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The Child Survivor: Healing Developmental Trauma and Dissociation
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THE CHILD SURVIVOR
In this second edition of Joyanna Silberg’s classic The Child Survivor,

practitioners who treat dissociative children will find practical tools that
are backed up by recent advances in clinical research.
Chapters are filled with examples of clinical dilemmas that can challenge
even the most expert child trauma clinicians, and Silberg shows how to
handle these dilemmas with creativity, attunement, and sensitivity to the
adaptive nature of even the most complex dissociative symptoms. The new
edition addresses the impact of the Covid-19 pandemic on children and
provides tips for working with traumatized children in telehealth. A new
chapter on organized abuse explains how children victimized by even the
most sadistic crimes can respond well to therapy.
Clinicians on the front lines of treatment will come away from the book
with an arsenal of therapeutic techniques that they can put into practice
right away, limiting the need for restrictive hospitalizations or out-of-home
placements for their young clients.
Joyanna L. Silberg, PhD, is a clinical child psychologist, an international

expert on dissociation in children and adolescents, and past president of
the International Society for the Study of Trauma and Dissociation.
THE CHILD SURVIVOR
HEALING DEVELOPMENTAL TRAUMA

AND DISSOCIATION
Second Edition
Joyanna L. Silberg
Second edition published 2022
by Routledge
605 Third Avenue, New York, NY 10158
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2022 Joyanna L. Silberg
The right of Joyanna L. Silberg to be identified as author of this work has been
asserted by her in accordance with sections 77 and 78 of the Copyright, Designs
and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from the
publishers.
First edition published 2012 by Routledge
Trademark notice: Product or corporate names may be trademarks or registered
trademarks, and are used only for identification and explanation without
intent to infringe.
Library of Congress Cataloging-in-Publication Data
A catalog record for this title has been requested
ISBN: 978-1-138-04476-0 (hbk)
ISBN: 978-1-138-04479-1 (pbk)
ISBN: 978-1-351-04886-6 (ebk)
Typeset in New Baskerville
by Apex CoVantage, LLC
For Ayla Rose, Judah Samson, Eden Maya, Levi Noah,
Ezra Ronen, Cora Sydney, and the promise of healthy
children and a healthy society in which to raise them
Contents
List of Tables ix
List of Figures xi
Acknowledgments xiii
Preface xv
Introduction xxi
1 Trauma and Its Effects 1
2 An Integrative Developmental Model of Dissociation 21
3 Diagnostic Considerations 39
4 Assessing Dissociative Processes 47
5 Beginning the Treatment Journey 69
6 Educate and Motivate: Introducing the EDUCATE Model 77
7 Bridging the Selves: Healing through Connections to

What’s Hidden 97
8 “I Try to Forget to Remember”: Reversing Amnesia 120
9 Befriending the Body: Somatic Considerations for

the Child Survivor 139
viii CONTENTS
10 Staying Awake: Reversing Dissociative Shutdown 159
11 Building Attachment across States: Affect Regulation in

the Context of Relationships 183
12 Child-Centered Family Therapy: Family Treatment as

Adjunct to Dissociation-Focused Interventions 205
13 Rewriting the Script: Processing Traumatic Memories and

Resolving Flashbacks 222
14 Countering Organized Abuse: Organized Attachment

and Love 254
15 Interfacing with Systems: The Therapist as Activist 284
16 Integration of Self: Towards a Healing Future 298
References 315
Appendices 339
Index 348
Tables
1.1 Symptoms of developmental trauma 13

1.2 Goals of therapy 19
3.1 Questions to guide the initial assessment of
a traumatized child 41
4.1 Five classes of symptoms related to dissociation 49
4.2 Imaginary friends in normal preschoolers compared
to dissociative inpatients 55
7.1 Ways to reframe a tormenting or self-destructive
inner voice 110
8.1 Clinician checklist for autobiographical amnesia 137
11.1 Clinician checklist for aggressive children and teens 202
12.1 Traumatic beliefs of families of traumatized children 217
13.1 Examples of traumatic thoughts with opposing thoughts 233
16.1 Insights from a group for dissociative girls 307
16.2 Healthy cognitions for child survivors 310
Figures
4.1 Six-year-old dissociative boy represents himself

with two heads 66
6.1 Picture of brain to depict effects of trauma to children 82
6.2 Baby bird hand puppet showing parts working together 84
6.3 Tina’s picture of voice of abuser in her mind 88
7.1 “Mr. Smiley” 98
7.2 Angela’s thank-you note to “Other Angela” 112
7.3 Monica’s thank-you note to “Black Monica” 113
7.4 Angela makes a deal with “Other Angela” 119
11.1 Deborah depicts feelings of grief 193
11.2 A feelings graph to help children depict the intensity
of various affects 194
13.1 Example of trauma picture created with virtual sandtray 228
13.2 Deborah depicts feelings of abandonment 229
13.3 Shantay draws herself as a neglected infant 230
13.4 Adina pastes mouth on picture to master feelings of
being silenced 236
13.5 Angela’s words for pain 239
13.6 The Cycle of Traumatic Attachment 242
13.7 Marcie’s empowerment letter 243
13.8 “Gooderator” that transforms Adina’s bad feelings about
her father 245
14.1 Symptoms in child victims of organized abuse in
the Israeli cohort 266
16.1 Tanya’s picture of staying together over day and night 299
16.2 The Cycle of Traumatic Demoralization 302
16.3 Letter from Timothy’s mother marking his progress 308
Acknowledgments
First, I would like to thank my family—Richard, Naomi, Shira, Dahlia,

Adam, Avi, and Drew—for their love, support, and patience. I would also
like to thank my mother, the late Edythe Samson, and my father, the late
Norman Samson, who cultivated in me compassion for the vulnerable and
pursuit of justice, which motivates my work with traumatized children.
I am indebted to the creative ideas and therapeutic skill of my col-
leagues in the Child Committee at the International Society for the Study
of Trauma and Dissociation. I am particularly grateful to Frances Waters for
her leadership in the field, collegial support, and case consultations over
the years. Our collaborations have enriched my thinking and my work.
Fran’s thoughtful attention to the initial draft inspired important innova-
tions such as the concept of transitional identities.
I have been lucky to have spent my career in a rich and diverse commu-
nity of mental health providers at the Sheppard Pratt Health System who
have provided a setting for these ideas to be nourished. Dr. Richard Loew-
enstein originally opened my eyes to the field of dissociation and Dr. Ste-
ven Sharfstein has always made the treatment of trauma-related disorders a
high priority. My colleagues locally and around the world have always been
supportive of my work and helped me refine ideas with stimulating discus-
sions and probing questions.
I also want to thank my colleagues at the Leadership Council on Child
Abuse & Interpersonal Violence who have served as a cushion of support
and a safe community in a world that is not always friendly to victims of
child abuse and their supporters, and my new colleagues at ChildUSA.
I was supported in the technical details of writing the first edition by
Elan Telem and editing help from Elizabeth Samson, and I am grateful for
xiv ACKNOWLEDGMENTS
their patience and attention to detail, which made editing this time around
more seamless. I am deeply grateful for the friendship, knowledge, edi-
torial skill, and scholarship of my cherished colleague Stephanie Dallam,
without whom this project would have been impossible.
I would like to thank the many brilliant trauma clinicians all over the
world who have invited me to teach and learn with them in Canada, Aus-
tralia, Sweden, Estonia, Finland, Norway, Scotland, England, Northern
Ireland, Germany, Spain, the Netherlands, New Zealand, and Israel. Your
commitment to children inspires me and gives me hope that as an interna-
tional community of professionals we are working together to improve the
plight of children around the world.
I am particularly indebted to my close colleagues in Israel and the sup-
portive group of clinicians who are committed as I am to treating severe
abuse.
Finally, I would like to thank the many clients and their families who
taught me so much and gave me permission to share their stories with you.
Preface
We are living in a different world than the one in 2013 when the first edition
of The Child Survivor was published. A global pandemic has caused wide-
spread death and chaos, as countries around the world have tried to battle
an unfamiliar virus, Covid-19, with scarce resources and poor preparation.
The current pandemic is superimposed over a much more ancient one—
that of child abuse. The Covid pandemic has exacerbated the effects of the
pandemic of child abuse, as many children have been trapped at home
in violent families without the respite of school and other outside activi-
ties. Like the anxious and suffering global population, children around
the world are also experiencing a pandemic of violence and vulnerability
to exploitative forces which they cannot control. The exploitation is often
invisible and ubiquitous—at the hands of parents, teachers, religious lead-
ers, coaches, etc.
During the Covid pandemic we have been saturated with information—
much of which is contradictory. Similarly, the awareness of how to deal
with our silent pandemic of child abuse and trauma is confused by contra-
dictory messages that waver between the polarities of concern and denial.
Traumatized children are trapped in cycles of enacting on themselves and
others the harm they have experienced. We need a trauma-informed soci-
ety aware of the ongoing harm that comes with the pandemic of global
child abuse.
In December of 2019, a novel coronavirus (Coronavirus Disease of 2019,
or Covid-19) was discovered in Wuhan China which is highly contagious,
causing severe respiratory disease and death, particularly among those with
preexisting infections. Covid-19 quickly made its way around the world,
leading to the infection of millions of people throughout countries in
xvi PREFACE
every inhabited continent, with over 500,000 deaths in the United States
and hundreds of thousands more predicted. Countries varied in their suc-
cess in coping with this global pandemic. Countries that had standardized
procedures based on epidemiological science involving testing, tracking
the infection, and isolation, such as South Korea, New Zealand, and Sin-
gapore, were the most effective in containing the virus. Countries with less
organized guidelines, such as the United States and Brazil, were less suc-
cessful in stemming the outbreak and reducing mortality.
In the beginning, myths about Covid-19 abounded. One myth was that
children and African-Americans were immune, when in fact children read-
ily spread the virus and people of color are at more risk due to preex-
isting conditions, close living quarters, and lack of access to health care.
In the United States, people were confused about whether wearing masks
was helpful, whether quarantine was necessary, and whether asymptomatic
people could spread the infection, as the leadership was not unified in
providing accurate public health messaging. Contradictory messages led to
public confusion and an increase in cases.
The global pandemic led to radical changes in people’s lives. Schools
were closed for months and many people lost their jobs. Parents able to
work from home were forced to do so while also attempting to care for
and provide schooling for their children. These conditions caused signifi-
cant family stress. Calls to domestic violence hotlines and abuse hotlines
increased dramatically, as outlets for safety were limited by the shutdown.
Children suffered increasing anxiety, depression, sleep disorders, and
regression (Canapari, 2020; Dana, 2020; Polizzi, Lynn, & Perry, 2020).
Therapy moved to electronic platforms, making it more difficult for thera-
pists to connect with their vulnerable clients. Whether for the best or not,
this new venue for offering therapy to traumatized children is here to stay,
and in this edition tips for providing teletherapy to children are covered.
Personal protective equipment was in short supply or ineffective, and
essential workers in food supply and health care put their lives on the line
as they were forced to balance ethical obligations to humanity with risk to
their own health and that of their family members. Balancing these huge
stresses brought a renewed sense of solidarity in some communities and
gratitude to essential workers. Applause at 7 pm nightly for the health care
workers of New York City became an empowering ritual for a traumatized,
but grateful, city. With testing limited, frightened and disrupted popula-
tions were left unsure of how widespread the infection was in their com-
munities. In November 2020 positivity rates among those tested reached
50% in parts of the United States. These levels were surprising and provide
further confirmation of how contagious this infection really is.
Similarly, epidemiological studies of abuse show that the prevalence
of sexual abuse in children in the general population is higher than the
PREFACE xvii
public expects. Child sexual abuse (CSA) is widespread globally. A 2009

