Complex Trauma in Children and Adolescents PDF

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Complex Trauma in Children and Adolescents
National Child Traumatic Stress Network
www.NCTSNet.org
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Editors: Alexandra Cook, Ph.D., Margaret Blaustein, Ph.D., Joseph Spinazzola, Ph.D., and
Bessel van der Kolk, M.D.
Contributor
Contributor s: Margaret Blaustein, Ph.D.,1, 2 Alexandra Cook, Ph.D., 1, 2 Marylene Cloitre, Ph.D.,3 Ruth DeRosa,
ors:
Ph.D., Julian Ford, Ph.D.,5 Michele Henderson, LICSW, 1, 2 Rebecca Hubbard, LMFT, 6 Kristine Jentoft, LICSW,
4
1
Cheryl Lanktree, Ph.D., 7 Jill Levitt, Ph. D, 3 Joan Liautaud, Psy.D.,8 Erna Olafson, Ph.D., Psy.D., 9 Richard
Kagan, Ph.D., 10 Karen Mallah, Ph.D., 11 Dan Medeiros, M.D., 12 David Pelcovitz, Ph.D., 4 Paul Pagones, M.Ed.8
Frank Putnam, M.D., 9 Raul Silva, M.D., 3 Sabina Singh, M.D., 12 Stefanie Smith, Ph.D., 1 Joseph Spinazzola,
Ph.D., 1, 2 Bessel van der Kolk, M.D. 1, 2
Af
Afffiliations: 1Trauma Center, Massachusetts Mental Health Institute; 2National Center on Family
Homelessness; 3New York University/Child Study Center Institute for Urban Trauma; 4North Shore University
Hospital Adolescent Trauma Treatment Development Center, 5Yale/University of Connecticut Center for
Children Exposed to Violence; 6Directions for Mental Health, Inc., 7Miller Children’s Abuse and Violence
Intervention Center; 8Heartland Health Outreach International FACES; 9Child Abuse Trauma Treatment
Replication Center, Cincinnati Children’s Hospital; 10Parsons Child Trauma Study Center; 11Family Trauma
Treatment Program, Mental Health Corp of Denver; 12Mount Sinai Adolescent Health Center.
The authors wish to acknowledge the invaluable feedback, support, and technical assistance of Robert
Pynoos, John Fairbank, William Harris, Lisa Amaya Jackson, Jenifer Wood, Debbie Ling, Melissa Brymer, Judy
Holland, Christine Siegfried, Becky Warlick, Marla Zucker, Julie Foss, the Learning from Research and Clinical
Practice Core, and the staffs of the National Center for Child Traumatic Stress and the Duke Clinical Research
Institute. This project was supported by the SAMHSA grants U79 SM 54284, 54587, 54254, 54251, 54318,
54314, 54272, 54282, 54292, 54276, 54300, and 54311; as well as by SAMHSA grant UD1 SM56111.

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2003
The National Child Traumatic Stress Network is coordinated by the National Center for Child Traumatic Stress,
Los Angeles, Calif., and Durham, N.C.
This project was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA),
U.S. Department of Health and Human Services (HHS). The views, policies, and opinions expressed are those
of the authors and do not necessarily reflect those of SAMHSA or HHS.
Illustration Credits: Cover art and illustrations featured throughout text were selected from submissions to a
drawing contest on how children cope with difficult experiences. All artists were children or adolescents
receiving therapeutic services at the Trauma Center, Allston, MA. All illustrations used by permission of the
children and their legal guardians.
Correspondence to Dr. Spinazzola, The Trauma Center, 14 Fordham Rd., Allston, MA, 02134.
E-mail: [email protected]
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Table of Contents
Contents
Vignette 4
What is Complex Trauma? 5
The Cost of Child Complex Trauma 5
Diagnostic Issues for Complex Trauma in Children 6
Table 1: Domains of Impairment in Children 7

Exposed To Complex Trauma
Impact of Complex Trauma on Development 8
Adaptation to Complex Trauma in Familial Context 16
Adaptation to Complex Trauma in Ethnocultural Context 18
Coping and Protective Factors 20
Approaches to Comprehensive Assessment of 21

Complex Trauma in Children
Approaches to Treatment of Complex Trauma in Children 23
Recommendations and Future Directions 28
National Child Traumatic Stress Network 30

Complex Trauma Survey
References 34
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COMPLEX TRAUMA IN CHILDREN AND ADOLESCENTS
Vignett
Vignett e
tte
Michael is a 14-year-old Caucasian boy who was placed with his maternal grandparents after he and
his two younger siblings were removed from the home of their biological parents. Although multiple
reports had been made to Child Protective Services, there had been insufficient evidence to remove
the children because neither Michael nor his siblings had been willing to speak with authorities. At
the age of 11, however, Michael showed his school guidance counselor some bruises, stating that
his father had hurt him and that he didn’t want to go home anymore. He and his two siblings were
removed that day. Following their removal from the home, the children described: frequent fights in
which their parents screamed and threw things; unpredictable violence by their father, including his
hitting them with a miniature baseball bat; being isolated and denied food and water for over a day
at a time; and ongoing substance use by both parents. The youngest sibling reported that his father
had touched his private parts. Although both older siblings denied any memory of sexual abuse,
Michael was found to have a sexually transmitted disease on physical exam. All three children
indicated that Michael had been particularly targeted in the home, with each parent aligning with
one of the other siblings. Michael was frequently restricted to his room, and both of his parents
made statements blaming him for the family’s problems. Michael reported that he purposefully
made himself a target to protect his younger siblings from being hurt. Based on the children’s
statements, their father was charged and criminally prosecuted for assault and battery against his
two older children.
After their removal from the home, the three siblings were separated. After court proceedings
terminated parental rights, the youngest sibling was placed in a pre-adoptive foster home, and the
two oldest were placed in different relatives’ homes. Michael initially presented as withdrawn and
quiet after removal and placement with his maternal grandmother. He spent long periods alone in
his room and created an inner world that he scrupulously hid from his grandmother. Although he
was polite and cooperative with adults, he had difficulty with peer relationships and was unable to
sustain involvement in activities. Despite testing which indicated that he had an above average IQ
with no evidence of learning disability, Michael consistently received failing grades in his classes,
due in large part to a refusal to complete homework assignments. Michael also suffered from
repeated migraine headaches, and numerous tests had ruled out a physical etiology. At night,
Michael surrounded himself with stuffed animals, stating that they made him feel safer.
Michael’s behavior became increasingly dysregulated after his middle sibling was placed in the
home with him; he was strongly reactive to indications that she was receiving more attention than
him and became easily angered by her statements. He stated in therapy that being around his sister
was like “all this old stuff coming back again.” His presentation shifted from constricted to volatile,
with frequent angry outbursts, verbal and physical aggression toward family members, and multiple
indications of arousal (e.g., difficulty sleeping, impaired concentration, edginess and irritability). His
grandmother, who had her own history of childhood trauma, became increasingly depressed and
overwhelmed by his emotional outbursts and had difficulty providing consistent caretaking to either
sibling. Child Protective Services became re-involved and considered more intensive level of care for
each sibling.
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et al., 2001; Felitti et al., 1998; Gordon, 2002;

