Childhood Trauma, PTSD, and TF-CBT Treatment Approaches

Focal Issues: Childhood Trauma and PTSD

America-based population research reveals that sudden death in the family constitutes one of the most commonly cited traumatic experiences, rendering the psychological effects of a sudden demise a major public health issue. According to epidemiological study findings, most American children have been exposed to potentially traumatic experiences or events (PTEs). One of the latest population surveys revealed that 68 percent of children surveyed had suffered a minimum of one PTE in their life, with over 50 percent experiencing multiple events (Stahmer et al., 2018).

Trauma-exposed persons each have unique reactions to such events, depending on a complicated set of protective and risk factors. Several kinds of stressors are capable of triggering post-traumatic stress disorder (PTSD), such as natural catastrophes (e.g., earthquakes, tsunamis) and human-made catastrophes (e.g., civilian violence, war). Certain events more strongly precipitate PTSD compared to others. Prior studies suggest that rogue civilian shootings, mass violence, terror attacks, and similar human-made calamities were more potent triggers compared to technological or natural disasters. Interpersonal trauma experienced in childhood is more likely to be linked to complex PTSD when compared with disaster-related, adulthood-onset, or accidental trauma (Farooqui et al., 2017).

Contributing Risk and Protective Factors

Risk factors under the compensatory model (such as stressors and genetic susceptibility) may add to and potentiate one another. Generally, several risk factors together hinder development rather than any single risk factor alone. However, this does not mean all risk factors are equally influential. For instance, genetic risk might be a more attributable risk factor for schizophrenia compared to others. Multiple risks often potentiate one another. Sameroff's (1987) research findings reveal that children from households characterized by a minimum of seven risk factors had IQ scores 30 points lower than children from no-risk-factor households. Early childhood risk factors are seemingly magnified synergistically in cases of negative household climates or when children experience stressful life events (Haggerty & Mrazek, 1994).

Individual childhood risk factors may result in susceptibility, with other kinds of risk factors potentially having a greater impact. For instance, low-birthweight, preterm babies may be at greater risk compared to healthy, full-term siblings within a suboptimal household environment. Gender also forms a key genetic factor. Prenatally and from birth until the age of ten years, boys are more likely to be susceptible to psychosocial and physical stressors compared to girls. From ages 10 to 20 years, the opposite phenomenon is observed — girls tend to display greater vulnerability to psychosocial factors — while early adulthood sees males again becoming more susceptible. Some familial factors that serve as major risk factors for greater childhood psychopathology include severe discord among parents, maternal psychological issues, low social class, large or overcrowded households, admission to local child welfare services, and paternal criminality (Haggerty & Mrazek, 1994).

Community determinants impacting children include being socially disadvantaged, especially if the child comes from a welfare household, and not merely because of low income. After controlling for income, impairment rates are substantially higher among children belonging to lower-income welfare households compared to low-income households not receiving state welfare. Furthermore, living in a subsidized housing arrangement situated in a locality with high community disorganization rates also increases childhood psychological disorder risks. Schools and other community institutions have the potential to both improve and undermine social and intellectual progress, thereby serving as either a protective setting or a community risk factor for young people (Haggerty & Mrazek, 1994).

While research on protective factors has progressed substantially, it is not as developed as research on risk factors, with numerous methodological and conceptual problems still inadequately resolved. Nevertheless, evidence exists of a core collection of support sources and individual traits that buffer the influence of psychosocial and biological childhood risk factors. Social skills, a positive attitude, and superior intelligence may each play a part in individual resilience (Haggerty & Mrazek, 1994).

Receptive and even-tempered children tend to evoke the best responses and experiences from their educators, parents, other adults, and peers. Superior intelligence facilitates academic performance and problem-solving skill development, as well as the child's ability to distinguish him- or herself from the surrounding community or family, promoting individuality and self-sufficiency vital to optimal functioning in adulthood. Social skills encompass the ability to get along effectively with others. A protective element at the teenage stage is rationality and an internal locus of control — the personal sense of effectively directing one's own life (Haggerty & Mrazek, 1994).

Community-level protective elements encompass relationships forged outside the family — with friends and significant adult figures — as well as external support systems such as schools, religious institutions, recreational programs, and youth groups that foster competence and contribute to child success (Jones and Offord, 1989; Werner, 1989; Werner and Smith, 1982). A good secondary school will positively influence the child's academic performance and, as a result, occupational outcomes. Moreover, it can lower absenteeism, juvenile court appearances, and dropout rates among children from disadvantaged communities (Haggerty & Mrazek, 1994).

Motivation and Stages of Change

The motivator for change among clients is frequently a topic of both frustration and interest in clinical circles. Motivation is considered a precondition for therapy; therapists seldom achieve success with an unmotivated client. The absence of motivation accounts for individuals not commencing, continuing, adhering to, and completing treatment. Until quite recently, motivation was perceived to be a static quality or inclination either possessed or not possessed by a client. Consequently, the client was blamed for failing to be motivated to change his or her behavior. Motivation to undergo therapy implied a readiness to follow the therapeutic prescription set for recovery by the therapist or intervention (Center for Substance Abuse Treatment, 1999).

Clients appearing to be open to clinical guidance or willing to acknowledge that they had abused drugs or alcohol were regarded as motivated; meanwhile, those who resisted diagnostic testing, declined treatment, or failed to comply with it were labeled "unmotivated." Additionally, motivation was typically viewed as a burden to be borne by the client and not the clinician. One client, for example, admitted to hiding empty cans of compressed air and bottles of beer in his room while claiming he had no disorder and had only once or twice attempted to drink or huff — suggesting he acknowledged the behavior without perceiving it as problematic or requiring change (Center for Substance Abuse Treatment, 1999).

All individuals struggling with addiction realize the need for change at some stage of life. Motivation is what distinguishes those who succeed in making the necessary changes from those who do not. Because motivation proves crucial for recovery, both clients and counselors must understand the factors that drive change — including the nature and extent of motivation and the various ways of increasing it. An adequately motivated individual is capable of successfully changing behavior. It is generally understood that the process of change does not happen overnight; it occurs gradually, and as it slowly unfolds, the individual's motivation also evolves (Monti, 2002).

While the Stages of Change (SOC) model has five stages, proactive drug and alcohol testing in trauma facilities often identifies only those in the initial three stages — pre-contemplation, contemplation, and preparation. Those in the final two stages of action (having recently effected change) or maintenance (sustaining change) have either stopped drinking entirely or at least moderated it, and will most likely not test positive. The client in question is at Stage I: Pre-Contemplation. Individuals at this stage, while potentially understanding the drawbacks of addiction, may perceive them as trivial compared to the perceived benefits. This stage is characterized by disinterest in changing and no intent or plan to change; such individuals may be labeled as "unaware" (Monti, 2002).