Developmental Trauma: An Introduction to the Section

ABSTRACT

This is an introduction to a collection of papers on developmental trauma which describe psychological and biological effects of exposure to extreme adversity that affects all of development from childhood into adulthood. Each of the papers contributes a different lens in the way we think about and treat people who have experienced trauma.

KEYWORDS:

• Developmental trauma
• complex trauma
• loss
• divorce
• adoption
• bereavement
• trauma treatment
• child psychoanalysis

It is well known in psychoanalysis that, for children, significant trauma “both interrupts development and stamps it forever,” leaves “indelible memory imprints (conscious and unconscious),” and has “an enduring organizational influence” throughout the lifespan (Gaensbauer and Jordan 2009). When one thinks of trauma diagnostically it is often PTSD that comes to mind where “isolated traumatic incidents tend to produce discrete conditioned behavioral and biological responses to reminders of the trauma” (van der Kolk 2005, 409). However, therapists working with children and adolescents now use the diagnostic term developmental trauma to describe chronic adverse and/or traumatic experiences in childhood and adolescence and the impact they have on a child or adolescent and the developmental process itself.

As early as 1956 Ernst Kris considered that trauma could take different forms. “Shock trauma,” the result of a single experience, occurs, he said, when reality powerfully and often suddenly impinges on the child’s life.” But Kris also considered another kind of trauma, akin to what we would today call developmental trauma, “strain trauma” which is “the effect of long-lasting situations which may cause traumatic effects” (Kris 1956, 72–73). Along similar lines, Masud Khan (1963) conceptualized the concept of “cumulative trauma” which “derives from the strains and stresses that an infant-child experiences in the context of his ego dependence on the mother [caregiver] as his protective shield and auxiliary ego throughout the course of the child’s development” (Khan 1963, 290–91). More recently, Bessel van der Kolk (2005) also considered these more complex traumas “to describe the experience of multiple chronic and prolonged developmentally adverse traumatic events, most often of an interpersonal nature … and early life onset” (van der Kolk 2005, 402). He and his colleagues went on to recommend a different diagnosis for these children with complex traumatic histories, Developmental Trauma Disorder (van der Kolk 2005).

Anna Freud (1979) explained that normality or pathology of development was dependent on four factors: “(1) constitutional and experiential elements within an average and expectable range; (2) the maturation of internal agencies at approximately the same rate of speed, i.e. neither delayed nor precocious; (3) the timing of external interventions; and (4) age-adequate ego mechanisms, neither too primitive nor too sophisticated” (Miller 1996, 152). Development entails both growth along numerous lines and harmony between them, but also synthesis, the integration of influences from internal and external sources into a whole. “Integration,” said Anna Freud, “serves healthy growth provided the elements synthesized by it – namely, the constitutional givens, the rate of structurization, and parental influence – remain within the limits of an expectable norm” (1979, 128). Developmental trauma, however, severely impacts this process and provides a seed for an extensive developmental disturbance, both distorting the developmental process itself, which becomes defective or unbalanced, and creating deficits in personality structure formation.

Developmental trauma refers to chronic traumatic experiences which occur during childhood and adolescence. It describes the psychological and biological effects of ongoing exposure to stress and adversity due to physical or sexual abuse, neglect, witnessing or being the object of violence, death or loss of a caregiver, attachment disruption, war, chronic stress in the family and their environment, serious cognitive and physical problems, and any events that overwhelm a child’s or adolescent’s coping strategies. Developmental trauma not only impairs the development of the body but of the brain and “the capacity to integrate sensory, emotional and cognitive information into a cohesive whole,” setting the stage for “unfocused responses to subsequent stress” (Ford 2005; van der Kolk 2005, 402) and leading to various physical, mental, and emotional problems that can persist into adulthood. Some of the common manifestations of developmental trauma include a lack of trust, attachment disorders, cognitive impairment, speech delay, sensory processing disorders, ADHD, oppositional defiant disorder, bipolar disorder, personality disorders, disorders in self-regulation, depression, dissociative disorders, a separation of thinking and feeling, anxiety, heightened awareness of surroundings and people, a lack of self-worth, to name some but not all of the effects it can cause. It can affect a child’s developmental trajectory, and it shapes the child’s sense of themselves, the adults who care for them, and the world in general.

