Trauma among children and legal implications

Abstract Trauma is a public health crisis that is increasingly growing and spreading into every facet of our communities, including our school systems, prison systems, and medical systems. When children experience trauma, the impact can have lasting and negative effects that can influence daily functioning. Considering the Constructivist Self-Development Theory (CSDT) assertion that a child’s perception of the self and the world may be changed following a trauma, it is important that continuity of care is trauma-informed, in that professionals interacting with children who experienced trauma are actively working to not induce further or seeking to minimize additional stressors that may occur in these contexts. The purpose of this paper is to provide a guide on how to create a trauma-informed care community when specifically working with children. To accomplish this task, trauma is first defined. Next the effects of trauma on children are explained. A summary of implications for the forensic interviewing process and for a trauma-informed court system is provided.


PUBLIC INTEREST STATEMENT
Trauma is a public health crisis that is increasingly growing and spreading into every facet of our communities, including our school systems, prison systems, and medical systems. To address this growing epidemic, it is imperative for organizations to not only develop a trauma-informed care approach when providing services, but to collaborate those efforts with other community agencies that work with children affected by trauma. The purpose of this paper is to provide a guide on how to create a trauma-informed care community when working with children. A summary of implications for the forensic interviewing process and for a trauma-informed court system is provided.
efforts with other community agencies that work with clients affected by trauma. The purpose of this paper is to define key trauma-informed care terminology and to provide a guide on how to create a trauma-informed care community, specifically when working with children.

Trauma defined
Trauma is conceptualized in many different ways, from the more stringent criteria of the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) to a more ecological view of trauma in which psychological harm can arise from a wide array of experiences overtime that interact with development. The DSM-5 (American Psychiatric Association, 2013) defines trauma as, exposure to war as combatant or civilian, threatened or actual physical assault, threatened or actual sexual violence, being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural disasters, or human-made disasters, and severe motor vehicle accidents; medical incidents that qualify as traumatic events involve sudden, catastrophic events; witnessing events that include observing threatened or serious injury, unnatural death, physical or sexual abuse of another person due to violent assault, domestic violence, accident, war or disaster, or a medical catastrophe in one's child; and indirect exposure through learning about an event is limited to experiences affecting close relatives or friends and experiences that are violent or accidental such as violent personal assault, suicide, serious accident, and serious injury (pp. 274-275). Harris and Fallot (2001) conceptualize trauma as an experience that occurs when an external threat overwhelms aperson's internal and external positive coping resources. Finally, Substance Abuse and Mental Health Services Administration [SAMHSA] (2012) provides a more detailed definition of trauma which includes the event, the experience, and the effect of the traumatic event. According to SAMSHA (2012), individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being. There is general agreement that traumatic stress impairs functioning, decreases coping, and represents a normal response to the occurrence of an abnormal event. Many symptoms that are labeled as mental illnesses are common and normal reactions to exposure to a traumatic event. It is incumbent on the clinician to keep this in mind when assessing and treating traumatized populations. Trauma is individually defined. The same experience can be identified as traumatic by one person, but not by another person. Trauma can be "in the eye of the beholder," and it is important to understand the individual experience rather than assume something was or was not traumatic.

Types of trauma
There are many different types of traumatic experiences, such as physical abuse, sexual abuse, neglect, psychological/emotional abuse, community violence, natural disasters, serious accidents, parental death/grief, medical procedures and/or conditions, and terrorism. Additionally, there are also three common patterns of trauma: acute, complex, and poly-victimization. Acute trauma is a single traumatic event that has occurred with no previous trauma history. Complex trauma is a group of precarious and damaging events that causes traumatic shock, disruption in one's development, and the interruption of primary attachment bonds (Ford, Chapman, Connor, & Cruise, 2012). Continuous exposure to complex traumas can lead to internal symptoms of fear, depression, and somatic complaints and external symptoms of anger, aggression, oppositional defiant disorder, conduct disorder, and substance abuse (Ford et al., 2012). Poly-victimization occurs when a person experiences concurrent types of victimization such as physical assault and sexual during a specific time frame including from childhood to adulthood (Cuevas, Sabina, & Milloshi, 2012).
Trauma, by virtue of trauma itself, can create vulnerability. However, there are some populations that are particularly vulnerable to trauma and its impacts. The term vulnerable population implies the disadvantaged subsets of the community (Preethi, 2013). Such populations are important to review because trauma may disproportionately affect disadvantaged/vulnerable populations (Hsia & Shen, 2011). This article will specifically focus on trauma among children. Within this population, we will provide an overview and summary of the prevalence of trauma as well as manifestation.