review of 65 prevalence studies on child sexual abuse across 22 countries
found a prevalence of child sexual abuse of 19.7% of women and 7.9% of
men (Pereda, Guilerab, Fornsa, & Gómez-Benito, 2009). Most worrisome,
children with histories of sexual abuse also experience high rates of emo-
tional abuse, physical abuse, and child neglect (Pérez-Fuentes et al., 2013),
adding to their overall risk of psychiatric sequelae, including posttraumatic
and dissociative symptoms.
Given these numbers and the risk posed to children, calling child abuse
a pandemic is not an exaggeration. In addition, as with Covid-19, contra-
dictory information, some of it based on myths, impedes our ability to
directly address the problem. Some of these myths, like labeling outcries
of abuse in a community as “mass hysteria,” blaming abuse reports on chil-
dren being “suggestible,” or misconstruing abuse symptoms in children as
“alienation” from a parent, will be covered throughout this volume.
The problems facing children in our world are not limited to the rav-
ages of intrafamilial and institutional abuse and the global Covid-19 pan-
demic. Children continue to be victimized by war, poverty, hunger, and
being placed in migrant detention camps. Victimization breeds victimiza-
tion. Children lacking consistent adult protection have also become vul-
nerable to another growing crisis: the ubiquity of sex trafficking. Globally,
sex trafficking has grown rapidly due to the increasing demand for both
videos and photographs of children being abused. During the Covid-19
pandemic, this risk to children has increased exponentially. According to
Eurpol (2020, p. 2):
The area of cybercrime is one of the crime areas most affected by the
COVID-19 crisis. This includes online child sexual abuse. As both children
and offenders have been forced to stay home and spend more time on the
internet, the threat stemming from online child sexual abuse has increased.
Children can be abused and videos of the abuse can be sent through Inter-
net connections that leave no electronic trace, such as live-streaming. This
Internet exploitation of children occurs throughout the world wherever
children are left unprotected by ill-informed or neglectful adults (Handra-
han, 2017). Often posing as peers, perpetrators will entice children to
send compromising pictures and then extort them for years threatening to
expose what they have done as they coerce them into engaging in increas-
ingly horrifc acts. Some children have developed posttraumatic symptoms
simply from the vicarious viewing of the abuse of other children on the
Internet. Also, cybercrime rings have proliferated where participants share
images and videos of children in order to turn a proft and feed the pru-
rient interests of themselves and others. Some children are forced into
xviii PREFACE
sexual acts on demand while customers request specifc acts, and they are
live-streamed to customers.
The most serious form of this cybercrime is termed “hurtcore,” in which
participants try to outdo each other regarding the level of harm and tor-
ture they can inflict on younger and younger children—sometimes even
resulting in the child’s death (Daly, 2019; Maxim, Orlando, Skinner, &
Broadhurst, 2016). Because of my recent therapeutic work with children
traumatized by this type of crime, I have included an additional chapter
in this book (see Chapter 14), which covers the organized abuse of chil-
dren, many of whom were victimized during the production of child sexual
abuse imagery.
A positive change that has taken place since the first edition of this book
was published in 2013 is the “#MeToo” movement and the increased media
attention to abuse by men in positions of power. Sexual assault and child
abuse are crimes that society loves to disbelieve until imposed on their field
of vision, inducing momentary outrage and then conveniently forgotten
once again. The phrase “me too” developed into a movement following
its 2017 use as a hashtag following sexual assault allegations against power-
ful movie mogul Harvey Weinstein. With Mr. Weinstein’s conviction for
rape, we turned a corner in the prosecution of sex crimes against vulner-
able women, as his conviction was upheld despite the fact that some of his
victims acknowledged consensual relations with Weinstein after the crime
(Ransom, 2020). After a hung jury in the first trial, Bill Cosby was finally
found guilty in 2018 of drugging and raping a woman. More than 50 other
women reported similar assaults. Mr. Cosby’s case was the first high-profile
sexual assault trial to unfold in the aftermath of the #MeToo movement,
and many considered the verdict a watershed moment, as a popular and
beloved man was finally convicted (Bowley & Hurdle, 2018). Cosby’s con-
viction seemed to signal that, going forward, the accounts of female accus-
ers may be afforded greater weight and credibility by jurors.
In 2018, Larry Nassar, a widely respected physician in the gymnastics
community, was sentenced to 40 to 125 years in prison after pleading guilty
to seven counts of sexual assault of minors. Nearly 200 girls spoke out in
person or in statements about how Nassar’s sexual abuse changed their
lives (Levenson, 2018). We watched a brilliant psychologist, Dr. Christine
Ford, bravely testify on national television about an attempted rape when
she was a teenager. Many watched in disbelief as her alleged rapist was con-
firmed to serve on America’s Supreme Court (Reston, 2018). People were
shocked to hear of Jeffrey Epstein’s organized sex trafficking of girls while
socializing with some of the most elite and influential members of society
(Calleman, 2020). The #MeToo movement has given abused women and
children more credibility and freedom to speak their truth. However, in a
powerful tug of the pendulum in the other direction, Australian Cardinal
George Pell, the highest-ranking Catholic official to ever be charged and
PREFACE xix
convicted of sexual abuse, had his conviction overturned unanimously by

the Australia Supreme Court (Albeck-Ripka & Cave, 2020).
While we struggle with this push and pull of societal awareness and
denial, is it possible that small inklings of change are perceptible? As I
travel around the world meeting colleagues across the continents, I find
that the awareness of the sequelae of child abuse has become more com-
mon among the wide range of clinicians that I encounter. Dissociation in
children is now rarely scoffed at, and instead respectfully acknowledged
as a possible consequence of early complex trauma. The newest edition
of the APA Handbook of Trauma Psychology contains a chapter on childhood
dissociation (Silberg, 2017), as does the newest edition of the Handbook
of Developmental Psychopathology (Silberg, 2014). The burgeoning research
about early brain development and trauma (e.g., Teicher, 2019) has made
the global effects of early trauma more understandable to clinicians across
many specialties and levels of expertise. Several important books have con-
tributed to the advancement of the field of child dissociation—Healing the
Fractured Child by Frances Waters (2016), Treating Children with Dissociative
Disorders (Sinason & Marks, 2022), and The Way We Are (Putnam, 2016).
The increased availability of literature on how children respond to trauma
has made trainings on the topic of early childhood trauma and dissociation
more popular around the world.
Disappointingly, there is often reluctance among treatment facilities or
providers to incorporate this new awareness of dissociation into structured
treatment programs. An article in the New York Daily News on November 19,
2015 reported on a 12-year-old girl diagnosed by three psychiatrists with
Dissociative Identity Disorder, who was refused entrance by 16 different
treatment facilities (Salinger, 2015). As a result, the girl languished in a
juvenile detention center in Indiana, as all the child and adolescent mental
health services in the surrounding area felt ill-equipped to handle her case.
However, the expertise to handle even the most difficult cases of dissocia-
tive disorder in children exists, and it is certainly the time for our previ-
ously marginalized field of expertise to reach the mainstream. I hope this
book contributes to this reality—a day when young girls like her can readily
find programs equipped to accept and treat them.
I also hope those reading this second edition will find that the resil-
ient healing energy that dissociative children bring to their therapy once
again affirms their faith in humanity and the capacity for individuals to
change given the right healing environments. The global pandemic has
illustrated in dramatic ways our mutual interdependence and responsibil-
ity. Bolstered by this knowledge, perhaps our collaborative efforts as a com-
munity of healers will tip the fragile balance in our topsy-turvy world to
become one where love, healing, and recovery are “pandemic” rather than
exploitation and abuse.
Introduction
Traumatized children and the mental health systems designed to help them
often seem to be in a standoff, a virtual battle of wills. Traumatized children
often develop symptoms that resist medication and seem impervious to all
of the treatments we try to offer them. Logical consequences don’t seem
to matter, and they are often caught in what seem to be repeated cycles of
self-harm, provocation, and self-destruction.
Our classification systems are often hard-pressed to come up with the
right labels, and often these labels cast judgment on what appear to be
inevitable consequences of the hard lives they have lived. Those of you who
work regularly with children in our mental health systems will be familiar
with what I mean. Children from serial foster homes are often diagnosed
with attachment disorders. Yet, these children in their wisdom have not
risked attachment knowing that foster homes change as quickly as each
new approaching birthday. Is this an appropriate adaptation or a symptom
of a psychological disorder?
Children exposed to extreme abuse and trauma are often labeled “bipo-
lar,” as their moods seem contradictory and shifting. Yet, shifting moods
may be adaptive when a child’s environment can quickly shift between
being safe and unpredictably frightening and abusive. Some traumatized
children hear voices commanding them to fight back or voices consoling
them with comforting words. They are often labeled psychotic. Yet when
lacking consistent parental guidance and support, children adapt by pro-
viding themselves with the soothing or protection that they so desperately
need. The labels we give traumatized children often restrict our thinking
and prevent us from acknowledging the internal wisdom and logic of the
symptoms our clients have “chosen” as their only hope of survival in the
xxii INTRODUCTION
war zone of their haphazard and violent lives. For many chronically trau-
matized children, the symptoms learned in a lifetime of thwarted goals
remain their only comfort. These symptoms represent the tools they devel-
oped to navigate the unpredictable worlds of their childhood—tools that
they do not want to give up despite our interventions.
This book will focus on the young survivors of early trauma—sexual
abuse, physical abuse, neglect, abandonment, multiple placements—who
often rely on dissociative strategies to cope with the dilemmas in their
world. In this book, you will learn how to understand the symptoms of
the severely traumatized child or teen as adaptive mechanisms to help
them cope with the chaotic world that is their habitat. They use “automatic
programs” like rage, retreat, or regression that help them avoid authen-
tic emotional engagement. Often these children adapt to the conflicting
pulls of their hidden emotional world by attributing responsibility for their
behavior to internal characters that represent their contradictory feelings
and attitudes. They sometimes have amnesia for recent events, as they have
learned remembering the reality of their own behavior and that of others
may result in overwhelming anxiety that they are not able to soothe.
Understanding the child as an adaptive survivor provides the necessary
key for unlocking tools that promote healing. A simple solution emerges:
provide a world where remembering what happened, trusting your caregiv-
ers, distinguishing the past from the present, and regulating emotions is
adaptive. As a therapist, your own office becomes that new resource-rich
habitat, and with your guidance leaving their survival symptoms behind
becomes both possible and worthwhile. In this book, guided by the knowl-
edge of the child survivor’s resourcefulness and adaptive potential, we will
look at each of the many symptoms that severely traumatized and disso-
ciative children and teens may display. The techniques discussed promote
healing and encourage new ways to cope with the stresses of dissociative
children’s lives.
Balina, like many of the children you will meet in this book, displayed
significant dissociative symptoms when I met her at age 9. She went into
“shutdown” states from which she had difficulty being aroused, and her
behavior fluctuated from calm to rageful without apparent precipitants.
Her history of sexual abuse, multiple placements, and inconsistent caregiv-
ing was typical of the many children you will encounter in these pages. When
faced with difficult interpersonal and academic challenges, she would curl
into a fetal position under a desk in her classroom. When faced with rules
or directives that she felt limited her unfairly, she attacked in rage. Balina
accumulated diagnoses with each new placement—bipolar disorder, oppo-
sitional defiant disorder, and major depression with psychotic features. As
she moved through nine different foster homes, Balina learned to under-
stand her behaviors, not in terms of diagnoses, but as adaptations to life’s
INTRODUCTION xxiii
circumstances. Her changing moods were understood as reactions to rap-

