Week 11

PSYCHIATRIC ANNALS 35:5 | MAY 2005 401

C M E

C
hildhood trauma, including abuse and neglect, is probably the single
most important public health challenge in the United
States, a challenge that has the po-

tential to be largely resolved
by appropriate

prevention
and intervention.
Each year, more than 3 mil-
lion children are reported to authorities
for abuse or neglect in the US; about 1 million
of those cases are substantiated.1 Many thousands more

Dr. van der Kolk is profes-

sor of psychiatry, Boston

University Medical School,

Boston, MA; clinical director,

The Trauma Center at Justice

Resource Institute, Brookline,

MA; and co-director, the Na-

tional Child Traumatic Stress

Network Community Pro-

gram, Boston.

Address reprint requests

to: Bessel A. van der Kolk, MD,

16 Braddock Park, Boston,

MA 02116.

Dr. van der Kolk has no in-

dustry relationships to disclose.

The following members

of the National Child Trau-

matic Stress Network DSM-

V task force contributed

to the development of the

proposed diagnosis of devel-

opmental trauma dis :

Marylene Cloitre, PhD; Julian

Ford, PhD; Alicia Lieberman,

PhD; Frank Putnam, MD;

Robert Pynoos, MD; Glenn

Saxe, MD; Michael Scheerin-

ga, PhD; Joseph Spinazzola,

PhD; Allan Steinberg, MD;

and Martin Teicher, MD, PhD.

doi:10.3928/00485713-

20050501-06

Developmental
Toward a rational diagnosis for children with complex trauma histories.

Bessel A. van der Kolk, MD

Trauma Dis

402 PSYCHIATRIC ANNALS 35:5 | MAY 2005

undergo traumatic medical and surgical
procedures and are victims of accidents
and of community violence (see Spinaz-
zola et al., page 433). However, most trau-
ma begins at home; the vast majority of
people (about 80%) responsible for child
maltreatment are children’s own parents.

Inquiry into developmental milestones
and family medical history is routine in
medical and psychiatric examinations.
In contrast, social taboos prevent obtain-
ing information about childhood trauma,
abuse, neglect, and other exposures to
violence. Research has shown that trau-
matic childhood experiences not only
are extremely common but also have a
profound impact on many different areas
of functioning. For example, children ex-
posed to alcoholic parents or domestic vi-
olence rarely have secure childhoods; their
symptomatology tends to be pervasive
and multifaceted and is likely to include
depression, various medical illnesses, and
a variety of impulsive and self-destructive
behaviors. Approaching each of these
problems piecemeal, rather than as expres-
sions of a vast system of internal disorga-
nization, runs the risk of losing sight of the
forest in favor of one tree.

COMPLEX TRAUMA
The traumatic stress field has adopted

the term “complex trauma” to describe
the experience of multiple, chronic and
prolonged, developmentally adverse trau-
matic events, most often of an interper-

sonal nature (eg, sexual or physical abuse,
war, community violence) and early-life
onset. These exposures often occur within
the child’s caregiving system and include
physical, emotional, and educational ne-
glect and child maltreatment beginning
in early childhood (Cook et al., page 390,
and Spinazzola et al., page 433).

In the Adverse Childhood Experi-
ences (ACE) study by Kaiser Permanente
and the Centers for Disease Control and
Prevention,2 17,337 adult health mainte-
nance organization (HMO) members re-
sponded to a questionnaire about adverse
childhood experiences, including child-
hood abuse, neglect, and family dysfunc-
tion. Eleven percent reported having been
emotionally abused as a child, 30.1% re-
ported physical abuse, and 19.9% sexual
abuse. In addition, 23.5% reported being
exposed to family alcohol abuse, 18.8%
were exposed to mental illness, 12.5%
witnessed their mothers being battered,
and 4.9% reported family drug abuse.

The ACE study showed that adverse
childhood experiences are vastly more
common than recognized or acknowledged
and that they have a powerful relationship
to adult health a half-century later. The
study confirmed earlier investigations that
found a highly significant relationship be-
tween adverse childhood experiences and
depression, suicide attempts, alcoholism,
drug abuse, sexual promiscuity, domes-
tic violence, cigarette smoking, obesity,
physical inactivity, and sexually transmit-
ted diseases. In addition, the more adverse
childhood experiences reported, the more
likely a person was to develop heart dis-
ease, cancer, stroke, diabetes, skeletal frac-
tures, and liver disease.

