Behind Closed Doors: Interpersonal Trauma in Early Childhood

Dianna Scholtes 2014

The word trauma tends to ignite images of war, natural disaster and terrorism which

dominate public awareness. However, practitioners believe that the most prevalent traumatic

risk occurs behind closed doors. These traumas are experienced by children in the form of

abuse, neglect, sexual violation, family violence, family dysfunction, exposure to drug and

alcohol abuse, mental health issues and/or criminality (Schneiderman et al. 1998). The

resultant trauma significantly affects a child’s social, emotional, psychological and

physiological development throughout their life course. It not only creates disruption, but

significantly impacts on the child’s ability to develop a secure attachment with their

parent/caregiver and their capacity to form new attachment relationships in the future, and

puts them at risk of developing behavioural problems and psychological disorders (Golding,

Debt, Nissim & Stott, 2006; Schneiderman et al. 1998). These risks have significant

implications for intervention approaches. For practitioners must have knowledge and

understanding of trauma, as well as being trauma-informed in order to focus on the various

challenges which traumatised children face. Thus, the importance of treating traumatised

children with up-to-date trauma-focused, evidence-informed interventions is crucial to

minimise family disruption and provide a continuum of care which meets the child’s

individualistic needs.

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American

Psychiatric Association, 2013) states that ‘trauma’ is any exposure to a major traumatic

event(s). Such exposure may include serious injury, physical or sexual violation, accidents,

natural disasters, war, traumatic death, and/or emotional abuse or neglect. Extensive literature

highlights that the exposure to traumatic events during childhood has acute detrimental

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effects which significantly affect one’s mental health and well-being (Briere & Scott, 2015;

Sanderson, 2009; Schneiderman et al. 1998).

Trauma has a history enriched with theoretical and clinical literature which has

focused on psychoanalysis and the manifestations of trauma. These trauma manifestations

have been emphasised by the likes of Alfred Binet, Jacques Lacan, Jean Martin Charcot,

Josef Breuer, Morton Prince, Pierre Janet, and Sigmund Freud (Leys, 2000). In recent years,

trauma has resurfaced in response to natural disasters, terrorism and war. This attention has

not only provoked research but established the development of appropriate diagnostic tools

and treatment interventions. Collectively, with enhanced knowledge and understanding of

childhood trauma and reporting practices, clinicians and researchers have begun to

investigate the concept of ‘interpersonal trauma’ (Sanderson, 2009).

Kuczyńska and Widera-wysoczańska (2010) state that interpersonal trauma, “is a

traumatic event that is repetitive, chronic and complex in nature, and is caused by the action

of a closely related person . . . . . in those times which are developmentally important for

her/him - and then through the juvenile years, often up to the current moment of her/his life”

(p.1). Likewise, Allen (2001) proposes that interpersonal trauma echoes Freyd’s (1996)

notion of ‘betrayal trauma’ in that it takes place within interpersonal milieus, in which a

parent/caregiver abuses their central role of providing the child with care and safety, which

fundamentally affects the attachment bond. Furthermore, Bowlby (1973) regarded

interpersonal trauma as a severe negative effect associated with the exposure and experience

of childhood abuse and neglect. Such an experience is considered as interpersonal in nature

and is associated with a specific style of attachment, usually an ambivalent, avoidant or

disorganised attachment, which is regarded as dysfunctional in nature (Ainsworth & Bell,

1970; Main & Solomon, 1990).

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 Goldberg (2000) describes the term ‘attachment’ as the emotional bond between a

child and their parent/caregiver. Such a bond provides the foundation for a child’s

development through which they learn to regulate emotions and affective responses and form

relationships with others (James, 1994; Schore, 2003). Fonagy (2005) considers this

attachment to have a vast influence on a child’s development and psychological health.

Conversely, the lack of a sufficient attachment between a child and their parent/caregiver is

largely responsible for a majority of psychological disorders. Therefore, parents/caregivers

have a significant role in the development and continuance of a child’s affect regulation,

owing to the significance of safety and distress in attachment processes (Simpson & Rholes,

1994).

