Complex Trauma in Post-Institutionalized Children
by Lynne Lyon, MSW; Nancy D'Antonio; Laura Beck, CSW
Imagine that you are but a few days old, and you wake up alone on the sidewalk or in a bus station. Instead of the familiar smell, heartbeat and arms of your mother to comfort you when you cry, no one comes for what seems like an eternity. When someone finally notices you, it is a stranger. Imagine then, that for the next 6 or more months you are confined to a crib where you are cared for sporadically by many people who also care for many other babies. No one picks you up when you cry. You are not fed when you are hungry, but fed when it is convenient for your caregiver. You are not held enough or loved enough. And when you are scared at night because of the dark and the crying of other babies, you are left to comfort yourself.
Many internationally adopted infants are at risk for Complex Trauma because of their earliest life experiences. The nature of International adoption presupposes that most parents will never know the full extent to which their children have suffered. We can only monitor their behavior for clues and piece it together with what we learn about life in China, whether in an orphanage or foster care. It is important to understand the causes and symptoms of PTSD, because it can interfere with normal development and learning in a child, and can lead to Reactive Attachment Disorder and other emotional problems.
Causes of Trauma in Post-Institutionalized Children
Trauma occurs when an event elicits fear, helplessness and overstimulation in a child. A basic criteria given by The American Psychiatric Association's Diagnostic Manual of Mental Disorders (DSM-IV) for the diagnosis of PTSD is that "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person's response to the event must involve intense fear, helplessness, or horror." The term Complex Trauma refers the constellation of symptoms resulting from multiple instances of interpersonal traumatic events experienced over time, such as physical and sexual abuse and neglect. This affects the child's ability to trust and form secure attachments, stay physically and emotionally regulated, and maintain a normal level of self esteem. It is essentially the combination of Reactive Attachment Disorder and PTSD.
Because a human infant is totally dependent on her mother for survival, one of the most traumatic events an infant can experience is abandonment in a public place under dangerous circumstances. She will literally fear for her life. To then live in an orphanage, where care is routine at best, and neglectful and abusive at its worst, can only add to the trauma. Daniel Hughes, PhD, author of several books on attachment, calls neglect "the trauma of absence." While many assume that abuse is far more traumatic than neglect, we now know that neglect is equally harmful. We also know that the combination of abuse and neglect can be shattering to a child's psyche.
Neurobiological Response to Threat
When a child is traumatized, neurophysiological and neurobiological changes occur. The initial reaction in the body is "hyperarousal", what scientists call the fight, flight or freeze alarm response. Because young children are unable to flee physically, they may "fight" to gain the attention of their caretaker that something is wrong. If aid is not forthcoming and the trauma continues, the child's response may be to "freeze" or immobilize, and later to flee mentally by dissociation or give up.
The initial alarm reaction, whether it is fight, flight, freeze or dissociation, enables survival, mobilizing the victim, to escape danger, either physically or mentally. If the trauma persists in duration, intensity, or frequency, it can lead to permanent physiological and psychological changes. While adaptive for dangerous or threatening situations, these changes are maladaptive once the child is in a normal situation. Instead of appropriately evaluating a current situation, she reacts as if she is still in danger. For example, a child might become hyperactive at bedtime, to avoid falling asleep, because sleeping reminds her of terrifying nights in the orphanage. Or she may react with extreme rage or fear when she is accidentally bumped, feeling that it is a deliberate attack. Or being left alone in daycare might remind her of long days in the orphanage and she might become spaced out or withdrawn, thinking she's been abandoned again.
Because traumatic memories are stored in more "primitive" areas of the brain, they are less accessible to language, logic and reasoning. They remain "frozen" in time, at the same intensity as when the trauma originally occurred. When a traumatic memory gets triggered, activity increases in the right hemisphere of the brain, which causes emotional arousal. At the same time, there is decreased activity in the left hemisphere, which controls language, thus lowering the capacity for the child to express herself with words. This can leave parents frustrated and confused if the child is screaming or acting out, mistaking terror for disobedience.