Herman, Perry, & van der Kolk, 1989; Lyons-
What Is Comple
plexx TTrauma?
Comple rauma? Ruth & Jacobovitz, 1999; Simpson & Miller,
2002; van der Kolk, Roth, Pelcovitz, Mandel, &
Spinazzola, in press; Yehuda, Spertus, & Golier,
2001).
The term complex trauma describes the dual
problem of children’s exposure to traumatic
events and the impact of this exposure on The Cost of Child Comple
plexx TTrauma
Comple rauma
immediate and long-term outcomes. Complex
traumatic exposure refers to children’s
experiences of multiple traumatic events that
occur within the caregiving system – the social Exposure to complex trauma in children carries
environment that is supposed to be the source an enormous cost to society, both in lives
of safety and stability in a child’s life. Typically, impacted and dollars spent. Although in many
complex trauma exposure refers to the ways the costs are inestimable, the
simultaneous or sequential occurrences of child repercussions of childhood trauma may be
maltreatment—including emotional abuse and measured in medical costs, mental health
neglect, sexual abuse, physical abuse, and utilization, societal cost, and the psychological
witnessing domestic violence—that are chronic toll on its victims.
and begin in early childhood. Moreover, the
initial traumatic experiences (e.g., parental Incidence of childhood abuse and neglect may
neglect and emotional abuse) and the resulting be estimated from the records of public Child
emotional dysregulation, loss of a safe base, Protection Service agencies and from national
loss of direction, and inability to detect or epidemiological research. Although both
respond to danger cues, often lead to methods are thought to underestimate actual
subsequent trauma exposure (e.g., physical and trauma incidence, the rising incidence of
sexual abuse, or community violence). childhood maltreatment is indisputable even
when relying upon the most conservative
Complex trauma outcomes refer to the range of estimates gleaned from official records. In
clinical symptomatology that appears after such 2001, according to the National Child Abuse and
exposures. Exposure to traumatic stress in early Neglect Data System developed by the
life is associated with enduring sequelae that Children’s Bureau of the U.S. Department of
not only incorporate, but also extend beyond, Human Services, 903,000 cases of child
Posttraumatic Stress Disorder (PTSD). These maltreatment were substantiated, including
sequelae span multiple domains of impairment neglect, medical neglect, physical abuse, sexual
and include: (a) self-regulatory, attachment, abuse, and psychological maltreatment.
anxiety, and affective disorders in infancy and
childhood; (b) addictions, aggression, social Epidemiological research has yielded evidence
helplessness and eating disorders; (c) of considerably higher incidence of children’s
dissociative, somataform, cardiovascular, exposure to complex trauma. The Third National
metabolic, and immunological disorders; (d) Incidence Study of Child Abuse and Neglect
sexual disorders in adolescence and adulthood; (NIS-3; 1996), a congressionally mandated
and (e) revictimization (Dube, Anda, Felitti, study, examined incidence of abuse and neglect
Chapman, et al., 2001; Dube, Anda, Felitti, Croft using a nationally representative sample of
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5,600 professionals spanning 842 agencies in narrowly defined PTSD diagnosis is often used, it
42 counties (Sedlak & Broadhurst, 1996). Using rarely captures the extent of the developmental
the Harm Standard, which includes only children impact of multiple and chronic trauma exposure.
who have already experienced harm from abuse Other diagnoses common in abused and
or neglect, an estimated 1,553,800 children neglected children include Depression, Attention
were abused or neglected in 1993. This figure Deficit Hyperactivity Disorder (ADHD),
includes 217,700 sexually abused children, Oppositional Defiant Disorder (ODD), Conduct
338,900 physically neglected children, 212,800 Disorder, Generalized Anxiety Disorder,
emotionally neglected children, and 381,700 Separation Anxiety Disorder, and Reactive
physically abused children. Using the Endanger- Attachment Disorder. Each of these diagnoses
ment Standard, defined as children who captures an aspect of the traumatized child’s
experience abuse or neglect that puts them at experience, but frequently does not represent
risk of harm, the estimated incidence of child the whole picture. As a result, treatment often
abuse or neglect in 1993 nearly doubled focuses on the particular behavior identified,
(2,815,600 children). These rates reflect sharp rather than on the core deficits that underlie the
increases from the previous NIS-2 study in presentation of complexly traumatized children.
1986; the total number of abused or neglected
children based upon both the Harm and An Organizing FFrame
rame
ramewwork of
ork
Endangerment Standards quadrupled between ple
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Comple
Com rauma Outcomes in Children
1986 and 1993.
The present paper highlights seven primary
Using the Harm Standard incidence numbers domains of impairment observed in children
from NIS-3, the total annual cost of child abuse exposed to complex trauma. These
and neglect has been estimated at 94 billion phenomenologically based domains have been
dollars (Fromm, 2001). Direct costs associated identified based on the extant child clinical and
with child abuse and neglect (24.4 billion research literatures, the adult research on
dollars) included hospitalization, chronic health “Disorders of Extreme Stress Not Otherwise
problems, mental health, child welfare, law Specified” (Pelcovitz et al, 1997; van der Kolk,
enforcement, and judicial system costs. Indirect Pelcovitz, Roth, Mandel, McFarlane, & Herman,
costs (69.7 billion dollars) included special 1996; van der Kolk, Roth, et al., in press), and
education, juvenile delinquency, adult mental the combined expertise of the NCTSN Complex
health and health care, lost productivity to Trauma Taskforce. These domains of impairment
society, and adult criminality. The daily cost of include: (I) Attachment; (II) Biology; (III) Affect
childhood abuse and neglect is estimated to be regulation; (IV) Dissociation; (V) Behavioral
$258 million (Pelletier, 2001). regulation; (VI) Cognition; and (VII) Self-concept.
Impairment is considered to occur within a
developmental context and in turn to impact
Diagnostic Issues ffor
or further development. Table 1 provides a list of
Com ple
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Comple rauma each domain along with examples of associated
symptoms. Valid diagnostic classification of
complex trauma sequelae in children awaits
The current psychiatric diagnostic classification formal epidemiological research. However, we
system does not have an adequate category to believe that this phenomenologically based
capture the full range of difficulties that framework for the impact of complex trauma
traumatized children experience. Although the exposure possesses sufficient clinical utility to
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serve as a vitally needed starting place for initiatives bearing on children’s adaptation to
research, treatment development, and policy complex trauma exposure.
Table 1:
Domains of Impairment in Children Exposed tto
Impairment o Comple
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Comple rauma
I. Attachment V. Behavioral Contr

Behavioral ol
Control
Uncertainty about the reliability and predictability of Poor modulation of impulses
the world Self-destructive behavior
Problems with boundaries Aggression against others
Distrust and suspiciousness Pathological self-soothing behaviors
Social isolation Sleep disturbances
Interpersonal difficulties Eating disorders
Difficulty attuning to other people’s emotional states Substance abuse
Difficulty with perspective taking Excessive compliance
Difficulty enlisting other people as allies Oppositional behavior
Difficulty understanding and complying with rules
II. Biology Communication of traumatic past by reenactment in
Sensorimotor developmental problems day-to-day behavior or play (sexual,
Hypersensitivity to physical contact aggressive, etc.)
Analgesia
Problems with coordination, balance, body tone VI. Cognition
Difficulties localizing skin contact Difficulties in attention regulation and executive
Somatization functioning
Increased medical problems across a wide span, Lack of sustained curiosity
e.g., pelvic pain, asthma, skin problems, Problems with processing novel information
autoimmune disorders, pseudoseizures Problems focusing on and completing tasks
Problems with object constancy
III. Af
Afffect Regulation
Regulation Difficulty planning and anticipating
Difficulty with emotional self-regulation Problems understanding own contribution to what
Difficulty describing feelings and internal experience happens to them
Problems knowing and describing internal states Learning difficulties
Difficulty communicating wishes and desires Problems with language development
Problems with orientation in time and space
IV
IV.. Dissociation Acoustic and visual perceptual problems
Distinct alterations in states of consciousness Impaired comprehension of complex visual-spatial
Amnesia patterns
Depersonalization and derealization
Two or more distinct states of consciousness, with VII. Self-Concept
impaired memory for state-based events Lack of a continuous, predictable sense of self
Poor sense of separateness
Disturbances of body image
Low self-esteem
Shame and guilt
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provides the scaffolding for the growth of many

Impact of Com
Impact ple
plexx TTrauma
Comple rauma developmental competencies, including the
on De
Devvelopment capacity for self-regulation, the safety with which
to explore the environment, early knowledge of
Complex trauma outcomes are most likely to agency (i.e., the capacity to exert an influence
develop and persist if an infant or child is on the world), and early capacities for receptive
exposed to danger that is unpredictable and and expressive communication. The child-
uncontrollable because the child’s body must caregiver relationship can be the source of the
allocate resources that are normally dedicated trauma, and/or it can be greatly impacted by
to growth and development instead to survival another type of traumatic exposure; therefore,
(Ford, in press; van der Kolk, in press). The many of these critical developmental
greatest source of danger, unpredictability, and competencies are disrupted.
uncontrollability for an infant or young child is
the absence of a caregiver who reliably and A secure attachment pattern, present in
responsively protects and nurtures the child approximately 55-65% of the normative
(Cicchetti and Lynch, 1995). The caregiver’s population, is thought to be the result of
ability to help regulate bodily and behavioral receptive, sensitive caregiving. The caregiver
responses provides experiences in “co- responds in a contingent way to infant cues,
regulation” that contribute to the acquisition of providing the infant with both stimulation and
self-regulatory capacities (Schore, 2002; Siegel, nurturing. Infants are able to internalize
1999). Lack of sustaining regulation with a regulation strategies offered to them by their
primary caregiver puts the child at risk for caregivers, and learn to communicate and
inadequate development of the capacity to interpret nonverbal signals. Responsive
regulate physical and emotional states. caregiving in the face of traumatic stress
provides the young child with a supportive
Hence, when examining traumatized children, environment in which to recover from and
the status of the attachment relationship is metabolize overwhelming experience.
often a critical element. In the current
conceptualizations of traumatic stress in Insecure attachment patterns have been
children, little effort has been spent on consistently documented in over 80% of
distinguishing between the impact of specific maltreated children. These failures to create a
traumatic events and that of disruptions in the secure dyadic relationship may leave an
attachment relationship. In order to understand environment of vulnerability which may allow for
the behavior of these children and to formulate the occurrence of complex trauma exposure. In
an adequate treatment plan, the impact of the aftermath of exposure, insecure or anxious
disruptions in the early caregiving relationship attachments may be further compounded if
must be integrated into developmental models children perceive a caregiver as too distressed
of trauma exposure and outcome. to deal with their experience (e.g., due to the
caregiver’s own level of stress, dissociation,
Attachment avoidance, intoxication or own unresolved
trauma history).
The early caregiving relationship provides a
relational context in which children develop their Children with insecure attachment patterns may
earliest models of self, other, and self in relation be classified as avoidant, ambivalent, or
to others. This attachment relationship also disorganized. The avoidant attachment style has
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been associated with predictably rejecting people to do what I want,” “No one can be
caregiving. Children whose parents repeatedly trusted to help—they’ll just use you”). Parents of
dismiss or reject them may learn to disregard or children with these behaviors have been
distrust their emotions, relationships, and even described as often failing to protect their
their own bodies. Moreover, they may avoid, children and feeling helpless in their roles as
dismiss, or feel profoundly ambivalent about mothers (George & Solomon, 1996).
attachment relationships, not only with
caregivers, but also with other adults and with Children living with unpredictable violence and
peers (Ainsworth, 1978). repeated abandonment often fail to develop
appropriate language and verbal processing
When children experience parents alternating abilities. They then cope with threatening events
between validation and invalidation in a and feelings of helplessness by restricting their
predictable manner, they may develop processing of what is happening around them.
ambivalent attachment patterns (Ainsworth, Thus, these children are repeatedly unable to
Blehar, & Waters, 1978) and learn to anticipate organize a coherent response to challenging
the adults’ change from detachment and events in their lives and instead act with
neglect to excessive intrusiveness in predictable disorganization (Siegel, 1999).
patterns. These children often cope by
disconnecting themselves from others at the
first signs that parents, teachers, or other
important adults are acting in either a rejecting
or overly engaging manner.
When co-regulation is not provided or results in

