Abstract

Children and adolescents with trauma-related presentations represent an important priority group for counsellors. Effective engagement and helpful interventions during this critical developmental phase have the potential to result in better coping trajectories throughout the life course. This chapter will provide an overview of trauma indicators in youth populations as well as associated changes young clients may experience as a result of trauma. This chapter is not intended to provide an exhaustive summary or all areas of youth trauma nor intended to be a compendium for use of interventions within these populations.

Introduction

Research has shown that the psychological impact of traumatic events can be different for children and adolescents, compared to adults exposed to such events (Lanktree & Briere, 2015). Some examples of traumatic experiences in childhood include, but are not limited to: physical, emotional, or sexual abuse or neglect; witnessing or being the direct victim of domestic, community, or school violence; severe motor vehicle and/or other accidents; natural and human-made disasters; violent or accidental death of a parent, sibling, or other important attachment figure; exposure to war, terrorism, or refugee conditions; and multiple traumatic events. It is important to first acknowledge that it is normal for children and adolescents to experience emotional distress and other reactions following traumatic events. Some emotional reactions have been found to be adaptive, and many children and adolescents find a way to cope and recover fairly quickly, but not all do. Some will present with symptoms that are consistent with a diagnosis—one of which may be PTSD. A meta-analysis on the incidence of PTSD based on 43 independent samples of trauma-exposed children and adolescents that were assessed with diagnostic interviews revealed an overall prevalence of 15% (Alisic et al., 2014).

Trauma symptoms in childhood and adolescence

Several factors, including developmental level, inherent or learned resiliency, and sources of social support, may influence which children or adolescents develop difficulties. Research has shown that the level of exposure (i.e., proximity to the event, level of involvement) to a traumatic event, combined with a perception of a threat to life (or threat to the life of a loved one), are most consistently associated with problems related to PTSD (Pine & Cohen, 2002). Children and adolescents have unique ways of understanding traumatic events: they can differ in how they make meaning of such events in relation to themselves, how they access familial and other forms of support, and how they integrate these events into their identity and sense of self (Van Horn & Lieberman, 2009). Early intervention appears crucial for children and adolescents experiencing PTSD symptoms, to mitigate the risks for mental health concerns into the future. For example, a 33-year follow-up of the children who survived the Aberfan landslide disaster found that 29% of those traced and interviewed still met criteria for PTSD (Morgan et al., 2003). In other words, in the absence of effective therapy, the long-term effects of traumatic events in childhood can be adverse.

Children and adolescents are often brought to counselling because of behavioural or emotional dysregulation rather than because of their exposure to traumatic events. Since parents, caregivers, and other adults may not understand that these problems are related to these traumatic experiences, it is critical to recognise, identify, and make connections between trauma reminders and the child or adolescent’s presenting concerns. Doing so helps the family better understand the problems as trauma responses, allowing them to embrace the need for interventions that are informed by the impact of these traumatic experiences. The remainder of this section will summarise some key developmental considerations across various domains, when identifying and understanding trauma in children and adolescents.

Changes in emotions and affect

Fear is both an instinctual and learned reaction to frightening situations. Children and adolescents instinctively experience fear in situations that they perceive as being life-threatening situations. It is important here to recognise that a child’s or adolescent’s perceptions of such situations may be different to those of the caregivers and adults—who may otherwise view such situations as relatively benign. For example, a child who was in a serious car accident may become very frightened whenever they ride past the location of the accident. This fear response can then become generalised so that people, places, or objects that are objectively innocuous but remind the child of the traumatic event will cause the same level of fear as the original trauma (Scheeringa et al., 2003). For instance, the child exposed to the car accident in the aforementioned example, might experience intense fear when riding in a car—irrespective of where the car was being driven to.

