Steven N. Sparta, PhD, and Robert T. Kinscherff, PhD, JD
DEFINITIONS OF TRAUMA
Children are commonly exposed to adverse events which they experience with some degree of stress. The reaction to these events may result in the development of adaptive coping strategies or the activation of resiliency factors such as effective problem-solving or seeking support from family or peers. Developing these capacities is a part of normal development. However, children exposed to adversities with which they cannot cope may develop specific symptoms or adopt strategies that become maladaptive over time. For example, a child who is bullied may become distrustful of peers, socially isolate, or more aggressive. However, trauma is a function of the individual child's response to the adverse event rather than the characteristics of the event.
Trauma is defined as a degree of impairment or suffering (psychological consequence) on the part of the child which has been caused (or contributed to) by a legally relevant event. For example, in a personal injury case, the issue may be whether the child's symptoms were caused by the automobile accident. The determination of whether or how exposures to adversities result in trauma and specific manifestations of trauma can be complicated, particularly if the child has been exposed to multiple incidents over time. The psychologist asked to evaluate such children should be careful to avoid assumptions about the nature, extent, or causality of psychological functioning based solely upon the characteristics of adverse events (e.g., sexual abuse, physical abuse, witnessing violence), especially when the fact or the specific nature of an adverse event remains legally contested. Similarly, assumptions about the presumed presence, nature or magnitude of psychological disruption cannot be based only upon the general description of adverse events. Whether a child has experienced disabling consequences from trauma proximally related to a legally relevant event can be determined only after a detailed and developmentally-informed assessment of the child takes place using multi-modal data-gathering methods that yield information which is then objectively analyzed.
A BRIEF HISTORICAL NOTE ON TRAUMA
Historical accounts of trauma appear related to natural disasters and warfare. Pynoos, Steinberg and Goenjian (1996) cite the letters (100-113 A.D.) of Pliny the Younger of an adolescent's reactions to the eruption of Mount Vesuvius. Kaminer, Seedat, and Stein (2005) report the term Posttraumatic Stress Disorder (PTSD) first appeared in DSM-II, although the concept and related clinical descriptions are considerably older. Grinage (2003) describes a stress syndrome in soldiers during the U. S. Civil War attributed to a cardiac disturbance. Shell-shock during World War I was believed to be an organic brain syndrome secondary to carbon monoxide gas (Linden, Hess, & Jones, 2012). World War II gave rise to combat neuroses or traumatic war neuroses, which led to an increased interest in PTSD, eventually resulting in an International Classification of Diseases (ICD) category of gross stress reaction. Additionally, World War II gave rise to descriptions of children exposed to strategic bombing, parental separation, and early institutionalization.
More recently, Melton, Petrila, Poythress and Slobogin (1997) describe the mental effects associated with emotional distress legal cases, but identify PTSD as the most likely diagnosis involved in mental injury cases. PTSD may also be used to describe a child involved in child protection, delinquency, guardianship, divorce child custody, or special education proceedings. While PTSD diagnosis is commonly relied upon to capture the suffering and impairments associated with traumatizing event(s), a specific psychiatric diagnosis is less important than a detailed and multi-sourced description of suffering and/or functional impairments and an analysis of how or why those arose from specific adverse events.
The Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition (DSM-5) (American Psychiatric Association [APA], 2013) states that the essential feature of PTSD is the development of characteristic symptoms. The stressful event can involve "exposure to actual or threatened death, serious injury, or sexual violence." There are four ways an individual can experience exposure. These are:
"1) directly experiencing the traumatic event(s);
2) witnessing, in person, the event(s) as it occurred to others;
3) learning that the traumatic event(s) occurred to a close family member or close friend; or
4) experiencing repeated or extreme exposure to aversive details of the traumatic event(s)" (APA, 2013, p. 271)
These symptoms can occur as early as one year after birth, and typically begin within three months following a traumatic event (although occasionally symptoms do not begin until years later) (APA, 2013, p. 276).
For children under the age of 6, the DSM-5 recognizes different forms of exposure. These consist of:
"1) directly experiencing the traumatic event(s);
2) witnessing, in person, the event(s) as it occurred to others, especially primary caregivers; or
3) learning that the traumatic events occurred to a parent or caregiving figure"
(APA, 2013, pp. 272-273).