And so, interpersonal trauma has a specific focus on the parent/caregiver relationship

with the developing child. Thus, Bowlby’s (1951) theory of attachment is interconnected with

interpersonal trauma and permits practitioners and researchers to focus on the developing

child and examine what is protective and what is detrimental. With this in mind, researchers

have identified a number of behaviours and psychological disorders related to interpersonal

trauma. Such behaviours and disorders may include substance abuse, self-harm,

attention-deficit hyperactivity disorder, suicidal ideation, dysregulation of affect, memory

disturbance, diminished social skills, personality disorders, anxiety disorders, depressive

disorders, bipolar disorder, dissociative disorders, schizophrenia and post-traumatic stress

disorder (Sanderson, 2009).

The literature clearly evidences that trauma in early childhood is particularly

problematic due to its effect on social, emotional, psychological and physiological

development throughout an individual’s life course (Levy & Orlans, 1998). With

Schneiderman et al. (1998) stating that traumatised children possess higher percentages of

psychopathology. Additionally, the Australian Institute of Health and Welfare (AIHW; 2013,

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p.10) confirms that in 2011-2012 that 252, 962 notifications of child abuse/neglect were

made nationally. Of those notifications, 37, 781 Australian children, aged between 0-17

years, were exposed to substantiated child abuse and neglect. Furthermore, the AIHW (2013)

found that children under the age of one were more prone to be the focus of a substantiation.

What’s more, over 50% of those substantiated were girls. Surprisingly, of the 37, 781,

substantiations reported only 19, 742 children commenced treatment and support (AIHW,

2013). Whilst AIHW (2013) evidences a decline in the number of substantiations, these

numbers are a reminder of the stark reality of what happens behind closed doors.

Extensive literature on child abuse emphasises that this type of trauma happens within

all ethnicities, races and economic classes (O’Donnell & Craney, 1992). With Briere et al.

(2015) reporting that child abuse occurs, “at the most vulnerable point in human

development” (p. 30), with the majority of onset occurring from the age of 3-8 years of age

(Finklehor, 1994). Trauma is unfortunately an everyday part of the lives of many children

thus, it is imperative that practitioners address the unique needs of these children through

trauma-informed models using evidence-informed practices.

Decades of research evidence the long-term effects associated with childhood trauma.

With Azar (2012) and Goodwin (2003) stating that 90% of childhood trauma victims have an

insecure or disorganised attachment. Therefore, due to the high proportion of insecurely or

disorganised attached individuals who present with associated behaviours and mental health

disorders, Bowlby’s (1951) attachment theory offers important insight into the development

of psychopathology and psychotherapy. Bowlby’s (1951) attachment theory proposes that a

child’s early relationships with their parent/caregiver affects one’s development and is

responsible for shaping future relationships. Accordingly, attachment theory provides a sound

developmental framework for understanding attachment relationships, and has been

commonly used by child welfare practitioners.

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 Furthermore, it has been evidenced that children tend to internalise their attachment

experiences into mental images or ‘mental models’. These mental models, in which children

create, shape their relationships later in life (NSW Department of Community Services,

2006). Fonagy (2005), states that children who experience a secure attachment with their

parent/caregiver construct mental models which include a secure, safe and kind world. One in

which they show mastery in affect regulation. Conversely, Schore (1994) states that children

who experience an insecure/disorganised attachment, have difficulty in affect regulation,

view the world as unsafe and volatile, and see themselves as undeserving of affection.

Herman (1998) and Kohut (1996) believe that the child’s experiences of trauma

during early childhood are considered to be a significant underlying dynamic in the

ontogenesis of psychopathology. Therefore, a secure attachment to one’s parent/caregiver is

the primary foundation for development. When this attachment fails the detrimental effects of

the traumatised child is evidenced through the loss of their basic sense of self, eroding their

personality structure and giving way to a fragmented sense of self.

