Forgotten Victims: Infants and Toddlers Who Witness Violence and Trauma

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Forgotten Victims Infants and Toddlers Who
Witness Violence and Trauma

• Briana S. Nelson, Ph.D., LCMFTKansas State
  UniversityMarriage Family Therapy
  ProgramSchool of Family Studies Human Services
• bnelson_at_ksu.edu 785-532-1490

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Psychological trauma is an affliction of the
powerless. At the moment of trauma, the victim
is rendered helpless by overwhelming force. When
the force is that of nature, we speak of
disasters. When the force is that of other human
beings, we speak of atrocities. Traumatic events
overwhelm the ordinary systems of care that give
people a sense of control, connection, and
meaning. -Herman, 1997
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Objectives

• To understand the impact of witnessing violence
  and trauma on infants and toddlers
• To identify the immediate and long-term effects
  on infants and toddlers exposed to trauma and
  abuse
• To gain knowledge of effective methods for
  identifying and working with infants and toddlers
  who may be traumatized

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Assumptions about Child Development

• Children do not develop in isolation they
  develop within the context of human systems
• Children both influence and are influenced by the
  systems in which they are members
• It is necessary to develop a conceptualization of
  the systemic effects when a child is
  trauma-exposed or traumatized

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What is trauma?

• ... the development of characteristic
  symptoms following exposure to an extreme
  traumatic stressor involving direct personal
  experience of an event that involves actual or
  threatened death or serious injury, or other
  threat to ones physical integrity or witnessing
  an event that involves death, injury, or a threat
  to the physical integrity of another person or
  learning about unexpected or violent death,
  serious harm, or threat of death or injury
  experienced by a family member or other close
  associate (DSM-IV,
  1994, p. 424)

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• Traumatic events that are experienced directly
  by children include, but are not limited to
• violent personal assault (sexual abuse or
  assault, physical abuse, robbery, mugging)
• being kidnapped or taken hostage
• terrorist attack
• school violence
• torture
• war
• natural or human disasters
• severe accidents
• being diagnosed with a life-threatening illness
  
  (DSM-IV, p. 424)

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• Witnessed events include, but are not limited
  to, observing the serious injury or unnatural
  death of another person due to violent assault,
  accident, war, or disaster...
• Events experienced by others that are learned
  about include violent personal assault, serious
  accident, or serious injury experienced by a
  family member or a close friend learning about
  the sudden, unexpected death of a family member
  or a close friend or learning that ones child
  has a life-threatening disease.
• (DSM-IV, p. 424)

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Every day in America...

• 6 children commit suicide
• 8 children are homicide victims
• 11 children are killed by firearms
• 76 babies die
• 131 children are reported as abused or neglected
• Childrens Defense Fund, 2001 report

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• In 1998, 2.9 million children were reported as
  abused or neglected in the US (903,000 confirmed)
• An estimated 1,100 children died as a result of
  abuse or neglect in 1998 (78 were lt5 y/o)
• A conservative estimate is that over 5 million
  children are exposed to traumatic events every
  year
• 1/3 of physical abuse victims are less than one
  year old
• Current estimates of PTSD rates in children range
  from 0-95 (average rate 37)

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But it doesnt happen to Kansas children...

• Every 13 minutes a child is reported abused or
  neglected
• 6,790 cases of child abuse or neglect were
  substantiated in 1998 (gt2x the 1995 rate)
• Every 7 days, 3 children die under 14 years of age

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Who is affected when a child is traumatized?
Larger Society Social Environment
Extended Family
Immediate Family

• Child

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How is a child affected when the system is
traumatized?
Larger Society Social Environment
Extended Family
Immediate Family

• Child

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Characteristics of Childhood Traumas

• Acute vs. Chronic
• Single event vs. multiple events
• Age of onset
• Relationship to perpetrator
• Adult vs. peer perpetrator
• Intrafamilial vs. extrafamilial
• Parental response

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Cycle of Violence
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Characteristics that Distinguish Traumatic from
Normative Stressors

• the amount of time one has to prepare
• previous experience with the stressor
• sources of guidance/support available
• the extent to which others have experienced the
  event
• the amount of time in a crisis state
• sense of loss of control or helplessness
• sense of loss
• disruption and destruction

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• danger experienced by those exposed to the event
• emotional impact of the event
• medical problems associated with exposure to the
  event
• personal role in the stressor event
• pretrauma vulnerability
• intensity and duration of the event
• postevent responses

