Complex Trauma in Early Childhood

The U.S. Department of Health and Human Services reported that in 2006 Child Protection Services substantiated 486,276 victims of abuse and/or neglect age 7 and under. A parent or primary caretaker maltreated 83% and almost half were reported as abused or neglected again within a 5-year period. The Third National Incidence Study of Child Abuse and Neglect reports that three times as many children are maltreated as are reported to CPS agencies. This study also found that children younger than 3 years of age were most likely to be victims of recurring maltreatment and that when the perpetrator of abuse or neglect was exclusively the mother, there was a much higher risk of repeated abuse.

Psychological trauma in early childhood can have a tremendous negative impact as it can distort the infant, toddler or young child’s social, emotional, neurological, physical and sensory development. This is especially true of young children who have experienced multiple and/or chronic, adverse interpersonal traumatic events through the child’s care giving system. Experts in the traumatic stress field such as J. Briere, J. Spinazzola and B.S. van der Kolk have developed the term “complex trauma” to identify this form of trauma.

The symptoms and behavioral characteristics of complex trauma have been categorized into seven domains:

1. Attachment - Uncertainty about the reliability and predictability of the world, problems with boundaries, distrust and suspiciousness, social isolation, difficulty attuning to other people's emotional states and points of view, difficulty with perspective taking and difficulty enlisting other people as allies.

2. Biology - Sensorimotor developmental problems, problems with coordination, balance, body tone, difficulties localizing skin contact, hypersensitivity to physical contact, analgesia, somatization, increased medical problems.

3. Affect or emotional regulation - easily-aroused high-intensity emotions, difficulty with emotional self-regulation, difficulty describing feelings and internal experience, chronic and pervasive depressed mood or sense of emptiness or deadness, chronic suicidal preoccupation, over-inhibition or excessive expression of anger and difficulty communicating wishes and desires.

4. Dissociation - distinct alterations in states of consciousness, amnesia, depersonalization and de-realization and two or more distinct states of consciousness, with impaired memory for state-based events.

5. Behavioral control - poor modulation of impulses, self-destructive behavior, aggressive behavior, sleep disturbances, eating disorders, substance abuse, oppositional behavior, excessive compliance, pathological self-soothing behaviors, difficulty understanding and complying with rules and communication of traumatic past by reenactment in day-to-day behavior or play (sexual, aggressive, etc.).

6. Cognition - difficulties in attention regulation and executive functioning, problems focusing on and completing tasks, difficulty planning and anticipating, learning difficulties, problems with language development, lack of sustained curiosity, problems with processing novel information, problems with object constancy, problems understanding own contribution to what happens to them, problems with orientation in time and space, acoustic and visual perceptual problems, impaired comprehension of complex visual-spatial patterns.

7. Self-concept - lack of a continuous and predictable sense of self, low self-esteem, feelings of shame and guilt, generalized sense of being ineffective in dealing with one's environment, belief that one has been permanently damaged by the trauma, poor sense of separateness, disturbances of body image and shame and guilt.

Diagnosis
Currently there is no diagnostic category that accurately reflects the full range of disturbances experienced by children with complex trauma. Medical and behavioral health professionals have no choice but to use multiple diagnostic categories in an attempt to convey the vast array of difficulties these children are experiencing. However the result is often a confusing picture that results in each problem area being addressed individually instead of focusing on the disorganization of child’s system as a whole. This often result in misinterpreting the difficulties the child is experiencing and therefore providing an ineffective intervention or an intervention for one diagnostic category that negatively impacts another.

Treatment
Because complex trauma affects many different domains, it can be difficult to treat. It is vital that a comprehensive assessment is conducted in order to provide appropriate treatment. Of primary importance in the assessment process is an evaluation of the child’s attachment relationships. It should also include a trauma history and information on past and current behaviors, moods and level of functioning in all areas: social, physical, emotional, sensory and mental. The most effective treatments provide a multi-modal approach and follow a phase based or sequential approach that has six central goals g

Safety:

1) Internal Safety:

• Ability to regulate and tolerate emotional experience
• Ability to modulate physiological arousal
• Ability to discriminate current fears from past danger

2) Relational Safety:

• Consistent response, safe limits, appropriate praise and reinforcement
• Sufficient predictability
• Appropriate boundaries

3) Physiological safety:

• Lack of reliance on self-harmful strategies to modulate experience
• Understanding of body/somatic connection to stress and internal experience.

4) Therapeutic Safety:

• Trust, therapeutic alliance, safe boundaries, supportive/affirming environment.

Self-regulation:

• Affective, Behavioral, Somatic
• Self-soothing capacity
• Healthy self-expression
• Impulse control and modulation of emotional states

Self-Processing:

• Executive functions: attention, anticipation, problem solving, planning
• Coherent narrative of self and other
• Future orientation
  

Trauma Experience Integration:

• Understanding how past experiences trigger current responses
• Containing traumatic reminders and mourning losses
• Differentiating fearful memories/body responses from current danger
• Shifting from reactive to active lifestyle
• Ability to live in the moment
• Addressing and mastering frightening experiences in a safe environment
• Incorporating historical experiences into larger sense of self and identity

Relational Engagement:

1) Attachment/Care giving System:

• Work with caregivers to create a safe environment that is able to support child in meeting developmental, emotional, and relational needs
• Build caregiver capacity to manage affect and develop routines and rituals
• Build caregiver/child attunement and consistency in caregiver response to child behavior
• Work with caregiver to build routines and rituals

2) Interpersonal Connection:

• Build child capacity to effectively build meaningful relationships with others

Positive Affect Enhancement:

• Creativity
• Imagination
• Pleasure and Joy
• Achievement
• Competence
• Mastery-seeking

Additional Readings:

Cook, A., Blaustein, M., Spinazzola, J., & van der Kolk, B. (Eds.) (2003). Complex trauma in children and Adolescents. White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force

van der Kolk B.A. (2005). Developmental trauma disorder: Towards a rational diagnosis for children with complex trauma histories. Psychiatric Annals, pp. 401-408.