aversive consequences early in life, the child is
at risk for a complex and severe type of
disruption of all of the core biopsychosocial
competencies that has been described as
disorganized attachment (Cassidy & Mohr,
2001; Cicchetti & Toth, 1995; Lyons-Ruth &
Jacobovitz, 1999; Maunder & Hunter, 2001).
Disorganized attachment in young children Disorganized attachment has been hypothesized
involves erratic behavior in relation to caregivers to interfere with the development of neural
(e.g., alternately clingy, dismissive, and connections in critical brain areas (e.g., the left
aggressive). In older children, adolescents, and and right hemispheres of the orbital prefrontal
adults, disorganized attachment appears to cortex and their connective pathways; Schore,
reflect primitive survival-based relational 2001). This attachment style may result in
working models that are rigid, extreme, and impairment in affect regulation, stress
thematically focused (Lyons-Ruth & Jacobovitz, management, empathy and prosocial concern
1999). These working models focus on either for others, and the use of language to solve
helplessness (e.g., abandonment, betrayal, relational problems. Over time, disorganized
failure, dejection—”Any expression of anger is attachments lead to symptoms of PTSD, as well
deadly,” “I’m damaged and deserve to be as borderline and antisocial personality
rejected”) or coercive control (e.g., blame, disorders (Herman, Perry, & van der Kolk, 1989;
rejection, intrusiveness, hostility—”I have to force Main, 1995).
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In a recent review, Maunder and Hunter (2001) branch of the ANS and modulating arousal
concluded that disrupted attachment in animals through the parasympathetic branch.
and humans often is not transient but can lead Deprivation of responsive caregiving due to
to a lifelong risk of physical disease and persistent maltreatment, neglect, or caregiver
psychosocial dysfunction. This risk occurs along dysfunction (e.g., maternal depression) can lead
three pathways that reflect impairments in the to lifelong reactivity to stress. Following a history
core biopsychosocial competencies which of early deprivation, even mild stress later in life
parallel the key features of disorganized can elicit severe reactivity and dysfunction
attachment: (1) increased susceptibility to stress (Gunnar & Donzella, 2002).
(e.g., difficulty focusing attention and
modulating arousal; i.e., detection, activation, In toddlerhood and early childhood, the brain
conservation, orientation); (2) an inability to actively develops areas responsible for: (1)
regulate emotions without external assistance filtering sensory input to identify useful
(e.g., feeling and acting overwhelmed by intense information (thalamus; somatosensory cortices),
or numbed emotions; i.e., activation, (2) learning to detect (amygdala) and respond
conservation, exploration; consolidation), and defensively (insula) to potential threats, (3)
(3) altered help-seeking (e.g., excessive help- recognizing information or environmental stimuli
seeking and dependency or social isolation and that comprise meaningful contexts
disengagement; i.e., deficiencies in affiliation (hippocampal area), and (4) coordinating rapid
and in exploration). Moreover, it is not only goal-directed responses (ventral tegmentum;
separation, but also the disruption of the striatum). During this time there is a gradual
development of a secure attachment bond, that shift from right hemisphere dominance (feeling
appear to produce lasting biological and sensing) to primary reliance on the left
dysregulation. hemisphere (language, abstract reasoning and
long range planning) (De Bellis, Keshavan, &
Biology Shifflett, 2002; Kagan, 2003). A young child
gradually learns to orient to both the external
Neurobiological development follows genetically and internal environment (rather than
“hard-wired” programs that are modified by responding reflexively to whatever stimulus
external stimuli. Extreme (low or high) levels of presents itself), and to detect and react.
stimulation (i.e., stress) are thought to trigger
adaptive adjustments that depend on the brain Trauma interferes with the integration of left and
structures and pathways that were formed in the right hemisphere brain functioning, which
course of development (Perry & Pollard, 1998). explains traumatized children’s “irrational” ways
Thus, the brain “sculpts” itself in response to of behaving under stress. In non-abused
external experiences at the same time as it is children, their semantic (i.e., verbal and left
developing via genetically-based maturation. brain based) schemas of themselves and the
world are generally in harmony with their
During the first few months after birth, only the emotional response to their surroundings (right
brainstem and midbrain (i.e., locus coeruleus brain based). In contrast, abused and neglected
and cerebellum) are sufficiently developed to children often display vast discrepancies
sustain and alter basic bodily functions and between how they make sense of themselves
alertness. These primitive structures regulate and how they respond to their surroundings.
the “autonomic nervous system” (ANS), Under stress, their analytical capacities (left
mobilizing arousal through the sympathetic brain based) disintegrate, and their emotional
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(right brain based) schemas of the world take stable and readily accessed” (Benes, Turtle, &
over, causing them to react with uncontrolled Kahn, 1994). Traumatic stressors or prior
helplessness and rage (Crittenden, 1998; deficits in self-regulatory abilities that manifest
Kagan, 2003; Teicher, Andersen & Polcari, during adolescence, in the absence of
2002). sustaining relationships (which in adolescence
often involve peers as well as adults), may lead
In early childhood, biologically compromised to disruptions in self-regulation (e.g., eating
children are at risk for disorders in reality disorders), interpersonal mutuality (e.g., conduct
orientation (e.g., autism), learning (e.g., disorders), reality orientation (e.g., thought
dyslexia), or cognitive and behavioral self- disorder), or a combination of these critical
management (e.g., ADHD). A toddler or competencies (e.g., borderline personality
preschool-age child who (a) is exposed to disorder; chronic addiction).
traumatic stressors, or (b) did not develop basic
capacities for self-regulation earlier in life, and Biology of Resilience
Resilience
who does not have a sustaining relationship with
caregiver(s), is at risk for failing to develop brain Many studies show that stressors early or later
capacities necessary to form interdependent in life that are predictable, escapable or
relationships (e.g., separation anxiety or ODD) controllable, or in which responsive caregiver
and for failing to modulate emotions in response contact is available, and safe opportunities for
to stress (e.g., major depression, phobias) exploration are reinstated, tend to enhance
(Kaufman, 2000). biological integrity. In biological terms, these
experiences increase hippocampal and
In middle childhood and adolescence, the most prefrontal cortex neuronal functioning;
rapidly developing brain areas are those behaviorally, they enhance curiosity, social
responsible for three core features of “executive status, working memory, anxiety management,
functioning” necessary for autonomous and the ability to nurture (Champagne &
functioning and engagement in relationships. Meaney, 2001; Gunnar & Donzella, 2002;
These features are: (1) conscious self- Schore, 2001). Moreover, the restoration of
awareness and genuine involvement with other secure caregiving after early life stressors has a
persons (anterior cingulate), (2) ability to assess protective effect, reducing long-term biological
the valence and meaning of complex emotional and behavioral impairment, even if: (a) only
experiences (orbital prefrontal cortex), and (3) visual, not tactile, or symbolic contact with the
ability to determine a course of action based on caregiver is possible, (b) the sociophysical
learning from past experiences and creation of environment is severely impoverished, or (c) the
an inner frame of reference informed by caregiver is not the biological parent (Gunnar &
accurate understanding of other persons’ Donzella, 2002).
different perspectives (dorsolateral prefrontal
cortex). In adolescence, there is a burst of brain Af
Afffect Regulation
Regulation
development in these areas and the limbic
system (e.g., hippocampus) due to Previous sections have described the
“myelination,” the growth of protective sheaths deleterious impact that early childhood trauma
surrounding nerve cells. This process can may have on core regulatory systems.
consolidate new learning in the form of decision Impairment of neurobiological systems involved
strategies and fundamental beliefs that become in emotion regulation leaves many traumatized
a system of “working memory that is highly children at risk for multiple manifestations of
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dysregulated affect. Deficits in the capacity to capacity to modulate internal experience are
regulate emotional experience may be broadly linked, and children with complex trauma
classified in three categories, including (a) histories show both behavioral and emotional
deficits in the capacity to identify internal expressions of impaired capacity to self-regulate
emotional experience, (b) difficulties with the and self-soothe. Children who are unable to
safe expression of emotions, and (c) impaired consistently regulate internal experience may
capacity to modulate emotional experience. turn to alternative strategies, including
dissociative coping (e.g., chronic numbing of
Identification of internal emotional experience emotional experience), avoidance of affectively
requires the ability to differentiate among states laden situations, including positive experiences,
of arousal, interpret these states, and apply and/or use of behavioral strategies (e.g.,
appropriate labels (e.g., “happy,” “frightened”). substance use). Those children who are unable
At birth, the infant has little capacity to to find consistent strategies to assist them in
discriminate among arousal states; predictable modulation of emotion may present as
and differential response of caregivers to emotionally labile, demonstrating extreme
specific needs provides a framework through responses to minor stressors, with rapid
which the developing child begins to escalation and difficulty self-soothing.
differentiate emotional experience and
response. Similarly, children learn to interpret Over time, traumatized children are vulnerable
the nonverbal cues of others through consistent to the development and maintenance of
pairing of others’ affective expressions with disorders associated with chronic dysregulation
behavior. When children are provided with of affective experience, including disorders of
inconsistent models of affect and behavior (e.g., mood. The prevalence of Major Depression
smiling expression paired with rejecting among individuals who have experienced early
behavior) or with inconsistent response to childhood trauma is an example of the lifelong
affective display (e.g., child distress met impact complex trauma may exert over
inconsistently with anger, rejection, nurturance, regulatory capacities.
neutrality), no framework is provided through
which to interpret experience. Deficits in the The existence of a strong relationship between
ability of maltreated children to discriminate early childhood trauma and subsequent
among and label affective states in both self depression is now well established (Putnam,
and other has been demonstrated as early as 2003). Recent twin studies, considered one the
30 months old (Beeghly & Cicchetti, 1996). highest forms of clinical scientific evidence
because they can control for genetic and family
Following the identification of emotional state, a factors, have conclusively documented that early
child must be able to express emotions safely, childhood trauma, especially sexual abuse,
and then modulate or regulate internal dramatically increases risk for major depression,
experience. Complexly traumatized children as well as many other negative outcomes. Twin
show impairment in both of these skills. studies indicate that, for women, a history of
Distortions of emotional expression in childhood sexual abuse increases the odds ratio
traumatized children have been observed to for major depression 3- to 5-fold (Dinwiddie,
range across a full spectrum, from overly Heath, et al., 2000; Nelson, Heath, et al., 2002).
constricted or rigid to excessively labile and Numerous factors influence the strength of this
explosive (e.g., Gaensbauer, Mrzaek & Harmon, relationship, including age of onset, duration,
1981). Capacity to express emotions and relationship to the perpetrator, number of
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perpetrators, use of coercion or force, maternal Dissociation

