance with a reli-
giously affiliated couple in Michigan. They invited her to stay at their
home until she could get back on her feet. Hope got the better of Jesse’s
common sense when she traveled north to live with her new friends.
3Child Trauma and Society
15. But the couple was not well intentioned.They belonged to a religious
cult that used Jesse’s vulnerability to entrap and hold her prisoner in
their basement for three months while they ritualistically raped and
tortured their captive. Fortunately, Jesse’s friend contacted the couple
and threatened police intervention if Jesse did not quickly appear. The
following day Jesse detected a faint light from a partially opened door
at the top of the stairs and made her escape. But Jesse refused to
report the crime. She feared that her report would be questioned, as
well as cult retaliation. She was not up for interrogation.
Back in Kentucky she found work at a university and quietly went
about her life, but narrowly escaped an attempted rape. But her expe-
riences were not without extensive fallout. Jesse suffered from terrible
nightmares, depression, migraine headaches, and ulcers. As she grew
older, Jesse developed other physical ailments that sabotaged her
quality of life, including high blood pressure, weight gain, and
endometriosis, followed by an early hysterectomy.
For a time, she was happily partnered and set up household in
another state. At the age of 53, Jesse entered the hospital for a routine
gallbladder operation. Friends were stunned when she failed to
regain consciousness after the operation. Her physical resiliency was
worn down from years of intense stress. Her physicians speculated
that her health had been severely compromised as a result of her prior
multiple traumas and may have ultimately contributed to her death
at a fairly young age.
Societal Bullying and Children
More recently, societal bullying is being studied as a root cause of child
and adolescent trauma. Bullying merges with humiliation and fear,
and when repeated it can cause multiple trauma symptoms. Bullying is
a behavior linked to child development, relationship formation, and
psychological well-being. According to the American Psychological
Association (APA), “Bullying is commonly characterized as aggressive
behavior that (a) is intended to cause distress or harm, (b) involves an
Working with Traumatized Children4
16. imbalance of power or strength between the aggressor and the victim,
and (c) commonly occurs repeatedly over time.”
Bullying among children and youth comes packaged in a variety of
ways and can occur in any number of settings. It has a harmful social,
physical, psychological, and academic impact on personal well-being.
When child and adolescent bullies are allowed to act aggressively, they
learn that antisocial behavior and exerting control over others is
acceptable. Bullying interferes with child and youth development and
can also lead to suicide, reciprocated aggression, low self-esteem, and
other trauma symptomatology.
In their 2004 Resolution on Bullying Among Children and Youth, the
APA stated bullying includes physical bullying; teasing or name-calling;
social exclusion;peer sexual harassment;bullying about race,ethnicity,reli-
gion, disability, sexual orientation, and gender identity; and cyberbullying.
The pioneering work of Dan Olweus in Norway and Sweden, as well
as other researchers, has found that:
• The most common forms of bullying in middle and high school
are related to physical appearance, disabilities, perceived sexual
orientation or gender expression, and exhibiting perceived or true
lesbian, gay, bisexual, or transgender-related characteristics
(Olweus, 1993).
• Bullying occurs in all geographic regions and all types of schools. It
involves large numbers of children and youth from the United States
in all socioeconomic backgrounds, racial groups, and in areas of dif-
ferent population density (urban, suburban, and rural settings).
• Whereas social stereotypes may convey the impression that certain
ethnic or socioeconomic groups are more likely to bully and per-
petrate, violence research reveals no significant racial differences in
the rates of bullying (Nansel, 2003).
• In a 2001 study by Kaiser Foundation in conjunction with
Nickelodeon TV network and Children Now, 86% of children ages
12-15 interviewed said they get teased or bullied at school, making
5Child Trauma and Society
17. bullying more prevalent than smoking, alcohol, drugs, or sex
among this age group (Coloroso, 2003, 2008).
• According to the National Youth Violence Prevention Resource
Center, 30% of teens in the U.S. are estimated to be involved in
bullying in one way or another.
• Victims are always vulnerable in some way. They are more anxious
and insecure than other students (Olweus, 1993).
Cyberbullying
Cyberbullying is a serious problem among children and youth, and yet
fewer than 30% of the victims know their bullies. Cyberbullying is any
harassment that occurs via the Internet. Name-calling in chat rooms,
posting fake profiles on websites, vicious forum posts, and cruel email
messages are different forms of cyberbullying. School bulletin boards
can be spammed with hateful rumors directed toward a specific stu-
dent, and fictitious profiles on a social networking site can prompt a
victim to falsely engage with someone who appears to be someone else.
In a survey of randomly selected middle school students in one of the
U.S.’s largest school districts,researchers found that cyberbullying victims
were 1.9 times more likely and cyberbullying offenders were 1.5 times
more likely to have attempted suicide than those who were not cyberbul-
lying victims or offenders. The researchers concluded that suicide pre-
vention and intervention should be included in schools’ bullying and
cyberbullying response programs. The most common forms of offending
were posting online information about another person to make others
laugh and receiving an upsetting email from someone known to the
victim (National Center for Child Traumatic Stress [NCCTS] 2009).
Many of the youth who have raged war on their own schools by shoot-
ing other students and teachers had been bullied earlier in their lives.
Consequently, it’s not a stretch to assume that kids who bully other kids
have probably been bullied themselves and are reenacting their experi-
ences (trauma reenactment is another trauma symptom) (Banks, 1997).
Working with Traumatized Children6
18. Bullying’s Long Reach
Nationwide, severe bullying has ended in death for too many children
and youth. In the case of one 15-year-old student’s death in 2010, sev-
eral students were charged. This young girl killed herself after being
harassed by teenagers at her high school.
The town’s district attorney charged the group with “relationship
aggression,” which identified three months of verbal insults and phys-
ical threats. The victim, who had a history of depression, was also tar-
geted electronically on Facebook, where she received messages encour-
aging her to kill herself. The young victim was targeted in the library
and hallways, shoved into lockers, and taunted while walking home
from school. According to some students, teachers observed a few of
the incidents. On the day the victim died, the bullying was extremely
intense. South Hadley students followed her home, calling her offen-
sive names while throwing a large drink in her direction.
After her death, students interviewed said they didn’t see her being
bullied as a serious problem, calling it “normal girl drama.” Many peo-
ple asked: Where were the adults? The high school principal stated,
“There were instances of name-calling … the week before she died.
These were brought to our attention, we dealt with those kids right
away.We also talked to her, we had her working with a school counselor,
we talked to her mom” (Bazelon, 2010). Could the school have done
anything else to prevent this suicide? Why didn’t the administrators
immediately call a trauma expert to intervene on behalf of this child?
In the past, conventional protocol has been to handle institutional
problems internally. And that would be okay if, for example, all school
counselors are required by law to be trained to identify traumatized stu-
dents and, as soon as possible, make appropriate referrals. While pock-
ets of our society are working to trauma-educate child advocates from
various child advocacy sectors, the uphill climb continues. Community
agencies that range from rape and domestic violence, child welfare, faith-
based, behavioral health, alcohol and drug, schools, and juvenile justice
have been slow to build continuity of care on this topic at the front line.
7Child Trauma and Society
19. Trauma-Informed Child Advocacy
As professionals and volunteers step into child advocacy roles, they
should be trauma-informed in the way they approach their work.
The National Center for Trauma-Informed Care states: “Trauma-
informed organizations, programs, and services are based on an
understanding of the vulnerabilities or triggers of trauma survivors
that traditional service delivery approaches may exacerbate, so that
these services and programs can be more supportive and avoid
re-traumatization, and know when and how to intervene directly in
a trauma-sensitive manner and through strategic referral.”
Trauma-informed service systems are behavioral health organ-
izations that acknowledge and understand the effects of trauma
and value consumer participation. They take into account knowl-
edge about trauma, its impact, interpersonal dynamic, and paths
to recovery. They incorporate this knowledge into all aspects of
service delivery (National Child Traumatic Stress Network
[NCTSN], 2015).
What Does It Mean to Be Mindfully Directed at Work?
Being mindful is the capacity for heightened present-moment
awareness that we all possess to a greater or lesser extent.
