Development and Psychopathology 23 (2011), 397–410

# Cambridge University Press 2011

doi:10.1017/S0954579411000137

SPECIAL SECTION ARTICLE

Trauma in early childhood: Empirical evidence and

clinical implications

ALICIA F. LIEBERMAN,a ANN CHU,b PATRICIA VAN HORN,a AND WILLIAM W. HARRISc
a
University of California, San Francisco; b University of Denver; and c Children’s Research and Education Institute

Abstract
Children in the birth to 5 age range are disproportionately exposed to traumatic events relative to older children, but they are underrepresented in the trauma
research literature as well as in the development and implementation of effective clinical treatments and in public policy initiatives to protect maltreated
children. Children from ethnic minority groups and those living in poverty are particularly affected. This paper discusses the urgent need to address the needs of
traumatized young children and their families through systematic research, clinical, and public policy initiatives, with specific attention to underserved groups.
The paper reviews research findings on early childhood maltreatment and trauma, including the role of parental functioning, the intergenerational transmission
of trauma and psychopathology, and protective contextual factors in young children’s response to trauma exposure. We describe the therapeutic usefulness of a
simultaneous treatment focus on current traumatic experiences and on the intergenerational transmission of relational patterns from parent to child. We
conclude with a discussion of the implications of current knowledge about trauma exposure for clinical practice and public policy and with recommendations
for future research.

The recent publication by the American Academy of Child &
Adolescent Psychiatry (AACAP, 2010) of the updated Prac-
tice Parameter for the Assessment and Treatment of Children
and Adolescents with Posttraumatic Stress Disorder high-
lights the centrality of trauma exposure as a pathogenic event
with potentially severe sequelae for the mental health of chil-
dren across the developmental continuum. In keeping with
advances in the field since the previous Practice Parameter
was published in 1998, the new document includes important
new recommendations among the minimum standards of care
supported by rigorous empirical evidence and/or overwhelm-
ing clinical consensus. These recommendations include the
routine inclusion of questions about trauma exposure and
symptoms of posttraumatic stress disorder (PTSD) in the psy-
chiatric assessment of children and adolescents; the inclusion
of parents or other caregivers in the child’s assessment; the as-
sessment and treatment for comorbid disorders in children di-
agnosed with PTSD; and the use of trauma-focused psycho-
therapies as first-line treatments for children and adolescents
diagnosed with PTSD, with the key elements of direct atten-
tion to the trauma, engaging the parent(s) as important agents
of change, and a focus not only on symptom improvement but
also on enhancing functioning and developmental trajectory
as treatment goals. The present paper examines the relevance
Address correspondence and reprint requests to: Alicia F. Lieberman, De-
partment of Psychiatry, Box 0852-CTRP, SFGH Building 20 2100, Univer-
sity of California, San Francisco, San Francisco, CA 94143-0852; E-mail:
alicia.lieberman@ucsf.edu.
397
of these recommendations to the field of infant mental health
in light of the high incidence of trauma exposure in the first 5
years of life. We discuss research findings on early childhood
maltreatment and trauma, including the role of parental func-
tioning, the intergenerational transmission of trauma and psy-
chopathology, and protective contextual factors in young
children’s response to trauma exposure. We describe the ther-
apeutic usefulness of a simultaneous treatment focus on cur-
rent traumatic experiences and on the intergenerational trans-
mission of relational patterns from parent to child. We
conclude with a discussion of the implications of current
knowledge about trauma exposure for clinical practice and
public policy and with recommendations for future research.
Contextual Factors in Maltreatment, Traumatic
Exposure, and Infant Mental Health
The first 5 years of life have the highest incidence of child
maltreatment, as attested by national statistics showing that
children aged birth to 5 represent 36% of those entering foster
care, 75.7% of the children who died from child abuse or ne-
glect were younger than 4 years old, and the highest maltreat-
ment death rate occurs between birth and 12 months of age,
with an overall victimization rate of 21.9 per 1000 children
(US Department of Health and Human Services [USDHHS],
2009). Children in this age range are also more likely than
older children to reside in homes with domestic violence
(Fantuzzo & Fusco, 2007). Whether from accidents, neglect,
or inappropriate supervision, children under age 5 are dispro-
398
portionately hospitalized and more likely to die from drowning
and submersion, burning, falls, suffocation, choking, and poi-
soning when compared to children in any other age group
(Grossman, 2000). A sample of 305 children aged 2–5 re-
cruited from a public pediatric clinic showed that 52.5% of the
children had experienced at least one severe traumatic stressor
in their lifetime; 20.9% had experienced the loss of a loved adult;
16% had been hospitalized; 9.9% had been in a motor vehicle
accident, 9.5% had a serious fall, and 7.9% had been burned.
Contrary to the widespread belief that young children are not
affected or recover quickly from stressful experiences, there
was a strong association between the number of stressors
experienced by a child and the likelihood of a psychiatric dis-
order, with 17.4% of the children showing such a disorder (Eg-
ger & Angold, 2004). These findings converge with a growing
body of research and clinical findings about the prevalence of
mental health disorders in the first years of life, making it im-
perative to develop and disseminate trauma-focused treatment
approaches that are solidly grounded in theoretical models
and supported by empirical evidence of efficacy.
Infant mental health is a multidisciplinary and pluralistic
field of inquiry, practice, and policy concerning the wellbeing
of young children in the prenatal to 5-year age range and de-
fined by five organizing premises: early experiences matter,
quality of caregiving relationships is a key factor in the child’s
psychological health, normative developmental trajectories
need ongoing support, infants and young children may suffer
from psychiatric disorders, and early psychopathology may
be enduring (Zeanah & Zeanah, 2009). In light of the high rates
of maltreatment and accidental injury among young children,
these premises have significant implications for the identifica-
tion of traumatic exposure and the treatment of its sequelae in
infancy and early childhood. Although infant mental health in-
terventions share a common therapeutic focus on enhancing the
child’s primary caregiving relationships, they differ substantially
in the etiological role attributed to the intergenerational transmis-
sion of psychopathology versus real-life experiential events
(Lieberman & Amaya-Jackson, 2005). The role of trauma in in-
fant mental health disorders is beginning to be addressed in treat-
ment approaches that show empirical evidence of efficacy, such
as child–parent psychotherapy (CPP; Lieberman & Van Horn,
2005, 2008) and cognitive behavioral therapy (CBT; Cohen,
Mannarino, & Deblinger, 2006; Scheeringa et al., 2007).
These treatment approaches are at the forefront of efforts to
implement the AACAP practice parameter in clinical settings.