support, and the type(s) of sexual abuse
(Putnam, 2003). Children who experienced Dissociation is one of the key features of
sexual intercourse abuses had an odds ratio of complex trauma in children. In essence,
8.1 for depression and 11.8 for a suicide dissociation is the “failure to integrate or
attempt (Fergusson, Horwood, & Lynskey, 1996; associate information and experience in a
Fergusson, Lynskey, & normally expectable
Horwood, 1996). fashion” (Putnam,
1997, p.7). Thus,
Childhood trauma cognition can be
appears not only to experienced without
increase risk for Major affect, affect can be
Depression, but also to experienced without
alter the course of cognition, somatic
illness in ways that sensations occur in a
contribute to a poorer void of awareness, or
prognosis. A history of behavioral repetitions
childhood trauma seems take place without
to predispose toward conscious awareness
earlier onset of affective (Chu, 1991).
problems, which in turn Dissociation runs along
is associated with more a continuum from
depressive episodes and normal kinds of
poorer outcome experiences such as
(Putnam, 2003). getting lost in thought
Depressed women with while driving, to
histories of child abuse peritraumatic
have longer durations of dissociation during
illness and are less likely traumatic exposures, to
to respond positively to dissociative disorders.
standard treatment Although dissociation
(Zlotnick, Ryan, Miller, & Keitner, et al., 1995). begins as a protective defense mechanism in
Treatment of depression is complicated by lack the face of overwhelming trauma, under
of proper diagnosis, inability to adhere to a circumstances of chronic traumatic exposure it
treatment regimen, or lack of insurance can develop into a problematic disorder that
coverage or financial resources to pay for then becomes the focus of treatment. Moreover,
treatment. Many of these barriers are raised by there is growing research on the negative impact
the negative life trajectories commonly of peritraumatic dissociation on the
associated with histories of childhood trauma, development of PTSD (Weiss, Marmar, Metzler,
such as lower education, mental illness, & Ronfeldt, 1995).
substance abuse, poor physical health, and
unemployment. Thus, the population at highest Dissociation has been linked to several
risk for depression is also the population least biological markers through the correlation of the
likely to receive adequate treatment. Dissociative Experiences Scale (Bernstein &
Putnam, 1986) to decreased left hippocampal
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volume in women (Stein, Koverola, Hanna, have been well documented in traumatized
Torchia, & McClarty, 1997) and to cerebrospinal children (see Cognition, below). One
fluid levels of neurotransmitters and their consequence of impaired executive functioning
metabolites (Demitrack, Putnam, & Rubinaw, is an increase in impulsive responses, such as
1993). Moreover, dissociation is postulated to aggression. Early trauma is significantly
be connected with the stress response system associated with the development of impulse
(i.e., the Hypothalamic-Pituitary Adrenal Axis) control disorders such as ODD (e.g., Ford et al.,
(Putnam, 1997). 2000).
According to Putnam (1997), the three primary An alternative way of understanding the
functions of dissociation are the automatization behavioral patterns of chronically traumatized
of behavior in the face of psychologically children is that they represent children’s
overwhelming circumstances, the defensive adaptations to overwhelming stress.
compartmentalization of painful memories and Children may re-enact behavioral aspects of
feelings, and the detachment from one’s self their trauma (e.g., aggression, self-injurious
when confronting extreme trauma. When trauma behaviors, sexualized behaviors, controlling
is chronic, a child will rely more and more heavily relationship dynamics) as automatic behavioral
upon dissociation to manage the experience, reactions to reminders or as attempts to gain
such that dissociation then leads to difficulties mastery or control over their experiences.
with behavioral management, affect regulation, Children may also use such strategies to cope
and self-concept. with their deficits in regulating internal
experience. For instance, in the absence of more
Behavioral R
Behavioral egulation
Regulation advanced coping strategies, traumatized youth
may use substances in order to avoid
Chronic childhood trauma is associated with experiencing intolerable levels of emotional
both under- and over-controlled behavior arousal. Similarly, in the absence of knowledge
patterns. Over-control is a strategy that may of how to negotiate interpersonal relationships,
counteract the feelings of helplessness and lack sexually abused children may engage in sexual
of power that are often a daily struggle for behaviors in order to achieve acceptance and
chronically traumatized children. Abused intimacy. Ultimately, a history of childhood
children demonstrate rigidly controlled behavior traumatic experiences raises the risk for adverse
patterns, such as compulsive compliance with outcomes, including substance use and abuse,
adult requests, as early as the second year of teen pregnancy and paternity, suicidality and
life (e.g., Crittenden & DiLalla, 1988). Many other self-injurious behaviors, criminal activity,
traumatized children are very resistant to and re-victimization (Anda, 2002).
changes in routine and display rigid behavioral
patterns, including inflexible bathroom rituals Cognition
and eating problems with rigid control of food
intake. During infancy and early childhood, children
form an early working model of the world and
Under-controlled or impulsive behaviors may be develop the basic cognitive building blocks of
due in part to deficits in executive functions: the later life. During this time period, children
cognitive capacities responsible for planning, develop an early sense of self, a model of self-in-
organizing, delaying response, and exerting relation-to-other, an understanding of basic
control over behavior. Executive function deficits cause-and-effect, and a sense of agency.
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Prospective studies have shown that children of problem-solving tasks than same-age peers
abusive and neglectful parents have impaired (Egeland et al., 1983). In later childhood,
cognitive functioning by late infancy, compared children and adolescents with a diagnosis of
with control children (Egeland, Sroufe, & PTSD secondary to abuse or witnessing violence
Erickson, 1983). The sensory and emotional demonstrate deficits in attention, abstract
deprivation associated with neglect appears to reasoning, and executive function skills (Beers &
be particularly detrimental to development, with de Bellis, 2002). Maltreated children have been
neglected infants and toddlers demonstrating found to exhibit increasingly impaired executive
delays in expressive and receptive language function performance from early childhood to
development, as well as deficits in overall IQ middle school age; in contrast, non-abused,
(Allen & Oliver, 1982; Culp, Watkins, Lawrence, psychiatrically-impaired children show a gradual
Letts et al., 1991; Vondra, Barnett, & Cicchetti, increase in executive function skills that lags
1990). Over time, these decrements in cognitive behind but, over time, approximates the growth
ability continue to be observed, such that curve of normative matched controls
abused and neglected children show lower IQ’s (Mezzacappa, Kindlon, & Earls, 2001).
and are disproportionately represented within
the developmentally delayed spectrum of By early elementary school, maltreated children
intellectual functioning (Sandgrund, Gaines, & are more frequently referred for special
Green, 1974). education services (Shonk & Cicchetti, 2001). A
history of maltreatment is associated with lower
During school age, academic functioning grades and poorer scores on standardized tests
represents a significant domain of and other indices of academic achievement.
developmental competence. Academic Maltreated children are found to have
performance is significantly influenced by significantly higher rates of grade retention and
children’s ability to regulate internal experience dropout; they have three times the dropout rate
and to interact competently with peers. By of the general school population. These findings
preschool, maltreated children demonstrate have been demonstrated across a variety of
deficits in both of these arenas, exhibiting lower trauma exposures (e.g., physical abuse, sexual
frustration tolerance, more anger and non- abuse, neglect, exposure to domestic violence)
compliance, and more dependency on others for and cannot be accounted for by the effects of
support than non-maltreated matched other psychosocial stressors such as poverty
comparisons (Egeland et al., 1983; Vondra et (Cahill, Kaminer, & Johnson, 1999; Kurtz,
al., 1990). In elementary school, maltreated Gaudin, Wodarski, & Howing, 1993; Leiter &
children are less persistent on and more likely to Johnsen, 1994; Shonk & Cicchetti, 2001;
avoid challenging tasks, and are overly reliant on Trickett, McBride-Chang, & Putnam, 1994).
teachers’ guidance and feedback (Shonk &
Cicchetti, 2001). By middle school and high Self-Concept
school, maltreated children are more likely to be
rated as working and learning below average, The early caregiving relationship has a profound
and they exhibit higher incidence of disciplinary effect on the development of a coherent sense
referrals and suspensions (Eckenrode, Laird, & of self. Over time, a child consolidates and
Doris, 1993). internalizes a secure, stable, and integrated
sense of identity (Bowlby, 1988). Responsive,
By early childhood, maltreated children sensitive caretaking and positive early life
demonstrate less flexibility and creativity in experiences allow children to develop a model of
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self as generally worthy and competent. In (e.g., Dissociative Disorder NOS and Dissociative
contrast, repetitive experiences of harm and/or Identity Disorder) in which the formation of
rejection by significant others, and the dissociative identities becomes the source of
associated failure to develop age-appropriate maladaptive coping (van der Kolk, van der Hart,
competencies, are likely to lead to a sense of & Marmar, 1996).
self as ineffective, helpless, deficient and
unlovable. Alterations in children’s self-
representations may impact their capacity to
cope with traumatic experience (Liem &
Adaptation ttoo Com ple
plexx TTrauma
Comple rauma
Boudewyn, 1999). Children who perceive
themselves as powerless or incompetent and in FFamilial
amilial Context
Conte
who expect others to reject and despise them
are more likely to blame themselves for negative
experiences and have problems eliciting and
responding to social support. The family plays a crucial role in determining
Traumatized children manifest alterations in how the child adapts to experiencing trauma.
their sense of self by early childhood. By 18 Factors that influence the child’s response
months, traumatized toddlers are more likely to include the extent to which the family
respond to self-recognition with neutral or environment itself was responsible for the
negative affect than non-traumatized youngsters victimization, parental response to the traumatic
(Schneider-Rosen & Cicchetti, 1991). In event or disclosure, and the extent to which
preschool, traumatized children are more parents themselves are influenced by their own
resistant to talking about internal states, childhood histories of loss and/or trauma, as
particularly those perceived as negative well as other parental psychopathology.
(Cicchetti & Beeghly, 1987). Traumatized
children have problems estimating their own In the aftermath of trauma, parental support is a
competence: early exaggerations of competence key mediating factor in determining how children
in preschool shift to significantly lowered adapt to victimization. Familial support and
estimates of self-competence by late elementary parental emotional functioning are strong
school (Vondra, Barnett, & Cicchetti, 1989). By factors that mitigate against the development of
adulthood, they suffer from a high degree of PTSD symptoms, as well as enhance a child’s
self-blame (Liem & Boudewyn, 1999). capacity to resolve the symptoms (Cohen,
Mannarino, Berliner, and Deblinger, 2000).
Dissociative coping further complicates the Research in the sexual abuse literature
development of a coherent sense of self. consistently supports Finkelhor and Kendall-
Habitual use of dissociation leads to “significant Tackett’s (1997) assertion that “the response of
disturbances in the continuity of an individual’s the child’s social support system, and
memory and integration of self” (Putnam, 1993, particularly the child’s mother, is the most
p.40). Over time, a reliance on dissociative important factor in determining outcome, more
coping may lead to serious disruptions in identity important than objective elements of the
development and integration due to the loss of victimization itself.” There are three main issues
autobiographical memory, as well as to the lack in parents’ responses to their children’s trauma:
of continuity in the traumatized individual’s 1) believing and validating their child’s
experience. Chronic dissociation is associated experience, 2) tolerating the child’s affect, and
with the development of dissociative disorders 3) managing their own emotional response.
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The connection between a parent and child is and to tell their own story coherently may be the
broken when a parent denies the child’s strongest indicators of parental capacity and
experiences. In such cases, the child is forced to effective parenting (Main & Goldwyn, 1994).
act “as if” the trauma did not occur. In this
context, a child learns he/she cannot trust the Parents with their own unresolved traumatic
primary caretaker and cannot utilize language experiences may avoid experiencing their own
and communication to overcome adversity. emotions, which may make it difficult for them to
Moreover, because the trauma is denied, the “read” and respond appropriately to the child’s
child remains unprotected from recurrence. emotional state. In addition, parents with their
Without safety, the child cannot begin to re- own unresolved trauma histories may have
integrate the traumatic experiences and find difficulty providing safe environments for their
new ways of coping. Instead, parental children because of their difficulty identifying
invalidation generates helplessness and dangerous circumstances. Moreover, children’s
hopelessness in a child. attachment-seeking behavior can trigger their
parents’ own painful memories. Parents and
Parents are often understandably distressed guardians may see a child’s behavioral
when their children have experienced traumatic responses to trauma as a personal threat or
events. In these instances, personal distress can provocation, rather than as a reenactment of
limit parents’ ability to provide adequate care to what happened to the child and a behavioral
their children (Winston et al., 2002). However, representation of what the child cannot express
Finkelhor & Kendall-Tackett (1997) note that it is verbally. The hurt child’s simultaneous need for
not parental distress per se that is necessarily and fear of closeness can trigger a parent’s own
detrimental to the child, but more specifically, memories of loss, rejection, or abuse.
when the parent’s distress overrides or diverts
attention away from the needs of the child that Ongoing psychopathology and substance use by
children are negatively affected. Children may parents also complicate their capacity to assist
respond to their parent’s distress by avoiding or in their children’s recovery from trauma. Chronic
suppressing the feelings or behaviors that mental illness or ongoing substance abuse
elicited the parent’s distress, by avoiding their prevents parents from being consistently
parent altogether, or by becoming “parentified” available or responsive to their children, thus
and attempting to reduce the distress of their leaving the child at risk for future victimization.
parent (Deblinger & Heflin, 1996). As a result, Violence or abuse in the home gives rise to a
the child may have difficulty identifying special set of characteristic adaptations. When
communicating and communicating emotions the trauma is the result of predictable caretaker
(Wiehe, 1997), both of which are crucial in violence, children may become compulsively
dealing with stressful or traumatic situations. compliant, constantly monitoring parental cues
and trying to modify their behavior in an attempt
Traumatized children often rekindle painful to prevent parental violence. Unpredictable
feelings in biological parents or in substitute parental aggression may lead to wide
parents trying to provide a child with a new fluctuations in children’s behavior and affect, as
home. Parents who have had impaired they are unable to figure out when or under what
relationships with attachment figures in their circumstances the parent may strike out
own lives are especially vulnerable to problems (Crittenden, 1998).
in raising their own children. Parents’ ability to
access information about their own childhood
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Intrafamilial victimization generally leaves connections to their primary culture, community,