Practitioners working with traumatised children need to be aware of the various

factors which may add to the traumatic nature of the child. These factors depend largely on

the type of trauma experienced, the timing, duration and intensity, the current environment

and available support and resources. These factors are often observable in some children,

whilst subtle in others. Factors which may be observable include maladaptive and unhelpful

beliefs, affective difficulties, avoidance strategies, emotional functioning, odd eating

behaviours, developmental delays, inappropriate modelling, posttraumatic stress disorder

and/or borderline personality disorder (Perry, 2001).

Maladaptive or unhelpful beliefs are one of the earliest impacts of interpersonal

trauma due to the internal representations of self and others. Such beliefs are constructed by

the child in relation to how they are treated by the parent/caregiver in the early attachment

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relationship. According to schema theory, these beliefs are likely to be dysfunctional if the

child has experienced abuse/neglect (Young, Klosko, & Weishaar, 2003). Such early

maladaptive schemas underlie various psychopathologies and psychological issues. Bosmans,

Braet, and Van Vlierberghe (2010), state that the relationship between psychopathology and

attachment style is mediated by these early schemas. Specifically schemas concerned with

rejection and disconnection. Such beliefs may include anger towards parents for allowing the

abuse to happen; a sense of guilt; an assumption that they are broken or damaged; fear that

others will behave differently towards them if they knew about the abuse; and/or feelings of

powerlessness (Briere & Elliott, 2003).

Additionally, children exposed to interpersonal trauma have been subjected to

overwhelming affective difficulties resultant from the acute abuse/neglect which they have

experienced. Therefore, the child’s affect regulation skills do not sufficiently develop due to

the enduring emotional pain which overwhelms their development. The self-trauma model

thus states that the affective difficulties which a traumatised individual experiences places

them at high risk of being overwhelmed by their traumatic memories. So to escape from this

pain they may use dissociation, distraction, thought suppression or other avoidance strategies

to allow them to function (Henderson, 2006).

Due to the experienced trauma, children lack the ability to modulate their own

emotions and may be hyper-responsive, and over-react to negative or stressful stimuli with

outward behaviors that calm, dull or decrease the pain, such as biting, rocking, head banging,

aggression, substance abuse, self-harm and/or bingeing or purging. Such behaviours usually

increase in times of stress (Perry, 2001; Briere, 1992; Briere & Gil, 1998).

Odd eating behaviours and food hoarding are another factor which may be noticed in

traumatised children. They may hide food in their rooms or eat like it’s their last meal. They

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may have failure to thrive, swallowing problems, or they may even vomit. Such odd eating

behaviors are frequently misdiagnosed as anorexia nervosa.

Additionally, these children display aggressive outbursts and hostility, linked to

attachment history, related to lack of empathy and remorse and poor impulse control. The

capacity for traumatised children to emotionally comprehend the impact of their behaviors on

others is significantly impaired. They often have a compelling need to hurt others less

powerful than themselves. Such aggression is usually followed by a lack of empathy and

remorse (Perry, 2001).

Developmental delays are another factor and occur due to the failed attachment bond

between the child and the parent/caregiver (Perry, 2001). Schore (1999b) states that failed or

negative attachment affects the structure of the brain. This is echoed in the developmental

psychological model in which Malekpour (2007) states that, “the developmental

psychological model clearly suggests direct links between secure attachment, development of

efficient right brain regulatory functions, and adaptive infant mental health, as well as

traumatic attachment, inefficient right brain regulatory function, and maladaptive infant

mental health” (p. 91). Furthermore, the experienced trauma affects the child’s emotional

functioning, resulting in anxiety, depression and/or safety seeking behaviours. Perry (2001)

states that safety seeking is often a behaviour evidenced by practitioners, as traumatised

children will be ‘loving’ and hug virtual strangers.

Another factor is inappropriate modelling in which abused children often have

difficulty in identifying and communicating emotions, as well boundary issues which can

lead to inappropriate sexualised behaviours. Ryan (2000a, 2000b) states that problematic

sexualised behavior may violate social norms and place the child at risk. This inappropriate

modelling may impede the child’s development and relations with others as these behaviours

are usually offensive and/or intimidating and make others uncomfortable and/or fearful.

