How might trauma experienced by children be treated so as to take into account their developmental limitations in cognition, social and emotional understanding.
This review will explore the experience of trauma on young and middle-aged children within the context of their relationships with significant others. A systemic framework will draw upon the complex literature of how early trauma disrupts not only brain development but across the entire nervous systems whereby the targets of therapy are decentralised to address a diverse range of physiological responses. Family attachment narratives and play based trauma therapy models of working with traumatised children will also be explored.
Developmental Trauma Disorder is proposed by Van der Kolk (2005) as a more relevant diagnosis than Post-Traumatic Stress Disorder for children and adolescents who have complex trauma narratives. He advocates that the ‘pervasive effects of trauma on child development’ are multi-layered, chronic and interpersonal in nature whereby the caregiving system exposes a child to adverse childhood experiences. Although pertinent, this disorder type was not introduced into the DSM-V. Complex trauma is another term exchanged to address interpersonal trauma, the intense emotions of fear, terror, helplessness and the range of developmental disruptions across early and middle childhood stages.
The effects of trauma on a developing brain are significant on a structural, neurological and functional level. When treating a traumatised child, it is important to recognise that brain development has been compromised due to traumatic stress. It is this fundamental understanding of neurophysiological changes when working with children’s triggers and their adaptive responses that is most relevant to clinicians during the assessment and early phase of intervention.
Perry (2003) explains that early treatment of children ought to target their adaptive response to trauma due to the heterogeneity of reaction configurations across key domains. Traumatised children are triggered by signals in their environment, which then activates high levels of arousal due to the activation of the limbic system in the face of danger. The establishment of greater empathy between the child, care-givers and educational supports is achievable when challenging behaviours are framed within the context of early relational trauma on the developing brain. Perry (2003) proposes that a child’s set of safety seeking responses sits along the hyperarousal or the hypoarousal continuum: (fight, flight, freeze or dissociation) and becomes their predominant physiological adaptation to current and anticipated threats of danger.
Offering knowledge about neurocognitive development to family members and relevant support systems promotes their understanding of recurring traumatic reactions for the child. Efforts to support the family, the school or early childcare system through psychoeducation will promote the healing process within the system. Furthermore, addressing the core issue of longstanding unmet emotional and relational needs and how this plays out in the educational setting can be an effective dialogue with educators to reduce the social stigma and problematic labels these children encounter.
A primary step in the healing process is therefore to decrease children’s arousal mechanisms through play-art based family trauma work. It is through play that children are able to tap into their imaginative capacity to find their inner stories and begin the journey of reconstruction of meaning and self-soothing adaptations (Cattanach, 2002). However, since traumatised children attend to deciphering the facial expressions and other non-verbal cues of significant adults it is important that clinicians attune to their own facial and emotional signals. Congruence between what is said and feeling are essential to the therapeutic process of creating and maintaining safety and predictability with stressed families.
Unfortunately, these children’s family experiences are often full of contradictions. Life tends to be chaotic because the cues, gestures and spoken words from loved ones which ought to reflect safety and care are not so. Hence overwhelming traumatised children who withdraw and the family cycle of love-despair perpetuates (Dallos and Vetere, 2014). Identifying strategies to establish safety and trust between children and their home-school-community context is achievable through child-centered play.
Assisting significant others within the wider network to better understand the impact of disruption to children’s developmental acquisition of new tasks follows in therapeutic consideration. When planning intervention with a distressed family, a systemic approach tailors to a child’s unique set of emotional, cognitive, behavioural, social and psychological deficits. The impact of long-standing loss and grief is such that children tend to have struggles with language and thinking processes e.g.: a poor attention span, language impairment and memory loss (Beers and de Bellis, 2002). Understanding a child’s cognitive limitations and verbal difficulties means establishing communication lines with their education system about targeting realistic cognitive goals.
Leading trauma clinicians assert that interventions ought to focus more on how to “reverse the physiological imprint of trauma. As clinicians it is necessary to adapt our clinical skill sets in order that the treatment approach to trauma work with children continues to shift away from a dominant cognitive treatment process to a more “body-oriented approach” as prescribed by Ogden (2021). This therapeutic model is well-suited to traumatised children who already find it difficult to sit and stay focused in school and home settings because their bodies are churned with automatic reactions stored in their procedural memories. She further advocates for a focus on shifting movement within the body and applying mindfulness principles in a well -tailored approach that can be readily adapted for traumatized children. She describes a resourcing of clients to their surroundings and body sensations while promoting increased self-awareness. Her interventions focus less on the trauma narratives and more so on how to address the functions of maladaptive procedural memories. Her work is challenging her clients to find ways to build a more tolerant brain-body-emotional system towards traumatic memories.