While Rank (1924) thought trauma began at birth, we now know that trauma can start in the womb when the mother experiences trauma in her life, when there is physical illness in the mother or illness that is affecting the fetus. Newborns who spend weeks in the neonatal intensive care nursery carry the trauma of medical procedures in their bodies, and their parents carry the trauma in their minds and bodies. Postpartum physical illness in the mother or baby can cause undue stress in the mother-infant relationship as can postpartum maternal depression. The mother’s own poor infant or early childhood care can affect her good enough care of her infant, causing attachment problems in the young child (Fonagy et al. 1991; Fraiberg, Adelson, and Shapiro 1975). Poverty and not being able to afford enough food and diapers can cause overwhelming stress on both the infant and the mother, leading to physical abuse (Smith et al. 2013; Tokgoz 2023). Severe childhood illnesses and hospitalizations are traumatic for children and adolescents (Miller 1999, 2000; Moran 1984). The loss of a parent is traumatic (Collins 2023; Furman 1974, 1986; Knight et al. 2023). Children and families amid war experience an intolerable trauma with lasting effects that go through subsequent generations (Apfel and Simon 2007; Auerhahn 2013; Freud and In collaboration with Burlingham, 1939–1945). Children and adolescents are traumatized by their parents who have been traumatized, as trauma can be intergenerational (Auerhahn 2013; Fonagy et al. 1991; Herzog 2000; Vaughans 2021). Children and adolescents are consistently bullied and traumatized because of their religion, race, nationality, gender, and the same sex people they love. We could fill pages of this journal with permutations of the trauma that can affect young people and their families, and we would probably miss many other examples. It’s a lesson in the importance of taking a careful initial child and generational family history at the beginning of treatment.

How a child or adolescent experiences and copes with trauma will depend on their inborn temperament, their premorbid coping strategies, the ongoing stresses in the child’s environment that include the social, cultural, and economic factors impinging on the family and the child, the degree to which the adults and social supports in their life are available to help them process the experience of their stress and trauma, and the degree to which consulting child and adult psychotherapists are sensitive to their patient’s life experiences and their patient’s difficulties that may be caused by stressors in their early life experiences.

In looking back over the many children, adolescents, and adults we have treated, most of them had experienced trauma in their childhood and adolescence. Studying middle childhood children hospitalized for elective surgery Knight et al. (1979) found that the children who used intellectual defenses – wanting to know all about what was going to happen to them – as a way of feeling effective throughout their surgery experience had lower cortisol rates before and after hospitalization and did significantly better socially and cognitively after their hospitalization than children who didn’t want to hear or know anything about what was the matter with them or going to happen to them. A child’s development of a sense of effectiveness when faced with a trauma, and the people who can help them process the trauma is an important indicator of how well they manage stress (Knight et al. 1979). Most often the children who show the greatest behavioral problems – the very squeaky wheels – do far better than those who are quiet and seem to be “handling well” the trauma they were going through. These children rely heavily on their brains to cope with their lives and are often overlooked because they seem to be managing well externally, as Graham Music nicely explains in his paper in this section.

Working with children and adolescents who have experienced trauma is a long and painful treatment that takes years of work to help a child process what they have experienced and the feelings they have about themselves, their parents, and the other people in their lives who did not help protect them. Whether you are treating a young child or one in middle childhood (Bram 2019; Downey 2000; Gaensbauer 1995; Knight 2003a, 2003b; Liberman and Harris 2007; Miller 1999; Music 2024; Shiller 2008), an adolescent (Collins 2023; Kennedy 1986; Knight 2024; Novak 2004), an emerging adult (Adams 2021; Knight 2008), or an adult (Colarusso 2009; Gaensbauer and Jordan 2009; Rosenstein 2024; Terr 2013), their pain, anger and sadness is palpable and must be borne and understood by the therapist and communicated to the patient, all the while the therapist is attending to her countertransference. At the same time, the therapist works to instill a different and trusting relationship between herself and the patient that will aid in shifting the individual’s sense of self, their narrative of self and other, and sense of safety in the world, hopefully promoting a more beneficial developmental trajectory. Surviving trauma and being willing to explore its effects on one’s psyche in treatment takes a great deal of courage and the therapeutic relationship forged in this process is a deep and lasting one. Patients often come back to talk again as they reach new developmental challenges in their lives, or sometimes just to reconnect. While some of the effects of trauma are mitigated, the echoes of trauma are always there, never forgotten, always evoking a recalling in one’s mind and body during the course of one’s life.

