How Is Early Childhood Trauma Unique ?

 Traumatic events have a profound sensory impact on young children. Their sense of safety may be shattered by frightening visual stimuli, loud noises, violent movements, and other sensations associated with an unpredictable frightening event. The frightening images tend to recur in the form of nightmares, new fears, and actions or play that reenact the event. Lacking an accurate understanding of the relationship between cause and effect, young children believe that their thoughts, wishes, and fears have the power to become real and can make things happen. Young children are less able to anticipate danger or to know how to keep themselves safe, and so are particularly vulnerable to the effects of exposure to trauma. A 2-year-old who witnesses a traumatic event like his mother being battered may interpret it quite differently from the way a 5-year-old or an 11-year-old would. Children may blame themselves or their parents for not preventing a frightening event or for not being able to change its outcome. These misconceptions of reality compound the negative impact of traumatic effects on children's development.

Children may blame themselves or

their parents for not preventing a

frightening event or for not being

able to change its outcome.

 As with older children, young children experience both behavioral and physiological symptoms associated with trauma. Unlike older children, young children cannot express in words whether they feel afraid, overwhelmed, or helpless. However, their behaviors provide us with important clues about how they are affected.

Young children who experience trauma are at particular risk because their rapidly developing brains are very vulnerable. Early childhood trauma has been associated with reduced size of the brain cortex. This area is responsible for many complex functions including memory, attention, perceptual awareness, thinking, language, and consciousness. These changes may affect IQ and the ability to regulate emotions, and the child may become more fearful and may not feel as safe or as protected. Read more about the impact of trauma on brain development in Excessive Stress Disrupts the Architecture of the Developing Brain [2], a working paper from the Center on the Developing Child.

Young children depend exclusively on parents/caregivers for survival and protection—both physical and emotional. When trauma also impacts the parent/caregiver, the relationship between that person and the child may be strongly affected. Without the support of a trusted parent/caregiver to help them regulate their strong emotions, children may experience overwhelming stress, with little ability to effectively communicate what they feel or need. They often develop symptoms that parents/caregivers don't understand and may display uncharacteristic behaviors that adults may not know how to appropriately respond to.

Scope of the Problem

Young children are exposed to traumatic stressors at rates similar to those of older children. In one study of children aged 2-5, more than half (52.5 percent) had experienced a severe stressor in their lifetime (Egger & Angold, 2004).

The most common traumatic stressors for young children include: accidents, physical trauma, abuse, neglect, and exposure to domestic and community violence.

Data from National Child Traumatic Stress Network (NCTSN) Sites

In 2002 the NCTSN Complex Trauma Task Force conducted a clinician survey on trauma exposure for children who were receiving assessment and/or intervention services. Among the findings, published in a white paper— Complex Trauma in Children and Adolescents [4](2003) (PDF) [5]—was that 78 percent of children had experienced more than one trauma type and that the initial exposure on average occurred at age 5. Additional data from more than 10,000 cases of children receiving trauma-focused services from sites in the NCTSN reveal that in this cohort, one-fifth of children are aged 0-6. The traumas these children most often received services for were exposure to domestic violence, sexual abuse, neglect, and traumatic loss/bereavement (NCTSN, 2009).

Symptoms and Behaviors Associated with Exposure to Trauma

Children suffering from traumatic stress symptoms generally have difficulty regulating their behaviors and emotions. They may be clingy and fearful of new situations, easily frightened, difficult to console, and/or aggressive and impulsive. They may also have difficulty sleeping, lose recently acquired developmental skills, and show regression in functioning and behavior.

Possible Reactions of Children 0-6 Exposed to Traumatic Stress

Click here to see these reactions in a separate window [6]

Protective Factors: Enhancing Resilience in Young Children and Families

The effects of traumatic experiences on young children are sobering, but not all children are affected in the same way, nor to the same degree. Children and families possess competencies, psychological resources, and resilience—often even in the face of significant trauma&1#151;that can protect them against long-term harm.

Children and families possess competencies,

psychological resources, and resilience—often even in

the face of significant  trauma—that can protect them

against long-term harm.

How Communities Can Help

Communities can do much to mobilize on behalf of children, and the larger society can make it a priority to make sure basic services are provided to children to help keep them safe.