Van der Kolk (2004) proposes that creating a mind-body connection through body-centered work such as grounding strategies, drama and movement promotes children’s attunement to their bodies with new experiences of relaxed and calm emotional states. Johnson and Thomas (2007) concur that body-centering, free and affective expression, building trust and safety are the building blocks of integrating traumatic events. Hudd (2002) applies a social construction approach to play therapy which embraces the wholeness of the child through its fluidity in moving between affective, cognitive and mentalisation processing. Clinicians’ skills at flexibility in accessing children’s right and left-brain processing to create wholeness and adaptability demonstrates sensitivity to the complex nature of trauma work.
Trauma-focused cognitive behavioural therapy, known as TF- CBT is a highly structured and detailed program developed by Cohen and Mannarino (2004). This is an evidence-based approach to resolving trauma symptoms, attending to complicated grief and improving social relations upon the death of a loved one. This program is distinct in that children of 6 – 12 years are involved in individual and group programs while the parents/care-givers are involved in parallel treatment, of 8 – 12 sessions. The four final sessions involve the parents/caregivers – child dyad. The TF-CBT model is delineated into two distinct interventions: trauma followed by grief focused work. Both components are then broken down into six steps of intervention. This model supports Perry’s (2003) emphasis on survival efforts through modulating thinking, feeling and behaviour.
The first intervention of TF-CBT attends to ‘Affective Expression Skills’ whereby fostering children’s ability to identify and express emotions in themselves and others is promoted through the use of puppets, Emotional Bingo and crafting masks. The second task highlights ‘Stress Management whereby offering parents’ skill training reinforces an underlying belief in parents’ competency and mastery of skills. An example is to support a parent in deep-breathing and mindfulness exercises. She then introduces this at her son’s bedtime routine. This creates a new positive family experience considered a first order change. The TF-CBT program is comprehensive however it fails to take into account the exploration of social, economic and cultural considerations as well as the child’s inherent capacity to shape therapy. TF-CBT also lacks a systemic focus beyond the parent-child dyad and is absent of engagement with potential therapeutic relationships such as with a coach or educator.
Blaustein, M and Kinniburgh, K (2010) developed the Attachment, Self-Regulation and Competency (ARC) framework as a means of offering a comprehensive approach to strengthening systemic resilience. This treatment framework is a flexible, evidence-based framework which recognises the diversity and complexity of treating traumatised children from within a systems approach. The ten key building blocks offer the clinician an opportunity to intervene at any point based on wide-ranging factors from cultural, developmental and relational. Within the attachment building block is capacity to explore how to address the ‘caregiver management of affect.’
Kobak and Mandelbaum (2003) theorise that when the “parent – child, caregiving alliance and adult attachment relationships become distressed and undermine the adult’s confidence as a caregiver and partner, distress can escalate in an exponential fashion and fundamentally jeopardize the care-givers availability to the child.” This attachment model attends to reframing the child’s problem to distress in the parent-child relationship and how poor relational health impacts on a child’s wellbeing. Frailberg (1980) suggests that unresolved trauma of parents from their family of origin offers a map of understanding the nature of current attachment disruptions.
Family of origin intervention aims at providing the caregiver with a secure base to explore cross-generational themes of insecure attachment relationships and build greater confidence with a partner or other significant adult. Healing adult relationships intends to promote more secure attachments whereby the caregivers’ working model of self transforms to being worthy of love and competency. Caregivers’ belief in others will also be shaped by these positive emotional experiences, to others can be relied upon and are trustworthy. The therapeutic benefit is that with a secure base the parent is more attentive and willing to examine aspects of parenting and introduce new routines and structure with a restored sense of wellbeing, hope and optimism.
Synchronicity with a loved one is a primary inbuilt emotional regulator that protects against feelings of distress and vulnerability in those children that experience a secure attachment to their primary care-givers. However, fear and uncertainty are the emotional engagement with those children whose attachment relationships are insecure. Children presenting with a Developmental Trauma Disorder are predominantly maintaining an attachment style known as disorganised whereby they enact a range of seeking out behaviours towards their care-givers to then respond with fearful avoidant behaviours of intimacy (Main and Hesse 1990). This pattern of repeated relationship distress perpetuates the cycle of relational trauma. The attachment relationship itself is perceived as the source of danger and neglects attachment repair processes. Interpersonal trauma is proven to have a profound impact on children’s capacity at affect regulation and information processing.
A most critical intervention focuses on transforming the internal working models of traumatized children, their parents and siblings through the engagement of safe and positive emotional experiences within the familial, community and education settings. Byng-Hall’s (1995) concept of family scripts in healing pain attends to the sequence of traumatic events and their different meanings to individuals and the collective meaning. By expressing painful recounts, the clinician is in a supportive role to be able to guide family members to a corrective script of what family life could look like when there is safety and greater predictability. Family scripts attend to restoring balance within a family’s emotional system.
