Trauma and Treatment in Early Childhood: A Review of the Historical and Emerging Literature for Counselors

Abstract

Young children are especially susceptible to exposure to trauma. Rates of abuse and neglect among this population are staggering. This article presents a review of relevant literature, including research findings specific to early childhood vulnerability to trauma, symptoms associated with traumatic events, diagnostic validity of early childhood trauma, and treatments for young children. In the past, misconceptions about the mental health of young children have hindered accurate diagnosis and treatment of trauma-related mental illness. Due to the prevalence of trauma exposure in early childhood, counselors are encouraged to become familiar with ways that clients and families are impacted and methods for treatment. Implications for future research also are presented.

Full text

225
Kristen E. Buss, NCC, is a counselor at Hope-Thru-Horses, Inc. in Lumber Bridge, NC. Jeffrey M. Warren, NCC, is an Assistant Professor at
the University of North Carolina-Pembroke. Evette Horton is a clinical instructor at the UNC OBGYN Horizons Program at the University
of North Carolina-Chapel Hill. Correspondence can be addressed to Jeffrey Warren, The University of North Carolina-Pembroke, P.O. Box
1510, School of Education, Pembroke, NC 28372, jeffrey.warren@uncp.edu.
Kristen E. Buss
Jeffrey M. Warren
Evette Horton
Trauma and Treatment in Early Childhood:
A Review of the Historical and Emerging
Literature for Counselors
Young children are especially susceptible to exposure to trauma. Rates of abuse and neglect among this population
are staggering. This article presents a review of relevant literature, including research ndings specic to early
childhood vulnerability to trauma, symptoms associated with traumatic events, diagnostic validity of early
childhood trauma, and treatments for young children. In the past, misconceptions about the mental health of young
children have hindered accurate diagnosis and treatment of trauma-related mental illness. Due to the prevalence
of trauma exposure in early childhood, counselors are encouraged to become familiar with ways that clients and
families are impacted and methods for treatment. Implications for future research also are presented.
Keywords: early childhood, trauma, treatment, mental health, mental illness
Children from birth to age 5 are at a particularly high risk for exposure to potentially traumatic events
due to their dependence on parents and caregivers (Lieberman & Van Horn, 2009; National Child Traumatic
Stress Network, 2010). Traumatic events are incidents that involve the threat of bodily injury, death or harm
to the physical integrity of self or others and often lead to feelings of terror or helplessness (National Library
of Medicine, 2013). The American Psychological Association (APA) Presidential Task Force on Posttraumatic
Stress Disorder (PTSD) and Trauma in Children and Adolescents (2008) indicated that traumatic events
include suicides and other deaths or losses, domestic or sexual violence, community violence, medical trauma,
vehicle accidents, war experiences, and natural and manmade disasters. With more than half of young children
experiencing a severe stressor, they are especially susceptible to accidents, physical trauma, abuse and neglect,
as well as exposure to domestic or community violence (National Child Traumatic Stress Network, 2010).
Over 20 years ago, Straus & Gelles (1990) estimated that three million couples per year engage in severe
in-home violence toward each other in the presence of young children. The Administration on Children, Youth,
and Families (2003) reported that in 2001, 85% of abuse fatalities occurred among children younger than 6
years of age, and half of all child victims of maltreatment are younger than 7. More recently, the Child Welfare
Information Gateway (2014) indicated that 88% of child abuse and neglect fatalities occurred among children
7 years of age and younger. Often, there is an overlap between domestic violence and child physical and sexual
abuse (Osofsky, 2003). In addition to domestic violence, young children also are vulnerable to community
violence.
A study conducted by Shahinfar, Fox, and Leavitt (2000) suggested that the majority of young children
enrolled in Head Start experienced violence in their communities. Young children also are exposed to traumatic
The Professional Counselor
Volume 5, Issue 2, Pages 225–237
http://tpcjournal.nbcc.org
© 2015 NBCC, Inc. and Affiliates
doi:10.15241/keb.5.2.225

226
stressors such as accidental burns or falls resulting in hospitalization or death (Grossman, 2000). It is common
for children to experience more than one traumatic event (APA Presidential Task Force on PTSD and Trauma in
Children and Adolescents, 2008).
Young children birth to age 5 are especially vulnerable to adverse effects of trauma due to rapid
developmental growth, dependence on caregivers and limited coping skills. However, despite decades of
statistical data, counselors generally have limited knowledge of the impact of traumatic events on younger
children in comparison to older children and adolescents (De Young, Kenardy, & Cobham, 2011). Reasons for
this disparity in knowledge include a historical resistance to the notion that early childhood mental health is
important and concerns about diagnosing young children with mental disorders.
Research in early childhood mental health has developed rapidly over the past 20 years. Practitioners and
researchers who work with this population continue to contribute to the understanding of trauma and early
childhood mental health. However, the broader counselor population seems less informed which hinders
referrals for this vulnerable population of young children. For example, a counselor may work with a victim
of domestic violence who has young children. However, due to the counselor’s limited knowledge of early
childhood trauma and the impact of domestic violence, the counselor may not consider support services for the
children. The present article examines the history and diagnostic validity of trauma-related mental illnesses in
young children, the symptoms of trauma in early childhood, the longitudinal impact of early childhood trauma,
the protective and risk factors associated with trauma in early childhood, and current and emerging treatments
for this vulnerable population.
Mental Health, Trauma and Young Children: A Historical Perspective
Historically, researchers have spent little time and energy researching the effects of trauma exposure in early
childhood. A widely held misconception has been that infants and young children lack the perception, cognition
and social maturity to remember or understand traumatic events (Zeanah & Zeanah, 2009). Additionally, mental
health counselors have been hesitant to diagnose trauma-related mental illness as a result of the associated
stigmas that plague young children. In some cases when a child is diagnosed with mental illness, society focuses
on the diagnosis and not the child.
Today it is widely accepted that children have the capacity to perceive and remember traumatic events. From
birth, the tactile and auditory senses of a child are similar to those of an adult, which suggests that a child can
experience stressful events (De Young et al., 2011). At 3 months of age, a child’s visual sensory development
increases exponentially. A study by Gaensbauer (2002) suggested that infants as young as 7 months of age
can remember and reenact traumatic events for up to 7 years. By 18 months of age, children begin to develop
autobiographical memory; however, it is unlikely that memories from before that age can be recalled verbally
(Howe, Toth, & Cicchetti, 2006). Researchers have demonstrated that infants and young children have the
perceptual ability and memory to be impacted by traumatic events (De Young et al., 2011; Howe et al., 2006).
While research ndings have conrmed that traumatic events can impact children, clinicians without proper
training in early childhood mental health may have difculty diagnosing trauma-related mental illness in
childhood. Children younger than 5 years of age typically experience rapid developmental changes that often
are misinterpreted or not fully accounted for which hinders proper diagnosis and intervention (Zero to Three,
2005). Given time and insurance reimbursement constraints, there can be difculties observing children’s
behaviors across settings (Carter, Briggs-Gowan, & Davis, 2004). Although verbal skills develop rapidly in
early childhood, children may lack the communication skills necessary to accurately express their thoughts,

