Download Graduate Module # 10

Graduate Module # 10
TRAUMA, POST-TRAUMATIC STRESS DISORDER AND ABUSE
This module will examine the effects of physical, sexual and emotional abuse and neglect on the
development of children and adolescents and the mechanisms they utilize to manage, control and
eradicate the trauma and its effects from their lives. This module will also address the trauma of
environmental violence such as war and do Graduate Module # 10
TRAUMA, POST-TRAUMATIC STRESS DISORDER AND ABUSE
This module will examine the effects of physical, sexual and emotional abuse and neglect on the
development of children and adolescents and the mechanisms they utilize to manage, control and
eradicate the trauma and its effects from their lives. This module will also address the trauma of
environmental violence such as war and domestic and neighbourhood violence. Attention will be given to
understanding post-traumatic stress disorder (PTSD).
Trauma, Post-Traumatic Stress Disorder and Abuse
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Learning Objectives
1. Review the current literature and research about child physical, emotional and sexual
abuse and its relation to the concept of trauma.
2. Critically examine the power of neglect and its connection to the maltreatment of
children and trauma.
3. Investigate environmental violence and its traumatic effect upon children as victims of war,
witnesses of domestic violence and affected by neighbourhood violence.
4. Examine post-traumatic stress disorder in children and adolescents - the theories about
how it is developed and diagnosed and the many ways it is manifested (internalizing
and externalizing behaviours).
5. Understand the connection between common behaviour and emotional problems and
trauma and abuse.
6. Develop abilities to create plans and strategies for treatment of children and
adolescents.
7. Understand connections between trauma, abuse, depression and suicide, selfmutilation and aggressive or acting out behaviour
Key Terms and Concepts:
Child Maltreatment
History
Definition of Child Maltreatment
Theories about Impact
Maltreatment in Canada
Forms of Maltreatment
Developmental Impact of Maltreatment
Environmental Violence and Trauma
Violent Neighbourhoods and Communities
Children of War
Sequalae of Abuse and Trauma
Stress and Distress
Post-Traumatic Stress Disorder
Developmental Effects of PTSD
Issues in Assessment
Issues in Treatment
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Trauma, Post-Traumatic Stress Disorder and Abuse
Content Notes
Introduction
Child Maltreatment
History
Defining Child Maltreatment
Etiology of Child Maltreatment
Developmental Context
The Immediate Context
The Broader Context
Theories About the Impact of Maltreatment and Trauma
Childhood Trauma Model
Developmental Psychopathology
Incidence of Maltreatment in Canada
Family Context
Forms of Maltreatment
Neglect
Physical Abuse
Sexual Abuse
Emotional Abuse
Developmental Impact of Child Maltreatment
Environmental Violence and Trauma
Violent Neighborhoods and Communities
Children of War
Understanding the Range of Emotional and Behavioral Responses to Trauma and Abuse and the
Differential Manifestations in Children and Adolescents
Sequalae of Abuse and Trauma
Issues in Assessment
Assessment Considerations
Parent/Child Relationship
Safety of the Child
Issues in Treatment
Common Goals of Therapy
Assigned Readings
Review Questions
References
Appendix I - Forms of Maltreatment
Appendix II - Symptoms Associated with Child Maltreatment
Appendix III - Symptoms of PTSD typical of young children
Symptoms of PTSD typical of school-aged children
Symptoms of PTSD typical of pre-adolescents and adolescents
Appendix IV - Factors that support children
Families can provide further protection
Appendix V – Range of Child Characteristics Associated with Physical Abuse, Neglect, and Sexual
Abuse
Appendix VI - Internalization Model
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Introduction
Every year, many children experience some form of traumatic occurrence, such as:
 Child maltreatment including physical and/or sexual abuse;
 Living in an environment of domestic violence;
 Experiencing natural disasters, car accidents; or
 Exposure to community violence.
By the time a child reaches the age of 18, the probability that he or she will have been touched directly by
interpersonal or community violence is about 25% (Perry, 2001). Trauma in children increases the risk for
a variety of social, mental health and physical problems.
Child Maltreatment
History
Concern about children’s welfare in Canada began with looking at marginalized families with so-called
deprived children. The issue of improving the living conditions for these children led to the establishment
of the first Children’s Aid Society in Toronto in 1891. Two years later, legislation was developed in
Ontario to prevent cruelty to and provide better protection for children. The emerging notion of harm to
children reflected a changing society.
Arousal of public and professional concern about child abuse dates back to 1962 with the publication of a
seminal article, The Battered-Child Syndrome (Kempe, Silverman, Steele, Broegemueller & Silver,
1962). Up to this point, all child maltreatment was considered single phenomena related to child neglect.
Concern focused primarily on inadequate care of children and child neglect remains the largest single
category of reported child maltreatment.
Identification of child abuse, as distinct from child neglect, focused initially on the most visible and
shocking physical abuse cases. Many parental actions, that today are considered abusive, were widely
accepted and used by previous generations of parents and others. For instance, using a belt or strap to
punish misbehavior was a common practice used not only by parents but also by teachers.
The extent of sexual misuse and exploitation of children has only been recognized since the mid-1970s.
Prior to this time, sexual abuse was assumed to occur rarely, to be of no consequence to the child victim,
to be a child’s fantasy, or to be provoked by the child. Today, much media attention is given to publicly
exposing child sexual abuse.
Today, child abuse is recognized as existing along a continuum of possible parental responses to children
ranging from appropriate to harsh and exploitative. A result is a lack of consensus about what constitutes
dangerous or unacceptable child rearing practices. For example, debate continues about the relative merits
of spanking. It should also be noted that definitions vary on the basis of differences in legal mandates,
professional practices as well as social and cultural values (Trocme, MacLaurin, Falon, Daciuk,
Billingsley, Touring, Mayer, Wright, Barter, Bulford, Hornick, Sullivan, & McKenzie, 2001).
Over the past two decades, the mental health issues for child victims of physical abuse, neglect, sexual
abuse and witnessing domestic violence have received much clinical and research attention. There is now
a substantial body of research literature affirming the increased risk of various mental health problems
and factors that mitigate these risks (Saunders, Berliner & Hansen, 2001).
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Defining Child Maltreatment
The term, child maltreatment, has been used to refer to all forms of child abuse. Wolfe (1998) says,
Child maltreatment is broadly defined as physical or mental injury, sexual abuse or
exploitation, negligent treatment or maltreatment of a child under 18 years of age by a
person who is responsible for the child’s welfare. The behavior must be avoidable and
non-accidental (p. 108).
Child abuse was initially believed to be extremely deviant acts committed by disturbed individuals. Much
greater attention has been paid to acute, dramatic and observable acts than to those that are more
insidious, persistent and common. It is now widely recognized that the various forms of abuse often
overlap and rarely occur in isolation from each other. Psychological abuse is implicated in all types of
abuse and is a critical issue in considering negative outcomes (Weekly & Wolfe, 1996).
Etiology of Child Maltreatment
Child maltreatment is widely recognized to be multiply determined by a variety of factors ranging from
life-course history to immediate-situational to historical evolutionary. A balance of stressors and supports
or risk and protective factors can prevent child maltreatment. Likewise, an imbalance of stressors and
risk factors and increase the probability of child maltreatment occurring. Belsky (1993) suggests it is
useful to consider a variety of contexts of maltreatment including the:
Developmental Context
Parent factors such as:
 Childhood histories of abusive and neglectful parents
 Personality and psychological characteristics such as agreeableness, aggression or
depression
 Psychological resources such as attributional style or affective orientation
Child Factors
 Age with younger children more at risk
 Physical health
 Behaviour
The Immediate Context
Parenting and Parent: Child Interaction
 Responsiveness to child
 Affective quality of interactions
 Negative or aversive behaviours
 Disciplinary practices
The Broader Context
Social support and isolation
Cultural factors
Evolutionary context of child maltreatment
Social factors such as poverty
There is agreement that the clinical profiles of abused children show them to exhibit developmental
deficiencies and adjustment problems. There is little evidence, however, to suggest specific physical or
emotional maltreatment leads to particular developmental outcomes. There is now a well-established
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consensus that there is also no single risk factor or cause of child abuse but rather a combination of
factors that can both increase the risk of harm and mitigate harm through protective mechanisms (Wolfe,
1998). There has been considerable work looking at the risk factors for child maltreatment. The four best
predictors of child maltreatment have been found to be:




Family revenue below the poverty line
Mother sole financial provider
Mother’s first pregnancy occurs before the age of 21
Four or more children in the family (Sullivan, 2000).
Maltreatment can have a major disrupting and complex influence on the child’s on-going development. It
is important to note that most child maltreatment goes unreported. Pearce and Perrot-Pearce (1997)
conclude that physical abuse is reported to authorities in one out of seven instances and only 2% of intrafamilial and 6% of extra-familial sexual abuse is reported. There are also interesting differences reported
in rates of child maltreatment between the United States and Canada. Rates are reported to be as much as
two times higher in the United States. Higher rates of poverty and fewer social supports may account for
this difference (Pearce & Perrot-Pearce, 1997; Wolfe, 1998).
Theories About the Impact of Maltreatment and Trauma
Understanding the impact of abuse and trauma on children is a complex undertaking. The following two
theories are useful in understanding current thinking about impact.
Childhood Trauma Model
This model would suggest that two psychological mechanisms account for the way traumatic experience
can result in long term threat, demand or responses that continue well after the original stress. Firstly,
traumatic episodes become associated with particular stimuli and lead to conditioned maladaptive or
atypical reactions. Conditioning may be important as repetitive acute episodes occur on an irregular basis
and elicit stress reactions in an unpredictable and chaotic way. Over time, such conditioning becomes
resistant to extinction because of its unpredictability and intensity. Secondly, post-traumatic stress
symptoms resulting from trauma can overwhelm the child’s coping abilities and become part of their
response to day-to-day issues. Hyper responsiveness then becomes part of the individuals’ functioning,
leaving them vulnerable to wide ranging adjustment disorders (Wekerle & Wolfe, 1996).
Developmental Psychopathology
This model considers child maltreatment in the context of the parent-child relationship. Normal
development occurs as a series of inter-related physical, biological and psychological competencies.
Maltreatment can interfere with important developmental milestones and a child’s failure to develop
competency at one stage of development will lead to greater probability of failure at subsequent stages.
When there are prominent disturbances in the parent/child system, the child is at greater risk for
subsequent failure in developmental areas such as attachment, emotional functioning, peer and social
relationships. Children who experience a family context that fails to provide appropriate developmental
opportunities and contains disruptive events will have development affected in both subtle and powerful
ways.
In order to understand the effects of child maltreatment on development, the child must be seen in the
larger context of the family and environment in which they exist. An ecological model is one method for
explaining this complexity. It is also important to remember there are not inevitable negative
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consequences of maltreatment; rather, there are multiple pathways to adaptive or maladaptive
developmental outcomes. A history of maltreatment alone, while a risk factor, does not determine
outcome (Wekerle & Wolfe, 1996).
Some children are also more vulnerable to trauma than others. The impact of the trauma is likely to be
greatest when the child or adolescent has already been a victim of child abuse or other form of trauma or
who already had some form of mental health problem. In addition, children without family support are
more likely to experience poor outcomes (NIMH, 2001). A variety of child and family factors may
mediate the long-term effects of maltreatment. Child factors that could contribute to resiliency include
age or stage of development and temperament. Family factors may include previous positive attachment
experiences, positive response to the child and ability to protect child from further maltreatment.
Community response to maltreatment and support to the family in addressing the issue can also help to
mitigate the impact and improve the trajectory for adaptive responses.
Incidence of Maltreatment in Canada
In 2001, the first Canadian study examining the incidence of reported child maltreatment was completed
(Trocme et al., 2001). This study included careful definitions of maltreatment and examined instances
where Canadian Child Welfare Services were involved in investigating reports of child abuse. See
Appendix I – Forms of Maltreatment. BROOKE: CAN YOU PUT A LINK OR SOMETHING HERE
The overall number of investigated cases were 135,573, or 21.52/1000 children in Canada. Of that
number, 61,201 investigations, maltreatment was confirmed or 9.71/1000 children. In addition, in 29,668
investigations, maltreatment remained a suspicion for the child welfare worker at the conclusion of the
investigation, while the remaining 44,704 were cases that were not substantiated. This is a conservative
estimate of the incidence of reported child maltreatment in Canada, as the study did not capture those
cases that were not detected, not reported to child welfare, reported to police only, or those cases that
were screened out prior to investigation.
Regarding the percentages that are used, that does indeed examine the primary forms, however, we also
determined the overlap between categories.

40% of substantiated investigations involved neglect including failure to care and provide or
supervise and protect. Within this group, failure to provide medical treatment, permitting
maladaptive or criminal behavior, abandonment or educational neglect was included.

31% of substantiated investigations involved physical abuse. Physical abuse was defined as
the child suffering, or at risk of suffering from, physical harm by shaken baby syndrome,
inappropriate punishment or other forms of physical abuse such as Munchasen by proxy. In 3% of
these cases, the abuse was significant enough to require medical treatment.

11% of substantiated investigations involved sexual abuse including oral, vaginal or anal
sexual activity, attempted sexual activity, sexual fondling or touching, exposure of genitals,
voyeurism, involvement in prostitution or pornography and sexual harassment.

19% of substantiated investigations involved emotional injury including emotional abuse
such as overtly hostile or punitive treatment or extreme threatening or belittling, emotional
neglect including inadequate nurturing or affection. Also included in this area was inadequate
nutrition and exposure to family violence (Trocme et al., 2001).
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Single and Multiple Categories of Maltreatment in Child Maltreatment
Investigations by Level of Substantiation in Canada in 1998*
Level of Substantiation**
Number
Substantiated
Suspected
Unsubstantiated
Row Total
Single Categories
Physical abuse only
Sexual abuse only
Neglect only
Emotional Maltreatment
Subtotal: Single Category
Multiple Categories
Physical and sexual
Physical and neglect
Physical and emotional
Sexual and neglect
Sexual and emotional
Neglect and emotional
Physical, sexual & neglect
Physical, sexual & emotional
Physical, neglect, emotional
Sexual, neglect & emotional
Subtotal: Multiple Categories
29,114
11,393
42,680
20,381
103,568
22%
8%
31%
15%
76%
32%
39%
39%
53%
40%
21%
20%
21%
28%
22%
47%
41%
40%
19%
38%
100%
100%
100%
100%
100%
480
5,017
9,067
2,323
924
10,973
-259
2,723
162
135,573
0%
4%
7%
2%
1%
8%
0%
0%
2%
0%
100%
29%
49%
54%
62%
51%
65%
--64%
-45%
35%
16%
31%
12%
36%
22%
--23%
-22%
36%
35%
15%
26%
13%
13%
--13%
-33%
100%
100%
100%
100%
100%
100%
--100%
-100%
Row Percentage
*
Weighted estimates are based on a sample of 7,672 child investigations with information about single and multiple
categories of maltreatment.
** Substantiation varies by level of aggregation.
Family Context
In considering findings related to family characteristics for 93% of investigations, the perpetrator was
either a parent or relative. It was found that 39% involved situations that had been going on for more than
6 months while 17% had been on going for less that six months and 23% involved single incidents.
Clearly, child abuse and neglect occur within a family context largely and usually over significant periods
of time. Wolfe (1998) suggests child maltreatment is a relational disorder that reflects problems of fit
between the parent, child and environment. Wekerle and Wolfe (1996) contend child maltreatment
denotes parenting failure, a failure to protect a child from harm and failure to provide positive aspects of a
relationship that can foster healthy development.
Common developmental issues shared by all forms of maltreatment are:
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

Maltreatment occurs in a relational context that potentially provides significant emotional
weight to an abuse experience
Maltreatment commonly includes violence that can create a situation of trauma for the child.
Given that children are most often maltreated in early infancy or childhood and maltreatment is often
accompanied by instability, disruption or isolation for the family, maltreated children have to adapt in
major ways to unpredictable and violent experiences. This interaction is understood to be very complex.
The impact of abuse on a child’s development was assumed to be invariably negative and disruptive, but
there is increasing recognition of the complexity of predicting outcomes. Whether maltreatment
experiences are extreme or powerful enough to outweigh other significant events and variables is a
critical issue.
The secondary events that follow maltreatment have also begun to receive attention in the literature. This
refers to events such as child welfare involvement, criminal proceedings, and maternal responses to
disclosure and family breakdown. Not only what has happened but also how it has been responded to are
important factors in predicting long-term adjustment. The family disruption, social and school change that
can result from the initial event can further traumatize the child. Disclosure of abuse creates other events
that may place new demands on the child and give rise to a chronic, stress-filled situation that makes
recovery from the trauma even more difficult.
Forms of Maltreatment
Neglect
Neglect is typically the largest category of reported child welfare investigations and was initially the least
studied. A very strong connection between neglect and poverty is noted. Some studies suggest that
outcomes for neglected children are the most negative of all types of child maltreatment. This form of
child abuse is often the most chronic and gets the least outside intervention. It may also be the most lethal
as over 50% of child deaths are estimated to be caused by neglect (Pearce & Pezzot-Pearce, 1997). There
tend to be few visible signs as neglect often consists of frequent and repeated deficits of caregiving for a
lengthy period prior to intervention. Part of the chronicity is related to the societal belief that neglect does
not result in serious consequences, that it is inappropriate to judge poor parents and solutions are limited
by larger social problems including poverty (Sullivan, 2000).
There are many forms of neglect with potentially different outcomes. Consistent, however, is a chronic
pattern of a lack of responsiveness to the child. The following categories have been used to define neglect
in the recent Canadian incidence study:
 Failure to supervise and protect leading to physical harm or sexual abuse
 Physical neglect
 Medical neglect
 Failure to provide treatment for mental or emotional or developmental problems
 Permitting maladaptive/criminal behavior
 Abandonment/refusal of custody
 Educational neglect (Trocme et al., 2001)
Neglect often leads to other forms of abuse, as children are not protected from further harm such as sexual
predators. Young children and infants are particularly at risk related to physical neglect given that the
brain does not reach full maturity until the age of two years. The physical development of the brain can be
affected by poor nutrition and/or under stimulating environments with resulting cognitive and expressive
language delays. This is a sensitive and critical period of development for children with life long
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consequences for the individual’s ability to regulate thought, emotions and behavior. There are additional
cognitive and behavioral consequences of neglect such as undisciplined activity or extreme passivity. In
addition, these children tend to be less flexible, persistent or enthusiastic.
Physical Abuse
Physical abuse can include shaken baby syndrome, inappropriate discipline and other forms of
maltreatment that result in the following:






