Complex Trauma and its Effects on Children

Complex trauma describes both children's exposure to multiple traumatic events—often of an invasive, interpersonal nature—and the wide-ranging, long-term impact of this exposure. These events are severe and pervasive, such as abuse or profound neglect. They usually occur early in life and can disrupt many aspects of the child's development and the very formation of a sense of self. Since these events often occur with a caregiver, they interfere with the child's ability to form a secure attachment. Many aspects of a child's healthy physical and mental development rely on this primary source of safety and stability.

Effects

Children whose families and homes do not provide consistent safety, comfort, and protection may develop ways of coping that allow them to survive and function day to day. For instance, they may be overly sensitive to the moods of others, always watching to figure out what the adults around them are feeling and how they will behave. They may withhold their own emotions from others, never letting them see when they are afraid, sad, or angry. These kinds of learned adaptations make sense when physical and/or emotional threats are ever-present. As a child grows up and encounters situations and relationships that are safe, these adaptations are no longer helpful, and may in fact be counterproductive and interfere with the capacity to live, love, and be loved.

Complex trauma can affect children in a multitude of ways. Below are some common effects.

Attachment and Relationships

The importance of a child's close relationship with a caregiver cannot be overestimated. Through relationships with important attachment figures, children learn to trust others, regulate their emotions, and interact with the world; they develop a sense of the world as safe or unsafe, and come to understand their own value as individuals. When those relationships are unstable or unpredictable, children learn that they cannot rely on others to help them. When primary caregivers exploit and abuse a child, the child learns that he or she is bad and the world is a terrible place.

The majority of abused or neglected children have difficulty developing a strong, healthy attachment to a caregiver. Children who do not have healthy attachments have been shown to be more vulnerable to stress. They have trouble controlling and expressing emotions, and may react violently or inappropriately to situations. One's ability to develop healthy, supportive relationships with friends and significant others depends on having first developed those kinds of relationships in one's family. A child with a complex trauma history may have problems in romantic relationships, in friendships, and with authority figures, such as teachers or police officers.

Physical Health: Body and Brain

From infancy through adolescence, the body's biology develops. Normal biological function is partly determined by environment. When a child grows up afraid or under constant or extreme stress, the immune system and body's stress response systems may not develop normally. Later on, when the child or adult is exposed to even ordinary levels of stress, these systems may automatically respond as if the individual is under extreme stress. For example, an individual may experience significant physiological reactivity such as rapid breathing or heart pounding, or may "shut down" entirely when presented with stressful situations. These responses, while adaptive when faced with a significant threat, are out of proportion in the context of normal stress and are often perceived by others as "overreacting" or as unresponsiveness or detachment.

Stress in an environment can impair the development of the brain and nervous system. An absence of mental stimulation in neglectful environments may limit the brain from developing to its full potential. Children with complex-trauma histories may develop chronic or recurrent physical complaints, such as headaches or stomachaches. Adults with histories of trauma in childhood have been shown to have more chronic physical conditions and problems. They may engage in risky behaviors that compound these conditions (e.g. smoking, substance use, and diet and exercise habits that lead to obesity).

Complexly traumatized youth frequently suffer from body dysregulation, meaning they overrespond or underrespond to sensory stimuli. For example, they may be hypersensitive to sounds, smells, touch, or light, or they may suffer from anesthesia and analgesia, in which they are unaware of pain, touch, or internal physical sensations. As a result, they may injure themselves without feeling pain, suffer from physical problems without being aware of them, or the converse—they may complain of chronic pain in various body areas for which no physical cause can be found.

Emotional Responses

Children who have experienced complex trauma often have difficulty identifying, expressing, and managing emotions, and may have limited language for feeling states. They often internalize or externalize stress reactions and as a result may experience significant depression, anxiety, or anger. Their emotional responses may be unpredictable or explosive. A child may react to a reminder of a traumatic event with trembling, anger, sadness, or avoidance. For a child with a complex-trauma history, reminders of various traumatic events may be everywhere in the environment. Such a child may react often, react powerfully, and have difficulty calming down when upset. Since the traumas are often of an interpersonal nature, even mildly stressful interactions with others may serve as trauma reminders and trigger intense emotional responses. Having learned that the world is a dangerous place where even loved ones can't be trusted to protect them, children are often vigilant and guarded in their interactions with others and are more likely to perceive situations as stressful or dangerous. While this defensive posture is protective when an individual is under attack, it becomes problematic in situations that do not warrant such intense reactions. Alternately, many children also learn to "tune out" (emotional numbing) to threats in their environment, making them vulnerable to revictimization.

Difficulty managing emotions is pervasive and occurs in the absence of relationships as well. Having never learned how to calm themselves down once they are upset, many of these children become easily overwhelmed. For example, in school they may become so frustrated that they give up on even small tasks that present a challenge. Children who have experienced early and intense traumatic events also have an increased likelihood of being fearful all the time and in many situations. They are more likely to experience depression as well.

Dissociation

Dissociation is often seen in children with histories of complex trauma. When children encounter an overwhelming and terrifying experience, they may dissociate, or mentally separate themselves from the experience. They may perceive themselves as detached from their bodies, on the ceiling, or somewhere else in the room watching what is happening to their bodies. They may feel as if they are in a dream or some altered state that is not quite real or as if the experience is happening to someone else. Alternatively, they may lose all memories or sense of the experiences having happened to them, resulting in gaps in time or even gaps in their personal history. At its extreme, a child may cut off or lose touch with various aspects of the self.