The Professional Counselor/Volume 5, Issue 2
227
emotions and experiences (Cohen, 2010). When conducting assessments, mental health professionals rely on
parental feedback, inventories and reports from multiple sources, thus increasing the accuracy of the assessment
(Carter, Briggs-Gowan, Jones, & Little, 2003).
There is a lack of psychometrically sound diagnostic tools for directly assessing trauma symptoms in
children (Strand, Pasquale, & Sarmiento, 2011). Those tools currently available do not appropriately consider
the developmental levels of young children (Carter et al., 2004; Egger & Angold, 2006; Strand et al., 2011).
However, there are well-designed instruments for early childhood that utilize indirect assessments such as
clinician observations and parent/teacher reports (Yates et al., 2008).
Diagnostic tools and assessments developed for children over age 5 are not suitable for assessing young
children. For example, young children may not fully understand the directions or the vocabulary used in certain
assessment tools. Furthermore, the diagnostic criteria for specic mental health issues (e.g., PTSD) are not
developmentally appropriate for children younger than 5 (Scheeringa & Haslett, 2010). The APA Presidential
Task Force on PTSD and Trauma in Children and Adolescents (2008) argues that children are not being
appropriately identied or diagnosed as having trauma histories and do not receive adequate help.
From a historical perspective, mental health counselors as well as society as a whole have hesitated to
acknowledge the plight that young children face in terms of trauma exposure. Several historical factors have
contributed to counselors’ general lack of knowledge and expertise regarding this population. However, recent
advances in research and in the counseling profession, such as the new American Counseling Association
division, the Association for Child and Adolescent Counseling, have begun to broaden counselor knowledge in
this area.
Symptoms of Trauma in Early Childhood
Trauma reactions can manifest in many different ways in young children with variance from child to child.
Furthermore, children often reexperience traumas. Triggers may remind children of the traumatic event and a
preoccupation may develop (Lieberman & Knorr, 2007). For example, a child may continuously reenact themes
from a traumatic event through play. Nightmares, ashbacks and dissociative episodes also are symptoms of
trauma in young children (De Young et al., 2011; Scheeringa, Zeanah, Myers, & Putnam, 2003).
Furthermore, young children exposed to traumatic events may avoid conversations, people, objects, places
or situations that remind them of the trauma (Coates & Gaensbauer, 2009). They frequently have diminished
interest in play or other activities, essentially withdrawing from relationships. Other common symptoms
include hyperarousal (e.g., temper tantrums), increased irritability, disturbed sleep, a constant state of alertness,
difculty concentrating, exaggerated startle responses, increased physical aggression and increased activity
levels (De Young et al., 2011).
Traumatized young children may exhibit changes in eating and sleeping patterns, become easily frustrated,
experience increased separation anxiety, or develop enuresis or encopresis, thus losing acquired developmental
skills (Zindler, Hogan, & Graham, 2010). There is evidence that traumas can prevent children from reaching
developmental milestones and lead to poor academic performance (Lieberman & Knorr, 2007). If sexual trauma
is experienced, a child may exhibit sexualized behaviors inappropriate for his or her age (Goodman, Miller, &
West-Olatunji, 2012; Pynoos et al., 2009; Scheeringa et al., 2003; Zero to Three, 2005).
The symptoms that young children experience as a result of exposure to a traumatic event are common to
many other childhood issues. Many symptoms of trauma exposure can be attributed to depression, separation