idly changing circumstances. Oppositional behavior could be seen as her
way of mastering the helplessness induced by her traumatic circumstances.
Dissociative retreat could be understood as necessary escape from unten-
able demands. With therapy she learned that her reactions did not make
her “sick” but rather a “survivor.” The problems she encountered were solv-
able and her own strengths, learned in an environment of struggle, could
help her navigate the ups and downs of her life.
At 18, as a college-bound high-school graduate, Balina was asked by her
foster care worker to speak at a conference for social workers as a “success”
of the foster care system. Balina’s oppositionality, now an expression of her
renewed self-confidence, kicked in. She refused. “I won’t be your poster
child,” she said. “I did well despite what you did to me.” She never accepted
the implicit message of her foster care placements that she should be
“grateful” she had a home at all. Her therapy helped her internalize the
message that she deserved safety, love, and a promising future, as did the
other children she had encountered going through similar struggles. Her
therapy helped her understand her dissociation as a helpful survival tool,
not a symptom of severe dysfunction.
In this book you will meet children and teens like Balina and follow their
course of treatment. You will meet Adina, a survivor of incest, who works
through her dissociation and her complex attachment to a parent abuser.
You will become acquainted with Timothy, filled with rage and uncon-
trolled aggression, who perceived any parental limit as abusive after a child-
hood of physical abuse by a grandparent. You will get to know Jennifer, a
survivor of domestic violence and peer sexual victimization, whose func-
tioning is compromised by repeated shutdown states, and Angela, whose
undiagnosed abdominal pain led her to develop an alternate sense of self
to handle chronic pain. Through these case studies and others, you will see
how children and teens compromised by disabling dissociative symptoms
can blossom into young people free to pursue their own life choices.
Dissociation, a well-described clinical phenomenon among adults, has
only started to gain attention in the clinical and research literature in the
last several decades. Dissociation presents in traumatized children as dazed
states, confusion in identity, voices, or apparent “imaginary friends” that
influence behavior, along with a variety of dysregulations in behavior, mood,
cognitions, somatic experiences, and relationships. Initially described in
contemporary literature by Kluft (1984) and Fagan and McMahon (1984),
dissociation in children and adolescents has been increasingly documented
by a variety of researchers and clinicians who have found that dissociative
symptoms are often associated with histories of significant trauma (e.g.,
Bonanno, Noll, Putnam, O’Neill, & Trickett, 2003; Collin-Vézina & Hébert,
2005; Hulette, Fisher, Kim, Ganger, & Landsverk, 2008; Hulette, Freyd, &
xxiv INTRODUCTION
Fisher, 2011; Macfie, Cicchetti, & Toth, 2001; Putnam, Hornstein, & Peter-
son, 1996; Sar et al., 2014; Teicher, Samson, Polcari, & McGreenery, 2006;
Trickett, Noll, & Putnam, 2011; Waters, 2016).
The experience of clinicians around the world suggests that many dis-
sociative children are not responsive to the standard trauma treatments
currently available (Waters, 2016; Wieland, 2015). Memory problems can
make it difficult for conventional forms of therapy to be effective, and
some of the most severe dissociative symptoms, like profound dissociative
“shutdown,” may be misdiagnosed as neurological symptoms. Dissociative
children present unique treatment challenges as the intensity of their act-
ing out and destructive behaviors are difficult to handle in outpatient and
even inpatient settings (Hornstein & Tyson, 1991; Ratnamohan et al., 2018;
Ruths, Silberg, Dell, & Jenkins, 2002).
There is emerging evidence that dissociation is indeed a predictor of
clinical severity in child and adolescent populations. In a study of children
entering the child welfare system, the presence of significant dissociation
was a key predictor of psychiatric hospitalization; and significant dissocia-
tion was the symptom that predicted the most rapid need for hospitaliza-
tion for children in care (Kisiel, Torgersen, & McClelland, 2020). When
successful treatment is offered, the interruption of the development of
adult Dissociative Identity Disorder (DID) will not only prevent a potential
lifetime of severe pathology, but may have significant economic benefit to
society as well. Studies show that the longer a client receives dissociation-
specific treatment, the lower the ultimate cost utilization for both outpa-
tient and inpatient services (Langeland et al., 2020; Myrick, Webermann,
Langeland, Putnam, & Brand, 2017). How much more cost savings would
be realized if children were treated in a more timely fashion?
This book describes a set of therapeutic interventions called Dissocia-
tion-Focused Interventions (DFI) (see Appendix A). Dissociation-Focused
Interventions uniquely address the needs of children and adolescents
who have dissociative symptoms that are resistant to more conventional
approaches to treatment. The approach described in this book can be used
alone or in combination with many other new and developing practices
that have shown promise in remediation of the symptoms of traumatized
children (Arvidson et al., 2011; Blaustein & Kinniburgh, 2010; Busch &
Lieberman, 2007; Cohen, Mannario, & Deblinger, 2006; Ford & Cloitre,
2009; Gomez, 2012; Perry, 2009; Struik, 2014).
Although more research is needed which focuses specifically on chil-
dren, there is reason to believe that, when properly utilized, treatment of
dissociation in children can be efficacious. In 1998, my colleague Frances
Waters and I presented preliminary results of our treatment of 34 disso-
ciative clients and found moderate to major improvement for clients who
stayed in treatment and who had consistent parental support (Silberg &
Waters, 1998). The positive outcomes possible with techniques focused
INTRODUCTION xxv
specifically on dissociation has been confirmed by the work of a group of