• Building Community Resilience for Children and Families [7] (PDF) [8]

How Parents/Caregivers Can Help
Research on resilience in children demonstrates that an essential protective factor for children is the reliable presence of a positive, caring, and protective parent/caregiver, who can help shield their children against adverse experiences. They can be a consistent resource for their children, encouraging them to talk about the experiences. And they can provide reassurance to their children that the adults in their life are working to keep them safe.

• Child Welfare Information Gateway: Enhancing Protective Factors [9]
• Scholastic-Early Childhood Today: Resilience: Where does It Come From? [10]

Identifying and Providing Services to Young Children Who Have Been Exposed to Trauma: For Professionals

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

Some of these systems now try to address possible traumatic experiences by including questions about specific traumas into their intake and/or assessment protocols. For example, both Head Start and Early Intervention intake protocols include questions about domestic violence in families. Other protocols may include targeted questions about accidents, loss of family members, and/or significant medical history.

The series NCTSN series "Young Children and Trauma: Service System Collaborations," features presentations by Network members on providing consultation to service systems. Access the free online series in the NCTSN Learning Center for Child and Adolescent Trauma [11]. [12]

For Mental Health Professionals

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

• Reactions of the child and parents/caregivers
• Changes in the child's behavior
• Resources in the environment to stabilize the child and family
• Quality of the child's primary attachment relationships
• Ability of parents/caregivers to facilitate the child's healthy socioemotional, psychological, and cognitive development

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

For Medical Professionals 

Screening/Assessment in Health Settings
Most young children are seen at regular intervals by providers in the pediatric health care system, enabling repeated opportunities for identifying early childhood trauma.

Medical providers can also play an important role in diminishing risks and in maximizing protective factors associated with young children's exposure to trauma. They can supply information to prevent accidents and can incorporate questions about stressful and traumatic experiences into their interviews with families.

Resources for Identifying Traumatic Stressors in Young Children

Online resources

• Child Trauma Academy [13]
• Groves, B. M., & Augustyn, M. (2009), Pediatric Care Settings [14] (PDF), Moving From Evidence to Action: The Safe Start Series on Children Exposed to Violence, Issue Brief #2, U.S. Department of Justice.
• Health Care Toolbox [15]
• Injury—A Risk at Any Stage of Life (2006) [16] (PDF)

Journal articles:

• Cohen, J. A., Kelleher, K. J., & Mannarino, A. P. (2008). Identifying, treating, and referring traumatized children: The role of pediatric providers. Archives of Pediatrics and Adolescent Medicine, 162(5), 447-452.
• Dehon, C., & Scheeringa, M. S. (2006). Screening for preschool posttraumatic stress disorder with the Child Behavior Checklist. Journal of Pediatric Psychology, 31(4), 431-435.

For Early Educators and Childcare Providers

Educators and childcare providers may inquire about children's safety; offer resources to reestablish safety for families; and, most importantly, support young children's learning through nurturing relationships, and through predictable expectations and routines in the classroom.

Resources for Educators

Online resources
   Center on the Social and Emotional Foundations for Early Learning
     For Teachers/Caregivers

• Resources: Practical Strategies for Teachers/Caregivers [17]
• Resources: Family Tools [18]

 Head Start

• Head Start Bulletin #73: Child Mental Health (2002) [19] (PDF)
• Head Start Bulletin #80: Mental Health (2009) [20] (PDF)

    NCTSN

• Child Trauma Toolkit for Educators/Caja de Herramientas Para Educadores Para el Manejo de Trauma Infantil [21] (2008) [5]

    Scholastic.com

• Scholastic Series for Teachers [22]
• Scholastic Early Childhood Today—"Meeting Learning Challenges: Working With the Child Who Has PTSD" [23]
• Scholastic—Early Childhood Today—"Death and Loss: Helping Children Manage Their Grief" [24]

Print resource

• Rice, K. F., & Groves, B. M. (2005). Hope and healing: A caregiver's guide to helping young children affected by trauma. Washington, D.C.: Zero to Three Press.

