Complex trauma through a trauma-informed lens: Supporting the wellbeing of infants and young children

Michele Hervatin, Australia, July 2021

Resource Summary

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This resource introduces complex trauma and trauma-informed care, including their importance in supporting the wellbeing and mental health of infants and young children. It explores the possible effects of complex trauma in early childhood (i.e. birth through to five years), and aims to support professionals to use a ‘whole-child’ approach that considers how early life experiences (including trauma) may shape development and behaviour. It also discusses how professionals can connect children and families with services to support resilience and recovery.

The information in this resource is intended to help professionals raise their awareness of complex trauma and its presentation. The practice reflection questions are to help professionals further explore the issues presented, reflect on their current practice and consider opportunities where a trauma-informed perspective may be useful in supporting the children in their practice.

Who is this resource for?

This resource is for professionals who work with infants, young children and/or the parents/caregivers of infants/young children. It will be particularly useful for professionals who are not specialists in trauma or child mental health, such as maternal and child health nurses, child care workers, early childhood teachers, social workers and general practitioners. These professionals are likely to be already working with infants and young children who experience complex trauma but may not fully understand what it is, how it presents and how to support children for the best outcomes.

Introduction

Most infants and young children in Australia grow up in healthy environments that provide safety and stability. Some children, however, are exposed to traumatic experiences that can present significant challenges to their development and wellbeing, such as child abuse and neglect (Council of Australian Governments, 2009). Infants younger than 12 months of age appear to be particularly vulnerable to such experiences, and are twice as likely as other age groups to have at least one substantiated child protection notification. This is when there is sufficient reason to believe the child has been, is being, or is likely to be harmed in some way (Australian Institute of Health and Welfare [AIHW], 2020b).

All children, even infants, can be significantly impacted by traumatic experiences. Early childhood, especially infancy, is a time of rapid development when the foundations for a range of critical skills and capacities are formed (Lawson & Quinn, 2013). This makes children particularly vulnerable to any stressors or traumatic events at this time. If a child is not appropriately supported, these stressors may have ongoing implications for their development and wellbeing (Lawson & Quinn, 2013; Lyons-Ruth et al., 2017).

Complex trauma: What does the evidence tell us?

Key messages

  • Complex trauma is distinct from other kinds of trauma. This means it can have different effects on the child and requires distinct interventions and supports.
  • Symptoms of complex trauma are coping strategies that help the child adapt to chronic stressors or threats. They only become maladaptive when these stressors or threats are no longer present.
  • Complex trauma affects each child differently. Not all children will show struggles in development or wellbeing.
  • Early identification and support for children who have experienced complex trauma (including through trauma-informed practice) can promote recovery and resilience.

Complex trauma: Concepts and issues

Defining complex trauma

Complex trauma (sometimes referred to as ‘type II trauma’) occurs when a child repeatedly experiences severe stressors or traumatic events over an extended period of time (Kliethermes, Schacht, & Drewry, 2014; Lawson & Quinn, 2013). These stressors start during childhood, at a developmental time point when the child is considered vulnerable. This may be related to the importance of this period for brain development and forming attachment relationships (Kliethermes et al., 2014). Traumatic experiences often occur in the context of a relationship with a trusted adult who would normally provide safety and consistency (Lawson & Quinn, 2013). Complex trauma can also sometimes be used to refer to the consequences or symptoms of the severe stressors (Kliethermes et al., 2014). However, this resource will use the term to refer to the traumatic events themselves.

Examples of common kinds of complex trauma experiences include physical, emotional or sexual abuse, neglect, or witnessing family and domestic violence. This resource focuses on these specific experiences as they are the focus of most complex trauma research. These kinds of experiences are also most likely to be relevant in the Australian setting. Other examples of complex trauma experiences include community violence and trauma in medical settings (Kliethermes et al., 2014; Lawson & Quinn, 2013).

Complex trauma is distinct from single incident trauma (sometimes referred to as ‘type I trauma’), which consists of a once-off traumatic event (Blue Knot Foundation, 2021b; Kliethermes et al., 2014). Post-traumatic stress disorder (PTSD) is also distinct, as it does not fully capture the possible effects of complex trauma experiences on a child’s development (Cook et al., 2005; Denton, Frogley, Jackson, John, & Querstret, 2016; Kliethermes et al., 2014). Understanding that complex trauma is distinct is important because the potential effects – and associated supports and treatments – differ from other kinds of trauma (Denton et al., 2016; Kliethermes et al., 2014).

Complex post-traumatic stress disorder and developmental trauma disorder are other concepts often present in research. Children who experience those disorders may present with similar signs and symptoms as if they experienced complex trauma (DeJong & Wilkinson, 2019; Denton et al., 2016). Those disorders are used to describe a collection of symptoms. However, this resource uses the term ‘complex trauma’ as it commonly appears in the Australian context and captures the experience of trauma itself (rather than describing the symptoms).

This resource relates to working with infants (birth through to 12 months) and young children (up to five years of age) with confirmed histories of complex trauma. The behaviours and difficulties discussed in this resource can also be part of typical variations in early childhood development – or might be temporary fluctuations in a child (Georgetown University Centre for Child and Human Development [GUCCHD], 2020; Zeanah & Zeanah, 2019). Therefore, behaviour or presentation alone cannot be viewed as indicating that a child has experienced complex trauma. It is vital that any difficulties are considered in terms of the child’s individual situation, including their history and family situation (GUCCHD, 2020).

Complex trauma affects each child differently

Complex trauma in early childhood can have physical, social, emotional and behavioural effects (Cook et al., 2005). While general patterns in effects have been identified, different children can show different outcomes (i.e. ‘individual variability’) (Kliethermes et al., 2014). However, negative effects tend to be more long-term and severe when the trauma experiences (Kliethermes et al., 2014):

  • occur earlier in a child’s life
  • have a longer duration; or
  • involve multiple forms of complex trauma experiences.

