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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Wiley Essential Clinical Guides to Understanding and Treating Issues of Child Mental Health
- Sprache: Englisch
An essential handbook for clinicians planning to involve the parents of trauma-impacted children in the treatment process In Trauma-Informed Parenting Program: TIPs for Clinicians to Train Parents of Children Impacted by Trauma & Adversity, distinguished behavioral healthcare practitioner, Dr. Carryl P. Navalta, delivers a practical and hands-on guide for clinicians to assist clients, and their families with emotion regulation in the face of trauma. In the book, readers will discover how to assess, conceptualize, and treat children suffering from the effects of exposure to various forms of trauma and adversity and to provide their clients' parents with the tools neccessary to facilitate further healing in the home and beyond. TIPs also Provides: * A thorough introduction to trauma that describes the historical roots and prevalence of trauma as well as the impact of adverse childhood experiences on child development and emotion regulation * A comrehensive exploration of case conceptualization and the creation of clinical formulations that identify, define, and integrate the primary problems facing the client * A fulsome discussion of treatment planning, including goal development, objective construction, intervention creation, and diagnosis determination * Psychologists can earn 6 continuing credits by reading the book and taking a post-test. This professional learning activity is offered by the National Prevention Science Coalition to Improve Lives An indespensible resource for clinicians dealing with trauma-impacted children, Trauma-Informed Parenting Program will earn a plce in the libraries of mental health counselors, social works, psychologists, psychiatrists, and all the practitioners who seek to make the parents of their clients an integral and usefual part of the treatment process.
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Table of Contents
Cover
Title Page
Copyright
Dedication
Foreword
Acknowledgements
About the Companion Website
1 Introduction and Foundations
Introduction
Trauma in Historical Context
Trauma and Children: The Case of Child Abuse and Neglect
Effects of ACEs on Child Development
Effects of ACEs on the Family
Dysregulation of Emotions and Related Behaviors
Overview of the Parent Training Program: From Emotion Dysregulation to Emotion Regulation
2 Clinical Assessment
“Assess to Understand”
Methods and Domains of Assessment
Summary
3 Case Conceptualization
“Understand Before You Intervene”
Case Conceptualization
A Framework for Case Conceptualization
Final “Food for Thought”
4 Treatment Planning
Developing the Treatment Plan
Treatment Plan for Lucas (An Example)
Reason for Referral
Background Information
Assessment Findings
Case Conceptualization
Trauma‐Informed Parenting Program (
TIP
s
for Clinicians
): An Introduction
5 Guidelines for Clinicians
TIP
s
for the Treatment Plan
Part I: Teaching Emotion Identification Skills
Part II: Teaching Emotion Regulation Skills
6 Final Thoughtsand Skills
Parenting from a Lifelong Learning Perspective
Conclusion: Being Healthy to Living Fully
Appendix A: Case Conceptualization Development Form
Primary Problem Template
Appendix B: Treatment Planning Form
Long‐Term Goal Template
Short‐Term Objective Template
Appendix C: Emotion Identification Worksheet
Appendix D: Problem-Solving Steps
References
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1 Terminology used to label exposure to trauma and adversity during ...
Table 1.2 Exposure to surveyed categories of violence.
Table 1.3 Risk factors for experiencing developmental adversity.
Table 1.4 US census data (US Census Bureau, 2021).
Chapter 2
Table 2.1 Rating scales to assess exposure to ACEs and related symptoms.
Chapter 3
Table 3.1 3 Ps across biopsychosociocontextual domains.
Table 3.2 Theories of human behavior across analytic‐experiential and object...
List of Illustrations
Chapter 2
Figure 2.1 Emotions as response tendencies.
Guide
Cover
Table of Contents
Title Page
Copyright
Dedication
Foreword
Acknowledgements
About the Companion Website
Begin Reading
Appendix A: Case Conceptualization Development Form
Appendix B: Treatment Planning Form
Appendix C: Emotion Identification Worksheet
Appendix D: Problem-Solving Steps
References
Index
End User License Agreement
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Trauma-Informed Parenting Program
TIPs for Clinicians to Train Parents of Children Impacted by Trauma & Adversity
Carryl P. Navalta
This edition first published 2022© 2022 John Wiley & Sons, Inc.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Carryl P. Navalta to be identified as the author of this work has been asserted in accordance with law.
