Child and Adolescent Trauma across the Spectrum of Experience: Research and Clinical Interventions

Abstract

This article introduces the first in a two-part special issue focusing on child and adolescent trauma across the spectrum of experience. This issue examines current research and clinical interventions specifically geared toward an array of possible traumatic events in the lives of children and adolescents. We briefly introduce the articles, which address the areas of child sexual abuse, traumatic loss, complex trauma in young children, exposure to severe natural disasters, and refugee youth mental health services. We then highlight factors that need to be accounted for in all interventions for children and adolescents impacted by trauma, including incorporating developmental, cultural, and ecological perspectives into intervention approaches.

Keywords:

• child trauma
• adolescent trauma
• ecology
• culture
• child sexual abuse
• natural disaster
• traumatic loss
• grief
• refugee youth

The topic of psychological trauma has generated extensive professional attention during the last decade, with significant basic and applied research efforts escalating in intricacy. Increasingly, issues specifically pertinent to child and adolescent trauma have been examined separately from trauma in adult populations, with the recognition that children are not merely “small adults”; instead, theory and literature have converged, suggesting that although child and adult trauma are consistent across many variables, important distinctions need to be understood and accounted for (e.g., Cook et al., 2005; Scheeringa, 2008). These are related to the types of potential traumatic experiences often encountered by children versus their adult counterparts; contextual and ecological factors associated with these events; the multiplicity of adversities experienced; symptom expression; and the modifications in developmental trajectories represented by traumatic experience, including psychobiological factors. All of these factors and many others (such as individual and unique child variables) impact overt indices of trauma, intervention approaches and strategies, and ultimately outcomes for children. Some of these issues have sparked significant debate, infused into current discussions of possible modifications to the extant Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [DSM-IV-TR], 2000) definition of posttraumatic stress disorder (PTSD). An example is the possibility of adding a new syndrome, developmental trauma disorder, to DSM-V (e.g., see American Psychiatric Association, 2010; van der kolk, 2005 for further information), to reflect developmental aspects of childhood trauma. The latter effort would lead to a fresh diagnostic outlook on child and adolescent traumatic response and a change in diagnostic decision making for clinicians. This would be a dramatic departure from the long-term reliance on the PTSD diagnostic category to capture the mental health challenges associated with trauma for both children and adults.

The current issue of the Journal of Child & Adolescent Trauma is devoted to further parsing facets of child and adolescent traumatic experiences by examining in detail current research and clinical interventions specifically geared toward an array of possible traumatic events in the lives of children and adolescents. We have undertaken this effort with the recognition that, although it is common to speak of child and adolescent trauma as a singular entity, “traumatic” experiences vary widely and intervention research has increasingly accounted for the unique characteristics associated with the spectrum of traumatic events. As noted in the brief explication of the articles later, traumatic experiences can range from discrete or acute to chronic, can involve interpersonal betrayal (as with incest) or not (as with certain disasters), can involve intense and sudden loss (e.g., death of a close family member), and can impact a child's entire ecology or be more focused yet not necessarily less severe. Some forms of trauma for children (e.g., neglect) can impact their fundamental ability to form a secure basis of primary attachment from the very start of life (e.g., Arvidson et al., this issue), while others instead disrupt already established, significant, and secure caregiving relationships, as may occur with the death of an important attachment figure such as a parent (e.g., Mannarino & Cohen, this issue). We contend that in order to develop meaningful models of trauma and effective interventions, these distinctions need to be elucidated. Indeed, as can be gleaned from the ensuing discussion, extant research has focused on intervention approaches researched independently based on trauma-specific variables. In the following we briefly introduce the articles in this special issue and then highlight some of the important factors that need to be accounted for in all interventions for children and adolescents impacted by trauma.

Articles in This Special Issue

The articles in this special issue, the first of two consecutive issues, were chosen to broadly represent the literature devoted to the spectrum of traumatic experiences. The articles focus in depth on unique factors associated with these potential traumas for children and adolescents. Although the perspectives presented represent a range of outlooks, many of the authors interweave discussion of theory as well as context, culture, and a developmental perspective into their explanations of intervention approaches and current research reviews.

We begin this issue with Olafson's excellent synthesis of literature regarding demographics, impacts, and interventions related to child sexual abuse (CSA). She distinguishes predominant risks unique to sexual abuse versus other forms of child maltreatment and highlights the diversity of experiences that can qualify as CSA, the variability in outcomes for children, and the particular type of interpersonal relationship betrayal that so often characterizes CSA, especially when it occurs by an adult known to the child. Interpersonal betrayal is often a distinctive and profoundly salient variable associated with CSA, not necessarily as prominent in other forms of significant childhood adversity, and arguably related to some of the more problematic and complex outcomes for children and adolescents. Although CSA differs in many regards from other common forms of childhood traumatic events, a noted similarity across types of extreme stress is the potential shielding effect for a child who has at least one protective caregiver devoted to his or her well-being.

