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In 2014 there were approximately 74 million children under the age of 18 in the United States. Of that number about 3 million are maltreated every year and suffer from a variety of trauma and behavioral health symptoms.

Therapists working with maltreated children see the immediate effects of their trauma among this group in symptoms of anxiety, depression, self-harm, suicidality, and difficulty with relationships.   This is the trauma turned inward upon themselves.  The Ace’s study reported by the CDC confirmed that childhood adverse events such as childhood abuse of all kinds (physical, emotional, and sexual) had a graded relationship with adult risk behaviors and diseases including alcoholism, drug abuse, depression, and suicide attempts.  The more trauma people had in childhood, the more risk behaviors and physical and mental diseases they had in adulthood.  This means that trauma harms the child and for some, the effect lasts into adulthood.

To help explain this phenomena think for a minute of children and their total trust of and dependency upon adults.  In a safe environment, they trust adults completely and learn from them how to cope with what the world hands them.  Developmentally, big people are all powerful and all good and little people know nothing and must depend on big people completely.  What big people praise is “good” and what they punish is “bad.”  This is an early childhood developmental stage.  Praising a child’s accomplishments, strengthens that particular coping skill which will be needed to be successful in life.  This is one reason why in raising children, praise should always outweigh punishment by a factor of 4 to 1. 

When children are harmed or even excessively or harshly punished by those responsible for their care, they may assume they are unlovable or that they are “bad.”  They may turn their shame and self hatred inward toward themselves.  This is the world turned upside down for these children.  “The world is supposed to be safe,” They may think.  “ My parents are supposed to take care of me!  My parents are perfect, yet they do not treat me as if they love me. I must be “unlovable.”  This must be my fault,” they might think.  They may build a shell between themselves and a world of people that they do not understand or trust.  The shame of being unloved is turned inward toward themselves.  It becomes depression, anxiety, suicidality, low self-worth, withdrawal, and self-harm.

It takes time and patience and caring for a therapist to break through the self protective wall and show these children that someone can care for them and not harm them.  However, I caution therapists that to start to heal the child’s relationships to others while someone at home is still hurting the child is a very risky proposition.  If you cannot help those in the home create a safe place for the child, you must teach the child to live in two worlds, one that is safe and one that is not.  It becomes urgent that they be able to tell the difference between the two types of environments and people.  They may still need to continue to use the coping strategies they have learned over the years in their dangerous environment.

Then there is the “rest of the story.”

Some youth turn their hurt and shame outward into acting out behaviors.  It is much harder to help a child that is angry and defiant.  Many therapists use the diagnosis, Oppositional Defiant Disorder.  It is a diagnosis I rarely use, if ever. It gives me a negative perspective of the child.  I don’t need that to gain empathy for the youth.  I use a diagnosis not yet recognized by the DSM committee in the cases of prolonged childhood trauma, Developmental Trauma Disorder (Bessel Van der Kolk).   These children are hard to reach and hard to love. Their shield is very hard and thick.  They function as if they are in a developmental stage more like that of a toddler in terms of functioning and coping in everyday life.   If we could see them as having a 2 year old temper tantrum in a 13 year old body, the change in perspective might give us ideas about using developmentally informed treatment.

Childhood trauma can be related to symptoms turned outward, as well.  However, the evidence between childhood trauma and acting out behaviors is less direct.  The ACE’s study distributed by the CDC does not show a direct relationship between adverse childhood experiences and outwardly directed behavioral health problems such as delinquency, but it does show a relationship to substance abuse which is related to delinquency and other behavioral health problems.  The Crossover Practice Model out of Georgetown University, however,  gives us more direct evidence of that relationship.  The professors there found in one study that 82% of the youth that had been arrested also had some involvement with the child welfare system.  Also, the youth involved in both systems (child welfare and juvenile services) had more severe and chronic offense histories, and were involved with juvenile justice earlier and longer that single system youth.  These youth went deeper into the system, as well.

The implications of this information for those working with children and youth are important.  Trauma informed care is a growing field and should be liberally applied in all settings where children who are being treated have been traumatized.  In the juvenile services field a growing body of evidence supports the efficacy of case management, family interventions, and coordination between the juvenile services and child welfare systems for those involved in both systems. 

Increasingly, systems must assist parents in supporting their children and must also hold them accountable when family violence is or has been a model for the youth’s acting out behaviors.    Therapists working with children exposed to trauma in the home must consider exchanging both the individual model of therapy and assessment for a more holistic and integrated model which includes the family, MD, substance abuse therapist, family therapist, teacher, developmental skill builder, and multiple systems.  For these children treating the individual child without impacting his or her toxic environment is less likely to be effective. 

Every child experiencing family trauma due to child maltreatment should be referred to the local behavioral health clinic to help resolve the trauma these children experience and prevent future negative consequences.  Those receiving these referrals need to look at new ways of providing interventions in a more extensive and integrated way.