Child & Adolescent Fact Sheet – For Caregivers

This sheet is for caregivers of children who have experienced trauma, and offers examples of traumatic experiences, trauma responses in children, and ways that caregivers can support their children.

Trauma and dissociation can impact a young person’s emotions, behavior, relationships, and learning. Caregivers (e.g., parents, extended family, foster families, and other guardians) are in a unique position to recognize when trauma responses and symptoms may be interfering with a child or adolescent’s well-being.  Caregivers also have important roles in helping young people to access specialized assessments, interventions, and support teams. The information below is intended to assist caregivers in understanding and supporting children and adolescents who have experienced trauma and may be experiencing dissociation. As you read through this fact sheet and learn to care for your child, caregiver self-care is considered important and encouraged.

What is considered trauma?

“Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. ”–SAMSHA, 2014, p.7

Trauma occurs when a child experiences an event that overwhelms them and exceeds their ability to cope, changing how they see and experience themselves, others, and the world around them. It may be an objectively stressful event (e.g., accident, abuse, severe illness) or a subjectively stressful event (e.g., separation from caregiver, witnessing violence), and may lead to psychological and biologically-based survival responses that can continue long after the traumatic event has passed.

A stressful event is not necessarily traumatic in and of itself, but may be traumatic in its effect on a particular individual. Thus, not every individual who experiences an extremely stressful event will actually be traumatized, but some will be. Some types of events are so extreme that they are likely to be traumatizing to most people. A traumatic event can be experienced directly by a person, witnessed happening to someone else, or learned about having happened to a loved one or one’s community. In psychological terms, “traumatic events” have traditionally been considered those that harm the psychological integrity of an individual.

Potentially traumatic events can be single occurrences, chronic and repetitive over time, or complex in nature, meaning more than one type of potentially traumatic event has been experienced, and may include:

• Natural disasters, including the climate crisis and COVID-19
• Human-made disasters
• Physical abuse
• Sexual abuse
• Incarceration of a loved one
• Trafficking (e.g., labor, sex)
• The intergenerational impacts of historical traumas in communities of people (e.g., genocide, chattel slavery, and colonization)
• Living in a war zone, experiences of immigration and being a refugee
• Bullying
• Emotional abuse (e.g., yelling, screaming, exploitation, and/or critical, demeaning statements being directed toward the child that leads to feeling unloved and/or thinking they are unwanted)
• Neglect of physical, emotional, medical, and educational needs
• Being cared for by chronically frightened or frightening parents
• Witnessing family and/or community violence
• Painful, scary, and/or life-threatening medical conditions and procedures
• Accidents that lead, or could have led, to serious physical injury or death
• School and community violence
• Substandard living conditions such as poverty, homelessness and/or poor quality housing, food scarcity, poor air and water quality, parental/guardian unemployment
• Oppression, discrimination, and hate crimes related to social and/or cultural identity (e.g. racism, ageism, transphobia and trans-erasure, homophobia and heterosexism, xenophobia, sexism, classism)
• Grief and loss, including violent, repeated and/or extended separations from loved ones (including abduction/kidnapping of the child)
• Parental separation, abandonment, and/or alienation
• Mental illness and/or substance abuse in the home

What is Complex Trauma?

Complex trauma describes exposure to multiple types of traumatic events that are repetitive and have wide-ranging and long-term impacts on a person. Adverse experiences that can result in complex trauma are usually severe, chronic and ongoing, pervasive, and interpersonal in nature. Complex trauma typically begins early in life and can disrupt many areas of child development including the ability to form safe, secure attachments with others.

Red Flags and What to Look For

Traumatic stress in children can be expressed through:

Behaviors
Significant changes in activity level and increased disruptive behaviors, or reduced activity observed as shutting down, zoning out, over-compliance, or flat affect; developmental regressions or delays in meeting social-emotional milestones such as communication, regulation, attention and play; oppositional and defiant behaviors; being easily startled; self-destructive and/or self-injurious behaviors; avoiding certain activities, people, places, and things; use of substances, disordered eating, and other unhealthy ways to cope.

Mood
Increased irritability; rapid mood swings; passivity; ‘spacing out;’ flat affect; depression or withdrawal; temper tantrums; emotional overwhelm of sadness, anxiety, worry, anger, fear, hopelessness; shutting down; thoughts of suicide or wanting to die.