international clinicians who participate in the child committee of the Inter-
national Society for the Study of Trauma and Dissociation (ISSTD; Baita,
2015; Grimminck, 2013; Marks, 2015; Silberg, 2015; Waters, 2015; 2016;
Wieland, 2015; Yehuda, 2015). A set of guidelines for treatment of dissocia-
tive symptoms and disorders in children and adolescents has been devel-
oped by the ISSTD (2003). These guidelines are currently being updated.
A consensus model for the treatment of adults with dissociation has
demonstrated that when patients with dissociative disorders are treated by
trained clinicians, those in treatment for 30 months showed a significant
reduction in dissociation, posttraumatic stress disorder (PTSD) symptoms,
hospitalizations and disabling symptoms, along with an overall increase in
adaptive behaviors and feelings of well-being (Brand et al., 2012). Using
a new therapeutic measure, a study of 177 therapist–client dyads dem-
onstrated that adult dissociative clients in treatment achieved improve-
ment in positive emotions, social relations, refraining from self-harm, and
reduction of dangerous behaviors (Schielke, Brand, & Marsic, 2017). This
groundbreaking research showed that 111 patients in the early stages of
treatment responded to a web-based program that focused on stabilization,
resulting in significant decreases in self-harm, affect regulation impair-
ments, and increases in adaptive capacities (Brand et al., 2019). The 29
younger patients (ages 18–30) in the sample made even more progress
relative to those who were over the age of 30 (Myrick et al., 2012). Consis-
tent with this research finding, my clinical observations confirm that the
younger the client, the easier it becomes to achieve significant remedia-
tion of dissociation. Developmentally informed interventions geared to the
unique symptomatology of this population may have the potential to pre-
vent the severe and disabling effects of early trauma across the life span.
The approach in this book is not focused specifically on DID, as disso-
ciative features found in children may be in a preliminary form that does
not meet adult DSM-5 criteria. DSM-5 criteria require that “Two or more
distinct identities or personality states are present, each with its own rela-
tively enduring pattern of perceiving, relating to and thinking about the
environment and self” (American Psychiatric Association, 2013, p. 292).
Instead, the manifestations of dissociation found in children range across
a continuum of severity and the differing states the child may present do
not always include an “enduring pattern,” as they may shift, and in some
ways resemble normal developmental processes, such as the phenomenon
of vivid imaginary friends in young children. All or nothing labels which
view the client as having a rigid disorder are less helpful than a view of dis-
sociative phenomena as existing on a continuum of severity.
Adult models that present a normalizing view of dissociation have been
particularly influential in the development of this approach (see, e.g., Chu,
1998; Gold, 2000; Rivera, 1996). Also influential to the theoretical basis of
xxvi INTRODUCTION
this approach are treatment models based on affect theory (Kluft, 2007;
Monsen & Monsen, 1999; Nathanson, 1992; Tomkins, 1962; 1963), mod-
els that stress attachment disruption (Hughes, 2006; James, 1994; Kagan,
2004), and models focusing on a relational approach to clients exposed to
early trauma (Pearlman & Courtois, 2005). The work of clinicians who are
part of the Child Committee of the International Society for the Study of
Dissociation has also played an important role in the development of the
ideas and concepts presented here (see e.g., Baita, 2020; Sinason & Marks,
in press; Waters, 2016; Wieland, 2015).
The acronym EDUCATE organizes a sequence of steps of Dissociation-
Focused Intervention. These steps begin with psychoeducation about
trauma and dissociation (E: Education), and assessing the child’s motiva-
tions to hold on to their dissociation (D: Dissociation motivation). The
next group of interventions assists the child in understanding (U) what is
hidden and claiming (C) the hidden parts of the self. The A in EDUCATE
stands for regulation of arousal, affect, and attachment. The techniques
covered under the “A” include managing hyperarousal, hypoarousal, and
regulating affect in the context of attachment relationships. Traumatic
processing and understanding triggers are the “T” in the EDUCATE
model. Processing traumatic events involves attending to the content of
early trauma, its sensory and affective associations, and its meaning to the
child. The final E of the EDUCATE model represents the ending stage
of therapy and provides techniques to help the child survivor face new
developmental challenges, while fully accepting the self and the meaning
of their traumatic history. As an integrated self, the true survivor learns to
leave the past in the past and comes to appreciate who they are despite
where they have come from.
People in other fields often ask me if it doesn’t sometimes become
depressing, working with children who have been so badly hurt and
abused. “No,” I answer, “It is exhilarating, discovering anew the amazing
resiliency and potential of each new client.” I hope you will find the same
exhilaration as you apply some of these techniques to the children on your
caseload, and admire the strength and adaptive potential of the children
you will meet in these pages, and the children you will treat. Through your
treatment of each individual child, you have the potential to reverse cycles
of abuse and help create for the next generation the safe, tolerant, loving
world that all of our young clients deserve.
Chapter 1
Trauma and Its Effects
“It’s like you’re on autopilot and someone else is controlling the switches,”
stated Shawn Hornbeck, kidnap victim and sexual abuse survivor. With these
words, he explained the dissociation, helplessness and terror that kept him
tied to his kidnapper for over four years until his rescue by the FBI in 2007
outside of St. Louis—only 50 miles from his home (Dodd, 2009). When
interviewed later about his trauma, Shawn stated, “Most people would say
their greatest fear is probably dying, but that’s not mine. I would have to say
my greatest fear is probably not being understood” (Keen, 2008).
At age 11, Shawn was abducted from his neighborhood and forced to
live with a sex offender, who enrolled him in school, gave him a pseud-
onym, and enforced his enslavement with threats and rewards for compli-
ance. Shawn felt his healing from the trauma of his abuse and captivity was
directly tied to people understanding the helplessness and terror that kept
him trapped with his abuser, enduring repeated trauma and humiliation.
Like Shawn Hornbeck, the children in this book have felt the helpless-
ness and terror of their plight, felt like they have been on “auto-pilot”
and that their behaviors are misunderstood even by well-meaning people.
However, unlike Shawn’s trauma, their stories have captured no headlines.
They have endured their trauma in isolation, but yearn to be understood
with the hope that healing can follow from this understanding.
Trauma has been defined as events that are outside of the individual’s
normal expected life experiences and are perceived as a threat to “life,
bodily integrity” or “sanity” (Pearlman & Saakvitne, 1995, p. 60). The indi-
vidual faced with trauma feels at that moment, or multiple moments in
time, that they will not be able to survive. This experience of intense pow-
erlessness is a hallmark of trauma. Martha Stout (2001) explained, “These
2 TRAUMA AND ITS EFFECTS
events open up a corridor of essential helplessness and the possibility of

death” (p. 53).
These feelings of being overwhelmed and pushed beyond the limits of
one’s capacity to cope can be mitigated when the experience is shared with
others. Traumatic experiences endured in isolation and secrecy, which is
often the case for the traumatic experiences of the children and teens you
will meet in this book, are some of the hardest experiences to overcome.
Protecting the secret, as well as enduring the multiple effects of these expe-
riences, causes children’s internal resources to become overtaxed, leaving
fewer resources for the difficult work of healing.
As research about the effects of childhood trauma has proliferated, the
field has made an important distinction between the traumatic results of
single incident events (Type I) and long-term chronic trauma (Type II)
whose onset is during early development (Terr, 1994). Herman (1992)
used the term “complex trauma” to refer to early onset, relational trauma
that leaves enduring effects on the traumatized person’s basic capacities.
Herman identified six key areas of functioning that are impacted by early
trauma, including alterations in affect regulation, consciousness, self-per-
ception, view of the perpetrator, relationships, and systems of meaning.
Later researchers and clinicians describing both adults and children have
continued to refer to long-term early chronic relational trauma as complex
trauma.
One source of information we have about the prevalence of trauma
comes from the Adverse Childhood Events (ACE) study. Felitti et al. (1998)
studied thousands of patients through the Kaiser Permanente Health sys-
tem and determined that 60% of the adult population had experienced
at least one “Adverse Traumatic Event,” including neglect, physical abuse,
emotional abuse, sexual abuse, observing violence, or having parents with
histories of mental illness or drug abuse. Most importantly, the number
of the traumatic events experienced correlated with a variety of negative
health outcomes showing that exposure to trauma has long-term and seri-
ous implications for individual health.
SOCIETAL DENIAL
The prevalence of multiple forms of trauma in the life of children has

been confirmed by the ongoing data collected from the National Child
Traumatic Stress Network database. The over 14,000 children referred for
services through this national network endured an average of 4.7 different
types of trauma—including physical abuse, sexual abuse, emotional abuse,
neglect, exposure to domestic violence, illnesses, losses or exposure to nat-
ural disaster, violent assaults, or community violence (Kisiel et al., 2011).
TRAUMA AND ITS EFFECTS 3
Despite emerging knowledge of how widespread childhood trauma is in

our society, the children we meet in our practices often come to us having
internalized society’s message of denial. Their demoralization and disbe-
lief in the possibility of change often is rooted in the fact that their disclo-
sures were not believed or, like Shawn Hornbeck, they may feel blamed
for their apparent “complicity.” Often, the crimes committed against them
were never prosecuted and important adults in their life failed to appre-
ciate the harm they suffered. Discomfort with trauma can lead adults to
quickly change the topic, ask doubting or minimizing questions, or chal-
lenge children about why they did not tell sooner.
Traumatized children are hyper-alert to any messages which appear to
minimize or discount their experiences, and they will often angrily reject
and then tune out any adults who they suspect don’t understand their suf-
fering. Twelve-year-old Deborah, adopted from a Romanian orphanage at
age 3, told me with disdain that her previous therapist had called her “a
liar” when she discussed her memories of the orphanage. Upon inquiry,
the therapist stated that she had responded to Deborah’s horrific mem-
ories by saying, “You were so young, are you sure you are remembering
it right?” This seemingly mild but questioning response made it impos-
sible for Deborah to trust her therapist. Children who encounter skeptical
police officers, defense attorneys or department of social service workers
often emerge from these interviews feeling re-traumatized by the doubt-
ing response they encounter. While most avoidance or denial of children’s
traumatic experiences is inadvertent, sometimes adults have a vested pro-
fessional, legal, or monetary interest, in refuting or disputing known trau-
matic events.
Unfortunately, there is a fervent backlash that seeks to deny or minimize
the effects of trauma and sexual abuse. This denial appears to serve pow-
erful vested interests, including defense attorneys and their defendants,
as well as the organized pedophile movement, which tries to justify the
abuse of children by “minor-attracted” individuals (the “neutral” term they
prefer). In 1998, Rind, Bauserman and Tromovitch published an article
in which they claimed to find that the sexual abuse of boys, which they
re-termed “adult-child sex,” was not harmful. My colleagues and I discov-
ered that the article was riddled with scientific reasoning errors and blatant
misrepresentations of data (Dallam et al., 2001). The Rind et al. article
was quickly touted by pedophiles as vindication for their lifestyle and cited
in their writings to justify their sexual exploitation of children under the
guise of an alternate lifestyle (Dallam, 2002).
Similar patterns of misrepresentation have been found in the writings
on suggestibility of children based on sex abuse cases in daycare centers in
the 1980s. Many of the convictions in these cases were overturned, and it
was widely believed that suggestive interviewing of children had led to false
allegations and mass hysteria. Yet, a careful analysis of actual case records
revealed that claims of police and clinician misconduct were often misre-
ported or exaggerated. Ross Cheit (2014) found the key that unravels this
scandal of misinformation that led to a backlash against believing young
children who report abuse.
The State v. Michaels trial against defendant Kelly Michaels, charged with
abusing children in the Wee Care daycare center in New Jersey, was a turn-
ing point. In 1993, the New Jersey Appellate Division overturned the con-
victions and established the requirement for “taint hearings” to evaluate
whether children’s claims are free of suggestive bias. However, a closer look
at the evidence reveals “a smoking gun.” The researchers who filed a friend
of the court brief for the defendant included in their brief interview tran-
scripts that had been edited in such a way that they misrepresented inter-
views with the children. By deleting children’s disclosures while including
interviewers’ questions after these disclosures, the edited transcripts gave
the erroneous appearance that suggestive interviewing techniques were
being used. The overall impression from these edited transcripts was that
the interviewer was leading the child and suggesting the answers. This brief
was very impactful in changing the discourse about childhood abuse, lead-
ing to the widespread misassumption that glaring errors in interviewing
were the basis of convictions against daycare providers nationally.
This strong bias against believing children became codified in profes-
sional literature such as Ceci and Bruck’s (1995) Jeopardy in the Courtroom
which based many of its conclusions about children’s suggestibility on
these mis-transcriptions of key interviews. One could conclude that a whole
science of “suggestibility” and the subsequent requirement in New Jersey of
taint hearings to determine if children’s testimony was suggested is based,
in part, on these misleading transcripts. These hearings have made it much
more difficult to prosecute child abuse. It is my hope that, in time, the
significance of this error will be exposed and some of these legal require-
ments re-examined.
While loud and often slickly packaged as if scientific, denials of the prev-
alence or the harm of abuse and trauma ring hollow, as increasingly per-
suasive research data document long-term health outcomes, psychological
co-morbidity, and even brain impairment as a measurable effect of a variety
of traumatic events.
PSYCHOLOGICAL EFFECTS OF MALTREATMENT
In a meta-analysis of 65 studies, a robust relationship was found between

