Common Client Issues in Counselling An Australian Perspective Trauma in Children and Adolescence

TRAUMA IN AND ADOLESCENCE 189 Trauma in Children and Adolescence AND AMY ABSTRACT Children and adolescents with presentations represent an important priority group for counsellors . Effective engagement and helpful interventions during this critical developmental phase have the potential to result in better coping trajectories throughout the life course . This chapter will provide an overview of trauma indicators in youth populations as well as associated changes young clients may experience as a result of trauma . This chapter is not intended to provide an exhaustive summary or all areas of youth trauma nor intended to be a compendium for use of interventions within these populations . Learning Objectives Describe trauma symptoms in childhood and adolescence . Describe changes in emotions , behaviours , and thoughts . Describe changes in attachment and relationships . INTRODUCTION Research has shown that the psychological impact of traumatic events can be different for children and adolescents , compared to adults exposed to such events ( 2015 ) Some examples of traumatic experiences in childhood include , but are not limited to physical , emotional , or sexual abuse or neglect witnessing or being the direct victim of domestic , community , or school violence severe motor vehicle other accidents natural and disasters violent or accidental death of a parent , sibling , or other important attachment figure exposure to war , terrorism , or refugee conditions and multiple traumatic events . It is important to first acknowledge that it is normal for children and adolescents to experience emotional distress and other reactions following traumatic events . Some emotional reactions have been found to be adaptive , and many children and adolescents find a way to cope and recover fairly quickly , but not all do . Some will present with symptoms that are consistent with a of which may be . A on the incidence of based on 43 independent samples of children and adolescents that were assessed with diagnostic interviews revealed an overall prevalence of 15 ( et , 2014 ) 189

190 TRAUMA SYMPTOMS IN CHILDHOOD AND ADOLESCENCE Several factors , including developmental level , inherent or learned resiliency , and sources of social support , may influence which children or adolescents develop difficulties . Research has shown that the level of exposure ( proximity to the event , level of involvement ) to a traumatic event , combined with a perception of a threat to life ( or threat to the life of a loved one ) are most consistently associated with problems related to ( Pine Cohen , 2002 ) Children and adolescents have unique ways of understanding traumatic events they can differ in how they make meaning of such events in relation to themselves , how they access familial and other forms of support , and how they integrate these events into their identity and sense of self ( Van Horn , 2009 ) Early intervention appears crucial for children and adolescents experiencing symptoms , to mitigate the risks for mental health concerns into the future . For example , a of the children who survived the landslide disaster found that 29 of those traced and interviewed still met criteria for ( Morgan et , 2003 ) In other words , in the absence of effective therapy , the effects of traumatic events in childhood can be adverse . Children and adolescents are often brought to counselling because of behavioural or emotional rather than because of their exposure to traumatic events . Since parents , caregivers , and other adults may not understand that these problems are related to these traumatic experiences , it is critical to recognise , identify , and make connections between trauma reminders and the child or adolescent presenting concerns . Doing so helps the family better understand the problems as trauma responses , allowing them to embrace the need for interventions that are informed by the impact of these traumatic experiences . The remainder of this section will summarise some key developmental considerations across various domains , when identifying and understanding trauma in children and adolescents . CHANGES IN EMOTIONS AND AFFECT Fear is both an instinctual and learned reaction to frightening situations . Children and adolescents instinctively experience fear in situations that they perceive as being situations . It is important here to recognise that a child or adolescent perceptions of such situations may be different to those of the caregivers and may otherwise view such situations as relatively benign . For example , a child who was in a serious car accident may become very frightened whenever they ride past the location of the accident . This fear response can then become so that people , places , or objects that are objectively innocuous but remind the child of the traumatic event will cause the same level of fear as the original trauma ( et , 2003 ) For instance , the child exposed to the car accident in the aforementioned example , might experience intense fear when riding in a of where the car was being driven to . In addition to specific fears , more diffuse anxiety may develop due to the sudden , unpredictable nature of the traumatic experiences . This anxious state may leave children and adolescents feeling generally unsafe and hypervigilant , on guard to protect themselves from being taken by surprise the next time . This sense of impending danger can impinge on a child ability to engage in developmentally appropriate tasks ( Perry , 2017 ) Such feelings of insecurity can lead to a range of behaviours , including disengaging from school , disengaging from appropriate peers , or even becoming aggressive in the belief that this is the only way to survive and not once again be the victim in traumatic circumstances . In this way , constant vigilance for possible omens of future threats and other behaviours begins to interfere with healthy adjustment and development ( et , 2019 ) Children and adolescents may develop sad or depressive feelings along with symptoms . Specifically , traumatic grief after a death or traumatic separation that might occur suddenly , perhaps due to parental incarceration or placement in foster care ( Cohen et , 2016 ) Natural disasters may result in children adolescent loss of personal belongings , their homes , or even the lives of loved ones . In the face of these real losses , children and adolescents often develop beliefs or ( described later in this section ) which significantly contribute to depressive and other negative emotional states . Children