Predictors of PTSD in Children
While the initial alarm reaction mobilizes the body to fight or flee, these are seldom options for an infant or small child. Their only option is to escape the trauma mentally. This is called dissociation. Dissociation is a coping mechanism where the child splits off and "disappears", so that it seems that the trauma is happening to someone else. Dissociating at the time of the trauma is the most significant predictor for developing PTSD. Lack of emotional security prior to the event, and lack of familial support and professional help in the immediate aftermath also increase the risk for PTSD. Interpersonal trauma (such as abandonment, neglect or abuse) is experienced as more severe than trauma of nonhuman origin (such as a car accident). In interpersonal trauma, the severity increases with the closeness of the relationship. Thus abandonment or violence inflicted by her mother would be experienced by a child as extremely devastating. Secondary adversities, such as displacement or relocation after the traumatic event add to the likelihood of developing PTSD. Therefore, an infant who has been abandoned by her birthparents, traumatized by a stay in an orphanage, and is then adopted by strangers is at exceptional risk for dissociation and Complex Trauma.
The Effect of Trauma on Development
Studies conducted by Bruce Perry, MD, PhD and Bessel van der Kolk, MD over the last decade show that the physiological response to trauma can change the biochemistry of the brain. Because the impact of these changes on the developing brain of a child is far greater than on a brain that is already formed, trauma has even greater consequences for children than adults. If early childhood is defined by threat, unpredictability, fear and trauma, the neural systems of the brain will reflect that. This in turn will be reflected in the child's developing personality and sense of self and in her way of relating to the world.
According to Dr. Bruce Perry, all aspects of a child's development can be affected, depending on what point in the development of the brain the trauma occurred. Children may show delays in cognition, gross and fine motor, language development, or appear to be withdrawn and mute.
According to the DSM-IV and child psychiatrist Lenore Terr, MD, who has been conducting long-term studies of children who have suffered various types of trauma, symptoms of PTSD fall into 3 general categories: re-experiencing of the trauma; numbing and avoidance of anything associated with the trauma; and increased physiological arousal. Children may experience symptoms in one or all of these categories, either simultaneously or alternating over time.
Young children frequently re-live traumatic events through nightmares, flashbacks and daydreaming. Any experience, including anniversaries, change in season, or medical procedures, that is in some way reminiscent of the traumatic event can trigger a stress reaction. The traumatic impact of abandonment may feel like an ongoing threat because constant mini-reminders such as being left at daycare or even going to sleep result in repeated remembering and reexperiencing which causes the same physiological responses as the initial trauma. Traumatic events may also be reexperienced through somatic (body) symptoms which are similar to the original trauma. For example, a child might experience a PTSD flashback of going hungry in the orphanage because a snack is unavailable when she is hungry. Parents may also detect signs of trauma by observing their child's play. Persistent, obsessive, repetitive or violent play that re-enacts aspects or metaphors of the traumatic event can give adults an idea of what happened. Rescue themes are often prevalent.
Exposure to trauma can also leave a child in a state of constant hyperarousal. Physiologically she remains locked in the fight/flight/freeze response. She is ever on the alert for danger. She may be overly sensitive to sudden noise or unexpected changes in the environment and may react with extreme fear. This may lead to extreme clinginess to mother or transitional objects and regression to earlier developmental stages. Panic or asthma attacks, stress-related diarrhea, disruption of circadian rhythm, and a lack of appetite may indicate an overwhelming increase in the child's anxiety. Children may also exhibit problems in affect (emotional) regulation, including modulating anger, chronic self-destructive behaviors and impulsive and risk taking behaviors. These symptoms represent attempts to cope and restore control over environmental stimulation because the child's core self has been programmed for self-defense.