Bruises/cuts/scrapes visible for at least 48 hours
Burns and scalds visible for at least 48 hours
Broken bones (i.e., fractured)
Head trauma requiring medical attention
Other health considerations such as untreated asthma or sexually transmitted disease
Death
Physical abuse investigations in which harm was reported most often involved bruises, cuts, and scrapes
(88% of harm situations). Cases involving more severe injuries were indicated less often and these
included broken bones (3%), burns and scalds (2%), and head trauma (5%).
Physical abuse can take many forms and can involve both minor and major injury to the child. Children
who are physically abused may present with a wide variety of injuries and developmental progress is
often impaired across several dimensions. The most notable signs of physical abuse appear to be
heightened aggression as well as resistant and avoidant behaviors towards others. Compulsive compliance
may also be seen. Physically abused children typically present with the most evident behavior problems.
These children are exposed to a family climate of domination and abuse of power where the child is
powerless to change the situation or abuse. In addition, delays in academic development that are not
accounted for by specific learning disabilities are evident.
Arousal related to fear and anger is also present as the child’s fight or flight mechanism is activated
(Perry, 2001). The pervasive threat of abuse and the child’s subsequent coping mechanisms can interrupt
development in ways that can continue into adulthood. For example, about 30% of victims of physical
abuse are estimated to be adult perpetrators of antisocial or abusive behavior. Delays in social-cognitive
development related to problems in moral reasoning and empathy for others are present. Physically
abused children are also impaired in the process of acquiring social knowledge and tend to replicate the
strong behavioral tendencies of their own abusive parents. These children take responsibility for parental
punishment, believing that punishment is a response to bad behavior. At the same time, physical
punishment is perceived to reflect the parents’ mean character. This may lay a foundation for further
difficulties as a bias toward inferring negative or hostile intent is created and sets up later difficulties with
social interaction.
Sexual Abuse
Definition: Sexual abuse could be defined as including completed or attempted sexual activity, touching
or fondling of genitals, adult exposure to genitals, sexual exploitation in prostitution or pornography,
sexual harassment or voyeurism.
Some form of emotional harm was noted in almost half of the substantiated cases of sexual abuse and
harm was significant enough in 38% to result in a need for treatment. Child sexual abuse, in contract to
other forms of maltreatment, was committed much less often by the child’s primary caregiver. Rarely,
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however, was child sexual abuse committed by a stronger (2%). Other relatives (44%) and known nonrelatives (29%) were perpetrators.
While all forms of abuse represent an abuse of power by an adult over a child, sexual abuse and its impact
on developing sexuality represents a particular challenge for the child. In general, sexually abused
children tend to be more socially competent than physically abused or neglected children as a group. One
third of sexually abused children show no symptoms. The other two thirds show significant recovery
within the first 12 to 18 months but many have delayed emergence of symptoms.
Sexualized behaviors are unique to child victims of sexual abuse. In addition, clinical impressions of
aggression, depression, withdrawal and anxiety are common. There tends to be more trauma-related
emotional and behavior problems resulting from sexual abuse than the cognitive and developmental
delays commonly found in children who have been physically abused and/or neglected. Sexual abuse
brings increased risk for depression, alcohol and drug abuse, sexual dysfunction, personality disorders and
eating disorders.
There is no classic pattern for victims of sexual abuse given diverse characteristics in the nature of the
abuse (intra versus extra-familial, number of perpetrators, type of abuse, duration, level of coercion and
violence). A range of common symptoms and adjustment disorders have been identified among victims of
sexual abuse, such as acute physical symptoms (i.e., headaches), psychological symptoms (i.e., fears),
behavioral symptoms (i.e., aggression), and, in adolescence, acting out behaviors (i.e., delinquency, drug
use or promiscuity). Sexualized behaviors including persistent sexualized behavior with other children,
age-inappropriate knowledge of sexuality, and/or seductive or promiscuous behavior may be noted
(Wekerle & Wolfe, 1996).
Emotional Abuse
Emotional maltreatment does not typically involve a specific incident or visible injury. Effects of
emotional maltreatment tend to be apparent over time. Emotional maltreatment has been defined as:




Emotional abuse
 Overly hostile
 Punitive treatment or habitual or extreme verbal abuse (threatening, belittling)
Non-organic failure to thrive
Emotional neglect (i.e., inadequate nuturance/affection)
Exposure to family violence
Emotional maltreatment was identified as either the primary or secondary category of maltreatment for
approximately 23,000 children or 37% of all substantiated maltreatment in Canada in 1998. Of this
number, child exposed to family violence was the form of emotional maltreatment identified most
frequently, followed by emotional abuse and then emotional neglect.
The child’s personal power or sense of self-efficacy is diminished as the child is raised in a climate where
there is a current of disrespect and devaluation. A damaged sense of self-esteem, self-concept and social
competency follow (Wekerle & Wolfe, 1996). See summary, Appendix II.
In recent years, researchers have included witnessing domestic violence in the category of emotional
abuse (Trocme et al., 2001). Domestic violence most often occurs in the home - the environment that
children tend to associate with their physical and emotional safety. Additionally, the aggressor and the
victim are the persons with whom the child is most likely to identify and to whom the child would want to
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turn for support. It can be concluded on the basis of these parameters that witnessing violence between
one’s parents can be a particularly insidious form of abuse. When considering the effects of witnessing
violence on children, it must be understood that there is a high correlation (between 40% and 75%)
between domestic violence and other forms of abuse (Margolin, 1998). This means that not only are
children vulnerable to the development of psychological, social, physiological and behavioral problems
associated with witnessing domestic violence but also highly likely to be targets of abuse themselves.
Children in these families may also be vulnerable to a variety of secondary mental health risks such as
separation of children from a parent due to divorce, incarceration of a parent, and school and home
relocation.
Witnessing violence has been associated with emotional, behavioural, and learning problems in children,
with children’s susceptibility affected by their developmental level, the chronicity of exposure, physical
closeness to the incident, and emotional closeness to the victim. The effects of witnessing domestic
violence tend not to be short-lived or limited to the time of exposure to these events. In fact, children’s
fundamental notions of the quality and safety of marital and family relationships may be profoundly
influenced by their exposure to marital conflict and violence. Children in these circumstances can have
little sense of predictability and warmth within their family, tend to worry, be chronically aroused, and
feel threatened and emotionally distressed. There is evidence that children’s general patterns of
behavioral, emotional, cognitive, social and physical functioning can be affected in relation to their
family, school and community (Cummings, 1998).
Developmental Impact of Child Maltreatment
Pearce and Pezzot-Pearce (1997) suggest the effects of child maltreatment and trauma can be categorized
into two major types (these are not mutually exclusive):

Localized Effects
Those effects specific to the trauma experience but without major developmental
ramifications. Effects are usually short-term and primarily affect behavior associated with the
victimization experience. These can be acute and distressing, for instance, nightmares or
flashbacks.

Developmental Effects:
Deep and generalized impact that results when a victimization experience and related trauma
interfere with developmental tasks or the course of normal development. Areas that can be
affected include attachment, behavioral and emotional self-regulation, development of self,
cognitive and academic functioning and peer relations.
Studies of child abuse and trauma suggest several domains of child functioning that can be affected by
child maltreatment.
Attachment
Abuse and neglect are recognized as having a profound impact on the child’s ability to form secure
attachments. Wolfe (1998) asserts that a failure to provide nurturing, sensitive and supportive caregiving
results in the breakdown of a secure parent/child attachment and creates a core disturbance in the child’s
ability to form future healthy relationships. The child’s lack of confidence in the parent as an available
and responsive provider sets up an adaptive response that leads the child to avoid the parent while under
stress in order to reduce the likelihood of rejection and angry interchanges. This, then, increases the
child’s tendency to isolate themselves, to respond defensively under a range of circumstances and to
respond with anger and aversion to the distress of others (Wekerle & Wolfe, 1996). In addition, lowered
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self-esteem and/or a negative or “bad” sense of identity can develop. Conceptualizations of the self as
alternately ‘good’ and ‘bad’ can occur as splitting or dissociation. Attachment theory suggests an internal
working model can develop where negative conceptualizations of the self reflect a child’s experience and
shape the way a child perceives events, forecasts the future and constructs plans. Abuse internalizations
can, therefore, become a predominant part of the child’s working model. See Appendix VI for
Internalization Model.
One consistent finding in the literature is that there are few differences in the impact of the various forms
of maltreatment on children but that there is generally a strong connection between maltreatment and
insecure attachment. There are current controversies about identifying attachment problems in children
given the very negative or even hopeless perceptions this labeling can create for children (Saunders,
Berliner & Hanson, 2001). Insecure attachment may become evident in the socio-emotional behavior of
these children in that they may have problems understanding the emotions of others, may respond to
distress in others with fear or anger, and experience an elevated risk of suicidal ideation and depression.
Neglected children, in particular, have difficulty learning strategies for engaging adults and independently
exploring their environments.
Physical Development
Physical abuse and neglect can lead to child fatalities, neurological impairment and minor and major
physical injuries. Perry (2001) found that children can experience a physical arousal state that originates
from a necessary ‘fight or flight’ response to danger. If traumatic events are ongoing, this state of physical
and emotional arousal can become chronic leaving the child vulnerable to persisting hyper-arousal related
symptoms and related disorders (e.g., PTSD, ADHD, conduct disorder). This activation can cause
hypervigilance, increased muscle tone, a focus on threat related cues, anxiety and impulsively which can
be adaptive during an episode but maladaptive if this response persists (Perry, 2001). It is common to see
signs of physical regression among children who have been maltreated. For example, children who had
been potty-trained may develop toileting difficulties, or children who had learned skills at school may
suddenly develop problems completing their work. Other physical signs may develop such as sleeping
problems or eating problems. There may be an increase in psychosomatic complaints such as
stomachaches or headaches. Sexual abuse can also alter physical functioning as urinary tract infections,
elevated risk for sexually transmitted diseases and pregnancies are common. In addition, sexuality is
shaped in developmentally inappropriate and interpersonally dysfunctional ways. Distorted views about
the body and sexuality generate risk for eating disorders and other mental health conditions.
Cognitive Development
One explanation for the differences in impact on children is the way in which harsh treatment is
cognitively processed and understood. The child’s coping mechanisms become challenged by the
rationales given by caregivers for the abuse, for instance, that it is discipline, love or a secret. The child
must create some form of defensive structure that allows them to cope with the incongruities of these
messages. Social cognition as it relates to the child’s inferences about the thoughts, feelings and
intentions of others is affected as they are unable to integrate their experience with what they are told or
with what they feel about their experiences. One of the more direct consequences of being abused or
witnessing violence may be the attitudes a child develops concerning the use of violence and conflict
resolution. Children may come to believe that violence is a reasonable method by which to conduct
relationships or that excessive passivity is required in order to keep relationships safe (Edelson, 1997).
Physical abuse, neglect and sexual abuse are all linked to cognitive impairment. Expressive language
delays and lower academic achievement are noted along with greater immaturity, poor reasoning skills
and a sense of inadequacy among both boys and girls. In this area, the potential impact of impoverished
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environments is noted. These findings suggest global cognitive delays and language deficits which may
relate to avoidance patterns in the home, poor care giving, limited stimulation, dissociation or
distractibility and as well as greater school avoidance such as more absences. Discontinuity in education
related to frequent moves, school transfers and suspensions are also a factor in outcome (Wekerle &
Wolfe, 1996).
Conceptions of Self
The maltreated child must create a defensive structure for coping that can include cognitive vigilance or
reality mediating strategies such as dissociation. Cognitive distortions and disruptions of a success based
orientation result from maltreatment. Strong explanatory links between maltreatment and the child’s
subsequent social behavior include misdirected inferences about the thoughts, feelings and intentions of
others. In addition, the child’s internal attributions of self-blame are linked to greater maladjustment.
For physically abused children, delays in social-emotional development are linked to problems in moral
reasoning and empathy for others. Conceptions of self are interrupted by a sense of powerlessness as the
child’s will, desire and sense of self-efficacy is thwarted by the abuse experience. A disruption in
relatedness occurs with an interpersonal wariness, interpersonal idealization, and labile interpersonal
interactions and indiscriminate interpersonal relationships.
Affect Regulation
Learning to modulate, redirect, regulate and modify feelings is a critical component for adaptive
functioning. Difficulties modulating affect frequently are cited as associated with an abuse experience.
Overall, child witnesses of domestic violence exhibit more aggressive and antisocial (externalized
behaviors) as well as fearful and inhibited behaviors (internalized behaviors) and show lower social
competence than other children. These children have also been found to show more anxiety, self-esteem,
depression, anger, and temperament problems than other children. They have difficulty understanding the
feelings of others and limited skills in seeing the perspective of others. Peer relationships, autonomy, selfcontrol, and overall competence are also found to significantly lower among these children. Another
common effect on these children may be an increased tendency to use violence (Margolin, 1998). At the
most extreme, maladaptive self-destructive behaviors can result such as self-mutilation, suicidal ideation
or drug and alcohol abuse.
Environmental Violence And Trauma
Violent Neighborhoods and Communities
Community violence refers to exposure, as a witness or through actual experience, to acts of interpersonal
violence perpetrated by individuals who are not intimately related to the victim. Children are victims of
community violence when they are the subject of a physical attack, or a threat of a physical attack, with or
without a weapon, by anyone who is not in their intimate circle; e.g., someone other than a parent,
caregiver, friend, or other individual living in the house. In communities with high rates of community
violence, family members may be subjected to criminal activity, such as sexual assault, burglary, use of
weapons, muggings, and the sound of bullet shots, as well as to community-based issues, such as the
presence of graffiti, teen gangs, drugs, and racial divisions (Linares, 2001).
Children who live in violent neighborhoods are at increased risk of exposure to violence and other
traumatic events as compared to children residing in other areas. In addition to violent acts by strangers,
common verbal and non-verbal aggressive acts performed by children against other children or adults in
their own community are seen to contribute to a context of community violence. For example, some
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children are bullied or victimized in verbally aggressive ways by older children as they walk to school,
ride the school bus, or play in the park. These acts, previously seen as falling within the realm of ‘normal’
child and adolescent behavior, are now becoming a great concern to parents, educators and community
leaders as possible precursors of more serious instances of community violence (Linares, 2001).
How does community violence affect children?
Children may be adversely affected by community violence whether they are victims or witnesses. For
example, children can experience trauma when they witness a stranger in the street, a casual acquaintance
from their neighborhood, or another student at their school, physically assaulting another person for the
purpose of robbing him, settling a fight, venting anger, or making a threatening statement. Past research
has documented that exposure to community violence may have enduring consequences on children's
development, beginning in the pre-school years and continuing through adolescence. The research has
demonstrated that children who witness community violence are likely to develop a view of the world that
is hostile and dangerous. In addition, children living in neighborhoods with high violent crime rates are
also likely to be exposed to domestic violence in their own homes and thus are highly vulnerable to being
victimized by different forms of interpersonal violence. Research has documented that children who are
exposed to multiple forms of violence are at more risk of developing psychological sequelae (including
posttraumatic stress disorder) than those exposed to only single or isolated violent events (either at home
or in the community) (Linares, 2001).
As a result of continued exposure to violence children may distrust adults and fear neighbors in their
community. Their feelings of safety and confidence in adults may erode or diminish. Reactions may take
several forms: some children become anxious, fearful or withdrawn (internalizing problems or taking
fears inward); others may believe that the use of violence is justified and shows they are strong and
powerful. These children may choose to use violence to attain their wishes, or to identify with the
aggressor, as a way to solve interpersonal conflict with the adult world or with their peers (externalizing
problems or expressing fears outward) (Linares, 2001).
A child’s exposure to community violence can also affect her/his family. Parents may experience extreme
anxiety concerning their child’s health and well-being and have limited resources available to them to
cope with their distress. Many parents blame themselves for not protecting their child adequately and may
become over-protective or use punitive discipline in response to their child’s trauma-related acting out
behavior. Relationships among family members can become strained as parents find themselves having to
face the task of reassuring their child while trying to cope with their own fears (Goguen, 2000).
Intervention must be multi-faceted and take place at the level of:
 The child who needs the support of a caring adult to feel safe
 The parents who need appropriate techniques for enhancing family coping strategies
 The community through upgrading the services and the quality of the neighborhood.
Children of War
The basis for the diagnosis and treatment of psychologic sequelea associated with traumatic events
originated from the experiences of soldiers (mostly men) in World War I and II. It was not until the
Vietnam War and the 1970s that the diagnosis of post traumatic stress disorder (PTSD) was formally
introduced in the mental health nomenclature (Williams & Steiner, 1998). Only in the last 20 years have
these ideas been broadened to include the experiences of the general population, women and most
recently, those of children. Research on the effects of war on children from Cambodia (Sack, 2000;
Boyden & Gibbs, 1997), Palestinian Children (Thabet & Vostanis, 2002), and adolescent refugees from
Bosnia (Ljubomirovic, 1999) have begun to document the impact of living in warlike situations on
children’s mental health.
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A context of war often means the collapse of traditional authority structures, social networks, weakening
of cultural and spiritual values and disruption of gender roles. Changes in the demographic structure of
households and communities, together with family impoverishment drastically reduce the age thresholds
for marriage, child-bearing, work and decision-making, forcing children to assume social and economic
responsibilities that lead to increases in exposure to physical danger and exploitation.
As well, living in a war zone puts children at risk of experiencing a variety of traumatic events. These can
include:
 Deprivation of basic needs such as food and shelter,
 Displacement from their homes and communities,
 Separation from or death of a parent,
 Injury of another family member or close friend,
 Exposure to combat.
Children growing up in a context of war are also highly vulnerable to experiencing secondary traumas
that occur as a result of the initial traumatic event. For example, children may be sent away by parents
who feel unable to care for them after an initial displacement, or a parent may turn to alcohol to cope with
feelings of inadequacy and stress.
Children exposed to war can experience a range of difficulties. These include behavior problems, somatic
complaints, mental health disorders and impaired moral reasoning and cognitive functioning. A study by
Thabet and Vostanis (2002) found that 73% of primary school age children interviewed reported PTSD
reactions of at least mild severity while almost 40% reported moderate to severe reactions. Garbarino
(1992) asserts that in addition to developing symptoms such as re-experiencing the event, numbing of
responsiveness, and symptoms of increased arousal, children who experience environmental violence are
vulnerable to ‘spiritual and philosophical consequences’ as a result of trauma. These include:

Loss of Security: Children who have experienced trauma have lost the idea of home, school
and/or community as a safe place. They have learned that their primary caregivers have limited
ability to protect them from traumatic events, and (in some cases) to respond to the child’s trauma
in a manner that is helpful and reassuring.