Isolated traumatic incidents tend to
produce discrete conditioned behavioral
and biological responses to reminders
of the trauma, such as those captured in
the posttraumatic stress dis (PTSD)
diagnosis. In contrast, chronic maltreat-
ment or inevitable repeated traumatiza-
tion, such as occurs in children who are
exposed to repeated medical or surgical

procedures, have a pervasive effects on
the development of mind and brain.

Chronic trauma interferes with neuro-
biological development (Ford, see page
410) and the capacity to integrate sensory,
emotional and cognitive information into
a cohesive whole. Developmental trauma
sets the stage for unfocused responses to
subsequent stress,3 leading to dramatic
increases in the use of medical, correc-
tional, social and mental health services.4
People with childhood histories of trau-
ma, abuse and neglect make up almost
the entire criminal justice population in
the US.5 Physical abuse and neglect are
associated with very high rates of arrest
for violent offenses. In one prospective
study of victims of abuse and neglect,
almost half were arrested for nontraffic-
related offenses by age 32.6 Seventy-five
percent of perpetrators of child sexual
abuse report to have themselves been
sexually abused during childhood.7

These data suggest that most inter-
personal trauma on children is perpetu-
ated by victims who grow up to become
perpetrators or repeat victims of violence.
This tendency to repeat represents an in-
tegral aspect of the cycle of violence in
our society.

TRAUMA, CAREGIVERS, AND AFFECT
TOLERANCE

Children learn to regulate their behav-
ior by anticipating their caregivers’ re-
sponses to them.8 This interaction allows
them to construct what Bowlby called
“internal working models.”9 A child’s in-
ternal working models are defined by the
internalization of the affective and cogni-
tive characteristics of their primary rela-
tionships. Because early experiences oc-
cur in the context of a developing brain,
neural development and social interac-
tion are inextricably intertwined. As Don
Tucker has said: “For the human brain,
the most important information for suc-
cessful development is conveyed by the
social rather than the physical environ-
ment. The baby brain must begin partici-

EDUCATIONAL OBJECTIVES

1. Identify emotional triggers
and patterns of re-enactment
in traumatized children.

2. Discuss the spectrum of de-
velopmental derailments sec-
ondary to complex trauma
exposure.

3. Describe patterns of accom-
modation in traumatized
children.

PSYCHIATRIC ANNALS 35:5 | MAY 2005 403

pating effectively in the process of social
information transmission that offers entry
into the culture.”10

Early patterns of attachment affect the
quality of information processing through-
out life.11 Secure infants learn to trust both
what they feel and how they understand
the world. This allows them to rely on both
their emotions and their thoughts to react
to any given situation. Their experience of
feeling understood provides them with the
confidence that they are capable of making
good things happen and that, if they do not
know how to deal with difficult situations,
they can find people who can help them
find a solution.

Secure children learn a complex vo-
cabulary to describe their emotions, such
as love, hate, pleasure, disgust, and anger.
This allows them to communicate how
they feel and to formulate efficient re-
sponse strategies. They spend more time

describing physiological states such as
hunger and thirst, as well as emotional
states, than do maltreated children.12

Under most conditions, parents are
able to help their distressed children re-
store a sense of safety and control. The
security of the attachment bond mitigates
against trauma-induced terror. When trau-
ma occurs in the presence of a supportive,
if helpless, caregiver, the child’s response
is likely to mimic that of the parent — the
more disorganized the parent, the more
disorganized the child.13

However, if the distress is overwhelm-
ing, or when the caregivers themselves
are the source of the distress, children
are unable to modulate their arousal. This
causes a breakdown in their capacity to

process, integrate, and categorize what is
happening. At the core of traumatic stress
is a breakdown in the capacity to regu-
late internal states. If the distress does not
ease, the relevant sensations, affects, and
cognitions cannot be associated — they
are dissociated into sensory fragments14
— and, as a result, these children cannot
comprehend what is happening or devise
and execute appropriate plans of action.