A child’s developmental stage can influence how symptoms present at a particular time (DeJong & Wilkinson, 2019; Denton et al., 2016; Kliethermes et al., 2014). Even traumatic experiences and stressors that occur in utero can impact the child, through the transfer of trauma effects from the parent(s) to the child (e.g. maternal exposure to domestic violence) (Horsch & Stuijfzand, 2019). However, trauma during the prenatal period is beyond the scope of this resource.

Not all children exposed to complex trauma will show difficulties in their wellbeing or mental health. It is crucial not to make assumptions about the impact these experiences might have (Danese, 2020). Some children have positive outcomes, with research suggesting that protective factors and resilience processes can play a role (Danese, 2020; DeJong & Wilkinson, 2019). Examples of factors that can support positive outcomes and recovery following complex trauma include having:

  • at least one stable and responsive caregiver (Berens & Nelson, 2019; Zeanah & Zeanah, 2019)
  • a caregiver who applies positive parenting practices (such as being engaged and warm) (Kliethermes et al., 2014)
  • a caregiver who believes and validates the child’s trauma experiences (Kliethermes et al., 2014)
  • a caregiver who is able to self-regulate their emotions (Cook et al., 2005); and,
  • a positive social support network (including those that can provide emotional support) (Cook et al., 2005).

Symptoms are coping strategies and adaptations

All symptoms children present with should be viewed as adaptations to complex trauma experiences (DeJong & Wilkinson, 2019; National Child Traumatic Stress Network [NCTSN], 2021). That is, if children present as withdrawn or aggressive, this may be their way of trying to cope with the experiences they have. It is only once these experiences are resolved (e.g. once a child receives safe, stable, appropriate care) that coping strategies may become problematic (Teicher & Samson, 2016). If struggles emerge, professionals should respond with understanding, sensitivity and patience.

Short- and long-term effects of complex trauma are both possible (Cook et al., 2005; Schechter, Willheim, Suardi, & Rusconi Serpa, 2019). These difficulties may persist into adulthood, with the potential to affect a range of areas, including family life, employment, productivity and physical and mental health (Blue Knot Foundation, n.d.; Cook et al., 2005; NCTSN, 2021). Long-term effects highlight the importance of early identification and support to minimise the impact of complex trauma and provide the child with the best opportunities for their future (Kliethermes et al., 2014). Supporting infants and young children who experience complex trauma as early as possible can help prevent these longer-term effects.

The importance of trauma-informed care

Trauma-informed care is a ‘framework for providing services, care or support that is based on knowledge and understanding of how trauma affects people’s lives and their service needs’ (Emerging Minds, 2021). When working with children, practising in a trauma-informed way involves applying a range of principles and practices including:

  • appreciating that trauma is possible in the lives of all children
  • understanding the potential effects of trauma on a child’s development and wellbeing, while acknowledging individual differences
  • adopting a ‘whole-child’ perspective, where symptoms are viewed as the child adapting to an adverse environment characterised by traumatic experiences. This includes not blaming the child for their efforts to cope, which may include concerning behaviour
  • aiming to avoid additional harm or trauma (e.g. through considering how typical daily activities might unintentionally act as triggers that worsen the effects of trauma); and
  • communicating messages of hope with a focus on strengths, resilience and recovery.

(Blue Knot Foundation, 2021a; Emerging Minds, 2021; Kezelman, 2014; Royal Australian and New Zealand College of Psychiatrists [RANZCP], 2020).

A deeper discussion of trauma-informed care is beyond the scope of this resource, but detailed guidance can be found in the e-learning course, Supporting children who have experienced trauma.

How can complex trauma affect the child’s body and brain?

Key messages

  • Complex trauma in early childhood can affect the child’s body in many ways. This may include disruptions to the development and regulation of stress response systems, including over-activation. Some changes may lead to increased vulnerability to health and wellbeing problems.
  • During early childhood, brain development is particularly sensitive to disruption by complex trauma. This may lead to changes in brain structure and function, which are believed to contribute to many of the common symptoms and developmental concerns that may follow complex trauma.

The experience of complex trauma can lead to many changes in the child, depending on the type and frequency of trauma and the developmental period during which children experience trauma. Children may experience changes in stress responses, brain development, how they respond to everyday experiences, their behaviours, and the development of certain skills.

Changes to a child’s stress responses

When there is a threat (whether real or perceived), the child’s stress response survival systems are activated to prepare them to ‘fight’ or ‘flee’ (Berens & Nelson, 2019). In infants or young children, the ‘fight’ response might present as increased vigilance, agitation, anxiety and aggression. Children are not always able to ‘fight’ or ‘flee,’ so instead might ‘freeze’ or dissociate (i.e. show changes in their state of consciousness).

When an infant or young child experiences complex trauma events, their body’s stress systems may be excessively and repeatedly activated (Thompson, Kiff, & McLaughlin, 2019). The development and regulation of the body’s stress response can also be disrupted; a common consequence of this is that reactions to stress can be blunted or exaggerated. These various stress system changes can increase a person’s vulnerability to mental health struggles (e.g. stress) and health problems (e.g. hypertension) later in life (Danese, 2020; Schechter et al., 2019; Thompson et al., 2019).

Changes in brain development

Brain development begins in utero and continues into adulthood. Early childhood experiences are important influences on brain development, due to sensitive periods when children’s brains are especially vulnerable to environmental experiences (Berens & Nelson, 2019; Zeanah & Zeanah, 2019). Therefore, traumatic events during this time can be particularly disruptive to brain structures and functions (Berens & Nelson, 2019; Zeanah & Zeanah, 2019).

During the first 3–5 years of life, particular brain areas are especially susceptible to disruption caused by complex trauma experiences (Berens & Nelson, 2019; Schechter et al., 2019; Teicher & Samson, 2016; Zeanah & Zeanah, 2019). Changes in these brain areas may contribute to many common symptoms of complex trauma, including social, emotional and behavioural difficulties (Kliethermes et al., 2014). They can also contribute to various child developmental issues, such as speech, language and cognitive difficulties.