TRAUMA IN AND ADOLESCENCE 191 developmentally appropriate egocentric view of the world may lead to for the traumatic event , which in turn may lead to depressive symptoms that include guilt , shame , diminished , feelings of worthlessness , and even a longing to die ( Cohen et , 2016 ) Grief reactions can manifest themselves in the form of persistent thoughts of suicide and may represent an adolescent attempts at reuniting with a deceased parent or attachment figure . Anger may result from the awareness that the traumatic event was unfair in the sense that the child or adolescent did not do anything to deserve the trauma . Other children and adolescents , particularly those experiencing physical abuse or bullying , may develop anger as they observe the behaviour of caretakers or others who cope inappropriately with difficulties or frustrations ( 2006 ) Anger in traumatised children and adolescents may take the form of behaviour , unpredictable rages or tantrums , or physical aggression toward property or other people . While it is important to clarify myths about all children and adolescents exposed to traumatic events becoming sexual predators or criminals . Careful assessment is required to clarify concerns about bullying , sexual aggression , and other possible coercive forms of antisocial behaviour ( et , 2019 ) Chronically traumatised children and adolescents may become highly sensitive and to perceived rejection because parental or other rejection in their past experience was associated with , and served as an early warning signal for , abusive or other traumatic acts . For example , one study indicated that children who have been physically abused perceive angry faces ( a trauma reminder for such children ) more readily than abused children ( Pine et , 2005 ) These children often display emotional changes in mood or affect accompanied by difficulties in modulating their emotions and regaining calm ( Teicher et , 2019 ) Severe emotional occurs more commonly in children and adolescents who are impacted by the cumulative harm of multiple traumatic experiences ( child abuse or domestic violence ) than in children who have experienced a single , traumatic event . These children and adolescents often lack a nurturing , supportive , and coping response from parents and caregivers after traumatic events . Such supportive responses model to children and adolescents the skills required in managing emotions , while demonstrating to them the value of seeking support from a safe and benevolent adult ( Hughes et , 2019 ) Children and adolescents who live in a household where they are exposed to domestic violence are at higher risk of being exposed to interactions with adults where their feelings are invalidated and disregarded . In fact , some children and adolescents are even punished by their caregivers for displaying feelings of fear , sadness , or anger . Thus , while traumatised children and adolescents may certainly benefit from learning skills to modulate their emotions , the cumulative harm of multiple past or current experiences of threat and maltreatment may interfere with a child capacity to use and benefit from counselling . Children and adolescents who are currently experiencing interpersonal trauma of this nature should be considered at risk and steps should be taken to ascertain whether a mandatory report is required to protect the child or adolescent from further . Helping a child or adolescent regulate their emotions by developing a sense of safety in the counselling environment may be the first task of counselling . While this may take longer for some children and adolescents who have experienced trauma compared to others , a child or adolescent ability to see counselling as a safe and supportive process is often a therapeutic intervention in may be aided through use of creative approaches such as art or puppets ( Desmond et , 2015 ) CHANGES IN BEHAVIOUR In order to escape overwhelming negative feelings , children and adolescents may try to avoid thoughts , Mandatory reporting of child maltreatment is a requirement of the Codes of Ethics of the accreditation bodies of counselling in and Counselling Federation ( see Code of Ethics , Section Ethical Standards of Clinical Practice ) and Australian Counselling Association ( see Code of Ethics , Section Exceptional Circumstances ) In , 2021 , a new section , was inserted into the Criminal Code Act 1899 ' making it a crime , punishable by up to years imprisonment , for all adults who , without reasonable excuse , fail to report child sexual abuse to police .

