A definition of trauma.
IRCT defines trauma as an event or series of events such as abuse, maltreatment, neglect or tragedy that causes a profound experience of helplessness leading to terror.
Trauma is defined by Perry (2011) as ‘a psychologically distressing event that is outside the range of usual human experience, often involving a sense of intense fear, terror and helplessness.’ An alternative explanation is that:
‘Trauma happens when any experience stuns us like a bolt out of the blue; it overwhelms us, leaving us altered and disconnected from our bodies. Any coping mechanisms we may have had are undermined, and we feel utterly helpless and hopeless. It is as if our legs are knocked out from under us.’ (Levine, 2006).
It is acknowledged that every child experiences stress in some ways and in some time and this can be a positive experience if the child has the appropriate support. A child may also experience a crisis and this can be challenging for the child but with positive relational processing, any impact of the crisis can be limited. Some children experience trauma. We know that from early infancy through to adulthood, trauma can alter the way we perceive ourselves, the world around us, and it can change how we process information and the way we behave and respond to our environment (Cozolino, 2006).
Traumatic stress is caused by exposure to or witnessing of extreme and potentially life threatening events. Traumatic exposure may be brief in duration (e.g. an accident), or involve prolonged, repeated exposure (e.g. sexual abuse). The former has been referred to as “Type I” trauma and the latter as “Type II” trauma (Terr, 1991). Knowledge of traumatic stress – how it develops, how it presents, and how it affects the lives of those who suffer with it – may be the first step towards being able to interact positively with those affected by it.
Traumatic experiences, and our responses to them, vary widely and therefore it is essential to use a trauma continuum (de Thierry, 2013) to describe how mild or severe a traumatic experience is. The trauma continuum can help all those who work with children to use a common language, which consequently enables a child to receive appropriate interventions that are suitable for their level of traumatic response. The trauma continuum begins with Type I trauma- single incident trauma and goes through to Type II trauma through to Type III which is pervasive, interpersonal, multiple traumatic experiences.
A single incident traumatic experience can be limited in its negative effect when the child’s context includes positive, consistent attachment figures who provide positive relationships where the trauma can be processed.
The trauma continuum needs to be considered together with the parenting capacity continuum, which illustrates how great the impact of a traumatic experience may be depending on the context of the child’s every day experience.
The most damaging trauma is one of interpersonal experience where the primary care giver is also the source of trauma, such as abuse or neglect or violence from the parent. It is in this context that the child is essentially held hostage by the very people who and should be their greatest protector and source of comfort. The abuse, torture or neglect is often continuous, and the child does not experience it necessarily as abuse or neglect, but rather ‘did I nearly die?’ This is the most profound and potentially damaging experience. It is not surprising that children who have had these experiences can only recover from them and move on from living with a baseline of terror and helplessness for the rest of their lives, IF they can find some resolution due to an appropriate long term intervention. This terror may manifest in a number of ways, such as appearing angry, or sad, or withdrawn, or they may appear to have behavioural difficulties. The adults in their lives need to respond to these manifestations recognising that they are actually terrified. These children need the adults around them to provide physical and emotional containment for their terror.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) field trial for posttraumatic stress disorder (PTSD) demonstrated that the age at which children are first traumatized, the frequency of their traumatic experiences, and the degree to which caregivers contribute to the event being traumatic, all have a profound impact on the extent of their psychological damage. This is expressed in problems with self-regulation, aggression against self and others, problems with attention and dissociation, physical problems, and difficulties in self-concept and capacity to negotiate satisfactory interpersonal relationships
Foundational and pioneering theorists
IRCT are committed to acknowledging the work of the early pioneers of child psychology who identified key concepts that unlocked the possibility of helping children who were traumatised recover. The following overview is of the founding professionals who have shaped the work that we champion and advocate.
Anna Freud (1895-1982) was one of the founders of child development psychology who, among other things, pioneered a way to help children who have departed from normal development return to normal development. She developed important work relating to defense mechanisms and she emphasized the importance of child development over time.
Melanie Klein (1880- 1960) another early pioneer understood that play could be helpful for children’s recovery and also introduced important ideas of projection, introjection and splitting.
Winnicott (1896-1971) was trained by Melanie Klein but became increasingly independent in his thinking over the course of his career, ultimately contributing original ideas that emphasised the importance of play in psychological development. He also introduced the idea of ‘the holding environment’ and the concept of the real and false self. Winnicott also made it clear that the infant develops within the context of an environment, which is essential to explore when looking at facilitating recovery from trauma.