Changes in how the child responds

Children may experience changes in their state of consciousness (sometimes referred to as dissociation). This may present as ‘freezing’ or as appearing detached, numb or disengaged (Cook et al., 2005; Kliethermes et al., 2014; Lawson & Quinn, 2013). These changes might be misinterpreted as attention problems or ‘daydreaming’ (DeJong & Wilkinson, 2019).

An ideal arousal level (sometimes also referred to as a ‘window of tolerance’) supports a child’s day-to-day functioning (Siegel, 2000). But complex trauma early in life can lead to changes in arousal or vigilance. Under- or over-arousal can be maladaptive for the child. For example, over-arousal might present as a child being startled by stimulation/events that wouldn’t trigger that response in most children of the same age, or appearing to startle excessively. They might also seem overly alert or vigilant to potential perceived threats in their environment (DeJong & Wilkinson, 2019; Lawson & Quinn, 2013). In contrast, under-arousal might present through the dissociative features described above.

If children experience changes in responses to sensory stimulation (e.g. noises, sights, touch), some sensory experiences may ‘trigger’ traumatic memories, which might lead to ‘under-responding’ (e.g. becoming numb or withdrawn) or ‘over-responding’ (e.g. showing heightened emotions or concerning behaviour) (DeJong & Wilkinson, 2019). Some children might avoid situations involving these sensory ‘triggers’ as an adaptive strategy.

Changes in behaviours

Children exposed to complex trauma may experience sleep disturbances. Young children may have nightmares, night terrors or fears of sleeping and being on their own (GUCCHD, 2020; Government of Western Australia, 2021; Schechter et al., 2019). Children may also experience disturbances in feeding and eating. They might refuse to eat, overeat, hoard food or use other attempts to control eating and its rituals (Schechter et al., 2019; Wotherspoon, Hawkins, & Gough, 2009).

Changes in developmental skills

Delays in developmental skills may be evident in children who have experienced complex trauma. For instance, children may present with delayed language skills, which may include their ability to listen and understand or speak (DeJong & Wilkinson, 2019; Schechter et al., 2019). Children may also experience difficulties with cognitive skills, such as their ability to pay attention or concentrate, higher-level thinking skills such as planning and reasoning, and overall cognitive functioning (i.e. IQ) (Cook et al., 2005; Danese, 2020; DeJong & Wilkinson, 2019; Kliethermes et al., 2014).

How can complex trauma affect children's wellbeing?

Key messages

  • Complex trauma experiences can affect a child’s social, emotional and behavioural wellbeing. Vulnerability to these effects is considered highest if exposure occurs during early childhood.
  • The development of secure child–caregiver attachment relationships can be disrupted by complex trauma. This may have flow-on effects for the child’s social and emotional development.
  • Complex trauma can disrupt social development and functioning, including the formation of healthy relationships. Time and patience can help to build a safe, trusting child–professional relationship.
  • Difficulties in emotional wellbeing and mental health can follow complex trauma, including in infants and toddlers.
  • Trauma-informed practice is especially critical when trying to understand behaviour, as otherwise a child might be given inappropriate (or even harmful) labels or miss out on appropriate support.

Complex trauma experiences may impact children’s social, emotional or behavioural development and wellbeing during infancy and early childhood (Cook et al., 2005; Kliethermes et al., 2014). Early childhood is a developmental period when vulnerability to the effects of trauma is highest (Lawson & Quinn, 2013). This may be because this period is crucial for developing foundations in critical areas and capacities such as relationships (including primary attachment relationships) and self-regulation skills (including emotional and behavioural regulation).

Disruptions in attachment

Attachment is an aspect of the child–caregiver relationship that provides protection, safety, comfort and nurturing to the child (Benoit, 2004; Finelli, Zeanah, & Smyke, 2019). While there are different attachment styles, they can generally be divided into two categories: ‘secure’ and ‘insecure’ (see below). Infancy is a critical time in the development of attachment relationships and is considered the most vulnerable to disruptions (Lyons-Ruth et al., 2017). Complex trauma early in a child’s life can compromise the development of a secure child–caregiver attachment relationship (Kliethermes et al., 2014; Lawson & Quinn, 2013), which can have flow-on effects for infant and child mental health (Finelli et al., 2019; Kliethermes et al., 2014; Lawson & Quinn, 2013; NCTSN, 2021).

Attachment is particularly at risk if traumatic experiences occur in the context of a child–caregiver relationship or involve the primary child–caregiver relationship being threatened (Cook et al., 2005; Kliethermes et al., 2014; Lawson & Quinn, 2013).

Attachment styles

Secure attachment – Develops when an infant has access to a caregiver who provides caring, reliable and timely responses when they are distressed (e.g. holding the infant and providing comfort) (Moore, Arefadib, Deery, Keyes, & West, 2017). It also includes promoting positive strategies to manage stress, such as helping the child regulate their emotions (Kliethermes et al., 2014; Moore et al., 2017). A secure attachment relationship supports a child’s social development and functioning, including the formation of a healthy foundation for developing future relationships.

Insecure attachment – Develops when caregivers are unavailable, unresponsive or unpredictable in responding to the child’s needs. Being near the caregiver does not reduce the infant or child’s distress. Instead, they develop other strategies for regulating their emotions (Moore et al., 2017).

In early childhood, difficulties with attachment may present as:

  • difficulties with separating from caregivers (e.g. being ‘clingy’) (Cook et al., 2005; GUCCHD, 2020)
  • inconsistent behaviour towards caregivers (e.g. switching between being ‘clingy,’ dismissive or even aggressive) (Cook et al., 2005)
  • lacking trust in others (GUCCHD, 2020; Kliethermes et al., 2014)
  • finding it challenging to seek help from others (GUCCHD, 2020); or
  • struggling to self-regulate emotions and behaviour (Cook et al., 2005; Kliethermes et al., 2014).