192 people , places , or situations that trigger recollection of their traumatic experiences . Unfortunately , such avoidance is seen to be linked to the of previously benign and safe situations begin to be associated with previous traumatic experiences , based on their resemblance to these circumstances ( Cohen et , 2016 ) It is difficult , if not impossible , for children and adolescents to avoid all trauma reminders . For a child or adolescent who has witnessed ongoing domestic violence , both parents may be trauma reminders . For a child or adolescent experiencing pervasive , ongoing community violence , their whole neighbourhood may become a trauma trigger . Among children and adolescents who are easily triggered and experience pervasive reminders of past traumas , avoidance is not a viable nor effective term management strategy . When avoidance is unsuccessful in protecting children and adolescents from overwhelming negative emotions , they may develop emotional numbing , or in more severe cases , dissociation . behaviours may also develop in response to modelling or traumatic bonding ( 2002 ) Modelling occurs when children who grow up in abusive or violent homes and communities have many opportunities to observe and learn behaviours and coping strategies . They may also see those behaviours being repeatedly the form of the perpetrator continuing to be in a position of power ( Foa et , 2008 ) Aggression and persistent behaviour have been linked to a phenomenon referred to as traumatic bonding . Traumatic bonding involves both modelling of inappropriate behaviours and attachment dynamics ( Dutton Painter , 1993 ) It also involves the acceptance of inaccurate explanations for inappropriate behaviours . In such situations , children and adolescents both fear and love the abusive parent . Such children and adolescents may bond with the violent parent out of . To manage the guilt and cognitive dissonance associated with turning against the victimised parent , these children and adolescents may adopt the violent parent views , attitudes , and behaviours toward the victimised parent and become abusive or violent themselves ( 2002 ) Other behaviours may emerge in children and adolescents including the avoidance of healthy peer interactions , with these children and adolescents preferring to associate with children and adolescents who share similar emotional and behavioural difficulties . Their choice of friends likely relates to the negative that many traumatised children and adolescents develop . These children and adolescents have been found to fear rejection by normal peers and find that associating with children and adolescents experiencing similar situations , such as those with ongoing maltreatment , feels more familiar or comfortable . The anger that many traumatised children and adolescents develop is typically manifested through oppositional , aggressive , destructive behaviours ( et , 2009 ) Children and adolescents who have experienced trauma are also at greater risk for substance abuse ( Barrett et , 2019 ) which may be used as a strategy for avoiding trauma reminders , a way of coping with negative image , or may arise as a result of associating with other children and adolescents engaging in antisocial behaviour . Other behaviours may include engaging in sexual behaviours driving under the influence of drugs or alcohol using guns , knives , or other weapons without considering the consequences ( Thompson et , 2017 ) behaviours place the youth in circumstances in which there is a high likelihood of experiencing causing serious injury or death . The serious risks of some youth behaviours warrant starting with interventions that reduce the risk of them engaging in these behaviours and enhancing their safety . such as cutting or burning , as well as suicidal behaviours , are also associated with childhood trauma . Adolescents who engage in describe these as methods for reversing the numbness that they feel . Others may be seeking connection and a sense of belonging that they feel unable to gain in more adaptive ways . Some youth describe cutting behaviour as a means of managing anxiety ( Thompson et , 2017 ) Sometimes children and adolescents are entrusted with the caretaking tasks for younger children an impaired parent . Over time , the family often comes to expect one child or adolescent to take on caretaking tasks and they come to believe that this is their indispensable family role , both of which contribute to maintaining the child or adolescent ( et , 2019 ) Also referred to as , such persists even if the child or adolescent is removed from the family home and placed