When caregivers are emotionally ab-
sent, inconsistent, frustrating, violent,
intrusive, or neglectful, children are
likely to become intolerably distressed
and unlikely to develop a sense
that the ex-

t e r n a l
environment
is able to provide relief.
Thus, children with insecure at-
tachment patterns have trouble relying
on others to help them and are unable
to regulate their emotional states by
themselves. As a result, they experience
excessive anxiety, anger, and longings
to be taken care of. These feelings may
become so extreme as to precipitate dis-
sociative states or self-defeating aggres-
sion. “Spaced out” and hyperaroused
children learn to ignore either what they

feel (their emotions), or what they per-
ceive (their cognitions).

When children are unable to achieve a
sense of control and stability, they become
helpless. If they are unable to grasp what
is going on and unable do anything about
it to change it, they go immediately from
(fearful) stimulus to (fight/flight/freeze)
response without being able to learn from
the experience. Subsequently, when ex-
posed to reminders of a trauma (eg, sen-
sations, physiological states,
i m a g e s ,

sounds, situ-
ations), they tend to be-
have as if they were traumatized
all over again — as a catastrophe.15 Many
problems of traumatized children can be
understood as efforts to minimize objec-
tive threat and to regulate their emotional
distress.16 Unless caregivers understand

Secure children learn a complex
vocabulary to describe their
emotions, such as love, hate,
pleasure, disgust, and anger.

404 PSYCHIATRIC ANNALS 35:5 | MAY 2005

the nature of such re-enactments, they are
likely to label the child as “oppositional,”
“rebellious,” “unmotivated,” or “antiso-
cial.”

THE DYNAMICS OF CHILDHOOD
TRAUMA

Young children, still embedded in the
here-and-now and lacking the capacity to
see themselves in the perspective of the
larger context, have no choice but to see
themselves as the center of the universe.
In their eyes, everything that happens is
related directly to their own sensations.
Development consists of learning to mas-
ter and “own” one’s experiences and to

learn to experience the present as part of
one’s personal experience over time.17
Piaget18 called this “decentration”: mov-
ing from being one’s reflexes, move-
ments, and sensations to having them.

Predictability and continuity are critical
for a child to develop a good sense of cau-
sality and learn to categorize experience.
A child needs to develop categories to be
able to place any particular experience in a
larger context. Only then will he or she be
able to evaluate what is happening and en-
tertain a range of options with which they
can affect the outcome of events. Imagin-
ing being able to play an active role leads
to problem-focused coping.15

If children are exposed to unmanage-
able stress and if the caregiver does not
take over the function of modulating the
child’s arousal, as occurs when children
are exposed to family dysfunction or vio-
lence, the child will be unable to organize
and categorize experiences in a coherent
fashion. Unlike adults, children do not
have the option to report, move away or
otherwise protect themselves; they depend
on their caregivers for their very survival.

When trauma emanates from within
the family, children experience a crisis of
loyalty and organize their behavior to sur-
vive within their families. Being prevent-
ed from articulating what they observe
and experience, traumatized children will
organize their behavior around keeping
the secret, deal with their helplessness
with compliance or defiance, and accli-
mate in any way they can to entrapment
in abusive or neglectful situations.19

When professionals are unaware of
children’s need to adjust to traumatizing
environments and expect that children
should behave in accordance with adult
standards of self-determination and au-
tonomous, rational choices, these mal-
adaptive behaviors tend to inspire revul-
sion and rejection. Ignorance of this fact
is likely to lead to labeling and stigmatiz-
ing children for behaviors that are meant
to ensure survival.

Being left to their own devices leaves
chronically traumatized children with
deficits in emotional self-regulation.
This results in problems with self-defi-
nition as reflected by a lack of a con-
tinuous sense of self, poorly modulated
affect and impulse control, including
aggression against self and others, and
uncertainty about the reliability and pre-
dictability of others, expressed as dis-
trust, suspiciousness, and problems with
intimacy, resulting in social isolation.20
Chronically traumatized children tend to
suffer from distinct alterations in states
of consciousness, including amnesia,
hypermnesia, dissociation, depersonal-
ization and derealization, flashbacks and

SIDEBAR.

Developmental Trauma Dis

A. Exposure

• Multiple or chronic exposure to one or more forms of developmentally ad-
verse interpersonal trauma (eg, abandonment, betrayal, physical assaults,
sexual assaults, threats to bodily integrity, coercive practices, emotional
abuse, witnessing violence and death).

• Subjective experience (eg, rage, betrayal, fear, resignation, defeat, shame).