Mannarino and Cohen (this issue) also address an aspect of interpersonal disruption and trauma with their discussion of traumatic loss and grief in children and adolescents. Mannarino and Cohen's groundbreaking work in the application of Cognitive-Behavioral Therapy to the treatment of child and adolescent trauma is well known (e.g., Cohen, Mannarino, & Deblinger, 2006) and has been widely accessible through web-based training (http://tfcbt.musc.edu). Here they distinguish traumatic grief and loss from child and adolescent trauma in general and discuss the challenges faced by children who lose a family member. They note that this combination of traumatic stress and loss (often with the death of a family member) uniquely characterizes Childhood Traumatic Grief (CTG). As they explain, CTG has been challenging to define, describe, and treat; therefore, their summary of distinguishing factors, research, and promising treatment paradigms is timely and a significant resource. Importantly, Mannarino and Cohen observe that a developmental paradigm has rarely been sufficiently utilized in research to date. Therefore, consensus has not yet emerged on how to recognize or evaluate posttraumatic symptoms in very young children. Consistently, at the present time, no validated assessment measure of CTG in very young children is yet available. This is an area of paramount importance in guiding the field in future efforts.

Significantly, compatible with Olafson's discussion, Mannarino and Cohen highlight the potential deleterious impact of parental negative emotional responses on outcomes for children, as represented in general trauma research. They also observe that the empirical research is yet to be forthcoming examining the associations between caregiver reaction and CTG.

Continuing with the theme of interpersonal trauma, Arvidson et al. address research on complex trauma in young children. As opposed to the articles described earlier, they specifically focus on a treatment model for addressing developmental and cultural factors when very young children are impacted by a complex array of significant stressors, which often involve severely traumatizing and chronic adversities including maltreatment. As they define it, complex trauma refers to the “dual problem of exposure and adaptation” observed in young children, which can impact the ability to form and sustain important developmental milestones, with potentially severe negative impacts on numerous critical domains of function. In a notable consistency across articles, they emphasize the importance of including the caregiving system in treatment for this population, while also underscoring the essential need to address ethnocultural factors and resources, which are not always directly integrated into intervention approaches.

The authors highlight the Attachment, Self-regulation and Competency (ARC) intervention model as a promising approach to treatment. The ARC model, as they point out, is an emerging, theoretically grounded, treatment approach, developed in partnership with the National Child Traumatic Stress Network (see Blaustein & Kinniburgh, 2010, for a more complete description of this promising intervention). The ARC model is designed to address three critical domains of function impacted in young children exposed to chronic interpersonal trauma, as noted in its title: Attachment, Self-Regulation and Developmental Competencies. The authors are able to illuminate aspects of this model by presenting clinical illustrations and preliminary evidence of effectiveness from a program evaluation conducted in the unique setting of the Alaska Child Trauma Center.

Finally, the last two articles in this issue move away form the realm of interpersonal trauma and instead involve in-depth discussions of natural disasters and refugee populations, respectively. Importantly, these situations can be quite complex, involving disruptions in the most fundamental aspects of a child's life. Often, interpersonal trauma may also be co-occurring, which can exacerbate mental health risks for a child. Both articles address the complexity of providing important mental health services while accounting for significantly compromised circumstantial factors. These “ecological” factors, such as destruction of homes and disruptions of important aspects of social life (e.g., peer groups) and social supports impact children in and of themselves but also at times impact the ability to provide services in traditional settings and/or through traditional means (e.g., stand-alone outpatient mental health clinics). In addition, many of these children have also experienced a multiplicity of other traumas including, as noted earlier, tremendous loss with associated grief. Clearly, developmental and cultural factors vary by child and situation but can profoundly impact associated outcomes as well.

Overstreet and her colleagues (this issue) present a superb review of research on clinical interventions for children postdisaster, highlighting the more salient challenges associated with effective treatment. These include the many secondary stressors co-occurring in postdisaster environments. Additionally, Overstreet et al. are able to use vignettes from Hurricane Katrina and its aftermath to exemplify many of the issues they address. As they note, the incidence of natural disasters has been rising globally and not surprisingly negative mental health effects have been linked to such events. Thus, it is critical to vigorously pursue an understanding of the factors facilitating positive child mental health outcomes and resilience even in the framework of dire circumstances and chaotic disruption. Among the many challenges is the need to have planned research ready to be rapidly implemented following disaster. This is critical if we hope for an empirical foundation for the interventions we employ in such times.

Overstreet et al. emphasize that mental health reactions of children are linked to those of their caregivers, a point repeatedly reinforced by other authors in this special issue. Similarly, in their discussion of refugee children and trauma, Ellis, Miller, Baldwin, and Abdi (this issue) draw attention to the fundamental need to integrate caregivers into treatment whenever possible. Overstreet et al., as well as Ellis et al., point to the potentially crucial roles of schools as the point of delivery for mental health interventions. Both articles also emphasize the necessity of utilizing ecologically based, culturally sensitive services, including participatory and collaborative approaches to child and adolescent interventions.