General sense of loss: One single traumatic event can result in any of the following losses: loss of
people (death), loss of physical capacity (injury to people), loss of protection (including loss of
adults’ ability to protect the child and loss of safe places to retreat), loss of control, loss of hope
(diminished future orientation.). Loss increases the child’s sense of vulnerability and can cause
chronic sadness and depression.

Blurring of Distinctions between ‘friend’ and ‘enemy’: Children may have trouble distinguishing
between who is their enemy and who is their friend. For example, close family members could be
members of a gang that uses violence as a method of gaining power in the community. In the
context of war, the child’s neighbours may become their enemy because of political affiliations.
Understanding the Range of Emotional and Behavioral Responses to Trauma and Abuse and the
Differential Manifestations in Children and Adolescents
Sequale of Abuse and Trauma
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Stress and Distress
Some stress is normal and even healthy for children as they negotiate the various daily and life challenges
they encounter. For example, most children attend school and will go through many transitions; most
adolescents will have to grapple with their sense of identity to determine where they "fit." The demands
placed on children and adolescents to successfully negotiate these situations can result in feelings of
stress. Small amounts of stress - such as experienced before a test or when meeting new people - are
necessary to present challenges for greater learning. Simple stress experienced when learning a new skill
or playing an exciting game can raise a person's level of excitement or sense of pressure above their
normal level.
Problems can begin when ordinary stress becomes too much stress or distress. Distress occurs when the
demands of the stressor exceed the child’s coping ability. Events that are unpredictable or beyond the
child’s control such as death, divorce, remarriage, moving, long illness, abuse, family or community
violence, natural disaster, fear of failure, and cultural conflict can contribute to the child experiencing
distress. Factors such as the child's stage of development, ability to cope, the length of time the stressor
continues, intensity of the stressor, and the degree of support from family, friends, and community all
impact the likelihood of stress becoming pathological (Jackson & Pynoos, 1994).
A child’s risk of developing a stress disorder is related to the seriousness of the trauma, whether the
trauma is repeated, the child’s proximity to the trauma, and his/her relationship to the victim(s) (Cohen,
1998). Developmental themes influence children’s experience of the stressor along with the attribution of
meaning, emotional and cognitive means of coping, the tolerance by adults of their reactions, expectations
about recovery, and parental effectiveness in addressing other secondary life changes that occur as a result
of the traumatic event. Interpersonal and intra-personal protective factors play a role in that children with
adequate social supports and familial networks, along with a range of biological, cognitive, and
psychological coping mechanisms are less likely to develop a psychiatric disorder as a result of trauma
and more likely to recover than others. Children with pre-existing psychopathology, poor parental and/or
community supports are more likely to be exposed to the types of stressors that lead to PTSD symptoms
and, once established, to become chronic (March, Amaya- Jackson & Pynoos, 1994).
Post Traumatic Stress Disorder
Post Traumatic Stress Disorder [PTSD] and other anxiety-related symptoms are among the most common
disturbances in self-regulation manifested by maltreated children (Pearce & Pezzot-Pearce, 1997). It is
defined as a specific set of symptoms that may develop in some children following exposure to an
intensely traumatic event(s) such as witnessing a homicide; traffic accidents; combat; natural disasters;
victimization; holocaust survivors/families; self-harming behavior; domestic violence; and HIV. To meet
the criteria for PTSD, the child must have been exposed to an ‘extreme stressor” characterized by threat to
life, potential for physical injury and an element of grotesqueness or horror that demarcates these events
from less traumatic experiences such as the expected death of a loved one from a serious illness (DSM
IV-TR). Children and adolescents generally react acutely to these traumatic events with surprise, terror,
and a sense of helplessness (Cohen, 1998). Post-traumatic Stress Disorder is differentiated from an acute
stress reaction or Acute Stress Disorder in that the symptom pattern of ASD, while similar to PTSD, must
occur and resolve within a 4-week period. A diagnosis of PTSD would not occur until the symptoms had
been in place for more that a 4-week period (DSM IV –TR). PTSD symptoms may or may not develop
immediately after the trauma occurs; in fact, many children develop symptoms some time after the event.
A diagnosis of PTSD must include a specific number of symptoms from each of three broad categories:
re-experiencing, avoidance/numbing, and increased arousal. These symptoms must be present for at least
1 month and cause clinically significant distress or impairment in functioning (DSM IV –TR).
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Re-experiencing symptoms - The traumatic event is persistently re-experienced through recurrent and
intrusive distressing memories of the event. In young children this may be manifested by repetitive play
in which traumatic themes occur, recurrent distressing dreams about the trauma, frightening dreams (in
young children there may be frightening dreams without recognizable content), acting or feeling as if the
trauma were recurring (includes a sense of reliving the experience, illusions, hallucinations, and
dissociative flashback episodes), intense distress at exposure to internal or external cues that symbolize
or resemble an aspect of the trauma; physiological reactivity at exposure to such cues.
Avoidance of stimuli - Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma) through efforts to avoid thoughts, feelings, or
conversations associated with the trauma, efforts to avoid reminders of the trauma, amnesia for an
important aspect of the trauma, diminished interest or participation in normal activities, feelings of
detachment or estrangement from others, restricted affective range, a sense of a foreshortened future
(e.g., does not expect to meet normal lifespan milestones such as career, marriage, children).
Persistent symptoms of increased arousal - Persistent symptoms of increased arousal (not present before
the trauma) such as: sleep difficulties; irritability or angry outbursts; difficulty concentrating; hypervigilance; or exaggerated startle response (March, Amaya-Jackson & Pynoos, 1994).
Developmental Effects of PTSD
Loss of acquired skills and/or the failure to develop new skills may reveal itself differently, depending on
the developmental age and stage of the child. For example, a young child may develop enuresis, while a
school-age child may become tearful when it comes time to leave home for school. Adolescents may
become socially withdrawn, choosing to stay at home rather than to engage in activities that were
previously enjoyed (March, Amaya-Jackson & Pynoos, 1994).
Research indicates that the majority of children suffering from single-episode PTSD recover with
relatively minimal intervention (e.g., an opportunity for catharsis and supportive treatments) and only
10% - 20% of children continue to suffer from psychopathology after one year. However, children who
have had one episode of PTSD tend to be more readily traumatized in the future by similar or related
events (Klyklo, Kay & Rube, 1998). Children who are repeatedly exposed to traumatic events and/or a
series of secondary traumatic events, may present with a preponderance of symptoms such as
dissociation, self-injurious behaviours, substance abuse and/or conduct problems, which may obscure the
post-traumatic origin of the disorder (Cohen, 1998).
In general, a prevention/early intervention model is recommended that incorporates a multi-modal
approach that includes support and strengthening of coping skills for anticipated grief/trauma responses,
treatment of other disorders that may develop or exacerbate in the context of PTSD and treatment of acute
PTSD symptoms. At this point, there is inadequate empirical support for the use of medications to
specifically treat PTSD; however, some medications can be helpful in treating individual symptoms such
as sleep disorders, depression, or anxiety.
Issues in Assessment
In assessing the impact of maltreatment and trauma, there must be consideration of the broad variability
of children’s responses and the many areas of functioning. Besides considering the child in terms of the
diverse facets of their functioning and behaviour, these domains of functioning may also be moderators of
the child’s response to maltreatment and possible sources of resiliency. A comprehensive assessment of
the child and family should incorporate a variety of methods and be based in multiple settings. No single
assessment strategy or test can render all the information needed about the child, context or family. The
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child and family’s functioning may vary in different contexts, a fact that may have implications for
intervention. Additionally, a full and comprehensive assessment takes an ecological perspective and
recognizes that children live in the context of their families, as well as in a larger social and cultural
context.
Many factors impact the response of the child or adolescent to abuse and various forms of trauma. Key
factors are:
1. Severity of the traumatic event
2. Family support and parental coping
3. Temporal proximity to the traumatic event
4. Amount of violence associated with the event such as assault or rape
5. Total number of previous traumas (Hamblen, 1998)
Assessment Considerations

Safety is the first priority and understanding the levels of risk for harm in the child’s environment is
key. Structural and contextual interventions such as child welfare involvement, as well as initial
treatment targets, are the basis for clinical intervention and treatment. Treatment cannot proceed
while danger or fear exists.

The stance of the parents is also a critical focus of assessment. Parents may be involved in treatment
as a result of child protection intervention and may dispute or minimize the abuse allegations.
Assessment of parental perceptions of and readiness to address child maltreatment is critical. Parental
responses to community violence are also key areas for assessment as these responses can
significantly alter outcomes for the child.

Common behavioral and emotional problems have been documented and include fear, anxiety, posttraumatic stress symptoms, depression, sexual difficulties, poor self-esteem, stigmatization, difficulty
with trust, cognitive distortions, difficulty with affective processing, aggression and peer socialization
deficits. Careful assessment of these issues is required. The nature and severity of disturbance can
vary substantially from child to child. Some children may be apparently asymptomatic; others may
experience moderate or major mental health concerns. In some cases, symptoms have a delayed onset.
Assessment should include current difficulties as well as identify risk factors for developing future
problems.

It is important to gain an understanding of the actual events of the abuse or trauma. The events
themselves, the response of the significant adults and the subsequent events are all part of the child’s
response. The direct effects of abuse or trauma are important to consider first. The most abusespecific outcome for maltreatment is post-traumatic stress disorder, with about 50% of sexually
abused children and 33% of physically abused children meeting the criteria for PTSD and many
others who experience distressing symptoms.

PTSD and other disorders related to trauma can occur in children who experience symptoms of other
disorders, and children with other disorders can have PTSD as a co-morbid condition. Additionally,
there is overlap in the criteria for the diagnosis of PTSD and a number of other disorders (e.g., some
of the symptoms of increased arousal that are present in PTSD can look similar to ADHD in some
children). It is important, therefore, that the assessment process include consideration of biological,
psychological and social factors that pre-existed and resulted from the traumatic event (Zide & Gray,
2001).
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
The indirect effects of abusive events are also important and an abuse-informed perspective is needed.
The child’s beliefs about what has happened (i.e., attributions of self-blame, guilt, stigmatization or
shame) are important to prognosis.

The assessment must be developmentally informed. What can begin as an abuse specific symptom
can lead to problems of functioning that can result in risks for further disrupted development. A
developmental focus is important for two reasons:
1. Knowledge of normal growth and development helps to determine the significance of a particular
behavior, that is, the behavior or symptom of a ‘problem’ deserving attention or is the problem
expected of a child of that particular age. For example, enuresis in a 2-year old child would have
different significance than in a 12-year old child.
2. Knowledge about a particular child’s developmental age and stage provides critical information
that guides the method of assessment strategies. For example, young children have poorly
developed concepts of time and may not be able to answer time-related questions accurately.
Parent/Child Relationship