The contextual framework for the findings of early child
maltreatment and traumatization provides strong support for
an ecological–transactional model of development and psycho-
pathology (Bronfenbrenner, 1979; Cicchetti & Lynch, 1993;
Sameroff & Fiese, 2000). Poor and minority children are
more likely to report that they experienced or witnessed vio-
lence at home (Finkelhor, Ormrod, Turner, & Hamby, 2005),
and children from families in poverty have greater lifetime ex-
posure to physical abuse, sexual abuse, and witnessing family
violence (Turner, Finkelhor, & Ormrod, 2006). Young children
living in poor and dangerous neighborhoods are also frequently
A. F. Lieberman et al.
exposed to community violence, with very high percentages of
preschool children witnessing muggings, fights, shootings, or
knifings; hearing gun shots; or seeing a dead body on the
way to school (Linares et al., 2001; Shahinfar, Fox & Leavitt,
2000; Taylor, Zuckerman, Harik, & Groves, 1994). Adversity
takes a toll on young children’s emotional wellbeing. Among
children in poverty, one in five has a diagnosable mental health
disorder (Masi & Cooper, 2006; Mills et al, 2006), and children
in the child welfare system, who come primarily from poor
families, have a greater prevalence of mental health problems
compared with those in the general population (Dore, 2005;
Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004). The
overlap between poverty and health problems originates in
early childhood, with the association mediated by increased
child exposure to chronic physical and emotional risk factors,
including substandard housing, lack of access to resources
such as high-quality childcare and safe, stimulating neighbor-
hoods, and environmental toxins as well as child abuse and
neglect, severe maternal depression, parental substance abuse,
harsher parenting, and family and community violence (Anda
et al, 2006; Evans, 2004; Repetti, Taylor, & Seeman, 2002).
The prevalence of risk factors and the scarcity of protective
factors conspire to create toxic ecological systems for children
from poor and disempowered families, creating a “supraclini-
cal” problem that includes but supercedes the mental health
domain (Harris, Lieberman, & Marans, 2007).
Although cultural considerations are crucial for under-
standing the context of traumatic exposure and its meaning
for the family and community, research findings about cul-
tural/ethnic differences in rates of child maltreatment are in-
consistent and at times contradictory as the result of defini-
tional differences and methodological limitations across
studies (Chu & Lieberman, 2010; Elliott & Urquiza, 2006).
Nevertheless, maltreatment reports to child protective ser-
vices show clear group differences, with African American,
American Indian or Alaska Native, and multiracial children
comprising the groups with the highest rates of reported mal-
treatment, and Asian children having the lowest report rate
(Hill, 2007; USDHHS, 2009). Once a maltreatment report
is made, the outcome for the child and the family also differs
according to ethnic group. African American and Latino
young children are more likely to be placed out of home,
stay longer in foster care, have more placement changes,
and are less likely to be reunified with their parents (Hill,
2007). It is likely that environmental factors such as poverty
and homelessness interacts with minority group status to mo-
bilize heightened attention from mandated reporters and state
authorities, disproportionately increasing the number of cases
reported among marginalized ethnic groups. Once a report is
made, unconscious bias toward marginalized minority groups
may interact with lack of resources in the child’s family,
neighborhood, and community to perpetuate differential re-
unification and permanency planning outcomes for children
in these minority groups. The overlap of poverty, minority
status, and child victimization has far-reaching public policy
implications because of the enduring gap between need and
Trauma in early childhood
access to care repeatedly identified in federal reports about the
state of mental health in the country (USDHHS, 2003). De-
spite these findings, there is a pervasive failure to include ser-
vices for infants, toddlers and preschoolers among the sys-
tems of care charged with addressing the needs of children
at risk (Osofsky & Lieberman, in press).
Cumulative versus single traumatic stressors
Assessment for traumatic exposure is often restricted to single
sources of trauma that are determined by the assessor’s exper-
tise or focus of inquiry (Finkelhor, Ormrod, & Turner, 2007a).
This research preference for focusing on single trauma persists
despite long-standing scientific evidence documenting the im-
portance of cumulative risk factors in predicting long-term out-
comes that can be traced back to the classic Isle of Wight Study
(Rutter, 1979) and the Rochester Longitudinal Study (Samer-
off, Seifer, Zax, & Barocas, 1987). The Adverse Childhood
Experiences study found that individuals who reported child-
hood exposure to four or more of nine risk factors related to
child maltreatment and severely impaired household environ-
ments had a 12-fold increase in risk for alcoholism, drug abuse,
depression, and suicide, and were more likely to suffer from is-
chemic heart disease, cancer, stroke, and diabetes (Dube, Fe-
litti, Dong, Giles, & Anda, 2003; Felitti et al., 1998). The Na-
tional Comorbidity Replication Study found a similar pattern in
a large, nationally representative sample that showed an asso-
ciation between cumulative risk score of childhood adversities
and a greater number of adult psychiatric diagnoses, with four
or more adversities associated with an average of more than
six psychiatric diagnoses (Putnam, Perry, Putnam, & Harris,
2008). A literature review of adult outcomes shows that re-
peated childhood victimization is associated with more severe
symptoms and negative outcomes than one such episode or
no victimization (Marx, Heidt, & Gold, 2005). Moreover, re-
peated exposure seems to be the norm rather than the excep-
tion. In a sample of 2,000 children, aged 2–17, selected for a
telephone survey through random digit dialing, 70% of the re-
spondents (either the child or the parent in the case of younger
children) reported at least one episode of exposure, with 64%
of these children reporting at least one additional, different
source of victimization during the same time period and a
mean of 2.8 for number of victimizations. In addition, four
or more episodes of violence significantly predicted trauma
symptoms in structured interviews conducted 1 year later, con-
trolling for prior victimization and prior mental health status
(Finkelhor, Ormrod, & Turner, 2007b). These findings suggest
that a pattern of repeated trauma exposure is significantly rep-
resented in the general population and is not limited to poor and
underserved children. Although socioeconomic adversity con-
tributes significantly to cumulative traumatization and abuse,
repeated victimization is not limited to single, discrete demo-
graphic or psychological patterns (Cicchetti & Aber, 1980).
The pattern of co-occurrence of traumatic events is also re-
flected in the literature on the comorbid overlap between child
maltreatment and witnessing domestic violence. One litera-
399
ture review of 35 published studies found that child maltreat-
ment and exposure to domestic violence ranged from 30% to
60% (Edleson, 1999). Another review showed that 45% to
70% of children exposed to domestic violence were also vic-
tims of physical abuse, and about 40% of physically abused
children were also exposed to domestic violence (Margolin,
1998). The growing evidence for the pervasiveness of cumu-
lative exposure to violence as contrasted to exposure to a sin-
gle discrete episode of maltreatment or family violence led
Finkelhor et al. (2007a) to postulate that victimization is a
“condition” rather than an “event.”
These findings have important implications for the prac-
tice of infant mental health. Young children tend to be re-
ferred for treatment either because of behavior problems or
because of known exposure to a discrete pathogenic event,
but exposure to previously unreported stressful and traumatic
events often emerges only when the initial assessment incor-
porates a structured questionnaire probing for this possibility.
In our clinical sample of young children referred for treatment
due to trauma exposure, the referral information identified ex-
posure to a single traumatic event in 53% of the children re-
ferred; only 6% were identified by the referral source as being
exposed to four or more traumatic events. However, after the
administration of a standardized screening instrument during
the initial assessment, it emerged that the majority of the chil-
dren (70.3%) had experienced four or more traumatic events
by mother’s report, and only 3% had a single traumatic expo-
sure (Ghosh Ippen, Harris, Van Horn, Guendelman, & Lie-
berman, 2009). This stark difference supports the AACAP
(2010) Practice Parameter’s recommendation of systematic
screening for traumatic exposure as well as the crucial role
of the parent as a source of information about the child.