children at higher risk for victimization outside of and homes (e.g., refugees or immigrants). Youth
the home. Children who are unable to get their and families who are not forced to leave their
needs met at home may seek support outside homes still may have critical ethnocultural ties
the home, and are therefore at higher risk for strained or broken by disaster, war, political
exploitation. Furthermore, chronic exposure to repression, poverty, racism, and community
threat can interfere with children’s natural violence (Garbarino & Kostelny, 1996; Rabalais,
internal warning systems, and may numb them Ruggiero, & Scotti, 2002).
to danger cues. Ultimately, a child who has been
exposed to multiple sources or types of trauma, Assessment of trauma history and PTSD
whether within or outside of the family, is more outcomes should always occur in a cultural
likely to be negatively affected (Garbarino, context that includes the background,
Kostelny & Grady, 1993; Margolin, 2000). community, and modes of communication that
both the assessor as well as the family bring to
their interaction (Manson, 1996). Exposure to
different types of trauma is variable across
Adaptation tto o Com
Compleple
plexx TTrauma
rauma diverse ethnocultural backgrounds (i.e.,
in Ethnocultural Cont Conteext exposure to war/genocide, family violence,
community violence, child maltreatment). In
addition, people of different cultural, national,
linguistic, spiritual, and ethnic backgrounds
While human beings share a common biological define key trauma-related constructs in many
heritage, each person belongs to not one, but different ways and with different expressions
many ethnocultural groups and has a unique (e.g., flashbacks may be “visions,” hyperarousal
family and cultural heritage and genetic may be “attacque de nerves,” dissociation may
makeup—all of which interact to shape be spirit possession; Loo et al., 2001; Manson,
development and the experience of trauma. One 1996). The threshold for defining a PTSD
must exercise caution applying categorical reaction as “distressing” or as a problem
delineations of ethnocultural variables (e.g., warranting intervention differs not only across
refugee, urban residence, ethnic group, primary national and cultural groups, but also within sub-
language, socioeconomic status, nationality) groups (e.g., geographic regions of a country
because doing so runs the risk of obscuring with different sub-cultures; different religious
significant differences within these larger groups communities within the same geographic area).
(Loo et al., 2001; Marsella, Friedman, Gerrity, & As a result, psychometric assessment with
Scurfield, 1996). In studying adaptation to standardized measures may confront children
complex trauma in ethnocultural context, one and families with questions that are considered
must start with the broad categories and then unacceptable (e.g., including peyote under use
delve deeper into the subcategories that reflect of illicit drugs), irrelevant (e.g., distinguishing
group, community, family, and individual blood family from close friends, in a group that
differences. considers all community members as family),
incomplete (e.g., limiting health care to Western
Although the specific forms may vary, the role of medical or therapeutic services, to the exclusion
culture is not limited to trauma-affected groups of traditional forms of healing and healers), or
who experience the disruption of their simply incomprehensible (Manson, 1996).
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With children, cultural factors may influence the determining whether individual or family therapy
substance or expression of developmental is the best approach. The chosen trauma
differences in ability to comprehend and treatment may be individualized to the family’s
communicate concepts such as social needs, but yet may not fit with the family’s
intentionality and causality, the distinction cultural understanding of a child’s role in the
between self and others, and the ability to family system. Furthermore, there are often
symbolize and to access working or long term different levels of acculturation within the same
memory (T. Miller, 1998; Salmon & Bryant, family. For example, children who are born in the
2002). For example, in some cultures children United States but whose parents moved here as
are socialized to view intentionality and causality adults often have developed a mixed sense of
as attributes of collective ethnic identity that is
groups rather than of bicultural, frequently
individuals in isolation. If leading to family
such children are sexually conflict around
molested, they may not cultural difference and
disclose the abuse because varying levels of ethnic
it might threaten their identity.
acceptance as a valued
member of their families and Interventions for
communities. This prevention or
acceptance may be treatment of children
perceived as more crucial to or adolescents’
recovery than having the posttraumatic
ability to say “no” or knowing impairment typically
how to counteract self- have been developed
blaming thoughts or self- within the context of
soothe if feeling the Western medical
overwhelmed. Culturally model (Parson, 1997).
sensitive approaches to However, evidence-
trauma assessment have based models such as
been developed for adults cognitive-behavior
(e.g., Loo et al., 2001) and therapy (Cohen et al.,
children (Ford et al., 2000). However, their 2000), Eye Movement Desensitization and
appropriateness and psychometric reliability, Reprocessing (EMDR) (Chemtob, Tolin, & van der
validity, and utility in different ethnocultural Kolk, 2000; Greenwald, 1998), or parent-child
groups, contexts, and communities have not dyadic psychotherapy (Lieberman, van Horn,
been systematically evaluated. Grandison, & Pekarsky, 1997) are eminently
adaptable to address not only developmental,
Different cultures have different concepts of but also ethnocultural, differences. For instance,
family, in terms of who is a member, the roles it is possible to incorporate features designed to
and responsibilities of each member, and how strengthen culture-specific resilience factors
involved family members are with different derived from empirical studies of children in
children. This becomes important when different cultures who have been exposed to
considering how to treat the child, especially in different types of complex trauma (e.g., mental
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flexibility among Palestinian children, coping within an individual, the family, and their social
resources of South African children, social environment (Masten & Coatsworth, 1998;
support among African American children). Waller, 2001). A child may function well in
certain domains (e.g., academic) while exhibiting
Naturalistic healing resources are also distress in others (e.g., behavior) (Luthar,
potentially vital to children’s recovery from Cicchetti & Becker, 2000). Areas of competence
complex trauma (Manson, 1996). There are can also shift as children are faced with new
many indigenous cultural mechanisms for stressors and developmental challenges.
addressing the disruptions of affect regulation, Understanding the continuum of responses to
body allostasis, and sense of meaning or trauma and the coping and protective factors
connection that result from complex trauma. The underlying resilience is vital to secondary and
Navajo, for example, have developed Enemy Way tertiary prevention efforts with children exposed
or Beauty Way ceremonies as approaches to to complex trauma (Egeland, Carlson & Stroufe,
spiritual purification and social reintegration for 1993).
warriors (Manson, 1996). The integration of
these methods and rituals in prevention or Competence and resilience have been linked
treatment services for children who are with several protective factors consisting of
survivors of complex trauma is warranted, but individual, family, and environmental variables
will require careful ethnographic study and (Masten & Coatsworth, 1998). Resilience
collaboration between professionals in the develops from very ordinary adaptational
traumatic stress field and varied cultural processes and is not limited to remarkable
communities. Finally, prevention and treatment individuals (Masten, 2001). Several factors have
interventions also must consider the impact of been found to be the most critical for promoting
racism and political/ethnic/class oppression as resilience, including: (a) positive attachment and
traumatic stressors (Loo et al., 2001). connections to emotionally supportive and
competent adults within a child’s family or
community, (b) development of cognitive and
self-regulation abilities, (c) positive beliefs about
Coping and Protectiv
Pro e FFact
ective actor
orss
actor oneself, and (d) motivation to act effectively in
one’s environment (Luthar, et al., 2000; Masten,
2001; Werner & Smith, 1992; Wyman, Sandler,
Wolchik, & Nelson, 2000). Additional individual
factors associated with resilience include an
While exposure to complex trauma has a easygoing disposition, positive temperament,
potentially devastating impact on the developing and sociable demeanor; internal locus of control
child, there is also the possibility that children in and external attributions for blame; effective
these situations can nevertheless function coping strategies; degree of mastery and
effectively and competently across a variety of autonomy; special talents; creativity; and
domains (Kendall-Tackett, Williams, & Finkelhor, spirituality (Werner & Smith, 1992). Additional
1993; Masten & Coatsworth, 1998). Resilience familial and environmental factors that have
is no longer regarded as a static attribute or a been found to foster resilience include parenting
single, global construct but rather is viewed as with warmth, structure, and high expectations of
multi-determined and evolving domains of the child; socioeconomic resources; ties to
competency, consisting of interacting forces extended family; involvement with prosocial
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community organizations; and effective schools

