What kind of impact does exposure to traumatic events have on children? While the trauma that children in different parts of the world might experience can include childhood physical and sexual abuse, surviving a natural or political disaster, or being a witness to a wide range of violent events, the psychological impact that trauma can have on children can vary widely. Since trauma responding is often subjective, there can be a wide variety of ways that a child can react to being traumatised. What influences how a child might respond to the trauma includes:
- the length of tie that the traumatic event is experienced (a single event that is over quickly is less likely to have lasting effects than long-term traumatic exposure)
- severity of the traumatic event (experiencing or witnessing extreme physical or sexual violence)
- availability of support resources available to the child afterward, whether through informal or formal social support services
While some children are able to experience traumatic events without apparent ill-effects, the long-term consequences for many children can be serious, whether by developing later psychological problems or even physical problems including substance abuse, personality problems, depression, or suicide.
In many cases, traumatized children can develop full-blown posttraumatic stress disorder and the latest version of the Diagnostic and Statistical Manual of Mental Disorders is expected to include a new diagnosis called Developmental Trauma Disorder (DTD) to be used for children who face repeated traumas while their brains are still developing. The proposed criteria for DTD include:
- Exposure: Multiple or chronic exposure to one or more forms of adverse developmental traumas
- Triggered dysregulation Dysregulation in response to specific, situational triggers. Can involve affective, somatic, or behavioural patterns of responding
- Persistently altered attributions and expectancies Loss of trust in protectors, negative self-attitude, perception that future victimization is inevitable
- Functional impairments Educational, familial, legal, or vocational impairments
The need for a specific diagnosis for childhood trauma stems from years of research showing how common exposure to trauma actually is in young people. According to one 2002 study involving interviews with 1,420 children and adolescents, one out of every four adolescent children had experienced at least one extreme stressor, such as being the victim of abuse or other extreme stress, at some point in their lives. Eighteen percent of the children studied reported two or more stressors and the researchers found that exposure to one extreme stressor increased the likelihood or being exposure to additional stressors over time. These findings have been supported by other studies showing that adolescents experiencing trauma need treatment as soon as possible to prevent or reduce long-term damage.
But what type of treatment works best for childhood trauma? A recent article published in Canadian Psychology provides a comprehensive overview of the different forms of treatment available for children and adolescents who have had traumatic experiences. Written by a team of psychologists at the University of British Columbia and Kelowna, B.C.’s Youth Forensic Psychiatric Services, the article points out that research into how effective different treatment methods for dealing with adolescent trauma is still fairly limited compared to similar research in treating traumatized adults.
Cognitive-behavioural therapies (CBT) are still the leading choice by most therapists, particularly since the available research tends to be far stronger than research looking at psychoanalytic or purely medication-based treatment. While CBT was first developed for trauma in adults and later adapted to adolescents, the special needs that adolescent trauma patients have has inspired the development of treatment methods focusing on children and adolescents alone. These treatment approaches include:
- Multi-modality trauma treatment (MMTT) - First developed in 1998, MMTT is based on the idea that trauma at a young age can disrupt normal physical and emotional development and uses age-appropriate CBT strategies to help children or adolescents cope with trauma. Usually conducted in school settings, MMBT programs have a 14-session format that can include psychoeducation, narrative writing (writing about the traumatic experience), exposure and relaxation techniques, and cognitive restructuring. Empirical studies of MMTT have shown marked reduction in trauma symptoms with similar results for symptoms of depression, anger and anxiety. The chief advantage of MMTT is that it was specifically developed for traumatized adolescents although the nature of the program focuses on adolescents who have experienced only one traumatic event. The value of MMTT for treating polytrauma cases is not as well-researched.
- Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - First developed in 2006 by Judith Cohen and her colleagues, TF-CBT was specifically developed for children between the ages of three and eighteen. Treatment programs using TF-CBT usually range from eight to twenty sessions involving the child alone or the child and a parent/caregiver. The main goal of TF-CBT is to help children and adolescents learn coping skills that will help them deal with traumatic memories. A component-based model, TF-CBT is organized using the acronym “PRACTICE”. In treatment, children receive psychoeducation, are taught relaxation skills, as well as affective expression and modulation, and cognitive coping skills. Children are also encouraged to use trauma narration and to cognitively process the trauma, use in vivo exposure to master trauma reminders, have conjoint parent– child sessions, and enhance safety. First developed for use with victims of sexual abuse, TF-CBT has been found to be effective with other forms of trauma as well and has been widely used in treatment settings around the world.
- Stanford Cue-Centered Therapy (SCCT) – Developed by researchers at the Stanford School of Medicine’s Early Life Stress Research Program, SCCT is a short-term treatment approach focusing on individual therapy for children and adolescents dealing with trauma. Designed to treat problems with a child’s cognitive, affective, behavioural and physical functioning, SCCT uses cognitive-behavioural techniques, relaxation training, narrative use and parental coaching. The goal of SCCT is to reduce the child’s negative thoughts and cognitions as well as sensitivity to traumatic memory. Typically 15 to 18 sessions long, SCCT encourages children to build coping skills including relaxation and self-empowerment. By helping children learn how trauma affects them, they are able to control how they respond to traumatic reminders. Despite its promise, SCCT requires extensive one-to-one therapy sessions which can be extremely time-consuming. Research testing SCCT’s value tends to be limited to case studies.
- Seeking Safety – First developed for use with substance abuse as well as trauma in adults and adolescents, Seeking Safety has five basic principles: personal safety as a priority, integrated of trauma and substance abuse, focusing on the client’s needs, attention to the therapy process, and focusing on cognitions, behaviours, interpersonal interactions, and case management. Seeking Safety was specifically adapted for treating adolescents and, like the other treatment models, uses psychoeducation, training in specific coping skills, and cognitive restructuring. Parental involvement is only needed in one Seeking Safety session and training programs are available online.
- Trauma Affect Regulation: A Guide for Education and Therapy (TARGET)- First developed and tested on young offenders, TARGET can be used individually or in group sessions. The goal of TARGET is to teach clients to understand how trauma changes the brain’s normal stress response and how to manage and control emotional responding to trauma. The TARGET model uses the FREEDOM acronym (focus, recognize triggers, emotion self-check, evaluate thoughts, define goals, options and make a contribution). Most similar to TF-CBT, one of the advantages of TARGET is that parents are not involved in the treatment. At this time, most empirical research on TARGET’s value is with young offenders.
Although there are other CBT approaches that can be used to treat trauma in children and adolescents including exposure therapy, art therapy and EMDR, it is CBT-type approaches that seem to work best for dealing with posttraumatic symptoms. For the CBT methods that have been developed specifically for younger clients, there are some common features including psychoeducation to teach children about traumatic stress and the effects it can have on them, relaxation techniques, a trauma narrative to encourage children to describe their experience in detail, and some sort of cognitive restructuring to correct maladaptive thoughts about the traumatic experience.
For all of the recognized CBT approaches for treating traumatized children, it is vital that children be encouraged to face their traumatic experience gradually and only in a way that they can handle emotionally. Since all children do not develop emotionally at the same pace, it is important to tailor the treatment to the child’s level of emotional and cognitive development. Otherwise, the therapist could end up doing more harm than good by retraumatizing their child patients.
In an ideal world, there would be no children experiencing trauma since potentially traumatic experiences would be prevented. Unfortunately, children and adolescents will experience things that they are not emotionally or psychologically equipped to handle. These experiences can disrupt their natural emotional and cognitive development if left untreated. The five CBT approaches described in the Canadian Psychology article seem to be the most promising treatment methods available to date. Parents and mental health professionals need to be especially vigilant to make sure that traumatized children and adolescents get the treatment they need in time to prevent later mental health problems.