Ellis et al., in the final article in this issue, provide a thoughtful description of obstacles to mental health treatment for refugee youth and an applied approach to intervention. They describe several prominent barriers to mental health service access similar to, but distinct from, the challenges discussed by Overstreet et al. and associated strategies to address these barriers effectively. As with Overstreet and colleagues, Ellis et al. advocate a tiered approach to intervention, ranging from community education and parent outreach to intensive intervention, utilizing the Trauma Systems Therapy (TST) model. TST is a multidisciplinary approach to treatment of traumatized children and adolescents, based on a social ecological model (see Saxe, Ellis, & Kaplow, 2007 for further information). Overstreet et al., similarly, propose a tiered approach to postdisaster services, based upon a public health model, with universal programs for all children and selected treatments for those with the most profound needs for services. Ellis et al. provide a detailed description of a model program, Supporting the Health of Immigrant Families and Adolescents (Project Shifa) representing an important intervention with Somali children and their families.

Future Directions

Several variables stand out as particularly important when considering intervention for any traumatized, or potentially traumatized, child. These include the singular value of a protective, stable, and committed caregiver; developmental factors; and cultural and ecological variables. As noted earlier, the current definitional structure of PTSD in DSM-IV-TR is under review and has been critiqued with regard to its lack of developmental perspective. Some authors (e.g., Koenen, 2010) suggest that a developmental perspective is necessary even for understanding PTSD in adult populations. Fundamentally, a diversity of issues is associated with the gamut of potential traumatic stressors, implying that trauma is not uniformly experienced or expressed and that unique contextual factors must be accounted for, a view that is consistent with well-documented developmental and ecological analyses described in literature (e.g., Belsky, 1993; Freisthler, Merritt, & LaScala 2006; Lynch & Cicchetti, 1998; Zielinski & Bradshaw, 2006). For those of us who embrace the idea of empirically informed intervention, acknowledging some of the areas in which research has lagged behind need is informative and should help to inspire future efforts. This should include developing and researching developmentally adaptable paradigms. For instance, Arvidson et al. do an excellent job of embedding their intervention within a developmentally informed framework. However, much more can be done along these lines. We need to not only account for the developmental impact of traumatic stress in children but also adapt intervention approaches to be optimally useful for the range of children and adolescent presenting with treatment needs. For instance, Mannarino and Cohen emphasize that traumatic reactions are not well understood in young children. Similarly, Olafson acknowledges that assessment of CSA concerns has not reached the sophistication levels in young children that are available in latency-aged and older children, when language skills are more mature. We suggest that, regardless of intervention approach, models should be tailored for use with children at all developmental levels. This can only be accomplished by acknowledging fundamental developmental characteristics, such as expectable abilities and milestones (i.e., competencies) across a range of domains and accounting for these during treatment design, implementation, and associated research. Models can also be modified to account for those children with atypical developmental patterns, such as those associated with autism spectrum disorders, learning disorders, and intellectual disabilities. We anticipate that the next decade will bring with it substantial new research integrating numerous perspectives including developmental neurobiology, epidemiology, and psychology, all of which can inform the approaches we use to optimally intervene with children, and facilitated by a new diagnostic system that may be poised to address the traumatic reactions of a greater range of children and adolescents.

Several of the articles in this issue recognize the importance of adopting both cultural and ecological perspectives in the construction of treatment approaches. Intervention models can be designed based on known intraindividual psychological and behavioral constructs and processes. However, a number of the articles in this issue (e.g., Arvidson et al.; Ellis et al.) suggest that, although necessary, this alone is insufficient. Instead, treatment efforts are likely to suffer in the absence of implementation strategies accounting for cultural values and expectations, coping practices acceptable within the particular culture, societal roles, assumptions, and resources. Recent publications have called for a culturally informed understanding of trauma (e.g., Ford, 2008; Lewis-Fernandez et al., 2010; Zayfert, 2008). In general, this is a priority for research, which can help extend and integrate cultural conceptualizations into empirically valid treatment practices.

As noted earlier, the articles in this issue cite a significant body of literature indicating that caretaker presence and behavior is singularly linked to child mental health outcomes. This finding exemplifies the broader principle that factors outside of the individual child, in the context and ecology of his or her life, fundamentally influence treatment success. Ecological factors, aside from those related to parents, are also pertinent and can be explored with relevance to mental health outcomes for children and building resilience. We know, for instance, that some child trauma is related to loss of a caregiver. Therefore, other opportunities to support children should be available in these unfortunate circumstances or to provide extra support even when another positive parent–child relationship exists. For example, Overstreet et al. as well as Ellis et al. discuss the school as a site of intervention. Others (e.g., Tishelman, Haney, Greenwald O'Brien, & Blaustein, 2010) have explored the ecology of schools as a potential source of support for a traumatized child, rather than as simply a convenient alternative location for traditional mental health services to be conferred.

In summary, child and adolescent trauma has been studied in a number of domains in the last decade, with treatment increasingly grounded in theory and empirical research. Overall, traumatic experiences in the lives of children and adolescents are all too common, while the mental health risks are quite serious. Therefore, sophisticated intervention research should be a priority, increasingly accounting for circumstance, culture, and ecology and embedded within a strong developmental framework.