Although children may not be able to purposely dissociate, once they have learned to dissociate as a defense mechanism they may automatically dissociate during other stressful situations or when faced with trauma reminders. Dissociation can affect a child's ability to be fully present in activities of daily life and can significantly fracture a child's sense of time and continuity. As a result, it can have adverse effects on learning, classroom behavior, and social interactions. It is not always evident to others that a child is dissociating, and at times it may appear as if the child is simply "spacing out," daydreaming, or not paying attention.

Behavior

A child with a complex trauma history may be easily triggered or "set off" and is more likely to react very intensely. The child may struggle with self-regulation (i.e. knowing how to calm down) and may lack impulse control or the ability to think through consequences before acting. As a result, complexly traumatized children may behave in ways that appear unpredictable, oppositional, volatile, and extreme. A child who feels powerless or who grew up fearing an abusive authority figure may react defensively and aggressively in response to perceived blame or attack, or alternately, may at times be overcontrolled, rigid, and unusually compliant with adults. If a child dissociates often, this will also affect behavior. Such a child may seem "spacey," detached, distant, or out of touch with reality. Complexly traumatized children are more likely to engage in high-risk behaviors, such as self-harm, unsafe sexual practices, and excessive risk-taking such as operating a vehicle at high speeds. They may also engage in illegal activities, such as alcohol and substance use, assaulting others, stealing, running away, or prostitution, thereby making it more likely that they will enter the juvenile justice system.

Cognition: Thinking and Learning

Children with complex trauma histories may have problems thinking clearly, reasoning, or problem-solving. They may be unable to plan ahead, anticipate the future, and act accordingly. When children grow up under conditions of constant threat, all their internal resources go toward survival. When their bodies and minds have learned to be in chronic stress response mode, they may have trouble thinking a problem through calmly and considering multiple alternatives. They may find it hard to acquire new skills or take in new information. They may struggle with sustaining attention or curiosity or be distracted by reactions to trauma reminders. They may show deficits in language development and abstract reasoning skills. Many children who have experienced complex trauma have learning difficulties that may require support in the academic environment.

Self-Concept and Future Orientation

Children learn their self-worth from the reactions of others, particularly those closest to them. Caregivers have the greatest influence on a child's sense of self-worth and value. Abuse and neglect make a child feel worthless and despondent. A child who is abused will often blame him or herself. It may feel safer to blame oneself than to recognize the parent as unreliable and dangerous. Shame, guilt, low self-esteem, and a poor self-image are common among children with complex-trauma histories.

To plan for the future with a sense of hope and purpose, a child needs to value him or herself. To plan for the future requires a sense of hope, control, and the ability to see one's own actions as having meaning and value. Children surrounded by violence in their homes and communities learn from an early age that they cannot trust, that the world is not safe, and that they are powerless to change their circumstances. Beliefs about themselves, others, and the world diminish their sense of competency. Their negative expectations interfere with positive problem-solving and foreclose on opportunities to make a difference in their own lives. A complexly traumatized child may view him or herself as powerless or "damaged," and may perceive the world as a meaningless place in which planning and positive action is futile. The child has trouble feeling hopeful. Having learned to operate in "survival mode," the child lives from moment to moment without pausing to think about, plan for, or even dream about a future.

Long-Term Health Consequences

Traumatic experiences in childhood have been linked to increased medical conditions throughout the individuals' lives. The Adverse Childhood Experiences (ACE) Study is a longitudinal study that explores the long-lasting impact of childhood trauma into adulthood.¹ The ACE Study includes over 17,000 participants ranging in age from 19 to 90. Researchers gathered medical histories over time while also collecting data on the subjects' childhood exposure to abuse, violence, and impaired caregivers. Results indicated that nearly 64 percent of participants experienced at least one exposure, and of those, 69 percent reported two or more incidents of childhood trauma. Results demonstrated the connection between childhood trauma exposure, high-risk behaviors (e.g. smoking, unprotected sex), chronic illness such as heart disease and cancer, and early death.

Economic Impact

The cumulative economic and social burden of complex trauma in childhood is extremely high. Based upon data from a variety of sources, a conservative annual cost of child abuse and neglect is an estimated $103.8 billion, or $284.3 million per day (in 2007 values). This number includes both direct costs—about $70.7 billion—which include the immediate needs of maltreated children (hospitalization, mental health care, child welfare systems, and law enforcement) and also indirect costs—about $33.1 billion—which are the secondary or long-term effects of child abuse and neglect (special education, juvenile delinquency, mental health and health care, adult criminal justice system, and lost productivity to society).

A recent study examining confirmed cases of child maltreatment in the United States found the estimated total lifetime costs associated with child maltreatment over a 12-month period to be $124 billion. In the 1,740 fatal cases of child maltreatment, the estimated cost per case was $1.3 million, including medical expenses and productivity loss.² For the 579,000 nonfatal cases, the estimated average lifetime cost per victim of child maltreatment was $210,012, which includes costs relating to health care throughout the life span, productivity losses, child welfare, criminal justice, and special education. Costs for these nonfatal cases of child maltreatment are comparable to other high-cost health conditions (i.e. $159,846 for stroke victims and $181,000 to $253,000 for those with Type 2 diabetes).

In addition to these costs are the "intangible losses" of pain, sorrow, and reduced quality of life to victims and their families. Such immeasurable losses may be the most significant cost of child maltreatment.

References

1. Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245–258. doi: http://dx.doi.org/10.1016/S0749-3797(98)00017-8
2. Fanga, X., Brown, D.S., Florencea, C.S., & Mercya, J.A. (2012, February). The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect, 36(2), 156–165. doi: 10.1016/j.chiabu.2011.10.006