228
anxiety, attention-decit/hyperactivity disorder, oppositional deant disorder or other developmental crises (see
American Psychiatric Association, 2013). It is important for counselors to consider trauma as a potential cause
of symptomology among young children.
Long-Term Consequences of Early Childhood Trauma
Recently, researchers have focused on how trauma during early childhood impacts mental and physical
health later in life. Symptoms of mental illness can manifest immediately after a trauma, but in some cases
symptoms do not emerge until years later. PTSD, anxiety disorders, behavior disorders and substance abuse
have all been linked to traumatic events experienced during early childhood (Kanel, 2015). The types and
frequencies of traumatic events and whether they were directly or indirectly experienced also can have various
effects on physical and mental health later in adulthood. In a review of literature, Read, Fosse, Moskowitz and
Perry (2014) described support for the traumagenic neurodevelopmental model. This model proposes that brain
functioning changes following exposure to trauma during childhood. These biological factors often lead to
psychological issues and physical and mental health concerns in adulthood.
Mental health professionals are often challenged to accurately diagnose PTSD in early childhood, leading
to inconclusive reports of the actual prevalence of post-traumatic stress (De Young et al., 2011). Still, there is
a clear relationship between PTSD diagnoses and trauma experienced in childhood. For example, higher rates
of PTSD are reported among children residing in urban populations where neighborhood violence is prevalent
(Crusto et al., 2010; Goodman et al., 2012). Briggs-Gowan et al. (2010) found an association between family
and neighborhood violence exposure and oppositional deant disorder, attention-decit/hyperactivity disorder,
conduct disorder and substance abuse. Additionally, noninterpersonal traumatic events (e.g., car accidents,
burns, animal attacks) are associated with PTSD as well as anxiety, phobias, seasonal affective disorder and
major depressive disorder (Briggs-Gowan et al., 2010).
Violence exposure is associated with externalizing problems while nonpersonal traumatic events are
associated with internalizing problems (Briggs-Gowan et al., 2010). In a more recent study, Briggs-Gowan,
Carter, & Ford (2011) found that exposure to neighborhood and family violence in early childhood is associated
with poor emotional health and poor performance in school. Low socioeconomic status and traumatic events in
early childhood also are correlated with low academic achievement in school (Goodman et al., 2012). Similarly,
De Bellis, Woolley, and Hooper (2013) found maltreated children demonstrated poorer neuropsychological
functioning and aggregate trauma was negatively related to academic achievement.
According to Schore (2001a), children and adults who experienced relational trauma during infancy are
often faced with the struggles of mental disorder due to right brain impairment (p. 239). More recently, Teicher,
Anderson, and Polcari (2012) found exposure to maltreatment and other types of stress as a child impacts
hippocampal neurons leading to alterations in the brain and potential developmental delays. Additionally,
there is evidence of relationships between mistreatment, bullying and accidents in early childhood and
the development of delusional symptoms in later childhood (Arseneault et al., 2011). Young children who
experience trauma and later use cannabis in adolescence are also at a higher risk for experiencing psychotic
symptoms (Harley et al., 2010). Other studies have shown a correlation between early childhood trauma and
development of schizophrenia later in life (Bendall, Jackson, Hulbert, & McGorry, 2008; Morgan & Fisher,
2007; Read, van Os, Morrison, & Ross, 2005). Changes in the brain may mediate these relationships between
trauma exposure and mental health, as suggested by Schore (2001a, 2001b) and others.
Infants exposed to trauma are often inhibited by emotional and behavioral dysregulation in childhood and as
an adult (Ford et al., 2013; Schore, 2001a, 2001b). Dysregulation resulting from trauma is predictive and related

The Professional Counselor/Volume 5, Issue 2
229
to substance use and functionality (Holtmann et al., 2011). For example, ndings from a study by Strine et al.
(2012) suggested that early childhood trauma and substance abuse are directly correlated. Children who had
experienced more than one traumatic event were found to be 1.4 times more likely to become alcohol dependent.
Strine et al. (2012) noted that females who experience trauma are more likely than males to abuse or become
dependent on alcohol. The relationship between trauma and alcohol use and dependence often stems from
untreated psychological distress (Strine et al., 2012).
In addition, there is ample evidence that early childhood trauma impacts later physical health. Some of the
most well-known data on this topic come from the adverse childhood experiences study (Edwards et al., 2005).
Multiple studies have found that early childhood trauma is associated with autoimmune disorders (Dube et
al., 2009), headaches (Anda, Tietjen, Schulman, Felitti, & Croft, 2010), heart disease (Dong et al., 2004), lung
cancer (Brown et al., 2010) and other illnesses. In fact, these studies often have found that the more frequent
the exposure to early childhood trauma, the higher the risk of poor health outcomes in adulthood (Felitti et al.,
1998).
Researchers have found clear evidence that children who experience traumatic events in early childhood
are impacted well beyond their youth. Mental health disorders as well as alcohol and substance abuse emerge
intermittently with age. Changes in brain functioning and physical health issues are also associated with early
childhood trauma.
Risk and Protective Factors
Researchers have begun to explore factors that interact with trauma and the effects they may produce in
young children. Environmental and demographic factors as well as parent–child relationships signicantly
impact outcomes for young children exposed to traumatic events (Briggs-Gowan et al., 2010). These factors may
either insulate a child from adverse effects of trauma or increase the child’s risk for developing psychological
distress.
Briggs-Gowan et al. (2010) found that symptoms of psychopathology and trauma were related to factors such
as economic disadvantage and parent depressive and anxious symptoms. While ethnicity of the minor, parental
education level and number of parents were associated with violence exposure, those factors were not associated
with symptoms of mental illness. A more recent study found that young children exposed to a traumatic event
along with a combination of socio-demographic factors (e.g., poverty, minority status, single parent, parental
education less than high school, teenage parenting) are at greater risk for mental illness (Briggs-Gowan et
al., 2011). Additionally, Crusto et al. (2010) found that high levels of parental stress are associated with
adverse trauma reactions in young children. Parental dysfunction, family adversity, residential instability and
problematic parenting can increase the impact of traumatic events as well (Turner et al., 2012). Young children
exposed to chronic and pervasive trauma in addition to these risk factors are especially vulnerable to adverse
effects (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008).
There are factors that may help protect young children from the negative impact of exposure to trauma.
Turner et al. (2012) found that nurturing familial relationships can insulate children from psychological distress
associated with traumatic events. Other factors such as safety and stability also might serve as protective
factors. Safety implies that the child is free from harm or fear of harm, both physically and socially. Stability
indicates consistency in the family environment, while nurturing suggests availability, sensitivity and warmth of
caregivers or parents. Well-established, secure parent–child relationships are likely to provide protection from
negative effects of trauma experienced by young children. A secure parental attachment has been shown to help
children effectively regulate emotional arousal (Aspelmeier, Elliot, & Smith, 2007). Emotional regulation may

