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Complex Trauma
in Children and Adolescents
Alexandra Cook, PhD; he immediate and long-term conse- EDUCATIONAL OBJECTIVES

Joseph Spinazzola, PhD; quences of childrens exposure to mal- 1. Describe a new theoretical framework
treatment and other traumatic experi- for understanding complex trauma in
Julian Ford, PhD; children.
ences are multifaceted. Emotional abuse and
Cheryl Lanktree, PhD; neglect, sexual abuse, and physical abuse, as 2. Explain how to apply new framework
to assessment of traumatized children
Margaret Blaustein, PhD; well as witnessing domestic violence, ethnic and families.
cleansing, or war, can interfere with the de-
Marylene Cloitre, PhD; 3. Discuss intervention models designed
velopment of a secure attachment within the specifically for traumatized children
Ruth DeRosa, PhD; caregiving system. and their families.
Rebecca Hubbard, LMFT; Complex trauma exposure results in a loss
of core capacities for self-regulation and in-
Richard Kagan, PhD;
terpersonal relatedness. Children exposed to
Joan Liautaud, PsyD; complex trauma often experience lifelong DIAGNOSTIC ISSUES
Karen Mallah, PhD; problems that place them at risk for addition- The diagnosis of posttraumatic stress disorder
al trauma exposure and cumulative impair- (PTSD) does not capture the developmental ef-
Erna Olafson, PhD, PsyD;
ment (eg, psychiatric and addictive disorders; fects of complex trauma exposure. Children ex-
Bessel van der Kolk, MD chronic medical illness; legal, vocational, and posed to maltreatment, family violence, or loss
family problems). These problems may extend of their caregivers often meet diagnostic criteria
from childhood through adolescence and into from the Diagnostic and Statistical Manual for
adulthood (van der Kolk, see page 401). Mental Disorders, fourth edition (DSM-IV),1

Dr. Cook is director of evaluation, Dr. Spinazzola is executive direc- Child Trauma Study Center, Albany, NY. Dr. Mallah is director, Family
tor, and Dr. Blaustein is director of training and education, The Trauma Trauma Treatment Program, Mental Health Center of Denver, Denver,
Center, Justice Resource Institute, and National Center on Family Home- CO. Dr. van der Kolk is professor of psychiatry, Boston University Medi-
lessness, Boston, MA. Dr. Ford is associate professor, Department of Psy- cal School, Boston, MA; clinical director, The Trauma Center at Justice
chiatry, University of Connecticut Health Center, Farmington CT, and Resource Institute, Brookline, MA; and co-director, National Child Trau-
research and evaluation director, Yale/University of Connecticut Child matic Stress Network Community Program, Boston.
Violent Trauma Center. Dr. Lanktree is director, Miller Childrens Abuse Address reprint requests to: Joseph Spinazzola, PhD, The Trauma
and Violence Intervention Center, Long Beach, CA. Dr. Cloitre is direc- Center at Justice Resource Institute, 545 Boylston St., Boston, MA 02116-
tor, New York University Child Study Center Institute for Urban Trauma 3606; or e-mail:
& Stress, New York, NY. Dr. DeRosa is associate director, North Shore This article is a condensation of the Complex Trauma White Paper
University Hospital Adolescent Trauma Treatment Development Cen- of the National Child Traumatic Stress Network (NCTSN) Workgroup on
ter, Manhasset, NY. Ms. Hubbard is child trauma specialist, Directions Complex Trauma. A full version of the report is available at http://www.
for Mental Health, Clearwater, FL. Dr. Liautaud is clinical adminstrator, This project was supported by SAMHSA grants U79
Heartland Health Outreach: International FACES, Chicago, IL. Dr. Olaf- SM 54587, 54284, 54254, 54251, 54318, 54314, 54272, 54282, 54292,
son is director, Child Abuse Trauma Treatment Replication Center, Cin- 54276, and 54300; as well as by SAMHSA grant UD1 SM56111.
cinnati Childrens Hospital, Cincinnati, OH. Dr. Kagan is director, Parsons The authors have no industry relationships to disclose.