Challenges to social wellbeing and functioning

Complex trauma experiences in early childhood can affect social development and functioning (Kliethermes et al., 2014) and may impact on the child’s ability to form relationships and friendships (Cook et al., 2005; DeJong & Wilkinson, 2019; Kliethermes et al., 2014).

In young children, these social struggles may present as:

  • difficulty trusting others and feeling safe in relationships (DeJong & Wilkinson, 2019; Kliethermes et al., 2014; NCTSN, 2021)
  • experiencing feelings of fear, threat, rejection or being unloved when socialising (DeJong & Wilkinson, 2019)
  • showing vigilance or guardedness when interacting with others (DeJong & Wilkinson, 2019; NCTSN, 2021)
  • struggling when interacting with authority figures, such as educators (NCTSN, 2021); or
  • struggling with social skills, which may, in turn, affect their ability to form friendships and navigate social interactions (DeJong & Wilkinson, 2019; Kliethermes et al., 2014).

There may also be disruptions to a child’s views of themselves, others and their world (Kliethermes et al., 2014; Lawson & Quinn, 2013). Building an effective child–professional relationship, where the child trusts the professional and feels safe, can be challenging and may take time (DeJong & Wilkinson, 2019; Kliethermes et al., 2014). Children may experience ongoing events in their lives that present extra challenges to developing healthy social skills and relationships (e.g. changes to their family unit, being placed in out-of-home care) (Kliethermes et al., 2014).

Challenges to emotional wellbeing and functioning

Complex trauma experiences in early childhood can lead to struggles with emotional wellbeing and functioning. For example, toddlers as young as 15 months who have been maltreated have been found to show hyper-responsivity to angry facial expressions (i.e. over-reacting or having an increased response) (Curtis & Cicchetti, 2013; Schechter et al., 2019). They may have difficulties with self-soothing; this is when an infant can become calm, relaxed and go back to sleep without caregiver support (Cook et al., 2005). Infants can also be susceptible to triggers for trauma memories. This can present as difficulties with emotional regulation when they experience high levels of negative emotion (Schechter et al., 2019).

In preschool children, complex trauma may lead to feelings of anxiety, anger, lowered self-esteem, shame and depression (DeJong & Wilkinson, 2019; Kliethermes et al., 2014). Some young children may show new fears, such as being scared of the dark (DeJong & Wilkinson, 2019). Complex trauma experiences can also lead to struggles in emotional learning and development, including with:

  • identifying, labelling and distinguishing between their own and others’ emotions
  • expressing emotions appropriately and safely
  • coping with, and regulating, their own emotions; and
  • tolerating emotional expression in others. (Cook et al., 2005; Kliethermes et al., 2014).

If a young child has never had the opportunity to learn how to regulate and manage their emotions appropriately, this may present as:

  • being easily overwhelmed by emotions or by situations that provoke emotions (e.g. situations they perceive as challenging or difficult), including the child withdrawing (DeJong & Wilkinson, 2019; NCTSN, 2021)
  • being easily changeable in emotions or experiencing quick escalations (Cook et al., 2005); or
  • struggling to calm themselves, such as when feeling upset, angry or excited (NCTSN, 2021).

Sometimes a young child’s emotional struggles or distress might present as a physical symptom, such as a headache or stomachache (National Child Traumatic Stress Network, 2021). Some young children might also have nightmares (about things not necessarily related to the trauma experiences themselves) (DeJong & Wilkinson, 2019).

Struggles and behaviour

There can be a diverse range of changes in a young child’s behaviour following complex trauma (Kliethermes et al., 2014). These changes may include developing under-controlled and over-controlled patterns of behaviour (Cook et al., 2005; Kliethermes et al., 2014).

Under-controlled behaviours in young children may include:

  • difficulties with regulating and controlling behaviour, which can include impulsivity (i.e. a tendency to act quickly without thinking ahead or considering the consequences); or,
  • increases in irritability and aggressive responses. (DeJong & Wilkinson, 2019; Kliethermes et al., 2014)

Over-controlled behaviours can include:

  • becoming more withdrawn, which might include disengaging from situations or tasks that trigger high levels of emotions
  • attempting to rigidly control any situations/routines they can (e.g. resisting changes to daily routines, lacking flexibility in toileting rituals, attempting to control eating); and,
  • not wanting to engage in typical play activities. (Cook et al., 2005; DeJong & Wilkinson, 2019; Kliethermes et al., 2014).

These emotional or cognitive struggles may contribute to, or intensify, any concerning behaviours the child already has. For example, if a child has difficulties with higher-level thinking skills (such as impulse control and reasoning) or emotional regulation, these struggles may result in additional negative effects on their behaviour (Cook et al., 2005; Danese, 2020; DeJong & Wilkinson, 2019; Kliethermes et al., 2014).

A trauma-informed perspective suggests that any struggles a child has be viewed as part of their way of adapting to traumatic experiences (Blue Knot Foundation, 2021a). Specific behaviours might act as coping mechanisms. For example, rigid/inflexible behaviour might be an attempt to regain a feeling of control in a world that has historically been unpredictable (Cook et al., 2005). Withdrawing from or refusing to take part in particular tasks might be a strategy to avoid situations that could trigger strong emotions. Some behaviours may be re-enacting trauma (e.g. aggressive behaviour, being controlling in relationships).

These various complexities must always be kept in mind when attempting to understand a child’s behaviour. Otherwise, children may be given inappropriate labels (e.g. ‘defiant’, ‘naughty’ or ‘oppositional’) or miss out on the trauma-informed support they need to thrive.

Case study: Jack’s story part one

The following case study is drawn from practitioner experience of working with children who may have experienced complex trauma. As such, it does not represent any individual case. The entire case study (presented in two parts) shows what can happen when a trauma-informed approach is not employed, and how using such an approach can lead to better outcomes. This section illustrates the context around a child who may have experienced complex trauma.