Constructivist self-development theory
Constructivist Self-Development Theory (CSDT) is founded upon the constructivist view of trauma. CSDT proposes that individuals' construct their own realities, as they live and interact with the world (McCann & Pearlman,199). As such, the theory describes the impact of trauma to be experienced within the individuals' development of the self (Saakvitnee, Tennen, & Afflect, 1998). According to CSDT, the self is composed of five interrelated aspects: self-capacities, ego-resources, frame of reference, psychological needs, and cognitive schemas (Pearlman & Saakvitne, 1995). Experiencing trauma can alter an individual's beliefs and cognitive schemas, thus altering his or her perception of the world (McCann & Pearlman, 1992). Understanding changes in the self-view, when working with children, is imperative. It is vital to consider how a child's perception of the self and world may change after experiencing a trauma, considering the developmental descriptions found below.

Overview of population
Childhood is a unique timeframe of the lifespan, characterized by rapid growth, both physically and mentally (Beck, 2010). Due to a child's developmental period and their lack of self-agency, childhood can also be a vulnerable time period. Risk factors are those factors that increase children's vulnerability to negative developmental outcomes (Engle, Castle, & Menon, 1996). To combat risk factors, factors that aid in development and resilience should be considered.
The early years of a child's life are extremely important to his or her development. Several levels of interaction are important to a child's development, including that of child/caregiver interaction and the interaction the child receives from his or her environment (i.e. school, community, and other social interactions (Engle et al., 1996)). The role of caregivers is especially important during childhood, in that, such care is correlated with emotional, behavioral, and cognitive development (Felfe & Hsin, 2012). Parents, caregivers, health professionals, educators, and others should work together to help a child reach his or her full potential (Center for Disease Control and Prevention, 2016).

Prevalence of trauma in this population
Trauma exposure among children and families has been noted as a major public health priority with widespread consequences, including anger, depression, hostility, risky sexual behavior, poor self-esteem, school dropout, increased juvenile justice involvement, and increased substance use (Finkelhor, Ormrod, & Turner, 2007;Graves, Kaslow, & Frabutt, 2010;Osofsky, 1995Osofsky, , 1999. Research has documented that child witnesses and victims of violence develop rates of PTSD similar to the rates of combat soldiers returning from war (Alisic, Zalta, Wesel, & Larsen, 2014). Research has primarily focused on individual types of victimization, failing to examine complete victimization profiles that may include multiple types of victimization. A plethora of research has documented that children who have been victims of violence are at high risk of becoming violent themselves, and child victims who experience poly-victimization have been linked with even more negative outcomes than single victimization, including mental health problems, delinquency and other difficulties, including serious subsequent health conditions (Finkelhor et al., 2007). Polyvictimization leads to more deleterious and less reversible effects (Felitti et al. 1998;Finkelhor et al., 2007), so all forms of victimization a child may have experienced are important to assess if we are to holistically intervene properly and successfully.
The significance of trauma exposure and poly-victimization as a public health priority is clear when one considers the finding from the Adverse Childhood Experiences (ACE) study documenting that the adults who were exposed as children to six or more traumatic events have a 20-year shorter life span (Felitti et al., 1998). The Children's Exposure to Violence study (Finkelhor et al., 2009) indicated that more than 60% of this nation's children were exposed to violence, either directly or indirectly, and that poly-victimization was common, with more than 33% of children experiencing two or more direct victimizations during the past year. Using a wider time frame of "ever been victimized" as an anchor, Finkelhor et al. (2007) found that 71% of children surveyed through a national sample experienced at least one form of victimization, with 69% of those indicating more than one type of victimization. With these national statistics, we must work hard to forward not only the research base on poly-victimization, but also apply this information to our understanding of how intervention models can work to ameliorate the effects of poly-victimization on children and families.
A substantial amount of research, including two meta-analytic reviews, indicates that child victims and witnesses of violence also are more prone to become perpetrators of violence both as children and as adults (Kitzman et al., 2003;Wolfe et al., 2003). These findings extend to exposure to both home and community violence as well, with meta-analyses indicating that child witnesses of violence show similar outcomes to child who are the direct victims of violence (Evans, Davies, & DiLillo, 2008). Research has documented that children who experience poly-victimization are at particularly elevated risk for later violence perpetration (Dehart, 2009).

