Developing a Trauma-Informed Therapeutic Service in the Australian Capital Territory for Children and Young People Affected by Abuse and Neglect

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Child Development and the Impact of Early Trauma

Children exposed to complex trauma can experience lifelong problems that place them at risk of further difficulties, including psychiatric and addictive disorders, chronic medical illnesses and legal, vocational, and family problems. These difficulties may extend from childhood through adolescence and into adulthood (Cook et al., 2005).

Child development is commonly broken down into four stages: prenatal, early childhood (infant, toddler and preschool), middle childhood, and adolescence. At each stage of development, children have various age and stage salient tasks to achieve in order to become a fully functioning human being. Chronic maltreatment and trauma interferes with neurological development and the capacity of the brain to integrate ‘sensory, emotional and cognitive information into a cohesive whole’ (van der Kolk, 2005:3). This can then impact on the ability of a child to master the major tasks faced at each developmental stage, potentially leading to developmental delays or disorders (Department of Human Services, 2007).
Prenatal: During prenatal development, the unborn child needs nourishment and a safe environment in order to survive and develop. Maternal stress and heightened emotional expression can impact negatively on the unborn child as it can release stress hormones which pass through the placenta (Wolkind, 1981). It has been demonstrated through research that prenatal exposure to various substances has negative effects on prenatal development, leading to physical abnormalities, reduced birth weight and size along with language and learning delays (Dozier, Albus, Fisher & Sepulveda, 2002).
Children 0–5 years: Trauma can lead to a disturbance of general functioning (e.g. sleeping, feeding and overall irritability, or withdrawal and lack of responsiveness) as well as a possible regression of acquired fine motor skills and acquired communication skills. Exposure to trauma can manifest itself in behavioural changes, such as regressing to the behaviour of a younger child and losing previously acquired skills, increased tension, irritability, an inability to relax, increased startle response and sleeping and eating disruptions. The overall neurological impact could lead to cognitive delays and memory difficulties, loss of acquired communication skills and insecure/disorganised attachment behaviour (Department of Human Services, 2007).
Children 6–12 years: The physiological responses can be similar to those described above, but may also include the disturbance of specific skills, e.g. social skills, communication skills, the ability to interpret the emotions/behaviours of others, and the development of a poor sense of self and identity. The impact of abuse and neglect on identity formation is particularly significant, as children of this age will often believe that the abuse is their fault, that they are an inherently bad child and thus develop a negative sense of self and internal working model; which without appropriate therapeutic support may persist through adolescence and into adulthood.
Adolescents 13–19 years: In adolescents, the manifestations can be less understood, given the presence of puberty and the behavioural changes that puberty can incur. Longer term outcomes include problems in interpersonal relationships, emotional dysregulation, ongoing vulnerability to stress and impaired sense of self.
As consistently outlined in the evidence, prolonged exposure to these circumstances and overwhelming stressful events can lead to ‘toxic stress’, which changes the child’s brain development (due to the constant flooding of cortisol and adrenalin to the brain), sensitises them to further stress, can lead to heightened activity levels and affect learning and concentration levels (Department of Human Services, 2007).

Key Theoretical Frameworks

The impact of child abuse and neglect on a child’s wellbeing is complex and requires a thorough understanding of child development, attachment and trauma theory. The extent to which a child is supported by their wider ecosystem (family, school, community) is also integral to understanding the cumulative impact of child abuse and neglect on a child or young person as well as planning for recovery.

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Attachment

Child Abuse

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Neglect

Trauma

The Neurobiology of Trauma

The neurobiology of trauma builds on the aforementioned knowledge of the impact of abuse and neglect on a child’s development. The brain develops in a sequential fashion from the ‘bottom up’, from the least (brainstem) to the most complex (limbic, cortical). Each of the four main regions of the brain (brainstem, diencephalon, limbic system and cortex) has a differing function and become fully functional at different times during childhood (Perry, 2009:242). Therefore if an impairment occurs in utero (due to exposure to alcohol for example) or in early childhood (due to trauma) this can affect the sequential development of other parts of the brain and/or lead to a range of abnormalities or deficits in function.