Jack is a young boy who experienced physical and emotional abuse from infancy into toddlerhood. At around three years old, Jack is placed with a foster carer, Lisa. During his preschool year, Jack’s teacher raises some concerns about struggles he is having in particular areas of his social, emotional and behavioural functioning. Some weaknesses in Jack’s cognitive skills are also reported, including attention difficulties.

During Jack’s kindergarten year, his teacher raises concerns that he often seems to be ‘on edge’ and ‘tense’. He can also be easily startled by sudden classroom noises that don’t seem to bother other children (e.g. the loud bang of a door closing; the ring of a musical bell). Jack’s teacher also notices that he can quickly ‘shut down’ and become withdrawn, without any obvious trigger. This can sometimes make it challenging for him to complete classroom tasks. There are also some difficulties with ‘daydreaming’, paying attention, and understanding spoken instructions; Jack’s teacher carefully uses various strategies to support these weaknesses and to optimise Jack’s learning.  

During his kindergarten year, Jack finds it difficult to separate from Lisa at the start of each day. When she tries to leave the kindergarten, he clings to her and shows signs of distress such as crying uncontrollably. This anxiety at separating from Lisa gradually improves over the year. Jack’s teacher initially finds it challenging to gain Jack’s trust – but through time, patience and understanding, the teacher is able to form a relationship that provides Jack with a sense of safety.

Midway through his kindergarten year, Jack’s teacher expresses concern that he can be ‘oppositional’ and wonders if this might be linked to his preference for being ‘in control’ of situations. Jack is also prone to quick escalations in emotions. Jack’s desire for control, in combination with some difficulties with social skills and emotional regulation, also seems to be making it challenging for him to form peer connections.

At the teacher’s suggestion, Lisa takes Jack to see a paediatrician to help understand what might be contributing to some of his social, emotional, behavioural and cognitive struggles. The paediatrician decides to monitor Jack’s development and see how he progresses after transitioning to primary school. 

Critical reflection

  • At this point, what are some of the issues you would consider as you work with Jack to try to support him through his struggles?
  • Consider a time in your professional practice when you may have worked with a child like Jack. What approach did you take? How successful was that approach? Did it include a trauma-informed perspective?
  • If your approach included a trauma-informed perspective, what did that add that you might have missed if you had not adopted such an approach?

Implications for practice

Key messages

  • Trauma-informed care supports an understanding of the ‘whole-child’ and considers how early-life experiences have shaped development, as well as any struggles that might be present.
  • Regardless of whether they have a diagnosis, any infant or young child who is experiencing struggles in wellbeing should be given support to experience positive mental health.
  • Some symptoms of complex trauma overlap with other child mental health concerns. This can make it challenging to determine if a child’s struggles in wellbeing or development are purely due to trauma. Clarifying these issues requires a specialised, comprehensive assessment by a trained practitioner. Professionals can play a valuable role in helping to identify concerns and supporting referrals.
  • Through understanding complex trauma and its potential effects, professionals can guide and support families to access trauma-specific services. This can help infants and young children to thrive through timely assessment and intervention.

Consider complex trauma to understand the ‘whole child’ and move beyond diagnostic labelling

Current diagnostic labels are limited in their ability to fully understand complex trauma (Denton et al., 2016; Kliethermes et al., 2014). Therefore, some children may receive multiple diagnoses from professionals trying to fully capture the child’s various struggles (Denton et al., 2016). Multiple or inappropriate diagnostic labels for a child’s behaviours can be problematic because:

  • each diagnosis only captures part of the child’s presentation (Cook et al., 2005; Kliethermes et al., 2014)
  • multiple labels can lead to confusion rather than increased understanding (Kliethermes et al., 2014)
  • overreliance on diagnoses can foster an ongoing lack of awareness and understanding of key environmental contributors to a child’s presentation, particularly their trauma experiences (Kliethermes et al., 2014); and
  • inappropriate diagnoses may lead to prescribing medication that is unnecessary or even harmful (Barnett & Concepcion, 2018).

Many children experiencing difficulties will not have symptoms that meet levels needed for a diagnosis (DeJong & Wilkinson, 2019; Denton et al., 2016). Regardless of whether they meet diagnostic criteria, any child who is experiencing struggles in their wellbeing should be supported to move to the ‘healthy’ end of the mental health continuum (DeJong & Wilkinson, 2019; Denton et al., 2016; National Mental Health Commission, 2020).

Acknowledge symptom overlap to reduce the likelihood of inappropriate diagnoses

Some symptoms of complex trauma can overlap with those of other common mental health struggles or diagnoses (e.g. attention-deficit/hyperactivity disorder, autism spectrum disorder, oppositional defiant disorder) (Lawson & Quinn, 2013). This crossover can make it challenging to understand a young child’s social, emotional and behavioural presentation, as well as to reach a clear, appropriate diagnosis. In some circumstances, children may even receive premature or incorrect labels. Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) offer two examples of the challenges that arise when trying to distinguish complex trauma effects from child mental health diagnoses (see below).

Overlap between complex trauma effects and child mental health disorders: Case examples of ADHD and ASD

It is not uncommon for children with complex trauma histories to be referred for assessment due to concerns about possible attention-deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). These diagnoses must be comprehensively investigated with careful consideration of the trauma background (DeJong & Wilkinson, 2019).

Attention-deficit/hyperactivity disorder

ADHD is a child mental health disorder that involves changes in brain development. It is characterised by difficulties with attention, hyperactivity and/or impulsivity. ADHD is distinct from complex trauma but symptom overlap can make it challenging to determine whether a diagnosis of ADHD is appropriate (Kliethermes et al., 2014). Examples of overlapping features include:

  • Some children with complex trauma may show difficulties with arousal, dissociation or attention. In some cases, these features might be misdiagnosed as ADHD.
  • Both presentations can show struggles with higher-level thinking skills (i.e. executive functions) and emotional regulation. (DeJong & Wilkinson, 2019; Kliethermes et al., 2014).