Barbara Dockar-Drysdale developed aspects of Winnacotts work. She focused again on the role of the primary care giver shaping personality development and the importance of understanding the needs of children, which led her to create the first therapeutic communities.
Bowlby’s (1907-1990) theoretical work on attachment and Ainsworth (1913-1999) and Main’s (and more recently Crittenden) empirical research building on his theory have been central to most understanding of the impact of trauma on the development of the child. When using these foundational frameworks for understanding children’s development and experience of trauma we have to be careful not to reduce the ideas of attachment as an interpersonal or relational process to one of typology in which we label children as having insecure attachments.
Ainsworth’s (1985) and Main and Solomon’s (2000) description of four different types of attachment can be helpful to provide a simple overview of the different ways that children learn to relate to firstly their primary caregiver and then others. When a child experiences trauma, their attachments can become disrupted. Disorganised attachment is the reason for much trauma in complex homes where the primary care giver is also the source of fear and inconsistent and volatile reactions that create terror for the child.
Closely associated with attachment theory is the important concept of an ‘internal working model’. This is the way a child develops their internal, subconscious perspective of life through their attachments and lasts into adulthood as an internal map of how to make sense of their world. When a child has created the blueprint of the internal working model they then live life from that perspective where they see the world as a hostile place, their parents as dangerous and intent on harm, adults as frightening and that they are inherently bad.
The impact of trauma
Since the beginnings of these theories there has been a developing understanding of the impact of trauma on child. It is now more publicly acknowledged that trauma affects a child in the short term and long term in significant ways. Trauma affects the cognitive process because thoughts and memory are affected by the negative experience. The impact of trauma is also experienced in the area of affect because the emotional responses to trauma can be very powerful, intense and usually includes terror. Another area of impact is behavioural as the child responds either with ‘acting out’ or ‘acting in’ behaviours in order to cope with the overwhelming feelings. Finally the impact of trauma is often demonstrated in the child’s social ability with challenges in interpersonal relationships often with issues of trust.
James (1989) states the following four consequences of experiencing trauma:
Dysregulation of affect and the inability to modulate intense emotions.
For example a child may stub their toe and scream and shout as if they have had a major accident as they do not know how to calm themselves in the face of pain.
Persistent fear state marked by primitive survival responses such as fright- flight-freeze.
For example a child may run away or fight another child in response to feelings of shame or fear despite their cognitive reasoning not wanting to draw attention to themselves or get into trouble.
Disorder of memory and trauma related memory disorganization with flashbacks (intense memory recollection) and dissociation (sudden alteration in the integrative function of consciousness)
For example a child may be calmly sitting in their classroom when they react to the sound of a door slamming and they throw their chair to the floor and hide under the desk but then are not aware how they got there.
Avoidance of intimacy and aversion to physical and emotional closeness that leads to feelings of vulnerability.
For example a child may be involved in fighting other children and rejecting them whilst also saying they feel lonely and wanting friends.
It also needs to be acknowledged that when a child experiences trauma, there is an impact on their development where damage can occur in terms of delaying or distorting important developmental processes.
The recovery process
It is now understood that the impact of trauma does not automatically heal with time and that this causes continued pain and distress until recovery is facilitated. This process of recovery then can be seen as one of healing in terms of finding new meaning that helps the children re-establish their development in more positive and fulfilling ways without the intense pain that abuse and trauma bring. The recovery journey is not one of simply ‘putting traumatised children back together’ but rather maximizing their potential and re framing their traumatic experience as a part of their narrative but not their primary identity.
A definition of recovery would be;
‘This awful thing happened to me, it no longer has the power to affect how I think and feel. I can see it in the context of my whole life and can take my place in society.’
Resilience is a key concept when looking at the recovery of children from trauma. It is often described as the capacity to bounce back or the ‘ordinary magic’ of many children and adolescents overcoming daunting social circumstances or traumatic life events (Masten, 2001). However resilience is more complex than this.