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Early Intervention in At-Risk Families
Recognizing Childrens Reactions to Abuse and
Trauma

• Cognition
• Affect
• Interpersonal relations
• Behavior
• Symptom formation
• Spiritual/moral

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Effects specific to preschool-age children

• Children typically only develop verbal memory of
  a traumatic event between 2 ½ to 3 years of age
• Even then, most recollections are spotty and
  incomplete
• Most common symptoms reported in younger victims
  of trauma fall under the category of behavioral
  effects, rather than cognitive symptoms

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Effects specific to preschool-age children

• withdrawal
• reenactments and play involving traumatic themes
• anxious attachment behaviors/separation fears
• regression to previous levels of developmental
  functioning
• disruptions in sleeping and toileting
• startle responses/freezing behaviors

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• repeated retelling of traumatic event
• increased aggressive, anti-social, and
  hyperactive behaviors
• changes in behavior, mood, personality
• general or trauma-specific fears
• psychosomatic symptoms

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Effects specific to school-age children

• decline in school performance
• increased inner behaviors
• repeated retelling of traumatic event
• isolation of affect
• constant anxious arousal/hypervigilance
• fearfulness/fear of recurrence
• sleep disturbances
• behavioral problems
• regression to previous levels of developmental
  functioning

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• visual image and traumatic memory intrusion
• problems relating to peers
• more elaborate reenactments
• psychosomatic symptoms
• loss of interest in pleasurable activities
• feelings of personal responsibility

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Effects specific to adolescents

• acting-out behavior
• self-criticism
• fear of repetition of event in the future
• efforts to avoid overwhelming feelings
• hypervigilance
• social withdrawal
• thoughts of revenge and action-oriented responses
  to trauma
• acute awareness and distress related to intrusive
  trauma images and memories
• increased vulnerability to psychiatric disorders
• flight into adulthood

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The 3 Rs of Trauma Recovery

• Reliving
• Releasing
• Reorganizing
• (Johnson, 1998)

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Long-term Consequences The Adult Survivor

• Many adults continue to be affected by traumatic
  experiences in childhood and adolescence
• Often the connection between early experiences
  and continuous cycles of problematic behavior are
  not recognized
• Traumatized child--Traumatized parent?

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Family System Effects

• Parents may constantly search for ways to make
  sense of or explain the traumatic event their
  child has experienced
• Often attempt to reduce their sense of
  helplessness or lack of power
• The family may serve as a resource for increased
  support and coping or an obstacle that blocks the
  traumatized childs adjustment and recovery
• Trauma membrane

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• Parental reaction to the childs trauma is of
  primary importance in dealing with trauma in
  children
• The reactions of parents or significant others
  may have a greater negative impact on children
  than the childrens own direct exposure or
  severity of their trauma experiences
• When parents or caretakers are distressed, it may
  impede their ability to assist their children
  with their own stress reactions

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• Parents who must deal with the sudden
  traumatization of someone they love who must
  cope with the physical, emotional, and behavioral
  changes that often follow trauma and who must
  face their own uncertainty and personal
  vulnerability are clearly candidates
  forsecondary traumatization (Barnes, 1998, p.
  76)

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• It is important to note the familys current
  level of adaptation and the amount of disruption
  caused by trauma
• If parents have different reactions or coping
  styles, a cycle of tension may occur in the
  couple relationship that negatively affects the
  child
• Some parents may be overwhelmed by the traumatic
  event and minimize the effects on themselves
  and/or their child

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• Parents who are able to manage and regulate their
  reactions to traumatic events will be more likely
  to effectively support and protect their child in
  his/her recovery

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Impact of Parental Trauma on Children

• Children may experience secondary traumatic
  stress as a result of parental traumatization,
  through
• Direct witnessing of a parents trauma (e.g.,
  domestic violence, sexual assault)
• Direct experiencing of the post-traumatic
  reactions of symptoms in the parent (e.g.,
  nightmares, flashbacks, startle responses)

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Impact of Childrens Trauma on Other Subsystems

• Siblings of traumatized children may experience
  feelings of guilt, fear, anxiety, and secondary
  trauma symptoms
• Surprisingly, the issue of sibling abuse has been
  relatively unaddressed in clinical and empirical
  literature
• Because of the impact of the childs trauma on
  parents, secondary stress reactions in siblings
  may be overlooked or ignored

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• In taking an ecological perspective of trauma,
  the circle of impact should be expanded beyond
  the immediate family system
• Symptoms present in a traumatized child can
  affect those with whom the child interacts at all
  system levels