This language reflects the crucial differences in the way children process emotionally stressful experience because of developmental considerations. For example, younger children may derive considerable security and stability from their relationship with a close family member or caretaker. Witnessing the perceived threat of loss of that person could result in significant psychological disruption.
Once PTSD develops, the symptom expression and duration of the illness varies. Complete recovery occurs within three months in one-half of adults (APA, 2013). The twelve month prevalence rate for U.S. adults is 3.5%, with lower estimates ranging from 0.5% to 1.0% in Europe, Asia, Africa, and Latin America (APA, 2013). Grinage (2003) reports that 8%-9% of the US population suffers from PTSD. The DSM-5 projects a lifetime risk of PTSD of 8.7% by age 75.
The Department of Veterans Affairs and Brown University Child and Adolescent Behavior Letter (2012) report that 14% to 43% of US children experience a trauma with 1-15% developing PTSD. Children's reactions to traumatic events and the duration of symptoms may vary depending on age of exposure and adequacy of social supports (APA, 2013). Even though they didn't manifest reactions at the time of exposure, children aged 6 or younger may express symptoms in play. Andreasen (1985) notes chronic PTSD is less common than the acute form which commonly resolves in less than six months. However, much of the literature on PTSD is not specific to children and so evaluators should consider that children traumatized by adverse events may represent a population with significant rates of duration or developmental impact not readily captured by the PTSD diagnosis.
In assessing childhood trauma, formulations about the nature and extent of the child's functioning should not be limited to the DSM-5. First, a DSM diagnosis does not necessarily describe a specific degree of functional impairment. Second, there are post-traumatic adaptations that result in functional and developmental impairment that are not addressed by the DSM diagnostic system.
The seminal work of Terr (1991) suggests that two classes of trauma may lead to PTSD in children. Type I involves single, sudden and unexpected experiences such as being victim of a violent crime; Type II involves repeated events which can sometimes be anticipated by the victim (such as ongoing physical or sexual abuse). Repeated exposure reduces the likelihood that a child will be able to activate protective social supports or establish positive personal coping strategies. Children exposed to Type I trauma often have clear reactions. Children exposed to Type II adversities may engage in psychological numbing, avoidance, and dissociation as well as adapt to chronic stressors.
Terr's work has yielded a clinical description of a developmental trauma disorder arising from extreme or cumulative traumatizing experiences which may result in biologically, socially or individually mediated outcomes. These include:
(a) repeated dysregulation triggered by cues of traumatizing experiences resulting in disturbances of attachment, behavioral re-enactments and self-harm, somatic experiences, cognitive distortions, and emotional dysregulation, or
(b) negative self-attributions, distrust of caregivers, and a sense of the inevitability of future victimization. These can result in an impact upon social, educational, familiar, peer, or legal domains (Cook et al., 2005).
The seminal Adverse Childhood Experiences Study (ACES) documents the correlation between ten adverse childhood experiences and subsequent risks in health behaviors (e.g., substance abuse, tobacco use, unsafe sexual practices). Five involve direct victimization of the child (sexual abuse, physical abuse, verbal abuse, physical neglect, emotional neglect). Five are family factors (parental incarceration, mental illness, or substance abuse; maternal victimization by domestic violence, loss of a parent due to death, divorce, or abandonment). The number of adverse childhood experiences correlates with increased risk in adulthood of psychological difficulties (e.g., depression, psychosis, suicide attempt), social adversities ( educational and vocational underachievement, juvenile and criminal justice system involvement, victimization), and poorer medical outcomes (ischemic heart disease, liver disease, diabetes). See Felitti et al. (1998).
Children exposed to multiple adverse experiences also present challenges in understanding the impact and interaction among traumatizing experiences, the consequences of individual adverse experiences, and the formulation of clinical interventions. Repeated exposure to traumatic stressors may result in significant psychological disruption due to the child's inability to profit from moderating variables of social support and heightened powerlessness. As a result, trauma assessment must extend beyond consideration of the impact of a single or a series of events to include description of the developmental trajectory of the child, past adverse events and their impact upon the child (including any positive adaptations and activation of resiliency factors), any pre-existing or co-existing risk, and mediating or protective factors at the time of the assessment. Analysis of the availability and quality of psychosocial supports both before and after exposure is crucial in understanding the impact of trauma and the prognosis for recovery.