According to Jon Kabat-Zinn, “mindfulness means paying
attention in a particular way; on purpose, in the present
moment, and non-judgmentally” (Kabat-Zinn, 1990).
Mindfulness involves paying attention to present-moment
experience without engaging conceptual elaboration and emo-
tional reactivity. For example, a mindfulness exercise would be
to sit quietly, allowing your mind to rest by focusing on your
breathing. When thoughts surface, gently let them pass like
clouds and refocus again on your breath.
Working with Traumatized Children8
20. Trauma-informed services accomplish the following:
• They integrate an understanding of trauma, substance abuse, and
mental illness through programs.
• They review service policies and procedures to ensure prevention
and re-traumatization.
• They involve consumers in designing and evaluating services.
• They recognize trauma as a defining and organizing experience
that can shape survivors’ sense of self and others.
• They create a collaborative relationship between providers and con-
sumers and place priority on consumer safety, choice, and control.
• They focus on empowerment and emphasize strengths.
Newer or more naive child advocates can unintentionally ignore the
causes behind short attention spans or temper flare-ups in young trau-
ma survivors, believing them to be intentional and attention-seeking.
Being trauma-informed, however, empowers them to successfully
work on behalf of traumatized kids while recognizing that the opposi-
tional or inappropriate behaviors demonstrated by these youngsters
should not be taken personally.
Being trauma-informed, no matter what frontline role you assume
(child protection worker, health services, juvenile probation counselor,
residential parent, law enforcement officer, guardian ad litem, or other),
means you should follow practices that include the following steps:
1. Gather information about each child’s trauma history and its
impact on the child’s development, behavior, and relationships in
order to guide services.
2. Use a strength-based approach that enhances children’s skills
to manage reactions, reduce high-risk behaviors, and promote
constructive activity.
9Child Trauma and Society
21. 3. Provide support and guidance to the child’s family and caregivers.
4. Support and promote positive, stable relationships in the
child’s life.
5. Coordinate services with other agencies.
6. Explain trauma-specific care to children and their families and
motivate them to participate in care.
7. Manage personal and professional stress (NCCTS, 2009).
What is Strength-Based Practice?
Strength-based practice concepts include resilience, hope, self-
efficacy, and empowerment that regularly occur under the
umbrella of many different therapy methodologies. According to
mental health practitioners, strength-based practice fortifies
clients against problems by identifying client strengths with clients
and balancing the use of strengths with a problem focus. Strength-
based practice helps to expand client perspective and foster client
awareness to include more positive views of self. This process is
used to uncover positives the client could value. Meanings are
formed about strengths by therapists listening and reframing
problems and solutions.
A University of Nebraska study examined the experiences of
eight therapists in their use of client strengths in therapeutic prac-
tice. The examination of the use of client strengths relied on ther-
apist recollections. Clients who were more intensely influenced by
their problems or clients in crisis were two situations identified as
less appropriate for the use of strength-based practice. Otherwise,
the eight therapists found the process to be helpful.
Strength-based practice continues to evolve and more studies are
needed to examine its efficacy (Scheel, Davis, & Henderson, 2012).
Working with Traumatized Children10
22. Your Role
While children within the child welfare system usually become trauma-
tized as a result of parental abandonment, abuse, and neglect, other
traumatized children have experienced natural disasters, refuge and war
trauma, accidents, death, and other terrifying encounters. They all fear for
their physical or emotional integrity, and when highly stressed they can
feel overwhelmed by their own physiological, emotional, and behavioral
responses.As a result, many of these children have developed an extensive
repertoire of self-destructive responses to stress. But they can be helped
with clear, loving, consistent, and enlightened intervention. In your role as
a child advocate, addressing these issues in children and youth is not easy
or simple. It entails seeking out continuing trauma education opportuni-
ties; understanding that caring alone may not be enough to help a trau-
matized child; and using a detective’s curiosity to uncover a child’s trauma
triggers by thoroughly reading a child’s file, checking facts, and interview-
ing the child and family, and also understanding a child’s referral needs.
In order to make trauma-informed referrals, child advocates should
know what type of treatment works best for traumatized children and
adolescents. Trauma treatment through behavioral health (mental
health) services that directly address trauma recovery include grounding
techniques that help trauma survivors manage dissociative symptoms;
desensitization therapies that help to render painful images more tol-
erable; and behavior therapies that teach skills for the modulations of
powerful emotions.
Child advocates have a big job because, at a grassroots level, you can
make a meaningful difference in how our society unfolds. You play a
major role in spotting trauma in kids and coordinating their care
before too much time passes.
Recognizing trauma symptoms has largely become part of the job,
but perhaps not all workers apply their trauma knowledge through
trauma-informed best practice interventions. “The difference between
what we know and what we do is lethal,” said former U.S. Surgeon
General David Satcher.
11Child Trauma and Society
23. Child advocates should not be solely responsible for intervening on
behalf of traumatized children either. The old saying that it takes a vil-
lage to raise a child applies to young survivors as well. Every commu-
nity must fully participate in healing traumatized children and their
families. Advocating for a traumatized child is a high calling, and one
that is difficult to do by yourself. This book serves to fill a supportive
void whenever you feel alone.
Working with Traumatized Children12
24. 2
TRAUMA’S RELATIONSHIP WITH
STRESSOR-RELATED DISORDERS
So hard to feel the stone and not the ripple.
—Mark Nepo
B
y age 16, approximately 25% of children and adolescents in the
U.S. experience at least one potentially traumatic event, includ-
ing life-threatening accidents, disaster, maltreatment, or family
and community violence (NCTSN, 2009). Keeping these statistics in
mind, people who advocate for children should familiarize themselves
with the primary mental health diagnoses identified with trauma so
they know what to look for when they need to make referrals or write
case plans on behalf of their young clients.
There are different types of trauma and stressor-related disorders.
They include reactive attachment disorder, disinhibited social engage-
ment disorder, posttraumatic stress disorder (PTSD), acute stress dis-
order, and adjustment disorders. Exposure to a traumatic or stressful
event is a diagnosis requirement.
Careful study of clinical, biochemical, and functional magnetic
resonance imaging (fMRI) data has also led investigators to conclude
13
25. that PTSD is not a fear- and anxiety-based disorder, as once thought.
Instead it is one of a wide array of disorders, mentioned in the last para-
graph, that arise in response to traumatic events. The disorders are char-
acterized by symptoms of avoidance and negative alterations of mood,
not fear. They are much more than anxiety disorders (Mays, 2015).
The more well-known trauma-related diagnosis, PTSD, is a chronic,
debilitating mental disorder that develops in response to catastrophic
life events (Wolf et al., 2015). It arises from acute, chronic, or delayed
reactions to physical injury or severe mental or emotional distress, such
as military combat, violent assault, natural disaster, abuse, deprivation
and neglect, or other life-threatening events. Having a life-threatening
illness such as cancer may also lead to posttraumatic stress disorder.
PTSD symptoms interfere with day-to-day living and include reliv-
ing the event in nightmares or flashbacks; avoiding people, places, and
things connected to the event; feeling alone and losing interest in daily
activities; a state of hyperarousal; diminished emotional responsive-
ness; or sleep problems.
Complex Trauma
“Complex trauma describes the dual problem of children’s expo-
sure to traumatic events and the impact of this exposure on
immediate and long-term outcomes. Complex traumatic expo-
sure refers to children’s experiences of multiple traumatic events
that occur within the caregiving system… Typically, complex trau-
ma exposure refers to the simultaneous or sequential occurrences
of child maltreatment — including emotional abuse and neglect,
sexual abuse, physical abuse, and witnessing domestic violence—
that are chronic and begin in early childhood” (Cook, Blaustein,
Spinazzola, & van der Kolk, 2003).
PTSD’s precursor, the diagnosis of acute stress, reflects trauma-
related symptoms or stress adaptations that continue for more than
Working with Traumatized Children14
26. one month. PTSD encompasses effects from trauma for a longer peri-
od and is identified as “acute” if symptom duration is less than three
months and “chronic” if duration is more than three months. PTSD
symptomatology reflects a physiologically based illness.
In children ages 6 and younger, they must have been exposed to actu-
al or threatened death, serious injury, or sexual violence through directly
experiencing the traumatic event(s) or witnessing, in person, the event(s)
as it occurred to others, especially primary caregivers, or learning that the
traumatic event(s) occurred to a parent or caregiving figure (APA, 2013).