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 Posttraumatic Stress Disorder (PTSD) is another factor evidenced in this population,

which is often attributed to attachment (Briere, 2002). The various difficulties discussed

above may impact on the development of PTSD. The Diagnostic and Statistical Manual of

Mental Disorders, 5th edition (2013) states that the major symptoms of PTSD are intrusion

symptoms such as dreams, flashbacks, distressing memories and heightened reactions that

cue the traumatic experience; avoidance of memories and stimuli; negative alterations such as

memory loss, negative outlooks, inaccurate cognitions, unhelpful emotional states,

diminished involvement in activities, feelings of disconnection, negative emotions; and

changes in reactivity and arousal such as wrathful outbursts, self-destructive behaviours,

amplified startle response, hypervigilance, attention issues and sleep difficulties (Briere et al.

2015). Extensive research constantly acknowledges the correlation between child

abuse/trauma and PTSD (Lindberg & Distad, 1985; Spila, Makara, Kozak, & Urbanska,

2008).

All of these observable factors signal the need for appropriate intervention with the

traumatised child. However, treating trauma is not easy. Significant research demonstrates

that practitioners treating traumatised children are susceptible to compassion fatigue,

vicarious trauma, burn out and secondary traumatic stress (Figley, 1995; McCann &

Pearlman, 1989). Engaging empathetically with traumatised children and listening to their

pain and helplessness can be transferred onto the practitioner and puts them at high risk of

being impacted by trauma within their role (Figley, 1995). Thus, it is imperative that

practitioners not only possess substantial knowledge and understanding of trauma, but they

recognise that treating traumatised children can have a psychological impact not only on the

client, but the practitioner themselves. As such, it is imperative that practitioners engage in

supervision, de-briefing and continuous professional development in relation to trauma and

the clients whom they see (Sanderson, 2009).

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 Furthermore, practitioners should possess a greater sense of self-awareness, allowing

them to be mindful of power dynamics and avoid re-traumatisation of the child. A sense of

self-awareness also assists in perceiving warnings to the practitioner’s well-being linked with

compassion fatigue, poor self-care, vicarious trauma, secondary traumatic stress and/or

burn-out (Figley, 1995). Additionally, practitioners treating this population are likely to

exhibit a desire to rescue the child. This practice is counter-productive to the intervention

process and thus results in counter-transference and/or transference. Thus, clinical

supervision, involvement in support networks, and continuous training are imperative to

safeguard the practitioner’s wellbeing whilst working with traumatised children (Sanderson,

2006).

In working with this population Perry (2001, 2009) states that it is critical that prompt

and professional treatment be provided to children exposed to trauma-related

psychopathology to lessen the effects of permanent impairment. Whilst most trauma-focused

interventions, focus on treating PTSD, Becker-Weidman (2006) state that trauma-exposed

children cope well when offered trauma-informed interventions. As such, extant literature

highlights evidence-based and supported intervention approaches specifically designed for

treating traumatised children (Deblinger & Heflin, 1996; Cohen, Mannarino & Deblinger,

2006). Some effective treatments are congruent with Bowlby’s (1951) attachment theory.

Alternatives for Families - A Cognitive Behavioral Therapy (AF-CBT; Kolko, 1996)

AF-CBT is an evidence-supported intervention designed for at-risk families with poor

parenting practices. This intervention is aimed at school-aged children and focusses on both

the parent/caregiver’s behaviours and the subsequent children’s behaviours and emotional

adjustment. AF-CBT is an intervention which borrows from many techniques, including

affect regulation, social skills training, behaviour management, problem-solving, cognitive

restructuring, communication and anger management.

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Attachment and Biobehavioral Catch-up (ABC; Dozier, Dozier & Manni, 2002)

ABC focusses on several matters which have been recognised as challenging with

traumatised children who have been subjected to disruptions in early life. This home based,

foster parent intervention is carried out with toddlers and foster parents/carers over ten

sessions and focusses on dysregulation. ABC is based on attachment theory and stress

neurobiology.