How does trauma manifest in this population?
Trauma can occur directly to children, or children can witness potentially traumatic events. Nevertheless, children who experience or witness trauma may develop a host of different symptoms, including internalizing thoughts such as being bad, unworthy, incompetent, or even believe the world is a threatening and dangerous place (Giaconia et al., 1995;Ringel & Brandell, 2012). Other symptoms of traumatic stress reactions in children include cognitive (e.g. memory problems, poor verbal skills, difficulty focusing or learning at school, poor skill development, development learning disabilities), behavioral (e.g. excessive temper, demand attention through both positive and negative behavior, regression, acting out in social situations, screams or cries excessively, startles easily), psychological/emotional (unable to trust others, development of new fears, nightmares, fear of being separated from caregiver, withdrawn, loss of interest in normal activities, irritability, sadness, anxiety, etc.), and physiological symptoms (poor appetite, weight change, digestive problems, difficulties sleeping, enuresis and/or encopresis, etc.) (American Psychological Association, 2018; Gabbay, Oatis, Silva, & Hirsch, 2004;National Child Traumatic Stress Network, n.d.).
When seeking to understand the impact of trauma on children, it is vital to consider the spectrum of developmental derailments that can occur in addition to trauma exposure. Oftentimes, when diagnosing children with PTSD, the developmental effects of childhood trauma are not fully captured. Research by Van der Kolk (2010) describes such examples as being: "the complex disruption of affect regulation; the disturbed attachment patterns; the rapid behavioral regressions and shifts in emotional states; the loss of autonomous strivings; the aggressive behavior against self and others; the failure to achieve developmental competencies; the loss of bodily regulation in the areas of sleep, food, and self-care; the altered schemas of the world; the anticipatory behavior and traumatic expectations; the multiple somatic problems, from gastrointestinal distress to headaches; the apparent lack of awareness of danger and resulting self endangering behaviors; the self-hatred and self-blame; and chronic feelings of ineffectiveness" (p. 6).
For children who experience trauma, such maladaptive mental health symptoms may occur (Centers for Disease Control and Prevention, 2016). Mental health in childhood means reaching developmental and emotional milestones, and learning healthy social skills and how to cope when there are problems. When working with children who have experienced trauma, the most pressing concern should be the establishment of safety and comfort for the child; later mental health goals should center around strengthening coping skills, making meaning from tragedy, and establishing new goals and a healthier world view (Ringel & Brandell, 2012).
When children have experienced and reported such trauma, the legal system may investigate allegations through the use of forensic interviews. Undergoing forensic interviews and even being involved in the court system in general can be a confusing experience for all populations, especially children. Considering the CSDT assertion that a child's perception of the self and the world may be changed following a trauma (McCann & Pearlman, 1990;Pearlman & Saakvitne, 1995;Saakvitnee et al., 1998), it is important that such continuity of care is trauma-informed, in that professionals are actively working to not induce further or seeking to minimize additional stressors that may occur in these contexts.

Implications for the forensic interviewing process
A forensic interview is a "non-leading, victim sensitive, neutral, and developmentally appropriate investigative interview that helps law enforcement determine whether a crime occurred and what happened; the goals of a forensic interview are to minimize any potential trauma to the victim, maximize information obtained from the victims and witnesses, reduce contamination of the victim's memory of the alleged event(s), and maintain the integrity of the investigative process" (O' Donohue & Fanetti, 2016;Office of Justice Programs, n.d.). While forensic interviewers are trained by national child advocacy centers or law enforcement agencies in specific, non-invasive, interviewing strategies (National Children's Advocacy Center, 2016; O 'Donohue & Fanetti, 2016, Volpini, Melis, Petralia, & Rosenberg, 2016, forensic interviewers are not required to hold a degree in any type of mental health studies. Therefore, understanding trauma, trauma symptoms, and appropriate responses to trauma reactions may not fully be understood, but nevertheless, is an understanding that is vital for working with children. When working with children through any forensics and/or court proceedings, specific characteristics of this population should be considered to utilize a trauma-informed approach. Working with children through the forensics and/or court processes can be more effective and sensitive if professionals are trauma-informed. In such settings, if the underlying trauma is not recognized or even not responded to appropriately, the chances of re-traumatization are increased (Knight, 2018).
In most cases, children are brought to the interview by adults… and at other's demands, rather than their own voluntariness to tell. Due to a child's developmental period and their lack of self-agency (Beck, 2010), children may feel anxious, nervous, and/or reticent (Saywitz, Larson, Hobbs, &Wells, 2015). Interviews in legal contexts often demand a level of honesty, openness, and trust from children that is rare in the way children typically interact with unfamiliar adults. Establishing a sense of safety should be the first objective for the professional.
Professionals should take into consideration the child's developmental level (i.e. their developmental abilities) (American Psychological Association, 2016), the child's mode of communication, and should never attempt to force a disclosure or continue when a child becomes distressed (this may re-traumatize the child); instead, additional, non-duplicative, interviews may be needed (U.S. Department of Justice, 2015). During the court process, closed courtrooms and prior orientation to the court and process may be beneficial to the child.