The good news is that most frontline child advocates are now famil-
iar with PTSD. The less good news is that this diagnosis label has been
overused, and, more than necessary, stamped on a child without proper
evaluation. Child advocates may forget that there are other trauma-
related diagnoses that can be extremely uncomfortable. Well-meaning
frontline child advocates, sans credentials, have been doing much of
the imprinting. For example, many of us have had conversations with
non-clinical coworkers who might say something like,“I spent an hour
with the child yesterday and by the looks of it, he has PTSD.”
In their eagerness to help, frontline workers who advocate for trau-
matized kids sometimes jump to the conclusion that just about any
child who encounters a catastrophic experience is a“lifer”in the“trauma
fallout” department. While the number is still too high, only about
20% of kids will develop PTSD following trauma. That leaves the rest
of the children falling within gray areas ranging from those not at all
affected to those moderately affected by a trauma occurrence. In addi-
tion, only half of children diagnosed with acute stress disorder will
develop PTSD (Mays, 2015).
This chapter discusses causal factors behind the diagnosis of trau-
ma- related stress disorders and describes how they impact the overall
integrity of the brain and body, leading to acute stress and posttrau-
matic stress disorders in young, middle, and older children. Three
mental health diagnosing manuals utilized by licensed mental health
professionals that address trauma symptomatology and are used as pri-
mary diagnosing resources are briefly described here.
15Trauma’s Relationship with Stressor-Related Disorders
27. 1. The Diagnostic Classification of Mental Health and Developmental
Disorders of Infancy and Early Childhood Revised (DC: 0-3R). The
DC: 0-3R is the diagnosing manual for infants ages zero to 5 and is
published by the Zero to Three Network.
2. The Diagnostic and Statistical Manual of Mental Health Disorders,Fifth
Edition (DSM-5) for children and adults is published by the American
Psychiatric Association. The DSM-5 was the go-to reimbursement
resource for U.S. mental health professionals for quite some time,
but things changed when the ICD-10 became popular in the U.S.
3. The International Classification of Diseases (ICD-10) is now the
diagnostic manual required when diagnosing for Medicaid and
Medicare patients under the U.S. Health Insurance Portability and
Accountability Act (HIPAA). ICD-10 is the standard diagnostic
tool for epidemiology, health management, and clinical purposes.
This includes the analysis of the general health situation of popu-
lation groups. It is used to monitor the incidence and prevalence of
diseases and other health problems, providing a larger picture of
the general health situation of countries and populations.
The ICD-10 has replaced the DSM-5 for reimbursement by the
government. It has been translated into 43 languages. ICD-10 was
endorsed by the Forty-third World Health Assembly in 1990 and came
into use in the World Health Organization Member States in 1994. ICD
is currently under revision, through an ongoing revision process, and
the scheduled release date for ICD-11 is 2018.
Because ICD-10 is now mandated by the federal government as the
reimbursement diagnosing tool for Medicaid and Medicare recipients,
this manual will be their reference. However, it helps to keep all three
manuals in the office for quick referencing when you speak with
licensed mental health professionals.
Frontline workers should also know that children diagnosed with
more than one diagnosis have what is called co-occurring disorders.
Working with Traumatized Children16
28. For example, a child might have dissociative disorder in addition to
posttraumatic stress disorder, and this will be reflected within the
child’s mental health evaluation.
The ICD-11 and the DSM-5 differ in their criteria requirements,
for example, posttraumatic stress disorder. The ICD-11 will include
complex PTSD as a separate diagnosis, whereas DSM-5 does not
(Friedman, 2014).
Posttraumatic Stress Disorder according to the DSM-5:
1. Does not include witnessing events on TV or other electronic
media.
2. No longer requires that an individual have a subjective experi-
ence of fear or horror, since that has not been useful in deter-
mining who develops PTSD. Well-trained emergency workers,
for example, often do not show emotions during the crisis, but
they may develop PTSD. The DSM-5 also includes reactive
attachment disorder of infancy and disinhibited social engage-
ment disorder. They replace reactive attachment disorder of
infancy or early childhood.
3. Is no longer classified as an anxiety disorder.
Child advocates were disappointed that the DSM-5 did not take
steps to expand or recognize the many attachment and mental health
problems abused and neglected children experience. Many of these
children also experience co-occurring disorders such as depression,
anxiety, conduct problems, and even psychosis, but the DSM-5 pro-
motes mental health professionals to treat these as specific syn-
dromes. Consequently, trauma-informed care may be overlooked
when addressing these separate categories.
ICD-11 has taken a much less conservative approach so that
DSM-5’s requirement for a large burden of scientific proof to change
any DSM-4 criterion has not been ICD-11’s guiding principle. As a
result, the ICD-11 revision is a bit more expansive than DSM-5. It
will contain a class of traumatic stress disorders with symptoms that
17Trauma’s Relationship with Stressor-Related Disorders
29. last more than one month, and there are different forms of posttrau-
matic stress disorder depending on the time of onset and the duration of
these stress symptoms. In the acute form, the duration of the symptoms is
between one to three months. In the chronic form, symptoms last more
than three months. With delayed onset, symptoms develop more than six
months after the traumatic event.
As discussed in Chapter 1, trauma types have been added to the
mix. Infants, children, and youth are exposed to new as well as older
types of trauma that cause them overwhelming distress. In addition to
child welfare causes, high stress levels in mothers can effect children in
utero, school-age children can be harmed by school bullies, and youth
can be terrified by online sexual predators.
Trauma is generated by a variety of events that can include:
• child abuse (physical, emotional, sexual) and neglect,
• sudden and/or violent death of a loved one,
• life-threatening accidents or illness,
• invasive medical procedures,
• refugee experiences,
• war,
• natural disasters,
• bullying,
• ongoing exposure to family or community fighting that includes
drive-by shootings, fighting, screaming, and shouting,
• domestic violence, and others.
Working with Traumatized Children18
30. Mary Jo
Mary Jo, age 4, would seek peace within an abandoned backyard
refrigerator—her refuge from her grandmother’s chaotic and
poverty-plagued household. One day, while sitting within her safe
haven, Mary Jo’s daydreams were disrupted by her granny’s shrill
voice demanding her presence back at the house. Fearing trouble,
the little girl closed the refrigerator door. After waiting for a time
and thinking the coast was clear, she attempted to open it, but the
rusty old appliance door was stuck. Her terror mounting, Mary Jo
pounded on the walls of the suffocating box. Her screams were
muffled but heard by a neighbor who happened to be taking out
the garbage.
The woman pulled the trembling and hysterical child from the
refrigerator and quickly carried her back to Mary Jo’s grandmother’s
house. But the neighbor was disturbed to hear the child’s grand-
mother scream at Mary Jo for hiding in the refrigerator and then
giving the child a sharp slap across her face. When the neighbor
attempted to defend Mary Jo, she was asked to mind her own busi-
ness and leave.
The aftermath of Mary Jo’s experience included nightmares and
exaggerated fear of being in a room with the door closed. Her social
and emotional development were slowed as she struggled to cope
with her overwhelming fear of abandonment as well. Her mother’s
long absences were unpredictable while her distracted grandmother
resented filling a caregiver role in the child’s life. Many male strangers
wandered in and out of the home, and a few, including her father,
molested her. Mary Jo began to withdrawal into her pretend world,
imagining herself being rescued by a kind family.
Like many at-risk children, Mary Jo’s support systems were mar-
ginal. Her emotional deprivation and sexual abuse held her back
developmentally as she withdrew into her pretend world. Entering
school proved to be her saving grace. She began to learn about saying
no when she did not want someone to touch her, and sharing
19Trauma’s Relationship with Stressor-Related Disorders
31. with safe adults when someone tried to hurt her in certain parts
of her body. One day, during story time, she announced she
didn’t like grown-ups touching her private spots. Mary Jo’s teacher
took her aside, and in a conversational tone, asked Mary Jo if she
could explain. Following the little girl’s disclosure, and after con-
sulting with school administrators, a report was made to child
protection services.