(Masten & Coatsworth, 1998). Approaches tto
Approaches o Comprehensiv
Comprehensiv
prehensive e
Assessment of Com ple
plexx TTrauma
Comple rauma
The greatest threats to resilience appear to in Children
follow the breakdown of protective systems:
damage to brain development and associated
cognitive and self-regulatory capacities;
compromised caregiver-child relationships; and
loss of motivation to interact with one’s Typically, regardless of the initial trauma event
environment, learn and develop new skills. In that prompts referral for treatment services, the
situations of severe adversity, poor parenting accepted standard of care involves conducting a
and cognitive skills increase the risk of comprehensive assessment, which uses
maladaptive child behavior patterns, while observations, clinical interviews with child/
normative intellectual skills and parenting adolescent and primary caretakers, collateral
protect the child and foster growth of information (as appropriate— schools, child
competence (Masten, 2001). Ultimately, protection, previous therapist, forensic
supportive connections and cognitive resources interviewer, pediatrician, etc.). Clinical interviews
help buffer children against the worst effects of should follow a consistent format using a
trauma and serve as “inoculations against specific comprehensive form completed by the
adversity” (Schimmer, 1999). clinician. The assessment should also include
the use of standardized assessment
Other research has illuminated the importance instruments that include self-report measures
of coping strategies on long-term mental health as well as measures completed by caretakers
outcomes in response to complex trauma and/or teachers based on types of trauma,
exposure in childhood (Vaillant, 1986; Vaillant, developmental/chronological factors, and
Bond, & Vaillant, 1986). Coping strategies availability of informants. Such a comprehensive
represent the expression of psychological assessment conducted over several sessions
defense mechanisms that develop in childhood will establish treatment goals based on the
as protective responses that accentuate, limit, or phase-oriented model of trauma treatment.
block perceptions of inner and outer reality as a
means of managing trauma and deprivation. Since trauma evaluations often involve the
The more severe the exposure to complex criminal and/or probate court systems, it is
trauma in childhood, the stronger the use of imperative that the evaluations be conducted in
certain coping strategies—such as sublimation, a forensically sound, as well as clinically rigorous
humor, altruism and suppression—has been manner. Specifically, questions must be asked in
associated with successful management of life a non-leading manner and be accompanied by
problems and promotion of positive mental thorough documentation of all relevant
health in adulthood. In contrast, reliance on disclosures. Even when referrals begin as a
primitive defense mechanisms including clinical assessment, any disclosures that occur
dissociation, projection, passive aggression and are often the backbone of legal efforts to keep a
hypochondriasis is linked to greater functioning child safe.
deficits and more severe psychopathology over
time.
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Areas tto
o Assess in Clinical Inter
Inter vie
ervie ws
views
Standardized Measures
Standardized
A comprehensive evaluation assesses both
complex traumatic exposures and complex Assessment measures are administered as part
traumatic outcomes or adaptations, and is of the initial evaluation; at 6-month, or ideally, 3-
accompanied by thorough psychological month intervals to track treatment progress and
evaluation of symptoms and history. The inform clinical decision-making in an
evaluation should begin with the reason for individualized and empirically based manner; as
referral, the presenting concerns, and the well as at termination so as to determine
history of those presenting problems. Important treatment outcome and guarantee the
historical information includes: developmental appropriateness of termination. Follow-up is also
history, family history, trauma history for child recommended, when possible, to determine
and family, attachment relationship(s) for child/ endurance of positive treatment outcomes.
adolescent and primary caregiver(s), child Standard psychological and neuropsychological
protective services involvement and placement testing can be useful in further understanding a
history, illnesses, losses, separation/ child’s adaptation to complex trauma, as well as
abandonment by parent, deaths, parental/family in defining the specifics of learning difficulties,
mental illness, substance abuse, legal history, thought disorder, and other possible organic
coping skills, strengths of child/adolescent and contributors. It is important to assess multiple
family, and any other stressors (e.g. community areas of functioning and to gather information
violence, economic issues, racial from multiple informants (i.e. parent, teacher,
discrimination). Clinicians need to evaluate for and child) across different settings (i.e. school
all types of traumatic experiences since there is and home). In a typical trauma evaluation, some
considerable evidence supporting multiple combination of the following measures would be
traumatic exposures. In addition to specific included:
information regarding the nature of the
traumatic experience(s), it is also important to Child/A dolescent Measures
Child/Adolescent
gather information regarding circumstances of Trauma Symptom Checklist for Children
disclosure, responses of family members and (TSCC, Briere), UCLA Trauma Reminders
agency professionals, safety concerns/issues, Inventory, Children’s PTSD-Reaction Index
and the child/adolescent’s ability to express (Pynoos), Adolescent-Dissociative
feelings about the traumatic experiences. Experiences Scale (A-DES, Putnam), Youth
Self-Report (YSR, Achenbach), Children’s
In addition to assessing traumatic exposures, Depression Inventory (CDI, Kovacs)
the clinicians must evaluate adaptations to
complex trauma in the seven domains described Parent/Care tak
arent/Caretak er Measures
taker
earlier: biology, attachment, affect regulation, Child Behavior Checklist (CBCL, Achenbach),
dissociation, behavioral management, cognition, Child Dissociative Checklist (CDC, Putnam),
and self-perception. These domains should be Child Sexual Behavior Inventory (CSBI,
assessed in terms of their current presentation, Friedrich), Traumatic Events Screening
as well as their developmental trajectories. Inventory (TESI, Ford)
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Teacher Measures
eacher
child and the family can begin to heal. Often,
Teacher Report Form (TRF, Achenbach):
this means clinicians working with child
Specific information regarding these
protective services and the court system to
measures and their relative merits as well as
develop a safer living environment. It is also
more detailed related to assessment
critical to engage the family and the school, as
approaches can be obtained from a number
well as other primary support figures, in order to
of sources (Friedrich, 2002; Ohan, Meyers, &
create a network that will develop safety within
Collett, 2002; Pearce & Pezzot-Pearce,
the living environment.
1997; Briere & Spinazzola, in press).
It is then possible for psychosocial treatments to
provide recovery from the damages of abuse
and rehabilitation of skills lost or never formed.
Development of these basic skills, e.g.
Approaches tto
Approaches o TTreatment
reatment of identifying feelings and forming a relationship
with another person, occurs in the therapeutic
Com ple
plexx TTrauma
Comple rauma in Children context partnered with significant caretaker
involvement, so that the newly learned skills are
reinforced at home. The final challenge is the
transmission and maintenance of these skills in
Phase-Based Approaches
Approaches the day-to-day world. This final effort can take
root in treatment but will need partnering with
Inter
ervvention Needs
Inter the family and with community agencies.
Interventions for traumatized children and Wh