Domains of Impairment in Children Exposed to Complex Trauma

I. Attachment IV. Dissociation VI. Cognition
Problems with boundaries Distinct alterations in states of Difficulties in attention regulation and
Distrust and suspiciousness consciousness executive functioning

Social isolation Amnesia Lack of sustained curiosity

Interpersonal difficulties Depersonalization and derealization Problems with processing novel

Two or more distinct states of information
Difficulty attuning to other peoples
emotional states consciousness Problems focusing on and completing
Impaired memory for state-based events tasks
Difficulty with perspective taking
Problems with object constancy
Difficulty planning and anticipating
II. Biology Problems understanding responsibility
Sensorimotor developmental problems V. Behavioral control Learning difficulties
Analgesia Poor modulation of impulses Problems with language development
Problems with coordination, balance, Self-destructive behavior Problems with orientation in time and
body tone Aggression toward others space
Somatization Pathological self-soothing behaviors
Increased medical problems across Sleep disturbances
a wide span (eg, pelvic pain, asthma, VII. Self-concept
Eating disorders
skin problems, autoimmune disorders, Lack of a continuous, predictable sense
pseudoseizures) Substance abuse of self
Excessive compliance Poor sense of separateness
Oppositional behavior Disturbances of body image
III. Affect regulation Difficulty understanding and complying Low self-esteem
Difficulty with emotional self-regulation with rules
Shame and guilt
Difficulty labeling and expressing Reenactment of trauma in behavior or
feelings play (eg, sexual, aggressive)
Problems knowing and describing
internal states
Difficulty communicating wishes and

for depression, attention-deficit/hyper- (ie, alterations in consciousness), behav- developmental competencies, including
activity disorder (ADHD), oppositional ioral regulation, cognition, and self-con- distress tolerance, curiosity, sense of
defiant disorder (ODD), conduct disor- cept.2 Sidebar 1 provides a list of each agency, and communication.
der, anxiety disorders, eating disorders, domain, along with examples of associ- When the child-caregiver relationship
sleep disorders, communication disor- ated symptoms. is the source of trauma, the attachment
ders, separation anxiety disorder, and re- relationship is severely compromised;
active attachment disorder. Each of these DOMAINS OF COMPLEX TRAUMA 80% of maltreated children develop
diagnoses captures a limited aspect of the insecure attachment patterns.3 When
traumatized childs complex self-regula- Attachment the primary caregiver is too preoccu-
tory and relational impairments. Early caregiving relationships pro- pied, distant, unpredictable, punitive,
A comprehensive review of the litera- vide the relational context in which or distressed to be reliably responsive,
ture on complex trauma suggests seven children develop the earliest psycholog- children become distressed easily and
primary domains of impairment ob- ical representations of self, other, and do not learn to collaborate with others
served in exposed children: attachment, self in relation to others. These working when their own internal resources are in-
biology, affect regulation, dissociation models form the foundation of a childs adequate. This sets the stage for many of


the problems outlined in this article and ment, rather than responding reflexively It is important to note that stressors
others in this issue. to whatever stimulus presents itself, early or later in life that are predictable,
Of the primary insecure patterns, the through a gradual shift from right hemi- escapable, or controllable, or in which
most problematic for childrens adapta- sphere dominance (feeling and sensing) responsive caregiver contact is available
tion is the disorganized attachment. In to primary reliance on the left hemi- and safe opportunities for exploration
younger children, the disorganized attach- sphere (language, abstract reasoning, are reinstated, tend to enhance biologi-
ment patterns consist of erratic behavior and long-range planning) and to an inte- cal integrity.
in relation to caregivers (ie, alternately gration of neural communication across
clingy, dismissive, and aggressive). In the two brain hemispheres (corpus cal- Affect Regulation
older children, adolescents, losum).5,6 Under stress, Posttraumatic impairment of attach-
and adults, disorganized abused and neglected ment and neurobiological integrity can
attachment manifests childrens analytical lead to severe problems with affect regula-
itself in survival-
based behaviors
that are rigid, ex- Deficits in the ability of maltreated children to
treme, and disso- discriminate among and label affective states
ciative.4 Disorga-
nized attachment have been demonstrated as early as 30 months.