While ADHD is certainly still possible in children with complex trauma, a specialised, trauma-informed assessment is essential for disentangling these complexities (DeJong & Wilkinson, 2019). This is especially applicable to children under four years of age, as ADHD diagnosis in this age group is particularly difficult, in part due to the rapid developmental changes occurring (American Academy of Pediatrics, 2017).

Autism spectrum disorder

ASD is a neuro-developmental child mental health disorder characterised by ongoing difficulties with:

  • social functioning (i.e. social communication and interaction); and
  • restricted, repetitive patterns of behaviour, speech, or interests (American Psychiatric Association, 2018).

Complex trauma experiences early in life can lead to symptoms that overlap with ASD features. This may lead families and/or professionals to worry that a young child may have underlying ASD. Examples of overlapping features include:

  • Children may show struggles in social development and functioning. Examples of possible challenges following complex trauma include difficulties with social skills and empathy, with possible contributors being an environment that promotes low trust in others and lacks the nurturing of social skills.
  • Some restricted, repetitive patterns of behaviour can also be seen following complex trauma. For example, while rigidity and difficulties with adjusting to change are common ASD features, these symptoms can also occur after complex trauma as an adaptive strategy to regain a sense of control and to cope with feelings of helplessness. Young children exposed to complex trauma experiences might also show repetitive themes in play, and this can present similarly to stereotyped play in ASD.

A comprehensive, specialised assessment is advisable to clarify these complexities. Paediatricians and mental health practitioners have been increasingly reluctant to confidently diagnose ASD if there is a history of complex trauma (DeJong & Wilkinson, 2019).

Understanding complex trauma is central to trauma-informed care

Understanding complex trauma and its potential effects is critical to trauma-informed care when working with infants and young children. It helps the professional to form a deeper understanding of the ‘whole child’ in terms of their unique environment, including how their experiences have shaped their development (and any struggles). It can also reduce the likelihood of a child being unintentionally re-traumatised, or even blamed for their efforts to adapt (Kezelman, 2014).

Best practice when working with infants and children with complex trauma histories involves various systems (e.g. school, health care, social services) that surround the child and family working collaboratively to offer support (Cook et al., 2005). This further supports the need for all professionals across sectors to understand complex trauma and trauma-informed care.

Awareness of complex trauma promotes timely access to appropriate supports

When professionals understand complex trauma and its potential effects, they can provide timely guidance and support to children and families who might benefit from trauma-specific services. This helps to ensure that children receive the specialised assessment and intervention they need to target the effects of complex trauma itself. Without this understanding, there is the risk that a child’s struggles might be quickly or automatically attributed to some other factor (e.g. defiance, possible ADHD), potentially leading to delays in care.

If a professional is working with an infant or young child that has a history of complex trauma – and they are uncertain whether any struggles in social, emotional and/or behavioural wellbeing can be explained by this adversity – they could explore the option of accessing specialised trauma-specific services with the family in a collaborative and sensitive way (and making referrals if appropriate).

Assessment and therapeutic work with families where the child has been exposed to complex trauma can be challenging for various reasons:

  • Extra time is often needed to build a sense of trust and safety in the child. Be mindful that the absence of an actual or physical threat does not necessarily mean that the young child will feel safe, and supporting their perceived sense of safety is also important.
  • Effects of complex trauma can overlap with symptoms of other mental health disorders.
  • Obtaining a comprehensive developmental history may be challenging if there is no access to a parent/caregiver who has known the child from birth (e.g. when a child is in out-of-home care).

Importantly, assessment and therapeutic work with children who have experienced complex trauma should always be done by professionals who are trained and skilled in this specialised work. Comprehensive approaches that consider the unique strengths and weaknesses of a child and their family are needed to support ‘thriving’ or ‘healthy’ wellbeing (DeJong & Wilkinson, 2019).

It is also helpful to consider whether additional supports or referrals might be needed for other areas of development that are at risk (DeJong & Wilkinson, 2019). Professionals can play a vital role in detecting possible child development issues, and then supporting families to connect with appropriate early intervention practitioners or services. Possible examples include paediatrician services (for developmental concerns), speech pathology (for speech or language delays), and neuropsychology (for cognitive concerns).

Case study: Jack’s story part two

Let’s return to the story of Jack. As a brief recap, Jack had been experiencing some social, emotional, behavioural and cognitive struggles. Lisa, his carer, had taken him for an assessment by a paediatrician who was monitoring his progress. This section illustrates what can happen when a trauma-informed approach is not employed, and how using such an approach can lead to better outcomes.

After a period of monitoring following his transition to primary school, Jack’s paediatrician diagnoses him with attention-deficit/hyperactivity disorder (ADHD). Jack is given various stimulant medications for ADHD during his early primary school years but they don’t seem to make a difference.

By age nine, Jack’s emotional and behavioural difficulties have worsened. He is also struggling to keep up with his peers academically. Lisa decides to seek a second opinion from another paediatrician, Dr Jane Smith. Dr Smith comes highly recommended by another foster carer in Lisa’s network, due to her expertise in working with children with trauma histories.

Lisa gets a second opinion from Dr Smith. She suggests that many of Jack’s struggles, including with attention, may be due to early childhood trauma. She also wonders if this might be why the medications prescribed for suspected ADHD were unsuccessful. After a discussion with Lisa and Jack, Dr Smith refers Jack to a trauma-specific service.

The trauma-specific service performs a comprehensive assessment to understand the impact of Jack’s early life experiences on his functioning, as well as to inform a plan for intervention and support. The assessment reveals that Jack’s struggles, including with attention and behaviour, can be explained by his complex trauma history. Therapeutic trauma-specific services are provided, which focus on building on Jack’s strengths and communicating messages of hope. With the support provided to both Jack and Lisa, Jack’s social, emotional and behavioural wellbeing starts to improve.