For Family Court Judges and Staff

The more that family court judges know about child development and the effects of child trauma, the better equipped they are to make decisions regarding permanency planning for abused and neglected children, to improve the lives of children who have witnessed domestic violence, and to adjudicate custody and visitation cases.

Online resources
    NCTSN

• Helping Traumatized Children: Tips for Judges [25] (2009) (PDF) [5]
• Judges and Child Trauma [26](2008) (PDF)

    Safe Start Center

• A Judicial Checklist for Children and Youth Exposed to Violence [27] (PDF)

Multimedia resource
    Zero to Three

• Helping Babies from the Bench: Using the Science of Early Childhood Development in Court (DVD): To access an order form to request this DVD, click here [28].

For Faith-Based, Community, and Mentoring Organizations

Community and faith-based organizations have in-depth knowledge of the resources and challenges in their communities. They play a vital role in linking families to resources that help stabilize and support them in the aftermath of trauma events. Advocating for families and increasing access to care can help families begin their recovery process.

Resources for Community Organizations

• Psychological First Aid Field Operations Guide, 2nd Edition [29] [30]
• Psychological First Aid Field Operations Guide for Community Religious Professionals [29] [30]

Helping Young Children Who Have Been Exposed to Trauma: For Families and Caregivers

When young children experience a traumatic stressor, their first response is usually to look for reassurance from the adults who care for them. The most important adults in a young child's life are his/her caregivers and relatives. These adults can help reestablish security and stability for children who have experienced trauma by:

• Answering children's questions in language they can understand, so that they can develop an understanding of the events and changes in their life
• Developing family safety plans
• Engaging in age-appropriate activities that stimulate the mind and body
• Finding ways to have fun and relax together
• Helping children expand their "feelings" vocabulary
• Honoring family traditions that bring them close to the people they love, e.g., storytelling, holiday celebrations, reunions, trips
• Looking for changes in behaviors
• Helping children to get back on track
• Setting and adhering to routines and schedules
• Setting boundaries and limits with consistency and patience
• Showing love and affection

 The most important adults in a

young child's life are caregivers

and relatives. These adults can

help reestablish security and

stability for children who have

experienced trauma.

NCTSN resources

• After the Hurricane: Helping Young Children Heal [31] (PDF)
• Helping Young Children and Families Cope with Trauma [32] (PDF)

Other resources

• After the Injury [33]
• Center on Social and Emotional Foundations for Early Learning Resources: Family Tools [18]
• "Talking with Children About Natural Disasters" [34]

When to Seek Help for Your Child

For many young children who have been affected by a traumatic experience, the most effective help is the reassurance and comfort provided by parents and trusted caregivers. However, if the trauma is severe or chronic, if it affects those close to the child, and/or if the child continues to be upset or have symptoms after a month or so has elapsed, it is advisable to seek help for the child.

Parents/caregivers may wish to consult their pediatrician, their child's teacher, and/or their childcare provider for suggestions of professionals who specialize in early childhood mental health. Because of the young age of the child and the importance of the parents/caregivers in the child's life, treatment for the child should actively include those adults. See the section below for a summary of treatments designed especially for young children.

Treatments for Children and Families

As recognition has grown about the prevalence and impact of trauma on young children, more age-appropriate treatment approaches have been developed and tested for this population. These interventions share many of the same core components. For example, they are generally relationship-based, and focus on healing and supporting the child-parent relationship. For an overview of these components, click here. [35]

Listed below are treatments that have been developed and evaluated for young children, each of which has significant support for efficacy. Many of these treatments are featured in the Network's listing of Empirically Supported Treatments and Promising Practices [36].

Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) for Preschoolers

Abused children are helped to view abuse as wrong and illegal; and are taught emotional comprehension, expression, and regulation as well as social skills. Parents learn proper emotion regulation skills, how to avoid potentially abusive situations, and healthy child management and disciplinary techniques. Dyadic work gives families an opportunity to measure progress, to help identify and clarify family miscommunication, and to establish a family no-violence agreement (Chalk & King, 1998; Kolko & Swenson, 2002).