Khanlou & Wray (2014) describe resilience as ‘an important element to maintaining and promoting child and youth mental health, and as a life-long buffer to potential threats to wellbeing over time and transition’ (p. 65). It is a strength based concept that builds on individual’s strengths rather than emphasizing deficits. Khanlou & Wray’s (2014) view that resilience needs to be considered as:
a process (rather than a single event),
a continuum(rather than a binary outcome), and
a global concept with specific dimensions
is extremely helpful when thinking about recovery from childhood trauma. Resilience is most often viewed as a process that refers to exposure to adversity and “positive” adaptation (Fergus & Zimmerman 2005; Luthar et al., 2000). Between these two points are a host of protective factors such as family, school, community and society that appear to modify vulnerability to the effects of adversity (Daniel & Wassell, 2000). Daniel and Wassell (2002) describe three fundamental building blocks of resilience:
A secure base which helps to create a sense of belonging and security
A high level of self-esteem that brings an internal sense of worth and competence
A sense of self-efficacy that involves a degree of mastery and control along with an understanding of strengths and weaknesses.
Importantly resilience recognises that although it may not always be able to protect a young person from further adversity, and that while it may not be possible to provide an ideal environment for them, boosting their resilience should enhance the likelihood of better long term outcomes. This can be achieved by a protective network and framework for intervention with the focus being on the assessment of potential areas of strength within the child or young person’s whole system. There will however, always be a need to acknowledge some of these young people will require specialised and on- going help throughout their life through no fault of their own.
Different interventions for trauma recovery
The recovery process will need the intervention of therapy and there are different approaches that have evidence of facilitating recovery.
Individual therapies are the backbone of trauma recovery as they offer individually tailored programmes of therapy provided to promote recovery and resilience.
Group therapies can be helpful to bring together children with similar experiences and giving them the opportunity to experience support and learn from each other. It can reduce the isolation that trauma can cause.
Creative therapies are essential for enabling the pre verbal memories or the traumatic experiences, which have caused the broca’s area of the brain, which is responsible for speech and language to shut down. When someone is rendered ‘speechless’ due to the intensity of the trauma and the powerful nature of the brainstem response of fight, fright and freeze, creative therapy can give language to the experience and begin to make sense of it.
Verbal therapies can eventually be helpful for processing trauma and enabling a cognitive response to be developed as part of the child’s transforming narrative.
Family therapies can be helpful for children who are returning to their family of origin to help them create a safe and healing family unit to facilitate recovery.
Therapeutic communities are an intervention that is can facilitate recovery by providing a ‘holding’ environment that can enable a child to grow and recover from some of the harm done to them. Perry and Szalavitz (2006) speak of how the repetition and routine are essential to recovery as the brain changes in response.
It is recognized that short term interventions can be appropriate for children who have experienced Type I trauma such as a one off incident but for children who have experienced longer term or interpersonal trauma longer term therapeutic intervention is essential and short term intervention can be counter productive.
Therapy significantly differs from therapeutic work because in therapy a client will work with the therapist to try to understand the unconscious responses and will process and gain insight into their situation and understanding about themselves. Over time this processing and integrating of experiences and feelings enables the symptoms of the trauma to reduce. The overall aim is to enable a client to change and grow on a personal level in a safe and facilitating environment. The relationship between the therapist and the client is of central importance. Therapy aims to deeply work and uncover difficult emotions and processes looking into the unconscious parts of the client to help them gain more understanding about themselves.
In order to enable the child to feel safe, feel emotionally and physically contained and be confident in positive attachments, it becomes a priority to empower the adults around the child to facilitate a healing environment by becoming therapeutic. Therapeutic work and mentoring aims to only work with what is already known and not work with the unconscious. They aim to enable practical skill development and build self-esteem and self confidence. Working in a mentoring group can also enable clients to negotiate social isolation and social skills.
Therapy and mentoring activities are on different ends of a spectrum or different parts of the trauma recovery triangle (see blog on continuum) but both are vital for the child to have a full recovery. The therapeutic interventions form an essential foundational base for a child whilst therapy is essential to explore the unconscious responses in the higher end of the triangle.
Oaklander (1989) spoke of the centrality of relationship in the recovery from trauma and this can occur in any therapy approach and therapeutic intervention.
‘Nothing happens without at least a thread of a relationship. The relation- ship is a tenuous thing that takes careful nurturing. It is the foundation of the therapeutic process and can, in and of itself, be powerfully therapeutic.’