The papers in this section are written by analysts who have worked with and studied children and their families who have experienced trauma. Each of their papers contributes a slightly different lens in the way we think about and treat the people we see who have had or are experiencing developmental trauma.

Diana Rosenstein is an analyst who works with families going through the process of divorce. Her paper makes the point right at the beginning that divorce can have an extreme, traumatic effect on a child’s development. While divorce is common in many cultures, it is shocking in each individual family experiencing the tensions, conflicts, and stress leading up to the actual trauma of the end of the parental relationship and the family as the child knows it and depends on it. Living with parents who are angry and preoccupied permeates the home environment and can affect a child’s sense of safety and freedom to express their feelings, develop their cognition, build a confident sense of self, and establish strong, lasting peer relationships. Most children of divorcing parents have to cope with changes in their living situation, often requiring a change in their school and having to give up their friends. They have to cope with the uncertainty of a totally different environment, change in economic status, and the potential loss of a parent or a parent who becomes emotionally unstable and unable to care for his or her children. Custody conflicts following divorce entrench dysfunctional parental conflicts and can haver traumatic effects on the parent-child relationships and put the child at risk for dysfunctional relationships with peers and intimates later in life. She discusses the mitigating factors that can lessen the trauma for youngsters at each age.

Rosenstein’s paper delineates the profound effect divorce can have on a child at each stage of development and the sleeper effects that can continue into later stages of development and in adulthood. She makes the point that in addition to the intrapsychic effects divorce has on a child, the cases presented demonstrate the pernicious effects on the child’s academic, social, physical and emotional development as well. She gives vivid examples of the difficulties children experience and stresses the importance of paying careful attention to the parental relationship and how it plays out and is experienced by the child. She ends her paper with a discussion of an adult analysis in which the experience of a divorce in childhood affected his sense of self and others throughout his development.

Graham Music is a trauma therapist who has worked at the Tavistock Centre in London. In this paper, he focuses on people whose early trauma experiences led them to rely on their minds and intellectual defenses because they lacked faith in the adults in their lives to protect them and help them develop “the capacity for relaxation and ‘just being,’” what Winnicott referred to as the ease of “going-on-being.” He describes some people he has worked with who have experienced such trauma and have become cut off from their emotional and bodily experiences and rely solely on their mental activity to feel alive. In the absence of a good enough parent to help them get through their development, these children use their minds as a parental object to rely on. The cost of this defense is never feeling safe, easeful, or fully alive. He notes that psychotherapies that mainly focus on intellectual understanding of one’s past ignore nonverbal body states and sensations that are necessary to focus on if trauma is to be fully addressed in treatment. When children do not feel safe, they use their minds, their sympathetic nervous system, and tightening of their bodies in response to trauma. They also repeat the lack of safety they felt in the original trauma later in their development, often leading to dangerous situations that cause bodily and mental trauma. And they often develop biological and neurological symptoms and diseases that can be their body’s expression of the pain they have experienced. Music has found that combining body work with psychodynamic treatment has led to “profound hopeful results.” He gives detailed descriptions of the treatment of some of the children and adults he has worked with to elucidate how working with both the mind and the body in concert can help people who are facing and/or living with trauma become more aware of what might be going on physiologically as well as mentally. In his paper he discusses the use of breathing techniques to help regulate powerful emotions and mindfulness to become aware of internal and external stimuli. Music makes the point that “Our psychoanalytic traditions, from Freud and Ferenczi to Winnicott and Milner onwards, encourage us to be aware of body states. I have aimed in this paper to raise questions about the extent to which a bodily perspective might enhance our therapeutic techniques … ” (Music 2024). While Music does not focus on other physical techniques directly in his paper, the use of EMDR, yoga, behavioral therapy, massage, and acupuncture conjointly with psychotherapy often will get a better result than just “talk therapy” with people who have experienced developmental trauma. And how many of us have suggested exercise and sports to help children and adolescents get out some of the big feelings they are carrying in their bodies?