TRAUMA IN CHILDREN AND ADOLESCENCE 193 in alternate or foster care ( et , 2019 ) Helping such children and adolescents learn appropriate developmental functioning ( to just be a child ) is often an important goal in counselling . CHANGES IN THINKING AND BELIEFS The intrusion of fearful thoughts and memories is characteristic of in children and adolescents itself in the form of intrusive , frightening thoughts during the day or scary dreams at night . In younger children , the content of these frightening dreams may not be related to the traumatic event in an obvious way , but may instead depict other frightening things and the development of new fears , with no apparent relationship to the trauma other than temporal proximity ( et , 2003 ) Following a traumatic event , children and adolescents typically search for an explanation for why something so terrible has happened to them or their loved ones . If no rational explanation is found , children may develop inaccurate or irrational beliefs about causation in order to gain some sense of control or predictability . A common irrational belief involves children and adolescents blaming themselves , either by taking responsibility for the event itself ( I was sexually abused because I wore a provocative dress ) or for not foreseeing and avoiding the event ( I should have known the flood was coming did I warn mum and dad that the water was coming ?

Alternatively , although not blaming themselves directly for the traumatic event , children and adolescents may come to believe that they are bad , shameful , or otherwise lacking in some way bad things happening to them ( I must be stupid for this to have happened to me ) Cohen et , 2016 ) In this manner the world remains fair , predictable , and makes sense it is only they who are deserving of bad fortune . Developing realistic of responsibility ( blaming the perpetrator ) is often more difficult and painful for children and adolescents than blaming themselves . Children and adolescents may their experience of betrayal by one person to mean that no one is trustworthy . This belief can lead to difficulties in peer relationships or in the child or attachment to the parent and other adults , which may further contribute to the child or impaired ( the child undermines these relationships , then attributes the disappointment to their own personal failings ) Children and adolescents may respond to a betrayal of trust by repeatedly trying to correct their experience by seeking out inappropriately close relationships with peers or adults who may or may not be safe . Underlying these behaviours are often beliefs about what it means to be involved in a loving relationship ( It normal to have some violence in every relationship ) Cohen et , 2016 ) Adjusting these beliefs is a critical component for successfully treating these youth ( Cohen et , 2016 ) Unhelpful thoughts can also contribute to negative affective states and behaviours because they are not to accurately reflect reality , or they focus only on the negative aspects of situations . For example , the cognition anybody could sexually abuse you might be true in a given environment , but equally true is the alternative cognition , most men do not sexually abuse children . It is clear that the first thought is likely to promote fear and avoidance , whereas the second , equally accurate thought is more reassuring and hopeful ( Cohen et , 2016 ) Traumatised children and adolescents often experience inaccurate unhelpful that reinforce their negative expectations of others and their destructive . CHANGES IN ATTACHMENT AND RELATIONSHIPS As with all aspects of early childhood development , it is important to understand the impact of such traumatic events in the context of their significant relationships , namely the relationship ( Hughes et , 2019 ) For example , a disaster home environment may mean that some parents and other caregivers are unable to provide basic needs such as food , clothing , or shelter . For families severely affected by natural disasters , and unstable living arrangements are common . For children , this may mean moving to a new home , a new school , and a general lack of familiarity with their new surroundings . Coping with such changes and transitions can be difficult , and sometimes distressing , for young children ( et , 2016 )