Psychologists will find the research and assessment of PTSD and other trauma-related DSM-5 diagnoses insufficient in light of (a) the manifestations of trauma that are not captured well in the DSM-5 diagnostic system; and (b) the ACES research documenting the cumulative impact of a variety of childhood adversities. A psychologist can improve the assessment of individual children by considering the assessment methods for a DSM-5 differential diagnosis and alternative conceptualizations and the positioning of a child within the history of exposure to adverse experiences. Indeed, this approach to child trauma assessment is emerging as a professional best practice.
ADVERSE EXPERIENCES THAT MAY RESULT IN TRAUMA
Researchers have documented a wide variety experiences associated with trauma. These experiences include the murder or suicide of a parent (The Brown University Child and Adolescent Behavior Letter, 2012;Sillito & Salari, 2011), war (Hodes, Jagdev, Chandra, & Cunniff, 2008; ), natural disasters (Lai, Greca, & Llabre, 2013), physical and sexual abuse (Wahlstrom, Michelsen, Schulman, & Backheden, 2010; Benjet, Borges, Mendez, Fleiz,, & Medina-Mora, 2011; Graham-Bermann & Miller, 2013; Hopton & Huta, 2013; Wilson & Scarpa, 2013; McCloskey, 2013), witnessing spousal abuse (Dorahy, Lewis, & Wolfe, 2007; McCloskey, 2013), physical and sexual assaults by peers or other caretakers (Reichmann-Decker, DePrince & McIntosh, 2009; Kochenderfer-Ladd, 2004; McCloskey, 2013) as well as parental divorce or hospitalization of a family member (Piemont, 2009; Kaplan, Kall, Bradley, & Alderfer, 2013). Studies suggest that more than half of sexually abused children meet the criteria for PTSD (The Brown University Child and Adolescent Behavior Letter, 2012; Danielson et al., 2012).
In addition to direct threats, PTSD can result when children perceive a threat to their major sources of psychological security. Norris and Stone (2013) report among the most prevalent traumatic forms of trauma are accident or fire (50%), threat or injury to a family member or friend (32%), and witnessing abuse (31%) (p. 2). Tierens et al. (2012) demonstrate that direct victims or witnesses of accidents lead to the development of PTSD in adolescents. Burns can result in protracted and disfiguring injuries. In pediatric burn cases, where repeated hospitalizations, surgeries and wound management occur, the child experiences considerable stress.
Whatever the origin of the traumatizing event, the nature of the psychological impact on the child is an interaction of the following:
• the child's developmental and individual vulnerabilities and resiliencies,
• the availability of external familial and social supports,
• the meaning attributed by the child and others to the adverse event,
• the child's reaction to it,
• the nature of the adverse event(s), and
• ongoing consequences arising from the event(s).
Sometimes the consequences substantively contribute to the experience of trauma, such as when the child feels responsible for incarceration of a parent or is removed from caretakers albeit for child protection purposes.
Children may be traumatized by observing the event (Tierens et al., 2012). Thus,
serious psychological detriment may result from the observation or knowledge of violence within the household (Insana, Kolko, Foley, Montgomery-Downs, & McNeil, 2013). However, reports by a parent or others of a child's exposure to family violence or their ratings of the child's functioning can be distorted by either under- or over-reporting the incidence of interpersonal violence.
CLASSES OF PSYCHOLOGICAL TRAUMA
Adverse experiences are often described as either non-interpersonal or interpersonal. Non-interpersonal sources of trauma include non-intentional injuries from fires, automobile or other accidents, or the impact of experiencing floods, earthquakes, or other natural disasters. Interpersonal forms of trauma include sexual/physical abuse, witnessing domestic violence or murder by a parent of a family member, chronic exposure to overt hostility in divorce conflicts, kidnapping, or shootings within school settings.