230
be a mechanism that protects young children from extreme trauma reactions (De Young et al., 2011). Similarly,
Crusto et al. (2010) found that caregiver support and healthy family functioning reduce the risk of psychological
distress in young children after a traumatic event.
Treatment
Early intervention and treatment can minimize the social and emotional impact of a child’s exposure to a
traumatic event. Professional counselors should consider making referrals to counselors trained in providing
early childhood mental health support. If the professional counselor has difculties nding a referral source,
the counselor’s basic counseling skills can provide the foundation for a safe, secure and trusting relationship
between the counselor, family and child. Demonstrating empathy, genuine care and acceptance also fosters
rapport among stakeholders (Corey, 2009). Mental health counselors can emphasize strengths and resources for
the child and family.
Incorporating existing coping strategies can serve to minimize family stress and foster rapport with the child.
Providing information about community support groups or other mental health agencies and resources also can
help support and encourage the family. Informing parents and caregivers about symptoms common to young
children exposed to traumatic events can foster awareness and allow for adequate support during the treatment
process. Counselors can help the family establish or reestablish routines that begin to restore stability for the
child, minimizing the adverse effects of the trauma (APA Presidential Task Force on PTSD and Trauma in
Children and Adolescents, 2008; Clay, 2010).
There are several evidence-based methods available to counselors treating trauma symptoms in young
children. Evidence-based approaches are rooted in theory, evaluated for scientic rigor and tend to yield
positive results (National Registry of Evidence-Based Programs and Practices, 2012). Trauma-focused
cognitive behavioral therapy (TF-CBT) is a popular evidence-based treatment used with children aged
3–18. Based on cognitive behavioral therapy, humanism and family systems theory, TF-CBT includes many
therapeutic elements for children and caretakers (Child Welfare Information Gateway, 2012). This form of
therapy helps children develop different perceptions and a more adaptive understanding of the traumatic event
(APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008). Caretakers learn
parenting and communication skills as they play active roles throughout the TF-CBT process. Multiple studies
demonstrate the effectiveness of TF-CBT in reducing symptoms of trauma in early childhood (see Cohen &
Mannarino, 1996, 1997; Deblinger, Stauffer, & Steer, 2001).
While TF-CBT is an established treatment for children and adolescents, there are evidence-based treatments
developed specically for treating trauma in children between birth and 6 years of age. Child–parent
psychotherapy (CPP), one of the most widely used interventions for young children, was created to address
exposure to domestic violence, although it can treat a variety of traumatic experiences (Lieberman & Van Horn,
2008). In this form of dyadic therapy, the child and the caregiver reestablish safety and security in the parent–
child relationship (Lieberman & Van Horn, 2008). CPP is one of the few early childhood treatments validated
for use with ethnic minorities (Lieberman & Van Horn, 2008). The primary goal of CPP is to equip parents to
meet the psychological needs of their child and maintain a secure relationship after treatment has ended.
Attachment and biobehavioral catch-up (ABC) is another treatment option that is designed primarily for use
with young children who have experienced neglect (Dozier, 2003). This approach was developed specically for
low-income families and later adapted for use with foster families. ABC is based on the neurobiology of stress
and attachment theory. The goal of ABC is to foster the development of the child’s optimal regulatory strategies
by equipping parents with tools for effective response (Dozier, 2003; Dozier, Peloso, Lewis, Laurenceau, &
Levine, 2008).

The Professional Counselor/Volume 5, Issue 2
231
Counselors also can utilize parent–child interaction therapy (PCIT) when working with traumatized youth.
PCIT is a structured technique for children ages 2–8 years in which the counselor teaches the parent or caregiver
how to interact with the child and set effective limits (Chafn et al., 2004). In this form of therapy, the counselor
often assumes the role of coach, instructing the client on specic skills. Counselors frequently use PCIT when
working with children abused by a caregiver. PCIT has been implemented successfully with various populations
including Hispanic and Latino clients (Chafn et al., 2004). The focus of PCIT is on improving the quality
of the parent–child relationship as well as child behavior management (Chafn et al., 2004; McCabe, Yeh,
Garland, Lau, & Chavez, 2005).
The treatment interventions previously mentioned are geared toward very young children, all incorporating
play as a treatment modality. Since young children do not have extensive vocabularies, they often communicate
information about themselves, their trauma and relationships with their caregivers through play (Landreth,
2012). Play therapy intervention research using samples with children between birth and 5 years of age is
scant; however, several case studies indicate that play therapy is effective with trauma in early childhood. For
example Dugan, Snow, and Crowe (2010) utilized play with a 4 year old exhibiting PTSD symptomology after
experiencing Hurricane Katrina in 2005. Anderson and Gedo (2013) provided a case study in which play was
used to treat a 3 year old with aggressive behaviors who was separated from his primary caregiver. There also
are intervention examples of using play therapy with young children exposed to domestic violence (Frick-
Helms, 1997; Kot, Landreth, & Giordano, 1998).
Finally, there are emerging approaches specically for treating young children exposed to trauma. Tortora
(2010) developed Ways of Seeing, a program combining movement and dance therapy with Laban movement
analysis to create a sense of regulation and homeostasis for the child exposed to a traumatic event. The Ways of
Seeing program does not yet have empirical evidence of its effectiveness. However, it is rooted in attachment
theory, multisensory processing, play and sensorimotor psychotherapy. Counselors can use this program to
determine how a parent and child experience each other, implement creative interventions for healthy bonding,
and renew a sense of efcacy for the parent and child. While much more research is needed, this program
appears to be a promising approach to treating trauma in early childhood (see http://www.suzitortora.org/
waysofseeing.html).
Another emerging treatment, known as Honoring Children, Mending the Circle (HC-MC), is based on TF-
CBT. The HC-MC approach was developed to address the spiritual needs of young Native American and Alaska
Native children exposed to trauma. This method emphasizes preestablished relationships, wellness and healing
during the treatment process. Spirituality is a critical component of healing and is integrated throughout the HC-
MC approach. The goal of HC-MC is to help the traumatized child attain and reestablish balance (BigFoot &
Schmidt, 2007, 2010). Additional research is needed on the efcacy of the HC-MC approach in working with
Native American and Alaska Native youth.
A third emerging treatment, Trauma Assessment Pathway, is an assessment-based treatment that focuses
on providing triage to young children exposed to traumatic events (Conradi, Kletzka, & Oliver, 2010). In
this approach, the counselor uses assessment domains to determine the focus of treatment, provides triage to
identify an appropriate pathway for intervention and establishes referrals to community resources if needed
(Chadwick Center for Children and Families, 2009). The trauma assessment pathway method, which includes
the trauma wheel, is a versatile mode of treatment available for the child and family. However, in many
instances counselors may determine that an evidence-based practice, such as CPP, is the most appropriate mode
of treatment (see Chadwick Center for Children and Families, 2009).