194 Parents who perpetrate ongoing interpersonal traumas ( child abuse or neglect domestic violence ) also disrupt the primary attachment relationship upon which children learn and model future trusting interpersonal relationships ( Hughes et , 2019 ) The result of such disruption is typically profound these children experience ongoing challenges when attempting to establish new relationships since the possibility of any trusting relationship itself serves as a trauma reminder of the caretakers who perpetrated the initial maltreatment . Children and adolescents who experience trauma may withdraw from peers or have difficulty enjoying social activities . Children and adolescents who feel shame or stigma related to their trauma experiences may not share these even with very close friends , leading to a change in the tenor of such friendships at times when children and adolescents are in even greater need of close friends ( Perry et , 2018 ) As noted above , after trauma experiences , some youth feel that their usual peers will not understand their experiences , and they begin to affiliate with deviant peers based on the assumption that only these youth can relate to their feelings of being different and the outside . Such affiliation can place the youth at heightened risk for additional trauma exposure and the development of more severe trauma responses . CONCLUSION In summary , although some children and adolescents who experience traumatic events are able to cope and recover , many others develop symptoms related to trauma . These symptoms can have a profound and negative impact on their development , health , and safety . The impact of traumatic may manifest uniquely in children and adolescents and can be observed across multiple domains of , relationships , cognition , and behaviour . While early referral and intervention are crucial ( such as seeking additional support , helping to a regular routine , and allowing the child or adolescent to share their concerns ) it is important for counsellors to be informed of how such traumatic experiences may impact on the child or adolescent presenting concerns and how trauma can influence the child , adolescent , and their family . The establishment ofa safe , calm , and predictable counselling environment , and therapeutic relationships , are the foundations of supporting a child or adolescent recovery from trauma . It is recommended that counsellors seek additional training and supervision in relation to providing more detailed therapeutic interventions for this population . LEARNING ACTIVITIES Learning Activity Please read the following journal article on a case study of the application of cognitive behaviour therapy with a boy , A . 2019 ) cognitive behavioral therapy with a old boy . Clinical Case Studies , 18 ( Questions How do your personal values and beliefs influence your reactions to the case material ?

How do trauma symptoms manifest in Casper difficulties ?

How might the complicating factors and access and barriers to care be overcome for children like Casper ?

TRAUMA IN AND ADOLESCENCE 195 Learning Activity What are your thoughts about how the intervention for Casper in Learning Activity is similar or different to supporting an adult with concerns relating to stress ?

Do you think you would feel more comfortable providing counselling with or adults ?

Why ?

What could assist you to develop more experience or in providing support or counselling to those at different developmental stages ?

RECOMMENDED READINGS Cohen , 2012 ) children and adolescents Treatment applications . Press . 2012 ) A road less travelled A guide to children , emotions and disasters . Authors . Teicher , Perry , Farmer , Hughes , 2019 ) The handbook of therapeutic care for children approaches to working with traumatized children and adolescents in foster , kinship and adoptive care . Jessica Publishers . GLOSSARY OF TERMS a child or adolescent is regularly expected to provide emotional or practical support for a parent or caregiver traumatic both modelling of inappropriate behaviours , attachment dynamics , and acceptance of inaccurate explanations for inappropriate behaviours REFERENCES , Van , Larsen , 2014 ) Rates of stress disorder in children and adolescents . The British journal , 204 ( 2002 ) The batterer as parent Addressing the impact of domestic violence on family dynamics . Sage Publications . Barrett , Adams , Kelly , Peach , Back , Mills , 2019 ) Service provider perspectives on treating adolescents with and substance use Challenges and rewards . Advances in Dual ( A . 2006 ) Treatment for children with disorders Dyadic developmental psychotherapy . Child and Adolescent Social Work journal , 23 ( Sanders , 2016 ) The role of parents , parenting and the family environment in children mental health . Current Psychiatry Reports , 18 ( Cohen , 2016 ) Treating trauma and traumatic grief in children and adolescents . Publications . Desmond , Smith , 2015 ) Using creative techniques with children who have experienced of Creativity in Mental Health , 10 (