In addition to specific fears, more diffuse anxiety may develop due to the sudden, unpredictable nature of the traumatic experiences. This anxious state may leave children and adolescents feeling generally unsafe and hypervigilant, on guard to protect themselves from being taken by surprise the next time. This sense of impending danger can impinge on a child’s ability to engage in developmentally appropriate tasks (Perry & Szalavitz, 2017). Such feelings of insecurity can lead to a range of maladaptive behaviours, including disengaging from school, disengaging from appropriate peers, or even becoming proactively aggressive in the belief that this is the only way to survive and not once again be the victim in traumatic circumstances. In this way, constant vigilance for possible omens of future threats and other anxiety-driven behaviours begins to interfere with healthy adjustment and development (Hambrick et al., 2019).

Children and adolescents may develop sad or depressive feelings along with PTSD symptoms. Specifically, traumatic grief after a death or traumatic separation that might occur suddenly, perhaps due to parental incarceration or placement in foster care (Cohen et al., 2016). Natural disasters may result in children r adolescent’s loss of personal belongings, their homes, or even the lives of loved ones. In the face of these real losses, children and adolescents often develop maladaptive beliefs or cognitions (described later in this section), which significantly contribute to depressive and other negative emotional states. Children’s developmentally appropriate egocentric view of the world may lead to self-blame for the traumatic event, which in turn may lead to depressive symptoms that include guilt, shame, diminished self-esteem, feelings of worthlessness, and even a longing to die (Cohen et al., 2016). Grief reactions can manifest themselves in the form of persistent thoughts of suicide and may represent an adolescent’s attempts at reuniting with a deceased parent or attachment figure.

Anger may result from the awareness that the traumatic event was unfair in the sense that the child or adolescent did not do anything to ‘deserve’ the trauma. Other children and adolescents, particularly those experiencing physical abuse or bullying, may develop anger as they observe the behaviour of caretakers or others who cope inappropriately with difficulties or frustrations (Becker-Weidman, 2006). Anger in traumatised children and adolescents may take the form of noncompliant behaviour, unpredictable rages or tantrums, or physical aggression toward property or other people. While it is important to clarify myths about all children and adolescents exposed to traumatic events becoming sexual predators or criminals. Careful assessment is required to clarify concerns about bullying, sexual aggression, and other possible coercive forms of antisocial behaviour (Yoder et al., 2019).

Chronically traumatised children and adolescents may become highly sensitive and over-reactive to perceived rejection because parental or other rejection in their past experience was associated with, and served as an early warning signal for, abusive or other traumatic acts. For example, one study indicated that children who have been physically abused perceive angry faces (a trauma reminder for such children) more readily than non-physically abused children (Pine et al., 2005). These children often display emotional dysregulation—sudden changes in mood or affect accompanied by difficulties in modulating their emotions and regaining calm (Teicher et al., 2019). Severe emotional dysregulation occurs more commonly in children and adolescents who are impacted by the cumulative harm of multiple traumatic experiences (e.g., child abuse or domestic violence), than in children who have experienced a single, nonintentional traumatic event. These children and adolescents often lack a nurturing, supportive, and well-modulated coping response from parents and caregivers after traumatic events. Such supportive responses model to children and adolescents the skills required in managing emotions, while demonstrating to them the value of seeking support from a safe and benevolent adult (Hughes et al., 2019).

Children and adolescents who live in a household where they are exposed to domestic violence are at higher risk of being exposed to interactions with adults where their feelings are invalidated and disregarded. In fact, some children and adolescents are even punished by their caregivers for displaying feelings of fear, sadness, or anger. Thus, while traumatised children and adolescents may certainly benefit from learning skills to modulate their emotions, the cumulative harm of multiple past or current experiences of threat and maltreatment may interfere with a child’s capacity to use and benefit from counselling. Children and adolescents who are currently experiencing interpersonal trauma of this nature should be considered at risk and steps should be taken to ascertain whether a mandatory report is required to protect the child or adolescent from further victimisation^[1]. Helping a child or adolescent regulate their emotions by developing a sense of safety in the counselling environment may be the first task of counselling. While this may take longer for some children and adolescents who have experienced trauma compared to others, a child or adolescent’s ability to see counselling as a safe and supportive process is often a therapeutic intervention in itself and may be aided through use of creative approaches such as art or puppets (Desmond et al., 2015).