232
Each method of treatment offers specic strategies for working with traumatized young children and
their families. However, ndings from most studies investigating the effectiveness of these treatments are
inconclusive (Forman-Hoffman et al., 2013). The strength of evidence for these and many other interventions
are relatively low while the magnitudes of treatment effects are small (see Fraser et al., 2013). Common to the
treatment models presented is the emphasis on system support, the importance of relationships in the recovery
process and developmentally appropriate intervention modalities. These factors likely will serve as integral
components of future methods focused on the treatment of traumatized young children.
Discussion and Implications
Young children are at high risk for exposure to traumatic events and are particularly vulnerable for several
reasons. They are dependent upon caregivers and lack adequate coping skills. Children also experience
rapid development and growth, leaving them particularly impressionable when faced with a traumatic event.
Young children benet from preventive psychoeducation aimed at teaching parents and caregivers about child
development and parenting skills (McNeil, Herschell, Gurwitch, & Clemens-Mowrer, 2005; Valentino, Comas,
Nuttall, & Thomas, 2013). Counselors who work with this population endeavor to increase protective factors
and decrease risk factors while exploring preventive methods, which may reduce young children’s exposure to
traumatic events. Similarly, legislators can inuence public policy related to enhancing childhood mental health.
For example, legislation can address prevention and offer incentives to parents participating in psychoeducation
focused on enhancing protective factors and reducing childhood trauma exposure.
In recent years research has emerged that provides an understanding of how trauma impacts young children.
Researchers and clinicians know that infants, toddlers and preschoolers have the capacity to perceive trauma
and are capable of experiencing psychopathology following a traumatic event. Although these children can
experience mental illnesses often associated with older children, adolescents and adults, the symptomology can
manifest in various ways. Additionally, professional counselors working with children in a variety of settings
should consider the residual impact of traumatic events experienced in early childhood. School-aged children
may experience behavioral problems and have difculty learning and forming relationships as a result of early
childhood trauma (Cole, Eisner, Gregory, & Ristuccia, 2013; Cole et al., 2005). A number of studies indicate
that trauma is a strong predictor of academic failure (Blodgett, 2012). Therefore, school counselors serving
as mediators between academics and wellness should explore ways to advocate for and support students with
known or suspected exposure to traumatic events in early childhood. For example, the trauma-sensitive schools
initiative provides school counselors with a framework for fostering schoolwide awareness and creating a safe
and supportive environment (Cole et al., 2013). School counselors can easily embed these types of preventive
measures as part of a comprehensive school counseling program. These efforts will presumably result in
increases in student success, wellness and awareness, three outcomes that will benet all children exposed to
traumatic events.
While great strides have been taken recently in understanding and treating early childhood trauma, there are
clear gaps in the dissemination of information to counselors. Professional counselors should receive training
in specically designed interventions and attempt to raise public awareness of early childhood trauma in hopes
that young children will receive necessary treatment. The ndings of this literature review suggest that various
methods of treatment might effectively reduce symptoms experienced by traumatized children. Parent–child
relationships and other environmental factors also can have signicant inuence on children’s reaction to
trauma.

The Professional Counselor/Volume 5, Issue 2
233
A major purpose of this article is to educate counselors about the impact of trauma in early childhood and
advocate for appropriate assessment and treatment of these traumatic exposures. While not all counselors choose
to work with this vulnerable population, they often work with clients who have extended families with young
children. Counselors who work with adult clients can provide psychoeducation about this important issue and
initiate referrals to counselors trained to work with early childhood trauma. There is a body of information about
trauma in early childhood available for further review. Sources include the National Child Traumatic Stress
Network (nctsnet.org), the California Evidence-Based Clearinghouse for Child Welfare (cebc4cw.org), and the
Association for Child and Adolescent Counseling (acachild.com). Counselors interested in learning more about
this issue can review these online resources.
Conict of Interest and Funding Disclosure
The authors reported no conict of
interest or funding contributions for
the development of this manuscript.
References
Administration on Children, Youth, & Families. (2003). Child maltreatment 2001. Washington, DC: Government Printing
Ofce. Retrieved from http://archive.acf.hhs.gov/programs/cb/pubs/cm01/cm01.pdf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA:
Author.
American Psychological Association Presidential Task Force on Posttraumatic Stress Disorder and Trauma in Children
and Adolescents. (2008). Children and trauma: Update for mental health professionals. American Psychological
Association. Retrieved from http://www.apa.org/pi/families/resources/update.pdf
Anda, R., Tietjen, G., Schulman, E., Felitti, V., & Croft, J. (2010). Adverse childhood experiences and frequent headaches
in adults. Headache, 5, 1473–81. doi:10.1111/j.1526-4610.2010.01756.x
Anderson, S. M., & Gedo, P. M. (2013). Relational trauma: Using play therapy to treat a disrupted attachment. Bulletin of
the Menninger Clinic, 77, 250–268. doi:10.1521/bumc.2013.77.3.250
Arseneault, L., Cannon, M., Fisher, H. L., Polanczyk, G., Moftt, T. E., & Caspi, A. (2011). Childhood trauma and
children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study. The American Journal
of Psychiatry, 168, 65–72. doi:10.1176/appi.ajp.2010.10040567
Aspelmeier, J. E., Elliot, A. N., & Smith, C. H. (2007). Childhood sexual abuse, attachment, and trauma symptoms in
college females: The moderating role of attachment. Child Abuse & Neglect, 31, 549–566.
Bendall, S., Jackson, H. J., Hulbert, C. A., & McGorry, P. D. (2008). Childhood trauma and psychotic disorders: A
systematic, critical review of the evidence. Schizophrenia Bulletin, 34, 568–579. doi:10.1093/schbul/sbm121
BigFoot, D. S., & Schmidt, S. R. (2007). Honoring children, mending the circle. Retrieved from http://www.icctc.org/
HC%20MC%20NICWA%202007-no%20pics.pdf
BigFoot, D. S., & Schmidt, S. R. (2010). Honoring children, mending the circle: Cultural adaptation of trauma-focused
cognitive-behavioral therapy for American Indian and Alaska native children. Journal of Clinical Psychology, 68,
847–856. doi:10.1002/jclp.20707
Blodgett, C. (2012). Adopting ACEs screening and assessment in child serving systems. Retrieved from http://extension.
wsu.edu/ahec/trauma/Documents/ACE%20Screening%20and%20Assessment%20in%20Child%20Serving%20
Systems%207-12%20nal.pdf
Briggs-Gowan, M. J., Carter, A. S., Clark, R., Augustyn, M., McCarthy, K. J., & Ford, J. D. (2010). Exposure to potentially
traumatic events in early childhood: Differential links to emergent psychopathology. Journal of Child Psychology
and Psychiatry, 51, 1132–1140. doi:10.1111/j.1469-7610.2010.02256.x
Briggs-Gowan, M. J., Carter, A. S., & Ford, J. D. (2011). Parsing the effects violence exposure in early childhood:
Modeling developmental pathways. Journal of Pediatric Psychology, 37, 11–22. doi:10.1093/jpepsy/jsr063