NCTSN resource

• AF-CBT: Alternatives for Families: A Cognitive Behavioral Therapy for Child Physical Abuse [37] (PDF)[Fact Sheet]

Attachment, Self-Regulation and Competency (ARC)

Within the three core domains, ten building blocks of trauma-informed treatment and service are identified. For each principle, the ARC manual provides key concepts and guiding theoretical structure, educational information for providers and parents/caregivers, tools for clinicians, and developmental issues to consider. ARC is designed for youth from early childhood to adolescence and their parents/caregivers or caregiving systems.

NCTSN and NCTSN Member resources

• ARC: Attachment, Self-Regulation, and Competency: A Comprehensive Framework for Intervention with Traumatized Youth [38] (PDF) [Fact Sheet]
• Attachment, Self-regulation, & Competency (ARC) Outcome Trial [39]

Child-Parent Psychotherapy(CPP)

The goals are to address issues of safety, improve affect regulation, improve the child-parent relationship, normalize trauma-related response, allow the parent and child to jointly construct a trauma narrative, and return the child to a normal developmental trajectory. The intervention runs for fifty weeks and can be conducted in the office or in the home.

NCTSN resource:

• CPP: Child-Parent Psychotherapy [40] (PDF) [Fact Sheet]

Parent-Child Interaction Therapy(PCIT)

Parents/caregivers are coached live by the therapist while engaging in specific play therapy and discipline skills with their child. PCIT is a short-term, mastery-based treatment that typically runs for sixteen to twenty weeks, based on the needs of the family.

NCTSN resource

• PCIT: Parent-Child Interaction Therapy [41] (PDF) [Fact Sheet]

Preschool PTSD Intervention

Treatment is for twelve weeks, and it can be focused on PTSD symptoms from any type of trauma. The cognitive-behavioral components include relaxation training, graded systematic exposure, and homework. The protocol also encourages coverage of parental and parent-child relational issues. The manual for this intervention, the Preschool PTSD Treatment Manual, was developed by Michael Scheeringa, MD, Judith Cohen, MD, and Lisa Amaya-Jackson, MD, and is available free by contacting Dr. Scheeringa at mscheer@tulane.edu [42].

Trauma Focused Cognitive Behavioral Therapy (TF-CBT)

Treatment generally consists of twelve treatment sessions. Maltreated children and their nonabusing family members learn stress-management skills; and they practice these techniques during graduated exposure to abuse-constructed trauma. The parents/caregivers learn how to address their own emotional reactions. Several joint parent/caregiver-child sessions are also included to enhance family communication about sexual abuse and other issues. Children who participate in TF-CBT show significant improvement in their fear reactions, depressive symptoms, inappropriate sexualized behaviors, and self-worth.

NCTSN and NCTSN Member resources

• How to Implement Trauma-Focused Cognitive Behavioral Therapy [43] (PDF) [Manual]
• TF-CBT Web [44]
• Trauma Focused Cognitive Behavioral Therapy (TF-CBT) [45] (PDF) [Fact Sheet]

References and Links

Abidin, R. R. (1995). Parenting Stress Index: Professional manual (3rd ed.). Odessa, FL: Psychological Assessment Resources.

Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the Achenbach System of Empirically Based Assessment (ASEBA) school-age forms and profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families.

Beach, P. S., & McCormick, D. P. (1997). Maintaining health in the infant and preschool child. In C. W. Daeschner, & C. J. Richardson (Eds.), Pediatrics: An approach to independent learning (pp. 87-103). Baltimore: Johns Hopkins Press.

Briere, J., Johnson, K., Bissada, A., Damon, L., Crouch, J., Gil, E., et al. (2001). The Trauma Symptom Checklist for Young Children (TSCYC): Reliability and exposure to abuse exposure in a multi-site study. Child Abuse & Neglect, 25(8), 1001-1014.

Chalk, R., & King, P. A. (Eds.). (1998). Violence in families: Assessing prevention and treatment programs. Washington, DC: National Academy Press.

Crusto, C. A., Finley, M., Kaufman, J., Griffin, A., Berson, I., & Garcia-Casellas, M., et al. (2009, March). Characteristics of children presenting to early childhood mental health systems of care. Paper presented at the annual research conference of the Research & Training Center (RTC) for Children's Mental Health, Tampa, FL. Retrieved November 6, 2009, from http://rtckids.fmhi.usf.edu/rtcconference/handouts/pdf/22/Session%2011/Whitson.pdf [46]

Davidson, J. R. T. (1996). Davidson Trauma Scale. North Tonawanda, NY: MHS Inc.