During the assessment phase, the use of story stems, narrative play and metaphors encourages children to explore attachment issues in a non-confronting way to offer insight into children’s internal attachment representations. During the course of play therapy, a therapeutic space grows whereby children feel secure enough to be able to make meaning of their experiences to build social competencies such as playing cooperatively with peers (Cattanach, 1997). From a young age, healthy attachment templates if in competition with negative attachment representations can become the dominant alternative. Scaffolding more secure attachment inner models is significant in play-based trauma therapy. By exploring children’s narratives around attachment disruptions, they recapture a sense of control over their future to connect on a more secure and loving basis.
For children to develop secure attachments and bonds there ought to be a clinician’s curiosity about wanting to understand families’ social and cultural contexts. Greenfield (1997 cited in St Thomas and Johnson, 2007) identifies that, “interpretation is never culture free, that there is always the imposition of a set of meaning structures that derive from a particular cultural context. Cultural, ethnicity and community profile warrant clinical attention because such components are contributors to repairing cohesion with disenfranchised families. Moreover Walsh (2006) reinforces the notion of family resilience as a greater capacity for adaptive change during highly stressful times.
Under-resourced families’ capacity to regulate emotional states and physiological dysregulation through intervening with subsystems, such as the sibling system and cross-generations are less researched areas. Unfortunately, the majority of evidence-based studies neglect to explore the potential in relational healing within these subsystems. It remains unclear as to whether these relatively untapped areas within trauma-based attachment work will be considered as widening the lens. To create building blocks which are more inclusive of working with siblings, grandparents, aunts and uncles infers that these unique relationships are fostered and lost opportunities at making meanings are restored.
In summary, recent findings are leaning heavily towards the notion that “Trauma doesn’t just impact the thinking brain. It can potentially impact every level of the brain, the nervous system and the body,” (Buczynski, 2021). Van der Kolk (2021) advocates that most of the trauma lies in deep experiences around threats of danger – safety (limbic system) that never really leaves the client. He reinforces that trauma therapists need to understand that it repeats itself in automatic maladaptive patterns of movement – thinking – emotions where the trauma sits unprocessed without a sense of past – present – future in one’s procedural memory. Neurocognitive difficulties, insecure attachment styles and relational trauma intersect in making the world a confusing set of messages for children. Complex trauma work endeavours to restore a child’s experience of care and protection through addressing attachment relationships, building up of inner resources and resilience with a clear goal on the integration of trauma in the procedural memory.
- Blaustein, M., & Kinniburgh, K.M. (2010). Treating traumatic stress in children and adolescents. London: The Guilford Press.
- Buczynski, R., Van der Kolk, B.A., Ogden, P., & Levine, P. (2021) Expert Strategies for Working with Traumatic Memory [Recorded Presentation], The National Institute for the Clinical Application of Behavioural Medicine. Storrs. Available at: https://www.nicabm.com/program/master-program-on-treating-trauma/?itl=homepagepopular (Accessed 14 Jan 2021).
- Byng-Hall, J. (1995). Rewriting Family Scripts: Improvisations and systems change. New York: Guildford Press. Chapter 14, 258 – 264.
- Dallos, R., & Vetere, A. (2014). Systemic therapy and attachment narratives. Attachment narrative therapy. Clinical Child Psychology and Psychiatry, 19(4), 494 – 501. doi: 10.1177/1359104514550556
- Cohen, J.A. & Mannarino, A.P. (2004). Treatment of childhood traumatic grief. Journal of Clinical Child and Adolescent Psychology, 33, 819-831.
- Hudd, S. (2002). Finding the way back home: Children’s stories of family attachment. In A. Cattanach (Ed.), The Story so Far: Play Therapy Narratives. London: Jessica Kingsley Publishers.
- Kelly, A. (2002). In the Wake of the Monster- When trauma strikes. In A. Cattanach (Ed.), The Story so Far: Play Therapy Narratives. London: Jessica Kingsley Publishers.
- Kianniburgh, K.J., Blaustein, M., & Spinazzola, J. (2010). Treating Traumatic Stress in Children and Adolescents. Canada: The Guildford Press.
- Kobak, R., & Mandelbaum, T. (Caring for the Caregiver: An Attachment Approach to assessment and treatment of child problems. In Johnson, S. M., & Whiffen., V.E. (2003). Attachment process in couples and family therapy. Guilford, New York.
- Pernicano, P. (2010). Family-Focused Trauma Intervention Using Metaphor and Play with Victims of Abuse and Neglect: Lanham: The Rowman & Littlefield Publishing Group, Inc.
- Perry, B. (2003). Effects of traumatic events on children. Child Trauma Academy Series, 1 – 21. http://www.ChildTrauma.org
- St Thomas, B. & Johnson, P. (2007). Empowering children through art and expression: culturally sensitive ways of healing trauma and grief. London: Jessica Kingsley Publishers.
- Van der Kolk, B.A. (2005). Developmental trauma disorder. Psychiatric Annals, 35 (5), 401-408.
- Walsh, F. (2006). Strengthening family resilience. (2nd ed.). New York: Guilford Press.