Conversely, some children may respond to trauma with a general numbing of their emotions, or by avoiding specific reminders of the trauma. "Shutting down", a lack of responsiveness to the external world, is referred to as "psychic numbing" or "emotional anesthesia." Withdrawn infants ignore their surroundings and the people in them. They barely laugh or cry. Children may intentionally avoid specific activities, situations, conversations, or feelings, which are reminders of the trauma. For example, a child adopted from China may ignore her parents if they attempt to discuss adoption; she may become distressed at a Chinese cultural event, in an American "Chinatown" or even by anyone who appears Asian. A traumatized child may exhibit a lack of interest or participation in group activities. She may feel detached from others, or be incapable of identifying or displaying emotions (especially those associated with intimacy and tenderness). She may be superficially polite, but hide her true self. She may have difficulty expressing herself with words and may lack a sense of humor - or may use humor to avoid painful or intimate subjects. Many traumatized children have a sense of a foreshortened future (e.g., not expecting to grow up, have a career, get married, or have children).
Because symptoms of trauma mimic those of many other disorders, children with Complex Trauma are at risk for misdiagnosis. Adopted children who appear to be hyperactive (ADHD) may be responding to early trauma that is still keeping them alert to danger. Youngsters who are unresponsive, avoidant, mute or withdrawn, day dreaming, robot-like, or show aggressive behaviors such as tantrums may be experiencing manifestations of Complex Trauma. Some of these symptoms may be mistaken for oppositional defiant behavior.
Complex Trauma and symptoms of intrusive thoughts and difficulty concentrating are likely to emerge in a school setting, interfering with learning and socialization. A calm child can focus on the words of the teacher and engage in abstract cognition. The fearful child will be less efficient at processing and storing verbal information because the dominantly functioning areas of the brain will be the sub-cortical and limbic areas which focus on non-verbal information. Therefore, the child will be focusing on the teacher's facial expressions, hand gestures and other non-verbal information, rather than the meaning of her words.
Neglected and abused children are less able than securely attached children to identify physiological states such as hunger and thirst and feelings of anger. Not knowing what one feels and how to express it with words may contribute to difficulty in impulse control. This inability to verbalize what she is experiencing in her body puts a child at risk for developing psychosomatic reactions to stimuli. For example, a child who is frightened by riding in a car because it is connected to an earlier trauma, may become chronically carsick.
Traumatized children often have difficulty learning collaborative play and reciprocal relationships with others. During play with peers, they tend to be either excessively shy and withdrawn or tend to bully or reject others. When children do not learn to play, they have a hard time integrating the positive and negative aspects of life: good and bad, power and helplessness, affection and anger - all roles that can be tried out and mastered during play. If children miss this developmental milestone, they are at risk for becoming fearful adults, incapable of tackling the inevitable hassles of daily life.
Trauma and Attachment
Because infants are totally dependent on their caregivers, they experience extreme distress when neglected or abused. They respond to unmet needs with excessive anxiety, anger, and desire for their attachment figures; an abysmal sense of desperation and abandonment occurs. Distress escalates to rage, but then turns to a loss of hope, often culminating in the development of dissociative states or self-defeating aggression, or a sense of despair seen in the biological shutdown which is seen in failure-to-thrive infants.
According to Bessel van der Kolk, M.D., psychiatrist and leading expert on trauma and how it affects the brain, as many as 80% of abused and neglected infants and children develop disorganized/disoriented attachment relationships, which are expressed as unpredictable approach and avoidance patterns towards mother, the inability to accept comfort from caregivers, rage at attachment figures, and pathological self-regulatory behaviors. Therefore, it is easy to see how an abandoned child who is raised in an orphanage or multiple foster homes during the first few months or years of life may develop Reactive Attachment Disorder (RAD) and Complex Trauma.