Illustrating the latter is the review by one author of the scalding death of a baby by the parents. Not only did the children witness this traumatic event, they were then considered for trial testimony in the prosecution of the parent for the death penalty. The potential involvement of a child testifying against a parent presents both significant ethical considerations for the professionals, as well potential exacerbations of secondary psychological harm. As suggested by this example, trauma of interpersonal origin may lead to more lasting or severe symptoms (Iverson et al. (2013).
DIFFERENTIAL SYMPTOMATOLOGY OF POSTTRAUMATIC AND ANXIETY STATES
PTSD is classified as a trauma and stress related disorder. Differential diagnosis of conditions with prominent anxiety symptoms is important when formulating opinions as to whether the symptoms documented are proximately caused by a legally related event or whether the symptoms are related to a preexisting or coexisting disorder.
Panic attacks in PTSD are cued by stimuli recalling the stressor, while panic attacks which occur in the context of other anxiety disorders are situationally bound, predisposed or more generalized. PTSD panic attacks can generalize to other situations but originate in stimuli reminiscent of the trauma before generalization occurs. In social phobia, the panic attack is cued by social situations, a particular object, or by exposure to the object of an obsession (APA, 2013). DSM-5 now categorizes trauma and stressor related disorders, where exposure to a presumed stressful or traumatic event is listed explicitly as a diagnostic criterion, as including the diagnoses of Reactive Attachment Disorder, Acute Stress Disorder, and Other Specified Trauma-And-Stressor Disorder.
Acute Stress Disorder is a closely related diagnosis for symptoms that occur within one month of an extreme stressor and also resolve within one month. For symptoms that persist longer than one month, a diagnosis of PTSD should be considered. Children who experience an extreme stressor but do not meet the PTSD criteria may warrant a diagnosis of Stress Response Syndrome or Acute Stress Disorder. Thus, by using DSM-5 classifications psychologists can carefully and accurately describe diagnoses and their implications for attorneys, judges, and other non-clinical readers.
This can be particularly challenging. For example, dissociative amnesia is characterized by a difficulty in recalling important personal information; trauma-related dissociative amnesia results in difficulty recalling details of traumatizing experiences and sometimes the ability to recall the experience(s) at all (APA, 2013). Dissociative amnesia needs to be distinguished from the defense mechanism of avoidance in which children may be able to recall events but the anxiety associated with recollection motivates them to avoid discussing what they can recall. This is different from situations where children can recall events and may not be avoidant out of anxiety arising from the recollections themselves, but may be motivated for other reasons.
Similarly, the DSM-5 criteria for PTSD in children younger than 6 years now recognize that traumatized children can experience the world in a dreamlike, distant way (derealization) or experience feelings of detachment, as if they were outside their body or mental processes (depersonalization). Evaluations of children who have experienced chronic sexual or physical abuse should address the possibility of dissociative reactions as part of PTSD. These evaluations require specific competencies in interviewing and the ability to evaluate the reliability of the information provided.
The range of children's symptomatology can vary significantly, based upon a number of factors including the following:
• temperament/personality traits of the child,
• presence of mitigating factors that help manage the stressful event,
• perceptions or understanding of the stressful event, and
• traumas or significant psychological preexisting conditions.
Evaluators should understand the many ways in which children manifest acute reactions to trauma, including those that are not well-described by the DSM-5 criteria. Sophisticated evaluators are aware that standardized psychological tests do not always detect traumatic stress. In particular, youth whose posttraumatic impairments arise from chronic traumatic exposure may not be readily recognized or diagnosed (Anderson, 2005).
Additionally, posttraumatic impacts at one phase of a child's development may contribute to complications at a later developmental phase. Careful assessment relying upon multiple sources of data gathering and informed by a developmental perspective on functional domains (e.g., affective, cognitive, somatic, social, behavioral) increases the evaluator's confidence in the data. This process also supports the evaluator in crafting written reports of the assessment and preparing for possible lines of cross-examination.