B. Triggered pattern of repeated dysregulation in response to trauma cues

Dysregulation (high or low) in presence of cues. Changes persist and do not
return to baseline; not reduced in intensity by conscious awareness.

• Affective.

• Somatic (eg, physiological, motoric, medical).

• Behavioral (eg, re-enactment, cutting).

• Cognitive (eg, thinking that it is happening again, confusion, dissociation,
depersonalization).

• Relational (eg, clinging, oppositional, distrustful, compliant).

• Self-attribution (eg, self-hate, blame).

C. Persistently Altered Attributions and Expectancies

• Negative self-attribution.

• Distrust of protective caretaker.

• Loss of expectancy of protection by others.

• Loss of trust in social agencies to protect.

• Lack of recourse to social justice/retribution.

• Inevitability of future victimization.

D. Functional Impairment

• Educational.

• Familial.

• Peer.

• Legal.

• Vocational.

PSYCHIATRIC ANNALS 35:5 | MAY 2005 405

nightmares of specific events, school
problems, difficulties in attention regu-
lation, disorientation in time and space,
and sensorimotor developmental disor-
ders. The children often are literally are
“out of touch” with their feelings, and
often have no language to describe in-
ternal states.21

When a child lacks a sense of predict-
ability, he or she may experience diffi-
culty developing object constancy and
inner representations of their own inner
world or their surroundings. As a result,
they lack a good sense of cause and ef-
fect and of their own contributions to
what happens to them. Without internal
maps to guide them, they act instead of
plan and show their wishes in their be-
haviors, rather than discussing what they
want.15 Unable to appreciate clearly who
they or others are, they have problems
enlisting other people as allies on their

behalf. Other people are sources of ter-
ror or pleasure but are rarely fellow hu-
man beings with their own sets of needs
and desires.

These children also have difficulty
appreciating novelty. Without a map to
compare and contrast, anything new is
potentially threatening. What is familiar
tends to be experienced as safer, even if it
is a predictable source of terror.15

Traumatized children rarely discuss
their fears and traumas spontaneously.
They also have little insight into the re-
lationship between what they do, what
they feel, and what has happened to them.
They tend to communicate the nature of
their traumatic past by repeating it in the
form of interpersonal enactments, both in

their play and in their fantasy lives.

CHILDHOOD TRAUMA AND
PSYCHIATRIC ILLNESS

Posttraumatic stress dis (PTSD)
is not the most common psychiatric diag-
nosis in children with histories of chronic
trauma (Cook et al., see page 390). For
example, in one study of 364 abused chil-
dren,22 the most common diagnoses in or-
der of frequency were separation anxiety
dis , oppositional defiant dis ,
phobic dis s, PTSD, and ADHD.22
Numerous studies of traumatized children
find problems with unmodulated
aggression and

impulse
control,23,24 at-
tentional and dissociative
problems,25 and difficulty negoti-
ating relationships with caregivers, peers,
and, later in life, intimate partners.26

A history of childhood physical and sex-
ual assault is associated with a host of other
psychiatric diagnoses in adolescence and
adulthood. These may include substance
abuse, b line and antisocial personal-
ity, or eating, dissociative, affective, so-
matoform, cardiovascular, metabolic, im-
munologic, and sexual dis s.27

The results of the Diagnostic and
Statistical Manual of Mental Dis s,
fourth ediction (DSM-IV),28 Field Trial
suggested that trauma has its most perva-
sive impact during the first decade of life
and becomes more circumscribed (ie,
more like “pure” PTSD) with age.29 The
diagnosis of PTSD is not developmen-
tally sensitive and does not adequately
describe the effect of exposure to child-
hood trauma on the developing child.
Because infants and children
who ex-

p e –
r i e n c e
multiple forms of
abuse often experience devel-
opmental delays across a broad spec
trum, including cog
nitive, language, motor, and social-
ization skills,30 they tend to dis-
play very complex disturbances, with

A history of childhood physical
and sexual assault is associated
with a host of other psychiatric
diagnoses in adolescence
and adulthood.

406 PSYCHIATRIC ANNALS 35:5 | MAY 2005

a variety of different, often fluctuating,
presentations.