Quality of attachment and children’s response to trauma
Young children’s sense of safety and wellbeing is organized
around the availability and responsiveness of the attachment
figure, whom they approach for protection and reassurance
when frightened or in need (Bowlby, 1969). Traumatic ex-
periences may damage the child’s trust in the reliability of
the attachment figure as a protector. The overpowering sen-
sory stimulation associated with traumatic exposure may
take the forms of pain and/or frightening visual, auditory, ol-
factory, and tactile sensations and is associated with a col-
lapse of coping mechanisms when the attachment figure is
absent, unable to help, or is the perpetrator of the trauma.
Traumatic expectations become the norm when the child en-
counters chronic and multiple traumas, leading to generalized
traumatic responses such as hypervigilance; constriction of
play, exploration, and motivation to learn; reexperiencing of
the trauma in the form of traumatic play, nightmares, and dis-
tress at trauma reminders; and new symptoms (Zero to Three,
2005). Long after the child has apparently recovered from the
event, reminders of the trauma can trigger a more attenuated
version of the strong negative emotions evoked by the origi-
nal event (Pynoos, Steinberg, & Piacentini, 1999).
400
Quality of attachment influences the child’s response and
subsequent recovery from a stressful event. Securely attached
infants are better able to modulate their physiological stress re-
sponse when compared to infants in insecure attachment rela-
tionships, and disorganized attachment is associated with
even greater physiological dysregulation (Gunnar & Cheatham,
2003; Gunnar & Quevedo, 2007). Maltreated children are much
more likely to have insecure attachments (Crittenden, 1992;
Lyons-Ruth & Block, 1996), as much as 5.3 times more than
comparison children (Carlson, Cicchetti, Barnett, & Braun-
wald, 1989; Main & Goldwyn, 1984). Traumatic stress reac-
tions are found more often among traumatized children with in-
secure attachments, suggesting that they may have difficulty
eliciting supportive exchanges from the parent that could buffer
the impact of the trauma (Lynch & Cichetti, 1998).
Threat to the mother has been identified as a traumatic stres-
sor in young children, suggesting that in infancy danger to the
mother is equated with danger to the self. Among young chil-
dren exposed to a severe trauma prior to 48 months of age,
PTSD was diagnosed more often and children had more symp-
toms of aggression, fear, and hyperarousal when they witnessed
threat to the mother as compared to children exposed to other
traumas (Scheeringa & Zeanah, 1995). In a subsequent replica-
tion study with children aged birth to 18 years admitted to an
inpatient unit in a Level 1 trauma center for physical injuries,
the authors found that witnessing a threat to the caregiver was
the only predictor of PTSD symptoms out of seven different
risk factors that included younger age, female gender, minority
group membership, prior traumatization, pretrauma externaliz-
ing behaviors, and pretrauma internalizing behaviors (Scheer-
inga, Wright, Hunt, & Zeanah, 2006). These findings suggest
that the safety of the mother figure may have long-term reper-
cussions across childhood.
Given the centrality of the parent figures in young chil-
dren’s emotional lives, traumatic events may simultaneously
affect both the child and the caregiver, creating complex
changes and adaptations in the parent–child relationship, a
situation we refer to as a “bimorbid condition” (W. W. Harris,
private communication, January 3, 2011). After reviewing
the empirical evidence showing the co-occurrence of trau-
matic stress in mothers and their young children, Scheeringa
and Zeanah (2001) proposed a relational PTSD model with
four different types of association between the traumatic
stress symptoms experienced by the child and by the parent.
The moderating effect postulates that the quality of the child–
caregiver relationship may affect the intensity of the associa-
tion between the traumatic event and the child’s response.
The caregiver’s accuracy and sensitivity in reading and re-
sponding to the child’s signals of need may exacerbate or al-
leviate the adverse effect of the traumatic event on the child’s
functioning. The vicarious traumatization effect describes sit-
uations where the caregiver’s responsiveness to the child is af-
fected by a traumatic event experienced by the caregiver but
not directly by the child. The compound effect is postulated
when both caregiver and child were exposed to the traumatic
event, and the symptoms of one member of the dyad exacer-
A. F. Lieberman et al.
bate the symptoms of the other. This condition may be man-
ifested through several mechanisms. Traumatized adults may
experience posttraumatic stress symptoms such as avoidance,
withdrawal, and hyperarousal, which limit their availability
and/or distort their responsiveness to the child. Simultane-
ously, the child’s trauma exposure generates symptoms that
are exacerbated by the indirect effect of the caregiver’s com-
promised responsiveness. Children’s symptoms of traumatic
stress may further burden an already overtaxed caregiver
and aggravate the adult’s posttraumatic responses. Another
possibility is that parents may become anxiously restrictive
and overprotective in their parenting, also intensifying the
child’s maladaptive stress responses. Finally, an imitative ef-
fect is seen if a young child becomes increasingly sympto-
matic from observing, being affected by, and imitating a par-
ent who shows reexperiencing symptoms and is emotionally
dysregulated or preoccupied with the trauma.
Research findings that traumatized young children often have
traumatized parents (for a review, see Chu & Lieberman, 2010)
suggest that the assessment and treatment of young children
with mental health problems should incorporate attention to
the interface between traumatic experiences and the quality of
the parent–child relationship as an integral component of the
clinical process. It is now well established that the quality of
the child–parent relationship affects young children’s capacity
to process and resolve traumatic experiences. Traumatic events
may introduce unmanageable stress in the parent–child relation-
ship and damage the quality of existing attachments, particularly
when the parent’s functioning is also negatively affected by past
or concurrent trauma. Assessing the etiology of infant mental
health disorders should include an assessment of exposure to
traumatic events in the child and the parents, and traumatic stress
in the first years of life should be treated in the context of the
child’s primary attachments.
Intergenerational transmission of psychopathology:
Clinical and research perspectives
The processes linking maladaptive functioning in the parents
with maladaptive functioning in the child have been the focus
of intense scrutiny both in clinical practice and in research,
leading to fruitful cross-pollination between both methods
of inquiry. Perhaps the most compelling metaphor describing
the phenomenon of transmission is Selma Fraiberg’s “ghosts
in the nursery” (Fraiberg, Adelson, & Shapiro, 1975), cred-
ited with marking the birth of infant mental health by Daniel
Stern (1995). In clinical work with infants and their care-
givers, Fraiberg and her colleagues noted that many mothers
who experienced multiple chronic risks repeated with their
infants the patterns of rejection and maltreatment that had
shaped their lives, whereas other mothers with similar back-
grounds did not relate to their infants through a perceptual
lens shaped by these experiences. What is it, they asked,
“that determines whether the conflicted past of the parent
will be repeated with this child?” (Fraiberg et al., 1975,
p. 388). In their seminal effort to find answers, they hypoth-
Trauma in early childhood
esized that the mother’s ability to access, process, and resolve
painful affect associated with past experiences influences her
current functioning, perceptions of the child, and quality of
the parent–child relationship. This conceptual framework
had profound generative repercussions for clinical practice,
leading to the creation of infant–parent psychotherapy as a
treatment focused on the mother’s reenactment with her
baby of negative attributions and damaging interactions origi-
nating in disowned, unprocessed, and unresolved past experi-
ences, with the goal of guiding the mother to a new under-
standing of herself and her baby and restoring the positive
developmental momentum of the mother–child relationship
(Fraiberg, 1980).