PHASE-RELATED TRAUMA SYMPTOMATOLOGY
Psychologists recognize that the acute, chronic and delayed-onset phases of PTSD or other posttraumatic reactions are subject to different symptoms, intensity or frequency. Children in the acute phase may have nightmares, distressing dreams, hypervigilance, difficulty falling asleep, generalized anxiety and an exaggerated startle response. Children whose PTSD had moved into a chronic stage suffers detachment, restricted range of affect, sadness, dissociative episodes, and estrangement from others (American Academy of Child and Adolescent Psychiatry, 2011).
DETERMINANTS OF TRAUMATIC EFFECTS ARISING FROM ADVERSE EXPERIENCES
How a child reacts to stressful events is a function of complex bio-psychosocial processes including: the nature of the traumatic event, the intensity and duration of the event(s), the physical and psychological proximity of the event(s), individual factors such as temperament, cognitive capacities, and vulnerability to autonomic arousal, history of attachment experiences, existing coping capacities and available resiliency resources prior to and following the traumatizing event(s), and, any pre-morbid or co-morbid developmental/psychological conditions (Saywitz, Mannarino, Berliner and Cohen, 2000). Briere (1997) grouped these into the nature of the stressor, victim-specific variables, subjective responses by the victim, and, the response of others to the victim.
Significant variability occurs among children who experience objectively comparable stressors. This variability makes it essential for evaluators to individually approach and assess each child's history and circumstances. This includes an individualized assessment of the response of parents or other caregivers to the adverse experience(s) the child has faced. This is particularly the case for younger children who have heightened dependency upon caregivers. Evaluators must also elicit children's self-report. Difficulties in offering narrative accounts of adverse experiences and their responses may arise from a variety of factors, including:
• very young age of the child,
• specific language-based or other disabilities,
• posttraumatic responses that complicate the child's ability to report,
• developmentally inept interviewing by the evaluator, or,
• coaching or intimidation of the child.
UNDERSTANDING TRAUMA AS DEVELOPMENTAL PSYCHOPATHOLOGY
The disruptive effects of traumatic experience can have consequences upon the child's future ability to process information, regulate affect or adapt socially (The National Child Traumatic Stress Network [NCTSN], 2013). The potential for future developmental disruption to a child's functioning is one distinguishing feature in assessing trauma in children as compared to adults. For example, a disfiguring dog bite injury to a 9 year old child's face may cause psychological problems significant in the short term but gradually improve over time. With the onset of adolescence, the same child might experience a resurgence of psychology injury when social relationships become especially important.
BIOLOGICAL REACTIONS TO TRAUMA
Traumatic events can produce a complex interaction between biological stress responses systems and their expressions in behavior. De Bellis and Putnam (1994) noted some two decades ago that multiple, densely interconnected, neurobiological systems are likely to be impacted by acute and chronic stressors associated with the traumatic event. Recent research documents that children are more vulnerable than adults to the neurodevelopment effects of childhood adversity and toxic stress and that these effects may have lifelong consequences (Shonkoff & Garner, 2012). These consequences include long-term compromise of emotional regulation, biological arousal systems, attention and concentration, and other functional domains.
Adequate trauma assessment includes the behavioral manifestations of emotional and behavioral dysregulation, disturbances of sleep, learning and memory deficits secondary to anxiety, and disturbances of attachment and interpersonal engagement. Understanding of the biological dimension of trauma disorders is important when considering pharmacological treatments, psychotherapeutic interventions, and mindfulness techniques.
COMORBIDITY AND PRE-EXISTING DYSFUNCTION
Traumatic experiences can manifest in a variety of symptoms and developmental domains. Additionally, how they manifest can change as the child grows older. This complexity has led to the characterization of trauma in children as a clinical chameleon that can present differently among children and over time for each individual and can pose assessment challenges, particularly in settings where children with trauma histories are overrepresented such as juvenile justice (Kinscherff, 2012). Assessment of trauma in children requires careful differential diagnosis and consideration of co-existing conditions that may be proximately related to a legally relevant event.