The Brain’s Connection to Trauma
Why should frontline child advocates know how trauma impacts the
brain? Well, for one thing, the human brain is amazing! But for the
purpose of working with traumatized children, it is the enlightened
approach to advocating on their behalf. Unless workers understand the
impact of trauma on the brain, they are attempting to solve a riddle
with only half the question. Twenty years ago, it was difficult to get this
message across to child welfare workers, and fairly impossible to con-
vince law enforcement. Thankfully, neural researchers have had a
tremendous impact on changing their minds and views. The tools?
Brain imaging and scanning devices that include:
• Computed Tomography (CT)
• Positron-Emission Tomography (PET)
• Magnetic Resonance Imaging (MRI)
• Functional Magnetic Resonance Imaging (fMRI)
• Magnetoencephalography (MEG)
• Transcranial Magnetic Stimulation (TMS)
Working with Traumatized Children20
32. Areas of the Brain
When these brain areas are mentioned during your consultations with
mental health professionals you will know what they mean. Expert
witnesses or psychological evaluators may refer to them as well.
Amygdala is an almond-shaped region in the brain and part of
the limbic system. This region generates fear. The amygdala initiates
the survival response and prompts the autonomic nervous system to
increase heart rate and breathing. It also signals the adrenal glands
to release stress hormones such as noradrenaline and cortisol.
Cortisol is a stress hormone that prompts mental arousal and
increases energy in addition to other functions, which include
regulating wake/sleep cycles and the immune system.
Hippocampus is shaped like a sea horse and is part of the lim-
bic system, which is involved in learning and memory. The hip-
pocampus identifies associations and consolidates memory. It also
evaluates and compares previous experiences.
Limbic system is located in the lower midbrain and comprises
various parts such as the amygdala, hippocampus, septum, cingu-
lated cortex, and basal ganglia. It processes socio-emotional com-
munication and regulates memory and emotion.
Neurotransmitters are brain chemicals that enable cells to talk
to each other about what is going on around and within us.
Neurotransmitters jump across gaps between cells and are generated
by electrical activity.
Noradrenaline is the brain’s alarm hormone. It prompts mental
arousal andincreasesenergybyproducingadrenalineandotherchemicals.
Prefrontal cortex is part of the cortex. It recognizes and identi-
fies threats.
Thalamus is the sensory filter for the brain. The thalamus recog-
nizes, integrates, and organizes sensory information.
Serotonin is a neurotransmitter that regulates impulses for emo-
tions and keeps aggression in check. If serotonin levels fall, violence
rises in both children and adults. Low levels of serotonin have been
shown to cause depression, bad temper, and explosive rage.
21Trauma’s Relationship with Stressor-Related Disorders
33. The brain is responsible for everything we do. In just nine months fol-
lowing conception, 100 billion neurons and 10 trillion glial cells are
formed within the brain.Their job is to organize,move,connect,and spe-
cialize to build a newborn’s brain.
But the brain is undeveloped at birth, and continues to change
throughout life. Most of the change occurs in a child’s first years. The
experiences of childhood express the child’s potential, and conse-
quently the more the child’s neural system is activated the more it
changes to a pattern that reflects that particular type of activation. For
example, if an infant is encouraged to crawl, the physical motor activ-
ity is patterned. The brain’s patterned activation is the basis for devel-
opment, memory, and learning (Perry, 1998).
With regard to advocating for traumatized kids, it is necessary to
know that the brain responds to threats, understand how it stores trau-
matic memories, and understand how it is altered by traumatic experi-
ences. All experience changes the brain. Two polar opposite examples
include listening to beautiful music and child neglect. The brain is
designed to change in response to patterned, repetitive stimulation.
The activating parts of the brain associated with fear and trauma
change the brain. Over the last 20 years, neuroscientists studying the
brain have learned how these two factors influence the developing brain.
It is increasingly evident that experience in early childhood has relative-
ly more impact on the developing child than later life experiences.
Functional capabilities of the mature brain develop throughout
life, but the vast majority of critical structural and functional organ-
ization takes place in childhood. By the age of 3 the brain has
reached 90% of adult size, while the body is still only about 18% of
adult size. By shaping the developing brain, experiences of childhood
define the adult.
Neurodevelopment includes:
1. Sequential (or scaffolding) development and sensitivity (the brain
“grows” from brainstem to the cortex). Deprivation of critical
Working with Traumatized Children22
34. experiences during development along with when they occurred,
and length of occurrence, can change a child’s brain. For example,
if there is an absence of meaningful sensations such as touch, taste,
sight, or sound, he will experience abnormal development.
Therefore, a child’s capacity to learn and remember is affected.
2. “Use it or lose it” organization. The sequential and use-dependent
properties of brain development result in an amazing adaptive flexibil-
ity, ensuring that, within its specific genetic potential, an individual’s
brain develops capabilities suited for the type of environment he or
she is raised in. If that world is characterized by threat, chaos, unpre-
dictability, fear, and trauma, the brain will reflect that by altering the
development of the neural systems involved in the stress and fear
response.In effect,to neglect or abuse a child is sentencing him to a life
that is often viewed and experienced through a very different lens.
Neurobiological Responses to Threat
Human beings and other animals have much in common, including
shared survival instincts and responses to threat. Like other animals,
human beings detect danger through their senses, including sight,
touch, vibration, sound, smell, and taste. Their brains monitor and
regulate these danger signals.
When humans are threatened, various neurophysiological and neu-
roendocrine responses are initiated. Consequently, when they experi-
ence terror their brains naturally register threat and alert survival
hormones to respond and prompt any number of survival responses
throughout the body. These can include:
• rapid or irregular
breathing,
• racing heart,
• panic,
• changes in perspiration,
23Trauma’s Relationship with Stressor-Related Disorders
• numbing,
• tingling sensations,
• loss of bowels,
• confusion, and
• elevated blood pressure.
35. If these responses persist, there will be use-dependent alterations in
the key neural systems involved in the stress response. These include
the hypothalamic-pituitary-adrenal axis (HPA). In animal models,
chronic activation of the HPA system in response to stress has negative
outcomes. Chronic activation may“wear out”parts of the body includ-
ing the hippocampus, a key area involved in memory, cognition,
and arousal. This may be occurring in traumatized children as well.
Researchers have demonstrated memory and emotion abnormalities
in a sample of abused children.
Another set of neural systems that become sensitized by repetitive
stressful experiences are the catecholamine systems. These key neuro-
chemical systems become altered following traumatic stress. The result
is associated changes in attention, impulse control, sleep, fine motor
control, and other functions as excessive cortisol—an acid-like neural
hormone—disrupts developing brain circuits.
Chronic stress such as poverty, parental drug abuse or mental ill-
ness, abuse, or neglect can be toxic to the brain. Because learning how
to cope with adversity is an important building block of child devel-
opment, toxic stress experienced early in life can take a toll and lead to
developmental delays and other problems in children. A traumatized
child can exhibit motor hyperactivity, anxiety, behavioral impulsivity,
sleep problems, tachycardia, and hypertension.
While all experiences change the brain, not all experiences have
equal impact on the brain. Because it is organizing at such an explosive
rate in the first years of life, experiences during this period have more
potential to influence the brain in positive and negative ways.
Traumatic experiences and therapeutic experiences can impact the
same brain and are limited by the same principles of neurophysiology.
Traumatic events impact the multiple areas of the brain that
respond to the threat. Use-dependent changes in these areas create
altered neural systems that influence future functioning.
Infants, children, and youth normally cope with their heightened
fear responses by freezing, fighting, fleeing, or submitting to the threat,
as their brains work to accommodate their fear.
Working with Traumatized Children24
36. A few examples (Rossi, 1986):
• Molly, age 3, froze when her mother threatened to take away her
favorite toy if Molly didn’t put her hand on top of a hot stove as
punishment for wetting the bed.
• Latisha, age 14, became enraged as she witnessed her father severely
beat her little brother. She picked up a knife and threatened him to
end the beating or be stabbed.
• Jimmy, age 4, watched helplessly as his intoxicated mother broke a
beer bottle over his father’s head. Fearing for his own safety, Jimmy
ran into his bedroom closet and closed the door.
• Cory, age 10, blamed himself for being molested. He thought he
could have stopped his sexual assault by an older and more aggres-
sive cousin. He believed that instead of submitting he should have
fought off his sexual predator.