Key elements of this framework were adapted and opera-
tionalized by researchers working within the paradigm of at-
tachment theory, who emphasized the intergenerational trans-
mission of the mother’s unresolved childhood fears through
frightened/frightening behaviors vis-à-vis the baby (Lyons-
Ruth, Bronfman, & Atwood, 1999; Main & Hesse, 1990).
The relationship diathesis model proposes three factors in
vulnerability to stress-related dysfunction: the characteristics
of the stressor, the individual’s genetic vulnerability to stress,
and the capacity of the attachment system to modulate the
high levels of arousal that accompany stress. Children be-
come symptomatic either when the stressor is too overwhelm-
ing or when the attachment relationship is unable to modulate
the child’s intensely negative affective response. Parents
whose unresolved fear dates back to their childhood may
have difficulty helping their children modulate fear and other
strong emotions because they curtail their conscious attention
to the child’s signals of need in an effort to protect themselves
from reexperiencing their early traumatic responses (Lyons-
Ruth et al., 1999). Building on Fraiberg’s hypothesis of dis-
owned and unprocessed maternal affect related to childhood
maltreatment, Fonagy and colleagues (1995) suggested that
victims of unresolved childhood trauma may protect them-
selves from its associated painful affects by failing to develop
mentalization as a reflective self-function that enables them to
attribute mental states to themselves and others. Empirical
findings link maternal state of mind in relation to attachment
to their infants’ quality of attachment and suggest that infants
develop disorganized attachment when they cannot rely on
the parent to modulate their fear (Lyons-Ruth, Yellin, Mel-
nick, & Atwood, 2005; Schechter et al., 2001). The role of
maternal dissociation, which can also be conceptualized as
a failure of mentalization, has been raised as an explanatory
mechanism by several studies, including findings that mater-
nal dissociation scores predict infant disorganized behavior
(Main & Hesse, 1996) and findings from the Minnesota Par-
ent–Child Project longitudinal study that attachment disorga-
nization in infancy predicts increased dissociation in adoles-
cence, mediated by maternal unavailability and quality of
caregiving (Carlson, 1998; Ogawa, Sroufe, Weinfield, Car-
son, & Egeland, 1997), suggesting a link between maternal
dissociation and later dissociative behavior in the child. Put-
nam et al. (2008) propose that maltreatment, high levels of
401
maternal dissociation, and disorganized attachment are inter-
generationally connected. This premise is supported by find-
ings from the Minnesota Parent–Child Project showing that
high maternal dissociation scores differentiated between
mothers with a history of childhood abuse who went on to
abuse their own children and mothers with a similar child
abuse history who were able to break the cycle of abuse.
The abused mothers who did not abuse their children had
lower dissociation scores, suggesting that they were able to
integrate their childhood abuse experiences into their adult
sense of self (Egeland & Susman-Stillman, 1996).
Efforts to measure the scope and prevalence of the inter-
generational transmission of maltreatment and maladaptive
patterns of functioning have a long history fraught with con-
ceptual and methodological problems. Criteria for the “per-
fect” study of intergenerational transmission were proposed
by Ertem, Leventhal, and Dobbs (2000), who acknowledged
that the basic criterion of random group assignment could not
be met on ethical, as well practical, grounds but singled out a
study from the Minnesota Parent–Child Project sample (out
of 200 studies reviewed) as fulfilling or approximating their
criteria. The study found that first-time mothers of lower so-
cioeconomic status who met clearly defined criteria for severe
childhood physical abuse were 12.6 times more likely to
abuse their children by the time the child was 24 months
old when compared with mothers from similar demographic
backgrounds who had emotionally supportive parents (Ege-
land, 1979; Egeland, Jacobvitz, & Sroufe, 1988). More recent
studies provide confirmation that childhood abuse victims
tend to abuse their own offspring at higher rates than the na-
tional average (DiLillo, Termblay, & Peterson, 2000; Dixon,
Hamilton-Giachritsis, & Browne, 2005).
Findings supporting the concept of intergenerational trans-
mission are not restricted to maltreatment. Extensive empirical
evidence links the child’s stress response to a variety of trau-
matic conditions or events with the quality of the child–parent
relationship. Maternal distress mediated the relationship be-
tween child exposure to community violence and problem
behaviors in a study of preschoolers living in high-crime neigh-
borhoods (Linares et al., 2001). Maternal psychological func-
tioning predicted concurrent and longer term child behavioral
problems in a longitudinal study of Israeli preschoolers whose
homes were damaged by SCUD missiles during the first Gulf
War (Laor, Wolmer, & Cohen, 2001). The association between
maternal functioning and child outcome has also been demon-
strated with clinical samples. Lieberman, Van Horn, and Ozer
(2005) showed that among preschoolers referred for treatment
after witnessing their mothers’ battering by their father figure,
there was a significant association between maternal life stress
and child behavior problems, and the association was mediated
both by maternal functioning and by the quality of the mother–
child relationship.
Intergenerational transmission processes unfold within a
larger ecological context characterized by complex transac-
tions between proximal and distal influences, risk and protec-
tive factors, and transient versus enduring stresses, all of
402
which influence children’s development and the quality of
the parent–child relationship (Bronfenbrenner, 1979, 1986;
Cicchetti & Lynch, 1993). Prevailing economic conditions
strongly influence the rates of maltreatment, including phys-
ical abuse and neglect (Berger, 2005; Paxson & Waldfogel,
2002; Waldfogel, 2005). The epidemiological findings from
the Smoky Mountain longitudinal study provide compelling
evidence of the transformations in individual and family
functioning that take place with improvements in social and
economic conditions (Costello, Compton, Keeler, & Angold,
2003; Costello, Erkanli, Copeland, & Angold, 2010) and
serve as a powerful reminder that infant mental health practice
at its best incorporates efforts to help the family with the con-
crete problems of living posed by poverty and marginaliza-
tion (Fraiberg, 1980).
The extensive literature linking trauma exposure and pov-
erty, community violence, and belonging to a marginalized
ethnic or racial group is beyond the scope of this paper, but
it is now evident that Winnicott’s (1964) much-quoted dictum
that “There is no such thing as a baby . . . A baby cannot exist
alone, but is essentially part of a relationship” (p. 88) needs to
be embedded within a broader ecological framework. We can
now say on the basis of decades of research that “There is no
such thing as a family . . . A family cannot exist alone, but is
essentially part of a social, economic, and cultural system.”
Preschooler Socioemotional, Cognitive, and
Behavioral Outcomes
The few studies specifically targeting preschool children show
significant associations between trauma exposure and malad-
aptive socioemotional and behavioral outcomes at this age.