Changes in behaviour

In order to escape overwhelming negative feelings, children and adolescents may try to avoid thoughts, people, places, or situations that trigger recollection of their traumatic experiences. Unfortunately, such avoidance is seen to be linked to the generalisation of triggers—where previously benign and safe situations begin to be associated with previous traumatic experiences, based on their resemblance to these circumstances (Cohen et al., 2016). It is difficult, if not impossible, for children and adolescents to avoid all trauma reminders. For a child or adolescent who has witnessed ongoing domestic violence, both parents may be trauma reminders. For a child or adolescent experiencing pervasive, ongoing community violence, their whole neighbourhood may become a trauma trigger. Among children and adolescents who are easily triggered and experience pervasive reminders of past traumas, avoidance is not a viable nor effective long-term management strategy. When avoidance is unsuccessful in protecting children and adolescents from overwhelming negative emotions, they may develop emotional numbing, or in more severe cases, dissociation. Trauma-related behaviours may also develop in response to modelling or traumatic bonding (Bancroft & Silverman, 2002). Modelling occurs when children who grow up in abusive or violent homes and communities have many opportunities to observe and learn maladaptive behaviours and coping strategies. They may also see those behaviours being repeatedly rewarded—in the form of the perpetrator continuing to be in a position of power (Foa et al., 2008).

Aggression and persistent anti-social behaviour have been linked to a phenomenon referred to as traumatic bonding. Traumatic bonding involves both modelling of inappropriate behaviours and maladaptive attachment dynamics (Dutton & Painter, 1993). It also involves the acceptance of inaccurate explanations for inappropriate behaviours. In such situations, children and adolescents both fear and love the abusive parent. Such children and adolescents may bond with the violent parent out of self-preservation. To manage the guilt and cognitive dissonance associated with turning against the victimised parent, these children and adolescents may adopt the violent parent’s views, attitudes, and behaviours toward the victimised parent and become abusive or violent themselves (Bancroft & Silverman, 2002).

Other trauma-related behaviours may emerge in children and adolescents including the avoidance of healthy age-appropriate peer interactions, with these children and adolescents preferring to associate with children and adolescents who share similar emotional and behavioural difficulties. Their choice of friends likely relates to the negative self-image that many traumatised children and adolescents develop. These children and adolescents have been found to fear rejection by “normal” peers and find that associating with children and adolescents experiencing similar situations, such as those with ongoing maltreatment, feels more familiar or comfortable. The anger that many traumatised children and adolescents develop is typically manifested through oppositional, aggressive, and/or destructive behaviours (Koffman et al., 2009). Children and adolescents who have experienced trauma are also at greater risk for substance abuse (Barrett et al., 2019), which may be used as a strategy for avoiding trauma reminders, a way of coping with negative self-image, or may arise as a result of associating with other children and adolescents engaging in antisocial behaviour.

Other trauma-related risk-taking behaviours may include: engaging in high-risk sexual behaviours; driving under the influence of drugs or alcohol; using guns, knives, or other weapons without considering the consequences (Thompson et al., 2017). Risk-taking behaviours place the youth in circumstances in which there is a high likelihood of experiencing and/or causing serious injury or death. The serious risks of some youth behaviours warrant starting with interventions that reduce the risk of them engaging in these behaviours and enhancing their safety. Self-injury, such as cutting or burning, as well as suicidal behaviours, are also associated with childhood trauma. Adolescents who engage in self-injury describe these as methods for reversing the numbness that they feel. Others may be seeking connection and a sense of belonging that they feel unable to gain in more adaptive ways. Some youth describe cutting behaviour as a means of managing anxiety (Thompson et al., 2017).