behaviors revolve
either on themes
of helplessness (eg, capacities tend to tion. Affect regulation begins with the ac-
abandonment, betrayal, disintegrate, leaving curate identification of internal emotional
failure, dejection) or coer- them disorganized cog- experiences, which requires the ability to
cive control (eg, blame, rejec- nitively, emotionally, and differentiate among states of arousal, in-
tion, intrusiveness, hostility). behaviorally and prone to react with terpret these states, and apply appropriate
When attachment is severely dis- extreme helplessness, confusion, with- labels (eg, happy, frightened). Defi-
rupted (in humans and animals), this drawal, or rage.7 cits in the ability of maltreated children
often engenders lifelong risk of physical In middle childhood and adolescence, to discriminate among and label affective
disease and psychosocial dysfunction. the most rapidly developing brain areas states in both self and others have been
This risk occurs along three pathways are those responsible for three core fea- demonstrated as early as age 30 months.8
that reflect impairments in core biopsy- tures of executive functioning neces- Following the identification of an
chosocial competencies: increased sus- sary for autonomous functioning and emotional state, a child must be able to
ceptibility to stress (eg, difficulty focus- engagement in relationships. These fea- express emotions safely and to modulate
ing attention and modulating arousal); tures, involving primarily the prefrontal or regulate internal experience. Com-
inability to regulate emotions without cortex, are conscious self-awareness and plexly traumatized children show im-
external assistance (eg, feeling and act- genuine involvement with other people, pairment in both of these skills. Children
ing overwhelmed by intense or numbed ability to assess the valence and mean- with complex trauma histories evidence
emotions); and altered help-seeking (eg, ing of complex emotional experiences, both behavioral and emotional expres-
excessive help-seeking and dependency and ability to determine a course of ac- sions of pathology due to impaired ca-
or social isolation and disengagement). tion based on learning from past expe- pacity to self-regulate and self-soothe.
riences and an inner frame of reference These expressions may include disso-
Biology informed by understanding others per- ciation, chronic numbing of emotional
Toddlers or preschool-aged children spectives. Traumatic stressors or prior experience, dysphoria and avoidance of
with complex trauma histories are at deficits in self-regulatory abilities that affectively laden situations (including
risk for failing to develop brain capaci- manifest during adolescence, in the ab- positive experiences), and maladaptive
ties necessary for modulating emotions sence of sustaining relationships, may coping strategies (eg, substance use).
in response to stress. Nontraumatized lead to disruptions in regulation of af- These children therefore often present as
young children gradually learn to orient fect, behavior, consciousness, cognition, emotionally labile, with extreme rapidly
to both the external and internal environ- and self-concept integration. escalating responses to minor stressors.


Thus, thoughts and emotions are discon-
nected, somatic sensations are outside
Six Core Components of Complex Trauma Intervention conscious awareness, and behavioral
repetitions take place without conscious
1. Safety:
The installation and enhancement of internal and environmental safety. choice, planning, or self-awareness.
Dissociation thus places a child at risk
2. Self-regulation:
for further victimization, other forms
Enhancement of the capacity to modulate arousal and restore equilibrium
following dysregulation across domains of affect, behavior, physiology, of trauma (eg, accident-proneness), and
cognition (including redirection of dissociative states of consciousness), learning difficulties. It also compounds
interpersonal relatedness and self-attribution. the problems associated with dysregu-
3. Self-reflective information processing: lated affect and attachment (eg, reducing
Development of the ability to effectively engage attentional processes emotional awareness and compromising
and executive functioning in the service of construction of self-narratives, bonding with adults or peers).
reflection on past and present experience, anticipation and planning, and Dissociation is associated with biolog-
decision making. ical alterations in the brain (eg, decreased
4. Traumatic experiences integration: left hippocampal volume in women)14
The transformation, incorporation, or resolution of traumatic memories, and in cerebrospinal fluid levels of neu-
reminders and associated psychiatric sequelae into a nondebilitating, rotransmitters and their metabolites15 that
productive, and fulfilling existence through such therapeutic strategies
as meaning-making, traumatic memory containment or processing,
are consistent with the biological mecha-
remembrance and mourning of the traumatic loss, symptom management nisms described above as likely sub-
and development of coping skills, and cultivation of present-oriented thinking strates of complex trauma. Chronic trau-
and behavior. ma exposure may lead to an increasing
5. Relational engagement: overreliance on dissociation as a coping
The repair, restoration or creation of effective working models of attachment, mechanism that, in turn, can exacerbate
and the application of these models to current interpersonal relationships, difficulties with behavioral management,
including the therapeutic alliance, with emphasis on development of such affect regulation, and self-concept.