Additionally, children may be assessed months to years after the trauma. It is essential to have as complete a history as possible of the child's functioning over the developmental life span up to the time of the trauma and continuing through any subsequent adverse experiences. Evaluators who focus on a recent precipitating event without sufficient inquiry concerning prior functioning do so at their peril. Many children are exposed to multiple adverse events, including some for whom the medical, social or other consequences of attempting to treat them or protect them from further victimization may come at a cost. For example, some children who have been removed from their parents for child protection concerns not only experience the removal but also the disruption of parental attachments and potential maltreatment while in substitute care. Children evaluated in a personal injury lawsuit for psychological damages stemming from a fire or an automobile accident may have previously been victims of chronic sexual or other abuse.
FACTORS MEDIATING TRAUMATIC RESPONSE
Prior exposure to adverse experiences can be a factor affecting the onset, duration or severity of the trauma response. The suddenness or severity of the stressor(s) and the child's understanding of such events are relevant. Situational factors such as stressors associated with protracted litigation can also have a contributing effect at the time of evaluation (Weissman, 1990). Temperamental characteristics and personality traits can support resilience or create vulnerabilities that limit adaptation and foster chronic impairment. Social support can have a dramatic effect upon children's adaptation to traumatic stress.
Shalev (1996) and Shalev, Bonne, and Eth (1996) note the factors that predict the likelihood of posttraumatic stress disorder, including:
• pre-trauma vulnerability,
• the magnitude of the stressor,
• immediate responses to the event, and
• posttraumatic responses.
Additional factors which can affect the duration or severity of posttraumatic responses include
• genetic predisposition,
• prior traumatization,
• preexisting personality, and
• the child's stage of development at the time of trauma (van der Kolk, 1987).
These factors provide useful factors to consider in any assessment.
COMPETENCY, RECALL, CREDIBILITY OF CHILDREN'S STATEMENTS
Weissman (1991) observed that competency in reporting events involves perceiving and recalling facts accurately, understanding truth from falsehood, and communicating personal knowledge of the facts. Being knowledgeable of children's cognitive capacity enables the psychologist to assess the child's reports more accurately because questions are framed in developmentally appropriate language. Preschool children are particularly susceptible to suggestibility as well as to different ways of experiencing time and sequence. Because of these developmental limitations, it is sometimes difficult to determine whether an absence of reported symptoms means no difficulty, limitations in expression, or avoidance of thoughts or feelings caused by the trauma.
When assessing young children, one must recognize that accurate recall represents a complicated process influenced by communications among family members, multiple interviews, and the child's shifting developmental interpretations of the original experience. If the child learns about the traumatic event from others, the child may internalize those understandings, attributions or beliefs. Then when the child recalls the experience, it may be at variance with corroborated aspects of the event.
Studies of memory show that events are not simply encoded and later replayed, analogous to a tape recorder. Accurate recall is malleable, subject to suggestibility, influenced by time delay, as well as emotions that existed at the time of the event followed by selective reinforcement for certain beliefs. In addition, the child will have a natural tendency to reach closure, which may lead to constructing a story to explain what happened. Such perceptions and beliefs reported by the child during evaluation may not be factually accurate, but they are psychologically important to understanding the child's adaptation. However, even these points need to be carefully considered, children should not be presumed incapable of accurate reporting of prior events, including child abuse.
TRAUMATIC REMINDERS AND SECONDARY ADVERSITIES
Reminders of the trauma may produce intermittent or chronic recurrence of trauma-cued anxiety, irritability, emotional or behavioral dysregulation. Children can experience recurrent and intrusive memories of the traumatic event or have distressing dreams where the content or affect reminds them of the traumatic experience. Interviews should differentiate direct reactions to traumatizing experience as contrasted to beliefs based on what others reported. Children's reports during assessment may reflect reactions of parents or caregivers to the traumatizing event(s), discussions by family about the event, reactions to the event by third parties (substitute care placement ), or the impact of multiple interviews with investigators who unwittingly imposed their own presumptions or understandings on the child.
CHILDHOOD TRAUMA CASE EXAMPLES
Children may experience trauma more intensely as they have a greater dependence upon parental or other caretakers. Evaluators should be mindful of intentional or inadvertent shaping of a child's self-reports in response to the perceived reactions or needs of parents or other attachment figures. Children, even very young children, can be remarkably capable of offering detailed and accurate accounts of events they have experienced, but they are also vulnerable to re-casting their experiences due to parents, caregivers and others.