234
Brown, D. W., Anda, R. F., Felitti, V. J., Edwards, V. J., Malarcher, A. M., Croft, J. B., & Giles, W. H. (2010). Adverse
childhood experiences are associated with the risk of lung cancer: A prospective cohort study. BMC Public
Health, 10, 10–20. doi:10.1186/1471-2458-10-20
Carter, A. S., Briggs-Gowan, M. J., & Davis, N. O. (2004). Assessment of young children’s social-emotional development
and psychopathology: Recent advances and recommendations for practice. Journal of Child Psychology and
Psychiatry, 45, 109–134.
Carter, A. S., Briggs-Gowan, M. J., Jones, S. M., & Little, T. D. (2003). The infant–toddler social emotional assessment
(ITSEA): Factor structure, reliability, and validity. Journal of Abnormal Child Psychology, 31, 495–514.
Chadwick Center for Children and Families. (2009). Assessment-based treatment for traumatized children: A trauma
assessment pathway (TAP). San Diego, CA: Author.
Chafn, M., Silovsky, J. F., Funderburk, B., Valle, L. A., Brestan, E. V., Balachova, T., . . . Bonner, B. L. (2004). Parent–
child interaction therapy with physically abusive parents: Efcacy for reducing future abuse reports. Journal of
Consulting and Clinical Psychology, 72, 500–510.
Child Welfare Information Gateway. (2012, August). Trauma-focused cognitive behavioral therapy for children affected
by sexual abuse or trauma. Washington, DC: U.S. Department of Health and Human Services, Administration for
Children and Families, Children’s Bureau. Retrieved from https://www.childwelfare.gov/pubs/trauma/trauma.pdf
Child Welfare Information Gateway. (2014). Child abuse and neglect fatalities 2012: Statistics and interventions.
Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved from https://
www.childwelfare.gov/pubs/factsheets/fatality.pdf
Clay, R. A. (2010, July/August). Treating traumatized children: Five years after Katrina, new data are illuminating the best
ways to help children after natural disasters. Monitor on Psychology, 41, 36–39.
Coates, S., & Gaensbauer, T. J. (2009). Event trauma in early childhood: Symptoms, assessment, intervention. Child and
Adolescent Psychiatric Clinics of North America, 18, 611–626. doi:10.1016/j.chc.2009.03.005
Cohen J. A., & Mannarino, A. P. (1996). A treatment outcome study for sexually abused preschool children: Initial
ndings. Journal of the American Academy of Child & Adolescent Psychiatry, 35, 42–50.
Cohen J. A., & Mannarino, A. P. (1997). A treatment study for sexually abused preschool children: Outcome during a one-
year follow-up. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 1228–1235.
Cohen, N. J. (2010). The impact of language development on the psychosocial and emotional development of young
children. In R. E. Tremblay, M. Boivin, & R. D. Peters (Eds.), Encyclopedia on early childhood development.
Retrieved from http://www.child-encyclopedia.com/sites/default/les/textes-experts/en/622/the-impact-of-
language-development-on-the-psychosocial-and-emotional-development-of-young-children.pdf
Cole, S. F., Eisner, A., Gregory, M., & Ristuccia, J. (2013). Helping traumatized children learn: Safe, supportive learning
environments that benet all children. Creating and advocating for trauma-sensitive schools. Boston, MA:
Massachusetts Advocates for Children.
Cole, S. F., O’Brien, J. G., Gadd, M. G., Ristuccia, J., Wallace, D. L., & Gregory, M. (2005). Helping traumatized children
learn: Supportive school environments for children traumatized by family violence. A report and policy agenda.
Boston, MA: Massachusetts Advocates for Children.
Conradi, L., Kletzka, N. T., & Oliver, T. (2010). A clinician’s perspective on the trauma assessment pathway (TAP) model:
A case study of one clinician’s use of the (TAP) model. Journal of Child and Adolescent Trauma, 3, 40–57.
doi:10.1080/19361520903520450
Corey, G. (2009). Theory and practice of counseling and psychotherapy (8th ed.). Belmont, CA: Brooks/Cole.
Crusto, C. A., Whitson, M. L., Walling, S. M., Feinn, R., Friedman, S. R., Reynolds, J., . . . Kaufman., J. S. (2010).
Posttraumatic stress among young urban children exposed to family violence and other potentially traumatic
events. Journal of Traumatic Stress, 23, 716–724. doi:10.1002/jts.20590
De Bellis, M. D., Woolley, D. P., & Hooper, S. R. (2013). Neuropsychological ndings in pediatric maltreatment:
Relationship of PTSD, dissociative symptoms, and abuse/neglect indices to neurocognitive outcomes. Child
Maltreatment, 18, 171–183. doi:1077559513497420.
Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative efcacies of supportive and cognitive behavioral
group therapies for young children who have been sexually abused and their non-offending mothers. Child
Maltreatment, 6, 332–343. doi:10.1177/1077559501006004006
De Young, A. C., Kenardy, J. A., & Cobham, V. E. (2011). Trauma in early childhood: A neglected population. Clinical
Child & Family Psychology Review, 14, 231–250. doi:10.1007/s10567-011-0094-3