Attention should be paid to both the offender/victim and parent/child aspects of the relationship.
Insecure attachment is often associated with abuse experiences and cannot only disrupt parent/child
relationships but also set up major risks for life-long problems relating to others.
Level of parental distress, as well as level of belief and support about the abuse experience, has been
found to be an important factor in outcome for the child (Saunders, Berliner & Hanson, 2001).
Safety of the Child
Legislation suggests that decisions should be based on the best interests of the child, however, in Alberta,
the points to consider include the primacy of the family unit, the importance of child rights, the
preservation of the well-being of the family and the right to the leas t intrusive form of intervention. In
cases where there is no consensus on the rights of the parents and the needs of the child, the lack of clarity
as to which principle has priority will jeopardize the safety and protection of some children. The tension
between ensuring child safety and providing supportive services within the child’s family and community
is one of the fundamental and critical challenges of child welfare – to determine when the risk of harm is
too great to leave a child at home.
Issues In Treatment
Since trauma can never be ‘undone,’ ‘cure’ is not the most appropriate treatment goal; however, trauma
victims can become well functioning if appropriate treatment is given and facilitation of healing takes
place (March, Amaya-Jackson, & Pynoos, 1994). Treatment must be comprehensive and ecologically
based, never occurring in isolation from the child’s family, caregivers and immediate environment. There
may be family and larger social factors that contribute to or moderate a child’s recovery and growth that
must be considered such as the extent to which the families ‘survival needs’ are met, the parents ability to
emotionally support their child, and the families access to community supports and resources.
Treatment must have a step-by-step focus that addresses developmental effects and supports children to
negotiate stage-salient developmental tasks. A child’s need for treatment may ebb and flow as the
meaning of the maltreatment changes as function of his or her progress through different developmental
stages. Therapy may be required, therefore, at various points in a child’s life as difficulties arise and then
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can be discontinued for extended periods when the child is functioning well. Treatment approaches
should be congruent with the developmental abilities and capacities of the child. For example, a child who
has a verbal learning disorder may not respond well to an approach that relies on verbal exchanges
(Pearce & Pezzot-Pearce, 1997).
Interventions with abused children should be abuse focused; that is, interventions should explicitly and
directly address the abuse incidents experienced by the child and the consequent emotions, cognitions,
and behaviors exhibited by the child as a result of the abuse. The child’s maladaptive behaviors, thoughts
and feelings related to the abuse should be the primary targets of intervention.
Common Goals of Therapy
1. Helping children acknowledge the maltreatment and express the associated feelings and cognitions.
In order for the maltreated child to develop healthier and more adaptive ways of coping with the
feelings associated with the victimization and to reformulate the meaning of these experiences, they
must first acknowledge that the maltreatment occurs and begin to identify and express the feelings
and attributions regarding responsibility connected to the maltreatment. This diminishes the
likelihood that the child will develop more intractable and serious symptoms and relieve some of the
child’s distress and anxiety (Pearce & Pezzot-Pearce, 1997). Children’s abuse experiences should be
acknowledged and characterized as wrong, unlawful, and harmful in all abuse-specific interventions
with children, families and parents.
2. Helping children develop more adaptive ways of expressing feelings regarding the maltreatment.
Children who have been maltreated often experience disruptions in their ability to regulate their
feelings and behavior. Teaching the child to use language to label and communicate emotions can
contribute significantly to his or her self-control and self-regulation (Pearce & Pezzot-Pearce, 1997).
3. Helping children reformulate the meaning of the maltreatment. The therapist may have to help the
child uncover and correct cognitive distortions regarding the maltreatment including inaccurate
accountings of events and beliefs that he or she was ultimately responsible for the abuse (Pearce &
Pezzot-Pearce, 1997).
4. Modify internal working models. Changing the child’s abusive or neglectful environment will not
automatically improve the child’s psychological functioning. The child may tend to impose an earlier
model of relationships upon others (such as the therapist, teachers, and caregivers). The
psychotherapeutic relationship is an opportunity to counter the child’s pessimistic and negative
beliefs and expectations of others and self. As well, the child has a greater probability of changing
maladaptive internal working models when they have multiple experiences and relationships that
consistently counter their negative beliefs and expectations. Therapy, therefore, is just one component
in an overall strategy to help reestablish progress along an adaptive developmental pathway. Other
interventions must be directed at the level of the family and factor in the broader environment to
support the child to establish, maintain and reinforce new beliefs and expectations of relationships
(Pearce & Pezzot-Pearce, 1997).
5. Self-perception. A common theme in treating children who have been traumatized is to help them
change their perception of themselves and develop greater feelings of mastery and self-efficacy
(Pearce & Pezzot-Pearce, 1997).
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Assigned Readings
Garbarino, J., Dubrow, N., Kostelny, K., & Pardo, C. (1992). Coping with the Consequences of
Community Violence. San Francisco, Jossey-Bass Pub. pp. 22-47
Wekerle, C. & Wolfe, D.A. (1996) Child maltreatment. In E.J. Mash & R.A. Barkley (Eds.),
Child psychopathology. New York: Guilford.
Review Questions
1. Identify two theories regarding the impact of child maltreatment and trauma. Discuss.
2. Identify the four major forms of child maltreatment along with common outcomes for mental health
concerns.
3. Choose one domain of functioning affected by child maltreatment and discuss.
4. Describe the impact on children of environmental sources of trauma.
5. Identify the key assessment and treatment considerations.
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Perry, MD, B. (2001). Violence and childhood: How persisting fear can alter the
developing child’s brain. Internet.
Pearce, J. & Pezzot-Pearce, T. (1997). Psychotherapy of abused and neglected children.
New York: Guilford Press.
Sack, W. (1999). Twelve-year follow-up study of Khmer youths who suffered massive
war trauma as children. Journal of the American Academy of Child and Adolescent Psychiatry.
Internet
Saunders, B.E., Berliner, L., & Hanson, R.F. (2001) Guidelines for the Psycho-social
Treatment of Intrafamilial Child Physical and Sexual Abuse. Final Draft Report: July 30, 2001.
Charleston: Authors. Internet.
Sulivan, S. (2000) Child neglect: Current definitions and models-A review of child neglect
research, 1993-98. Ottawa, National Clearinghouse of Family Violence.
Thabet, A. & Vostanis, P. (2002). Post-traumatic stress reactions in children of war.
Internet
The Peel Committee Against Woman Abuse, Breaking the Cycle of Violence: Children
Exposed to Woman Abuse: A Resource Guide for Parents and Service Providers, November
2000, Internet.
Trocme, N., MacLaurin, B., Falon, B., Daciuk, J., Billingsley, D., Tourigny, M., Mayer, M.,
Wright, J., Barter, K., Burford, G., Hornick, J., Sullivan, R., & McKenzie, B. (2001). Canadian incidence
study of reported child abuse and neglect: Final report. Ottawa, ON: Minister of Public Works and
Government Services Canada.
Trauma, Post-Traumatic Stress Disorder and Abuse
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Wekerle, C. & Wolfe, D.A. (1996). Child maltreatment. In E.J. Mash & R.A. Barkley (eds.),
Child psychopathology. New York: The Guilford Press.
Wieland, S. (1998). Techniques and issues in abuse-focused therapy with children and
adolescents. London: Sage.
Williams, S., & Steiner, H. (1998). Childhood trauma. In W. Klyklo, J. Kay, & D. Rube
(Eds.), Clinical child psychiatry (pp. 263-277). Toronto; W.B. Saunders Co.
Wolfe, D.A. (1998). Prevention of child abuse and neglect in Health Canada (eds.)
Determinants of Health, Children and Youth. Ottawa:Canadian Government Publishing.
Zide, M. & Gray, S. (2001) Psychopathology: A competency-based assessment model for
social workers. Toronto: Brooks/Cole Thomson Learning.
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Trauma, Post-Traumatic Stress Disorder and Abuse
Appendix I - Forms of Maltreatment
FORMS OF MALTREATMENT
1. P 1. Physical Abuse: The child has suffered or is at substantial risk of suffering physical harm, at the hands of the
child’s caretaker.
 Shaken baby syndrome: Brain or neck injuries resulting from the infant being shaken.
 Inappropriate Punishment: Child abuse has occurred as a result of inappropriate punishment. Includes
inappropriate use of corporal punishment, as well as other forms of punishment that has led to physical
harm or put the child at substantial risk of harm. The judgment of appropriateness is based on many factors,
including the severity of harm or potential harem, the amount of force used, the type of punishment relative
to the age of the child, and the frequency of punishment.
 Physical Abuse: Other physical abuse includes any other form of physical assault that is inflicted on a
child, such as intentionally burning a child or hitting the child in a manner that does not appear to be
intended as punishment.
2. Sexual Abuse:
 Sexual Activity Completed: Includes oral, vaginal, or anal sexual activities.
 Sexual Activity Attempted: Includes attempts to have oral, vaginal, or anal sex.
 Touching/Fondling Genitals: Sexual activity involving touching/fondling genitals.
 Adult Exposing Genitals to Child: Sexual activity consisting of exposure of genitals.
 Sexual Exploitation: Involved in Prostitution or Pornography: Includes situations in which an adult
sexually exploits a child for purposes of financial gain or for profit.
 Sexual Harassment: Includes propositions, encouragement, or suggestions of a sexual nature.
 Voyeurism: Includes activities in which a child is encouraged to exhibit himself/herself for the sexual
gratification of the alleged perpetrator.
3. Neglect: Includes situations in which children have suffered harm, or their safety or development has been
endangered as a result of the caregiver’s failure to provide for or protect them.
a. Failure to Supervise or Protect Leading to Physical Harm: The child suffered or was at substantial risk
of suffering physical harem because of the caregiver’s failure to supervise and protect the child
adequately. Failure to protect includes situations in which a child is harmed or endangered as a result of a
caregiver’s actions (e.g. drunk driving with a child, or engaging in dangerous criminal activities with a
child.).
b. Failure to Supervise or Protect Leading to Sexual Abuse: The child has been or is at substantial risk of
being sexually molested or sexually exploited, and the caregiver knew or should have known of the
possibility of sexual molestation and failed to protect the childe adequately.
c. Physical Neglect: The child has suffered or is at substantial risk of suffering physical harm caused by the
caregiver’s failure to care and provide for the child adequately. This includes inadequate
nutrition/clothing and unhygienic and/or dangerous living conditions. There must be evidence or
suspicion that the caregiver is at least partially responsible for the situation.
d. Medical Neglect: The child requires medical treatment to cure, prevent, or alleviated physical harm or
suffering, and the child’s caregiver did not provide, refused or was unavailable or unable to consent to the
treatment.
e. Failure to Provide Treatment for Mental, Emotional or Developmental Problem: The child is at
substantial risk of suffering from emotional harm as demonstrated by severe anxiety, depression,
withdrawal, self-destructive or aggressive behavior, or suffering from a mental, emotional or
developmental condition that could seriously impair the child’s development. The child’s caregiver did
not provide, or refused, or was unavailable or unable to consent to treatment to remedy or alleviate the
harm. This category can include failing to provide treatment for school-related problems such as learning
and behavior problems, as well as treatment for infant development problems such as non-organic failure
to thrive.
f. Permitting Maladaptive/Criminal Behavior: A child has committed a criminal offence with the
encouragement of the child’s caregiver, or because of the caregiver’s failure or inability to supervise the
child adequately. Alternatively, services or treatment are necessary to prevent a recurrence and the child’s
caregiver did not provide, refuse, or was unavailable or unable to consent to those services or treatment.
Trauma, Post-Traumatic Stress Disorder and Abuse
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Abandonment/Refusal of Custody: The child’s caregiver has died or was unable to exercise custodial
rights and did not make adequate provisions for care and custody, or the chills was in a placement and the
caregiver refused or was unable to take custody.
h. Educational neglect: Caregivers knowingly allowed chronic truancy (5 or more days a month), failed to
enroll the child, or repeatedly kept the child at home.
Emotional Maltreatment: This category is difficult to document because if often does not involve a specific
incident or visible injury. In addition, the effects of emotional maltreatment, although often severe, tend to
become apparent over time (e.g. impaired cognitive, social, and emotional development).
 Emotional Abuse: The child has suffered or is at substantial risk of suffering from mental, emotional, or
developmental problems caused by overtly hostile, punitive treatment, or habitual or extreme verbal abuse
(threatening, belittling, etc.).
 Non-organic Failure to Thrive: A child under 3 has suffered a marked retardation or cessation of growth
for which no organic reason can be identified.
 Emotional Neglect: The child has suffered or is at substantial risk of suffering from mental, emotional, or
developmental problems caused by inadequate nurturance/ affection.
 Exposed to Family Violence: A child has been a witness to, or involved with family violence within
his/her home environment. This includes situations in which the child indirectly witnessed the violence
(e.g. saw the physical injuries on his/ her caregiver the next day).
g.
2.
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Trauma, Post-Traumatic Stress Disorder and Abuse
Appendix II - Symptoms Associated with Child Maltreatment
INFANTS
Disruption in eating and sleeping routines
Fearful reactions to loud noises
Excessive crying
III.
Physical neglect
Delays in Development
PRESCHOOL CHILDREN
Low self-esteem
Frequent illness
Poor concentration
Eating and sleep disturbances
Post-traumatic stress*
Fear
Separation anxiety
IV.
Anger and aggression
Clinging
Withdrawing
Hitting, biting
Inappropriate sexual behaviour
Cruelty to animals
Destruction of property
Problems in pre-school/day care
Pleasing behaviour
Regressive behaviour (thumb sucking, bed wetting)
ELEMENTARY SCHOOL (5-12 YEARS)
Low self-esteem
Frequent illness
Poor concentration
Eating and sleep disturbances
V.
Post traumatic stress*
Fear
Anxiety and tension
Anger and aggression
Withdrawing
Bullying
Alcohol/Drug Abuse
Depression
Inappropriate sexual behaviour
Self-harm
Perfectionism
Destruction of property
Problems in school
Pleasing behaviour
Peer relationship problems
Disrespect for females
EARLY ADOLESCENCE (12-15
YEARS)
Low self-esteem
Frequent illness
Poor concentration
Eating and sleep disturbances
Post traumatic stress*
Fear
Anxiety and tension
Anger and aggression
Bullying
Being abused or becoming abusive
Depression
Alcohol/drug use
Self-harm
Suicidal behavior
Inappropriate sexual behaviour
Perfectionism
Running away from home
Pleasing behaviour
Problems in school
Peer relationship problems
Disrespect for females
Feeling over-responsible
LATER ADOLESCENCE (15-18
YEARS)
Low self-esteem
Frequent illness
Poor concentration
Eating and sleep disturbances
Post traumatic stress*
Fear
Anxiety and tension
Anger and aggression
Bullying
Being abused or becoming abusive
Depression
Alcohol/drug use
Self-harm
Suicidal behavior
VI.
Inappropriate sexual behaviour
Perfectionism
Running away from home
Pleasing behaviour
Problems in school
Peer relationship problems
Disrespect for females
Feeling over-responsible
*Post Traumatic Stress: Symptoms include nightmares, intrusive thoughts or images, flashbacks, fear,
anxiety, tension, hyper-alert, easily startled, irritability, outbursts of anger and aggression
Trauma, Post-Traumatic Stress Disorder and Abuse
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Appendix III
Symptoms of PTSD typical of young children (1-6) can include:


















Helplessness and passivity; lack of usual responsiveness
Generalized fear
Heightened arousal and confusion
Cognitive confusion
Difficulty talking about event; lack of verbalization
Difficulty identifying feelings
Sleep disturbances, nightmares
Separation fears and clinging to caregivers
Regressive symptoms (e.g., bedwetting, loss of acquired speech and motor skills)
Unable to understand death as permanent
Anxieties about death
Grief related to abandonment of caregiver
Somatic symptoms (e.g., stomach aches, headaches)
Startle response to loud/unusual noises
"Freezing" (sudden immobility of body)
Fussiness, uncharacteristic crying, and neediness
Avoidance of or alarm response to specific trauma-related reminders
Involving sights and physical sensations.
Symptoms of PTSD typical of school-aged children (6-11 years) can include:























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Responsibility and guilt
Repetitious traumatic play and retelling
Reminders trigger disturbing feelings
Sleep disturbances, nightmares
Safety concerns, preoccupation with danger
Aggressive behavior, angry outbursts
Fear of feelings and trauma reactions
Close attention to parents' anxieties
School avoidance
Worry and concern for others
Changes in behavior, mood, and personality
Somatic symptoms (Complaints about bodily aches, pains)
Obvious anxiety and fearfulness.
Withdrawal and quieting
Specific, trauma-related fears; general fearfulness.
Regression to behavior of younger child.
Separation anxiety with primary caretakers.
Loss of interest in activities.
Confusion and inadequate understanding of traumatic events most evident in play
rather than discussion.
Unclear understanding of death and the causes of "bad" events.
Magical explanations to fill in gaps in understanding.
Loss of ability to concentrate and attend at school, with lowering of performance.
"Spacey" or distractible behavior.
Trauma, Post-Traumatic Stress Disorder and Abuse
Symptoms of PTSD typical of pre-adolescents and adolescents (12-18 years) can include:













Self-consciousness
Life-threatening reenactment
Rebellion at home or school
Abrupt shift in relationships
Depression, social withdrawal
Decline in school performance
Trauma-driven acting-out behavior: sexual acting out or reckless, risk-taking
behavior.
Effort to distance from feelings of shame, guilt, and humiliation.
Flight into driven activity and involvement with others or retreat from others in order
to manage their inner turmoil.
Accident proneness.
Wish for revenge and action-oriented responses to trauma.
Increased self-focusing and withdrawal.
Sleep and eating disturbances; nightmares.
Trauma, Post-Traumatic Stress Disorder and Abuse
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Appendix IV
Factors that support children and create a safety net for them during stressful times include:










A healthy relationship with at least one parent or close adult.
Well-developed social skills.
Well-developed problem-solving skills.
Ability to act independently.
A sense of purpose and future.
At least one coping strategy.
A sense of positive self-esteem and personal responsibility.
Religious commitment.
Ability to focus attention.
Special interests and hobbies.
Families can provide further protection by:







Developing trust, particularly during the first year of life.
Having supportive family and friends.
Showing caring and warmth.
Having high, clear expectations without being overly rigid.
Providing ways for children to contribute to the family in meaningful ways.
Being sensitive to family cultural belief systems.
Building on family strengths.
Children who live in supportive environments and develop a range of coping strategies become
more resilient.
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Trauma, Post-Traumatic Stress Disorder and Abuse
APPENDIX V
Table 14.1. Range of Child Characteristics Associated with Physical Abuse, Neglect, and Sexual Abuse
Dimension of development Physical Abuse
Neglect
Sexual Abuse
Physical
Minor: Bruises, lacerations, Failure to thrive symptoms: Physical symptoms: Headaches,
abrasions
Slowed growth, immature
stomach aches, appetite changes,
Major: Burns, brain
physical development
vomiting, gynecological complaints
damage, broken bones
Cognitive
Mild delay in areas of
cognitive and intellectual
functioning; academic
problems; difficulties in
moral functioning
Mild delay in areas of
cognitive and intellectual
functioning; academic
problems; difficulties in
moral reasoning
No evidence of cognitive impairment;
self-blame; guilt
Behavioral
Aggressivity; peer
problems; “compulsive
compliance”
Passivity; “hyperactivity”
Fears, anxiety, PTSD-related
symptoms; sleep problems
Socioemotional
Social incompetence;
hostile intent attributions;
difficulties in social
sensitivity
Social incompetence;
withdrawn, dependent;
difficulties in social
sensitivity
Symptoms of depression and low selfesteem; “sexualized” behavior;
behaviors that accommodate to the
abuse (e.g., passive compliance, no or
delayed disclosure)
Adapted from Wekerle, Christine, Wolfe, David A. Child Maltreatment. E.J. Mash & R.A. Bakley (Eds) (1996). Child Psychopathology. New
York: The Guilford Press.
Trauma, Post-Traumatic Stress Disorder and Abuse
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Appendix VI
Abuse
Experience
Behaviors
Internalization
1. Intrusion
I am different, damaged
I am powerless
2. Self-related
I am bad, guilty, an object
to be used
physical 
situational
 noabuse

protection


closeness
betrayal
7. Distorted family
boundaries
9. Sexuality with

no understanding

overstimulation

negative
experiences
10. Distorted messages
11. Distortions of reality
I feel chaotic
Emotions: cut off, extreme
swings
I am betrayed by people
close to me
Expects betrayal, feels unsafe
I have no boundaries
Child & Family
Love-want
Hate-fear
6. Juxtaposition of
Fearful of situations, decisions
Overly responsible
Disrupted functioning:
Intrusive thoughts, flashbacks,
nightmares, triggered
responses, dissociation
Memories
5.Entanglement