critical interpersonal skills as assertiveness, cooperation, perspective-taking,
boundaries and limit-setting, reciprocity, social empathy, and the capacity for
physical and emotional intimacy. Behavioral Regulation
Complex childhood trauma is associ-
6. Positive affect enhancement:
ated with both undercontrolled and over-
The enhancement of self-worth, esteem and positive self-appraisal through
the cultivation of personal creativity, imagination, future orientation, controlled behavior patterns. Abused
achievement, competence, mastery-seeking, community-building and the children may demonstrate rigidly con-
capacity to experience pleasure. trolled behavior patterns as early as the
second year of life, including as compul-
sive compliance with adult requests, re-
The long-term effect of complex trau- Dissociation: Alterations in sistance to changes in routine, inflexible
ma on affect regulation is illustrated by Consciousness bathroom rituals, and rigid control of
the findings of twin studies, where ge- Maltreated children make three fun- food intake.16 Childhood victimization
netic and family factors were controlled.9 damental dissociative adaptations in also has been shown to be associated
Children who experienced sexual abuse their awareness of self and experience:13 with the development of aggressive be-
involving penetration had adjusted odds automatization of behavior (ie, deficits havior and oppositional defiant disorder.
ratios for depression and suicide attempts in judgment, planning, and organized Overcontrolled or undercontrolled
that were 8 and 12 times higher, respec- goal-directed behavior), compartmental- behavior may be due to the re-enactment
tively, than those not reporting sexual ization of painful memories and feelings, of specific aspects of traumatic experi-
abuse.10 Childhood trauma appears not and detachment from awareness of emo- ences (eg, aggression, self-injurious
only to increase risk for major depres- tions and self. These alterations in con- behaviors, sexualized behaviors, con-
sion but also to predispose toward earlier sciousness reflect a failure to integrate trolling relationship dynamics). Such
onset,11 longer duration, and poorer re- or associate information and experience behaviors serve a number of functions
sponse to standard treatments.12 in a normally expectable fashion.13 for the traumatized child, including au-


tomatic behavioral reactions to remind- Self-Concept There are three main elements in
ers (eg, compulsive avoidance behav- By age 18 months, maltreated toddlers caregivers responses to their childrens
iors), attempts to gain a sense of mastery already are more likely to respond to trauma: believing and validating their
or control, avoidance of intolerable lev- self-recognition with neutral or negative childs experience, tolerating the childs
els of emotional arousal, or attempts to affect than nontraumatized children.22 affect, and managing the caregivers
achieve acceptance and intimacy. Over time, children normally consolidate own emotional response. When a care-
a stable and integrated sense of identity.23 giver denies the childs experiences, the
Cognition Responsive, sensitive caretaking and child is forced to act as if the trauma did
Prospective studies have shown that positive early life experiences allow chil- not occur. The child also learns he or she
children of abusive and ne- dren to develop a model of cannot trust the primary caregiver and
glectful parents demon- self as generally worthy does not learn to use language to deal
strate impaired cog- and competent. with adversity.
nitive functioning
by late infancy
when compared A history of maltreatment is associated with
with nonabused lower grades and poorer scores on standardized
children.17 The
sensory and emo- tests and other indices of academic achievement.