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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication Data applied for
Paperback ISBN: 9781119772361
Cover Design: WileyCover Image: © seamind224/Shutterstock
I am deeply honored to dedicate this book to my late father, Feliciano S. Navalta, Jr., M.D. The love and support he provided to his family, friends, colleagues, and patients were unparalleled.
I love you, Dad!
Foreword
Over the last 25 years, I have worked as a clinical researcher interested largely in the areas of treatment development, implementation, and dissemination. In doing this work, I have seen first‐hand how important it is to train and support the clinical workforce, particularly community providers. Remarkably, I met Dr. Carryl P. Navalta nearly 10 years ago as part of a national initiative designed to improve access to and quality of care for youth who have experienced trauma, the National Child Traumatic Stress Network. We were actually working on a study that compared child‐perpetrator relationships for physical and sexual abuse and disparate mental health outcomes. Dr. Navalta has continued on his journey to explore how trauma, abuse, and other adversities create a heavy weight for families to carry and how care‐giving relationships play an important role in the youth's response.
Whether you are a seasoned clinician or someone just getting started with their clinical career, it is important to understand how trauma affects children, adolescents, and their families. Specifically, clinicians need to be able to address the rippling effects that trauma and adversity have on the developing brains and behaviors of children and adolescents. This book on the Trauma‐Informed Parenting Program is a valuable resource that guides clinicians on how to empower parents in their role as caregivers, enhance their child's response, and develop emotion regulation skills. The book summarizes key research findings and contextualizes this information with relevant history and background information while answering common questions from beginning to end. It also uses easy to understand language and provides the reader with a roadmap with helpful tips and strategies to use along the way. Of course, as a self‐proclaimed foodie, my favorite parts are the delicious recipes for success – something we can all use in doing this challenging but rewarding work.
Chapters 3 and 4 are undoubtedly the bread and butter of the book. They address two critical concepts (case conceptualization and treatment planning) that are the basis for effective treatments and interventions. Far too often, when clinicians skip these critical steps of assessment and case formulation they do not obtain the clinical understanding needed to guide treatment selection and implementation. Failure to understand the primary problem and their context can lead to the wrong selection of treatments and can be potentially harmful to the child and family. The treatment planning section really addresses how clinicians can individualize treatment for that specific child/family based on the assessment information gathered. This approach goes beyond a “cookie cutter” approach to tailor interventions to address specific problems as well as cultural and developmental considerations related to their trauma exposure and specific response. Understanding these two concepts alone is worth the price of the book.
As the pandemic continues to unfold and the mental health crisis for youth worsens, we need resources such as this book in our back pockets. I wish I had this easy read back in the day when I was learning how to effectively treat the children, adolescents and families who trusted me with their clinical care. Perhaps now more than ever, we need practical guides and resources to assist our workforce as many are struggling to respond to the increased demand that is a result of the mounting mental health crisis for our youth. Likewise, as the syndemics of COVID‐19, racial injustice, and violence and trauma continue to plague our nation, we need resources with tips and strategies that complement existing treatment manuals aimed at parent training, screening and assessment, and intervention delivery that address the growing complexity of the clinical cases flooding our doorsteps. Dr. Navalta's book has the potential to assist clinicians in their quest to help youth and their families live meaningful lives that are free of trauma‐related symptoms and distress.
Ernestine Briggs‐King, Ph.D.Associate Professor in Psychiatry and Behavioral SciencesDuke University School of Medicine
Acknowledgements
The work that I've done in the field of developmental adversity has been influenced by notable individuals who've shared their collective wisdoms with me. First, the late Donald J. Levis, Ph.D. emboldened me while I was a doctoral student to account for experiences of child abuse and neglect in the histories of everyone I treat as he was fiercely adamant that such maltreatment is a predominant risk factor for most (if not all) forms of psychopathology. Second, both Martin H. Teicher, M.D., Ph.D. and Glenn Saxe, M.D. underscored to me the need for clinical sensitivity and sophistication across neurobiological and social environmental contexts, respectively, to better understand and help youth impacted by exposure to trauma and adversity. Third, Bessel van der Kolk, M.D. reinforced for me the notion that we need to take a wholistic perspective with every individual we encounter but also to keep in front of our brains the reality that trauma and adversity in all forms affect society as a whole. Lastly, Susan L. Andersen, Ph.D. taught (and continues to inform) me that intervening as early in development as possible must be the overarching goal so that the youth can have the maximal chances and time to live fulfilling and meaningful lives.