Unable to self-protect,
care comfort
I am responsible for …
Distorted interacting with
others
When I am sexual, good
things happen
Repeats sexualized behavior
My sexuality means

no feelings

no control

negative feelings
Distorted sexual responding
What I am told  what is
meant
I have



no emotions
no experiences
no integrated self
Distorts future statements
Characteristics
4. Acts
8. Sexualized behavior
brings

attention

sensual pleasure
Extreme Sexual Abuse
Treats self as damaged
(self-abuses/misinterprets
development)
Helplessness, aggressivity
Hypervigilant, hyperarousal
Verbal
3.Threats
Child Characteristics
& Earlier Internalizations
Sexual Abuse by someone close
All sexual abuse experiences
Internalization
Continues distortions
Figure 1.1. Internalization Model
Adapted from Wieland, S. (1998). Techniques and issues in abuse-focused therapy with children and
adolescents. London: Sage.
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Trauma, Post-Traumatic Stress Disorder and Abuse
mestic and neighbourhood violence. Attention will be given to understanding post-traumatic stress
disorder (PTSD).
Trauma, Post-Traumatic Stress Disorder and Abuse
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Learning Objectives
8. Review the current literature and research about child physical, emotional and sexual
abuse and its relation to the concept of trauma.
9. Critically examine the power of neglect and its connection to the maltreatment of
children and trauma.
10. Investigate environmental violence and its traumatic effect upon children as victims of war,
witnesses of domestic violence and affected by neighbourhood violence.
11. Examine post-traumatic stress disorder in children and adolescents - the theories about
how it is developed and diagnosed and the many ways it is manifested (internalizing
and externalizing behaviours).
12. Understand the connection between common behaviour and emotional problems and
trauma and abuse.
13. Develop abilities to create plans and strategies for treatment of children and
adolescents.
14. Understand connections between trauma, abuse, depression and suicide, selfmutilation and aggressive or acting out behaviour
Key Terms and Concepts:
Child Maltreatment
History
Definition of Child Maltreatment
Theories about Impact
Maltreatment in Canada
Forms of Maltreatment
Developmental Impact of Maltreatment
Environmental Violence and Trauma
Violent Neighbourhoods and Communities
Children of War
Sequalae of Abuse and Trauma
Stress and Distress
Post-Traumatic Stress Disorder
Developmental Effects of PTSD
Issues in Assessment
Issues in Treatment
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Trauma, Post-Traumatic Stress Disorder and Abuse
Content Notes
Introduction
Child Maltreatment
History
Defining Child Maltreatment
Etiology of Child Maltreatment
Developmental Context
The Immediate Context
The Broader Context
Theories About the Impact of Maltreatment and Trauma
Childhood Trauma Model
Developmental Psychopathology
Incidence of Maltreatment in Canada
Family Context
Forms of Maltreatment
Neglect
Physical Abuse
Sexual Abuse
Emotional Abuse
Developmental Impact of Child Maltreatment
Environmental Violence and Trauma
Violent Neighborhoods and Communities
Children of War
Understanding the Range of Emotional and Behavioral Responses to Trauma and Abuse and the
Differential Manifestations in Children and Adolescents
Sequalae of Abuse and Trauma
Issues in Assessment
Assessment Considerations
Parent/Child Relationship
Safety of the Child
Issues in Treatment
Common Goals of Therapy
Assigned Readings
Review Questions
References
Appendix I - Forms of Maltreatment
Appendix II - Symptoms Associated with Child Maltreatment
Appendix III - Symptoms of PTSD typical of young children
Symptoms of PTSD typical of school-aged children
Symptoms of PTSD typical of pre-adolescents and adolescents
Appendix IV - Factors that support children
Families can provide further protection
Appendix V – Range of Child Characteristics Associated with Physical Abuse, Neglect, and Sexual
Abuse
Appendix VI - Internalization Model
Trauma, Post-Traumatic Stress Disorder and Abuse
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Introduction
Every year, many children experience some form of traumatic occurrence, such as:
 Child maltreatment including physical and/or sexual abuse;
 Living in an environment of domestic violence;
 Experiencing natural disasters, car accidents; or
 Exposure to community violence.
By the time a child reaches the age of 18, the probability that he or she will have been touched directly by
interpersonal or community violence is about 25% (Perry, 2001). Trauma in children increases the risk for
a variety of social, mental health and physical problems.
Child Maltreatment
History
Concern about children’s welfare in Canada began with looking at marginalized families with so-called
deprived children. The issue of improving the living conditions for these children led to the establishment
of the first Children’s Aid Society in Toronto in 1891. Two years later, legislation was developed in
Ontario to prevent cruelty to and provide better protection for children. The emerging notion of harm to
children reflected a changing society.
Arousal of public and professional concern about child abuse dates back to 1962 with the publication of a
seminal article, The Battered-Child Syndrome (Kempe, Silverman, Steele, Broegemueller & Silver,
1962). Up to this point, all child maltreatment was considered single phenomena related to child neglect.
Concern focused primarily on inadequate care of children and child neglect remains the largest single
category of reported child maltreatment.
Identification of child abuse, as distinct from child neglect, focused initially on the most visible and
shocking physical abuse cases. Many parental actions, that today are considered abusive, were widely
accepted and used by previous generations of parents and others. For instance, using a belt or strap to
punish misbehavior was a common practice used not only by parents but also by teachers.
The extent of sexual misuse and exploitation of children has only been recognized since the mid-1970s.
Prior to this time, sexual abuse was assumed to occur rarely, to be of no consequence to the child victim,
to be a child’s fantasy, or to be provoked by the child. Today, much media attention is given to publicly
exposing child sexual abuse.
Today, child abuse is recognized as existing along a continuum of possible parental responses to children
ranging from appropriate to harsh and exploitative. A result is a lack of consensus about what constitutes
dangerous or unacceptable child rearing practices. For example, debate continues about the relative merits
of spanking. It should also be noted that definitions vary on the basis of differences in legal mandates,
professional practices as well as social and cultural values (Trocme, MacLaurin, Falon, Daciuk,
Billingsley, Touring, Mayer, Wright, Barter, Bulford, Hornick, Sullivan, & McKenzie, 2001).
Over the past two decades, the mental health issues for child victims of physical abuse, neglect, sexual
abuse and witnessing domestic violence have received much clinical and research attention. There is now
a substantial body of research literature affirming the increased risk of various mental health problems
and factors that mitigate these risks (Saunders, Berliner & Hansen, 2001).
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Trauma, Post-Traumatic Stress Disorder and Abuse
Defining Child Maltreatment
The term, child maltreatment, has been used to refer to all forms of child abuse. Wolfe (1998) says,
Child maltreatment is broadly defined as physical or mental injury, sexual abuse or
exploitation, negligent treatment or maltreatment of a child under 18 years of age by a
person who is responsible for the child’s welfare. The behavior must be avoidable and
non-accidental (p. 108).
Child abuse was initially believed to be extremely deviant acts committed by disturbed individuals. Much
greater attention has been paid to acute, dramatic and observable acts than to those that are more
insidious, persistent and common. It is now widely recognized that the various forms of abuse often
overlap and rarely occur in isolation from each other. Psychological abuse is implicated in all types of
abuse and is a critical issue in considering negative outcomes (Weekly & Wolfe, 1996).
Etiology of Child Maltreatment
Child maltreatment is widely recognized to be multiply determined by a variety of factors ranging from
life-course history to immediate-situational to historical evolutionary. A balance of stressors and supports
or risk and protective factors can prevent child maltreatment. Likewise, an imbalance of stressors and
risk factors and increase the probability of child maltreatment occurring. Belsky (1993) suggests it is
useful to consider a variety of contexts of maltreatment including the:
Developmental Context
Parent factors such as:
 Childhood histories of abusive and neglectful parents
 Personality and psychological characteristics such as agreeableness, aggression or
depression
 Psychological resources such as attributional style or affective orientation
Child Factors
 Age with younger children more at risk
 Physical health
 Behaviour
The Immediate Context
Parenting and Parent: Child Interaction
 Responsiveness to child
 Affective quality of interactions
 Negative or aversive behaviours
 Disciplinary practices
The Broader Context
Social support and isolation
Cultural factors
Evolutionary context of child maltreatment
Social factors such as poverty
There is agreement that the clinical profiles of abused children show them to exhibit developmental
deficiencies and adjustment problems. There is little evidence, however, to suggest specific physical or
emotional maltreatment leads to particular developmental outcomes. There is now a well-established
Trauma, Post-Traumatic Stress Disorder and Abuse
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consensus that there is also no single risk factor or cause of child abuse but rather a combination of
factors that can both increase the risk of harm and mitigate harm through protective mechanisms (Wolfe,
1998). There has been considerable work looking at the risk factors for child maltreatment. The four best
predictors of child maltreatment have been found to be:




Family revenue below the poverty line
Mother sole financial provider
Mother’s first pregnancy occurs before the age of 21
Four or more children in the family (Sullivan, 2000).
Maltreatment can have a major disrupting and complex influence on the child’s on-going development. It
is important to note that most child maltreatment goes unreported. Pearce and Perrot-Pearce (1997)
conclude that physical abuse is reported to authorities in one out of seven instances and only 2% of intrafamilial and 6% of extra-familial sexual abuse is reported. There are also interesting differences reported
in rates of child maltreatment between the United States and Canada. Rates are reported to be as much as
two times higher in the United States. Higher rates of poverty and fewer social supports may account for
this difference (Pearce & Perrot-Pearce, 1997; Wolfe, 1998).
Theories About the Impact of Maltreatment and Trauma
Understanding the impact of abuse and trauma on children is a complex undertaking. The following two
theories are useful in understanding current thinking about impact.
Childhood Trauma Model
This model would suggest that two psychological mechanisms account for the way traumatic experience
can result in long term threat, demand or responses that continue well after the original stress. Firstly,
traumatic episodes become associated with particular stimuli and lead to conditioned maladaptive or
atypical reactions. Conditioning may be important as repetitive acute episodes occur on an irregular basis
and elicit stress reactions in an unpredictable and chaotic way. Over time, such conditioning becomes
resistant to extinction because of its unpredictability and intensity. Secondly, post-traumatic stress
symptoms resulting from trauma can overwhelm the child’s coping abilities and become part of their
response to day-to-day issues. Hyper responsiveness then becomes part of the individuals’ functioning,
leaving them vulnerable to wide ranging adjustment disorders (Wekerle & Wolfe, 1996).
Developmental Psychopathology
This model considers child maltreatment in the context of the parent-child relationship. Normal
development occurs as a series of inter-related physical, biological and psychological competencies.
Maltreatment can interfere with important developmental milestones and a child’s failure to develop
competency at one stage of development will lead to greater probability of failure at subsequent stages.
When there are prominent disturbances in the parent/child system, the child is at greater risk for
subsequent failure in developmental areas such as attachment, emotional functioning, peer and social
relationships. Children who experience a family context that fails to provide appropriate developmental
opportunities and contains disruptive events will have development affected in both subtle and powerful
ways.
In order to understand the effects of child maltreatment on development, the child must be seen in the
larger context of the family and environment in which they exist. An ecological model is one method for
explaining this complexity. It is also important to remember there are not inevitable negative
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Trauma, Post-Traumatic Stress Disorder and Abuse
consequences of maltreatment; rather, there are multiple pathways to adaptive or maladaptive
developmental outcomes. A history of maltreatment alone, while a risk factor, does not determine
outcome (Wekerle & Wolfe, 1996).
Some children are also more vulnerable to trauma than others. The impact of the trauma is likely to be
greatest when the child or adolescent has already been a victim of child abuse or other form of trauma or
who already had some form of mental health problem. In addition, children without family support are
more likely to experience poor outcomes (NIMH, 2001). A variety of child and family factors may
mediate the long-term effects of maltreatment. Child factors that could contribute to resiliency include
age or stage of development and temperament. Family factors may include previous positive attachment
experiences, positive response to the child and ability to protect child from further maltreatment.
Community response to maltreatment and support to the family in addressing the issue can also help to
mitigate the impact and improve the trajectory for adaptive responses.
Incidence of Maltreatment in Canada
In 2001, the first Canadian study examining the incidence of reported child maltreatment was completed
(Trocme et al., 2001). This study included careful definitions of maltreatment and examined instances
where Canadian Child Welfare Services were involved in investigating reports of child abuse. See
Appendix I – Forms of Maltreatment. BROOKE: CAN YOU PUT A LINK OR SOMETHING HERE
The overall number of investigated cases were 135,573, or 21.52/1000 children in Canada. Of that
number, 61,201 investigations, maltreatment was confirmed or 9.71/1000 children. In addition, in 29,668
investigations, maltreatment remained a suspicion for the child welfare worker at the conclusion of the
investigation, while the remaining 44,704 were cases that were not substantiated. This is a conservative
estimate of the incidence of reported child maltreatment in Canada, as the study did not capture those
cases that were not detected, not reported to child welfare, reported to police only, or those cases that
were screened out prior to investigation.
Regarding the percentages that are used, that does indeed examine the primary forms, however, we also
determined the overlap between categories.

40% of substantiated investigations involved neglect including failure to care and provide or
supervise and protect. Within this group, failure to provide medical treatment, permitting
maladaptive or criminal behavior, abandonment or educational neglect was included.

31% of substantiated investigations involved physical abuse. Physical abuse was defined as
the child suffering, or at risk of suffering from, physical harm by shaken baby syndrome,
inappropriate punishment or other forms of physical abuse such as Munchasen by proxy. In 3% of
these cases, the abuse was significant enough to require medical treatment.

11% of substantiated investigations involved sexual abuse including oral, vaginal or anal
sexual activity, attempted sexual activity, sexual fondling or touching, exposure of genitals,
voyeurism, involvement in prostitution or pornography and sexual harassment.

19% of substantiated investigations involved emotional injury including emotional abuse
such as overtly hostile or punitive treatment or extreme threatening or belittling, emotional
neglect including inadequate nurturing or affection. Also included in this area was inadequate
nutrition and exposure to family violence (Trocme et al., 2001).
Trauma, Post-Traumatic Stress Disorder and Abuse
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Single and Multiple Categories of Maltreatment in Child Maltreatment
Investigations by Level of Substantiation in Canada in 1998*
Level of Substantiation**
Number
Substantiated
Suspected
Unsubstantiated
Row Total
Single Categories
Physical abuse only
Sexual abuse only
Neglect only
Emotional Maltreatment
Subtotal: Single Category
Multiple Categories
Physical and sexual
Physical and neglect
Physical and emotional
Sexual and neglect
Sexual and emotional
Neglect and emotional
Physical, sexual & neglect
Physical, sexual & emotional
Physical, neglect, emotional
Sexual, neglect & emotional
Subtotal: Multiple Categories
29,114
11,393
42,680
20,381
103,568
22%
8%
31%
15%
76%
32%
39%
39%
53%
40%
21%
20%
21%
28%
22%
47%
41%
40%
19%
38%
100%
100%
100%
100%
100%
480
5,017
9,067
2,323
924
10,973
-259
2,723
162
135,573
0%
4%
7%
2%
1%
8%
0%
0%
2%
0%
100%
29%
49%
54%
62%
51%
65%
--64%
-45%
35%
16%
31%
12%
36%
22%
--23%
-22%
36%
35%
15%
26%
13%
13%
--13%
-33%
100%
100%
100%
100%
100%
100%
--100%
-100%
Row Percentage
*
Weighted estimates are based on a sample of 7,672 child investigations with information about single and multiple
categories of maltreatment.
** Substantiation varies by level of aggregation.
Family Context
In considering findings related to family characteristics for 93% of investigations, the perpetrator was
either a parent or relative. It was found that 39% involved situations that had been going on for more than
6 months while 17% had been on going for less that six months and 23% involved single incidents.
Clearly, child abuse and neglect occur within a family context largely and usually over significant periods
of time. Wolfe (1998) suggests child maltreatment is a relational disorder that reflects problems of fit
between the parent, child and environment. Wekerle and Wolfe (1996) contend child maltreatment
denotes parenting failure, a failure to protect a child from harm and failure to provide positive aspects of a
relationship that can foster healthy development.
Common developmental issues shared by all forms of maltreatment are:
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Trauma, Post-Traumatic Stress Disorder and Abuse


Maltreatment occurs in a relational context that potentially provides significant emotional
weight to an abuse experience
Maltreatment commonly includes violence that can create a situation of trauma for the child.
Given that children are most often maltreated in early infancy or childhood and maltreatment is often
accompanied by instability, disruption or isolation for the family, maltreated children have to adapt in
major ways to unpredictable and violent experiences. This interaction is understood to be very complex.
The impact of abuse on a child’s development was assumed to be invariably negative and disruptive, but
there is increasing recognition of the complexity of predicting outcomes. Whether maltreatment
experiences are extreme or powerful enough to outweigh other significant events and variables is a
critical issue.
The secondary events that follow maltreatment have also begun to receive attention in the literature. This
refers to events such as child welfare involvement, criminal proceedings, and maternal responses to
disclosure and family breakdown. Not only what has happened but also how it has been responded to are
important factors in predicting long-term adjustment. The family disruption, social and school change that
can result from the initial event can further traumatize the child. Disclosure of abuse creates other events
that may place new demands on the child and give rise to a chronic, stress-filled situation that makes
recovery from the trauma even more difficult.
Forms of Maltreatment
Neglect
Neglect is typically the largest category of reported child welfare investigations and was initially the least
studied. A very strong connection between neglect and poverty is noted. Some studies suggest that
outcomes for neglected children are the most negative of all types of child maltreatment. This form of
child abuse is often the most chronic and gets the least outside intervention. It may also be the most lethal
as over 50% of child deaths are estimated to be caused by neglect (Pearce & Pezzot-Pearce, 1997). There
tend to be few visible signs as neglect often consists of frequent and repeated deficits of caregiving for a
lengthy period prior to intervention. Part of the chronicity is related to the societal belief that neglect does
not result in serious consequences, that it is inappropriate to judge poor parents and solutions are limited
by larger social problems including poverty (Sullivan, 2000).
There are many forms of neglect with potentially different outcomes. Consistent, however, is a chronic
pattern of a lack of responsiveness to the child. The following categories have been used to define neglect
in the recent Canadian incidence study:
 Failure to supervise and protect leading to physical harm or sexual abuse
 Physical neglect
 Medical neglect
 Failure to provide treatment for mental or emotional or developmental problems
 Permitting maladaptive/criminal behavior
 Abandonment/refusal of custody
 Educational neglect (Trocme et al., 2001)
Neglect often leads to other forms of abuse, as children are not protected from further harm such as sexual
predators. Young children and infants are particularly at risk related to physical neglect given that the
brain does not reach full maturity until the age of two years. The physical development of the brain can be
affected by poor nutrition and/or under stimulating environments with resulting cognitive and expressive
language delays. This is a sensitive and critical period of development for children with life long
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consequences for the individual’s ability to regulate thought, emotions and behavior. There are additional
cognitive and behavioral consequences of neglect such as undisciplined activity or extreme passivity. In
addition, these children tend to be less flexible, persistent or enthusiastic.
Physical Abuse
Physical abuse can include shaken baby syndrome, inappropriate discipline and other forms of
maltreatment that result in the following:






