ArticlePDF Available

Complex Trauma in Children and Adolescents

Authors:
  • Foundation Trust
  • The Trauma Center at JRI

Abstract

Preliminary data from some of the various treatment approaches outlined above suggest that they provide symptom relief as well as improvement in social competence and emotion management, and that they are consistently superior to nonspecific supportive therapies. These programs, however, are in an early phase of development and require refinement and adaptation for culturally and geographically diverse populations. Finally, there is consensus that interventions should build strengths as well as reduce symptoms. In this way, treatment for children and adolescents also serves as a prevention program against poor outcomes in adulthood.
... Department of Health & Human Services, 2019). In addition to the potential for trauma stemming from maltreatment and/ or some of the contributing factors to maltreatment (e.g., poverty, homelessness; caregiver substance misuse, etc.), the experience of living in out-of-home care (foster care) is frequently developmentally disruptive and an additional source of trauma (Cook et al., 2005;Mitchell, 2018). The accumulation of these experiences can have serious developmental, emotional, and biological consequences, resulting in what has been termed 'complex trauma' (Cook et al., 2005;Rosenfield et al., 2018;Spinazzola et al., 2013). ...
... In addition to the potential for trauma stemming from maltreatment and/ or some of the contributing factors to maltreatment (e.g., poverty, homelessness; caregiver substance misuse, etc.), the experience of living in out-of-home care (foster care) is frequently developmentally disruptive and an additional source of trauma (Cook et al., 2005;Mitchell, 2018). The accumulation of these experiences can have serious developmental, emotional, and biological consequences, resulting in what has been termed 'complex trauma' (Cook et al., 2005;Rosenfield et al., 2018;Spinazzola et al., 2013). A number of studies suggest that too often, clinicians default to prescribing psychotropic medication to address the appearance of emotional and behavioral challenges, which may be manifestations of childhood trauma rather than diagnosable mental health problems. ...
... Whereas ample research has documented greater rates of mental health diagnoses among youth in foster care as compared to similar youth not in foster care (Pecora et al., 2009;Scozzaro & Janikowski, 2014), the conceptualization of complex trauma indicates that such diagnoses may be confounded by the expression of behaviors related to traumatic experiences (National Child Traumatic Stress Network, n.d.). In fact, the concept of complex trauma emerged from research on gaps in research and practice addressing childhood trauma following the Diagnostic and Statistical Manual III (DSM-3) (American Psychological Association [APA], 1980) Post-Traumatic Stress Disorder (adult PTSD) diagnosis, which was viewed as inadequate for the symptoms and challenges manifested by children who had endured chronic trauma (Cloitre et al., 2009;Courtois, 2004;Herman, 1992;van der Kolk et al., 2005). Significant revisions to the criteria for PTSD diagnosis were made in subsequent versions of the DSM (e.g., DSM-V, APA, 2013), however the PTSD diagnosis still does not adequately address the complex trauma often experienced by youth in child welfare. ...
Article
Full-text available
Youth in the US foster care system are disproportionately prescribed antipsychotic and psychotropic medication compared to youth not involved with foster care. Research on the relationship between experiences of trauma, mental health symptoms, evidence-based treatment, and safe psychotropic prescribing practices for youth in foster care is limited. We explored stakeholders’ perspectives of the relationship between psychotropic medications and trauma informed care (TIC) for youth in foster care. We conducted semi-structured individual and group interviews with foster caregivers, caseworkers, prescribing clinicians, and alumni of the foster care system. Data were recorded and transcribed verbatim, and analyzed using a directed content analysis approach. Five themes emerged across and within stakeholder groups: (1) acknowledging trauma; (2) role of psychotropic medication; (3) psychosocial resources; (4) additional supports; and, (5) training and education. Stakeholders identified TIC as an important component of mental health services for youth in foster care. There was not consensus around the role of psychotropic medication in treating trauma; however, most stakeholders felt that it was overused. Respondents suggested including additional supportive team members to help guide youth through the mental health treatment system, and emphasized the importance of support from individuals with common lived experiences. Results demonstrate the need for a system that emphasizes trauma-sensitive clinical interactions and psychosocial supports. Improving training and education for stakeholders, and providing additional sources of support for youth in foster care, could help better identify and treat the effects of trauma and the safe pharmacotherapy for youth in foster care.