196 Dutton , Painter , 1993 ) Emotional attachments in abusive relationships A test of traumatic bonding theory . and Victims , Foa , Cohen , A . 2008 ) treatments for Practice guidelines from the International Society for Traumatic Stress Studies . Press . Brawner , Perry , Brandt , Collins , 2019 ) Beyond the ACE score Examining relationships between timing of developmental adversity , relational health and developmental outcomes in children . Archives of Psychiatric Nursing , 33 ( Hughes , Golding , Hudson , 2019 ) Healing relational trauma with interventions Dyadic developmental psychotherapy with children and families . Norton Company . A . 2019 ) cognitive behavioral therapy with a boy . Clinical Case Studies , 18 ( Ray , Berg , Covington , Vasquez , 2009 ) Impact ofa comprehensive whole child intervention and prevention program among youths at risk involvement and other forms of delinquency . Children Schools , 31 ( 2015 ) Treating complex trauma in children and their families An integrative approach . Sage Publications . Morgan , Williams , Jasper , Lewis , 2003 ) The disaster of survivors . The of Psychiatry , 182 ( Perry , Griffin , Davis , Perry , Perry , 2018 ) The impact of neglect , trauma , and maltreatment on Implications justice practice , and policy . In Beech , Carter , Mann , The Wiley handbook neuroscience ( Wiley . Perry , 2017 ) The boy who was raised as a dog And other stories from a child psychiatrist traumatised children can teach us about loss , love , and healing . Basic Books . Pine , Cohen , A . 2002 ) Trauma in children and adolescents Risk and treatment of psychiatric sequelae . Biological psychiatry , 51 ( 01 ) Pine , A . 2005 ) Trauma , proximity , and developmental psychopathology The effects of war and terrorism on children . 30 ( 10 ) Myers , 2003 ) New findings on alternative criteria for in preschool children . journal of the American Academy of Child Adolescent Psychiatry , 42 ( I . 2019 ) An upbringing with parents Experiences of and dysfunctional communication . Nordic Studies on Alcohol and Drugs , 36 ( Teicher , Perry , Farmer , Hughes , 2019 ) The handbook of therapeutic care for children approaches to working with traumatized children and adolescents in foster , kinship and adoptive care . Jessica Publishers . Thompson , Lewis , English , Proctor , 2017 ) Child maltreatment and risky sexual behavior Indirect effects through trauma symptoms and substance use . Child Maltreatment , 22 ( Van Horn , A . 2009 ) Using dyadic therapies to treat traumatised young children . In , Ford ( Treating traumatised children Risk , resilience , and recovery ( Francis Group . Hodge , 2019 ) Effects of childhood on in juvenile correctional facilities The mediating role of trauma symptomatology . Youth Violence justice , 17 (

TRAUMA IN CHILDREN AND ADOLESCENCE 197 AUTHOR INFORMATION , University of Southern is a clinical psychologist and senior lecturer in the School of Psychology and Wellbeing at the University of Southern . He has worked for over a decade in both public and private sectors offering child and adolescent mental health services . As a of the Trauma Informed Positive Behaviour Support ( program , research and clinical experience has focused on addressing the social and emotional needs of children and adolescents impacted by child maltreatment . Amy , BA , MAPS , University of Southern Professor is a clinical and health psychologist in the School of Psychology and Wellbeing at the University of Southern . She has worked for over twenty years across public and private sectors working with clients who experience mental and physical health . Professor research and clinical experience focuses on novel health promotion initiatives to reduce health disparities in partnership with priority communities . Please reference this chapter as , A . 2023 ) Trauma in Children and Adolescence . In , Machin du ( Common Client Issues in Counselling An Australian Perspective . University of Southern .