Implications for the court process
Trauma-informed court is defined as a system in which all aspects (including environments, policies, procedures, and practices) are specifically designed by professionals to strive to reduce that chances of potential and unnecessary stress reactions in those who have been exposed to trauma (National Council of Juvenile and Family Court Judges, 2015). Whereas the court environment can be a place for toxic stress, courts and judges are in a unique position to identify those suffering for such traumatic stress and help create safe court systems and practices (Sickmund, 2016). While professionals working in the court system and handling court proceedings are trained in their specific area, many may not have the mental health educational background to fully understand the trauma-informed care approach to working with victims experiencing posttrauma symptoms.
The stress of the courtroom environment may affect testimony of the survivors by diminishing their ability to communicate effectively with the judge or court personnel (Crenshaw, Stella, O'Neill-Stephens, & Watsen, 2016;SAMSHA, 2014). During court proceedings and among all populations, it may be the first time the survivor has seen the abuser since the incident. Traumatic triggers and reminders may cause the survivor to feel uneasy, anxious, afraid, or terrified (Otto, 2015).
In such instances, trauma symptoms may be overwhelming (Hart, 2015). It is vital to help the survivor has some control in the situation. This can include having control of where to sit, which way to face, and whom to look at. Planning support for the client, offering virtual tours of the courtroom in advance, suggesting a "night before plan", and helping them to make a "what if plan" can be helpful in feeling some control in an environment that is overwhelming (National Center on Domestic Violence, Trauma & Mental Health, 2015). Grounding techniques may be needed for the client's answers that are incomplete or slow in response (a sign of dissociation) (Hart, 2015).
For those in the judicial profession, working with trauma survivors can be complemented by the way the court proceeding is set up and handled. By communicating effectively, with dignity and respect, professionals and convey care and understanding to the survivors (SAMSHA, 2014). Legal proceedings may be stressful for all individuals, regardless of age. For children who have experienced trauma, there may be an even greater need for rapport building efforts (Saywitz et al., 2015). The courtroom environment may be modified so that any threatening or unnecessary court procedures are eliminated; Providing victim advocates, safe waiting areas, and closed courtrooms to reduce fear can help victims in these legal processes (SAMSHA, 2014).
Trauma-informed procedures should be applied when working with child survivors in legal proceedings. A culturally relevant, trauma-informed framework takes into consideration advocacy during legal interviews, traumatic triggers, memory, trust building, frustration and anger, emotional safety planning for court, preparing for court, staying on track, and reflective practice (National Center on Domestic Violence, Trauma & Mental Health, 2012). For all individuals who have experienced trauma, forensic interviews and court proceedings may be a stressful process that can have the possibility of exacerbating post-trauma symptoms (Crenshaw et al., 2016;Hart, 2015;Otto, 2015). Professionals working with survivors in these settings should fully understand the ramifications of post-traumatic stress on the legal process and work with the children in ways that aid in recovery, rather than run the risk of inducing more stress on the survivors.

Conclusions: toward a trauma-informed court system
The mission of the legal proceedings and the court system is complex indeed. The legal system is tasked with protecting society, safeguarding children and their families, and holding perpetrators accountable while also supporting their rehabilitation (National Council of Juvenile and Family Court Judges, 2014; SAMSHA, 2014). To be most effective in its mission, the legal system must also understand the role of trauma in the lives of survivors and engage in resources and interventions that address traumatic stress in a trauma-informed, sensitive way.
Creating more coordination and communication across forensics and court systems through an understanding of trauma and its impacts would prove greatly beneficial (Crenshaw et al., 2016). Trauma-informed court systems must collaborate with other systems to provide cross-training and cross-interdisciplinary integration among forensic teams, court staff, law enforcement, and social service and community agencies. Joining forces together can help minimize the risk of re-exposing children to additional trauma and encourage consistent trauma-informed services throughout the legal process. Another way of creating trauma-informed systems is to provide trauma-focused education and skill-building trainings to all forensic and court staff. Systems should educate and train their staff on a variety of topics on a regular schedule (Sickmund, 2016). Once the staff has been educated on traumainformed care, the staff will need to learn how to apply the education they have learned within their work setting and be supported by effective supervisors (Guarino, Soares, Konnath, Clervil, & Bassuk, 2009).
By developing a greater knowledge about trauma and its impacts, and successfully integrating these components through cross-systems coordination, forensic teams and courts can move toward becoming more trauma-informed. As trauma-informed systems begin to develop partnerships within their community, trauma-informed communities will begin to emerge. Traumainformed communities include collaborative efforts among multidisciplinary practices that provide trauma-focused interventions that minimize re-traumatization.
In sum, creating a greater awareness regarding the prevalence and impact of trauma in children has the potential to result in more effective, less re-traumatizing forensic and court proceedings. As we understand that experiencing trauma can impact a child's perception of the self and the world (McCann & Pearlman, 1990), aftercare procedures need not further traumatize the child. In this sense, court systems can become more trauma-informed through an increased awareness and understanding about the impact trauma can have across a variety of vulnerable populations.

Funding
This study was not grant funded and received no compensation of any sort.