About the Companion Website
This book is accompanied by a companion website:
www.wiley.com/go/navalta/tipsforclinicians
This website includes editable and downloadable versions of the forms found in this book.
1Introduction 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 experience
s (
ACE
s) on child development
Describe dysregulation of emotions and related behaviors
Outline the effects of ACEs on the family
Recite the overall premise of TIP
s
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).
Term
ACEs
Child traumatic stress
Complex PTSD
Acute vs. chronic trauma
Developmental trauma disorder
Allostatic load
Complex trauma
Chronic stress
Post‐traumatic stress disorder
Toxic stress
Poly‐victimization
Developmental adversity
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 experiences, the scale also included several sub‐threshold traumatic experiences (for example, parental marital discord, living with a household member who had a substance use, behavioral health, or criminal problem). Due to this combination of experiences, the investigators created the term, adverse childhood experiences (or ACEs), to encapsulate both and consequently named their study the Adverse Childhood Experiences (ACE) Study.
Prevalence of ACEs
ACEs know no geographical boundaries and are thus a worldwide phenomenon. Unfortunately, the extent of exposure to ACEs (especially interpersonal ones) is both appalling and unacceptable, which will continue to fuel prevention efforts to decrease their incidence, frequency, and magnitude. In the United States, state and national data are collected on the prevalence of child abuse and neglect. For example, the Children's Bureau (Administration for Children & Families, US Department of Health & Human Services) has an annual Child Maltreatment report that comprises data provided by each state to the National Child Abuse and Neglect Data Systems. For 2018, approximately 678,000 children were identified as abuse and neglect survivors with a prevalence rate of 9.2 per 1,000 children (9.6 per 1,000 for females; 8.7 per 1,000 for males; US Department of Health & Human Services, Administration for Children and Families, & Administration on Children, Youth, and Families, Children's Bureau, 2020). Racial and ethnic inequities were observed, with American Indian or Alaska Native children having the highest rate at 15.2 per 1,000 and African American children with the second‐highest rate (14.0 per 1,000 children).
The National Incidence Study (NIS) is a congressionally mandated, periodic research effort to assess the incidence of child abuse and neglect in the United States. In collaboration with the Children's Bureau, the Office of Planning, Research, and Evaluation conducted the Fourth National Incidence Study of Child Abuse and Neglect (NIS‐4; 2010)—the data for which was collected in 2005 and 2006. In contrast to the Children's Bureau annual Child Maltreatment report that is based on state‐level data on official reports of child maltreatment, the NIS studies include cases that both are and aren't reported to the authorities to more broadly determine the incidence of child maltreatment in the United States. Using a strict definition of maltreatment (that is, demonstrable harm is present), 1 in 58 children in the United States was a survivor of maltreatment (an estimated 1,256,600 children). This finding corresponds to 17.2 per 1,000 children, which is almost twice the prevalence documented in Child Maltreatment (2018) but a 32% decline in the rate compared to NIS–3 (1993). Most children were exposed to neglect (61%), whereas 44% were abuse survivors (Footnote: Because the NIS classifies children in every category that applies, the sum of the components is more than 100%).
Using a more inclusive definition of maltreatment (that is, “endangered” children who were not yet harmed; adding children abused and neglected by non‐parent adult caregivers in certain maltreatment categories as well as teenage caregivers as perpetrators of sexual abuse) resulted in markedly higher rates. Specifically, 1 in every 25 children was a maltreatment survivor, which corresponds to a rate of 40 per 1,000 children. Across types, more than three‐fourths (77%; ∼2,251,600 children) were neglected and 29% (∼ 835,000 children) were abused. Within the overall neglect category, rates were in the following order: physical neglect (53%), emotional neglect (52%), and educational neglect (16%). Of the abuse survivors, 57% were physically abused, 36% were emotionally abused, and 22% were sexually abused. In nearly all cases (that is, overall maltreatment, overall abuse, overall neglect, and physical abuse), maltreatment rates for African‐American children were significantly higher than for White and Latin‐American children regardless of definitional standard, which is similar to the Child Maltreatment findings.