childhood maltreatment and neglect and dissociation in adults (Vonderlin
et al., 2018).
Higher dissociation scores in adults were predicted by the earlier age

of onset of the abuse, longer duration of the abuse, and the parent as
abuser. This is a powerful finding of the long-lasting effects of maltreat-
ment through the life span. Each form of child maltreatment contributes
significant risk to vulnerable children, to overall psychopathology, and to
dissociation in particular.
Sexual Abuse
A systematic review by Moody, Cannings-John, Hood, Kemp, and Robling

(2018) found that in North America approximately 20.4% (13.2–33.6%) of
girls, and 6.5% (4.0–16.0%) of boys are victims of child sexual abuse. Sex-
ual abuse is found in all socioeconomic levels and cultures and over 90%
is perpetrated by someone the child or child’s family knows (Finkelhor &
Shattuck, 2012). Research suggests that sexual abuse, particularly when it
is more invasive, is associated with a variety of psychiatric sequelae such as
sexualized behavior and sexual risk-taking, depression, eating disorders,
self-harm, drug and alcohol abuse, and significant risks of subsequent re-
victimization (Putnam, 2003; Trickett, Noll, & Putnam, 2011).
Finkelhor and Browne (1985) theorize that the harm of sexual abuse
may relate to the stigmatizing effects of the experience, the experience of
powerlessness, and the boundary violations associated with sexual abuse.
It is difficult to develop a sense of self-worth and autonomy when one’s
experience of one’s body is as an object of another’s pleasure. Compound-
ing these effects are the psychological experiences of the child survivor as
they internalize and react to the messages of the perpetrator. Self-justifying
rationalizations are typical of the sexual offender (Courtois, 2010), such as
“This is an expression of love,” “You made me do this to you,” or “This is
what you deserve.”
When these rationalizations are expressed by a parent or close family
member, it becomes hard for child survivors to extricate themselves from
these beliefs as their attachment to the family member would be jeopar-
dized. If even Shawn Hornbeck, who was abused by a stranger, felt this
loyalty and fear of escape, imagine the bind felt by children abused by their
own parents.
Trickett et al. (2011) followed 84 sexually abused girls for 23 years and
found significant physiological sequelae of sexual abuse, including obesity,
gynecological abnormalities, including early onset of puberty, major ill-
nesses, increased health care utilization, cognitive deficits, abnormal levels
of the stress hormone cortisol, and disruption of the hypothalamic-pituitary-
adrenal axis. Of significant concern, the children born to abused girls were
also at risk, with more referrals to child protective services, primarily for
neglect. In addition, sexually abused children are at risk for further sexual
victimization and when victimized suffer more severe consequences (Bri-
ere, Runtz, Rassart, & Godbout, 2020). Research on sexually abused chil-
dren and teens documents high levels of dissociation in this population
(Bonanno, Noll, Putnam, O’Neill, & Trickett, 2003; Collin-Vézina & Hébert,
2005; Hagan, Gentry, Ippen, & Lieberman, 2017; Macfie, Cicchetti, & Toth,
2001) with dissociative symptoms related to early onset of sexual abuse, multi-
ple perpetrators (Trickett et al., 2011), and duration of sexual abuse (Hébert
et al., 2017). Dissociative symptoms are also associated with risk-taking behav-
ior (Kisiel & Lyons, 2001), self-harm (Hoyos et al., 2019), affect dysregulation,
and disorganized attachment (Hébert, Langevin & Charest, 2020).
A new form of sexual exploitation that therapists are just beginning to
see in their practices is children abused for the purpose of creating child
sexual abuse imagery (CSAI). This term has been used to replace the older
term “child pornography” which people often understood as simply nude or
suggestive pictures of children. The added experience of having been vic-
timized “digitally” significantly adds to the victims’ posttraumatic stress and
negatively impacts their quality of life and subjective well-being (Hamby et al.,
2018). These digital images often portray scenes of horrific sexual and physi-
cal torture. The trend has been toward portraying younger and younger chil-
dren and subjecting them to the most horrific acts imaginable. In a survey by
Gewirtz-Meydana, Walsh, Wolak, and Finkelhor (2018), 22% of victims whose
images were found online reported their abuse began at age 2 or younger.
The most severe form of child sexual abuse imagery exploitation has been
termed “hurtcore” (Maxim, Orlando, Skinner, & Broadhurst, 2016; Daly,
2019). Arrests in Australia reveal that networks of perpetrators interested
in these materials may establish communities in which they trade images
and promote the trafficking of live children often exploiting them through
streaming sexual torture scenarios in real time. These children suffer with
the awareness that depictions of their abuse remain on the Internet in per-
petuity and their suffering is enjoyed by others. These survivors are dealing
with unique issues as they are often plagued by guilt that their images may
be used to induce others into sexual exploitation, and the forced smiles cap-
tured in still or moving images make them feel a sense of ongoing complic-
ity with the crimes (Gewirtz-Meydana et al., 2018; Leonard, 2010). The fact
that their abusers are, for the most part, anonymous and nameless makes it
hard to deal with specific episodes of exploitation in therapy. In addition,
these survivors may become increasingly inhibited with computers becom-
ing triggers for overwhelming anxiety (Leonard, 2010).
This new area of child exploitation created the provocative legal ques-
tion of whether each new viewer of a child’s images owes restitution to that
individual victim as a potential cause of the victim’s suffering. The Supreme
Court in US v. Paroline (572 US__2014) was asked to consider whether a
“perpetrator” who viewed her image long after Amy’s sexual abuse as a
child and who never met the real Amy could still be a cause of her harm
and owe her restitution. The Supreme Court has answered affirmatively
and determined that each viewer owes the survivor monetary compensa-
tion as if they “virtually” participated in the original crime. Justice Kennedy
wrote:
The cause of the victims’ general losses is the trade of her images and Paro-
line is a part of that cause for he is one of those who viewed her images. While
it is not possible to identify a discrete readily definable incremental loss he
caused, it is indisputable that he was a part of the overall phenomenon that
caused her general losses.
The federal government solved the question of a dollar amount to quantify

the restitution owed victims of child sexual abuse imagery exploitation in
the Amy, Vicky, and Andy Child Pornography Victim Assistance Act of 2018.
According to this law, the offender who traded or watched the CSAI must pay
at least $3,000, or the victim can receive $35,000 from a Crime Victim Fund.
For victims of CSAI, these important legal decisions can never undo the
harm they have suffered. Amy writes in her victim impact statement: “I am
there forever in pictures that people are using to do sick things. I want it all
erased. … But I am powerless to stop it just like I was powerless to stop my
uncle. … How can I get over this when the shameful abuse I suffered is out
there forever and being enjoyed by sick people?” (Amy, 2009).
For children like Amy, whose images have been traded online, dis-
sociative disorders and dissociation symptoms are a frequent outcome
(Canadian Centre for Child Protection, 2017). CSAI often contains other
elements associated with dissociative symptoms such as early onset of sex-
ual abuse and multiple perpetrators (Trickett et al., 2011).
As Amy (2009) writes, “Sometimes I just go into staring spells when I am
caught thinking about what happened and not paying any attention to my
surroundings. … Forgetting is the thing I do best since I was forced as a
little girl to live a double life and ‘forget’ what was happening to me.” Like
Amy, survivors often vividly describe their experiences of dissociation—“I
floated to the ceiling and watched myself from above,” or “I split into two
people, and let the other me feel the pain.”
Many of the children you will meet in these pages developed dissociative
coping tools to handle the trauma of sexual abuse. Sexual abuse experi-
ences, because of their invasiveness, the associated arousal that induces an
unfamiliar physiological state, and their association with the betrayal from
attachment figures (Freyd, 1996), may readily trigger dissociative coping
strategies. In Chapter 14 of this book, I present a more detailed look at
some effective treatment strategies for children whose abuse included ele-
ments of exploitation through CSAI.
Physical Abuse
Physical abuse may affect as much as 23% of children and, like sexual
abuse, has broad-ranging implications for later adjustment (Kolko, 2002).
In addition to the physical effects of early physical injury such as scarring, or
feeding problems, the physically abused child is likely to suffer a variety of
cognitive and emotional consequences as well. Physically abused children
have been found to have academic and attentional problems, with lower
scores in both reading and math and higher risk of repeating an academic
grade (Kolko, 2002). Physically abused children may also have significant
problems with anger, and are two times more likely than their peers to be
arrested for violent crimes when they reach adolescence (Widom, 1989).
In addition to problems with aggression and anti-social behavior, physically
abused children have higher levels of depression, anxiety, and suicidal ide-
ation and suicide attempts (Silverman, Reinherz, & Giaconia, 1996).
There appears to be a particularly robust relationship between a history
of physical abuse and dissociation (Hulette, Freyd, & Fisher, 2011; Macfie
et al., 2001). The children I have worked with who have been victims of
physical abuse describe learning how to disconnect their experience of the
physical sensation of pain, and this dulling in their sensory experiences
often generalizes to other physical sensations as well. Boys who have been
physically abused often struggle to control aggressive reactions to even
minor provocations and may seem to turn these aggressive responses “on”
and “off” dramatically, to the consternation and confusion of those around
them. The realization that someone chose to hurt them consciously often
becomes a prominent theme that must be addressed in their treatment.
Relationships tend to be fraught with suspicion and hypervigilance about
potential harm, and this may affect the development of intimate relation-
ships as these children grow older. Research suggests that when sexual
abuse is associated with physical abuse, the long-term effects on later adjust-
ment are more severe (Fergussen, Boden, & Horwood, 2008).
Neglect
Of the 3.3 million reports of child abuse that came into child services in the
United States in 2010, 78% were for suspected neglect (U.S. Department of
Health and Human Services, 2011). These numbers likely underestimate
the actual incidence of neglect, which is often unreported and affects a
high percentage of infants and young children.
Neglect has profound long-term implications for development, with
neglected children having difficulties with cognitive development and
early language skills, insecure attachment, peer difficulties, problems with
modulation of emotional arousal, negative self-perceptions, early signs of
depression, lack of enthusiasm, and low frustration tolerance (Erickson &