Bruises/cuts/scrapes visible for at least 48 hours
Burns and scalds visible for at least 48 hours
Broken bones (i.e., fractured)
Head trauma requiring medical attention
Other health considerations such as untreated asthma or sexually transmitted disease
Death
Physical abuse investigations in which harm was reported most often involved bruises, cuts, and scrapes
(88% of harm situations). Cases involving more severe injuries were indicated less often and these
included broken bones (3%), burns and scalds (2%), and head trauma (5%).
Physical abuse can take many forms and can involve both minor and major injury to the child. Children
who are physically abused may present with a wide variety of injuries and developmental progress is
often impaired across several dimensions. The most notable signs of physical abuse appear to be
heightened aggression as well as resistant and avoidant behaviors towards others. Compulsive compliance
may also be seen. Physically abused children typically present with the most evident behavior problems.
These children are exposed to a family climate of domination and abuse of power where the child is
powerless to change the situation or abuse. In addition, delays in academic development that are not
accounted for by specific learning disabilities are evident.
Arousal related to fear and anger is also present as the child’s fight or flight mechanism is activated
(Perry, 2001). The pervasive threat of abuse and the child’s subsequent coping mechanisms can interrupt
development in ways that can continue into adulthood. For example, about 30% of victims of physical
abuse are estimated to be adult perpetrators of antisocial or abusive behavior. Delays in social-cognitive
development related to problems in moral reasoning and empathy for others are present. Physically
abused children are also impaired in the process of acquiring social knowledge and tend to replicate the
strong behavioral tendencies of their own abusive parents. These children take responsibility for parental
punishment, believing that punishment is a response to bad behavior. At the same time, physical
punishment is perceived to reflect the parents’ mean character. This may lay a foundation for further
difficulties as a bias toward inferring negative or hostile intent is created and sets up later difficulties with
social interaction.
Sexual Abuse
Definition: Sexual abuse could be defined as including completed or attempted sexual activity, touching
or fondling of genitals, adult exposure to genitals, sexual exploitation in prostitution or pornography,
sexual harassment or voyeurism.
Some form of emotional harm was noted in almost half of the substantiated cases of sexual abuse and
harm was significant enough in 38% to result in a need for treatment. Child sexual abuse, in contract to
other forms of maltreatment, was committed much less often by the child’s primary caregiver. Rarely,
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however, was child sexual abuse committed by a stronger (2%). Other relatives (44%) and known nonrelatives (29%) were perpetrators.
While all forms of abuse represent an abuse of power by an adult over a child, sexual abuse and its impact
on developing sexuality represents a particular challenge for the child. In general, sexually abused
children tend to be more socially competent than physically abused or neglected children as a group. One
third of sexually abused children show no symptoms. The other two thirds show significant recovery
within the first 12 to 18 months but many have delayed emergence of symptoms.
Sexualized behaviors are unique to child victims of sexual abuse. In addition, clinical impressions of
aggression, depression, withdrawal and anxiety are common. There tends to be more trauma-related
emotional and behavior problems resulting from sexual abuse than the cognitive and developmental
delays commonly found in children who have been physically abused and/or neglected. Sexual abuse
brings increased risk for depression, alcohol and drug abuse, sexual dysfunction, personality disorders and
eating disorders.
There is no classic pattern for victims of sexual abuse given diverse characteristics in the nature of the
abuse (intra versus extra-familial, number of perpetrators, type of abuse, duration, level of coercion and
violence). A range of common symptoms and adjustment disorders have been identified among victims of
sexual abuse, such as acute physical symptoms (i.e., headaches), psychological symptoms (i.e., fears),
behavioral symptoms (i.e., aggression), and, in adolescence, acting out behaviors (i.e., delinquency, drug
use or promiscuity). Sexualized behaviors including persistent sexualized behavior with other children,
age-inappropriate knowledge of sexuality, and/or seductive or promiscuous behavior may be noted
(Wekerle & Wolfe, 1996).
Emotional Abuse
Emotional maltreatment does not typically involve a specific incident or visible injury. Effects of
emotional maltreatment tend to be apparent over time. Emotional maltreatment has been defined as:




Emotional abuse
 Overly hostile
 Punitive treatment or habitual or extreme verbal abuse (threatening, belittling)
Non-organic failure to thrive
Emotional neglect (i.e., inadequate nuturance/affection)
Exposure to family violence
Emotional maltreatment was identified as either the primary or secondary category of maltreatment for
approximately 23,000 children or 37% of all substantiated maltreatment in Canada in 1998. Of this
number, child exposed to family violence was the form of emotional maltreatment identified most
frequently, followed by emotional abuse and then emotional neglect.
The child’s personal power or sense of self-efficacy is diminished as the child is raised in a climate where
there is a current of disrespect and devaluation. A damaged sense of self-esteem, self-concept and social
competency follow (Wekerle & Wolfe, 1996). See summary, Appendix II.
In recent years, researchers have included witnessing domestic violence in the category of emotional
abuse (Trocme et al., 2001). Domestic violence most often occurs in the home - the environment that
children tend to associate with their physical and emotional safety. Additionally, the aggressor and the
victim are the persons with whom the child is most likely to identify and to whom the child would want to
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turn for support. It can be concluded on the basis of these parameters that witnessing violence between
one’s parents can be a particularly insidious form of abuse. When considering the effects of witnessing
violence on children, it must be understood that there is a high correlation (between 40% and 75%)
between domestic violence and other forms of abuse (Margolin, 1998). This means that not only are
children vulnerable to the development of psychological, social, physiological and behavioral problems
associated with witnessing domestic violence but also highly likely to be targets of abuse themselves.
Children in these families may also be vulnerable to a variety of secondary mental health risks such as
separation of children from a parent due to divorce, incarceration of a parent, and school and home
relocation.
Witnessing violence has been associated with emotional, behavioural, and learning problems in children,
with children’s susceptibility affected by their developmental level, the chronicity of exposure, physical
closeness to the incident, and emotional closeness to the victim. The effects of witnessing domestic
violence tend not to be short-lived or limited to the time of exposure to these events. In fact, children’s
fundamental notions of the quality and safety of marital and family relationships may be profoundly
influenced by their exposure to marital conflict and violence. Children in these circumstances can have
little sense of predictability and warmth within their family, tend to worry, be chronically aroused, and
feel threatened and emotionally distressed. There is evidence that children’s general patterns of
behavioral, emotional, cognitive, social and physical functioning can be affected in relation to their
family, school and community (Cummings, 1998).
Developmental Impact of Child Maltreatment
Pearce and Pezzot-Pearce (1997) suggest the effects of child maltreatment and trauma can be categorized
into two major types (these are not mutually exclusive):

Localized Effects
Those effects specific to the trauma experience but without major developmental
ramifications. Effects are usually short-term and primarily affect behavior associated with the
victimization experience. These can be acute and distressing, for instance, nightmares or
flashbacks.

Developmental Effects:
Deep and generalized impact that results when a victimization experience and related trauma
interfere with developmental tasks or the course of normal development. Areas that can be
affected include attachment, behavioral and emotional self-regulation, development of self,
cognitive and academic functioning and peer relations.
Studies of child abuse and trauma suggest several domains of child functioning that can be affected by
child maltreatment.
Attachment
Abuse and neglect are recognized as having a profound impact on the child’s ability to form secure
attachments. Wolfe (1998) asserts that a failure to provide nurturing, sensitive and supportive caregiving
results in the breakdown of a secure parent/child attachment and creates a core disturbance in the child’s
ability to form future healthy relationships. The child’s lack of confidence in the parent as an available
and responsive provider sets up an adaptive response that leads the child to avoid the parent while under
stress in order to reduce the likelihood of rejection and angry interchanges. This, then, increases the
child’s tendency to isolate themselves, to respond defensively under a range of circumstances and to
respond with anger and aversion to the distress of others (Wekerle & Wolfe, 1996). In addition, lowered
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self-esteem and/or a negative or “bad” sense of identity can develop. Conceptualizations of the self as
alternately ‘good’ and ‘bad’ can occur as splitting or dissociation. Attachment theory suggests an internal
working model can develop where negative conceptualizations of the self reflect a child’s experience and
shape the way a child perceives events, forecasts the future and constructs plans. Abuse internalizations
can, therefore, become a predominant part of the child’s working model. See Appendix VI for
Internalization Model.
One consistent finding in the literature is that there are few differences in the impact of the various forms
of maltreatment on children but that there is generally a strong connection between maltreatment and
insecure attachment. There are current controversies about identifying attachment problems in children
given the very negative or even hopeless perceptions this labeling can create for children (Saunders,
Berliner & Hanson, 2001). Insecure attachment may become evident in the socio-emotional behavior of
these children in that they may have problems understanding the emotions of others, may respond to
distress in others with fear or anger, and experience an elevated risk of suicidal ideation and depression.
Neglected children, in particular, have difficulty learning strategies for engaging adults and independently
exploring their environments.
Physical Development
Physical abuse and neglect can lead to child fatalities, neurological impairment and minor and major
physical injuries. Perry (2001) found that children can experience a physical arousal state that originates
from a necessary ‘fight or flight’ response to danger. If traumatic events are ongoing, this state of physical
and emotional arousal can become chronic leaving the child vulnerable to persisting hyper-arousal related
symptoms and related disorders (e.g., PTSD, ADHD, conduct disorder). This activation can cause
hypervigilance, increased muscle tone, a focus on threat related cues, anxiety and impulsively which can
be adaptive during an episode but maladaptive if this response persists (Perry, 2001). It is common to see
signs of physical regression among children who have been maltreated. For example, children who had
been potty-trained may develop toileting difficulties, or children who had learned skills at school may
suddenly develop problems completing their work. Other physical signs may develop such as sleeping
problems or eating problems. There may be an increase in psychosomatic complaints such as
stomachaches or headaches. Sexual abuse can also alter physical functioning as urinary tract infections,
elevated risk for sexually transmitted diseases and pregnancies are common. In addition, sexuality is
shaped in developmentally inappropriate and interpersonally dysfunctional ways. Distorted views about
the body and sexuality generate risk for eating disorders and other mental health conditions.
Cognitive Development
One explanation for the differences in impact on children is the way in which harsh treatment is
cognitively processed and understood. The child’s coping mechanisms become challenged by the
rationales given by caregivers for the abuse, for instance, that it is discipline, love or a secret. The child
must create some form of defensive structure that allows them to cope with the incongruities of these
messages. Social cognition as it relates to the child’s inferences about the thoughts, feelings and
intentions of others is affected as they are unable to integrate their experience with what they are told or
with what they feel about their experiences. One of the more direct consequences of being abused or
witnessing violence may be the attitudes a child develops concerning the use of violence and conflict
resolution. Children may come to believe that violence is a reasonable method by which to conduct
relationships or that excessive passivity is required in order to keep relationships safe (Edelson, 1997).
Physical abuse, neglect and sexual abuse are all linked to cognitive impairment. Expressive language
delays and lower academic achievement are noted along with greater immaturity, poor reasoning skills
and a sense of inadequacy among both boys and girls. In this area, the potential impact of impoverished
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environments is noted. These findings suggest global cognitive delays and language deficits which may
relate to avoidance patterns in the home, poor care giving, limited stimulation, dissociation or
distractibility and as well as greater school avoidance such as more absences. Discontinuity in education
related to frequent moves, school transfers and suspensions are also a factor in outcome (Wekerle &
Wolfe, 1996).
Conceptions of Self
The maltreated child must create a defensive structure for coping that can include cognitive vigilance or
reality mediating strategies such as dissociation. Cognitive distortions and disruptions of a success based
orientation result from maltreatment. Strong explanatory links between maltreatment and the child’s
subsequent social behavior include misdirected inferences about the thoughts, feelings and intentions of
others. In addition, the child’s internal attributions of self-blame are linked to greater maladjustment.
For physically abused children, delays in social-emotional development are linked to problems in moral
reasoning and empathy for others. Conceptions of self are interrupted by a sense of powerlessness as the
child’s will, desire and sense of self-efficacy is thwarted by the abuse experience. A disruption in
relatedness occurs with an interpersonal wariness, interpersonal idealization, and labile interpersonal
interactions and indiscriminate interpersonal relationships.
Affect Regulation
Learning to modulate, redirect, regulate and modify feelings is a critical component for adaptive
functioning. Difficulties modulating affect frequently are cited as associated with an abuse experience.
Overall, child witnesses of domestic violence exhibit more aggressive and antisocial (externalized
behaviors) as well as fearful and inhibited behaviors (internalized behaviors) and show lower social
competence than other children. These children have also been found to show more anxiety, self-esteem,
depression, anger, and temperament problems than other children. They have difficulty understanding the
feelings of others and limited skills in seeing the perspective of others. Peer relationships, autonomy, selfcontrol, and overall competence are also found to significantly lower among these children. Another
common effect on these children may be an increased tendency to use violence (Margolin, 1998). At the
most extreme, maladaptive self-destructive behaviors can result such as self-mutilation, suicidal ideation
or drug and alcohol abuse.
Environmental Violence And Trauma
Violent Neighborhoods and Communities
Community violence refers to exposure, as a witness or through actual experience, to acts of interpersonal
violence perpetrated by individuals who are not intimately related to the victim. Children are victims of
community violence when they are the subject of a physical attack, or a threat of a physical attack, with or
without a weapon, by anyone who is not in their intimate circle; e.g., someone other than a parent,
caregiver, friend, or other individual living in the house. In communities with high rates of community
violence, family members may be subjected to criminal activity, such as sexual assault, burglary, use of
weapons, muggings, and the sound of bullet shots, as well as to community-based issues, such as the
presence of graffiti, teen gangs, drugs, and racial divisions (Linares, 2001).
Children who live in violent neighborhoods are at increased risk of exposure to violence and other
traumatic events as compared to children residing in other areas. In addition to violent acts by strangers,
common verbal and non-verbal aggressive acts performed by children against other children or adults in
their own community are seen to contribute to a context of community violence. For example, some
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Trauma, Post-Traumatic Stress Disorder and Abuse
children are bullied or victimized in verbally aggressive ways by older children as they walk to school,
ride the school bus, or play in the park. These acts, previously seen as falling within the realm of ‘normal’
child and adolescent behavior, are now becoming a great concern to parents, educators and community
leaders as possible precursors of more serious instances of community violence (Linares, 2001).
How does community violence affect children?
Children may be adversely affected by community violence whether they are victims or witnesses. For
example, children can experience trauma when they witness a stranger in the street, a casual acquaintance
from their neighborhood, or another student at their school, physically assaulting another person for the
purpose of robbing him, settling a fight, venting anger, or making a threatening statement. Past research
has documented that exposure to community violence may have enduring consequences on children's
development, beginning in the pre-school years and continuing through adolescence. The research has
demonstrated that children who witness community violence are likely to develop a view of the world that
is hostile and dangerous. In addition, children living in neighborhoods with high violent crime rates are
also likely to be exposed to domestic violence in their own homes and thus are highly vulnerable to being
victimized by different forms of interpersonal violence. Research has documented that children who are
exposed to multiple forms of violence are at more risk of developing psychological sequelae (including
posttraumatic stress disorder) than those exposed to only single or isolated violent events (either at home
or in the community) (Linares, 2001).
As a result of continued exposure to violence children may distrust adults and fear neighbors in their
community. Their feelings of safety and confidence in adults may erode or diminish. Reactions may take
several forms: some children become anxious, fearful or withdrawn (internalizing problems or taking
fears inward); others may believe that the use of violence is justified and shows they are strong and
powerful. These children may choose to use violence to attain their wishes, or to identify with the
aggressor, as a way to solve interpersonal conflict with the adult world or with their peers (externalizing
problems or expressing fears outward) (Linares, 2001).
A child’s exposure to community violence can also affect her/his family. Parents may experience extreme
anxiety concerning their child’s health and well-being and have limited resources available to them to
cope with their distress. Many parents blame themselves for not protecting their child adequately and may
become over-protective or use punitive discipline in response to their child’s trauma-related acting out
behavior. Relationships among family members can become strained as parents find themselves having to
face the task of reassuring their child while trying to cope with their own fears (Goguen, 2000).
Intervention must be multi-faceted and take place at the level of:
 The child who needs the support of a caring adult to feel safe
 The parents who need appropriate techniques for enhancing family coping strategies
 The community through upgrading the services and the quality of the neighborhood.
Children of War
The basis for the diagnosis and treatment of psychologic sequelea associated with traumatic events
originated from the experiences of soldiers (mostly men) in World War I and II. It was not until the
Vietnam War and the 1970s that the diagnosis of post traumatic stress disorder (PTSD) was formally
introduced in the mental health nomenclature (Williams & Steiner, 1998). Only in the last 20 years have
these ideas been broadened to include the experiences of the general population, women and most
recently, those of children. Research on the effects of war on children from Cambodia (Sack, 2000;
Boyden & Gibbs, 1997), Palestinian Children (Thabet & Vostanis, 2002), and adolescent refugees from
Bosnia (Ljubomirovic, 1999) have begun to document the impact of living in warlike situations on
children’s mental health.
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A context of war often means the collapse of traditional authority structures, social networks, weakening
of cultural and spiritual values and disruption of gender roles. Changes in the demographic structure of
households and communities, together with family impoverishment drastically reduce the age thresholds
for marriage, child-bearing, work and decision-making, forcing children to assume social and economic
responsibilities that lead to increases in exposure to physical danger and exploitation.
As well, living in a war zone puts children at risk of experiencing a variety of traumatic events. These can
include:
 Deprivation of basic needs such as food and shelter,
 Displacement from their homes and communities,
 Separation from or death of a parent,
 Injury of another family member or close friend,
 Exposure to combat.
Children growing up in a context of war are also highly vulnerable to experiencing secondary traumas
that occur as a result of the initial traumatic event. For example, children may be sent away by parents
who feel unable to care for them after an initial displacement, or a parent may turn to alcohol to cope with
feelings of inadequacy and stress.
Children exposed to war can experience a range of difficulties. These include behavior problems, somatic
complaints, mental health disorders and impaired moral reasoning and cognitive functioning. A study by
Thabet and Vostanis (2002) found that 73% of primary school age children interviewed reported PTSD
reactions of at least mild severity while almost 40% reported moderate to severe reactions. Garbarino
(1992) asserts that in addition to developing symptoms such as re-experiencing the event, numbing of
responsiveness, and symptoms of increased arousal, children who experience environmental violence are
vulnerable to ‘spiritual and philosophical consequences’ as a result of trauma. These include:

Loss of Security: Children who have experienced trauma have lost the idea of home, school
and/or community as a safe place. They have learned that their primary caregivers have limited
ability to protect them from traumatic events, and (in some cases) to respond to the child’s trauma
in a manner that is helpful and reassuring.