Critical reflection

  • Have there been times in your career when your work with children has been negatively affected because they have been misdiagnosed?
  • How have you attempted to support the child and their family through the process of receiving a more appropriate diagnosis and treatment?
  • How have families responsed to misdiagnosis and/or a more accurate diagnosis that was able to support the child to achieve better outcomes?

What to do when child safety issues arise

Child safety issues may sometimes arise that are beyond a professional’s scope of practice or training (e.g. concerns about suspected or confirmed child abuse and/or neglect). Professionals must be aware of their mandatory and organisational reporting responsibilities when they suspect a child is at risk of harm – and contact should be made with the appropriate child protection service in their state/territory. Consulting up-to-date information can also be helpful: see Mandatory reporting of child abuse and neglect; Reporting child abuse and neglect: Information for service providers.

Ensuring that parents and caregivers are supported

Infant and child mental health is a positive state of wellbeing influenced by multiple factors, including environmental and social factors, that interact in a complex way. Children’s wellbeing can be promoted in a range of ways, including through prevention and early intervention. In particular, it is important that the parent/caregiver is supported with any struggles they may be facing, as this can have positive flow-on effects for child development and wellbeing. Hence, a whole-of-family approach is needed when working with infants and young children. This includes helping parents/caregivers to access any supports they may need for themselves (DeJong & Wilkinson, 2019). This should always occur through a collaborative discussion that is sensitive, supportive and non-judgemental.

Whether or not extra support is needed, and the kinds of referrals or services that might be appropriate, will depend on the family’s individual circumstances. Examples of services that might be offered to parents/caregivers in response to particular needs include:

  • Emotional support: Parents/caregivers could be encouraged to speak with their general practitioner to explore whether a referral to a specialist (e.g. psychologist, counsellor) might be helpful and/or appropriate.
  • Parenting assistance: Professionals may offer parents/caregivers information about local services or qualified practitioners (e.g. family support workers, psychologists) that offer specialised parenting support (including referrals if this is within the professional’s role). The Raising Children Network provides a list of providers in each state/territory.
  • Domestic and family violence support: Professionals can access information about supporting children and families who have experienced family and domestic violence from 1800Respect (the National Sexual Assault, Family & Domestic Violence Counselling Service), as well as from the Emerging Minds courses listed under the Suggested resources for professionals at the end of this resource. The Australian Government’s Stop it at the start campaign provides a list of family and domestic violence support services (including by state/territory and target group).
  • Support for their own trauma experiences: Parents/caregivers may have experienced trauma themselves. If these experiences seem to be fostering ongoing struggles (e.g. emotional difficulties), then encouraging parents to discuss these issues with their GP could be helpful. This may assist with referrals for additional support (e.g. psychology, trauma-specific services) (DeJong & Wilkinson, 2019; Paterson, Price-Robertson, & Hervatin, 2021).

Self-care when working with children who have experienced complex trauma

Working with infants and young children who have experienced complex trauma can be a rewarding and meaningful experience, but it can also be challenging at a professional and personal level (Children’s Hospital of Philadelphia Research Institute, 2021; Kliethermes et al., 2014). Hearing about the traumatic experiences of a child or family can be confronting and distressing. It might even lead to the professional feeling overwhelmed, stressed or emotionally or physically fatigued (Australian Child and Adolescent Trauma Loss and Grief Network, 2010). It is important to be aware of the potential impact this kind of work can have on one’s wellbeing, as well as the need for self-care.

The Health Care Toolbox offers a range of helpful self-care tips to consider. Emerging Minds’ self-care planner can help you to identify your own personal signs of stress and plan strategies to manage your stress and emotions. You can also download a completed version of the planner to use as a guide.

Critical reflection

  • Working with children who have experienced complex trauma can be challenging for practitioners. Explore what options you have available for self-care, and make sure they are in place and accessible, so you can draw on them easily.
  • Parents and other caregivers in the lives of infants and young children who have experienced complex trauma may also need support. What options do you have available to present to caregivers when they are needed? Reflect on when you might present these options – helping caregivers to put support in place early on can be the best option.

Conclusion

The purpose of this resource is to introduce complex trauma and trauma-informed care as essential concepts to consider and implement when working to support the mental health and wellbeing of infants and young children. Incorporating these concepts can help to achieve a ‘whole-child’ perspective where any social, emotional and behavioural struggles are viewed as the child adapting to their world and its adversities – rather than as ‘pathologies’ or behaviours for which the child is blamed. This is essential so that unwarranted diagnoses are avoided and infants and young children receive appropriate care and support as early as possible.

By being aware of complex trauma, professionals can play a vital role in connecting infants, children and families with appropriate services as early as possible. This includes ensuring that parents/caregivers are also supported, as this can have positive flow-on effects for parenting and children’s wellbeing. Adopting a trauma-informed approach also promotes recovery and resilience, and supports the rights of Australian children to enjoy positive development and mental health. This has the potential for beneficial flow-on effect for a healthier and more productive Australian society.

Suggested resources for professionals

Emerging Minds e-learning courses

The impact of trauma on the child – This foundation course introduces the impacts of trauma on children and families, as well as ways to provide support through a trauma-informed approach.

Supporting children who have experienced trauma – This course provides guidance on supporting children who have experienced trauma through trauma-informed practice. It is designed for practitioners who work with children who have experienced trauma (and their families).

The impact of family and domestic violence on the child – The first of two e-learnings, this course introduces practitioners to the impact of family and domestic violence on children. It is primarily designed for practitioners who work in adult-focused services but can be used by other professionals.

Family and domestic violence and child-aware practice – The second of two e-learnings on family and domestic violence, this course explores practice skills and opportunities for supporting children’s mental health and wellbeing.

