Forgotten Victims Infants and Toddlers Who Witness Violence

Forgotten Victims: Infants and Toddlers Who Witness Violence and Trauma Briana S. Nelson, Ph. D. , LCMFT Kansas State University Marriage & Family Therapy Program School of Family Studies & Human Services bnelson@ksu. edu 785 -532 -1490

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

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

Assumptions about Child Development l l l 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

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 one’s 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)

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)

“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 one’s child has a life-threatening disease. ” (DSM-IV, p. 424)

Every day in America. . . l l l 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 Children’s Defense Fund, 2001 report

l l l 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 <5 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%)

But it doesn’t happen to Kansas children. . . l l l Every 13 minutes a child is reported abused or neglected 6, 790 cases of child abuse or neglect were substantiated in 1998 (>2 x the 1995 rate) Every 7 days, 3 children die under 14 years of age

Who is affected when a child is traumatized? Child

How is a child affected when the system is traumatized? Child

Characteristics of Childhood Traumas l l l l Acute vs. Chronic Single event vs. multiple events Age of onset Relationship to “perpetrator” Adult vs. peer perpetrator Intrafamilial vs. extrafamilial Parental response

Cycle of Violence

Characteristics that Distinguish Traumatic from Normative Stressors l l l l 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

l l l l 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

Early Intervention in At-Risk Families: Recognizing Children’s Reactions to Abuse and Trauma l Cognition l Affect l Interpersonal relations l Behavior l Symptom formation l Spiritual/moral

Effects specific to preschool-age children l l l 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

Effects specific to preschool-age children l l l 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

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

Effects specific to school-age children l l l l l 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

l l l 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

Effects specific to adolescents l l l l l 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

The 3 R’s of Trauma Recovery l Reliving l Releasing l Reorganizing (Johnson, 1998)

Long-term Consequences: The Adult Survivor l l l 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?

Family System Effects l l 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 child’s adjustment and recovery “Trauma membrane”

l l l Parental reaction to the child’s 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 children’s 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

l “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 for…secondary traumatization” (Barnes, 1998, p. 76)

l It is important to note the family’s 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

l 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

Impact of Parental Trauma on Children l Children may experience secondary traumatic stress as a result of parental traumatization, through: • Direct witnessing of a parent’s 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)

Impact of Children’s Trauma on Other Subsystems l l l 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 child’s trauma on parents, secondary stress reactions in siblings may be overlooked or ignored

l l 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

Resiliency l l l Certain individuals manage to succeed in spite of the odds Interplay between the child’s basic traits and the environment Post-traumatic growth

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

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

Secondary Traumatic Stress l l l “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 posttraumatic 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

l l l 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”

Secondary trauma in professionals may include the following: • Sharing the survivors’ nightmares • Sharing the hopelessness of survivors • Feelings of aggression • Confronting one’s own vulnerability and moral values • Feelings of numbing and avoidance • Victim blaming/dehumanizing • Other PTSD-like symptoms

Secondary Traumatic Stress Guidelines l 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; l 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, l Professionals should recognize an ethical duty to self care (Munroe, 1995)

Suggestions for Parents and Child Care Workers l l l 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

Where do we go from here? l l More prevention will reduce the need for intervention Training non-mental health professionals Recognizing potentially traumatic events Societal awareness and education

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.

Recommended References l l l 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 (2 nd edition). New York: Basic. Books Johnson, K. (1998). Trauma in the lives of children: Crisis and stress management techniques for teachers, counselors, and student service professionals (2 nd 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. Mc. Farlane, & L. Weisaeth (Eds. ), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 331 -358). New York: Guilford.