General sense of loss: One single traumatic event can result in any of the following losses: loss of
people (death), loss of physical capacity (injury to people), loss of protection (including loss of
adults’ ability to protect the child and loss of safe places to retreat), loss of control, loss of hope
(diminished future orientation.). Loss increases the child’s sense of vulnerability and can cause
chronic sadness and depression.

Blurring of Distinctions between ‘friend’ and ‘enemy’: Children may have trouble distinguishing
between who is their enemy and who is their friend. For example, close family members could be
members of a gang that uses violence as a method of gaining power in the community. In the
context of war, the child’s neighbours may become their enemy because of political affiliations.
Understanding the Range of Emotional and Behavioral Responses to Trauma and Abuse and the
Differential Manifestations in Children and Adolescents
Sequale of Abuse and Trauma
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Stress and Distress
Some stress is normal and even healthy for children as they negotiate the various daily and life challenges
they encounter. For example, most children attend school and will go through many transitions; most
adolescents will have to grapple with their sense of identity to determine where they "fit." The demands
placed on children and adolescents to successfully negotiate these situations can result in feelings of
stress. Small amounts of stress - such as experienced before a test or when meeting new people - are
necessary to present challenges for greater learning. Simple stress experienced when learning a new skill
or playing an exciting game can raise a person's level of excitement or sense of pressure above their
normal level.
Problems can begin when ordinary stress becomes too much stress or distress. Distress occurs when the
demands of the stressor exceed the child’s coping ability. Events that are unpredictable or beyond the
child’s control such as death, divorce, remarriage, moving, long illness, abuse, family or community
violence, natural disaster, fear of failure, and cultural conflict can contribute to the child experiencing
distress. Factors such as the child's stage of development, ability to cope, the length of time the stressor
continues, intensity of the stressor, and the degree of support from family, friends, and community all
impact the likelihood of stress becoming pathological (Jackson & Pynoos, 1994).
A child’s risk of developing a stress disorder is related to the seriousness of the trauma, whether the
trauma is repeated, the child’s proximity to the trauma, and his/her relationship to the victim(s) (Cohen,
1998). Developmental themes influence children’s experience of the stressor along with the attribution of
meaning, emotional and cognitive means of coping, the tolerance by adults of their reactions, expectations
about recovery, and parental effectiveness in addressing other secondary life changes that occur as a result
of the traumatic event. Interpersonal and intra-personal protective factors play a role in that children with
adequate social supports and familial networks, along with a range of biological, cognitive, and
psychological coping mechanisms are less likely to develop a psychiatric disorder as a result of trauma
and more likely to recover than others. Children with pre-existing psychopathology, poor parental and/or
community supports are more likely to be exposed to the types of stressors that lead to PTSD symptoms
and, once established, to become chronic (March, Amaya- Jackson & Pynoos, 1994).
Post Traumatic Stress Disorder
Post Traumatic Stress Disorder [PTSD] and other anxiety-related symptoms are among the most common
disturbances in self-regulation manifested by maltreated children (Pearce & Pezzot-Pearce, 1997). It is
defined as a specific set of symptoms that may develop in some children following exposure to an
intensely traumatic event(s) such as witnessing a homicide; traffic accidents; combat; natural disasters;
victimization; holocaust survivors/families; self-harming behavior; domestic violence; and HIV. To meet
the criteria for PTSD, the child must have been exposed to an ‘extreme stressor” characterized by threat to
life, potential for physical injury and an element of grotesqueness or horror that demarcates these events
from less traumatic experiences such as the expected death of a loved one from a serious illness (DSM
IV-TR). Children and adolescents generally react acutely to these traumatic events with surprise, terror,
and a sense of helplessness (Cohen, 1998). Post-traumatic Stress Disorder is differentiated from an acute
stress reaction or Acute Stress Disorder in that the symptom pattern of ASD, while similar to PTSD, must
occur and resolve within a 4-week period. A diagnosis of PTSD would not occur until the symptoms had
been in place for more that a 4-week period (DSM IV –TR). PTSD symptoms may or may not develop
immediately after the trauma occurs; in fact, many children develop symptoms some time after the event.
A diagnosis of PTSD must include a specific number of symptoms from each of three broad categories:
re-experiencing, avoidance/numbing, and increased arousal. These symptoms must be present for at least
1 month and cause clinically significant distress or impairment in functioning (DSM IV –TR).
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Re-experiencing symptoms - The traumatic event is persistently re-experienced through recurrent and
intrusive distressing memories of the event. In young children this may be manifested by repetitive play
in which traumatic themes occur, recurrent distressing dreams about the trauma, frightening dreams (in
young children there may be frightening dreams without recognizable content), acting or feeling as if the
trauma were recurring (includes a sense of reliving the experience, illusions, hallucinations, and
dissociative flashback episodes), intense distress at exposure to internal or external cues that symbolize
or resemble an aspect of the trauma; physiological reactivity at exposure to such cues.
Avoidance of stimuli - Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma) through efforts to avoid thoughts, feelings, or
conversations associated with the trauma, efforts to avoid reminders of the trauma, amnesia for an
important aspect of the trauma, diminished interest or participation in normal activities, feelings of
detachment or estrangement from others, restricted affective range, a sense of a foreshortened future
(e.g., does not expect to meet normal lifespan milestones such as career, marriage, children).
Persistent symptoms of increased arousal - Persistent symptoms of increased arousal (not present before
the trauma) such as: sleep difficulties; irritability or angry outbursts; difficulty concentrating; hypervigilance; or exaggerated startle response (March, Amaya-Jackson & Pynoos, 1994).
Developmental Effects of PTSD
Loss of acquired skills and/or the failure to develop new skills may reveal itself differently, depending on
the developmental age and stage of the child. For example, a young child may develop enuresis, while a
school-age child may become tearful when it comes time to leave home for school. Adolescents may
become socially withdrawn, choosing to stay at home rather than to engage in activities that were
previously enjoyed (March, Amaya-Jackson & Pynoos, 1994).
Research indicates that the majority of children suffering from single-episode PTSD recover with
relatively minimal intervention (e.g., an opportunity for catharsis and supportive treatments) and only
10% - 20% of children continue to suffer from psychopathology after one year. However, children who
have had one episode of PTSD tend to be more readily traumatized in the future by similar or related
events (Klyklo, Kay & Rube, 1998). Children who are repeatedly exposed to traumatic events and/or a
series of secondary traumatic events, may present with a preponderance of symptoms such as
dissociation, self-injurious behaviours, substance abuse and/or conduct problems, which may obscure the
post-traumatic origin of the disorder (Cohen, 1998).
In general, a prevention/early intervention model is recommended that incorporates a multi-modal
approach that includes support and strengthening of coping skills for anticipated grief/trauma responses,
treatment of other disorders that may develop or exacerbate in the context of PTSD and treatment of acute
PTSD symptoms. At this point, there is inadequate empirical support for the use of medications to
specifically treat PTSD; however, some medications can be helpful in treating individual symptoms such
as sleep disorders, depression, or anxiety.
Issues in Assessment
In assessing the impact of maltreatment and trauma, there must be consideration of the broad variability
of children’s responses and the many areas of functioning. Besides considering the child in terms of the
diverse facets of their functioning and behaviour, these domains of functioning may also be moderators of
the child’s response to maltreatment and possible sources of resiliency. A comprehensive assessment of
the child and family should incorporate a variety of methods and be based in multiple settings. No single
assessment strategy or test can render all the information needed about the child, context or family. The
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child and family’s functioning may vary in different contexts, a fact that may have implications for
intervention. Additionally, a full and comprehensive assessment takes an ecological perspective and
recognizes that children live in the context of their families, as well as in a larger social and cultural
context.
Many factors impact the response of the child or adolescent to abuse and various forms of trauma. Key
factors are:
6. Severity of the traumatic event
7. Family support and parental coping
8. Temporal proximity to the traumatic event
9. Amount of violence associated with the event such as assault or rape
10. Total number of previous traumas (Hamblen, 1998)
Assessment Considerations

Safety is the first priority and understanding the levels of risk for harm in the child’s environment is
key. Structural and contextual interventions such as child welfare involvement, as well as initial
treatment targets, are the basis for clinical intervention and treatment. Treatment cannot proceed
while danger or fear exists.

The stance of the parents is also a critical focus of assessment. Parents may be involved in treatment
as a result of child protection intervention and may dispute or minimize the abuse allegations.
Assessment of parental perceptions of and readiness to address child maltreatment is critical. Parental
responses to community violence are also key areas for assessment as these responses can
significantly alter outcomes for the child.

Common behavioral and emotional problems have been documented and include fear, anxiety, posttraumatic stress symptoms, depression, sexual difficulties, poor self-esteem, stigmatization, difficulty
with trust, cognitive distortions, difficulty with affective processing, aggression and peer socialization
deficits. Careful assessment of these issues is required. The nature and severity of disturbance can
vary substantially from child to child. Some children may be apparently asymptomatic; others may
experience moderate or major mental health concerns. In some cases, symptoms have a delayed onset.
Assessment should include current difficulties as well as identify risk factors for developing future
problems.

It is important to gain an understanding of the actual events of the abuse or trauma. The events
themselves, the response of the significant adults and the subsequent events are all part of the child’s
response. The direct effects of abuse or trauma are important to consider first. The most abusespecific outcome for maltreatment is post-traumatic stress disorder, with about 50% of sexually
abused children and 33% of physically abused children meeting the criteria for PTSD and many
others who experience distressing symptoms.

PTSD and other disorders related to trauma can occur in children who experience symptoms of other
disorders, and children with other disorders can have PTSD as a co-morbid condition. Additionally,
there is overlap in the criteria for the diagnosis of PTSD and a number of other disorders (e.g., some
of the symptoms of increased arousal that are present in PTSD can look similar to ADHD in some
children). It is important, therefore, that the assessment process include consideration of biological,
psychological and social factors that pre-existed and resulted from the traumatic event (Zide & Gray,
2001).
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
The indirect effects of abusive events are also important and an abuse-informed perspective is needed.
The child’s beliefs about what has happened (i.e., attributions of self-blame, guilt, stigmatization or
shame) are important to prognosis.

The assessment must be developmentally informed. What can begin as an abuse specific symptom
can lead to problems of functioning that can result in risks for further disrupted development. A
developmental focus is important for two reasons:
3. Knowledge of normal growth and development helps to determine the significance of a particular
behavior, that is, the behavior or symptom of a ‘problem’ deserving attention or is the problem
expected of a child of that particular age. For example, enuresis in a 2-year old child would have
different significance than in a 12-year old child.
4. Knowledge about a particular child’s developmental age and stage provides critical information
that guides the method of assessment strategies. For example, young children have poorly
developed concepts of time and may not be able to answer time-related questions accurately.
Parent/Child Relationship