Sometimes children and adolescents are entrusted with the caretaking tasks for younger children and/or for an impaired parent. Over time, the family often comes to expect one child or adolescent to take on caretaking tasks and they come to believe that this is their indispensable family role, both of which contribute to maintaining the child or adolescent’s over-functioning (Tedgard et al., 2019). Also referred to as parentification, such over-functioning persists even if the child or adolescent is removed from the family home and placed in alternate or foster care (Tedgard et al., 2019). Helping such children and adolescents learn appropriate developmental functioning (i.e., to ‘just be a child’) is often an important goal in counselling.

Changes in thinking and beliefs

The intrusion of fearful thoughts and memories is characteristic of PTSD in children and adolescents —manifesting itself in the form of intrusive, frightening thoughts during the day or scary dreams at night. In younger children, the content of these frightening dreams may not be related to the traumatic event in an obvious way, but may instead depict other frightening things and the development of new fears, with no apparent relationship to the trauma other than temporal proximity (Scheeringa et al., 2003). Following a traumatic event, children and adolescents typically search for an explanation for why something so terrible has happened to them or their loved ones. If no rational explanation is found, children may develop inaccurate or irrational beliefs about causation in order to gain some sense of control or predictability.

A common irrational belief involves children and adolescents blaming themselves, either by taking responsibility for the event itself (e.g., I was sexually abused because I wore a provocative dress) or for not foreseeing and avoiding the event (e.g., I should have known the flood was coming —why didn’t I warn mum and dad that the water was coming?). Alternatively, although not blaming themselves directly for the traumatic event, children and adolescents may come to believe that they are bad, shameful, or otherwise lacking in some way that justifies bad things happening to them (e.g., I must be stupid for this to have happened to me) (Cohen et al., 2016). In this manner the world remains fair, predictable, and makes sense; it is only they who are deserving of bad fortune. Developing realistic cognitions of responsibility (i.e., blaming the perpetrator) is often more difficult and painful for children and adolescents than blaming themselves.

Children and adolescents may generalise their experience of betrayal by one person to mean that no one is trustworthy. This belief can lead to difficulties in peer relationships or in the child or adolescent’s attachment to the non-offending parent and other adults, which may further contribute to the child or adolescent’s impaired self-image (i.e., the child undermines these relationships, then attributes the disappointment to their own personal failings). Children and adolescents may respond to a betrayal of trust by repeatedly trying to correct their experience by seeking out inappropriately close relationships with peers or adults who may or may not be safe. Underlying these behaviours are often long-standing beliefs about what it means to be involved in a loving relationship (e.g., It’s normal to have some violence in every relationship) (Cohen et al., 2016). Adjusting these beliefs is a critical component for successfully treating these youth (Cohen et al., 2016).

Unhelpful thoughts can also contribute to negative affective states and behaviours because they are not contextualised to accurately reflect reality, or they focus only on the negative aspects of situations. For example, the cognition ‘anybody could sexually abuse you’ might be true in a given environment, but equally true is the alternative cognition, ‘most men do not sexually abuse children’. It is clear that the first thought is likely to promote fear and avoidance, whereas the second, equally accurate thought is more reassuring and hopeful (Cohen et al., 2016). Traumatised children and adolescents often experience inaccurate and/or unhelpful cognitions that reinforce their negative expectations of others and their destructive self-views.

Changes in attachment and relationships

As with all aspects of early childhood development, it is important to understand the impact of such traumatic events in the context of their significant relationships, namely the parent-child relationship (Hughes et al., 2019). For example, a post-natural disaster home environment may mean that some parents and other caregivers are unable to provide basic needs such as food, clothing, or shelter. For families severely affected by natural disasters, disorganisation and unstable living arrangements are common. For children, this may mean moving to a new home, a new school, and a general lack of familiarity with their new surroundings. Coping with such changes and transitions can be difficult, and sometimes distressing, for young children (Cobham et al., 2016).