Social
Clingy or withdrawn and isolated; trouble forming and sustaining relationships; anticipating and perceiving rejection and abandonment.

Cognitive
Difficulties with memory, processing new information, making inferences, concentration, communication, attention and focus, remembering tasks and expectations, distractibility, learning new things; ‘spacing out’; expressing a foreshortened sense of their future; having negative thoughts and expectations about themselves, others and the future; and low self-esteem and self-confidence.

Dissociation can be considered a biological and psychological response that may occur during or after traumatic events as a means of coping.Dissociation is when the brain disconnects awareness from experience, feeling, sensation, and/or the self. Children, like adults, may dissociate when they are overwhelmed by fear or pain and cannot escape. When there is no escape from the widespread and repetitive nature of complex trauma, children may use dissociation to disconnect from and block out what is happening to them, what they are feeling, what they are thinking, who is causing the harm or pain, and what they are sensing in order to cope and survive. The ability to dissociate is rooted in protection and the innate ability to survive the unimaginable.

A child may dissociate during and after any of the traumatic events listed above, or when reminded about any of the events listed above, even long after the event(s) are over. Reminders are called “triggers.” It is important to remember that if your child receives support and feels safe soon after a frightening event, any dissociation may be temporary and, therefore, not problematic. Besides dissociating during and after a traumatic event, for some people dissociation can become a longer term coping strategy to get through stressful, but potentially not traumatic, situations in everyday life.

What Symptoms May I See in My Child or Adolescent?

Dissociation can show up in unique ways for kids and youth, leaving adults confused at what may be happening. These symptoms may occur only a few times a year, or may be much more frequent and occur several times a day. Some of the common symptoms of dissociation that may warrant further investigation include:

• Sudden and abrupt changes in mood, behavior, feelings, or attitudes that a child may not be able to explain or remember.
• Behaving very grown up one moment and then behaving like a much younger child (even a baby) at another moment.
• Behaving aggressively or mean at one point, and then becoming passive, loving or caretaking at another time.
• Sudden emotional shifts from one extreme feeling to a completely different or opposite feeling without showing any of the in-between emotions. The reason for this change in emotion may not be clear or make sense to you.
• Seeming calm one moment, and then in the next moment becoming explosive, aggressive, frightened, tearful or panicky.
• Expression of emotions that do not fit what is happening, such as laughing during a sad and upsetting situation or becoming sad or angry in a joyful situation.
• Not showing emotions, denying having feelings, or appearing to not be aware of any feelings at all.
• Using different names to refer to themselves, or referring to themselves as “we.”
• Using different voices or mannerisms at different times.
• Dramatic and sudden changes in facial expression, such as going from smiling to angry with no apparent reason.
• Eyes appear to be in a dead stare when you are talking to them, like they are miles away, or with a glazed look, particularly when aggressive, enraged or scared.
• Wanting to wear their favorite outfit, eat their favorite food, or play with their favorite toy or game, but then later on, or perhaps the next day, they say they hate the clothes, food, toy or game. They may also not be able to explain this change, stating they never liked the outfit or food.
• Having certain skills or being able to do certain activities easily and well (handwriting, sports, math, reading, assignments), but then, the next day, may have trouble with them or no longer know how to do or complete them.

• ’Spacing out’ or ‘zoning out’ at home, school or social events, and not knowing what is going on around them. Time may pass and they don’t know what happened during that time. They may have difficulty remembering information.
• Finding themselves in a place and not knowing or remembering how they got there. For example, they may be sent to the principal’s office for misbehaving and not remember leaving the classroom, walking to the office, or even why they are even there.
• Thinking and feeling that a completely safe situation is extremely unsafe and presenting as very fearful, or alternatively, interpreting unsafe situations as safe.
• Having no recall of important events, such as birthdays, holidays, family vacations or camping trips.
• Having no memory of having done something even when someone saw them do it.
•  ‘Hearing’ voices inside her head (note that children seldom talk about this unless directly asked).
• Reporting that there are people inside them that say mean things and boss them around, or that provide comfort. These are different from the pretend or imaginary friends that young children commonly have and outgrow.
• Thinking badly about themselves, perhaps even wanting to die, and seeing the world as a frightening and threatening place. Then suddenly they may feel good about themselves and the world, and hopeful about the future.
• Flashbacks, or reliving a traumatic event, where they are unaware of their present surroundings.
• Physical or bodily changes that a doctor may not be able to find a medical problem or cause for, which may be a result of the tension or anxiety from trauma that is being ‘held’ unconsciously in the body.
• Wetting or soiling themselves without feeling it, smelling it, or even knowing it is happening.
• Getting hurt (e.g., getting a cut, breaking a bone, or harming themselves) and not feeling the pain or being aware that they have been hurt.
• Feeling their body parts change and get smaller or bigger, or feeling like parts of their body have disappeared or are not real.
•  Feeling like they are seeing everything around them through a fog or like a dream, as if the world around them isn’t real or feels very far away.
• Complaints of stomach aches, headaches, seizure-like motions, or other physical problems (for example, difficulty breathing, walking, genital pain) that cannot be physically explained.