Of course, ACEs comprise other adversities besides child maltreatment. Since the original ACE Study, the list of ACEs has been expanded to ten items. Besides five types of abuse and neglect (that is, physical abuse, psychological abuse, sexual abuse, physical neglect, and emotional neglect), five other items are focused on parent‐ or family‐related problems: parental loss through divorce, death or abandonment, parental imprisonment, parental mental health problems, parental substance use problems, and violence against the mother. Using data collected by the National Child Traumatic Stress Network (NCTSN), Pynoos et al. (2014) documented that the original ACEs were the most prevalent adversities in their sample of children and adolescents (that is, traumatic loss/bereavement/separation, domestic violence, impaired caregiver, emotional abuse, neglect, physical abuse, and sexual abuse). However, our discussions and understanding need to include other relevant adversities because they can also have negative, long‐term developmental effects (Finkelhor et al., 2015a). Such ACEs comprise childhood bullying and peer victimization, isolation and peer rejection, poverty and deprivation, and exposure to community violence. Thus, the prevalence of these experiences needs to be part of our present conversation.
The second National Survey of Children's Exposure to Violence was conducted in 2011 as a follow‐up to the original study. The research included a nationwide representative sample of 4,503 children and their caregivers regarding the children's exposure to violence, crime, and abuse across several major categories: conventional crime, child maltreatment, victimization by peers and siblings, sexual victimization, witnessing and indirect victimization (including exposure to community violence, family violence, and school violence and threats), and Internet victimization (Finkelhor et al., 2015b). Overall, approximately three in five children (57.7%) experienced at least one exposure to five categories of violence in the past year (physical assault, sexual victimization, maltreatment, property victimization, and witnessed or indirect violence). Table 1.2 illustrates the major findings across exposure types. Multiple exposures to violence among children and youth were documented (also known as complex trauma and poly‐victimization). Specifically, almost one‐half (48.4%) of the participants reported more than one type of direct or witnessed victimization in the past year—about 1 in 6 (15.1%) reported six or more types of direct or witnessed victimization, and 1 in 20 (4.9%) reported ten or more types of direct or witnessed victimization. Exposure to one type of violence, crime, or abuse increased the chance that a child had exposure to other types. In general, the risk for an additional type of exposure was increased two‐ or three‐fold for a past‐year exposure and somewhat more for lifetime exposure.
Table 1.2 Exposure to surveyed categories of violence.
Exposure type
Past year (%)
Lifetime (%)
Any physical assault
41.2
54.5
Any sexual victimization
5.6
9.5
Any child maltreatment
13.8
25.6
Any property victimization
24.1
40.2
Witnessing violence
22.4
39.2
Indirect exposure to violence
3.4
10.1
Unique characteristics of perpetrators and survivor gender were observed. In regard to physical assaults, siblings and non‐sibling peers were both common perpetrators. Assaults by siblings occurred the most among 6‐ to 9‐year‐old children (28.0% in the past year), whereas assaults by non‐sibling peers were most common among 10‐ to 13‐year‐olds (23.5% in the past year), although such assaults were typical throughout childhood and adolescence. Although boys experienced more assaults overall (45.2% vs. 37.1% for girls), girls were survivors of more dating violence (4.7% vs. 1.9%).
Rates of bullying were also surveyed (the terms, physical intimidation and relational aggression, were used in the study). Within the past year, 13.7% of children and youth were physically intimidated, and 36.5% were survivors of relational aggression. Past‐year rates of exposure to relational aggression and Internet/cell phone harassment were higher for girls (41.4% vs. 31.9% and 8.3% vs. 3.8%, respectively). Rates of physical intimidation in the past year differed by age, with the highest rate experienced by children younger than ten years old, although such rates for boys and girls were comparable overall. Among other victimization types occurring in the past year, relational aggression was highest for children 6‐9 years old; Internet/cell phone harassment was highest for 14‐ to 17‐year‐old youth.