However, because there currently is
no other diagnostic entity that describes
the pervasive effects of trauma on child
development, these children are given
a range of “comorbid” diagnoses, as if
they occurred independently from the
PTSD symptoms. None of these do
justice to the spectrum of problems of
traumatized children, and none provide
guidelines on what is needed for effec-
tive prevention and intervention. By
relegating the full spectrum of trauma-
related problems to seemingly unrelated
“comorbid” conditions, fundamental
trauma-related disturbances may be lost
to scientific investigation, and clinicians
may run the risk of applying treatment
approaches that are not helpful.

A NEW DIAGNOSIS:
DEVELOPMENTAL TRAUMA
DISORDER

The question of how best to organize
the very complex emotional, behavioral,
and neurobiological sequelae of child-
hood trauma has vexed clinicians for sev-
eral decades. Because DSM-IV includes a
diagnosis for adult onset trauma, PTSD,
this label often is applied to traumatized
children as well. However, the majority
of traumatized children do not meet di-
agnostic criteria for PTSD31 (Cook et al.,
see page 390), and PTSD cannot capture
the multiplicity of exposures over critical
developmental periods.

Moreover, the PTSD diagnosis does
not capture the developmental effects of
childhood trauma: the complex disrup-
tions of affect regulation; the disturbed
attachment patterns; the rapid behavioral
regressions and shifts in emotional states;
the loss of autonomous strivings; the ag-
gressive behavior against self and others;
the failure to achieve developmental com-
petencies; the loss of bodily regulation in
the areas of sleep, food, and self-care; the
altered schemas of the world; the anticipa-
tory behavior and traumatic expectations;

the multiple somatic problems, from gas-
trointestinal distress to headaches; the
apparent lack of awareness of danger and
resulting self endangering behaviors; the
self-hatred and self-blame; and the chron-
ic feelings of ineffectiveness.

Interestingly, many forms of interper-
sonal trauma, in particular psychological
maltreatment, neglect, separation from
caregivers, traumatic loss, and inappro-
priate sexual behavior, do not necessar-
ily meet DSM-IV “Criterion A” defini-
tion for a traumatic event. This criteria
requires, in part, an experience involving
“actual or threatened death or serious in-
jury, or a threat to the physical integrity
of self or others.”28 Children exposed to
these common types of interpersonal ad-
versity thus typically would not qualify
for a PTSD diagnosis unless they also
were exposed to experiences or events
that qualify as “traumatic,” even if they
have symptoms that would otherwise
warrant a PTSD diagnosis.

This finding has several implications
for the diagnosis and treatment of trauma-
tized children and adolescents. Non-Cri-
terion A forms of childhood trauma expo-
sure — such as psychological or emotional
abuse and traumatic loss — have been
demonstrated to be associated with PTSD
symptoms and self-regulatory impair-
ments in children32 and into adulthood.33
Thus, classification of traumatic events
may need to be defined more broadly, and
treatment may need to address directly the
sequelae of these interpersonal adversities,
given their prevalence and potentially se-
vere negative effects on children’s devel-
opment and emotional health.

The Complex Trauma taskforce of the
National Child Traumatic Stress Network
has been concerned about the need for a
more precise diagnosis for children with
complex histories. In an attempt to more
clearly delineate what these children suf-
fer from and to serve as a guide for ratio-
nal therapeutics this taskforce has started
to conceptualize a new diagnosis, pro-
visionally called developmental trauma

dis (Sidebar, see page 404). This
proposed diagnosis is organized around
the issue of triggered dysregulation in re-
sponse to traumatic reminders, stimulus
generalization, and the anticipatory orga-
nization of behavior to prevent the recur-
rence of the trauma effects.

This provisional diagnosis is based
on the concept that multiple exposures
to interpersonal trauma, such as aban-
donment, betrayal, physical or sexual as-
saults, or witnessing domestic violence,
have consistent and predictable conse-
quences that affect many areas of func-
tioning. These experiences engender in-
tense affects, such as rage, betrayal, fear,
resignation, defeat, and shame, and ef-
forts to ward off the recurrence of those
emotions, including the avoidance of ex-
periences that precipitate them or engag-
ing in behaviors that convey a subjective
sense of control in the face of potential
threats. These children tend to reenact
their traumas behaviorally, either as per-
petrators (eg, aggressive or sexual acting
out against other children) or in frozen
avoidance reactions. Their physiological
dysregulation may lead to multiple so-
matic problems, such as headaches and
stomachaches, in response to fearful and
helpless emotions.