Parents who perpetrate ongoing interpersonal traumas (e.g., child abuse or neglect; domestic violence) also disrupt the primary child–parent attachment relationship upon which children learn and model future trusting interpersonal relationships (Hughes et al., 2019). The result of such disruption is typically profound: these children experience ongoing challenges when attempting to establish new relationships since the possibility of any trusting relationship itself serves as a trauma reminder of the caretakers who perpetrated the initial maltreatment.

Children and adolescents who experience trauma may withdraw from peers or have difficulty enjoying social activities. Children and adolescents who feel shame or stigma related to their trauma experiences may not share these even with very close friends, leading to a change in the tenor of such friendships at times when children and adolescents are in even greater need of close friends (Perry et al., 2018). As noted above, after trauma experiences, some youth feel that their usual peers will not understand their experiences, and they begin to affiliate with deviant peers based on the assumption that only these youth can relate to their feelings of being different and ‘on the outside’. Such affiliation can place the youth at heightened risk for additional trauma exposure and the development of more severe trauma responses.

Conclusion

In summary, although some children and adolescents who experience traumatic events are able to cope and recover, many others develop symptoms related to trauma. These symptoms can have a profound and long-lasting negative impact on their development, health, and safety. The impact of traumatic event/s may manifest uniquely in children and adolescents and can be observed across multiple domains of functioning—emotions, relationships, cognition, and behaviour. While early referral and intervention are crucial (such as seeking additional support, helping to establish/maintain a regular routine, and allowing the child or adolescent to share their concerns), it is important for counsellors to be informed of how such traumatic experiences may impact on the child or adolescent’s presenting concerns and how trauma can influence the child, adolescent, and their family. The establishment of a safe, calm, and predictable counselling environment, and therapeutic relationships, are the foundations of supporting a child or adolescent’s recovery from trauma. It is recommended that counsellors seek additional training and supervision in relation to providing more detailed therapeutic interventions for this population.

Learning Activities

Recommended Readings

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (Eds.). (2012). Trauma-focused CBT for children and adolescents: Treatment applications. Guilford Press.

McDermott, B., & Cobham, V. (2012). A road less travelled: A guide to children, emotions and disasters. Authors.

Teicher, M. H., Munkbaatar, O., Schore, A. N., Gatwiri, K., Perry, B. D., Kickett, G., Chandran, S., Farmer, E., Kiraly, M., Macnamara, N., & Hughes, D. (2019). The handbook of therapeutic care for children: Evidence-informed approaches to working with traumatized children and adolescents in foster, kinship and adoptive care. Jessica Kingsley Publishers.

Glossary of Terms

parentification—when a child or adolescent is regularly expected to provide emotional or practical support for a parent or caregiver

traumatic bonding—involves both modelling of inappropriate behaviours, maladaptive attachment dynamics, and acceptance of inaccurate explanations for inappropriate behaviours

References

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Author Information

Govind Krishnamoorthy, PhD, University of Southern Queensland

Dr Krishnamoorthy is a clinical psychologist and senior lecturer in the School of Psychology and Wellbeing at the University of Southern Queensland. He has worked for over a decade in both public and private sectors offering child and adolescent mental health services. As a co-developer of the Trauma Informed Positive Behaviour Support (TIPBS) program, Dr Krishnamoorthy’s research and clinical experience has focused on addressing the social and emotional needs of children and adolescents impacted by child maltreatment.

Amy B. Mullens, BA, MSc, PhD, MAPS, University of Southern Queensland

Professor Mullens is a clinical and health psychologist in the School of Psychology and Wellbeing at the University of Southern Queensland. She has worked for over twenty years across public and private sectors working with clients who experience mental and physical health comorbidities. Professor Mullens’ research and clinical experience focuses on trialling novel health promotion initiatives to reduce health disparities in partnership with priority communities.