Attachment, Self-Regulation, and Competency (ARC; Kinniburgh, Bloustein,

Spinazzola & van der Kolk, 2005)

ARC is a comprehensive intervention used with traumatised children aged 5-17 years.

This strength-based model provides a flexible framework embedded in a social and

developmental context which focus on three core principles: attachment, self-regulation and

competency. ARC contains no set sessions, rather it is worked through at an individualistic

pace covering ten key building blocks across three core principles.

Child Centred Play Therapy (CCPT; Axline, 1989)

CCPT is a non-directive, child-led intervention which focusses on supporting young

children in overcoming issues resultant from poor attachment and development. CCPT is

grounded in person-centred, attachment and child developmental theories. CCPT sessions are

designed to create a safe environment in which the child can explore unconstrained in

self-expression, allowing them to overcome their thoughts and fears.

Child and Family Traumatic Stress Intervention (CFTSI; Berkowitz, Stover & Marans,

2010)

CFTSI is a strength-based brief intervention for traumatised children 7-18 years of

age and their parent/caregiver. This intervention is carried out immediately after disclosure of

a traumatic event in 4-6 manualised sessions with the aim of reducing traumatic stress

symptoms and PTSD. CFTSI temporarily serves as an intervention between crisis and longer

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evidence-based treatments. The aim of the intervention is to reduce early posttraumatic stress

symptoms, capitalise on protective factors, and to identify those at greater risk of needing

long-term treatment.

Child Parent Psychotherapy (CPP; Lieberman & Van Horn, 2004)

CPP is a dyadic relationship-based intervention for traumatised children from 0-5

years of age who display behavioural issues, attachment problems and/or mental health

concerns. Largely based on attachment theory CPP also integrates cognitive-behavioural,

social learning, psychodynamic, developmental and trauma theories. CPP sessions are

conducted weekly for approximately one year, with the main objective being to encourage

and improve the child-parent/caregiver attachment relationship. The focus is on learning how

to provide a safe and nurturing environment, which will assist in improving the child’s

behaviours and overall functioning.

Combined Parent-Child Cognitive-Behavioral Therapy for Families that Physically

Abuse (CPC-CBT; Runyon, Ryan, Kolar & Deblinger, 2004)

CPC-CBT is a structured therapy which can be conducted individually or in groups.

The intervention is delivered to children aged 3 -18 years and their parents/caregivers, over

16 treatment sessions. CPC-CBT is grounded in CBT and integrates features from family

systems, motivational, development and trauma theories. CPC-CBT aims to assist children

heal from traumatic experiences, lessening behavioural issues and posttraumatic stress

symptoms, whilst educating and improving parent/caregiver’s parenting skills.

Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 1989)

EMDR is a short-term intervention for traumatised children. This integrative

eight-phase approach essentially consists of the use of eye movements and/or finger taps in

children during re-collection of traumatic memories.

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Integrative Treatment of Complex Trauma for Children (ITCT-C; Lanktree & Briere,

2008)

ITCT-C is an assessment-driven treatment to treat children with psychological trauma

and often parent-child attachment issues. ITCT-C uses standardised protocols and involves

using empirically-based trauma interventions. It also comprises several treatment approaches

which includes cognitive, exposure, family and play therapy, as well as relational treatment.

It further incorporates particular approaches for treatment of trauma, including traumatic grief

therapy, trauma-focused cognitive behavioral therapy and the self-trauma model.

Parent-Child Interaction Therapy (PCIT; Eyeberg, 1988)

PCIT is a family-centred dyadic treatment for abused and at-risk children ages 2 to 8

years and their parents/caregivers. It uses an in vivo training technique to teach

parents/caregivers effective parenting skills, whilst improving children’s behaviours. PCIT is

conducted over an average of 12 -14 sessions and strengthens attachment and builds

resilience.