Normal Stress and Trauma Are Different
Everyday stress is normal but trauma is not, because trauma
prompts extreme, intense, and prolonged stress responses within
the brain and body. Normal stress, for example, could be worrying
about bills or meeting work deadlines. But trauma elicits terror
and is experienced as life-threatening (APA, 1994; Gunnar, 2000).
When children experience trauma, normal neurological function-
ing can be disrupted as a surge in survival hormones (cortisol is one
example) flood the brain. As a result, neural chemicals may become
impaired and over time even change brain structure (Perry, 1998).
Stress-Related Hormones
Cortisol is a danger hormone that responds to danger signals and pre-
pares the body for fight or flight. It regulates sleep-wake cycles, mental
arousal, and the immune system. It can also affect the ability to speak.
25Trauma’s Relationship with Stressor-Related Disorders
37. Noradrenaline is an alarm hormone that compels the brain to
respond to danger, producing adrenaline and other chemicals that pre-
pare the body for fight or flight. It is thought that imbalance in nora-
drenaline creates impulsive behaviors or cold-blooded violence.
Again, when stress hormones become overactive as a result of ongo-
ing stressors encountered during fetal development or early childhood,
neural connections can be altered. These essential neural networks
assist children in making associations, laying the foundation for future
intelligence, imagination, and creativity.
If neural connections are altered, hypersensitivity to cues or triggers
that represent danger can occur and cause children to spontaneously
experience fear responses. Their fear responses are experienced
throughout the entire body and affect the autonomic, endocrine,
immune, and limbic systems. The survival response engages these
essential functions. Overall, the brain can naturally become unstable as
a result of overactive stress hormones that potentially keep the body in
a constant state of readiness or anxiety (Kotulak, 1996).
Autonomic nervous system is responsible for gastrointestinal
functions.
Endocrine system is responsible for the body’s metabolism
and blood pressure.
Limbic system is the memory, learning, and emotion center.
Immune system involves the thymus, spleen, lymph nodes,
and skin.
Danger Cues: Trauma Triggers
A trauma trigger is usually a symbolic or actual sensory association with
a trauma memory and is picked up through a child’s senses and inter-
preted in the brain. Mentioned earlier in this chapter, after a traumatic
experience a child may misinterpret the association and register it as a
Working with Traumatized Children26
38. threat, prompting the stress hormones to flood the brain and cause a
highly aroused state. These conditions explain why traumatized children
are hypervigilant and overly concerned for their safety (Gunnar, 2000).
Depending on their circumstances, youngsters can be regularly
triggered into a hyperaroused state, prompting stress hormones to
surge repeatedly and causing them to acquire multiple activation
patterns that are presented as PTSD symptoms. Consequently, trau-
matized children often exhibit rather puzzling behaviors. Because
traumatized children unintentionally misinterpret their triggers, they
continue to respond to their environment as though they are still in
danger; this can happen even long after their traumatic experiences
have occurred. In time reactive patterns emerge. If they live in out-of-
home care, their multiple symptoms are often behind child and youth
placement disruption.
Allison’s Trauma Triggers
Allison remembers lying in a blue bedroom at her Uncle Mack’s
house the morning he molested her when she was 11 years old. She
also remembers her uncle’s aftershave and his weight on her body as
well as his breathing in her ear.
Now at age 20, she panics when her boyfriend whispers in her ear
while they are making love. She has also forbidden him to use the
same fragrance worn by her uncle, and she has an aversion to the
color blue.
Safety Is Key
While safety is a concern for all people, traumatized children are espe-
cially vulnerable and need to be reassured they are safe in spite of the
fact that everything their brains and bodies are telling them is different.
Children and youth often continue to respond as though they are being
threatened long after their trauma experiences. This can be difficult
when a sudden and abrupt sensory trigger prompts a survival response.
27Trauma’s Relationship with Stressor-Related Disorders
39. Trauma triggers include just about anything that has been stored as
memory, but here are some examples:
• loud noises
• music
• odors
• colors
• physical examinations
• bathing
• sexual contact
• stress
• discussion about their traumatic experience
• dressing or undressing
• certain types of music, sounds, smells, or textures
• certain anniversaries such as deaths, birthdays, trauma
anniversaries, or holidays
• reminders of certain people, such as physical characteristics
• certain hours of the day
• exposure to weapons
• nightmares
• being held
• certain rituals, such as lighting candles, locking doors, or kneeling
• periods of calm
• certain adult behaviors, such as drinking, arguing, anger, or rejection
• television or video games
• facial hair
When a young child, youth, or even young adult is protected by
supportive relationships with adults they can begin to resonate with
Working with Traumatized Children28
40. how it feels to be safe. Feeling secure or safe can sometimes prompt
spontaneous disclosure. This was Juanita’s trauma disclosure experience.
Juanita
Juanita’s older brother molested her when she was 5. She was terri-
fied by the experience, but he warned her not to say anything to their
mother. Juanita, thinking she would be punished, kept quiet.
The following year, Juanita was temporarily placed in a foster
home when her mom became ill. Almost immediately her caseworker,
foster parents, and new teacher noticed Juanita’s lack of focus, aca-
demic challenges, and short attention span.
While playing with other neighborhood children one day, Juanita
was overheard casually mentioning that her brother had put his
“peter” in her mouth. When her foster parents learned about her
comment and gently inquired about it, she became hysterical because
she thought she had done something wrong. She was also terrified her
brother would find a way to seek revenge.
After a while Juanita was calmed as she was reassured she would
not be punished. Her foster parents and child protection services
advocates repeatedly assured her that they would make sure her
brother would not harm her. Her disclosure prompted an immediate
referral to a child therapist as well. Her therapist believed that
Juanita had grown to feel safe at her foster home and consequently
spontaneously disclosed her traumatic experience.
EXERCISE 1
Here is a simple exercise you can do to better understand the power of
association and spontaneous physical and emotional response in your
young clients.
Close your eyes, take a deep breath, and exhale. As you continue
to breathe and exhale, recall an emotional experience. Notice if you
29Trauma’s Relationship with Stressor-Related Disorders
41. experience any physical or emotional changes when recalling the cir-
cumstances that prompted the emotion. Next, consider thoughts or
beliefs that come to mind during this memory exercise.
For example, do you feel tightness in your throat or a knot in your
stomach? Or, if the experience was pleasant, do you notice yourself
smiling or feeling warm? Do your thoughts match your physical and
emotional responses, or are you judging yourself for having them at all?
Now take another deep breath and exhale. This time think of an
experience completely different than the one you just remembered.
Again, notice any physical changes and corresponding thoughts. Do
you find yourself telling yourself something about who you are
because of your associative physical attachments?
EXERCISE 2
Music has a huge impact on the human mind and body and can cause
rapid mood changes and other changes. Try listening to two very dif-
ferent pieces of music and notice how your mind and body respond.
These simple exercises demonstrate how triggers can cause rapid-fire
reactions within our bodies, explaining why children react quickly to
sensory, symbolic, and other associations to their traumatic experiences.
Trauma Sequencing
Human beings are traumatized by life-threatening events and begin to
acquire trauma symptoms through the following stages:
1. During a traumatic experience a child experiences a surge in stress
hormones that flood his brain when he is exposed to actual or
threatened death or injury. At the same time, the experience is
stored by association as a memory.
2. The brain can change as a result of highly stressful circumstances.
Repeated stress conditions and the person’s responses may cause
Working with Traumatized Children30
42. hypersensitivity to symbolic or literal trauma memory association
cues (triggers) that threaten the child’s sense of security or safety.
Association triggers and altered neurological physiology also
prompt the child to repeatedly experience the survival response,
even when there is no present danger or threat of danger.
3. The child further develops physical or psychological coping/self-
defense responses in order to deal with his repeated activation of
neural patterns caused by trauma reminders. These coping defens-
es are practiced and later become reinforced self-protective pat-
terns. Some examples include self-mutilation, avoidance, early
substance abuse, temper flare-ups, or oppositional behavior.
For example, children can become (1) triggered by a trauma asso-
ciation such as witnessing an argument, (2) respond in fear, and (3)
become avoidant with regard to any potential association trigger that
causes the fear to surface again.