Egeland, 2002; Hildyard & Wolfe, 2002). Emotionally neglected children
tend to have difficulties with peer relationships with low levels of popu-
larity, a variety of school problems, and high incidence of later psychiat-
ric problems, including suicide risk and delinquency (Hildyard & Wolfe,
2002). Neglectful caregiving is also associated with high levels of dissocia-
tion in children. Longitudinal follow-up studies have measured significant
dissociation in children of parents who are psychologically insensitive and
avoidant (Lyons-Ruth, 2020; Dutra, Bureau, Holmes, Lyubchik, & Lyons-
Ruth, 2009), neglectful (Ogawa, Sroufe, Weinfield, Carlson, & Egeland,
1997) or punitive (Kim, Trickett, & Putnam, 2010).
The clinician may find a child who has been a victim of early neglect to
relate to the therapist in odd ways, sometimes acting overly friendly and
solicitous, while at other times acting distant and avoidant. The relational
components of therapy become particularly significant when working with
children who have been victimized by early neglect.
Emotional Abuse
Emotional abuse is receiving increasing attention as negatively impacting

brain development and predisposing young people to dissociative symp-
toms. Emotional abuse generally encompasses name-calling, isolation from
social contact, intimidation, humiliation, and even corruption of basic val-
ues. Research suggests that the results of emotional abuse can be equal to
that of neglect and physical abuse, so its impact should not be minimized
(Vachon, Krueger, Rogosch, & Cicchetti, 2015). Teicher, Samson, Polcari,
and McGreenery (2006) found that emotional abuse alone, even from
peers, can lead to long-term damage of the corpus callosum.
Teicher, Samson, Sheu, Polcari, & McGreenery (2010) found that sub-
stantial exposure to peer verbal abuse was associated with an over ten-
fold increase in dissociation with a greater effect in females compared
to males. Gušić, Cardeña, Bengtsson, and Søndergaard (2016) found
that emotional abuse alone was predictive of dissociative symptoms,
particularly in teenage girls. In the case of severe dissociative symptoms
in young people, the nature of the emotional abuse is often intensely
cruel, including verbal abuse suggesting the child should never have
been born, the child being blamed for family problems, and the child
receiving punishment with no relation to the severity of the perceived
transgression. Children and teens report parents screaming they don’t
deserve life, they should have been aborted, and they do not deserve
basic human comforts or rights. This type of verbal abuse often leads
young people to see themselves as damaged to the core and undeserving
of goodness in their life.
Witnessing Domestic or Community Violence
In the United States, approximately 15.5 million children live in households

experiencing intimate partner violence (McDonald, Jouriles, Ramisetty-
Mikler, Caetano, & Green, 2006). Children’s exposure to violence in the
home, whether or not they were the direct victims of this violence, has been
shown to predict a variety of subsequent mental health problems, includ-
ing posttraumatic stress, aggression, and negative affect (Kitzman, Gaylord,
Holt & Kenny, 2003). The higher the level of violence between parents that
is observed by the child, the worse the child’s outcome.
Many of the children described in this book were exposed to domestic
violence in their homes. The unpredictable nature of sudden eruptions of
violence in their homes has led many of these children to be hypervigilant
and reactive to raised voices and angry faces, fearing that these might sig-
nal a sudden escalation in danger to themselves or their loved ones.
Children around the world are exposed to violence from war as well.
Several studies have documented profound dissociative experiences in
children who have been victims of war trauma (Cagiada, Camaido, &
Pennan, 1997; Gušić, Malešević, Cardeña, Bengtsson, & Søndergaard,
2018). These wartime reactions may involve profound states of near
comatose shutdown that can last years. A new phenomenon described
in the literature has been called “Resignation Syndrome,” seen in child-
hood war refugees (Sallin et al., 2016), with children showing profound
shutdown and food refusal, which is likely a manifestation of dissociative
processes.
Covid-19
The global pandemic that began in March of 2020 left an underlying layer
of turmoil that has exacerbated and compounded the ubiquitous trauma
in children’s lives. The rates of child abuse, domestic violence, and com-
munity violence went up during this troubling time (Faller, 2020). The
isolation of children from teachers, the most common reporters to child
protective services, has removed the protective eyes of adults concerned
about children’s welfare. The stresses of unemployed parents, confined in
close quarters with their children, or parents working from home trying
to manage their children, adds significant risk factors for the possibility
of child maltreatment. Initial research shows that child maltreatment is
increasing and that children brought to emergency rooms during the pan-
demic have injuries that are more life-threatening (Faller, 2020). Since the
pandemic, an increasing number of children are also coming to emergency
rooms with psychiatric symptomatology (Leeb et al., 2020).
Fear of the virus itself leaves children feeling vulnerable, anxious, and
fearful for their lives and the lives of their family members. Disruption of
school and friendships during stay-at-home orders leaves children feeling
disconnected. Symptoms in children during this troubling time include
depression, anxiety, sleep disorders, and regression (Canapari, 2020; Dana,
2020; Polizzi, Lynn, & Perry, 2020). The need to wear masks often makes
children feel that they cannot breathe, and that they have difficulty read-
ing facial expressions from adults who interact with them with masks.
Reprimands from parents for approaching strangers, friends or even fam-
ily members becomes confusing for children’s sense of basic trust, even
though these reprimands stem from the desire for safety for the children
and others. Electronic schooling can lead to feelings of depression and
alienation, and physical symptoms of headaches. Therapy using electronic
means is helpful for some children, but for others this medium is too dif-
ficult for them to maintain focus, and thus families are left with little sup-
port from mental health professionals they may have previously relied on.
Time spent online also increases the risk for online exploitation. Surveys
show that parenting has taken a step backwards during the pandemic, as
parents are more prone to losing their temper and using physical punish-
ment (Lee & Ward, 2020).
It will take years before we understand the full impact of all of these
stresses on children, but the impact of Covid-19 should not be minimized
as we examine global effects of trauma on children. It provides an under-
lying source of risk to children, particularly those most at risk for child
maltreatment.
While each of the forms of early trauma has known consequences, it
is the repeated exposure to multiple forms of trauma for children that
produce the most severe and long-lasting consequences. Some evidence
suggests that multiple kinds of trauma are associated with the highest levels
of dissociation (Hulette, Fisher, Kim, Granger, & Landsverk, 2008; Hulette
et al., 2011; Teicher et al., 2006). Other types of trauma such as early aban-
donment, death of parents, painful medical procedures, and exposure to
natural disaster may also lead to long-term consequences, which are magni-
fied when compounded with the other forms of early trauma.
Institutional Racism and Bigotry
No discussion of trauma is complete without the acknowledgment that

children and teens suffer from the deeply embedded cultural values that
marginalize people on the basis of sex, race, religious affiliation, socioeco-
nomic status, or sexual orientation. Many ethnic and racial groups experi-
ence higher rates of posttraumatic stress disorder (PTSD) as compared to
their European American counterparts. Being bullied at school for being

“different,” racial profiling by police, and workplace harassment can all
be DSM-5 Criterion A events for PTSD, though these are rarely included
in conventional trauma checklists (Williams, Metzger, Leins, & DeLapp,
2018).
Children with gender struggles may find identification within the
LBGTQ (lesbian, bisexual, gay, transgender, and queer or questioning)
community. LBGTQ youth are often the object of derision and rejection
by their family, peers, and the community at large. Cyberbullying is a par-
ticular risk for these young people. Discrimination can also exacerbate the
effects of other sources of trauma in the lives of young people. Discussion
of these issues is beyond the scope of this book, but important for consid-
eration when considering the global effects of trauma on youth.
DEVELOPMENTAL TRAUMA
The phrase developmental trauma has been used to describe early relational
trauma, particularly when the study population is children and adoles-
cents (van der Kolk et al., 2009). Researchers often count the number or
duration of caregiver-related traumas when assessing complex or develop-
mental trauma and have consistently found that the higher exposure to
multiple forms of trauma the more the severity of symptoms across a variety
of developmental domains increases. Exposure to multiple forms of trauma
impacts multiple affective and interpersonal domains (Cloitre et al., 2009),
creates significant disturbances in children’s affect regulation, impulse
control, and self-image (Spinalzzola et al., 2005), and increases the overall
severity of mental health symptoms (Kisiel et al., 2011).
The documentation of deficits in multiple domains of functioning
among those who have suffered from more severe forms of chronic trauma
led Bessel van der Kolk to propose a new diagnostic category for the DSM-5
called “Developmental Trauma Disorder” (van der Kolk, 2005; van der Kolk
et al., 2009). This diagnostic category aptly describes children who have
had exposure to chronic early trauma by focusing on the multiple dysregu-
lations in behavior, affect, perception, relationships, and somatic experi-
ences that are typical of chronically traumatized children. Unfortunately,
it was rejected from inclusion in DSM-5 despite the fact that research con-
tinues to find this diagnostic category uniquely descriptive of a population
of victimized children (Ford, Spinazzola, van der Kolk, & Grasso, 2018).
Developmental Trauma Disorder has been found to have construct, con-
vergent and discriminant validity and reliability. It successfully identified a
group of youngsters who were victims of multiple forms of victimization,
distinguished them from children with other diagnoses including PTSD,
and revealed evidence of emotional, physiological, cognitive, behavioral,

interpersonal, and self-identity impairments. Ford et al. conclude that
DTD describes a distinct diagnostic syndrome that is a beneficial addition
to our understanding and description of severely traumatized children.
Table 1.1 lists symptoms measured on these tools for evaluating devel-
opmental trauma. While the DSM-5 does not include this diagnosis, this
conceptualization has advanced our clinical understanding of the multi-
ple deficits commonly found in chronically traumatized children. As you
read case histories throughout this book, many of the symptoms listed in
Table 1.1 will come to life in vivid ways.
For the purpose of this book, I will use the term developmental trauma to
refer to the children and adolescents who have suffered multiple forms
of early onset trauma. Some of the children have been removed from
their home of origin after physical abuse, sexual abuse, and/or neglect.
Some have chronic medical conditions, which combined with other forms
of trauma have reduced their ability to cope. The term child survivor will
refer to children and adolescents who have experienced multiple forms of
Table 1.1 Symptoms of developmental trauma
Affective or Body Dysregulations