Because trauma can have such a profound impact on all areas of a child's functioning, and because trauma symptoms can mimic those of other disorders, it is very important that PI children be assessed for trauma. This is done by observing their behavior, play, artwork, and reviewing their history of trauma exposure. Parents may have difficulty recognizing the distress responses of their children. This could be because they are in denial or it may simply reflect a lack of knowledge. Some parents might attempt to avoid feelings of pain and helplessness at the thought of their children having been traumatized, and hope they will simply outgrow their odd behaviors. Children, fearful of facing their own buried terrors, may also collude in this process of denial.
Lenore Terr, writes in Too Scared to Cry: Psychic Trauma in Childhood, "Putting off treatment for trauma is about the worst thing one can do. Trauma does not ordinarily get "better" by itself. It burrows down further and further under the child's defenses and coping strategies. Suppression, displacement, overgeneralization, identification with the aggressor, splitting, passive-into-active, undoing, and self-anesthesia take over. The trauma may actually come to "look" better after all these coping and defense mechanisms go into operation. But the trauma will continue to affect the child's character, dreams, feelings about sex, trust, and attitudes about the future. Count on that. If the child is a genius, his trauma may come to be incorporated into a parade of thematically linked works. But if the trauma had been effectively treated, the genius probably would have produced a more universal, more versatile kind of art."
In order to heal, therapy must activate those areas of the brain which have been impacted and altered by trauma. Therapy should become a place where overwhelmingly painful events and feelings can be re-experienced safely, preferably with the adoptive parents. Cognitive distortions can be addressed and corrected through art, storytelling, and play-therapy, which may contain literal or metaphorical depictions of the event or portions of it. Effective treatment should transform a child's self-image from victim to survivor.
Eye Movement Desensitization and Reprocessing (EMDR) is a technique that helps people revisit and reprocess trauma. Clinicians take a history of the client to determine (a) what earlier life experiences have contributed to the symptoms of PTSD, (b) what present triggers elicit PTSD episodes, and (c) what preparation does the client need for the future. Reprocessing the earlier, negative experiences with EMDR allows the client to change her thinking and respond with more appropriate reactions. When considering this therapy, it is important to find someone who has experience treating young children. Most literature and studies about EMDR relate to adults who have suffered from environmental trauma, such as car accidents, or war veterans.
Other evidence-based treatment techniques include: Dyadic Developmental Psychotherapy, Family Narrative Therapy, Neurofeedback, Theraplay and Trauma Focused-Cognitive Behavioral Therapy (TF-CBT). More information about these therapy techniques can be found in the next section.
The family and their coping styles are critical in helping a child recover from trauma. It is important for parents to overcome avoidance and denial and the desire to overprotect their child against thinking about their trauma. The goal of treatment is to help the child regain her sense of security by validating the child's emotions, anticipating situations which bring up the trauma again and decreasing secondary stresses such as overstimulating events, absence of mother, or excessive changes or transitions in daily routine. Treatment may need to be repeated at later developmental stages, such as adolescence, when hormonal changes may cause PTSD to reemerge.
Internationally adopted children who are abandoned and spend their earliest months in an orphanage or foster care, and then are adopted by strangers are at high risk for PTSD and RAD (Complex Trauma). The physiological response to trauma alters the brain so that a child may become hyper- or hypo vigilant. Further, neglected children tend to develop disorganized/disoriented attachment relationships. The symptoms that children with Complex Trauma exhibit to regain control of environmental stimulation may be misinterpreted as oppositional defiant behaviors or hyperactivity, and therefore mistakenly treated with ineffective behavioral management techniques or medication. It is important for adoptive parents to understand the earliest months and/or years of their child's life, so that they can respond correctly to their child's behavior. Obtaining professional help in a therapeutic setting while our children are still young will help re-wire the neuropathways in the brain, and allow them to live happy, productive lives.
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© 2001, 2014, all rights reserved. Written by Lynne Lyon, Nancy D'Antonio and Laura Beck, CSW. May not be reproduced in any form without written permission of the authors.
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Lilo (to Stitch):"What happened to your family? I hear you cry at night. Do you dream about them? I know that’s why you wreck things and push me."
from Lilo & Stitch (2002, movie)