... Complex trauma can present as a risk to children's cognitive functioning in ways that are apparent from late infancy (Cook et al., 2005). These effects include delays in developing receptive and expressive language, problem solving skills, attention span, memory and abstract reasoning (Cook et al., 2005;Shonkoff et al., 2012). ...
... Complex trauma can present as a risk to children's cognitive functioning in ways that are apparent from late infancy (Cook et al., 2005). These effects include delays in developing receptive and expressive language, problem solving skills, attention span, memory and abstract reasoning (Cook et al., 2005;Shonkoff et al., 2012). As would be expected, cognitive deficits such as these adversely affect children's academic outcomes. ...
... Studies demonstrate that individuals who report adverse childhood experiences are 2.5 times more likely to experience difficulties at school (Anda et al., 2006). Such difficulties are multiple and include low achievement, participation in special support programs, early drop out, suspension and expulsion (Cook et al., 2005;Anda et al., 2006;Porche et al., 2016). ...
Article
Full-text available
Advances in trauma-informed practices have helped both researchers and educators understand how childhood trauma impacts the developmental capacities required for successful learning within school. However, more investigation is required to understand how leaders can implement trauma-informed practices in targeted areas of their schools. This paper is a case study of one school who intentionally implemented a trauma-informed instructional practice approach after undertaking trauma informed positive education professional learning over a period of two and a half years. The research was guided by three questions: how are students supported in their learning and wellbeing; how can teachers be supported to develop consistent trauma-informed practice in their classrooms; and what is the role of leadership in this process? To research the approach, quantitative measures of staff and student perceptions and qualitative strategies centering the voices and experiences of students, teachers, and school leaders, were employed. Implications for school leaders suggest that when implemented as a whole-school approach through multiple and simultaneous mechanisms, trauma-informed positive education instructional practices have the possibilities of yielding enhanced outcomes for wellbeing and enable students to be ready to learn.
... Exposure to complex trauma in childhood and/or adolescence has been associated with a range of negative health correlates across the life-course, including the development of mental health disorders (e.g., Cook et al., 2005;Spinazzola et al., 2005;Kisiel et al., 2009). Furthermore, ample evidence indicates that CTE in childhood and/or adolescence is associated with (the onset of) internalizing mental health disorders, such as depressive and anxiety disorders, across the lifespan. ...
... However, in a family environment of child maltreatment, children are exposed to caregivers who cannot satisfy this educational task appropriately. Child maltreatment, and CTE in particular, may therefore lead to emotion regulation difficulties by hampering the development of adaptive strategies (e.g., distraction, reappraisal, acceptance), while fostering the development of maladaptive strategies (e.g., self-devaluation, suppression, withdrawal; Cook et al., 2005;Spinazzola et al., 2005;D'Andrea et al., 2012). In support of this, research has repeatedly documented medium to high correlations between cumulative child maltreatment and emotion regulation difficulties in samples of diverse ages (for children/adolescents examples, see Dunn et al., 2018;Hébert et al., 2018;Haselgruber et al., 2021; for adults examples, see Carvalho Fernando et al., 2014;Jennissen et al., 2016;Dutcher et al., 2017). ...
... Moreover, combining this research with a lifespan perspective could provide knowledge on the still insufficiently understood topic of mental health disparities in older age (e.g., Thoma et al., 2021). Finally, despite the broad consensus between researchers and practitioners for a dose-response relationship of child maltreatment and psychopathology (Cook et al., 2005;Putnam et al., 2013), comparative studies are scarce (e.g., Lewis et al., 2021;Pfluger et al., 2021). Further comparative evidence is needed, particularly on the long-term correlates of CTE, to coherently integrate findings into the existing trauma literature. ...