Can’t tolerate or recover from negative affect states
Can’t recover from or modulate negative body states
Perceptual sensitivity to noise or touch
Physical complaints which are not easily explained
Diminished awareness of body or emotions
Diminished ability to describe emotions
Attention or Behavioral Dysregulation
Avoidance of threat related signals
Hypervigilance about future danger
Risk-taking
Impaired or inappropriate self-soothing (i.e. compulsive masturbation)
Self-harming behaviors
Inability to follow through with plans
Self and Relational Dysregulations
Seeing self as damaged, helpless, impaired
Worries about caregiver
Extreme distrust of caregiver
Oppositionality
Aggression
Inappropriate attempts to get physical intimacy or extreme dependency in
relationships
Lack of empathy
Inability to tune out distress of others
Adapted from Ford and the Developmental Trauma working Group (2011) and van der Kolk
et al. (2009)
trauma, and experienced some disruption in caregiving, often because a

caregiver was also the source of trauma.
NEUROLOGICAL EFFECTS OF TRAUMA
Martin Teicher (2010) of Harvard University explains that early maltreat-

ment alters the trajectory of brain development in traumatized children
in predetermined ways dependent on the child’s age and type of maltreat-
ment. One of the most consistently documented effects of maltreatment on
the brains of maltreated children and adolescents are changes in the corpus
callosum, the brain “superhighway” that connects the right and left sides
of the brain (De Bellis et al., 1999; Teicher et al., 1997; Teicher et al., 2000;
Teicher et al., 2003). Teicher and colleagues (2003) found that boys who
suffered neglect had the most profound damage to the corpus callosum;
while for girls the experience of sexual abuse was associated with a more
depleted corpus callosum. Remarkably, research by Teicher et al. (2010)
also found abnormalities of the corpus callosum in young people exposed
to verbal abuse from peers, particularly during their middle school years.
The finding of an underdeveloped corpus callosum in maltreated chil-
dren may suggest a potential neurological underpinning of the disconnec-
tions, flashbacks, and dissociative phenomena observed in traumatized
children. The undeveloped corpus callosum may inhibit the ability to inte-
grate visual information (right side) with verbal encoding (left side) or may
lead the individual to respond to events in contradictory ways, depending
on whether the right or left side of the brain is being stimulated. Research
supports the notion that traumatized individuals show a preference for
processing traumatic content on the right side of the brain compared to
normal comparison subjects (Schiffer, Teicher, & Papanicolaou, 1995).
If information cannot be integrated across the corpus callosum and pro-
cessed verbally, the result may be the recurrent re-experiencing of trau-
matic sights and sounds, a problem frequently found during flashbacks.
Both hypermnesia, vivid memory that feels like it is really happening,
and amnesia for traumatic or autobiographical events, may be associated
with abnormalities in the hippocampus. Deficits in the hippocampus have
been traced to excessive cortisol, which affects the hippocampus’s ability to
turn off an excessively stimulated amygdala (Teicher et al., 2003).
Another region of the brain that appears to be disrupted by trauma is
the amygdala, the center for conditioned fear responses. Research on the
brains of Romanian orphans shows a comparatively larger right amygdala
(Mehta et al., 2009). Similarly, reduction in the size of the left amygdala has
been reported among sexually abused young adults (Teicher et al., 2003).
The amygdala appears to be on a hyper-alert mode among traumatized
people. There appear to be two critical periods for maltreatment that dis-
rupt the functioning of the amygdala, leading to over-reactivity and prim-
ing of the fear response—ages 4 and 13–15 (Teicher, 2019). Research
by Lyons-Ruth (2020) suggests that left amygdala enlargement relates to
avoidant or neglectful parenting while right amygdala dysfunction is associ-
ated more with maltreatment.
Joseph LeDoux (1996), a well-known neuroscientist, explained that
there are two “roads” for response to fear. The “low road” involves process-
ing fear instantaneously from the thalamus to the amygdala with resulting
immediate physiologic reactivity. In contrast, the “high road” involves the
processing of fear responses through the prefrontal cortex, which allows
careful matching of how close this stimulus resembles the original source
of trauma, and allows ongoing analysis inhibiting immediate reactivity.
Those who have been traumatized repeatedly, particularly at identified
critical periods, appear to have limited access to the “high road,” and as a
result trauma responses are immediate and uninhibited.
When this fear pathway is stimulated over and over again, the amyg-
dala becomes sensitized so that lower levels of stimuli can trigger condi-
tioned fear responses. Throughout this book you will meet young people
who show unthinking reactivity to stimuli in their environments—fight-
ing, rages, shutting down, hypersexuality—demonstrating the difficulty of
inhibiting conditioned responses to their traumatic past.
Also impaired by the effects of trauma are the more primitive areas of
the brain, such as the cerebellar vermis, which is involved in coordinat-
ing intentional body movements and associated with cognitive, linguistic,
social, and emotional skills (Teicher et al., 2003). Teicher’s work found
decreased blood flow in this area in the brains of abused individuals com-
pared to normal subjects. Teicher and colleagues noted that Harlow’s
famous baby monkeys who were deprived of tactile stimulation with their
mothers also showed deficits in this area of the brain. However, when pro-
vided with rocking stimulation, even with wire mother surrogates, these
deficits appear to be minimized.
The higher centers of the brain are also vulnerable to the effects of mal-
treatment. Evidence of cortical abnormalities in children suffering from
posttraumatic stress or histories of abuse has been demonstrated repeat-
edly (Carrion et al., 2001; De Bellis, Keshavan, Spencer, & Hall, 2000; Tei-
cher et al., 2003). Teicher et al. (2010) found that sexual abuse disrupts
the development of gray matter in both the right and left primary and
secondary visual cortex. The prefrontal cortex appears to be particularly
vulnerable to the effects of traumatic stress. The prefrontal cortex con-
tains regions that help evaluate current experiences and determine their
relevance to past experience. Without input from the prefrontal cortex,
the fear response activated in the amygdala cannot easily be calmed down.
Corporal punishment appears to specifically affect the medial and dorso-