Whyy Use Phase-Based Inter
ervvention?
Inter
adolescents must be developed and tested
which directly address the specific complex There is consensus that treatment development
trauma domains. Treatments for traumatized should take a phase-based, or sequential
youth thus far have been conceptualized as approach. Research with traumatized adults
having four central goals: (1) safety in one’s indicates that treatments in which all aspects of
environment, including home, school, and work occur simultaneously tend to create
community, (2) skills development in emotion “information overload” such that learning never
regulation and interpersonal functioning, (3) fully occurs. This is likely to be especially true of
meaning-making about past traumatic events children whose ability to attend to and process
they have experienced so that youth can information is less well developed than adults.
consider more positive, adaptive views about The sequential order of the treatment is such
themselves in the present, and experience hope that the lessons learned in one phase serve as a
about their future, and (4) enhancing resiliency building block for those to come next. The
and integration into social network. process is not linear, however, so that it is often
necessary to revisit earlier phases of treatment
Almost all traumatized youth face the task of in order to remain on the overall trajectory.
living in a continually traumatizing environment
or finding a place in a new environment. Thus, Before any treatment can truly begin, the safety
the initial tasks of treatment are focused on of the child and family must be addressed. It
creating a system of care and safety in which a would be impossible for any child, or adult, to
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take in new information when he or she is youth to achieve and develop their unique
fighting for survival. The focus of treatment at talents. The traumatic experience can then
this early juncture largely involves building a move from being the central aspect of their lives
network for the child and family. Thus, clinicians to being a part of their history.
work closely with child protective services, the
school system, and other providers for the family Com ple
plexx TTrauma
Comple rauma TTreatment
reatment Programs ffor
Programs or
to develop safety and a treatment plan that Children and A dolescents
Adolescents
addresses the needs of the child, as well as the
family. Within the treatment relationship, the While most treatment of traumatized children
focus is on building trust and a positive working and their families takes place within community
relationship. mental health settings, hospitals, schools, and
home-based family stabilization teams, there are
The emotion regulation skills of the second a number of trauma-specific treatment
stage help clients review their traumatic programs in development for children and
experiences. Once children possess improved adolescents. Several of these are modeled upon
methods for coping and an increased capacity earlier work conducted with adults (Cloitre et al,
for emotion regulation, they are better able to 2002; Ford, in press; Turner, DeRosa, Roth &
communicate and process traumatic memories. Davidson, 1996), although these interventions
This process leads to a decrease in are clearly modified in order to be
psychological distress concerning their history developmentally appropriate. There are several
and to reduced reactivity to the inevitable treatment models designed for children of
traumatic reminders (schools, streets, sounds) different ages and their families (Cloitre et al.,
in their home environment. The development of 2002; Cohen & Mannarino, 1998; DeRosa, et
emotion regulation along with social skills also al., 2003; Hembree-Kigin & McNeil, 1995;
allows youth to see themselves as different from Kagan, in press; Lieberman, et al., 1997; Lyons
the people they were at the time of the Ruth & Jacobvitz, 1999; Rivard et al., 2003).
traumatic events. The contrast between who
they were during these events and who they are The treatment of choice for infants and toddlers
becoming, with the help of the skills work, uses a parent-child dyadic model (Hembree-
provides them with a more confident view of Kigin & McNeil, 1995; Lieberman et al., 1997;
themselves and the notion that change is Lyons Ruth & Jacobvitz, 1999). Because
possible. attachment is critical to overall healthy
development, as well as to recovery from
The goal of the last phase of treatment is to trauma, parental attunement is the primary goal
instill principles of resiliency in youth so that of treatment. Without it, there can be no healthy
they can continue to develop in positive, healthy, attachment in preschool age children. Thus, the
and functional ways and avoid future child has the best chances for healing and
victimization and/or aggressive behaviors. recovery when intervention is early and focuses
Phase 4 interventions involve the creation or on the parent-child relationship.
reinforcement of assets that build resiliency
(DeRosa et al., 2003). These activities can For latency age children who have been sexually
include involving the youth in creative projects or abused, Cohen & Mannarino (1998) have
youth programs, identifying expectations and designed a treatment program in which children
responsibilities, working with families and participate in a short-term trauma-specific
communities to maximize safety and encourage intervention, while parents simultaneously
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attend separate therapy sessions in order to Each of the treatments just reviewed has been
learn about the children’s treatment and to manualized in order to carefully document the
learn ways to help their children cope. This details and mechanisms of the interventions,
intervention has been associated with a and to ensure fidelity across treatment
reduction in depressive symptomatology and an providers. With the creation of manuals
increase in social competence. Similarly, Kagan documenting effective treatments for children
(in press) has developed Real Life Heroes, a and adolescents experiencing complex trauma
program for traumatized children that utilizes outcomes, we can begin to affect standards of
creative arts, life story work, and the metaphor care and influence best practices guidelines.
of heroes to help children and their parents to The clear benefit of manualized treatments is
increase skills for overcoming trauma and to that they can be disseminated and used to train
build or rebuild attachments. clinicians across various settings. However,
treatment manuals also have limitations.
There are several group models in development Treatments for traumatized youth are not “one-
for adolescent girls with histories of sexual or size-fits-all.” As manuals are brought to
physical abuse (Cloitre, Koenen, Cohen & Han, community clinics, they must be adapted in
2002) and witnessing domestic violence order to be culturally relevant and to be flexible
(DeRosa et al., 2003). Cloitre and colleagues are enough to meet the needs of individual children
developing a 16-session treatment for and their families. Manuals must also be
adolescent girls who have been physically or tailored to address developmental differences in
sexually abused. This treatment is organized into children and adolescents. Most importantly,
three of the phases described earlier: skills clinical decision-making about complex trauma
training in emotion management and intervention with children should always begin
interpersonal effectiveness, trauma narrative with comprehensive assessment of the
story telling, and resiliency-building. Similarly, impacted child’s needs, strengths and trauma
the broad treatment goals of DeRosa and outcomes in order to provide more
colleagues’ model include: “Managing the individualized, empirically based treatment.
Moment”, strategies to help girls manage and
regulate their affect and impulses more Going int
intoo the Community
effectively “here and now” when experiencing
acute distress; “Building Coping Strategies”, The mental health field has been moving
strategies to enhance ability to cope with the toward greater accessibility for families, which
impact of the trauma including identifications of has led to more community-based programs
triggers, anger management and problem (e.g. schools, child protective services, shelters,
solving strategies; and “Enhancing Resiliency”, family courts). Focusing on one of these types of
strategies designed to help participants identify community intervention, school-based
current adaptations to the trauma that are interventions can provide critical access for
proving successful. Preliminary data thus far students in need of mental health services, and
suggest this phase-based approach is much can address multiple financial, psychological
more successful than either supportive and logistical barriers to treatment. Trauma-
treatment or skills only treatment in improving informed programs are currently being
PTSD symptoms, emotion regulation, implemented and tested in schools and
depression, dissociation, anger and social residential settings and are also confronting the
competence (Cloitre, 2002). “real world” challenge of working with the large
and underserved population of children and
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adolescents who live and remain in chronically adaptive coping in regard to his or her own
stressful and unstable environments, such as emotional response to difficult circumstances.
homes or communities where violence The fourth principle revolves around praise,
commonly occurs (DeRosa, et al., 2003; Cook, reinforcement and the opportunities to focus on
Henderson, and Jentoft, 2003). a child doing something positive so as to help
the child to identify with competencies rather
The traumatized children and adolescents seen than deficits. These principles are likely to
in schools and the community are often those promote increased security in attachment
easily identified as “at risk” due to chronic relationships, which will then become the basis
deficits in their ability to regulate attention, for the development of all other competencies
affect and behavior. These deficits often lead to including regulation of attention, affect, and
specialized and/or alternative school and home behavior. It should be noted that these principles
placements in which the staff, teachers, and could be applied in a variety of contexts
counselors frequently become primary including clinic based, school based, home
caretaker(s) and attachment figures. Therefore, based and community based settings.
when working with traumatized children in the
community; providers must consider both the Enhancement of self-regulatory capacities and
child and the context as the targets of increases in competency across domains are
intervention. Cook, Henderson, and Jentoft, common goals among trauma-specific school-
(2003) propose a “milieu” model of working with based approaches (DeRosa et al., 2003; Cook et
traumatized children in the community. This al., 2003). The goal is to increase cognitive,
conceptual model (ARC) emphasizes the child emotional, physical, and spiritual mastery
and the adults in their environment and focuses (James, 1989). Examples of techniques used to
on three key areas: (1) building secure promote cognitive mastery include direct
“a”ttachments between child and caregiver(s); teaching, story telling, and bibliotherapy.
(2) enhancing self –”r”egulatory capacities; and Emotional mastery is achieved through art, play,
(3) increasing “c”ompetencies across multiple and body-oriented strategies. Children who are
domains. traumatized or neglected often exhibit inhibited
play or the inability to play while others may
In order to strengthen the attachment between reenact their experiences. Thus, play is essential
child and caretaker(s), it is essential that four to facilitate healing and to learn skills that are
basic principles be implemented. The first is to later necessary in different developmental
create a structured and predictable environment phases (James, 1994).
through the establishment of rituals and
routines. This includes behavior management Physical mastery comes through involvement in
and limit setting. The second is enhancement of physical activities. Activities such as yoga,
the adult’s ability to “tune in” to the child’s music, movement, sports (in school/program
affect in order to respond to the affect rather settings, and drama can be modified to be
than react to the behavioral manifestation. The included in individual and group work. In
third principle is that the caretaker is helped to addition, such activities can and should be
model effective management of intense affect included in treatment planning as adjunctive
by supporting the child in both labeling and auxiliary treatment methods. These activities
coping with emotional distress. It should be support children in a number of ways including:
noted that in order to respond to rather than (1) Finding a new vehicle of expression that
react to a child requires that the adult model decreases arousal and increases soothing; (2)
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Gaining trust in their environment; (3) Psy chopharmacological Int

Psychopharmacological er
ervventions
Inter
Decreasing isolation; and, (4) Developing
accessible tools (visual, tactile, auditory, Psychopharmacological interventions for
kinesthetic) for dealing with distress (Macy, R., traumatized children and adolescents are
Macy, D., Gross, S., Brighton, P., & Rozelle, D., primarily considered to be adjunctive to
1999-2003). Body oriented treatments and psychosocial treatment modalities. They aid in
activities can teach children to change their the management of symptoms that might
physiological response to threatening stimuli, interfere with the attention and learning
which will ultimately lead to improvement in their demands of psychosocial treatments, or that
functioning. These techniques provide effective can threaten to disrupt a placement. However,
therapy for children who experience extreme medication should only be used in conjunction
physical vulnerability and who have distorted with trauma-specific treatment and not in place
body concepts (James, 1989). Finally, adjunctive of it. Six open label studies are available in the
therapies provide a natural forum for mentoring, medical literature and at least one double-blind
affiliation, integration, and socialization all of study with a positive outcome has been
which are essential to enhancing resiliency. published on the treatment of PTSD in children.
Drawbacks to these studies include modest
Trauma-specific milieu treatment appears to samples sizes. Recent studies on the use of the
have been successful in increasing ability to Selective-Serotonin-Reuptake-Inhibitor agents
regulate affect. This has been demonstrated by (SSRI’S) have shown promise. In general, early
fewer suspensions and aggressive outbursts, intervention with medication should be reserved
increasing ability to regulate attention as for the more extreme cases, existing
indicated by increased time spent on academic comorbidities, or as an adjunct to other forms of
tasks, increasing affiliation and group cohesion treatment. Further research in this area is
as reflected by fewer peer conflicts, and needed to assess the efficacy and safety of
increasing compliance with rules and medications for use and the conditions under
expectations, which may also suggest which they may be helpful adjuncts or even
improvement in adult-child attachment preferred to psychosocial interventions (See
relationships (Cook et al., 2003). Silva, Cloitre, Davis et al., 2003).
The principles of the school-based model Child Com ple

plexx TTrauma
Comple rauma TTreatment
reatment Summar
Summaryy
described are designed to be applicable in other
types of community settings, including Preliminary data from youth-oriented phase-
residential programs, shelter systems, and child based treatments for complex trauma suggest
protection agencies. In order to effect significant that they provide symptom relief, as well as
systemic change for traumatized children, it is improvement in social competence and emotion
imperative to work closely with these community management, and that they are consistently
systems, so that a phase-oriented model that superior to nonspecific supportive therapies.
focuses on safety first, skill building, meaning These programs, however, are in the earliest
making, and enhancing resiliency can be phase of development. Several more years of
implemented on a broad scale. work are necessary to test the treatments’ core
aspects and adapt them for culturally and
geographically diverse populations. In addition,
it is critical that the field and the NCTSN
continue to develop and explore new multi-
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modal, empirically based interventions that a. increase external safety

