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Introduction and Foundations

At the end of this chapter, you will be able to:

• Describe the historical roots of trauma
• State how prevalent childhood trauma exposure is
• Summarize the effects of adverse childhood experiences (ACEs) on child development
• Describe dysregulation of emotions and related behaviors
• Outline the effects of ACEs on the family
• Recite the overall premise of TIPs
• Characterize effective emotion regulation as an index of resilience

Introduction

This book was initially proposed to focus on children who've been affected by trauma on mostly an individual level, such as exposure to child abuse or neglect or other forms of interpersonal violence. However, the coronavirus/COVID-19 pandemic and its consequences have ultimately impacted, either directly or indirectly, perhaps every child on Planet Earth in what is known as mass or collective trauma. This backdrop of trauma on a global scale makes this book both timely and relevant. Perhaps at no other time in history have parents needed to be supported and guided by behavioral healthcare professionals to effectively care for and nurture their children, especially if they are experiencing negative consequences of the pandemic or other types of trauma (Putnam et al., 2015). Although long overdue, this manual is in many ways "just what the doctor ordered"!

Although the term, "trauma", is generally used to refer to a significant adverse event, how an individual child has experienced the pandemic has varied, including conditions that meet formal definitions of trauma (e.g., death of a family member) as well as situations that fall short of such definitions but are nevertheless highly stressful (e.g., parental job loss and resulting financial strain). This variation highlights the need to visit the historical roots of trauma before providing a contemporary account of what is now known as adverse childhood experiences (ACEs) or developmental adversity (see Table 1.1 for other similar terms).

Table 1.1 Terminology used to label exposure to trauma and adversity during childhood and adolescencea).

a) Adapted from Childhood Adversity Narratives (Putnam et al., 2015).

Trauma in Historical Context

As with most behavioral health-related phenomena, the concept of trauma was first associated with adults rather than children. For example, the advent of the train and railway system during the late 1800s resulted in anxiety of the technology and the identification of new health disorders tied to railroad crashes, collisions, or other mishaps, such as railway spine (Trimble, 1981). In his seminal book, On Railway and Other Injuries of the Nervous System, Erichsen (1866) documented symptoms of injured train passengers, which today would be recognized as post-traumatic stress symptoms. Although the prevailing view was that such symptoms were caused by organic factors (e.g., Eulenberg, 1878), a few forward-thinking individuals speculated psychological reasons for them (e.g., Page, 1883).

Work in the early 1900s helped to validate the concept of trauma in adults. Hesnard (1914), for example, provided some of the earliest descriptions of post-traumatic stress symptoms in first responders when he investigated the effects of French ship explosions. These investigations were a precursor to the identification of shell shock in World War I military veterans. Although initially believed to be organic brain damage due to shock waves from explosions, the condition came to be ultimately understood as psychological in origin, hence the term becoming disfavored (Myers, 1915, 1940).

Influential people pre-, peri-, and post-World War II continued to shape the present understanding of trauma. Studies of World War I veterans illustrated the post-traumatic stress symptoms of those individuals exposed to combat, including physiological hyperarousal (labeled as physioneurosis by Kardiner, 1941). Combat exhaustion (i.e., psychosomatic reactions + fatigue) was identified in many World War II combat-exposed military personnel (Grinker & Spiegel, 1945), whereas concentration camp syndrome was observed by Hermann and Thygesen (1954) in former prisoners of war. Similarly, war sailor syndrome was defined in Allied Merchant Navy personnel (Askevold, 1976), who weren't physical trauma survivors but nonetheless experienced behavioral health symptoms, anxiety in particular (Hartvig, 1977).

In the 1970s, a number of syndromes associated with varied trauma exposures were examined, such as rape trauma syndrome, Vietnam War syndrome, battered woman syndrome, and abused child syndrome (Burgess & Holmstrom, 1974; Figley, 1978; Terr, 1979). In Scandinavia, studies of disasters uncovered five pathogenic factors: (a) physical injury; (b) severe danger; (c) profoundly negative experiences of witness survivors; (d) loss of close ones; and (e) responsibility trauma (Weisaeth, 1984). Although the new focus on children led to the acknowledgment of taking a developmental approach to the consequences of trauma (Terr, 1979), this emphasis was, in fact, renewed in that the earlier theorizing and writings of Freud targeted the hypothesized causal role that child sexual abuse plays in the development of behavioral health problems (Freud, 1959).

Trauma and Children: The Case of Child Abuse and Neglect

Child abuse and neglect have their historical underpinnings as far back as the first century ACE. For example, Lynch (1985) referred to writings during this period suggesting that "those caring for young children were capable of physical abuse, rejection, and neglect" (p. 7). In 1962, Kempe (1962) published what is highly regarded as the initial seminal article that jump-started the clinical and scientific field of child abuse and neglect. Dr. Kempe coined the term, battered-child syndrome, to describe the clinical condition in which children had been physically abused, typically by a primary caregiver. He was also among the first to use the term, trauma, to characterize the phenomenon and recognize its role as a significant cause of childhood disability. Today, not only does this field include physical and sexual abuse, experiences of neglect and emotional abuse also fall under this generic category (related terms include emotional maltreatment, psychological abuse, and psychological battering; Navalta et al., 2008a). As a whole, child abuse and neglect are common worldwide and are the primary problems that child protective/social services address (Djeddah et al., 2000; Jud et al., 2012).

Generally speaking, trauma refers to events or experiences that involve the possibility of or actual severe physical injury or life threat. These factors that characterize trauma are highlighted in the definition of trauma found in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5; American Psychiatric Association, 2013a). According to the definition, trauma is exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. However, this narrow focus on death, injury, or violence has been expanded both in clinical practice and research (especially with children) to include experiences that do not meet formal definitions of trauma (e.g., DSM-5), but are nevertheless quite stressful (in other words, sub-threshold traumatic experiences). In clinical circles, the term, little Ts, is sometimes used by practitioners to reference such experiences (as opposed to big Ts).

The Advent of "Adverse Childhood Experiences"

In the mid-1990s, researchers at the United States Centers for Disease Control and Prevention (CDC) collaborated with staff from a large health maintenance organization in the state of California, Kaiser Permanente, to initiate what is presently regarded as a landmark research project on identifying key social determinants of health (and health problems) during childhood and adolescence (Felitti et al., 1998). Specifically, the investigators focused on serious adversity and how such experiences influence functioning later in life. A questionnaire was devised to assess for exposure to various adversities, including abuse, witnessing domestic violence, and serious household dysfunction. Besides assessing for a wide range of abusive and neglectful...