When these responses are repeatedly practiced, avoiding or with-
drawing from society can become a way to cope with fear. Traumatized
children normally unconsciously develop these defenses or adapta-
tions to cope with their patterned hyperalert physiology, which can
reflect a changed neural chemical condition such as a lower serotonin
level or change in brain structure.
Trigger Arousal Protective State Response
Resting State Activation of Arousal State State-Dependent Response Defense
Calm Trauma Trigger/Reminder Terror Withdrawal
When Trauma Symptoms Don’t Develop
Most children exposed to traumatic events do not acquire PTSD.
When their trauma responses are short-lived and when they remain
symptom-free following a traumatic episode, it generally has to do
with the following reasons.
31Trauma’s Relationship with Stressor-Related Disorders
43. Caregiver Support
Children are likely to be negatively affected when their caregivers
ignore, blame, or fail to acknowledge them as a result of traumatic
experiences. Appropriate caregiver support should not be confused
with overzealous or exaggerated caregiver response following a child’s
traumatic experience.
For example, children can be secondarily impacted by their trau-
matic experiences when caregiver reactions include:
• lacking of caregiver emotional regulation,
• focusing more on the caregiver,
• reinforcing self-blame, guilt, or shame on the part of the child,
• continuing exposure to perpetrators or other danger associations
that prompt trauma triggers, or
• forcing children to deal with their traumatic experiences in coun-
terproductive ways, such as bullying, carrying weapons, or other-
wise causing further harm to themselves or others.
The Severity of Their Trauma
Depending on the scope of the trauma, children may not be affected.
For example, certain children can become traumatized after witnessing
caregivers being physically harmed, whereas other children may not
have a strong bond with their caregivers and are not as affected. And
yet, sexual abuse in early childhood can severely affect all youngsters.
A Child’s Life Before and After a Traumatic Experience
Positive nurturing and supportive care prior to a traumatic experience
has a lot to do with how children cope with and integrate trauma into
their lives. If they have received strong, supportive early care, they
probably have a stronger attachment to their caregivers and are likely
Working with Traumatized Children32
44. to recover more quickly. On the other hand, if children have experi-
enced marginal caregiver nurturing, the chances are greater that they
will be negatively impacted.
Immediate care soon after their traumas has shown to diminish trauma
symptoms and assist children in resuming their lives more easily. When
trauma is immediately addressed it can positively alter trauma fallout.
Genetic Makeup
Due to their genetic makeup, children may be predisposed to lesser or
greater degrees of vulnerability with regard to developing acute stress or
PTSD. Certain genotypes may either be protective or increase risk of
PTSD exposure to traumatic events. It is now evident that genetics pro-
vide a predisposition for children to develop in certain ways, but interac-
tions in the environment have a major effect on how children’s genetic
predispositions will be expressed. These interactions organize the brain’s
development and thus shape how children are affected by trauma.
According to Nancy C. Andreasen (2001), our genetic code is not as
rigid as once thought: “Genes do not contain a static and unchanging
set of instructions … rather they modify their influences on the body
in response to their own ‘environmental’ or ‘non-genetic’ experiences.”
Therefore, genetic makeup may tip the bar when it comes to respond-
ing to stress.
Scientists are currently focusing on genes that play a role in creat-
ing fear memories. Understanding how fear memories are created may
help to refine or find new interventions for reducing the symptoms of
trauma-related disorders. For example, researchers have pinpointed
genes that make the following.
• Stathmin, a protein needed to form fear memories. In one study,
mice that did not make stathmin were less likely than normal mice
to “freeze”—a natural, protective response to danger—after being
exposed to a fearful experience. They also showed less innate fear
by exploring open spaces more willingly than normal mice.
33Trauma’s Relationship with Stressor-Related Disorders
45. • Gastrin-releasing peptide (GRP), a signaling chemical in the brain
released during emotional events. In mice, GRP seems to help con-
trol the fear response, and lack of GRP may lead to the creation of
greater and more lasting memories of fear.
Researchers have also found a version of a gene (5-HTTLPR) that con-
trols levels of serotonin—a brain chemical related to mood—that appears
to fuel the fear response. As in other mental disorders, it is likely that
many genes with small effects are at work in trauma-related disorders.
Studying parts of the brain involved in dealing with fear and stress
also helps researchers better understand possible causes of trauma-
related disorders. One such brain structure is the amygdala, known for
its role in emotion, learning, and memory. The amygdala appears to be
active in fear acquisition (learning to fear an event) and in the early
stages of fear extinction (learning not to fear).
Storing extinction memories and dampening the original fear
response appears to involve the prefrontal cortex (PFC) area of the
brain, involved in tasks such as decision-making, problem-solving, and
judgment. Certain areas of the PFC play slightly different roles. For
example, when it deems a source of stress controllable, the medial PFC
suppresses the amygdala, an alarm center deep in the brainstem, and
controls the stress response. The ventromedial PFC helps sustain long-
term extinction of fearful memories, and the size of this brain area may
affect its ability to do so.
Individual differences in these genes or brain areas may only set the
stage for trauma-related disorders without actually causing symptoms.
More research may show what combinations of these or perhaps other
factors could be used someday to predict who will develop trauma-
related symptoms following a traumatic event (NIMH, 2014).
Ongoing Stress Following a Traumatic Experience
Trauma may not immediately create acute stress or PTSD symptoms in
children. Later losses, such as the departure of a consistent caregiver,
may trigger the reactions that earlier appeared benign.
Working with Traumatized Children34
46. Natural Resilience and Temperament
Resilience is the ability to recover from adversity and to give adversity
or suffering meaning. There are a number of attributes that assist chil-
dren in overcoming traumatic experiences and they will be discussed in
Chapter 7. Temperament is closely related to genetics, and while some
children may be highly sensitive to their environment others may not.
Linking Trauma to the Brain and Trauma Stressor-
Related Disorders
This chapter’s focus has been on the physiological link between a terror
experience and brain-body function, leading to the mental health diag-
nosis of PTSD and other related diagnoses. Fully understanding the
trauma chain of events lets child advocates know that children do not
make up their trauma symptoms. It also helps advocates understand
why children may react to reminders of their earlier traumatic experi-
ences long after their experiences have occurred. Safety becomes a
major issue for traumatized children.
Understanding trauma-related brain-body connections also bol-
sters you to recognize trauma’s impact on youngsters soon after a trau-
matic experience and immediately mediate intervention to further
examine their life-threatening encounter.
35Trauma’s Relationship with Stressor-Related Disorders
47. 37
3
TRAUMA SYMPTOMS
It’s all my fault. Bad things keep happening to me.
—A young trauma survivor
T
he words shared above by a young trauma survivor reflect her
self-perception. She is not alone. As a result of their traumatic
experiences, children can develop multiple symptoms that ulti-
mately affect how they view themselves and their place, or worth, in
the world.
Children, particularly those in child abuse and neglect situations,
can become psychologically detached from their surroundings and feel
invisible. (After reading the Harry Potter books, I am reminded of the
description of a magical invisibility cloak worn by Harry and friends
when they did not want to be seen.) Traumatized kids often armor
themselves with an imaginary invisibility cloak, used as a coping
mechanism, which psychologically separates them from connecting
with others and their surroundings.
Their perceptions of invisibility and self-worth are the result of how
the human brain handles catastrophic life events. For example, in the
memory part of the brain, overactive stress hormones can affect the
48. hippocampus to the extent that trauma memories can be blocked, dis-
torted, surfaced easily by association, or forgotten. Positron-emission
tomography (PET) images have shown that people with blocked mem-
ories have less activity in certain parts of the brain, substantiating
abnormal brain function.
Memories
Memories can be radically impacted by trauma. For example, trauma
memories may surface in traumatized children when they are exposed
to sensory or literal trauma reminders (triggers). Flashbacks, or disso-
ciated real-feeling internal images of the trauma event, can also occur
(American Psychiatric Association [APA], 2013). These disturbing
trauma memories and flashbacks normally continue to aggravate
hyperaroused conditions and keep children on the physical or emo-
tional vulnerability merry-go-round.