tional deprivation
associated with ne-
glect appears to be In contrast, re- Also, it is not caregiver distress per
particularly detrimen- petitive experiences of se that is necessarily detrimental to the
tal to cognitive develop- harm, rejection, or both child. Instead, when the caregivers
ment, with neglected infants by significant others, and the distress overrides or diverts attention
and toddlers demonstrating delays in ex- associated failure to develop age-appro- away from the needs of the child, the
pressive and receptive language develop- priate competencies, are likely to lead to child is adversely affected. Children
ment, as well as deficits in overall IQ.18 a sense of self as defective, helpless, de- may respond to their caregivers dis-
By early childhood, maltreated children ficient, and unlovable. Children who per- tress by avoiding or suppressing their
demonstrate less flexibility and creativity ceive themselves as powerless or incom- own feelings or behaviors, by avoiding
in problem-solving tasks than same-age petent and who expect others to reject and the caregiver altogether, or by becoming
peers. Children and adolescents with a despise them are more likely to blame parentified and attempting to reduce
diagnosis of PTSD secondary to abuse or themselves for negative experiences and the distress of the parent.26
witnessing violence demonstrate deficits have problems eliciting and responding In addition, victimized children often
in attention, abstract reasoning, and ex- to social support. rekindle painful feelings in caretaking
ecutive function skills.19 adults. Caregivers who have had im-
By early elementary school, maltreat- ADAPTATION TO COMPLEX TRAUMA paired relationships with attachment fig-
ed children are more frequently referred IN THE FAMILIAL CONTEXT ures in their own lives are especially vul-
for special education services. A history The response of the childs social sup- nerable to problems in raising their own
of maltreatment is associated with lower port system, and particularly the childs children. Caregivers ability to access
grades and poorer scores on standardized mother, is perhaps the most important fac- information about their own childhood
tests and other indices of academic achieve- tor in determining the child outcomes and is and to tell their own story coherently
ment. Maltreated children have three times more important than objective elements of may be the strongest indicators of paren-
the dropout rate of the general population. the victimization itself.24 Caregiver support tal capacity and effective parenting.27
These findings have been demonstrated is a critical mediating factor in determining Caregivers with histories of child-
across a variety of trauma exposures (eg, how children adapt to victimization. Famil- hood complex trauma may avoid expe-
physical abuse, sexual abuse, neglect, ex- ial support and parental emotional func- riencing their own emotions, which may
posure to domestic violence) and cannot be tioning strongly mitigate the development make it difficult for them to respond
accounted for by the effects of other psy- of PTSD symptoms and enhance a childs appropriately to their childs emotional
chosocial stressors such as poverty.20,21 capacity to resolve the symptoms.25 state. Parents and guardians may see a


childs behavioral responses to trauma competence also can shift as children are or adolescents own disclosures, collat-
as a personal threat or provocation, faced with new stressors and developmen- eral reports from caregivers and other
rather than as a reenactment of what tal challenges. The factors that have been providers, the therapists observations,
happened to the child or a behavioral shown to be linked to childrens resilience and standardized assessment measures.
representation of what the child cannot in the face of stress mirror the seven do- Standardized assessment measures that
express verbally. The victimized childs mains affected by complex trauma:30 are culturally sensitive and language-ap-
simultaneous need for and fear of close- Positive attachment and connections to propriate are completed by the patient,
ness (ie, disorganized attachment) also emotionally supportive and competent the caregiver, and, if possible, by the
can trigger a caregivers own memories adults within a childs family or com- childs teacher.32
of loss, rejection, or abuse, and diminish munity (attachment). Because many traumatized children
parenting abilities. Development of cognitive and self-reg- have potential court involvement, the
ulation abilities (affect regulation, cog- evaluation needs to be conducted in a fo-
ETHNOCULTURAL ISSUES nition, altered consciousness, biology). rensically sound and clinically rigorous
Childrens risk of exposure to com- Positive beliefs about oneself (self- manner. Assessment should address both
plex trauma also can be affected by concept). complex trauma exposures and complex
where they live and by their ethnocultur- Motivation to act effectively in ones posttraumatic outcomes. These should
al heritage and traditions (eg, war/geno- environment (behavioral control). be investigated in addition to develop-
cide are prevalent in some parts of the Additional individual factors associ- mental history, family history, trauma
world; inner cities are frequently plagued ated with resilience include an easygo- history for child and family, primary at-
with high racial tension).28 Children, ing disposition, positive temperament, tachment relationships, child protective
parents, teachers, religious leaders, and and sociable demeanor; internal locus services involvement and placement his-
the media from different of control and external at- tory, parental/family mental illness, sub-
cultural, national, lin- tributions for blame; stance abuse, legal history, coping skills,
guistic, spiritual, and
ethnic backgrounds
define key trauma-
Childrens risk of exposure to complex trauma
related constructs can be affected by where they live and by their
in many different
ways and with
ethno-cultural heritage and traditions.