The literature also indicates that the ‘organising, sensitive brain of an infant or young child is more malleable to an experience than a mature brain’ (Perry, 2009). Therefore, any adverse or prolonged traumatic experience is likely to greatly affect the structure of an infant’s brain. Conversely, it is quite feasible to assume that children can still be helped with sensitive and nurturing care-giving and positive experiences regardless of the severity and chronic nature of the maltreatment — if it is introduced early in life whilst the brain is still malleable and adaptive (Perry, 2009).
Therapeutic interventions which focus on the neurobiology of trauma, including Perry’s (2009) Neurosequential Model of Therapeutics, look to implement therapeutic interventions based on the developmental age of the child. This requires a thorough assessment of a child’s social, emotional and cognitive stage as well as an understanding of the age at which the trauma occurred, in order to determine the parts of the brain that are likely to have been compromised as a result of the trauma experienced.

Attachment/Trauma Theories

Attachment is a general term that describes the state and quality of an individual’s emotional ties to another. Attachment theory is a theory of child development that focuses on the quality of children’s early relationships with their parents or caregivers and the profound influence these have on children’s social and emotional development (Evolve Therapeutic Services Framework, 2012).

Frederico, Jackson and Black (2005) postulate that a major learning from trauma theory is the understanding that those who have been traumatised are trying to survive, even if their presentation and behaviours appear contrary to this. This is evident where the child/young person experiences extreme anxiety, and then compensates for a lack of security by attempting to control all elements of their environment. Typical examples of these types of behaviours include aggression, distress in response to change and uncertainty, non-compliance, controlling behaviours with peers and family members, and defiant behaviours.
Attachment theory provides the framework for understanding the effects of early abuse, neglect, separation and loss. Each child requires the experience of a relationship with a significant parenting figure who will provide them with their first sense of self, and experience them as a worthwhile person (Hughes, 2007). This relationship also provides the child with a ‘secure base’, from which the child is able to safely explore the world knowing that someone is protecting them and keeping them in mind (Hoffman, Marvin , Cooper & Powell, 2006).
The way an infant/child relates to new caregivers or adult figures can be heavily influenced by how the child learnt to relate to birth parents early in life. During this early stage of development, infants and toddlers are wholly dependent on their parents to meet their physical and psychological needs. As an infant’s overwhelming need is towards attachment, the infant will accommodate to the parenting style they experience (Department of Human Services, 2007). When faced with chronic stress, uncertainty, inconsistent care-giving and persistent frightening experiences, infants and young children will adapt using the body’s survival mechanisms – the autonomic nervous system will become activated and switch to the freeze/fight/flight response (Department of Human Services, 2007). When the body is in this state, the brain is flooded with cortisol and adrenalin, leaving the child feeling and looking agitated or hypervigilant. Alternatively infants may display ‘frozen watchfulness’.
When the first years of a child’s life are characterised by experiences of loss, trauma and disruption, the child’s capacity to develop secure attachment relationships as well as their capacity to later form attachments with a new carer, are significantly impacted (Golding, 2006). Interventions that are attachment focused assist parents/carers develop their understanding of the importance of attachment. For example, this may be characterised by parents/carers resisting responding to a child as the child is anticipating and instead, responding to the child in a more meaningful and attuned way. This will allow or enable the child to begin to experience a more secure attachment relationship than previously (Golding, 2008).

Systems Theory

Taking a systemic focus means that emphasis is placed on intervening with the system rather than focusing solely on the individual. Ecological and family systems theories provide a framework for understanding this type of practice. Ecological Systems Theory (Bronfenbrenner, 1979) considers a child’s development within the context of the system of relationships that forms his or her environment and recognises that each part of the system impacts all other parts. Structural factors such as poverty, social isolation, and access to education and essential services are therefore considered in the application of this theory and are seen as factors that require strengthening, in order to enhance positive outcomes for a child. Any intervention therefore, needs to focus not only on the child but also supporting the child’s relationship with their parents, carers, and siblings and strengthening connections to their school, community and wider service sector.

Grief and Loss

Grief and loss is an integral feature of the lives of children/young people in care. Understanding the grief and loss experienced through both loss of family of origin, and often, the multiple transitions and changes that children in care have experienced, is important in the universality of the experience. For Aboriginal and Torres Strait Islander children/young people, grief and loss is referred to as ‘sorry business’ that affects not only the family but the whole of the community (Evolve Therapeutic Services Framework, 2012).

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