About one‐quarter of the sample were survivors of property victimization (that is, robbery, vandalism, and theft by non‐siblings; 24.1%) or had witnessed violence in the past year (22.4%), either in the family or community. More than one in five children surveyed (20.8%) witnessed a family assault over their lifetimes, with the oldest youth (ages 14‐17 years) witnessing any family assault at 34.5% (28.3% witnessing one parent assaulting another). Few significant gender or age differences were seen in witnessing family assaults. The rate of witnessing a community assault for all children and youth was 16.9% in the past year and 58.9% over the lifetime of the oldest youth.
Exposure Across Development
Besides understanding the variety of ACEs that occur and their prevalence rates, the timeframe of exposure to such adversity is important to know because of the differential impact on a child's biopsychosocial development. The developmental timing of exposure to ACEs is illustrated by findings of the Developmental Victimization Survey (Finkelhor et al., 2009), which was a national telephone survey of the victimization experiences of 2,030 children and adolescents who were 2‐17 years old. Overall, the mean number of victimizations during a single year increased with age, as did the percentage of children with poly‐victimizations (four or more different kinds of victimization). Specifically, the mean number of different kinds of victimizations increased from about 1.7 for 2‐ to 5‐year‐olds to 3.4 for 14‐ to 17‐year‐old youth (boys experienced more kinds of victimizations than girls in the 6–9 and 10–13 age groups); the increase in polyvictimization was greatest for boys older than 6–9 years and girls older than 10–13 years.
However, some specific types of victimization were highest before adolescence and then declined. For example, assaults by siblings peaked at ages six to nine years for both boys and girls, then declined thereafter. Similarly, physical bullying was at its highest for children six to nine years old, especially for boys, and the extent of emotional bullying dropped for both boys and girls in the 14‐ to 17‐year‐old age range. In contrast, sexual victimization increased with age, especially with girls 14‐17 years old.
Developmental patterns of other victimization types varied by gender. Child maltreatment also had a pattern that varied significantly by gender. Compared to girls, boys experienced more maltreatment (physical abuse, neglect, and emotional abuse) up to 13 years old. The maltreatment of girls aged 14‐17 years old, however, increased significantly to a rate higher than the rate for boys. Likewise, property crime victimization of girls increased for 14‐ to 17‐year‐olds.
The results of the Developmental Victimization Survey indicate that the overall extent of victimization is high across childhood and adolescence. Although the general pattern is that victimization increases as children get older, the pattern varies depending on the specific types of victimization as well as gender (Finkelhor et al., 2009). A recent replication study validated and extended these findings by showing that increasingly complex patterns of developmental adversity occur in middle childhood and adolescence compared to early childhood (Grasso et al., 2016).
In the case of exposure to ACEs, children are not unfortunately created equal. In other words, some children are at greater risk of experiencing ACEs compared to others. Thus, we need to know as best we can who these children are so that we can intervene as early as possible to lessen the negative consequences of such adversity or, better yet, decrease the chances that ACEs actually occur. Preventative measures would need to address the inequities identified below that exist across children regarding developmental adversity.
Table 1.3 Risk factors for experiencing developmental adversity.
Factor
Descriptor
Sex
Girls are sexually abused more often than boys
Age
Older age across most abuse and neglect categories
Disability status
Children with confirmed disabilities have lower rates of physical abuse but higher rates of emotional neglect
School enrollment
Children not enrolled in school are sexually abused more often than enrolled children
Parental job status
Unemployment
Family financial status
Low socioeconomic status
Family structure/living arrangement
Children whose single parent has a live‐in partner have higher rates of maltreatment overall compared to children living with married biological parents
Family size
Incidence rates are highest for children in the largest families
County metropolitan status
Children from rural counties have a higher rate of overall maltreatment
Evidence of risk for ACEs comes from studies of both children and adults. As described earlier, the NIS‐4 (Sedlak et al., 2010) demonstrated that rates of maltreatment for African American children are significantly higher than rates for White/European American and Latin American children. Other risk factors identified in the NIS‐4 are highlighted in Table 1.3.