different expres-
sions (eg, flash-
backs may be vi- effective coping strengths of child/adolescent and family,
sions, hyperarousal strategies; degree of and environmental stressors (eg, com-
may be attacque de mastery and autono- munity violence, racial discrimination).
nervios, dissociation may my; special talents; and
be spirit possession).29 The creativity and spirituality.31 TREATMENT OF CHILDREN WITH
threshold for defining a complex trauma COMPLEX TRAUMA IMPAIRMENT
reaction as a problem warranting inter- COMPREHENSIVE ASSESSMENT OF Employing an expert consensus
vention differs not only across national COMPLEX TRAUMA IN CHILDREN model, the Complex Trauma Workgroup
and cultural groups, but also within Thorough and ongoing assessment is (CTWG) of the National Child Trau-
sub-groups (eg, geographic regions of a essential for case conceptualization and matic Stress Network has identified six
country with different subcultures; dif- determination of treatment goals. Before core components of complex trauma
ferent religious communities within the the clinician can implement appropri- intervention (Sidebar 2, see page 394).
same geographic area). ate interventions, the child needs to be While often implemented concurrently
evaluated in the seven relevant domains in practice, these components build on
RESILIENCE FACTORS discussed earlier in this article. each other in a sequential, phase-ori-
A victimized child may function well A comprehensive assessment of com- ented manner. In light of the many indi-
in certain domains (eg, academic) while plex trauma includes information from a vidual and contextual differences in the
exhibiting distress in others.30 Areas of number of sources, including the childs lives of children and adolescents affect-


ed by complex trauma, implementation for infants, toddlers, and young elemen- REFERENCES
of these core intervention components tary-school aged children specifically 1. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders.
rarely can be conducted successfully target the caregiver-child dyad.38 Sev- 4th ed. Washington, DC: American Psychiat-
based on rigid adherence to a specific eral treatment protocols for complex ric Publishing; 1994.
manualized protocol. Instead, good treat- trauma, particularly those for use with 2. van der Kolk B, Roth S, Pelcovitz D, Sunday
S, Spinazzola. Disorders of extreme stress:
ment requires the flexible adaptation of adolescents, use a group therapy format the empirical foundation of complex adapta-
treatment strategies in response to such to address skills development, affect tion to trauma. J Trauma Stress. In press.
factors as patient age and developmen- regulation, interpersonal connection, 3. Friedrich WN. Psychological Assessment of
Sexually Abused Children and their Families.
tal stage, gender, culture and ethnicity, and competence and resiliency-building.
Thousand Oaks, CA: Sage Publications; 2002.
socioeconomic status, and religious or These include Skills Training in Affect 4. Lyons-Ruth K, Jacobovitz D. Attachment dis-
community affiliation. and Interpersonal Regulation (STAIR),33 organization: unresolved loss, relational vio-
Further, best practice with this popu- Structured Psychotherapy for Adoles- lence, and lapses in behavioral and attentional
strategies. In: Cassidy J, Shaver PR, eds.
lation typically involves adoption of a cents Responding to Chronic Stress Handbook of Attachment: Theory, Research,
systems approach to intervention and (SPARCS),34 and Trauma Adaptive Re- and Clinical Application. New York, NY: The
use of multiple intervention modalities. covery Group Education and Training Guilford Press; 1999:520-554.
5. De Bellis MD, Keshavan MS, Shifflett H.
This may include individual, family and (TARGET).39 Common across these in- Brain structures in pediatric maltreatment-re-
group psychotherapy, parent training, tervention protocols is an emphasis on lated posttraumatic stress disorder: a sociode-
and milieu-based intervention. Often, contextualization of symptoms through mographically matched study. Biol Psychia-
try. 2002;52(11):1066-1078.
this means working with child protective a trauma lens, development of concrete
6. Kagan J. Surprise, Uncertainty and Mental
services, the court system, the schools, skills, and use of group process to de- Structures. Cambridge, MA: Harvard Univer-
and social service agencies. crease stigmatization and increase nor- sity Press; 2003.