Attention should be paid to both the offender/victim and parent/child aspects of the relationship.
Insecure attachment is often associated with abuse experiences and cannot only disrupt parent/child
relationships but also set up major risks for life-long problems relating to others.
Level of parental distress, as well as level of belief and support about the abuse experience, has been
found to be an important factor in outcome for the child (Saunders, Berliner & Hanson, 2001).
Safety of the Child
Legislation suggests that decisions should be based on the best interests of the child, however, in Alberta,
the points to consider include the primacy of the family unit, the importance of child rights, the
preservation of the well-being of the family and the right to the leas t intrusive form of intervention. In
cases where there is no consensus on the rights of the parents and the needs of the child, the lack of clarity
as to which principle has priority will jeopardize the safety and protection of some children. The tension
between ensuring child safety and providing supportive services within the child’s family and community
is one of the fundamental and critical challenges of child welfare – to determine when the risk of harm is
too great to leave a child at home.
Issues In Treatment
Since trauma can never be ‘undone,’ ‘cure’ is not the most appropriate treatment goal; however, trauma
victims can become well functioning if appropriate treatment is given and facilitation of healing takes
place (March, Amaya-Jackson, & Pynoos, 1994). Treatment must be comprehensive and ecologically
based, never occurring in isolation from the child’s family, caregivers and immediate environment. There
may be family and larger social factors that contribute to or moderate a child’s recovery and growth that
must be considered such as the extent to which the families ‘survival needs’ are met, the parents ability to
emotionally support their child, and the families access to community supports and resources.
Treatment must have a step-by-step focus that addresses developmental effects and supports children to
negotiate stage-salient developmental tasks. A child’s need for treatment may ebb and flow as the
meaning of the maltreatment changes as function of his or her progress through different developmental
stages. Therapy may be required, therefore, at various points in a child’s life as difficulties arise and then
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can be discontinued for extended periods when the child is functioning well. Treatment approaches
should be congruent with the developmental abilities and capacities of the child. For example, a child who
has a verbal learning disorder may not respond well to an approach that relies on verbal exchanges
(Pearce & Pezzot-Pearce, 1997).
Interventions with abused children should be abuse focused; that is, interventions should explicitly and
directly address the abuse incidents experienced by the child and the consequent emotions, cognitions,
and behaviors exhibited by the child as a result of the abuse. The child’s maladaptive behaviors, thoughts
and feelings related to the abuse should be the primary targets of intervention.
Common Goals of Therapy
6. Helping children acknowledge the maltreatment and express the associated feelings and cognitions.
In order for the maltreated child to develop healthier and more adaptive ways of coping with the
feelings associated with the victimization and to reformulate the meaning of these experiences, they
must first acknowledge that the maltreatment occurs and begin to identify and express the feelings
and attributions regarding responsibility connected to the maltreatment. This diminishes the
likelihood that the child will develop more intractable and serious symptoms and relieve some of the
child’s distress and anxiety (Pearce & Pezzot-Pearce, 1997). Children’s abuse experiences should be
acknowledged and characterized as wrong, unlawful, and harmful in all abuse-specific interventions
with children, families and parents.
7. Helping children develop more adaptive ways of expressing feelings regarding the maltreatment.
Children who have been maltreated often experience disruptions in their ability to regulate their
feelings and behavior. Teaching the child to use language to label and communicate emotions can
contribute significantly to his or her self-control and self-regulation (Pearce & Pezzot-Pearce, 1997).
8. Helping children reformulate the meaning of the maltreatment. The therapist may have to help the
child uncover and correct cognitive distortions regarding the maltreatment including inaccurate
accountings of events and beliefs that he or she was ultimately responsible for the abuse (Pearce &
Pezzot-Pearce, 1997).
9. Modify internal working models. Changing the child’s abusive or neglectful environment will not
automatically improve the child’s psychological functioning. The child may tend to impose an earlier
model of relationships upon others (such as the therapist, teachers, and caregivers). The
psychotherapeutic relationship is an opportunity to counter the child’s pessimistic and negative
beliefs and expectations of others and self. As well, the child has a greater probability of changing
maladaptive internal working models when they have multiple experiences and relationships that
consistently counter their negative beliefs and expectations. Therapy, therefore, is just one component
in an overall strategy to help reestablish progress along an adaptive developmental pathway. Other
interventions must be directed at the level of the family and factor in the broader environment to
support the child to establish, maintain and reinforce new beliefs and expectations of relationships
(Pearce & Pezzot-Pearce, 1997).
10. Self-perception. A common theme in treating children who have been traumatized is to help them
change their perception of themselves and develop greater feelings of mastery and self-efficacy
(Pearce & Pezzot-Pearce, 1997).
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Assigned Readings
Garbarino, J., Dubrow, N., Kostelny, K., & Pardo, C. (1992). Coping with the Consequences of
Community Violence. San Francisco, Jossey-Bass Pub. pp. 22-47
Wekerle, C. & Wolfe, D.A. (1996) Child maltreatment. In E.J. Mash & R.A. Barkley (Eds.),
Child psychopathology. New York: Guilford.
Review Questions
6. Identify two theories regarding the impact of child maltreatment and trauma. Discuss.
7. Identify the four major forms of child maltreatment along with common outcomes for mental health
concerns.
8. Choose one domain of functioning affected by child maltreatment and discuss.
9. Describe the impact on children of environmental sources of trauma.
10. Identify the key assessment and treatment considerations.
REFERENCES
Berman, S., Silverman, W. & Kurtines, W. (2000). Children’s and adolescents’ exposure
to community violence, post-traumatic stress reactions, and treatment implications. The
Australian Journal of Disaster and Trauma Studies, (2000 –1), Internet.
Besky, J. (1993). Etiology of child maltreatment: A developmental-econologi9cal
analysis. Psychological Bulletin, 114(3), 413-434.
Boyden, J., & Gibbs, S., (1997). Children of war: Responses to psycho-social stress in
Cambodia. Switzerland: The United Nations Research Institute for Social Development.
Cohen, Judith. (1998). Summary of the practice parameters for the assessment and
treatment of children and adolescents with post-traumatic stress disorder. Internet.
Cummings, E.M. (1998) Children exposed to marital conflict and violence: Conceptual
and theoretical directions. In G. Holden, R. Geffener, & E. Jouriles (Eds.), Children exposed to
marital violence: Theory, research, and applied issues (pp. 55-93). Washington, DC: American
Psychological Press.
Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed.), (2000).
M.B. First, (Ed.). Washington, DC: American Psychiatric Association.
Edleson, J. (1999). Problems associated with children’s witnessing of domestic violence.
Internet
Goguen, C. (2000). The effects of community violence on children and adolescents.
Internet.
Garbarino, J., Dubrow, N., Kostelny, K., & Pardo, C. (1992). Coping with the
consequences of community violence. San Francisco: Jossey-Bass.
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Jaffe, P., Wolfe, D., & Wilson. S. (1990). Children of battered women. Newbury Park:
Sage.
Kempe, C. H., Silverman, F.N., Steele, B.FF., Croegenmueller, W., & Silver, H. K.
(1962). The battered child syndrome. Journal of the American Medical Association, 181, pp. 1724.
Ljubomirovic MD, N. (1999). Therapeutic group work with adolescent refugees in the
context of war and its stresses. Internet.
March, MD, J., Amaya-Jackson, MD, L., & Pynoos, MD, R. (1994). Pediatric
posttraumatic stress disorder. In J. Wiener, MD. (Ed.), Textbook of child and adolescent
psychiatry, (2nd ed.) (pp. 507-524). Washington, DC: American Psychiatric Press.
Margolin, G. (1998). Effects of domestic violence on children. In P. Trickett, & C.
Schellenback (Eds.), Violence against children in the family and community (pp. 57-101).
Washington, DC: American Psychological Press.
Meloy, J. (1997). Violent attachments. New Jersey: Jason Aronson Inc.
Perry, MD, B. (2001). Violence and childhood: How persisting fear can alter the
developing child’s brain. Internet.
Pearce, J. & Pezzot-Pearce, T. (1997). Psychotherapy of abused and neglected children.
New York: Guilford Press.
Sack, W. (1999). Twelve-year follow-up study of Khmer youths who suffered massive
war trauma as children. Journal of the American Academy of Child and Adolescent Psychiatry.
Internet
Saunders, B.E., Berliner, L., & Hanson, R.F. (2001) Guidelines for the Psycho-social
Treatment of Intrafamilial Child Physical and Sexual Abuse. Final Draft Report: July 30, 2001.
Charleston: Authors. Internet.
Sulivan, S. (2000) Child neglect: Current definitions and models-A review of child neglect
research, 1993-98. Ottawa, National Clearinghouse of Family Violence.
Thabet, A. & Vostanis, P. (2002). Post-traumatic stress reactions in children of war.
Internet
The Peel Committee Against Woman Abuse, Breaking the Cycle of Violence: Children
Exposed to Woman Abuse: A Resource Guide for Parents and Service Providers, November
2000, Internet.
Trocme, N., MacLaurin, B., Falon, B., Daciuk, J., Billingsley, D., Tourigny, M., Mayer, M.,
Wright, J., Barter, K., Burford, G., Hornick, J., Sullivan, R., & McKenzie, B. (2001). Canadian incidence
study of reported child abuse and neglect: Final report. Ottawa, ON: Minister of Public Works and
Government Services Canada.
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Wekerle, C. & Wolfe, D.A. (1996). Child maltreatment. In E.J. Mash & R.A. Barkley (eds.),
Child psychopathology. New York: The Guilford Press.
Wieland, S. (1998). Techniques and issues in abuse-focused therapy with children and
adolescents. London: Sage.
Williams, S., & Steiner, H. (1998). Childhood trauma. In W. Klyklo, J. Kay, & D. Rube
(Eds.), Clinical child psychiatry (pp. 263-277). Toronto; W.B. Saunders Co.
Wolfe, D.A. (1998). Prevention of child abuse and neglect in Health Canada (eds.)
Determinants of Health, Children and Youth. Ottawa:Canadian Government Publishing.
Zide, M. & Gray, S. (2001) Psychopathology: A competency-based assessment model for
social workers. Toronto: Brooks/Cole Thomson Learning.
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Appendix I - Forms of Maltreatment
FORMS OF MALTREATMENT
1. P 1. Physical Abuse: The child has suffered or is at substantial risk of suffering physical harm, at the hands of the
child’s caretaker.
 Shaken baby syndrome: Brain or neck injuries resulting from the infant being shaken.
 Inappropriate Punishment: Child abuse has occurred as a result of inappropriate punishment. Includes
inappropriate use of corporal punishment, as well as other forms of punishment that has led to physical
harm or put the child at substantial risk of harm. The judgment of appropriateness is based on many factors,
including the severity of harm or potential harem, the amount of force used, the type of punishment relative
to the age of the child, and the frequency of punishment.
 Physical Abuse: Other physical abuse includes any other form of physical assault that is inflicted on a
child, such as intentionally burning a child or hitting the child in a manner that does not appear to be
intended as punishment.
2. Sexual Abuse:
 Sexual Activity Completed: Includes oral, vaginal, or anal sexual activities.
 Sexual Activity Attempted: Includes attempts to have oral, vaginal, or anal sex.
 Touching/Fondling Genitals: Sexual activity involving touching/fondling genitals.
 Adult Exposing Genitals to Child: Sexual activity consisting of exposure of genitals.
 Sexual Exploitation: Involved in Prostitution or Pornography: Includes situations in which an adult
sexually exploits a child for purposes of financial gain or for profit.
 Sexual Harassment: Includes propositions, encouragement, or suggestions of a sexual nature.
 Voyeurism: Includes activities in which a child is encouraged to exhibit himself/herself for the sexual
gratification of the alleged perpetrator.
4. Neglect: Includes situations in which children have suffered harm, or their safety or development has been
endangered as a result of the caregiver’s failure to provide for or protect them.
a. Failure to Supervise or Protect Leading to Physical Harm: The child suffered or was at substantial risk
of suffering physical harem because of the caregiver’s failure to supervise and protect the child
adequately. Failure to protect includes situations in which a child is harmed or endangered as a result of a
caregiver’s actions (e.g. drunk driving with a child, or engaging in dangerous criminal activities with a
child.).
b. Failure to Supervise or Protect Leading to Sexual Abuse: The child has been or is at substantial risk of
being sexually molested or sexually exploited, and the caregiver knew or should have known of the
possibility of sexual molestation and failed to protect the childe adequately.
c. Physical Neglect: The child has suffered or is at substantial risk of suffering physical harm caused by the
caregiver’s failure to care and provide for the child adequately. This includes inadequate
nutrition/clothing and unhygienic and/or dangerous living conditions. There must be evidence or
suspicion that the caregiver is at least partially responsible for the situation.
d. Medical Neglect: The child requires medical treatment to cure, prevent, or alleviated physical harm or
suffering, and the child’s caregiver did not provide, refused or was unavailable or unable to consent to the
treatment.
e. Failure to Provide Treatment for Mental, Emotional or Developmental Problem: The child is at
substantial risk of suffering from emotional harm as demonstrated by severe anxiety, depression,
withdrawal, self-destructive or aggressive behavior, or suffering from a mental, emotional or
developmental condition that could seriously impair the child’s development. The child’s caregiver did
not provide, or refused, or was unavailable or unable to consent to treatment to remedy or alleviate the
harm. This category can include failing to provide treatment for school-related problems such as learning
and behavior problems, as well as treatment for infant development problems such as non-organic failure
to thrive.
f. Permitting Maladaptive/Criminal Behavior: A child has committed a criminal offence with the
encouragement of the child’s caregiver, or because of the caregiver’s failure or inability to supervise the
child adequately. Alternatively, services or treatment are necessary to prevent a recurrence and the child’s
caregiver did not provide, refuse, or was unavailable or unable to consent to those services or treatment.
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Abandonment/Refusal of Custody: The child’s caregiver has died or was unable to exercise custodial
rights and did not make adequate provisions for care and custody, or the chills was in a placement and the
caregiver refused or was unable to take custody.
h. Educational neglect: Caregivers knowingly allowed chronic truancy (5 or more days a month), failed to
enroll the child, or repeatedly kept the child at home.
Emotional Maltreatment: This category is difficult to document because if often does not involve a specific
incident or visible injury. In addition, the effects of emotional maltreatment, although often severe, tend to
become apparent over time (e.g. impaired cognitive, social, and emotional development).
 Emotional Abuse: The child has suffered or is at substantial risk of suffering from mental, emotional, or
developmental problems caused by overtly hostile, punitive treatment, or habitual or extreme verbal abuse
(threatening, belittling, etc.).
 Non-organic Failure to Thrive: A child under 3 has suffered a marked retardation or cessation of growth
for which no organic reason can be identified.
 Emotional Neglect: The child has suffered or is at substantial risk of suffering from mental, emotional, or
developmental problems caused by inadequate nurturance/ affection.
 Exposed to Family Violence: A child has been a witness to, or involved with family violence within
his/her home environment. This includes situations in which the child indirectly witnessed the violence
(e.g. saw the physical injuries on his/ her caregiver the next day).
g.
3.
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Appendix II - Symptoms Associated with Child Maltreatment
INFANTS
Disruption in eating and sleeping routines
Fearful reactions to loud noises
Excessive crying
VII.
Physical neglect
Delays in Development
PRESCHOOL CHILDREN
Low self-esteem
Frequent illness
Poor concentration
Eating and sleep disturbances
Post-traumatic stress*
Fear
Separation anxiety
VIII. Anger and aggression
Clinging
Withdrawing
Hitting, biting
Inappropriate sexual behaviour
Cruelty to animals
Destruction of property
Problems in pre-school/day care
Pleasing behaviour
Regressive behaviour (thumb sucking, bed wetting)
ELEMENTARY SCHOOL (5-12 YEARS)
Low self-esteem
Frequent illness
Poor concentration
Eating and sleep disturbances
IX.
Post traumatic stress*
Fear
Anxiety and tension
Anger and aggression
Withdrawing
Bullying
Alcohol/Drug Abuse
Depression
Inappropriate sexual behaviour
Self-harm
Perfectionism
Destruction of property
Problems in school
Pleasing behaviour
Peer relationship problems
Disrespect for females
EARLY ADOLESCENCE (12-15
YEARS)
Low self-esteem
Frequent illness
Poor concentration
Eating and sleep disturbances
Post traumatic stress*
Fear
Anxiety and tension
Anger and aggression
Bullying
Being abused or becoming abusive
Depression
Alcohol/drug use
Self-harm
Suicidal behavior
Inappropriate sexual behaviour
Perfectionism
Running away from home
Pleasing behaviour
Problems in school
Peer relationship problems
Disrespect for females
Feeling over-responsible
LATER ADOLESCENCE (15-18
YEARS)
Low self-esteem
Frequent illness
Poor concentration
Eating and sleep disturbances
Post traumatic stress*
Fear
Anxiety and tension
Anger and aggression
Bullying
Being abused or becoming abusive
Depression
Alcohol/drug use
Self-harm
Suicidal behavior
X.
Inappropriate sexual behaviour
Perfectionism
Running away from home
Pleasing behaviour
Problems in school
Peer relationship problems
Disrespect for females
Feeling over-responsible
*Post Traumatic Stress: Symptoms include nightmares, intrusive thoughts or images, flashbacks, fear,
anxiety, tension, hyper-alert, easily startled, irritability, outbursts of anger and aggression
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Appendix III
Symptoms of PTSD typical of young children (1-6) can include:

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Helplessness and passivity; lack of usual responsiveness
Generalized fear
Heightened arousal and confusion
Cognitive confusion
Difficulty talking about event; lack of verbalization
Difficulty identifying feelings
Sleep disturbances, nightmares
Separation fears and clinging to caregivers
Regressive symptoms (e.g., bedwetting, loss of acquired speech and motor skills)
Unable to understand death as permanent
Anxieties about death
Grief related to abandonment of caregiver
Somatic symptoms (e.g., stomach aches, headaches)
Startle response to loud/unusual noises
"Freezing" (sudden immobility of body)
Fussiness, uncharacteristic crying, and neediness
Avoidance of or alarm response to specific trauma-related reminders
Involving sights and physical sensations.
Symptoms of PTSD typical of school-aged children (6-11 years) can include:

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

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Responsibility and guilt
Repetitious traumatic play and retelling
Reminders trigger disturbing feelings
Sleep disturbances, nightmares
Safety concerns, preoccupation with danger
Aggressive behavior, angry outbursts
Fear of feelings and trauma reactions
Close attention to parents' anxieties
School avoidance
Worry and concern for others
Changes in behavior, mood, and personality
Somatic symptoms (Complaints about bodily aches, pains)
Obvious anxiety and fearfulness.
Withdrawal and quieting
Specific, trauma-related fears; general fearfulness.
Regression to behavior of younger child.
Separation anxiety with primary caretakers.
Loss of interest in activities.
Confusion and inadequate understanding of traumatic events most evident in play
rather than discussion.
Unclear understanding of death and the causes of "bad" events.
Magical explanations to fill in gaps in understanding.
Loss of ability to concentrate and attend at school, with lowering of performance.
"Spacey" or distractible behavior.
Trauma, Post-Traumatic Stress Disorder and Abuse
Symptoms of PTSD typical of pre-adolescents and adolescents (12-18 years) can include:













Self-consciousness
Life-threatening reenactment
Rebellion at home or school
Abrupt shift in relationships
Depression, social withdrawal
Decline in school performance
Trauma-driven acting-out behavior: sexual acting out or reckless, risk-taking
behavior.
Effort to distance from feelings of shame, guilt, and humiliation.
Flight into driven activity and involvement with others or retreat from others in order
to manage their inner turmoil.
Accident proneness.
Wish for revenge and action-oriented responses to trauma.
Increased self-focusing and withdrawal.
Sleep and eating disturbances; nightmares.
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Appendix IV
Factors that support children and create a safety net for them during stressful times include:

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


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


A healthy relationship with at least one parent or close adult.
Well-developed social skills.
Well-developed problem-solving skills.
Ability to act independently.
A sense of purpose and future.
At least one coping strategy.
A sense of positive self-esteem and personal responsibility.
Religious commitment.
Ability to focus attention.
Special interests and hobbies.
Families can provide further protection by:







Developing trust, particularly during the first year of life.
Having supportive family and friends.
Showing caring and warmth.
Having high, clear expectations without being overly rigid.
Providing ways for children to contribute to the family in meaningful ways.
Being sensitive to family cultural belief systems.
Building on family strengths.
Children who live in supportive environments and develop a range of coping strategies become
more resilient.
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Trauma, Post-Traumatic Stress Disorder and Abuse
APPENDIX V
Table 14.1. Range of Child Characteristics Associated with Physical Abuse, Neglect, and Sexual Abuse
Dimension of development Physical Abuse
Neglect
Sexual Abuse
Physical
Minor: Bruises, lacerations, Failure to thrive symptoms: Physical symptoms: Headaches,
abrasions
Slowed growth, immature
stomach aches, appetite changes,
Major: Burns, brain
physical development
vomiting, gynecological complaints
damage, broken bones
Cognitive
Mild delay in areas of
cognitive and intellectual
functioning; academic
problems; difficulties in
moral functioning
Mild delay in areas of
cognitive and intellectual
functioning; academic
problems; difficulties in
moral reasoning
No evidence of cognitive impairment;
self-blame; guilt
Behavioral
Aggressivity; peer
problems; “compulsive
compliance”
Passivity; “hyperactivity”
Fears, anxiety, PTSD-related
symptoms; sleep problems
Socioemotional
Social incompetence;
hostile intent attributions;
difficulties in social
sensitivity
Social incompetence;
withdrawn, dependent;
difficulties in social
sensitivity
Symptoms of depression and low selfesteem; “sexualized” behavior;
behaviors that accommodate to the
abuse (e.g., passive compliance, no or
delayed disclosure)
Adapted from Wekerle, Christine, Wolfe, David A. Child Maltreatment. E.J. Mash & R.A. Bakley (Eds) (1996). Child Psychopathology. New
York: The Guilford Press.
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Appendix VI
Abuse
Experience
Behaviors
Internalization
1. Intrusion
I am different, damaged
I am powerless
2. Self-related
I am bad, guilty, an object
to be used
physical 
situational
 noabuse

protection


closeness
betrayal
7. Distorted family
boundaries
9. Sexuality with

no understanding

overstimulation

negative
experiences
10. Distorted messages
11. Distortions of reality
I feel chaotic
Emotions: cut off, extreme
swings
I am betrayed by people
close to me
Expects betrayal, feels unsafe
I have no boundaries
Child & Family
Love-want
Hate-fear
6. Juxtaposition of
Fearful of situations, decisions
Overly responsible
Disrupted functioning:
Intrusive thoughts, flashbacks,
nightmares, triggered
responses, dissociation
Memories
5.Entanglement


Unable to self-protect,
care comfort
I am responsible for …
Distorted interacting with
others
When I am sexual, good
things happen
Repeats sexualized behavior
My sexuality means

no feelings

no control

negative feelings
Distorted sexual responding
What I am told  what is
meant
I have



no emotions
no experiences
no integrated self
Distorts future statements
Characteristics
4. Acts
8. Sexualized behavior
brings

attention

sensual pleasure
Extreme Sexual Abuse
Treats self as damaged
(self-abuses/misinterprets
development)
Helplessness, aggressivity
Hypervigilant, hyperarousal
Verbal
3.Threats
Child Characteristics
& Earlier Internalizations
Sexual Abuse by someone close
All sexual abuse experiences
Internalization
Continues distortions
Figure 1.1. Internalization Model
Adapted from Wieland, S. (1998). Techniques and issues in abuse-focused therapy with children and
adolescents. London: Sage.
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