lateral prefrontal cortex (Tomoda et al., 2009).
Some evidence suggests that brain abnormalities on the right side of
the cortex may be uniquely related to the development of dissociative
phenomena (Lanius et al., 2002; Schore, 2009). According to Schore, this
area of the brain is particularly sensitive to stimulation from an attuned
caregiver, and may suffer impairment due to the lack of this stimulation.
Schore explains that the right orbito-frontal cortex in traumatized dissocia-
tive patients may have impaired connectivity to limbic structures leading to
the “inability to flexibly shift internal states and overt behavior in response
to stressful external demands” (p. 119).
Ford (2009) differentiated between the child’s survival brain—the brain
in emergency survival mode—and the learning brain, the brain poised for
taking in new information and growing. Deficits in the cortical areas of
the brain, particularly the ventral and medial prefrontal cortex, affect a
person’s overall ability to observe themselves, talk about their experiences
objectively, and put their experiences into context. These areas are under-
developed in traumatized people, in part, because the “survivor brain” is
too busy protecting itself from incoming threats. At the same time, these
meta-cognitive skills are the exact skills that we want to encourage in our
traumatized clients. Ford (2013) proposes that at its essence dissociation is
a deficit in self-regulation. Ford notes that self-regulation is an overarching
concept that cuts across multiple domains, including attachment-seeking
behavior, emotional reactivity, and self-awareness. The child who can self-
regulate is on a faster path to overall recovery and stabilization of mood
in the face of breaches to safety barriers in their lives. The framework of
self-regulation provides an underlying conceptual organizing tool for the
interventions described in this book. All interventions aim to restore the
self-regulatory function of the child in the face of traumatic disruptions.
In addition to the structural changes in the brain associated with early
trauma, children exposed to chronic stress often develop imbalances in the
brain’s chemical makeup, with excesses of stress hormones, or catechol-
amines, such as epinephrine and norepinephrine which lead to increased
startle responses, irritability, and high heart rate. As the child’s brain
becomes sensitized and is re-activated into stress reactions by signals that
remind him of the original trauma, over time this hyperarousal may become
an enduring trait (Perry, Pollard, Blakely, Baker, & Vigilante, 1995). Hyper-
activity, anxiety, impulsivity, sleep difficulties, and tachycardia are some of
the symptoms observed in children with states of chronic hyperarousal.
Alternatively, the child might experience hypoarousal, which involves sur-
render or freezing response. These children may have increased circu-
lating epinephrine, but it is accompanied by increased vagal tone which
decreases blood pressure and heart rate. Perry and colleagues note that in
this state there is stimulation of the dopaminergic system so that the body
may release endogenous opioids which decrease sensations of pain. These
findings are of particular interest as these are some of the physiological
correlates of dissociative states (see Chapter 10).
Steven Porges’s (2003; 2011) polyvagal theory sheds further light on
the physiology of dissociation and its phylogenetic roots. Porges proposes
that the stress management system in humans has developed a pathway
through the ventral vagus nerve which allows social engagement to help
regulate primitive physiological stress reactions. Stress can cause activation
of the sympathetic nervous system leading to fight response such as anger
and aggression, or to flight response like fleeing from the source of stress.
According to Porges, a third system mediated through the vagal nerve
can dramatically affect the body’s response to threat. This third pathway
involves the vagus nerve—either the higher nerve pathways (ventral) that
flow to the face, ears, and eyes, or the lower pathways (dorsal), which lead
to the digestive system and heart, inducing immobilization or collapse.
This immobilization or collapse is also found in some of our primitive ani-
mal ancestors and involves handling stress by total immobilization or “play-
ing dead,” and it can be seen in our clients when they are in a state of total
dissociative shutdown. Porges’s theory also highlights the survival value of
immobility responses for an organism trapped and faced with life-threat-
ening stressors. However, as human beings we are capable of activating the
higher-level ventral vagal pathway to experience the calming and soothing
effects of social engagement. Porges’ theory helps therapists appreciate the
important role of social engagement such as eye contact, smiles, and sooth-
ing vocalizations in helping to calm the stress response.
Lyons-Ruth’s (2020) research also emphasizes the role of the attach-
ment system in predisposing a child to dissociative and other pathological
attachment patterns. Her research team has identified a pattern she calls
“seek and squeak,” which is the response of babies and toddlers to the with-
drawal of maternal affections—seeking mother and making noises to gain
her attention. This response to the threat of abandonment, rather than
the threat of direct harm, can be found throughout the lifespan in behav-
iors of seeking attention from attachment objects despite repeated rejec-
tions. This may also help account for borderline attachment disruptions
following early maternal withdrawal and abandonment. These patterns are
associated specifically with the enlarged amygdala and hippocampal size
anomalies found in children with a history of maternal deprivation.
In summary, the brains of traumatized children are affected both struc-
turally and chemically by the effects of enduring stress. Multiple areas of
function are compromised resulting in disconnection and dysregulation.
The healthy brain is a brain that is well integrated, where communication
through brain chemicals flows freely in cascades of arousal and inhibition.
The brains of traumatized children lack integration with less fluid com-
munication both horizontally, between the right and left hemispheres,
and vertically between the higher and lower centers. The hippocampus
and prefrontal cortex do not readily communicate with the amygdala to
reduce fear reactions. The social engagement system can become tempo-
rarily “off-line” as the primitive vagal responses lead to states of collapse or
immobility or attention seeking without parental responsiveness leading to
self-punishing behaviors. Barriers to integration result from structural and
chemical effects of repeated traumatic experiences and the resulting use-
dependent pruning of brain cells.
The child’s traumatized brain has a dual handicap: Reactivity is
enhanced while regulation is impaired. As a result, the sensitized brain
overreacts to any suggestion of trauma and the regulating effects of higher
brain processes and chemical inhibitors are minimal. Research on the neu-
robiological effects of trauma also hints at multiple avenues for the remedi-
ation of symptoms. The brain grows by pruning and discarding underused
pathways, while strengthening new ones. Thus, the dysregulated brains of
traumatized children are uniquely adapted to the traumatic, chaotic, and
unpredictable environment in which the child finds himself. Getting out
of the way quickly is important for a child frequently exposed to danger.
To survive, there is no time to reflect or perform careful matching func-
tions to compare a new stimulus to an older source of fear. Disruptions
in memory may be adaptive when trauma and caregiving emanate from
the same source, as often happens in the environment of abused children.
Conversely, improvements in brain function may follow from targeted
therapeutic interventions. In fact, some preliminary research indicates that
therapeutic interventions, such as teaching mindfulness or building empa-
thy, can change the brain by increasing hippocampal grey matter (Joss,
Lazar & Teicher, 2020).
Understanding that certain abnormalities may be necessary to survive
trauma can help us appreciate what needs to be done to help the child
survivor adapt to a healthier, more regulated, and loving environment. The
parts of the brain affected by early trauma thus become the indirect tar-
get of our efforts, while the symptoms, behaviors, chronic reactivity, and
protective behaviors of the “survivor brain” become our direct targets. By
being aware of the ways exposure to chronic trauma has disrupted these
children’s developmental trajectory, we can target interventions to these
domains. The children you will meet throughout this book are a testament
to the potential of the brain to absorb and respond to the new healing
experiences we offer them in our therapeutic interventions.
The overarching goals of therapy are summarized in Table 1.2, with
speculation about how specific interventions might affect the developing
Table 1.2 Goals of therapy
Treatment Goal Methodology Associated Brain Structure
1. Be safe (stop any Environmental Prevent further brain

current trauma) management compromise
(chapter 15 and
throughout)
2. Stay calm in the Regulate affect and Connectivity of the medial
face of triggers arousal (chapters 9, prefrontal cortex with the
10, 11) limbic areas, cerebellar
vermis
3. Increase Practice grounding, Connectivity of left
Self-awareness Memory, Body prefrontal cortex
Awareness
(chapters 8, 9, 10)
4. Tell the trauma Understand what Activate brain function in
story happened and what the hippocampus, and
it means about the connect to prefrontal
self. (chapter 13) cortex
5. Develop reciprocal Family therapy Interpersonal attunement
relationships relationship to may stimulate the right
therapist (chapters orbital-frontal cortex
5, 12)
6. Turn helplessness Behavioral practice, New brain pathways emerge
into mastery or imagery work through practice
(throughout)
7. Develop coherent Dissociative Focused Both vertical and horizontal
and integrated Interventions neural integration; corpus
consciousness (throughout) callosum connectivity, and
connectivity of prefrontal
cortex to limbic and lower
brain functions
brains of traumatized children. This book will address many of these inter-
ventions with a special emphasis on Dissociation Focused Interventions
that address disruptions in the children’s continuity of awareness. Most
of the children and teens you will meet in these pages have significant
symptoms of dissociation as well as features of developmental trauma.
Like Shawn Hornbeck, they see themselves as living their life on “autopi-
lot,” feeling little control over their choices or behavior. Exploring their
dissociation can give us insight into the disruptions in affect regulation,
somatic experiences, cognitions, self-views, behaviors, and relationships,
that we often see in these children. We will explore the nature of the
types of dissociation found in chronically traumatized young people in
the next chapter.
SUMMARY
In this chapter, I reviewed the helplessness felt by the survivor of trauma in

relation to society’s pressure towards denial. The effects of trauma on the
brain and body were reviewed, with a summary of the significant impact
of trauma on the development of dissociation. The concept of develop-
mental trauma was introduced, which describes the early onset of multiple
forms of trauma associated with disruptions in early caregiving. This type of
trauma commonly results in developmental handicaps in multiple domains
of functioning, and these domains of functioning need to be addressed
for successful treatment. These patterns of impairment form the basis for
interventions I have developed to remediate the disintegration, irregular
arousal patterns, and reactivity of the brain of traumatized children. This
chapter also reviewed the neurobiological underpinnings of dissociation
which include both structural and chemical changes in the brain due to
trauma. The phenomenon of dissociation has not been well defined by the
previous literature on developmental trauma and that will be the focus of
the next chapter.
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The Child Survivor: Healing Developmental Trauma and Dissociation

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In this second edition of Joyanna Silberg’s classic The Child Survivor,

Joyanna L. Silberg, PhD, is a clinical child psychologist, an international

HEALING DEVELOPMENTAL TRAUMA

1 Trauma and Its Effects 1

2 An Integrative Developmental Model of Dissociation 21

4 Assessing Dissociative Processes 47

5 Beginning the Treatment Journey 69

6 Educate and Motivate: Introducing the EDUCATE Model 77

7 Bridging the Selves: Healing through Connections to

8 “I Try to Forget to Remember”: Reversing Amnesia 120

9 Befriending the Body: Somatic Considerations for

10 Staying Awake: Reversing Dissociative Shutdown 159

11 Building Attachment across States: Affect Regulation in

12 Child-Centered Family Therapy: Family Treatment as

13 Rewriting the Script: Processing Traumatic Memories and

14 Countering Organized Abuse: Organized Attachment

15 Interfacing with Systems: The Therapist as Activist 284

16 Integration of Self: Towards a Healing Future 298

1.1 Symptoms of developmental trauma 13

4.1 Six-year-old dissociative boy represents himself

First, I would like to thank my family—Richard, Naomi, Shira, Dahlia,

public expects. Child sexual abuse (CSA) is widespread globally. A 2009

convicted of sexual abuse, had his conviction overturned unanimously by

circumstances. Her changing moods were understood as reactions to rap-

specifically on dissociation has been confirmed by the work of a group of

Trauma and Its Effects

events open up a corridor of essential helplessness and the possibility of

The prevalence of multiple forms of trauma in the life of children has

Despite emerging knowledge of how widespread childhood trauma is in

PSYCHOLOGICAL EFFECTS OF MALTREATMENT

In a meta-analysis of 65 studies, a robust relationship was found between

Higher dissociation scores in adults were predicted by the earlier age

A systematic review by Moody, Cannings-John, Hood, Kemp, and Robling

The federal government solved the question of a dollar amount to quantify

depression, lack of enthusiasm, and low frustration tolerance (Erickson &

Emotional abuse is receiving increasing attention as negatively impacting

Witnessing Domestic or Community Violence

In the United States, approximately 15.5 million children live in households

Institutional Racism and Bigotry

No discussion of trauma is complete without the acknowledgment that

their European American counterparts. Being bullied at school for being

and revealed evidence of emotional, physiological, cognitive, behavioral,

Table 1.1 Symptoms of developmental trauma

Affective or Body Dysregulations

trauma, and experienced some disruption in caregiving, often because a

NEUROLOGICAL EFFECTS OF TRAUMA

Martin Teicher (2010) of Harvard University explains that early maltreat-

Corporal punishment appears to specifically affect the medial and dorso-

Table 1.2 Goals of therapy

Treatment Goal Methodology Associated Brain Structure

1. Be safe (stop any Environmental Prevent further brain

In this chapter, I reviewed the helplessness felt by the survivor of trauma in

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