Memories are categorized three ways:
• Motor memories, such as tying shoelaces or lifting a glass
• Cognitive memories, such as counting or problem solving
• Emotional memories, such as happy or sad feelings
People who remember childhood abuse later in life may be experi-
encing something called “directed forgetting” because they were sus-
ceptible to subtle or even not-so-subtle direction from their former
abusers or even naysaying caregivers.As a result of this kind of direction,
kids repeatedly inhibit access to their traumatic memories. Temporary
forgetting is more common than total amnesia. Directed forgetting
often helps children manage their environments until they can leave
home or otherwise experience safer conditions.
Working with Traumatized Children38
49. Mentioned in Chapter 2, toxic stress can also wear out certain areas
of the brain and create memories that continue to shape a child’s per-
ception and response to her environment, even after the stress
improves. When positive memories are not embedded in early life,
children have a difficult time understanding joy or demonstrating
compassion (Brohl, 2004). Consequently, if children are not stimulat-
ed by appropriate early nurturing, acts of kindness can be met with
confusion and even anger.
To more deeply understand the impact of trauma on the memory-
making part of the brain, I want to share Jimmy’s story. He was one of
my wonderful serendipitous teachers. His trauma experience has a
happy ending and is worth sharing. I am still grateful for our session
time together.
Jimmy was the cutest 3-year-old, filled with wonder along with the
energy of a cyclone. I share his narrative with the addendum that sev-
eral years later I received a letter from his mom letting me know how
Jimmy, with the help of early trauma intervention and supportive par-
enting, grew into a loving and accomplished young man. I was grate-
ful for her letter because child advocates do not regularly hear their
clients’ follow-up stories. Jimmy’s story demonstrates how even very
young children can recall memories and that with early intervention,
it’s possible for them to realize their potential.
Jimmy’s Story and the Power of Memory
From birth to 18 months, Jimmy witnessed his father repeatedly beat
his mother. His father was subsequently incarcerated and after release
from prison, he was court-ordered to physically stay away from Jimmy
and his mom.
However, the judge allowed phone visitation contact between
the father and son, now age 3. Following phone interaction with his
dad, day care workers noticed that the little boy became aggressive
with other children. Jimmy’s aggressiveness at the day care center
was reported to surface within minutes after speaking to his father.
39Trauma Symptoms
50. His symptoms were also apparent at home, where he repeatedly hit
his mother and cried out in his sleep. It was puzzling that before
father-son contact was reestablished Jimmy had exhibited none of
these behaviors.
Jimmy’s early care teacher contacted his mother to report that
after one of the phone visitations Jimmy had awakened from a nap
crying, “No Daddy, no hit Mommy!” Fearing for her son’s well-
being, his mother engaged me to help. This little guy and I began to
see one another regularly in play therapy.
During one of our sessions I was reading Jimmy a metaphorical
story (discussed in a later chapter) as he ran circles around me. At
the end of the story, and to my amazement, he suddenly stopped
and blurted out, “My Daddy hit my Mommy with a duck on
her back!” then sighed deeply and laid down on a cushion. The child
was exhausted.
Prior to this particular session, Jimmy never referred to his
father’s battering. He hadn’t been verbal when it occurred months
earlier. The next day, I shared his session behavior with his mother
and inquired about his comment. At first mom wasn’t able to relate
to the statement, and said, “We live in a condo, so there are no ducks
around.” Then I heard a gasp at the other end of the phone. Slowly
she began to recount that during the last violent episode with her
former husband, Jimmy had witnessed him charge his mom with
a large ceramic duck, hitting her on the back. (Jimmy’s mother
did not appear to consciously or unconsciously bias her child,
although doing so is not uncommon, even when parents have the best
of intentions.)
Jimmy’s trauma symptoms were hyperaggression, oppositional
behavior, depression, and sleep disturbance. Following his disclo-
sure, a report was submitted to the court stating that Jimmy was
triggered, through trauma-related stored memory, into experiencing
toxic levels of stress when hearing his dad’s voice. Visitations were
Working with Traumatized Children40
51. suspended, and the little boy’s symptoms subsided. I hope that, over
time, father and son were able to repair their damaged relationship.
Emotions
Other areas of the brain are affected by catastrophic life events as well.
One of them is the limbic system that regulates emotion, among other
tasks. Overactive stress hormones can cause irritability in this emotion
regulating part of the brain. Consequently, mood disorders, impulsive-
ness, and hyperaggression may surface.
Emotions can become desensitized as well, meaning that the ability
to respond normally to real threats is impaired. Numbing and exagger-
ated emotional reactions are examples. Numbing promotes that feeling
of invisibility and detachment from society in children and youth.
Infants born to depressed mothers risk reduced electrical activity in
their emotion centers. At age 3 they are more likely to be withdrawn,
disobedient, and aggressive (Gunnar, 2000).
It comes as no surprise that aggressive and violent behaviors are
linked to chronic stress and neglect in children and youth. Some stud-
ies indicate that when some traumatized children enter puberty, the
neural chemical noradrenaline can convert from high to low levels and
create low arousal and predatory behavior. Hence, young victims can
later become adolescent victimizers.
Learning
Trauma, generated by neglect and childhood malnutrition, can also
cause difficulties in cognition or problem solving, motor delays, anxi-
ety, depression, and social and attention problems in children. Neural
researchers have discovered that spoken language boosts intelligence,
social skills, and scholastic achievements. Conversely, a lack of words
stunts the brain. And stress can also affect a child’s ability to remember
and transmit information.
41Trauma Symptoms
52. Alexithymia
Alexithymia, another trauma symptom, is the inability to identify
and express emotion. Before it was understood, this condition was
interpreted by interventionists as resistance or a sign that trauma
had not occurred. One comment I heard repeated 30 years ago by
child abuse investigators and state’s attorneys about child abuse
disclosures was, “The child isn’t telling the truth because she
didn’t express emotion when she gave her statement.”But the abil-
ity to identify an emotion or speak can be impaired during and
following a traumatic experience.
Alexithymia is often behind the responses and behaviors of
parents whose children have entered the child welfare system.
Because many are trauma survivors themselves, they, too, are
unable to identify what they’re feeling and articulate what they
need. Very often, they will simply demonstrate passive resistance
or full-blown rage, behaviors that always complicate our work.
Sara’s Inability to Identify Her Feelings
or Express Herself
Sara, age 10, was terrified when she witnessed her father slap her mother
on several occasions. Later, when she and her mother arrived at a
domestic violence shelter, a counselor asked Sara how she was doing.
She said simply, “Okay.” Deep inside Sara was frightened and lonely,
but until the counselor helped to explain feelings in one of their
engagement therapy sessions, Sara was unable to speak about her feel-
ings, let alone identify them.
Brain Structure
Children with severe sensory deprivation as a result of abuse and neg-
lect risk developing smaller brains due to abnormal growth within the
Working with Traumatized Children42
53. cortex. Neural scientists have discovered that the hippocampus may
shrink in size due to overactive stress hormones, hypothesizing that it
limits this area’s memory sorting and organizing functions. Abnormal
secretions of cortisol, a stress hormone, play a major role in these
structural changes (Brohl, 2004).
PTSD Symptoms — Lasting Longer Than One Month
The DSM-5 symptoms for posttraumatic stress disorder are listed here
and will assist you when you compare them with your client’s post-
trauma responses. The symptoms apply to children, adolescents, and
adults over the age of 6. They are related to a trauma experience that
exposes a person to actual or threatened death, serious injury, or sexu-
al violence. In other words, a person must directly experience a trau-
matic event, witness in person a traumatic event that occurred to
another person, learn a traumatic event happened to someone close to
the person, or experienced repeated or extreme exposure to aversive
details of a traumatic event. Sometimes symptoms are delayed
(delayed expression) and can emerge months following the traumatic
event (APA, 2013).