malization and social support. 7. Teicher MH, Andersen SL, Polcari A, Ander-
son CM, Navalta CP. Developmental neurobi-
Complex Trauma Treatment Models Psychopharmacologic interventions ology of childhood stress and trauma. Psychi-
A number of trauma-specific treat- for victimized children and adolescents atr Clin North Am. 2002;25(2):397-426.
ment programs are being developed for primarily are adjunctive to psychoso- 8. Beeghly M, Cicchetti D. Child maltreatment,
attachment, and the self system: emergence of
children and adolescents.33-39 One par- cial treatment modalities, aiding in the an internal state lexicon in toddlers at high so-
ticularly important framework for sys- management of symptoms that might cial risk. In: Hertzig M, Farber E, eds. Annual
temic, milieu-based intervention with interfere with the attention and learning Progress in Child Psychiatry and Child De-
velopment. Philadelphia, PA: Brunner/Mazel;
complex trauma in children and adoles- demands of psychosocial treatments, or
cents, Attachment, Self-Regulation, and that can threaten to disrupt a placement. 9. Dinwiddie S, Heath AC, Dunne MP, et al.
Competence (ARC), is described else- Early sexual abuse and lifetime psychopathol-
where in this issue (Kinniburgh et al., SUMMARY ogy: a co-twin-control study. Psychol Med.
see page 424) . Preliminary data from some of the 10. Fergusson DM, Horwood LJ, Lynskey MT.
A number of treatments have been de- various treatment approaches outlined (1996). Childhood sexual abuse and psy-
veloped to target complex trauma expo- above suggest that they provide symp- chiatric disorder in young adulthood: II.
Psychiatric outcomes of childhood sexual
sure and sequelae during specific phases tom relief as well as improvement in
abuse. J Am Acad Child Adolesc Psychiatry.
of child development. Several treatments social competence and emotion man- 1996;35(10):1365-1374.
specifically address the effects of com- agement, and that they are consistently 11. Putnam F. Ten-year research update review:
plex trauma on youth and their caregiv- superior to nonspecific supportive thera- child sexual abuse. J Am Acad Child Adolesc
Psychiatry. 2003;42(3):269-278.
ing systems. These vary in method (ie, pies. These programs, however, are in an 12. Zlotnick C, Ryan C, Miller I, Keitner G. (1995).
group versus individual), point of inter- early phase of development and require Childhood abuse and recovery from depression.
vention (ie, child, caregiver, dyad), and refinement and adaptation for culturally Child Abuse Negl. 1995;19(12):1513-1516.
length, but all address to varying extents and geographically diverse populations. 13. Putnam FW. Dissociation in Children and
Adolescents: A Developmental Perspective.
some or all of the six primary domains Finally, there is consensus that interven- New York, NY: The Guilford Press; 1997.
discussed above. tions should build strengths as well as 14. Stein MB, Koverola C, Hanna C, Torchia MG,
For young children, expert consensus reduce symptoms. In this way, treatment McClarty B. Hippocampal volume in women
victimized by childhood sexual abuse. Psy-
highlights the importance of the attach- for children and adolescents also serves
chol Med. 1997;27(4):951-959.
ment system to overall healthy develop- as a prevention program against poor 15. Demitrack MA, Putnam FW, Rubinow DR,
ment, and treatment protocols designed outcomes in adulthood. et al. Relation of dissociative phenomena to


levels of cerebrospinal fluid monoamine me- 24. Finkelhor D, Kendall-Tackett K. A develop- University Press; 1992.
tabolites and beta-endorphin in patients with mental perspective on the childhood impact 32. Briere J, Spinazzola J. Phenomenology and
eating disorders: a pilot study. Psychiatry Res. of crime, abuse and violent victimization. psychological assessment of complex post-
1993;49(1):1-10. In: Cicchetti D, Toth S, eds. Rochester Sym- traumatic states. J Trauma Stress. In press.