The Professional Counselor/Volume 5, Issue 2
235
Dong, M., Giles, W. H., Felitti, V. J., Dube, S. R., Williams, J. E., Chapman, D. P., & Anda, R. F. (2004). Insights into
causal pathways for ischemic heart disease: Adverse childhood experiences study. Circulation, 110 , 1761–1766.
Dozier, M. (2003). Attachment-based treatment for vulnerable children. Attachment and Human Development, 5, 253–
257.
Dozier, M., Peloso, E., Lewis, E., Laurenceau, J. P., & Levine, S. (2008). Effects of an attachment-based intervention on
the cortisol production of infants and toddlers in foster care. Development and Psychopathology, 20, 845–859.
doi:10.1017/S0954579408000400
Dube, S. R., Fairweather, D., Pearson, W. S., Felitti, V. J., Anda, R. F., & Croft, J. B. (2009). Cumulative childhood stress
and autoimmune diseases in adults. Psychosomatic Medicine, 71, 243–250. doi:10.1097/PSY.0b013e3181907888
Dugan, E. M., Snow, M. S., & Crowe, S. R. (2010). Working with children affected by hurricane Katrina: Two case
studies in play therapy. Child and Adolescent Mental Health, 15, 52–55. doi:10.1111/j.1475-3588.2008.00523.x
Edwards, V. J., Anda, R. F., Dube, S. R., Dong, M., Chapman, D. F., & Felitti, V. J. (2005). The wide-ranging health
consequences of adverse childhood experiences. In K. A. Kendall-Tackett & S. M. Giacomoni (Eds.), Child
victimization: Maltreatment, bullying, and dating violence prevention and intervention (pp. 8-1–8-12). Kingston,
NJ: Civic Research Institute.
Egger, H. L., & Angold, A. (2006). Common emotional and behavioral disorders in preschool children: Presentation,
nosology, and epidemiology. Journal of Child Psychology and Psychiatry, 47, 313–337.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998).
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The
adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, 245–258.
Ford, J. D., Grasso, D., Greene, C., Levine, J., Spinazzola, J., & van der Kolk, B. (2013). Clinical signicance of a
proposed developmental trauma disorder diagnosis: Results of an international survey of clinicians. Journal of
Clinical Psychiatry, 74, 841–849.
Forman-Hoffman, V., Knauer, S., McKeeman, J., Zolotor, A., Blanco, R., Lloyd,…Viswanathan, M. (2013). Child
and adolescent exposure to trauma: Comparative effectiveness of interventions addressing trauma other than
maltreatment or family violence (Review No. 107). Retrieved from Agency for Healthcare Research and Quality,
Effective Health Care Program website: www.effectivehealthcare.ahrq.gov /reports/nal.cfm
Fraser, J. G., Lloyd, S. W., Murphy, R. A., Crowson, M. M., Casanueva, C.,Zolotor, A.,…Viswanathan, M. (2013). Child
exposure to trauma: Comparative effectiveness of interventions addressing maltreatment (Review No. 89).
Retrieved from Agency for Healthcare Research and Quality, Effective Health Care Program website: www.
effectivehealthcare.ahrq.gov /reports/nal.cfm
Frick-Helms, S. B. (1997). “Boys cry better than girls:” Play therapy behaviors of children residing in a shelter for
battered women. International Journal of Play Therapy, 61, 73–91.
Gaensbauer, T. J. (2002). Representations of trauma in infancy: Clinical and theoretical implications for the understanding
of early memory. Infant Mental Health Journal, 23, 259–277. doi:10.1002/imhj.10020
Goodman, R. D., Miller, M. D., & West-Olatunji, C. A. (2012). Traumatic stress, socioeconomic status, and academic
achievement among primary school students. Psychological Trauma: Theory, Research, Practice, and Policy, 4,
252–259. doi:10.1037/a0024912
Grossman, D. C. (2000). The history of injury control and the epidemiology of child and adolescent injuries. The Future
of Children, 10, 23–52.
Harley, M., Kelleher, I., Clark, M., Lynch, F., Arseneault, L., Connor, D., . . . Cannon, M. (2010). Cannabis use and
childhood trauma interact additively to increase the risk of psychotic symptoms in adolescence. Psychological
Medicine, 40, 1627–1634. doi:10.1017/S0033291709991966
Holtmann, M., Buchmann, A. F., Esser, G., Schmidt, M. H., Banaschewski, T., & Laucht, M. (2011). The Child Behavior
Checklist-Dysregulation Prole predicts substance use, suicidality, and functional impairment: A longitudinal
analysis. Journal of Child Psychology and Psychiatry, 52(2), 139–147. doi:10.1111/j.1469-7610.2010.02309.x.
Howe, M. L., Toth, S. L., & Cicchetti, D. (2006). Memory and developmental psychopathology. In D. Cicchetti & D. J.
Cohen (Eds.), Developmental psychopathology, Vol. 2: Developmental neuroscience (pp. 629–655). Hoboken, NJ:
Wiley.
Kanel, K. (2015). A guide to crisis intervention (5th ed.). Belmont, CA: Brooks/Cole.
Kot, S., Landreth, G. L., & Giordano, M. (1998). Intensive child-centered play therapy with child witnesses of domestic
violence. International Journal of Play Therapy, 7(2), 17–36.