Bruce Perry (see below) echoes the idea that the therapy (healing) takes place in doses both within therapy and the therapeutic environment (school and home). Given the idea the brain forms (and therefore repairs) from bottom (brain stem) to top (neo cortex) and to bottom, he explains that there are core elements of positive, developmental, educational and therapeutic experiences:
Relevant (developmentally matched)
Rhythmic (resonant with neural patterns)
Respectful (child, family, culture)
It might be worth adding
➢ Reciprocal (taking turns, which will happen once a child begins to feel able to be in relationship)
Through these experiences in therapy and throughout the environment of the home the child’s brain can rewire from bottom (brain stem) to top (neo cortex) and between the left and right brain. This is an ongoing process and the more damaging the early experiences have been and the older the child the more repetitive, rewarding and rhythmic experiences need to happen over a longer period of time to enable the new connections in the neural pathways to become strong.
Contemporary theorists insights into trauma recovery
There are the more current writers and researchers such as Stern (1934-2012) who introduces important ideas around mother and infant constellation and the need for attuning and amplification that needs to be present in therapy. Green (1927-2012) who explores the internalisation of external objects that leads to an understanding that if a child that’s never had the experience of consistent enduring care therefore needs to be able to experience that, if he is to become someone who can show that care himself.
There are other significant contemporary thinkers such Fonagy, Cairns, Music, Trevarthan who are all continuing to build on elements of the importance of this early relationship.
We also need to ensure that we contextualise children’s development. Bronfenbrenner’s (1917-2005)work on understanding the ecology of development has made an important shift in how we view development. It is critical that attachment and the impact of trauma and future resilience is seen in the broader context of the child’s life so we can move beyond individualistic views of recovery and resilience for these children. All psychodynamic approaches need to be complemented by sociological insights.
Trauma recovery work is not simply an adult ‘doing something’ to a child to facilitate their recovery but helping the child to move from being a victim to being a survivor. This is a process that therapists would often refer to as ‘co-construction of a new narrative’. It transforms the narrative from being focused on shame, fear, pain and insecurity to one that has confidence, healing, security, self-awareness and hope.
How contemporary neuroscience affirms the recovery priorities
The other area of new research that is crucial to our understanding of trauma and recovery in children is the work on the impact of trauma on the developing brain. The work of Bruce Perry, Allan Schore, Bessel Van de Kolk, Stephen Porges and Graham Music are key to this developing understanding as it has given us much clearer insight into the impact on the brain and the ability of traumatised children to regulate their emotions, impulses and behaviour. An understanding of brain development is key to helping us understand how we respond to facilitate recovery. Evidence suggests that relationship is central in supporting recovery in traumatised children.
Perry and Van der Kolk write of how the developing brain organizes and internalizes new information in a use- dependent fashion which demonstrates that the more children live in a disorganized physiologic state (hyperarousal or detachment), the less they are capable of dealing with stressful experiences and the more likely their development is thrown off course by exposure to traumatic experiences.
Perry continues this theme by asserting that children are most likely to reach their full potential if they experience consistent, predictable, enriched, and stimulating interactions in a context of attentive and nurturing relationships. He explains that the brain can change through the repetitive relational experiences due to plasticity of the brain.
‘It is important to understand that the brain altered in destructive ways by trauma and neglect can also be altered in reparative, healing ways. Exposing the child, over and over again, to developmentally appropriate experiences is the key. With adequate repetition, this therapeutic healing process will influence those parts of the brain altered by developmental trauma. Unfortunately most of our therapeutic efforts fall short of this’ (Perry. 2006).
Contemporary research that supports the notion that prolonged alarm reactions alter limbic, midbrain, and brain stem functions through ‘‘use-dependent’’ modifications. Chronic exposure to fearful stimuli affects the development of the hippocampus, the left cerebral cortex, and the cerebellar vermis and alters the capacity to integrate sensory input. Current research is beginning to demonstrate the underlying pathophysiology of the difficulties with cognition, impulse control, aggression, and emotion regulation commonly seen in severely traumatized children. (Van der Kolk. 2003).
Under the umbrella of interpersonal neurobiology, Siegel’s approach (2012) applies the emerging principles of interpersonal neurobiology to promote compassion, kindness, resilience, and well-being in our personal lives, our relationships, and our communities. Seigel emphasises the importance of integration so that separated areas with their unique functions, in the skull and throughout the body, become linked to each other through synaptic connections. These integrated linkages enable more intricate functions to emerge—such as insight, empathy, intuition, and morality.
Other researchers are currently adding to the work highlighting the essential elements of trauma recovery work are Stephen Porges, Allan Schore, Graham Music, Louis Cosolino and Joyanna Silburg. Each of these offer essential theories and good practice models to enable children to recover from trauma.
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Written by Alex Hassett, James McAllister, Betsy de Thierry, Mary Walsh. IRCT Trustees.