In a recent study of adults (Cronholm et al., 2015), demographic characteristics associated with higher risk for ACEs included adults who reported a race of “other” (versus white); were living with a partner (versus married); were disabled (versus working full‐time); younger age; and being separated from one's partner (versus married). Combined with findings from child studies, this evidence has a direct bearing on both preventive interventions and social justice. Primary prevention efforts, for example, include preventing ACEs so that children (especially those with marginalized backgrounds) grow up with less adversity and are less likely to have their own children who are exposed to ACEs (Oral et al., 2016). To address the known racial and ethnic inequities, prevention strategies also need to comprise more resources in place for those children at relatively greatest risk for ACEs (for example, African American and Latin American children). Perhaps most importantly, though, we need to acknowledge and recognize how experiences of racism impact children and their health.
Exposure to Racism as a Developmental Adversity
In today's society, we can no longer discuss trauma and adversity without including racism as a vital topic. In the United States, the total population comprises 38.4% of people of color/non‐white (US Census Bureau, 2021). Table 1.4 outlines the major races and ethnicities documented in this most recent census. At its most basic level, racism is the belief that all members of a given race possess characteristics or abilities specific to that race, consequently distinguishing them as supposedly inferior or superior to other races. This erroneous thinking can then lead to racial discrimination in which a person acts for or against an individual or group based on apparent “membership” of that race. Exposure to such behavior is rampant in the United States (and worldwide), with rates of discriminatory treatment of people of color upward to 75%, especially toward non‐Latino African Americans (Lee et al., 2019; Woo, 2018).
Although racism is based on a classification system of race as a primarily biological factor, the accepted contemporary view is that race is a social construct (Jones, 2001). Thus, racism occurs at multiple levels of our social ecology (Paradies et al., 2015; Paradies, 2006). The most proximate level is intrinsic to a given individual, who has an internalized worldview of prejudice, attitudes, and beliefs of racism. The next level is interpersonal in nature when racism occurs during interactions between individuals. Lastly, systemic racism is at the level of organizations and institutions, such as governmental bodies, laws, and policies. Regardless of level, however, racism exemplifies the many dimensions of childhood adversity derived from social inequities that have been typically ignored by clinicians and researchers alike (McEwen & Gregerson, 2019).
For our purposes, racism must be viewed and understood as yet another ACE to which children can be exposed. As a distinct adversity, racism in all its forms and levels is a stressor that can impact an individual's health and psychosocial functioning (Clark et al., 1999; Mays et al., 2007; Meyer, 2003). The potential chronicity of racism can thus be likened to what we know about children's biobehavioral development when their stress response systems are highly activated for extended durations—a significant wear‐and‐tear effect on their developing brains and other biological systems with long‐term effects on learning, behavior, and health (Forde et al., 2019; Geronimus et al., 2006; McEwen, 2006). This perspective thus indicates that continual coping with discrimination and systemic racism is a potent activator of the stress response (Center on the Developing Child, n.d[[dot]]n.d.).
Table 1.4 US census data (US Census Bureau, 2021).
Race or ethnicity
Percentage of population (%)
White alone
a)
61.6
Hispanic/Latino
18.7
Black/African American alone
12.4
American Indian/Alaska Native alone
1.1
Asian alone
6.0
Native Hawaiian/Pacific Islander alone
0.2
Some Other Race alone
8.4
Multiracial
10.2
a) Three racial composition concepts were used: race alone, race in combination, and race alone or in combination.
Summary
Clearly, children can experience a variety of severe adversities. Besides different forms of child abuse and neglect (which, by definition, are perpetrated by parents or other caregivers), other seriously negative experiences count as well, such as the ones identified in the ACE Study (for example, parental impairment), even though they don't meet the threshold definition of trauma. Exposure to violence is yet another adversity that requires our attention and that comprises various types (for example, conventional crime, victimization by peers and siblings, witnessing and indirect victimization, and Internet victimization; Finkelhor et al., 2015b). The scientific literature also indicates that inequities exist in which certain children are at increased risk of exposure to ACEs compared to others. Factors identified to distinguish such children include race/ethnicity, sex, age, disability status, school enrollment, and family size. Lastly, racism is a relatively neglected and underappreciated adversity that impacts most non‐white children. ACEs are thus collectively vast in number and type and ultimately affect many children regardless. The next section provides an overview of the impact of developmental adversity on developmental processes.