Miriam Steele et al. report and discuss the results from the Adoption and Attachment Representations study established 30 years ago to gain an understanding of intergenerational patterns of attachment in a group of previously maltreated children and their adoptive parents. They look at both late placed children and those adopted in their infancy before six months of age. In a previous study, they followed these families one year and two years after the child was first placed, whereas this paper follows them at four to eight years of age and again in early adolescence. Several measures were used: an Adult Attachment Interview with both adoptive parents, the Parent Developmental Interview, and the Story Stem Assessment Profile. In assessing these families, Steele and her colleagues explained multiple significant findings. For example, using attachment measures to identify the strengths and challenges of both the children and the adults, they found that children whose adoptive mothers had their own difficulties with unresolved prior loss or trauma, or an insecure (dismissing or preoccupied) state of mind, experienced a more difficult time adjusting to their new family compared to children placed with more secure parents. Furthermore, in these situations, the emotional worries of the recently adopted child were exacerbated as these adoptive mothers were less able to help their child develop an organized strategy to deal with conflicts of daily life. An additional significant finding was that children from the late adopted previously maltreated group showed increased secure attachments within the first two years of adoption. This finding shows the success of the adoption intervention in this high-risk group, but researchers also found that feelings of aggression and disorganization did not diminish in the two years since they were placed. This and other findings suggest that, “it seems much easier to accommodate and take on positive representations than to ‘extinguish’ negative representations” (Steele et al. 2024), as old and new internal representations coexist side by side. This makes sense as memories of abuse and the feelings attached to those memories continue to exist in the brain and the body and can get triggered by present day events or interactions (Perl et al. 2023). When the subjects were assessed in early adolescence, the late placed group had almost caught up to the early placed group in measurements of secure attachment. Considering the intensity of adversity the late placed group experienced, the data suggest that children’s attachment can change when there is a long and abiding interaction with the people who are caring for them. These findings are important for anyone working with traumatized children to know and understand, as it helps to explain the vulnerabilities these children live with throughout their lives and the importance of building up secure, stable self and self and other external experiences and internal working models that can be relied on when faced with traumatic memories.

The type of working models that facilitated attachment were the ability to maintain “a positive emotional exchange (at the nonverbal level of facial expression), and the verbal level involving use of the child’s name, reference to we or us, and reference to shared past experiences even when the duration of their shared history is no more than a few months” (Steele et al. 2024). Expressions of avoidance, even subtle ones, correlated with a poor attachment outcome, an important finding for parents, teachers, therapists, and other childcare workers to understand so that the child learns they won’t be rejected but helped when their negative feelings are too big to contain. Also of note was the finding that children placed with one or more of their siblings showed better adaptive strategies, including the ability to reach out to others and discuss difficult emotional issues, than those adoptees placed alone, which highlights children’s need for other children to help them work out their feelings and relationships as they move forward in development. Steele and her colleagues illustrate and explain many other findings, as well as provide suggestions that arise out of the research results regarding policy and therapeutic interventions. In their conclusion, they describe how the Adoption and Attachment Representations study is unique and closely related to Bowlby’s work as it heeds “Bowlby’s plea to explore the complexities of the development of the parent-child relationship in an adoption context by infusing the study with psychodynamic understanding of the children and their parents alongside state-of-the-art measures of attachment in a longitudinal design” (Steele et al. 2024).

While this study is about adopted children, the findings apply to helping children who have experienced many different types of developmental trauma, as noted in the other two papers in this section. Development is transactional and a child’s relationships with caregivers and peers, the environment and culture they live in, and their biology are affected by both the good and traumatic experiences in their lives. Stress anywhere in this dynamic system can impact the entire developmental system. These papers discuss several examples of the many types of developmental trauma and point to some ways to help the children and families we treat best cope with such challenging circumstances.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Rona Knight

Rona Knight, PhD, is a Child, Adolescent, and Adult Psychoanalyst. She is an Assistant Professor of Pediatrics and Psychiatry at the Boston University School of Medicine, a Faculty Member and Consulting Child Analysis Supervisor at the Boston Psychoanalytic Society and Institute, and a Senior Editor of the Psychoanalytic Study of the Child.

Jill M. Miller

Jill M Miller, PhD, is a Child, Adolescent, and Adult Psychoanalyst in private practice in Washington DC, Past President of the Association for Child Psychoanalysis, and Co-Editor-in-Chief of the Psychoanalytic Study of the Child. She is a Clinical Professor of Psychiatry at the University of Colorado Medical School, a Faculty Member and Training and Supervising Analyst at the Washington Baltimore Psychoanalytic Center, and a Supervising Analyst for child and adolescent candidates at several institutes across the country.