Preschoolers exposed to domestic violence showed signifi-
cantly more negative affect, more peer aggression, less appro-
priate responses to situational challenges, and more ambivalent
relationships with their caregivers than their peers when ob-
served in group play and in interaction with their preschool
teachers (Graham-Bermann & Levendosky, 1998). Trauma-
tized preschoolers also have frequent co-occurrence of differ-
ent psychiatric diagnoses, with children diagnosed with
PTSD having significantly higher rates of separation anxiety
disorder, oppositional defiant disorder, more separation anxi-
ety disorder and oppositional defiant disorder symptoms, and
higher scores on the Child Behavior Checklist (Achenbach
& Rescorla, 2001) internalizing and total subscales when com-
pared to healthy controls and to preschoolers who had been ex-
posed to traumatic events but showed no evidence of PTSD
(Scheeringa, Zeanah, Myers, & Putnam, 2003).
The effects of traumatic exposure in the first 5 years may
continue to be evident at later ages. A community sample
of children, followed prospectively for 9 years from the
time they entered kindergarten, showed that children who ex-
perienced physical abuse before age 5 were at greater risk for
developing internalizing and externalizing behavior problems
than children who experienced physical abuse after age 5
(Keiley, Howe, Dodge, Bates, & Pettit, 2001). Eigsti and Cic-
A. F. Lieberman et al.
chetti (2004) found that preschool aged children who had ex-
perienced maltreatment prior to age 2 exhibited language de-
lays in vocabulary and language complexity. The mothers of
these maltreated children directed fewer utterances to their
children and produced a smaller number of overall utterances
compared to mothers of nonmaltreated children, with a signif-
icant association between maternal utterances and child lan-
guage variables. There are indications that young children’s
cognitive deficits are linked to exposure to violence and to
the quality of children’s caregiving relationships. Domestic
violence exposure was uniquely associated with IQ suppres-
sion among 5-year-old monozygotic and dizygotic twin pairs
in England, with a dose–response relationship so that children
exposed to high levels of domestic violence had IQs that were
eight points lower on average than nonexposed children
(Koenen, Moffitt, Caspi, Taylor, & Purcell, 2003). Domestic
violence exposure is also negatively correlated with pre-
school children’s performance on explicit memory tasks,
with children exposed to higher levels of violence performing
more poorly and with this association moderated by the
mothers’ positive parenting practices (Jouriles et al., 2008).
The role of maternal functioning as an influential factor in
the association between child trauma exposure and cognitive
performance was also found in a clinical sample of preschool-
ers referred for treatment after witnessing domestic violence
where children had lower IQ scores when their mothers
were rated as unclassifiable, unresolved/insecure, or had
lower coherence scores on the Adult Attachment Interview
after controlling for maternal education (Busch & Lieberman,
2010). These findings point to the intricate interconnections
linking children’s emotional, social, and cognitive function-
ing to maternal functioning and to the quality of caregiving
they receive, and highlight the importance of targeting malad-
aptive caregiving patterns in the treatment of infant mental
health problems.
The biological substrate of the behavioral outcomes iden-
tified in traumatized children is the focus of extensive re-
search, but studies to date have included school-aged children
and adolescents rather than infants, toddlers, and preschool-
ers, so that an extrapolation of the findings to this age range
would be speculative. Brain areas and systems consistently
implicated in traumatized older children and adults include
the amygdala, medial prefrontal cortex, dopamine system,
norepinephrine/epinephrine (adrenergic) system, hypothala-
mic–pituitary–adrenal axis, hippocampus, and corpus collo-
sum, serotonin system, and the endogenous opiate system,
all of which show dysregulations in patients with PTSD. Al-
though the specific findings vary across studies and different
patterns have been found for children and adults, physiolog-
ical and anatomical irregularities are consistently associated
with earlier age of maltreatment, longer duration of maltreat-
ment, and greater severity of PTSD (DeBellis, Hooper & Sa-
pia, 2005). The plasticity of the brain makes it difficult to in-
terpret the findings with any certainty because children’s
neural systems are under development, areas of the brain
may reach their peak volume in late childhood or adoles-
Trauma in early childhood
cence, and ongoing adversity and traumatization may contrib-
ute to heterogeneous outcomes (Gunnar & Quevedo, 2007;
for a review, see Giedd, 2009). In addition, quality of parental
care may be a powerful moderator of psychobiological child
measures in young children. For example, Scheeringa, Zea-
nah, Myers, and Putnam (2004) found that in a sample of
traumatized children aged 20 months to 6 years, those with
the most severe PTSD symptoms had decreased respiratory
sinus arrhythmia during a trauma stimulus when their care-
givers showed less positive discipline during a clean-up task.
The study of GeneEnvironment interaction is a growing
area of research with potentially far-reaching implications for
understanding the biological substrate of trauma responses.
Two recent meta-analyses reported small to medium effect
sizes (0.17 and 0.18) for the monoamine oxidase A genotype
and maltreatment interaction for antisocial behavior (Kim-
Cohen et al., 2006; Taylor & Kim-Cohen, 2007). In another
recent study with children who had been removed from their
parents due to abuse and a comparison group with no history
of trauma this gene–environment interaction for child aggres-
sion was found in low to moderate levels of trauma exposure
only, although children with exposure to extreme levels of
trauma had high aggression scores regardless of genotype
(Weder et al., 2009). A twin study also supports a gene–envi-
ronment interaction for conduct disorder among physically
abused 5-year-olds, who showed an increase of 2% in the
probability of a conduct disorder diagnosis in children with
lowest genetic risk, compared to an increase of 24% in chil-
dren at highest genetic risk (Jaffee et al., 2005). Although
most of the existing studies involve older children and adults,
the momentum for research in this area is likely to result in
the examination of proximal and distal effects of the interac-
tion between nature and nurture in very young children in the
future.
Diagnosing PTSD in early childhood
According to the Diagnostic and Statistical Manual of Men-
tal Disorders, Fourth Edition (DSM-IV; American Psychiat-
ric Association, 2000), PTSD is characterized by the onset of
clusters of characteristic symptoms following exposure to an
event that threatens the life or physical integrity of the self or
others (Criterion A). The clusters of symptoms involve reex-
periencing of the traumatic event (Criterion B); avoidance of
stimuli associated with the trauma and numbing of general re-
sponsiveness (Criterion C); and increased arousal (Criterion
D). Each of these criteria contains specific symptoms, and a
logarithm is provided to determine whether the person meets
sufficient criteria for a clinical diagnosis: at least one symp-
tom from Criterion B (reexperiencing), at least three symp-
toms from Criterion C (avoidance), and at least two symptoms
from Criterion D (arousal). The full symptom picture must be
present for longer than 1 month (Criterion E), and the distur-
bance must cause clinically significant distress or impairment
in important areas of functioning such as work or social rela-
tions (Criterion F).