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Resiliency

• Certain individuals manage to succeed in spite of
  the odds
• Interplay between the childs basic traits and
  the environment
• Post-traumatic growth

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Resiliency Factors

• Personality factors
• Agreeable
• Social
• Compassionate
• Internal locus of control
• Cognitive factors
• Creativity
• Insight
• Initiative
• World-view beyond trauma

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• Affective factors
• Ability to manage affective reactions
• Broad range of emotions
• Sense of humor
• Behavioral factors
• Persistence
• Ability to generate relationships with peers and
  adults
• Resourcefulness
• Ability to self-soothe

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Secondary Traumatic Stress

• Secondary Traumatic Stress (STS) is the
  experience of tension and distress directly
  related to the demands of living with and caring
  for someone who displays the symptoms of
  post-traumatic stress disorder (PTSD) (Figley,
  1998)
• Because of the emotional connection, being in
  close, prolonged contact with a traumatized
  person becomes a constant stressor
• Family members and professionals often experience
  symptoms of traumatization

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• Also referred to as compassion fatigue, vicarious
  traumatization, trauma transmission, burnout
• Symptoms communicable infect mimic
• Symptoms are considered secondary because they
  occur in those who have not directly experienced
  the event.
• May resemble PTSD-like symptoms, but may be less
  intense
• Therapists may not be aware of or they may deny
  secondary trauma effects
• Savior/Rescuer

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Secondary trauma in professionals may include the
following

• Sharing the survivors nightmares
• Sharing the hopelessness of survivors
• Feelings of aggression
• Confronting ones own vulnerability and moral
  values
• Feelings of numbing and avoidance
• Victim blaming/dehumanizing
• Other PTSD-like symptoms

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Secondary Traumatic Stress Guidelines

• Professionals should acknowledge the effects of
  secondary trauma on themselves and their
  colleagues and take regular, ongoing actions to
  insure the welfare of professionals and to
  preserve their ability to deliver quality
  services
• Professionals should not work alone but instead
  should seek out or create arrangements in which
  they have regular and open input from other
  professionals regarding the effects of secondary
  trauma and its impact on the services they
  deliver,
• Professionals should recognize an ethical duty to
  self care (Munroe, 1995)

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Suggestions for Parents and Child Care Workers

• Recognize the value of multiple perspectives
• Watch and listen to the children
• Use development as a guide for action with adult
  and child
• Identify factors related to poor growth, learning
  and relationships within the family system and
  work for change in the system
• Help promote strengths and find opportunities to
  increase resiliency in children

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Where do we go from here?

• More prevention will reduce the need for
  intervention
• Training non-mental health professionals
• Recognizing potentially traumatic events
• Societal awareness and education

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• When one thinks about how a traumatic event
  impacts one child and then begins to piece
  together the number of people with whom that one
  child has contact throughout his or her life, the
  realization that a single event does not have a
  single victim becomes clear. The repercussions
  from trauma are infinite. Beginning to identify
  and understand these repercussions on traumatized
  children is critical to prevent further loss of
  innocence.

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Recommended References

• Barnes, M. F. (1998). Understanding the secondary
  traumatic stress of parents. In C. R. Figley
  (Ed.), Burnout in families The systemic costs of
  caring (pp. 75-89). Boca Raton, FL CRC Press.
• Herman, J. L. (1997). Trauma and recovery (2nd
  edition). New York BasicBooks
• Johnson, K. (1998). Trauma in the lives of
  children Crisis and stress management techniques
  for teachers, counselors, and student service
  professionals (2nd edition). Alameda, CA
  Hunter House.
• Monahon, C. (1993). Children and trauma A
  guide for parents and professionals. San
  Francisco Jossey-Bass.
• Nelson, B. S., Schwerdtfeger, K. L. (2002). The
  systemic impact of traumatized children. In D.
  Catherall (Ed.), Handbook of stress, trauma, and
  the family. Washington DC American Psychological
  Association. (Peer-reviewed chapter submitted for
  publication revise and resubmit).
• Pynoos, R. S., Steinberg, A. M., Goenjian, A.
  (1996). Traumatic stress in childhood and
  adolescence Recent developments and current
  controversies. In B. A. van der Kolk, A. C.
  McFarlane, L. Weisaeth (Eds.), Traumatic
  stress The effects of overwhelming experience on
  mind, body, and society (pp. 331-358). New York
  Guilford.