Article
Individuals with complex trauma exposure (CTE) in early life (i.e., childhood/adolescence) are at heightened risk for developing problems in various domains of functioning. As such, CTE has repeatedly been linked to internalizing mental health disorders, such as depression and anxiety, as well as emotion dysregulation across the lifespan. While these correlates of CTE are comparatively well studied up to middle adulthood, they are insufficiently studied in older adulthood. Therefore, this study aimed to (a) compare Swiss older adults with and without a CTE history regarding current and lifetime internalizing mental health disorders and emotion regulation strategies; and (b) to examine the potential mediating role of emotion regulation in the mental health disparities between these groups. A total of N = 257 participants (age = 49–95 years; 46.3% female) were assessed in a retrospective, cross-sectional study, using two face-to-face interviews. The CTE group (n = 161; Mage = 69.66 years, 48.4% female) presented with significantly more current and lifetime internalizing mental health disorders than the non-affected (nCTE) group (n = 96; Mage = 72.49 years, 42.7% female). The CTE group showed significantly higher emotion suppression and lower emotion reappraisal compared to the nCTE group. Mediation analysis revealed that the two emotion regulation strategies were significant mediators between CTE history and internalizing mental health disorders. Findings emphasize the relevance of emotion (dys-)regulation in understanding mental health disparities in older age and deciding about treatment strategies. Research and practice should pay more attention to the needs of this high-risk group of older individuals.
... The theoretical background of such findings might be in the Complex trauma theory. Complex trauma in children or adolescents is a result of exposure to severe adverse experiences, often in the family system-from persons who should be sources of security, protection and stability, with the consequence in the form of disruption of the sense of self leading to mental health problems and the need for psychosocial care (Cook et al., 2017). As regards other types of ACE, a lot of adolescents have experienced the death of somebody else he or she loves, which can have a significant impact as well (Johnson et al., 2017;Pachalla et al., 2020). ...
Article
Full-text available
Background Adverse childhood experiences (ACEs) can cause serious mental problems in adolescents and therefore may expected to be associated with higher use of psychosocial care, potentially varying by type of specific ACE. The aim of our study is to explore the association of the number of ACE and types of specific ACE with entering and using psychosocial care.Methods We used data from the Slovak Care4Youth cohort study, comprising 509 adolescents from 10 to 16 years old (mean age 13.2 years, 48.6% boys). We used logistic regression models adjusted for age, gender, and family affluence to explore the associations of number and type of specific ACE with the use of psychosocial care.ResultsHaving three or more ACE as well as experiencing some specific ACE (death of a mother/father, death of somebody else you love, problems of a parent with alcohol or drugs, conflicts or physical fights between parents, and separation/divorce of parents) increased the likelihood of using psychosocial care. Regarding experience with the death of somebody else you love, we found a decreased likelihood of the use of psychosocial care.Conclusion Experiencing ACE above a certain threshold (three or more) and parent-related ACE increase the likelihood of adolescent care use.
... It is argued that occupational therapy contribution to education within a three tiered, collaborative consultative model (Fuchs & Fuchs, 2006;Lane et al., 2009;Missiuna et al., 2012;Sugai & Horner, 2002;Villeneuve, 2009) to students with SEBD is valuable. In developing the Movement Maters programme, the occupational therapists drew on Ayres Sensory Integration Theory (Ayres, 1972(Ayres, , 1979, attachment theory (Cook et al., 2005;Gerhardt, 2013;van der Kolk, 2005) and the Person-Environment-Occupation model (Law et al., 1996) which resulted in a unique, context specific 'Level 3' intervention accompanied by weekly coaching, mentoring and review related to the specific needs of each student. In keeping with recent best practice in inclusive education (National Council for National Council for Special Education, 2014), and in-school occupational therapy practice (Missiuna et al., 2012;Villeneuve, 2009), the Movement Matters programme was conducted within the mainstream education context and also built on the capacity of educators to practice with students with SEBD. ...