Dicker, S., Gordon, E., & Knitzer, J. (2001). Improving the odds for the healthy development of young children in foster care. New York: Columbia University, National Center for Children in Poverty. Retrieved October 19, 2009, from http://www.ithaca.edu/mbentley/pdf/dicker.pdf [47]

Egger, H., & Angold, A. (1999). The Preschool Age Psychiatric Assessment (PAPA): A structured parent interview for diagnosing psychiatric disorders in preschool children. Durham, NC: Duke University, Center for Developmental Epidemiology.

Egger, H., & Angold, A. (2004). Stressful life events and PTSD in preschool children. Paper presented at the annual meeting of the American Academy of Child & Adolescent Psychiatry, Washington, DC.

Eisen, M. (1997). Post Traumatic Symptom Inventory for Children. Unpublished data, California State University, Department of Psychology.

Fantuzzo, J., Boruch, R., Beriama, A., & Atkins, M. (1997). Domestic violence and children: Prevalence and risk in five major U.S. cities. Journal of the American Academy of Child & Adolescent Psychiatry, 36(12), 116-122.

Ghosh-Ippen, C., Ford, J., Racusin, R., Acker, M., Bousquet, K., Rogers, C., et al. (2002). Traumatic Events Screening Inventory: Parent report revised. San Francisco: The Child Trauma Research Project of the Early Trauma Network and The National Center for PTSD Dartmouth Child Trauma Research Group.

Grossman, D. C. (2000). The history of injury control and the epidemiology of child and adolescent injuries. The Future of Children, 10(1), 4-22.

Kolko, D. J., & Swenson, C. C. (2002). Assessing and treating physically abused children and their families: A cognitive behavioral approach. Thousand Oaks, CA: SAGE Publications.

Levendosky, A. A., Huth-Bocks, A. C., Semel, M. A.., & Shapiro, D. L. (2002). Trauma symptoms in preschool-age children exposed to domestic violence. Journal of Interpersonal Violence, 17(2), 150-164.

National Child Traumatic Stress Network (2009). [Core Data Set]. Unpublished data.

Scheeringa, M. S., & Zeanah, C. H. (1994). PTSD semi-structured interview and observation record for infants and young children. New Orleans: Tulane University Health Sciences Center, Department of Psychiatry and Neurology.

Shahinfar, A., Fox, N. A., & Leavitt, L. A. (2000). Preschool children's exposure to violence: Relation of behavior problems to parent and child reports. American Journal of Orthopsychiatry, 70(1), 115-125.

Taylor, L., Zuckerman, B., Harik, V., & Groves, B. M. (1994). Witnessing violence by young children and their mothers. Journal of Developmental and Behavioral Pediatrics, 15(2), 120-123.

U.S. Department of Health and Human Services, Administration on Children, Youth & Families. (2010). Child maltreatment 2008. Washington, DC: U.S. Government Printing Office.

Wolfe, J., Kimerling, R., Brown, P. J., Chrestman, K. R., & Levin, K. (1996). Psychometric review of the Life Stressor Checklist—Revised. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 198-201). Lutherville, MD: Sidran Press.

Wulczyn, F., Hislop, K., & Jones, B. H. (2002). The placement of infants in foster care. Infant Mental Health Journal, 23(5), 454-475.

Links

Organizations
Center on the Developing Child [48]

Child Witness to Violence Project, Boston Medical Center [49]

Children's Relief Nursery [50]

How Kids Develop [51]

Zero to Three [52]

Publications
Center on the Developing Child
Excessive Stress Disrupts the Architecture of the Developing Brain [2]

NCTSN resources

• Early Childhood Trauma Reading List [53]

Other resources

• Elena Cohen and Barbara Walthall
  The National Child Welfare Resource Center for Family-Centered Practice
  Silent Realities: Supporting Young Children and Their Families Who Experience Violence [54] (PDF)
• William Steele
  The National Institute for Trauma and Loss in Children
  When Cognitive Interventions Fail with Children of Trauma: Memory, Learning, and Trauma Intervention [55] (PDF)