address the range of complex trauma b. develop internal safety and
adaptations, while simultaneously providing competence
clinicians with access to the requisite training c. alter developmental trajectory in
and resources to implement, modify, and positive, health-promoting direction
evaluate the effectiveness of available d. foster healthy primary attachment
treatments across diverse child complex trauma relationship, as well as cultivating
populations. Finally, there is consensus that other social supports
interventions should build strengths as well as
reduce symptoms. In this way, treatment for 5. Develop, implement, disseminate and support
children and adolescents also serves as a prevention programs and services that reduce
prevention program for poor outcomes in children’s exposure to violence in the home,
adulthood. school and community.
Recommendations ffor
or R esear
Resear cher
cherss
esearcher
Recommendations and Studying Child Comple
plexx TTrauma
Comple rauma
Future Directions Populations
1. Implement multi-site epidemiological
characterization studies of complex child trauma
exposure and outcomes.
Recommendations fforor Clinicians
2. Conduct evidence-based development and
Working with Child Com
orking ple
plexx TTrauma
Comple rauma testing of phase-oriented treatments for complex
Populations trauma in children and adolescents.
1. Increase public and professional awareness of 3. Review and evaluate promising programs and
chronic complex trauma in children and innovative intervention models that span service
adolescents. sectors (e.g., Head Start; juvenile justice; mental
health) and attempt to reach complexly
2. Develop comprehensive continuum of care traumatized children through multiple contexts
based on phase-oriented model of treatment for (e.g., parent-child, peer-based, faith-based
complex trauma. communities) and across multiple domains (e.g.,
clinical services; auxiliary services, academic
3. Increase collaboration among community and vocational development).
agencies and organizations serving traumatized
children and their caregivers. 4. Establish and cultivate ongoing partnerships
between academic settings and community
4. Recognize and address the following goals of clinics to develop and test community-based,
multi-modal treatment intervention with culturally relevant, age-appropriate interventions
complexly traumatized children: for traumatized children and adolescents.
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5. Increase focus on understanding 4. Work to influence the creation and design of

characteristics of resilient youth, and the impact state, federal and foundation service, training
of treatments and strengths-based initiatives and research grants dedicated to increasing
that focus on building competence, positive self- understanding, intervention and access to
regard and resiliency in traumatized children resources for children and families impacted by
and adolescents. complex child trauma.
Recommendations fforor Policy Mak

Policy er
erss
Maker 5. Lobby for the inclusion of exemplary
Acting on Behalf of Child Com ple
plexx
Comple intervention and prevention programs for
complex child trauma in local, state and federal
Trauma P opulations
Populations budgets, with a prioritization for integrated
programs across federal, state and local
1. Advocate for recognition of complex child agencies including the Departments of Defense,
trauma as a public health problem effecting Justice, Education, and Health and Human
millions of children in the United States each Services; the Center for Disease Control; and the
year. Substance Abuse and Mental Health Services
Administration.
2. Engage in policy efforts aimed at closing the
gap between needs of children and families 6. Advocate for the incorporation of an
impacted by complex trauma and available empirically based parity diagnosis of the impact
resources. of complex child trauma in the DSM-V in order to
improve clinician understanding of complex
3. Increase awareness that effective trauma outcomes in children and adolescents,
interventions for children exposed to complex anchor treatment guidelines, and increase third
trauma can be implemented; however, these party compensation mental health services
interventions need to be integrated across the required by this population.
systems in which impacted children are located.
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Comple
plexx TTrauma
Comple rauma Sur
Survvey: National Child TTraumatic
Netw or
twork
ork
T
he NCTSN conducted a survey on complex trauma exposure, outcomes and treatment
approaches for impacted children and their families receiving intervention and/or
comprehensive assessment services in 2002. Aggregate data was provided on a sample
of 1,699 children across 25 network sites (Spinazzola et. al., 2003). This sample constitutes
approximately 15% of the total population of children directly served by the network during a
typical quarter.
Findings revealed that the vast majority of children served by the network (78%) have been
exposed to multiple and/or prolonged trauma, with a modal number of 3 trauma exposure
types. Findings further revealed that initial exposure typically occurs early, with an average
age of onset of 5 years old. Moreover, 98% of clinicians surveyed reported average trauma
onset prior to age 11, and 93% reported average onset by age 8.
Interpersonal victimization uniformly emerged as the most prevalent form of trauma exposure
experienced by children in the network, with the locus of impact typically in the home (see
Figure 1). Specifically, each of the following types of trauma exposure was reported for
approximately one-half of the children surveyed: psychological maltreatment (CEA; i.e., verbal
abuse, emotional abuse or emotional neglect); traumatic loss; dependence on an impaired
caregiver (i.e., parental mental illness or substance abuse); and domestic violence. These
experiences were closely followed by sexual maltreatment/assault (CSA), and neglect (i.e.,
physical, medical, or educational neglect), both observed in at least one-in-three children.
Smaller but notable percentages of children had histories of exposure to physical
maltreatment/assault (CPA) or terrorism within the United States. Forms of trauma exposure
not involving interpersonal victimization were significantly less common: fewer than one-in-ten
children included in the survey had been exposed to serious accidents, medical illness or
disaster.
The survey further revealed that a large percentage of trauma exposed children exhibit
several forms of posttraumatic sequelae not captured by standard PTSD, depressive or
anxiety disorder diagnoses (see Figure 2). Notably, 50% or more of the children surveyed were
reported to exhibit significant disturbances in the following domains: affect regulation;
attention and concentration; negative self-image; impulse control; and aggression or risk
taking. In addition, approximately one-third of the sample exhibited significant problems with
somatization, attachment, conduct disorder or ODD; sexual interest, activity or avoidance; and
dissociation.
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Comple
plexx TTrauma
Comple rauma Sur
Survvey: National Child TTraumatic
Netw or
twork
ork
Continued
Despite the wide array of interventions reported to be available for child exposed to complex
trauma, no clear clinical consensus emerged regarding the relative effectiveness of available
modalities. Notably, 5 the top 7 intervention modalities identified by clinicians to be most
effective with complex trauma in children—play therapy, expressive therapies, multisystemic
therapy, group therapy, and self-management/coaching—were also ranked among the 7 least
effective interventions with this population. Only weekly individual therapy and family therapy
were unequivocally perceived to be effective modalities with this population, with
pharmacotherapy and home-based therapies consistently rated as ineffective. Nevertheless,
the majority of clinicians surveyed spontaneously identified the active involvement of
caregivers in children’s treatment as a crucial element of the treatment’s effectiveness. A
number of clinicians also noted the utility of combined approaches to intervention, as well as
the need to tailor intervention services to children’s specific needs based on contextual
factors, which include developmental stage, sociocultural context, and the availability of
environmental resources. Finally, several clinicians pointed to the importance of coordinating
services across service sectors (e.g., schools, mental health, social services) to ensure
effective intervention for children exposed to complex trauma.
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Figure 1: TTrauma
rauma Exposure Pre
Prevvalence in the
Netw or
twor k (N = 1
ork ,699)
1,699)
60%
59.3%
55.6%
47.1% 45.8%
45%
40.8%
uent Exposure TTypes
ypes
33.8%
30% 28.1%
18.4%
15%
requent
0%
er
.)
s
EA
SA
PA
ct
V
s
.S
iv
y: Most FFreq
D
req
le
Lo
eg
C
(U
eg
ar
m
C
s
or
d
re
r
er
i
pa
/T
ar
Im
W
ory:
Histor
or
15%
rauma Hist
Child TTrauma
6.2% 5.7%
3.0% 2.8%
1.6%
0%
t
t
)
en
al
en
tl.
te
ic
id
( In
m
as
ed
c
e
is
Ac
m
M
ac
D
is
s/
y/
pl
or
s
r
is
ju
ne
D
er
In
Ill
/T
ed
ar
rc
W
Fo
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Figure 2: Com ple

plexx TTrauma
Comple rauma Adaptation in the
Adaptation
Netw or
twor k (N = 1
ork ,699)
1,699)
75%
61.5% 59.2% 57.9%
60% 53.1%
45.8%
45%
30%
15%
0%
n
n
l
e
ng
tro
t io
tio
ag
ki
ra
on
a
Im
ta
ul
nt
k-
lf-
eg
lse
is
Se
nc
sr
R
Co
pu
Dy
n/
e
iv
io
Im
n/
ct
at
s
io
fe
es
eg
nt
Af
gr
te
Ag
At
45%
33.2%
29.0% 28.7% 28.0% 27.7%
30%
25.3%
15%
9.5%
0%
s
ep
ss
s
/o
n
n
em
m
io
ne
io
D
td
le
at
e/
at
bl
gi
ob
iz
ro
ci
us
du
in
at
Pr
so
tP
Ab
Cl
on
m
is
l
e/
en
ua
So
/C
e
nc
nc
m
x
D
Se
de
ch
ta
O
bs
en
ta
At
Su
ep
r-D
ve
O
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Citation ffor
or this Document:
Cook, A., Blaustein, M., Spinazzola, J., & van der Kolk, B. (Eds.) (2003).Complex trauma in children and
adolescents. National Child Traumatic Stress Network. http://www.NCTSNet.org
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National Child TTraumatic

What is Complex Trauma? 5

The Cost of Child Complex Trauma 5

Diagnostic Issues for Complex Trauma in Children 6

Table 1: Domains of Impairment in Children 7

Impact of Complex Trauma on Development 8

Adaptation to Complex Trauma in Familial Context 16

Adaptation to Complex Trauma in Ethnocultural Context 18

Coping and Protective Factors 20

Approaches to Comprehensive Assessment of 21

Approaches to Treatment of Complex Trauma in Children 23

Recommendations and Future Directions 28

National Child Traumatic Stress Network 30

et al., 2001; Felitti et al., 1998; Gordon, 2002;

I. Attachment V. Behavioral Contr

provides the scaffolding for the growth of many

When co-regulation is not provided or results in

perpetrators, use of coercion or force, maternal Dissociation

Intrafamilial victimization generally leaves connections to their primary culture, community,

community organizations; and effective schools

Interventions for traumatized children and Wh

Gaining trust in their environment; (3) Psy chopharmacological Int

The principles of the school-based model Child Com ple

modal, empirically based interventions that a. increase external safety

5. Increase focus on understanding 4. Work to influence the creation and design of

Recommendations fforor Policy Mak

Figure 2: Com ple

Page purposely left blank for back cover sheet

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