Persistent sensitivity to reminders inter-
feres with the development of emotional
regulation and causes long-term emotional
dysregulation and precipitous behavior
changes. Children’s over- and underre-
activity is manifested on multiple levels:
emotional, physical, behavioral, cognitive,
and relational. They have fearful, enraged,
or avoidant emotional reactions to minor
stimuli that would have no significant ef-
fect on secure children. After having be-
come aroused, these children have a great
deal of difficulty restoring homeostasis
and returning to baseline. Insight and un-
derstanding about the origins of their reac-
tions seems to have little effect.

In addition to the conditioned physi-
ological and emotional responses to re-
minders characteristic of PTSD, children

PSYCHIATRIC ANNALS 35:5 | MAY 2005 407

with complex trauma develop a view of
the world that incorporates their betrayal
and hurt. They anticipate and expect the
trauma to recur and respond with hyper-
activity, aggression, defeat, or freeze re-
sponses to minor stresses. Cognition in
these children also is affected by remind-
ers of the trauma. They tend to become
confused, dissociated, and disoriented
when faced with stressful stimuli. They
easily misinterpret events in the direction
of a return of trauma and helplessness,
which causes them to be constantly on
guard, frightened, and overreactive.

In addition, expectations of a return of
the trauma permeate their relationships.
This is expressed as negative self-attri-
butions, loss of trust in caretakers, and
loss of the belief that some somebody
will look after them and make them feel
safe. They tend to lose the expectation
that they will be protected and act ac-

cordingly. As a result, they organize their
relationships around the expectation or
prevention of abandonment or victim-
ization. This is expressed as excessive
clinging, compliance, oppositional defi-
ance, and distrustful behavior. They also
may be preoccupied with retribution
and revenge. All of these problems are
expressed in dysfunction in multiple ar-
eas of functioning: educational, familial,
peer-related, legal, and work-related.

TREATMENT IMPLICATIONS
In the treatment of traumatized chil-

dren and adolescents, there often is a
painful dilemma of whether to keep them
in the care of people or institutions who
are sources of hurt and threat, or whether

to play into abandonment and separation
distress by taking the child away from fa-
miliar environments and people to whom
they are intensely attached but who are
likely to cause further substantial dam-
age.15 Treatment must focus on three
primary areas: establishing safety and
compentence, dealing with traumatic re-
enactments, and integration and master
of the body and mind.

Establishing Safety and Competence
Complexly traumatized children need

to be helped to engage their attention
in pursuits that do not remind
them of trauma-

r e l a t e d
triggers and
that give them a sense of
pleasure and mastery. Safety, pre-
dictability, and “fun” are essential for the
establishment of the capacity to observe
what is going on, put it into a larger con-
text, and initiate physiological and mo-
toric self-regulation.

Before addressing anything else, these
children need to be helped how to re-
act differently from their habitual fight/
flight/freeze reactions.15 Only after chil-
dren develop the capacity to focus on

pleasurable activities without becoming
disorganized do they have a chance to
develop the capacity to play with other
children, engage in simple group activi-
ties and deal with more complex issues.

Dealing With Traumatic
Re-enactments

After a child is traumatized multiple
times, the imprint of the trauma becomes
lodged in many aspects of his or her
makeup. This is manifested in
multiple ways:

fearful
reactions, ag-
gressive and sexual acting
out, avoidance, and uncontrolled
emotional reactions. Unless this tendency
to repeat the trauma is recognized, the
response of the environment is likely to
replay the original traumatizing, abusive,
but familiar, relationships. Because these

After a child is traumatized
multiple times, the imprint of the
trauma becomes lodged in many
aspects of his or her makeup.

408 PSYCHIATRIC ANNALS 35:5 | MAY 2005

children are prone to experience anything
novel, including rules and other protective
interventions, as punishments, they tend to
regard teachers and therapists who try to
establish safety as perpetrators.15

Integration and Mastery
Mastery is, most of all, a physical ex-

perience: the feeling of being in charge,
calm, and able to engage in focused efforts
to accomplish goals. Children who have
been traumatized experience the trauma-
related hyperarousal and numbing on a
deeply somatic level. Their hyperarousal
is apparent in their inability to relax and in
their high degree of irritability.

Children with “frozen” reactions need
to be helped to re-awaken their …