1. Intrusive symptoms: These symptoms are associated with trauma
reactivity.
a. Recurrent involuntary and distressing memories
b. Recurrent distressing dreams in which the content or effect of
the dream are related to the trauma
c. Dissociated reactions (flashbacks, for example) in which the
individual feels or acts as if the traumatic event is recurring
d. Intense or prolonged psychological distress at exposure to
internal or external cues that symbolize or resemble an aspect
of the traumatic event
e. Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the trauma events
43Trauma Symptoms
54. Jamie
At age 7, Jamie watched one of his brother’s friends be shot outside
Jamie’s apartment window. Shocked and overwhelmed by what he wit-
nessed, Jamie calmly reported what he saw when the police came to the
crime scene. Jamie’s mom could not get home from her work site in time
to hear Jamie relate his experience to the officers, and only later heard
the report from her neighbor after Jamie had been put to bed.When she
asked him how he was doing the following morning, he replied, “Okay.”
But over the course of the next several weeks, his mother was awakened
by his cries from nightmares and was disturbed to discover that he slept
with a kitchen knife. He began to spend more time in his bedroom.
When asked why he stayed in his room, Jamie replied, “Every time I
leave my room, I remember what happened and I get scared.”
2. Negative alterations in thinking and mood: These symptoms are
associated with the traumatic event that begins or worsen after the
traumatic event has occurred.
a. Inability to remember an important part of the traumatic event
b. Persistent and exaggerated negative beliefs or expectations about
oneself or others (see quote at the beginning of this chapter)
c. Persistent negative emotional state
d. Markedly diminished interest or participation in significant
activities
e. Feelings of detachment or estrangement from others
f. Persistent inability to experience positive emotions
Persistent avoidance of stimuli associated with the trauma: Traumatized
children often demonstrate persistent avoidance of stimuli associated
with the trauma and numbing of general responsiveness not present
before the trauma.
a. Efforts to avoid thoughts, feelings, or conversations associated
with the trauma
Working with Traumatized Children44
55. b. Efforts to avoid activities, places, or people that arouse recollec-
tions of the trauma
Sharon
Sharon was repeatedly molested by her grandfather beginning at age
11. Afterward, he would offer her special treats and money with the
promise that it was their secret. When Sharon turned 13 she stopped
attending holiday celebrations at her grandparents’ house and began
stealing her parents’ prescription pain medication in order to curb her
intense anxiety. By then she had dropped out of gymnastics class and
at times convinced herself that her molestation had never happened.
When she was referred to a school counselor she demonstrated little
emotion in their meeting and would not disclose her abuse due to her
fear of being punished.
3. Dissociative symptoms: These symptoms are not caused by use of
substances or other medical conditions other than trauma reactiv-
ity. They include depersonalization and derealization.
a. Depersonalization is feeling detached from, and as if one were
an outside observer of, one’s mental processes or body (cloak of
invisibility). It may be described as feeling as though one were
in a dream, as a sense of unreality of self or body, or as feeling
like time is moving slowly.
b. Derealization experiences center on feelings of unreality of sur-
roundings and feelings of being distant or seeing circumstances
as distorted.
Other ways people become numb or dissociate include the follow-
ing (Pais, 2006).
Fugue—sudden, unexpected travel away from home or one’s usual
place of work, with an inability to recall the experience
Feeling separated from one’s body
Excessive fantasizing that includes magical thinking
45Trauma Symptoms
56. Lack of focus or concentration to the point of not noticing physical
obstacles or hearing what others are saying
High-risk behavior
Auditory hallucinations that include hearing unexplained noises such
as crying or screaming
Visual hallucinations such as seeing ghost-like figures near the bed
upon waking or falling asleep
Short- or long-term memory loss
Dissociative Identity Disorder
This is a condition in which a person has two or more distinct
identity or personality states, which may alternate within some-
one’s conscious awareness. These states usually have distinct
names, identities, temperament, and self-image. At least two of
these personalities repeatedly assert themselves to control the
affected person’s behavior. It is thought to be a result of dissociative
processes, which include the splitting off from conscious awareness
and control of thoughts, feelings, memories, and other mental
components as a response to situations that are painful, disturbing,
and unacceptable to the person experiencing them. It appears to be
a naturally occurring defense against childhood trauma.
4. Persistent symptoms of increased arousal: These are persistent symp-
toms of increased arousal not present before trauma.
a. Difficulty falling or staying asleep
b. Irritability or outbursts of anger
c. Exaggerated startle response
d. Reckless or self-destructive behavior
e. Difficulty concentrating, hypervigilance
f. Exaggerated startle response
Working with Traumatized Children46
57. Adrienne’s symptoms described here reflect increased arousal.
Adrienne
Adrienne was abandoned by her parents and placed in a foster
home. Her loving foster parents had plans to adopt the 4-year-old girl
and were concerned that Adrienne did not appear to be developmen-
tally like other children her age. They wondered why she became
upset so easily and why, in spite of all their nurturing support, she
continued to behave as though she was waiting for the other shoe to
drop. The slightest noise or outside thump would prompt her to
express tears and anger. In addition, Adrienne was behind in school
and seemed to be happiest when she was playing pretend games alone
in her room. Her foster-adoptive parents were particularly bothered
by her inability to fall and stay asleep.
Other Trauma-Related Symptoms
Children can develop a long menu of trauma adaptations/symp-
toms that include:
• phobias • anxiety • depression • anger • hostility • trust issues
• substance abuse or addiction • self-mutilation • panic disorders
• learning disorders • hyperactivity • hypersensitivity • nightmares
• suicide and suicidal ideation • avoidance • body tension • fire-
setting • animal abuse • shame • poor bonding and attachment
with caregivers (attachment disorder) • sexual play, reenactment,
or addiction • dissociation • antisocial behavior • eating disorders
• impulsiveness • oppositional deviant behavior • somatic complaints
• headaches • low self-esteem • rage and anger • immaturity
• fragile immune system • poor school performance • truancy
• numbing • high-risk behavior • sleep disturbances • obsessive-
compulsive behaviors • trauma reenactment • posttraumatic play
• avoidance • flashbacks • audio or visual hallucinations
47Trauma Symptoms
58. PTSD Symptoms in Children Age 6 and Younger
These symptoms are not related to physiological effects of medication,
abuse, etc., and last more than one month, causing significant distress or
impairment in relationships with parents, siblings, peers, or caregivers,
or in school behavior.
1. Presence of one or more of the following intrusion symptoms associ-
ated with a traumatic experience following the event:
a. Recurrent, involuntary, and intrusive distressing memories of
the experience that may not necessarily appear distressing and
are expressed in play
b. Recurrent and distressing dreams related to the traumatic experience
c. Dissociative reactions such as flashbacks that feel real to the child
d. Intense or prolonged psychological distress at exposure to
trauma triggers
e. Intense psychological reactions to reminders of the traumatic
experience
2. Persistent avoidance of trauma associations or negative changes in
thinking and mood associated with the traumatic experience:
a. Avoiding activities, places, or physical reminders that prompt
trauma memories
b. Avoiding people, conversations, or interpersonal situations that
prompt trauma memories
c. Increased frequency of negative emotion states
d. Diminished interest or participation in significant activities,
including constricted play
e. Social withdrawal
f. Reduction of positive emotions
Working with Traumatized Children48
59. 3. Changes in arousal and reaction associated with the traumatic expe-
rience that begins or worsens after the event:
a. Irritable and angry outbursts
b. Hypervigilance
c. Exaggerated startle response
d. Problems concentrating
e. Sleep disturbance (APA, 2013)
Trauma Reenactment and Posttraumatic Play
Two symptoms that occur frequently in younger trauma survivors are
trauma reenactment and posttraumatic play. Trauma reenactment
occurs when children or youth recreate aspects of their traumatic
experience, such as carrying weapons or joining a gang.
Clinton
Clinton grew up in a tough neighborhood. He was his mother’s
favorite child and was protected by his older brothers who began
earning their money by running drugs. One day they found
Clinton’s brother lying dead in known gang territory, a victim of a
gunshot wound to the head. Clinton, a kind, sweet 10-year-old, began
to obsess about his own safety and started carrying his brother’s gun
for protection. In his own way he was reenacting his brother’s death.
Posttraumatic play is different from reenactment because it doesn’t
seem to relieve children’s anxieties and is a compulsive repetition of
their experience.
Angela
Angela, age 6, repeatedly simulated sex with her Barbie and Ken
dolls. One day, she was simulating sex with her dolls when a friend’s
mother asked where Angela learned this type of play. “My big brother
and I play this all the time. Why?” Angela replied.
49Trauma Symptoms