The Circle of Security (COS; Hoffman, Marvin, Cooper & Powell, 2006)

COS is an attachment-based intervention for parents/caregivers and children that

focusses on relationships. A central element of this intervention is the use of the COS map,

which assists parents/caregivers to learn, understand and follow a child’s cues. The COS map

illustrates a distinct connection between attachment research, child development, learning and

emotional regulation.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al. 2006)

TF-CBT is a short-term psychotherapy based, child/family-focused treatment.

Designed for traumatised children, aged 3 to 18 years. It combines CBT with behavioural

therapy, family therapy and trauma interventions to give parents/caregivers and children

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skills and education in relation to the processing and managing of trauma, as well as the

related behaviours and symptoms.

Trauma Systems Therapy (TST; Saxe, Ellis & Fogler, 2005)

TST is a phase-based treatment grounded in Bronfenbrenner’s (1979)

social-ecological model, which recognises the complexities of the child’s social environment.

It is aimed at assisting children who are struggling to regulate their emotions owing to the

interaction of their traumatic experience(s) and environmental stressors. The length of the

treatment varies based on the child’s severity level.

As evidenced, there are many evidence-based and evidence-supported interventions

which could be used with this population, some of them have been discussed above.

However, the literature highlights that TF-CBT is the most commonly used and recognised

intervention to treat the negative effects of childhood trauma. TF-CBT uses well-established

procedures which have been adapted and refined to treat childhood traumas. Furthermore,

TF-CBT literature highlights its effectiveness in various environments and cultural

backgrounds. Increased accessibility of TF-CBT, as well as increased knowledge amongst

professionals making referrals, would certainly present considerable outcomes in assisting

children to process their trauma and its associated symptoms following child abuse and/or

neglect.

Extant literature, wide-spread dissemination and several trials have shown that

TF-CBT is effective in dealing with depression, PTSD, sexualised behaviours, anxiety and

autonomy in traumatised children. With evidence further demonstrating that TF-CBT

significantly improves parenting practices (The National Child Traumatic Stress Network,

2015). TF-CBT is rated ‘1’ by several world-wide task forces and clearinghouses as being a

well-supported treatment approach with the greatest level of empirical support, and as such is

considered best practice for childhood trauma (Saunders, Berliner & Hanson, 2004).

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 Conversely, as per Damashek and Chaffin (2012), I tend to believe that there is not

one intervention approach which is suitable for all traumatised children. Therefore,

practitioners need be trauma-aware and informed, so they can deliver appropriate

interventions, which attend to the various challenges of this population across a wide array of

dimensions. Thus, it should be noted that the core components of several existing

trauma-focused treatment models are similar in approach and content. So, when treating this

population practitioners should consider if the intended approach contains the anticipated

intervention components; by what means are the components conveyed; and if the

components ‘fit’ appropriately with the particular needs of the traumatised child, taking into

consideration age, culture and developmental level (Damashek et al. 2012).

The literature highlights that trauma exposure is viewed by society as being relatively

limited however, trauma is much more prevalent, especially behind closed doors. As has been

highlighted throughout the paper attachment insecurity is a key attribute of psychopathology,

with insecure or disorganised attachment associated with a wide range of disorders,

highlighting how one’s experiences in childhood shape the immediate and future health of the

child. Therefore, in preparing this paper, I have learnt that when treating traumatised children

it is imperative to take into account that the problematic behaviours often displayed by the

child are actually coping behaviours, resultant from the child’s experience of trauma and the

chaotic way of life that they have experienced.

Interpersonal trauma is thus a significant issue for the children in which practitioners

treat. Therefore, it is essential that in working with this population I have current, up-to-date

knowledge of and understanding of definitions, pervasiveness, treatments and effects of

childhood trauma. I need to recognise the difference between evidence-informed,

trauma-focused interventions and those that are not, and implement or refer the child to

appropriate interventions which meet their individualistic needs. Furthermore, I need to have

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the ability to step back and examine with open, objective eyes, my own processes and take

time to ensure my own well-being in treating this specific population.

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