403
There is widespread consensus that the DSM-IV-R list of
symptoms for PTSD does not include behavioral manifesta-
tions that are developmentally appropriate for infants, toddlers,
and preschoolers, and empirical findings have provided evi-
dence that alternative PTSD criteria are needed for children
aged birth to 5 years. In a study comparing traumatized and
nontraumatized children aged 20 months to 6 years using pa-
rental interviews and behavioral checklists, Scheeringa et al.
(2003) found that none of the traumatized children met the
DSM-IV criteria for PTSD, but 26% of these traumatized chil-
dren met diagnostic criteria when alternative, developmentally
appropriate criteria and a revised algorithm were used, consist-
ing of one symptom from cluster B (reexperiencing) symptom,
one symptom from cluster C (avoidance/numbing) symptom,
two symptoms from cluster D (arousal), and four novel symp-
toms. The children diagnosed with PTSD using the revised cri-
teria had significantly more comorbid symptoms (separation
anxiety disorder; oppositional defiant disorder; major depres-
sive disorder; attention-deficity/hyperactivity disorder; Child
Behavior Checklist internalizing, externalizing, and total prob-
lems) when compared to children in the trauma/no PTSD group
or the no trauma group. During a follow-up study of the same
children conducted 1 and 2 years after the initial assessment,
the researchers found that the children originally diagnosed
with PTSD showed significantly more PTSD symptoms and
functional impairment in more domains over the course of 2
years than children not diagnosed with PTSD during the initial
study (Scheeringa, Zeanah, Myers, & Putnam, 2005). Subse-
quent studies also support the importance of developmentally
appropriate symptoms and an altered algorithm for diagnosing
PTSD in young children (Meiser-Stedman, Smith, Glucksman,
Yule, & Dalgleish, 2008; Scheeringa et al., 2006).
These research efforts and the developmental of the alter-
native criteria and algorithm received impetus from a multi-
disciplinary Diagnostic Classification Task Force established
in 1987 by Zero to Three: National Center for Infants, Tod-
dlers and Families and cochaired by Stanley Greenspan and
Serena Wieder in response to the need for a developmentally
appropriate instrument to diagnose mental health problems in
infancy and early childhood. This effort led to the publication
of the Diagnostic Classification of Mental Health and Devel-
opmental Disorders of Infancy and Early Childhood (DC:0–
3; Zero to Three, 1994), which included a diagnostic category
for traumatic stress disorder that followed the criteria of the
DSM-IV but included developmentally appropriate behav-
ioral symptoms within each criteria. The manual was revised
under the leadership of Robert Emde and published as the re-
vised version of DC:0–3 (DC:0–3R; Zero to Three, 2005).
The mutual influences between infant mental health research-
ers and clinicians resulted in modifications in the DC:0–3R
that changed the nomenclature of the original diagnostic cat-
egory of traumatic stress disorder to align it with the DSM-IV
usage of PTSD and the adoption in the DC:0–3 R of the algo-
rithm developed by Scheeringa and colleagues: at least one
reexperiencing symptom (posttraumatic play, recurrent and
intrusive recollections of the traumatic event outside play,
404
repeated nightmares, physiological distress, and episodes of
flashbacks or dissociation), at least two hyperarousal symp-
toms (sleep problems, concentration problems, hypervigi-
lance, exaggerated startle response, irritability/anger), and at
least one numbing of responsiveness/interference with devel-
opmental progress symptom (increased social withdrawal,
restricted range of affect, markedly diminished interest or
participation in significant activities, and efforts to avoid
trauma reminders). The diagnostic criteria also include asso-
ciated symptoms (regression of developmental skills, new ag-
gression, new fears, and inappropriate sexual behaviors). This
pattern of symptoms should last for at least 1 month.
The DC:0–3R change of nomenclature from the original
traumatic stress disorder to PTSD is worth noting. The diag-
nosis of PTSD is predicated on the notion that trauma contin-
ues to have psychological sequelae after the traumatic event is
no longer present. This assumption does not reflect the every-
day reality of millions of children exposed to ongoing mal-
treatment and community violence, as well as recurrent expo-
sure to other traumatic stressors. Although there is much value
in adopting a single nomenclature for mental health disorders,
researchers and clinicians should incorporate an awareness of pre-
sent trauma in their research designs and clinical interventions,
and monitor for the ever-present possibility of new traumas in
the lives of the children and families they study or treat.
Diagnosing young children exposed to trauma remains a
challenge, complicated by the rapid developmental changes
in the first 5 years of life, the influence of observational con-
text on the young child’s behavior, the lack of verbal self-re-
port capacities in preverbal children, the limitations of parents
and caregivers as accurate observers and reporters, and the
time and expense involved in observing young children in a
variety of settings and for appropriately long periods of
time to gain a detailed understanding of their functioning in
the relevant developmental domains. Current research relies
on parent reports of children’s posttraumatic symptoms using
semistructured interviews or behavior checklists, which can
be biased, subjective, or insufficiently detailed. There re-
mains a need to have standardized instruments that improve
reliability and validity, with objective and precise reports of
symptoms. Progress in this area is under way. The Preschool
Aged Psychiatric Assessment is a structured psychiatric as-
sessment interview showing sound psychometric properties
(Egger et al., 2006; Sterba, Egger, & Angold, 2007). The
widely used Child Behavior Checklist (Achenbach & Rescorla,
2001) has been modified to assess PTSD in young children,
with promising results showing significantly higher scores in
children who had the full diagnosis of PTSD based on a semi-
structured diagnostic interview (Dehon & Scheeringa, 2006).
In summary, although knowledge in the area of the impact
of trauma on young children’s biological makeup and devel-
opmental course is still in its early stages, there is robust evi-
dence that children’s development is negatively affected by
traumatic exposure and that the brain structure and physiol-
ogy are implicated in these outcomes. These findings high-
light the urgency of preventing child victimization, screening
A. F. Lieberman et al.
for early trauma identification, developing effective treat-
ments that include both the child and the parent, and deploy-
ing the public health resources needed for these treatments to
be administered in a timely and effective manner.
Cumulative protective factors and resilience
Resilience in the face of childhood adversity has been defined
as a multifaceted amalgamation of genetic predispositions
and personal, familial, and environmental risk and protective
factors (Rutter, 1999). There is an extensive literature uphold-
ing the importance of protective psychological factors in the
prevention of negative outcomes (Taylor, Kemeny, Reed,
Bower, & Gruenewald, 2000), and children exposed to differ-
ent kinds of adversity frequently show resilience in the form
of protective characteristics that follow multiple pathways to
foster their positive development (Bonanno, 2004; Garmezy,
1991; Luthar, Cicchetti, & Becker, 2000; Luthar & Goldstein,
2004; Masten, 2001). Resilient maltreated children have been
characterized as showing positive self-esteem, ego flexibility,
and ego overcontrol (Cicchetti & Rogosch, 1997).