16. Crittenden PM, DiLalla DL. Compulsive posium on Developmental Psychopathology 33. Cloitre M, Koenen K, Cohen LR, Han H.
compliance: the development of an inhibitory and Developmental Perspectives on Trauma. Skills training in affective and interper-
coping strategy in infancy. J Abnorm Child Rochester, NY: University of Rochester Press; sonal regulation followed by exposure: a
Psychol. 1988;16(5):585-599. 1997:1032. phase-based treatment for PTSD related to
17. Egeland B, Sroufe LA, Erickson M. (1983). 25. Cohen JA, Mannarino AP, Berliner L, De- childhood abuse. J Consult Clin Psychol.
The developmental consequence of different blinger E. Trauma-focused cognitive behav- 2002;70(5):1067-1074.
patterns of maltreatment. Child Abuse Negl. ioral therapy for children and adolescents: 34. DeRosa R, Pelcovitz D, Kaplan S, et al.
1983;7(4):459-469. an empirical update. J Interpers Violence. Group Treatment for Adolescents With Com-
18. Culp R, Watkins R, Lawrence H, et al. Mal- 2000;15(11):1202-1223. plex PTSD Manual. North Shore University
treated childrens language and speech devel- 26. Deblinger E, Heflin A. Cognitive Behavioral Hospital, Adolescent Trauma Treatment De-
opment: abused, neglected, and abused and Interventions for Treating Sexually Abused velopment Center, National Child Traumatic
neglected. First Language. 1991;11(33 Pt Children. Thousand Oaks, CA: Sage Publica- Stress Network. 2003.
3):377-389. tions; 1996. 35. Hembree-Kigin TL, McNeil CB. Parent-Child
19. Beers SR, De Bellis MD. Neuropsychologi- 27. Main M, Goldwyn R. Adult Attachment Rat- Interaction Therapy. New York, NY: Kluwer
cal function in children with maltreatment- ing and Classification Systems, Version 6.0. Academic/Plenum Press; 1995.
related posttraumatic stress disorder. Am J Berkeley, CA: University of California at 36. Kagan R. Rebuilding Attachments With Trau-
Psychiatry. 2002;159(3):483-486. Berkeley; 1994. matized Children: Healing from Losses, Vio-
20. Shonk SM, Cicchetti D. Maltreatment, com- 28. Garbarino J, Kostelny K, Grady J. Children in lence, Abuse, and Neglect. Binghamton, NY:
petency deficits, and risk for academic and dangerous environments: child maltreatment Haworth Press. In press.
behavioral maladjustment. Dev Psychol. 2001; in the context of community violence. In: Cic- 37. Lanktree C. Treatment of complex trauma
37(1):3-17. chetti D, Toth S, eds. Child Abuse, Child De- in children and adolescents: an integrative,
21. Trickett P, McBride-Chang C, Putnam F. velopment, and Social Policy. Norwood, NJ: empirically based model. Paper presented at:
The classroom performance and behavior of Ablex Publishing; 1993:167-189. 19th Annual Meeting of the International So-
sexually abused females. Dev Psychopathol. 29. Loo C, Fairbank J, Scurfield R, et al. Mea- ciety of Traumatic Stress Studies; November
1994;6:183-194. suring exposure to racism: development and 1, 2003; Chicago, IL.
22. Schneider-Rosen K, Cicchetti D. Early self- validation of a Race-Related Stressor Scale 38. Lieberman AF, Van Horn P, Grandison CM,
knowledge and emotional development: Visual (RRSS) for Asian American Vietnam veter- Pekarsky JH. Mental health assessment
self-recognition and affective reactions to ans. Psychol Assess. 2001;13(4):503-520. of infants, toddlers, and preschoolers in a
mirror self-images in maltreated and non- 30. Luthar SS, Cicchetti D, Becker B. (2000). The service program and a treatment outcome
maltreated toddlers. Dev Psychopathol. 1991; construct of resilience: a critical evaluation research program. Infant Ment Health J.
27:471-478. and guidelines for future work. Child Dev. 1997;18(2):158-170.
23. Bowlby J. A Secure Base: Parent-child At- 200;71(3):543-562. 39. Ford JD, Russo E, Mallon S. Integrating post-
tachment and Healthy Human Development. 31. Werner AA, Smith AE. High Risk Children traumatic stress disorder (PTSD) and substance
New York, NY: Basic Books; 1988. from Birth to Adulthood. Ithaca, NY: Cornell abuse disorder treatment. J Couns Dev. In press.