236
Landreth, G. L. (2012). Play therapy: The art of the relationship (3rd ed.). New York, NY: Taylor & Francis.
Lieberman, A. F., & Knorr, K. (2007). The impact of trauma: A developmental framework for infancy and early childhood.
Psychiatric Annals, 37, 416–422.
Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress
and trauma on early attachment. New York, NY: Guilford.
Lieberman, A. F., & Van Horn, P. (2009). Giving voice to the unsayable: Repairing the effects of trauma in infancy
and early childhood. Child and Adolescent Psychiatric Clinics of North America, 18, 707–720. doi:10.1016/j.
chc.2009.02.007.
McCabe, K. M., Yeh, M., Garland, A. F., Lau, A. S., & Chavez, G. (2005). The GANA program: A tailoring approach
to adapting parent child interaction therapy for Mexican Americans. Education and Treatment of Children, 28,
111–129.
McNeil, C. B., Herschell, A. D., Gurwitch, R. H., & Clemens-Mowrer, L. (2005). Training foster parents in parent-child
interaction therapy. Education and Treatment of Children, 28, 182–196.
Morgan, C., & Fisher, H. (2007). Environmental factors in schizophrenia: Childhood trauma—a critical review.
Schizophrenia Bulletin, 33, 3–10. doi:10.1093/schbul/sbl053
National Child Traumatic Stress Network. (2010). Early childhood trauma. Retrieved from http://www.nctsn.org/sites/
default/les/assets/pdfs/nctsn_earlychildhoodtrauma_08-2010nal.pdf
National Library of Medicine. (2013). Traumatic events. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/
article/001924.htm
National Registry of Evidence-Based Programs and Practices. (2012). A roadmap to implementing evidence-based
programs. Substance Abuse and Mental Health Services Administration. Retrieved from http://www.nrepp.
samhsa.gov/Courses/Implementations/resources/imp_course.pdf
Osofsky, J. D. (2003). Prevalence of children’s exposure to domestic violence and child maltreatment:
Implications for prevention and intervention. Clinical Child and Family Psychology Review, 6, 161–170.
doi:10.1023/A:1024958332093
Pynoos, R. S., Steinberg, A. M., Layne, C. M., Briggs, E. C., Ostrowski, S. A., & Fairbank, J. A. (2009). DSM-V PTSD
diagnostic criteria for children and adolescents: A developmental perspective and recommendations. Journal of
Traumatic Stress, 22, 391–398. doi:10.1002/jts.20450
Read, J., Fosse, R., Moskowitz, A., & Perry, B. (2014). The traumagenic neurodevelopmental model of psychosis
revisited. Neuropsychiatry, 4(1), 65-79.
Read, J., van Os, J., Morrison, A. P., & Ross, C. A. (2005). Childhood trauma, psychosis and schizophrenia: A literature
review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112 , 330–350. doi:10.1111/
j.1600-0447.2005.00634.x
Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. W. (2003). New ndings on alternative criteria for PTSD in
preschool children. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 561–570.
Scheeringa, M. S., & Haslett, N. (2010). The reliability and criterion validity of the diagnostic infant and preschool
assessment: A new diagnostic instrument for young children. Child Psychiatry & Human Development, 41, 299–
312. doi:10.1007/s10578-009-0169-2
Schore, A. N. (2001a). The effects of early relational trauma on right brain development, affect regulation,
and infant mental health. Infant Mental Health Journal, 22(1–2), 201–269. doi:10.1002/1097-
0355(200101/04)22:1<201::AID-IMHJ8>3.0.CO;2-9
Schore, A. N. (2001b). Effects of a secure attachment relationship on right brain development, affect regulation, and infant
mental health. Infant Mental Health Journal, 22(1–2), 7–66. doi:10.1002/1097-0355(200101/04)22:1<7::AID-
IMHJ2>3.0.CO;2-N
Shahinfar, A., Fox, N. A., & Leavitt, L. A. (2000). Preschool children’s exposure to violence: Relation of behavior
problems to parent and child reports. American Journal of Orthopsychiatry, 70, 115–125.
Strand, V. C., Pasquale, L. E., & Sarmiento, T. L. (2011). Child and adolescent trauma measures: A review. Retrieved
from http://www.ncswtraumaed.org/wp-content/uploads/2011/07/Child-and-Adolescent-Trauma-Measures_A-
Review-with-Measures.pdf
Straus, M. A., & Gelles R. J. (1990). How violent are American families? Estimates from the national family violence
resurvey and other studies. In M. A. Straus & R. J. Gelles (Eds.), Physical violence in American families: Risk
factors and adaptations to violence in 8,145 families (pp. 95–112). New Brunswick, NJ: Transaction.

The Professional Counselor/Volume 5, Issue 2
237
Strine, T. W., Dube, S. R., Edwards, V. J., Prehn, A. W., Rasmussen, S., Wagenfeld, M., . . . Croft, J. B. (2012).
Associations between adverse childhood experiences, psychological distress, and adult alcohol problems.
American Journal of Health Behavior, 36, 408–423. doi:10.5993/AJHB.36.3.11
Teicher, M. H., Anderson, C. M., & Polcari, A. (2012). Childhood maltreatment is associated with reduced volume in the
hippocampal subelds CA3, dentate gyrus, and subiculum. Proceedings of the National Academy of Sciences,
109(9), E563–E572. doi:10.1073/pnas.1115396109
Tortora, S. (2010). Ways of seeing: An early childhood integrated therapeutic approach for parents and babies. Clinical
Social Work Journal, 38, 37–50. doi:10.1007/s10615-009-0254-9
Turner, H. A., Finkelhor, D., Ormrod, R., Hamby, S., Leeb, R. T., Mercy, J. A., & Holt, M. (2012). Family context,
victimization, and child trauma symptoms: Variations in safe, stable, and nurturing relationships during early and
middle childhood. American Journal of Orthopsychiatry, 82, 209–219. doi:10.1111/j.1939-0025.2012.01147x
Valentino, K., Comas, M., Nuttall, A. K., & Thomas, T. (2013). Training maltreating parents in elaborative and emotion-
rich reminiscing with their preschool-aged children. Child Abuse & Neglect, 37, 585–595. doi:10.1016/j.
chiabu.2013.02.010
Yates, T., Ostrosky, M. M., Cheatham, G. A., Fettig, A., Shaffer, L., & Santos, R. M. (2008). Research synthesis on
screening and assessing social-emotional competence. Center on the Social Emotional Foundations for Early
Learning. Retrieved from http://csefel.vanderbilt.edu/documents/rs_screening_assessment.pdf
Zeanah, C. H., Jr., & Zeanah, P. D. (2009). The scope of infant mental health. In C. H. Zeanah, Jr. (Ed.), Handbook of
infant mental health (3rd ed., pp. 5–21). New York, NY: Guilford Press.
Zero to Three. (2005). Diagnostic classication of mental health and developmental disorders of infancy and early
childhood (DC: 0-3R; revised edition). Washington, DC: Author.
Zindler, P., Hogan, A., & Graham, M. (2010). Addressing the unique and trauma-related needs of young children.
Tallahassee, FL: Florida State University Center for Prevention & Early Intervention Policy.