Emerging Minds webinars

Practice skills of working with children who have experienced trauma – In this webinar, a panel of guest speakers describe the skills practitioners can use to engage children who have experienced trauma, and the therapeutic theories that underpin these skills.

Engaging children and parents affected by child sexual abuse – This webinar discusses strategies for practitioners to consider when working with children who have experienced sexual abuse and their families. It features an interdisciplinary panel discussion of a case study.

Collaborative practice in child and family welfare: Building practitioners’ competence – This webinar, co-produced by CFCA and Emerging Minds, explores strategies for improving cross-sectoral relationships between child protection and government and non-government partners.

The effects of trauma on children’s mental health – This webinar explores the effects of trauma on children’s mental health using a case study from Emerging Minds’ e-learning courses. It also provides practical examples of how GPs can engage with parents and children.

The effects of adverse experiences on children – This webinar uses a case study to explore the key characteristics of adverse childhood experiences (ACEs), their prevalence and their impact on children in Australia. It also presents strategies that practitioners can use to support parents and children to make sense of adversity, in order to promote resilience and recovery.

Emerging Minds podcasts

Supporting the communication needs of children with complex trauma (part 1) – This is the first in a two-part conversation exploring the role of speech pathology in supporting children who’ve experienced complex trauma. Speech pathologist Kate Headley provides rich examples of how she builds trusting relationships with children to support their language and communication needs.

Supporting the communication needs of children with complex trauma (part 2) – In part two of this series, speech pathologist Kate Headley continues to explore the approaches she uses to ensure her work is child-centred, and elaborates on the role of speech pathology in a multidisciplinary complex trauma service.

An interview with Secrecy – In this interview, Secrecy discusses their work in preventing children from disclosing child sexual abuse. They explain how they convince children that nobody will believe them or accept them if they tell them what has happened. Secrecy also talks about the work they do in society to keep abuse hidden and to suppress the rights of children.

An interview with Shame – Children who experience violence or trauma at home commonly experience increased feelings of shame over time. Without support, these feelings can have significant negative effects on children’s mental health, and can convince them that they are responsible for adult perpetration of violence.

An interview with Resilience – Resilience is a crucial part of positive mental health in infants and children. It is important that people who work with children have a sound understanding of the factors that help children to grow, stay strong and remain present.

Other resources from Emerging Minds

Making use of practitioners’ skills to support a child who has been sexually abused – This practice paper draws attention to the issue of child sexual abuse (CSA), and highlights the skills all practitioners have that can support children and the key principles that can support practice when working with CSA.

Working and walking alongside Aboriginal and Torres Strait Islander children and young people: A practical guide for non-Indigenous workers – To fully understand the lives and circumstances of Aboriginal and Torres Strait Islander families, it is necessary to understand and accept the impacts of trauma across generations, without judgement, but with clear insight and intention to use your skills and capacities for healing. This resource is designed to provide information, concepts, practical skills and suggestions to guide non-Indigenous professionals working with Aboriginal and Torres Strait Islander children and young people and their families/communities.

Useful links

Australian Childhood Foundation – Provides specialised support, including therapeutic services, to promote the recovery of infants and children who have experienced trauma. Their website also offers various resources to support professionals and organisations in their work.

Australian Child and Adolescent Trauma, Loss and Grief Network (Australian National University) – The Network’s ‘Resource Centre’ aims to support professionals in their work with infants and children who have experienced trauma, loss or grief. Resources cover a diverse range of topics, including child maltreatment and trauma in the perinatal period.

The National Child Traumatic Stress Network – This organisation is located in the USA and aims to strengthen the care and support of children and families who have experiened trauma. Their website offers helpful resources for both practitioners and families.

Blue Knot Foundation (National Centre of Excellence for Complex Trauma) – This Australian organisation provides support to adult survivors of childhood abuse and trauma, including through specialist counselling services via the Blue Knot Helpline. The website also contains resources for practitioners and organisations about complex trauma and trauma-informed practice.

Berry Street – This Victorian-based organisation provides a range of services to children and families, including those who have experienced trauma and adversity. Berry Street also offers a state-based therapeutic trauma service (i.e. ‘Take Two’). Their website provides helpful resources for professionals and the general public, as well as links to training and other learning options.

Neurosequential Model of Therapeutics – Developed by Dr Bruce Perry, this model offers a developmentally-sensitive approach to working with children and families who have experienced trauma. The model is informed by core principles of childhood brain development and trauma.

Open access journals

Complex trauma – This article from Child and Adolescent Psychiatric Clinics of North America explores the prevalence and causes of complex trauma in children and adolescents. The article also discusses family- and system-related issues, assessment, diagnosis and clinical intervention.

Complex trauma in children and adolescents – This article from Psychiatric Annals explores how interventions in cases of complex trauma should build strengths as well as reduce sypmtoms. In this way, treatment for children and adolescents also serves as a prevention program against poor outcomes in adulthood.

Suggested resources for parents

The impact of trauma on the child – This Emerging Minds e-learning course is designed to introduce parents/caregivers (as well as professionals) to the impact of trauma on the child and their family. It includes a discussion of how to provide support through a trauma-informed approach.

The in utero experience: Trauma before birth – This PDF from the ACT Government provides both professionals and parents/caregivers with helpful explanations of how trauma can impact the child while they are still in utero. Guidance is also provided on what professionals can do to help the child and their family, as well as how parents/caregivers can support their child.

Authors and acknowledgements

At the time of writing, Michele Hervatin was a Senior Research Officer at the Australian Institute of Family Studies (AIFS).

Special thanks to Nikola Balvin, Trina Hinkley, Nerida Joss and Kathryn Lenton for assistance in preparing this resource, and to Dan Moss and Jacquie Lee for their helpful feedback on the final draft.

Views expressed in this publication are those of the individual authors and may not reflect those of the Australian Institute of Family Studies or the Australian Government.

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