Quality of attachment seems to operate in conjunction with
ecological factors such as personal and contextual risk to in-
fluence child resilience. A prospective study with a commu-
nity sample of adolescent mothers recruited during their first
pregnancy and followed up during the first 3 years of their
child’s life found that most children showed a normative tra-
jectory of decline in problem behaviors over the preschool
years, but securely attached children whose mothers engaged
in positive parenting behaviors were significantly less likely
to develop a problem behavior trajectory when compared to
their anxiously attached peers (Keller, Spieker, & Gilchrist,
2005). A small proportion of children evidenced high initial
levels of disruptive behaviors that escalated over time. Specif-
ically, insecurely attached children with high levels of infant
negativity had a significantly greater likelihood of having a
high behavioral problem trajectory compared to securely at-
tached children with similarly high levels of infant negativity.
Children with avoidant attachment had a significantly higher
risk of a problem trajectory than children with any other at-
tachment classification, and three times the rate of securely at-
tached children (Keller et al., 2005).
Mothers who were maltreated as children but are able to
break the cycle of abuse when raising their own children con-
stitute an important group in understanding resilience, and
their experiences are particularly relevant to the practice of in-
fant mental health. The Minnesota Child–Parent Project study
provides some illuminating findings in this regard. The origi-
nal study recruited 267 primiparous women living in poverty
and with a history of childhood physical abuse, and followed
them prospectively from the third trimester of pregnancy until
their children were 24 months old. Sixty-two percent were sin-
gle mothers and over 85% of the pregnancies were unplanned.
Forty-four of the women in the sample had maltreated their chil-
dren by the time the child was 2 years old. A subsample of the
mothers was interviewed about their childhood history by
Trauma in early childhood
coders who did not know whether the mothers had abused
their children. The mothers who had continued the abuse
cycle described their childhoods in fragmented, disjointed,
inconsistent, and often highly idealized ways that were not
congruent with the factual events. In contrast, mothers who
had discontinued the abuse cycle provided coherent narra-
tives of their lives and were forthright in discussing their
childhood abuse with the interviewer, acknowledging what
had happened as an integral part of their identity but also
adopting a future-oriented stance toward their lives (Egeland
& Sussman-Stillman, 1996).
Clinical implications and empirically supported treatment
The findings about the predictors of resilience and interrup-
tion of the intergenerational transmission of trauma are con-
sistent with current clinical best practice in trauma treatment,
which consistently encourages the development of a trauma
narrative as a core component of the therapeutic process,
along with building a therapeutic working alliance, affect
modulation, trust in bodily sensations, realistic appraisal of
danger, ability to differentiate between reliving and remem-
ber, clinical stabilization, capacity for safe intimate relation-
ships, and placing the traumatic experience in the context
of creating positive engagement with developmentally appro-
priate goals (AACAP, 2010; Marmar, Foy, Kagan, & Pynoos,
1993). The AACAP Preschool Psychopharmacology Work-
ing Group reviewed existing literature to develop treatment
recommendations for preschool children with a range of psy-
chiatric diagnoses, and its recommendations for the assess-
ment and treatment of PTSD include made recommendations
for the assessment and treatment of PTSD in preschool chil-
dren (Gleason et al., 2007), including the adoption of devel-
opmentally sensitive use of the DSM-IV criteria in assessing
PTSD in preschoolers, regular monitoring for baseline symp-
toms with a structured measure, and the use of CPP and pre-
school-specific CBT as first-line therapeutic interventions for
preschoolers exposed to traumatic events (Gleason et al.,
2007). In light of the empirically documented treatment ef-
fects of psychotherapeutic interventions for preschoolers
with PTSD, the Preschool Psychopharmacology Working
Group did not recommend the use of psychopharmacological
treatment for PTSD in preschoolers. These recommendations
are consistent with those included in the 2010 AACAP Prac-
tice Parameter for the assessment and treatment of PTSD.
CPP is a relationship-based intervention grounded in psy-
choanalytic, attachment, and trauma theory that also includes
social learning and cognitive behavioral intervention strate-
gies as vehicles for change (Lieberman & Van Horn, 2005,
2008). CPP is guided by the core premise that young children
rely on their parent(s) or primary attachment figures for pro-
tection and safety, and that trauma shatters the child’s percep-
tion of the parent as a competent and reliable protector. In the
context of joint child–mother sessions, the CPP therapist sup-
ports the dyad in using play, words, and other forms of inter-
action to express and respond to emotional needs, cocreating
405
a narrative of their lives that includes the traumatic event with
the goal of breaking the taboo of silence about the trauma,
helping to modulate unmanageable traumatic stress, and re-
storing trust in the attachment relationship. The efficacy of
CPP is supported by several randomized clinical trials with
samples varying in child age, referring problems, and ethnic
and socioeconomic backgrounds in two separate university
settings. The samples include maltreated infants in the child
protection system (Cicchetti, Rogosch, & Toth, 2006), anx-
iously attached toddlers of low-income, recently immigrated
and often undocumented Latina mothers (Lieberman, Wes-
ton, & Pawl, 1991), toddlers of middle-class depressed moth-
ers (Cichetti, Toth, & Rogosch, 2000; Toth, Rogosch, Manly,
& Cichetti, 2006), maltreated preschoolers in the child wel-
fare system (Toth, Maughan, Manly, Spagnola, & Cicchetti,
2002), and preschoolers who witnessed domestic violence
against the mother in addition to other violence-related trau-
matic stressors (Lieberman, Van Horn, & Ghosh Ippen,
2005). Outcome findings include reductions in child and ma-
ternal psychiatric symptoms; more positive child attributions
of parents, themselves, and relationships; improvement in
quality of child–mother relationship and measures of security
of attachment; and improvements in child cognitive function-
ing. In a randomized trial with preschoolers who witnessed
domestic violence, the children in the CPP treatment group
not only maintained their therapeutic gains, but their mothers
continued to improve in their global psychiatric symptoms
when compared with mothers in the comparison group,
who received monthly case management as well as individual
treatment in the community (Lieberman, Ghosh Ippen, & Van
Horn, 2006).
These findings are important because they indicate that re-
lationship-based, trauma-focused treatment can lead to last-
ing improvements in the mother’s individual functioning
and buttress her emotional capacity to provide appropriate
care for the child.
Trauma-focused CBT (Cohen & Mannarino, 2008) is a
multicomponent model that can be summarized by the acro-
nym PRACTICE, which stands for the following compo-
nents: parental treatment, including parental skills; psychoed-
ucation; relaxation and stress management skills; affective
expression and modulation skills; cognitive coping skills;
trauma narrative and cognitive processing of the child’s trau-
matic experiences; in vivo desensitization to trauma remind-
ers; conjoint child–parent sessions; and enhancing safety
and future development. The parental treatment components
parallel the child components, with the parent and the child
learning their respective skills in separate sessions. Toward
the end of treatment, child and parent meet in joint sessions
to enable the child to share the trauma narrative with the par-
ents and to engage in tasks that build communication, en-
hance safety, and communicate and address remaining ques-
tions and concerns. Trauma-focused CBT for preschoolers is
supported by a randomized trial with sexually abused chil-
dren, who showed significant improvements in PTSD, inter-
nalizing, and sexual behavior symptoms when compared with
406
a control group receiving nondirective supportive therapy
(Cohen & Mannarino, 1996, 1997, 1998). A second, recently
published randomized study with preschoolers exposed to
events ranging from single-blow trauma to exposure to do-
mestic violence and victimization by Hurricane Katrina
showed that children in the trauma-focused CBT condition
showed significant improvement on symptoms of PTSD but
not on depression, separation anxiety, oppositional–defiant,
or attention-deficit/hyperactivity disorders (Scheeringa et al.,
2010).