Psychologists should avoid preconceptions when determining whether or how adverse events result in trauma. Consider the following hypothetical example: An eight-year-old child and his younger brother in a rural setting wander into a grain elevator. While playing, one brother falls into a tower filled with grain and begins to sink. His brother holds one arm and attempts to pull him free but is unable to do so. The child disappears beneath the grain. After running for help, the surviving brother learns that it is too late to save his brother from asphyxiation with whom he had a close relationship. A tremendous sense of loss and guilt on his behalf is perpetuated by observing his mother's grief.
The child was referred for assessment prior to initiating any psychological treatment. The interview revealed pervasive references to survivor guilt and a profound sense of responsibility for failure to save his brother. He commonly experienced intrusive recollections which he attempts to avoid or disrupt; these are not even known to the mother. When asked about his wellbeing, the child consistently denied any complaints. Later, during a psychological evaluation, his drawings reflected feelings of loss and fear and he admitted to intrusive recollections of his brother's death. The content provided an opportunity for follow-up questions which yielded disclosures of significant emotional distress specifically associated with the traumatic event. The child's normal needs for developing age-appropriate autonomy were compromised, as he maintained close proximity to his mother in order to lessen what he perceived as her intense anxiety.
Assessment revealed that the boy was experiencing disruptions in a variety of areas, including the following:
• compromised learning at school due to intrusive thoughts
• increased peer isolation and difficulty attending school due to anxiety in being away from his mother
• developmental regression and compromise of previously mastered developmental tasks and,
• persistently sad mood and/or anhedonic experience that diminished his interest in previously satisfying activities.
A thorough analysis of his prior life functioning revealed no comparable experience and his reports of emotional difficulty were specifically linked to the experience of witnessing his brother die. Continuing and long term problems followed.
Consider another hypothetical example: Two children are driving with their father in his truck in a rural area. When the father swerves to avoid debris on the highway, the truck overturns, ending up in a canal filled with water, its occupants upside down and strapped in by seat belts. The father is unconscious but the two children are not. As the water continues to fill the cab, the oldest child recognizes they are being increasingly submerged, but she is unable to free herself. Eventually, a passerby runs to help the victims, discovers them submerged below water, but successfully pulls one of the children to safety. The second child, who was very young, also survived, but the father died. In this case, while the children suffered tremendous anxiety and loss from the death of their father, the mother provided tremendous support, continuity and reassurance to the children. Extended family members provided the children with a continuing sense of stability, helping them maintain preexisting school relationships and routines. The professional conducting the evaluation determined that the child being evaluated was resilient, with excellent coping skills. Psychological counseling was provided. Although the traumatic events are serious in both examples, the psychological outcomes are different because of individual, preexisting or mediating factors.
Proper understanding of psychological trauma in children has many potential applications. The assessment of a child's reactions to stressful events is very complex, and is based upon an understanding of how developmental considerations help explain the nature and extent of the psychological impact and the prognosis for recovery. The psychological research in the last decades related to this subject has been considerable. The DSM-5 is more developmentally sensitive in that diagnostic thresholds have been lowered for children (APA, 2013, p. 812), and separate criteria have been added for children younger than 6 years. This article highlights some of the important considerations when conducting an assessment of children and should provide a useful beginning for further education in this most important subject.
Steven N. Sparta is Clinical Professor of Psychiatry, University of CA at San Diego & Adjunct Prof. of Law, Thomas Jefferson School of Law. He is Boarded in Forensic and Clinical Psychology from ABPP and is in independent practice. He has been credentialed by the National Register since 1984.
Robert Kinscherff is a psychologist and attorney at the Massachusetts School of Professional Psychology in adminsitration and as faculty in the doctoral clinical psychology program. He is also Senior Associate at the National Center for Mental Health and Juvenile Justice. His publication and practice areas include underserved children and families challenged by multiple adversities and at elevated risk of child welfare and/or juvenile justice system involvement.
The authors appreciatively acknowledge the research assistance of Stacey Goldstein-Dwyer, MA, LMHC at Massachusetts School of Professional Psychology in preparation of this article.
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