Effects of ACEs on Child Development
Child Abuse and Neglect
The majority of research on the impact of ACEs on child development comes from studies of child abuse and neglect. The effects of such adversity on children's psychosocial development and long‐term behavioral health have been well documented. Characteristics of the experience (such as timing, duration, frequency, severity, degree of threat, and relationship to the perpetrator) have been shown to be associated with outcome (Bulik et al., 2001; Keiley et al., 2001; Manly et al., 2001). For example, Navalta et al. (2006) showed that the duration of sexual abuse in females directly relates to the extent of their memory problems. Curiously, although earlier research and clinical lore strongly suggested that children who are traumatized by a parent/caregiver have more severe symptoms than youth who are traumatized by a non‐caregiver, more recent findings indicate that abuse by caregivers results in fewer symptoms and problems than abuse perpetrated by a non‐caregiving relative (e.g., Kiser et al., 2014).
Consequences of exposure to childhood maltreatment include dysfunctional behaviors, such as conduct problems, oppositional behavior, aggression, and substance use problems (Cicchetti & Handley, 2019; Fergusson et al., 1996; Schuck & Widom, 2001). The former externalizing behavior problems have been hypothesized to link alcohol use in adolescents with maltreatment and violence during childhood (Cornelius et al., 2016; Proctor et al., 2017). Exposure to child abuse and neglect also leads to an increased risk for later mental health problems, including depression, suicide, anxiety disorder, somatization disorders, and post‐traumatic stress disorder (PTSD) (Brown et al., 1999; Fergusson et al., 1996; Fergusson & Lynskey, 1997; Lansford et al., 2002). In general, interpersonal trauma (such as child maltreatment) is much more likely to lead to PTSD than non‐interpersonal trauma (Alisic et al., 2014). Emerging research indicates that earlier adversity more strongly influences anxiety, mood, and anhedonia, whereas relatively later adversity has greater effects on externalizing behavior problems (Andersen, 2015). Associations with psychopathology during adulthood are independent of other associated environmental adversities (Brown et al., 1999; Fergusson et al., 1996).
Both commonalities and distinctions exist in the effects of maltreatment across abuse types. Physical abuse, for example, is associated with symptoms of depression, emotional distress, and suicidal ideation (Green, 1988; Waldrop et al., 2007) as well as increased risk of developing a substance use disorder in adolescence (Kilpatrick et al., 2003). Sexual abuse‐specific symptoms include PTSD, dissociation, depression, and sexual problems (for a comprehensive review, see Sanjeevi et al., 2018). Emotional abuse, in contrast, is particularly associated with aggressive behavior, especially when the abuse is developmentally early and severe (Manly et al., 2001) or primarily verbal (Vissing et al., 1991). Children who have been neglected also exhibit high levels of aggression (de Paúl & Arruabarrena, 1995; Kaufman & Cicchetti, 1989; Kotch et al., 2008).
The clinical picture becomes complex when children experience multiple incidents and forms of child abuse and neglect or ACEs in general (Finkelhor et al., 2007). Generally, a dose‐response relationship exists whereby: (a) a certain minimal number of exposures is necessary for the development of an adverse outcome, such as persistent internalizing or externalizing disorders; and (b) the greater the number of forms of ACEs, the more severe the subsequent problems and the greater the amount of utilization of psychiatric care (Caspi et al., 2003; Edwards et al., 2003; Putnam et al., 2013; Teicher et al., 2006).
Child maltreatment is associated with a host of neurocognitive deficits and related psychosocial impairment. Poor school performance is tied to exposure to child abuse and neglect (Crozier & Barth, 2005; Trocme & Caunce, 1995; Veltman & Browne, 2001), such as problems with grades, test scores, and school absences as well as later dropout (Leiter & Johnsen, 1994). Children who have been neglected exhibit lower performance scores in reading and math, lower grades, and higher levels of suspensions, disciplinary referrals, grade repetitions, dropouts, absences, and special education involvement (Eckenrode et al., 1993; Kendall‐Tackett & Eckenrode, 1996; Leiter & Johnsen, 1997; Wodarski et al., 1990). Such scholastic deficiencies are associated with problems in auditory attention, flexibility, response inhibition, and visual‐motor integration (Nolin & Ethier, 2007