Conclusions and Future Directions
Children in the birth to 5 age range are disproportionately vul-
nerable to traumatic events in the forms of inflicted and acci-
dental injury, and there is substantial overlap among different
forms of traumatization, with high percentages of traumatized
children exposed to more than one traumatic event and more
than one type of trauma and with interpersonal violence com-
prising the most frequent form of trauma exposure. Review-
ing the incidence and developmental and social sequelae of
children’s exposure to interpersonal violence, Steve Sharf-
stein (2006) concluded that this form of trauma is “the largest
single preventable cause of mental illness” and made the
analogy that “What cigarette smoking is to the rest of medi-
cine, early childhood violence is to psychiatry.” Research,
clinical intervention, and public policy need to respond to
this challenge within their own domains and through system-
atic collaboration across areas of specialization. The special
needs of children in the birth to 5 age range should be system-
atically incorporated in each of these efforts.
Research efforts should move away from focusing on single
sources of trauma and adopt methodologies that incorporate
structured assessments for the range of traumatic stressors
that are common in infancy and early childhood, from acci-
dents such as dog bites, severe burns, cuts and falls, car acci-
dents, and near drownings to witnessing domestic and commu-
nity violence, enduring physical and/or sexual abuse, and death
of a primary caregiver, sibling, or another person with whom
the child had close emotional ties. Although the long-term re-
percussions of cumulative adversities and traumatic exposures
has been studied among adults and older children, there is at
present no systematic assessment of the differential impact of
cumulative trauma exposure on young children. Epidemiolog-
ical surveys and longitudinal studies that investigate the impact
of different forms of trauma should include the birth to 5 age
range as a separate category to better understand the role of
the early years in children’s long-term developmental trajec-
tory. Clinical and research priorities converge in pointing to
the need for more accurate and developmentally sensitive
screening and assessment measures for trauma histories, symp-
tomatology, and general functioning for children in the birth to
5 age range. Closer research attention is needed to the cultural
dimensions of exposure to trauma and adversity, traumatic
stress, and coping mechanisms that promote resilience in differ-
ent ethnic, racial, and socioeconomic groups. Researchers
A. F. Lieberman et al.
should continue their efforts to develop and refine comprehen-
sive, standardized screening assessment instruments for early
childhood. The ethical challenges involved in these efforts
need to find a forum for debate and consensus in the field be-
cause there are legal repercussions among mandated reporters
who know about child abuse but do not report it. Researchers
may choose to not inquire about trauma exposure in order to
bypass the obligation to report abuse, an understandable self-
protective response that may have the unintended effect of im-
peding scientific progress. The problem of false-positive
screens that misidentify a child as being abused is a related con-
cern that can be minimized through the use of multiple evalua-
tions that increase the specificity of the screen (Harris, Putnam,
& Fairbank, 2006).
Appropriate clinical responses to trauma exposure for young
children are undermined by a “don’t ask, don’t tell” approach
where clinicians fail to probe systematically for the child’s pos-
sible exposure to traumatic events. The AACAP Practice Pa-
rameter (2010) recommendation of routinely asking for trauma
exposure and PTSD symptoms whenever a child is referred for
mental health services is in urgent need to widespread imple-
mentation. Although there is progress in developing and imple-
menting empirically supported forms of treatment for trauma-
tized young children, there are important limitations related to
attrition rates, length of follow-up, fidelity, treatment effect
size, efficacy versus effectiveness when research-based treat-
ment is disseminated to heterogeneous community-based clin-
ical settings, and the unanswered question of “what works for
whom?” (Roth & Fonagy, 2005). The problem of access to
mental health care for poor and minority children and their fam-
ilies is serious and protracted (President’s New Freedom Com-
mission on Mental Health, 2003). There is a significant lag time
between initial identification of children’s mental health or de-
velopmental impairment and the beginning of appropriate inter-
ventions, a situation that may lastingly derail the child’s healthy
developmental trajectory because early dysfunction can trigger
a cascade of maladaptive consequences that become progres-
sively more entrenched and resistant to intervention (Duncan,
Tildesley, Duncan, & Hops, 1995; Pynoos et al., 1999). The
lag between initial referral and treatment is particularly glaring
for children in the child welfare system, with 75% of diagnosed
children not having received treatment 12 months after initial
diagnosis (National Research Council and Institute of Medi-
cine, 2006). A powerful obstacle to mobilizing trauma re-
sources for young children is the erroneous but persistent as-
sumption among practitioners and the public at large that
young children are not affected by trauma and adversity (Na-
tional Research Council and Institute of Medicine, 2000).
The problem of access to timely and effective treatment is
compounded by the scarcity of mental health providers skilled
in treating children in the birth to 5 age range. The core cur-
riculum for graduate studies in psychology, psychiatry, social
work, and other mental health disciplines do not systematically
incorporate developmental psychopathology of infancy and
early childhood, and child mental health providers are gener-
ally trained in individual treatment approaches that do include
Trauma in early childhood
parents and are therefore not well suited for young children.
The shortage of infant mental health providers from minority
groups has a particularly negative impact on immigrant and
minority children and families, who need interventions that
are provided in their native language by practitioners who un-
derstand their cultural values and childrearing practices. The
current economic downturn aggravates this situation because
drastic staff layoffs in community programs and the child wel-
fare system create higher case loads, lower morale, and increase
staff vicarious traumatization. Specialized training and tech-
nical assistance are needed to create the workforce capacity
to close these service gaps (President’s New Freedom Com-
mission on Mental Health, 2003).
Public policy is an essential instrument to implement bene-
ficial change. The mental health service gaps deficits and efforts
to remedy them must engage a partnership between profession-
als working with young children, elected representatives, and
public interest advocates (Harris et al., 2007, 2006). A focus
on reducing significant stress and adversity in early childhood
has been proposed as an alternative to the traditional reliance
on pharmacological interventions to prevent disease and pro-
mote health (Shonkoff, Boyce, & McEwen, 2009). Public pol-
icy must systematically address the deficits in access to services
for traumatized young children and their families. Most trauma-
tized young children and families are not found in mental health
clinics but are users of pediatric care, childcare, the child welfare
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community-based services. Each of these systems represents a
significant entry point for intervention, and their effectiveness
can be significantly enhanced by adapting the principles of
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a comprehensive federal effort to increase access to service
and raise the standard of care for children and their families
across the United States (see http://www.nctsn.org). As a cen-
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is a collaborative of four university-based infant and early
childhood trauma programs at the University of California,
San Francisco, Boston Medical Center, Louisiana State Uni-
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goal of creating, evaluating, and disseminating effective
forms of intervention with traumatized young children and
their families across systems of care. Large randomized stud-
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with the goal of making empirically supported treatment
available for young traumatized children. Simultaneously,
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