When a child or adolescent is showing symptoms of trauma or dissociation, start by discussing your concerns with the professionals who may already be involved in the youth’s life. This may include counselors or therapists, doctors (e.g., pediatrician or psychiatrist), and school staff (e.g., school counselor, other educators) working with your child. Describe what you see and why you are concerned. Ask for an assessment or a referral for an assessment from a trauma-informed lens. This assessment would evaluate the child’s symptoms, strengths and challenges, as well as identify the supports that would be most beneficial for your particular child. As many mental health professionals have not been trained in assessing trauma, you may need to request a referral to an alternate mental health professional specializing in trauma and dissociation. See ISSTD Adult Fact Sheet V: Getting Treatment for Complex Trauma and Dissociation for information about finding the right mental health professional. Symptoms of trauma and dissociation respond well to specialized treatment, particularly with early diagnosis and treatment.

Complex trauma and dissociation may present very differently when it comes to various aspects of a child’s life. For example, a child may have separation anxiety issues, low self-worth, sleeping problems, self-harm, academic and social issues, dissociative behaviors, or unexplained medical complaints, among other challenges. All of these can make it confusing to search for appropriate help. For some children and families the diagnosis of complex trauma may be felt as a relief and provide a framework for understanding and addressing a child’s trauma responses and symptoms. For others, a diagnosis can also feel overwhelming, and might require facing the reality that traumatizing events had indeed happened to the child. It is important to realize that due to the growing insights into complex trauma and dissociation, as well as resilience and treatment possibilities, there are effective treatments for trauma and dissociation available. Depending on the child’s specific strengths and challenges, treatment may sometimes be lengthy; however, the therapeutic process can help bring about profound change.

Steps You Can Take in the Assessment and Treatment Process

• Learn about what the child has experienced, their unique trauma responses, and how important it is for key adults in the child’s life to support the child.
• Understand dissociation, recognize when it is happening, and learn how to talk with your child at those times.
• Develop a greater sense of safety in the home.
• Identify the triggers that elicit your child’s dissociative responses and how to decrease these triggers. A trigger is something in the child’s present experience that is similar in some way to the situation at the time of the trauma, and that reminds the child of their trauma. A trigger can be a person, place, thing, situation, emotion, or piece of sensory information (e.g. sound, smell, color). Triggers reignite the child’s fear and the child is likely to respond to them just as they did when the actual trauma happened.
• Establish a word or gesture that can help you reorient your child when dissociation starts to happen.
• Learn specific supportive strategies and trauma-informed caregiving parenting techniques that can help your child assume responsibility for all of their behaviors and experience a more consistent and growing sense of self.
• “Recover before you uncover” which means work on helping the child to feel safe both on the inside and outside, such as by building safe relationships and teaching children to regulate emotions and distress. This helps children to recover by teaching them tools to calm the brain.
• When the child has the necessary tools to manage the resulting distress, children can be supported by helping professionals to work through their traumatic memories. The helping professional attends to the needs and symptoms of the child to find a pace that suits the child’s ability to process the traumatic memories. Trauma-specific therapies are tailored to the child’s unique strengths, challenges, and history.

Caregivers may also benefit from support for themselves as they work towards helping their child. Caregivers are encouraged to reach out to their informal support network (e.g., friends, family) and/or to their own mental health professionals (e.g., therapist, physician) to help them maintain their own wellbeing within the context of caring for a child with unique needs. Although healing can sometimes seem like a long process, children can experience relief and improvements. Children heal best when they have a supportive team around them. Caregivers have key positions within this team and also benefit from the support of other mental health, medical, and school professionals involved in the child’s care. Healing is achieved through working together.