Article
Full-text available
Introduction Although non-standardized qualitative and quantitative reports from 39 Irish students aged 12 to 14 years, with complex social and emotional needs and their 13 teachers had established benefits of ‘Movement Matters’, an occupational therapy designed participatory curriculum for learning self-regulation in mainstream schools (National Behaviour Support Service, 2015a), standardized measures were required for quality assurance by the Irish Government funded service. Objective The relevance of findings of standardized attitude measurements on the impacts of an occupation focused intervention with a discrete school population in areas of social disadvantage are discussed. Method Findings of the ‘Pupil Attitude to Self and School’ (PASS) (Granada Learning, 2021) and ‘Strengths and Difficulties Questionnaire’ (SDQ) (Youth in Mind, 2021), both well-established standardized measures of attitude and behaviours completed (pre and post intervention) by teachers, parents and students are presented. Results No statistically significant differences were found between the standardized pre and post intervention measures. However, findings indicate a disparity between how these students in complex environments experience school in comparison to large UK study populations. Conclusion This paper discusses the use of these standardized measures for capturing impacts of an occupation focused intervention in a school environment. It calls for an increased appreciation on outcomes measurement related to the intervention’s aim of providing experiences of meaningful participation and well-being. Further collaborative research on outcome measurement of participation of students in complex mainstream school environments is required. Keywords: Schools; Adolescents; Reliability of Result; Social Justice; Occupational Therapy/Education
... Individuals exposed to complex trauma, which typically begins in early childhood and involves repeated incidence of maltreatment over an extended period of time, often experience lifelong difficulties across various domains. Further, such difficulties in turn place these individuals at elevated risk for additional trauma exposure and cumulative impairment that may extend from childhood through adolescence and well into adulthood (Cook et al., 2005;Lawson et al., 2013). Thus, the provision of more targeted and effective trauma-informed intervention services largely relies on a more nuanced and thorough understanding of the sequelae of early exposure to complex trauma (Courtois & Ford, 2013). ...
Article
Our interest is in the development of gratitude as a moral virtue, and its variability across different cultural contexts. Given psychology's overreliance on samples collected from the United Sates, Western Europe, and Australasia, we contrasted patterns of age-related expressions of gratitude among a sample of U.S. 7- to 14-year-old children with those from same-age samples from Brazil, China, Russia, South Korea, and Turkey (N = 2,540, 54.7% female, Mage = 10.61 years). The U.S. sample was diverse (n = 730: Black 26.4%, White 40.4%, Latinx 19.9%, Asian 3.8%, Other 1.6%, Missing 7.0%; 55.7% female, Mage = 10.52 years). The remaining samples were largely homogeneous by ethnicity. Our data were gathered using one quantitative scale to measure variations in the extent of gratitude that children expressed, and one qualitative measure to assess variability in the types of gratitude expressed by children of different ages. Both measures were chosen for their fit with the definition of virtuous gratitude. Hypotheses that the U.S. sample would differ from the others in extent and type of gratitude were largely supported. However, age-related differences in the type of gratitude expressed were similar across societies (e.g., in most samples older children were less likely to express concrete gratitude and more likely to express connective gratitude). Our results reveal the importance of treating gratitude as a virtue that develops during childhood and that is influenced by one's cultural group. Reliance on samples from a limited set of cultures is thus to be avoided. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Article
Full-text available
This qualitative study focused upon ways teachers make meaning when working with students who are affected by trauma. An 11-month longitudinal design was used to explore teachers’ perspectives (N = 18 teachers) as they reflected upon the impacts of trauma within their classrooms and as they learned about trauma-informed practice strategies. Data from group interviews and participant journals were analyzed using interpretative phenomenological analysis. Results emerged that suggested common pathways in the ways teacher perspectives evolved; and these pathways were then analyzed in light of the meaningful work literatures to further suggest how work became more meaningful to these teachers when learning trauma-informed practice strategies. Teachers fostered a greater sense of meaning at work via two pathways: first by increasing their own wellbeing via personal use of trauma-informed strategies; then second, by incorporating trauma-informed strategies into their pedagogy to more effectively engage their students with learning. Increasing meaningful work for teachers who are working with trauma-affected students has promising implications for teacher professional development and workforce sustainability in schools experiencing high rates of teacher turnover and burnout as a result of teacher exposure to adverse student behavior.
Article
Sexual abuse can result in significant negative sequelae for victims. One particularly harmful consequence is suicidal ideation, which can lead to suicide attempts and even death. It is essential to screen children and adolescents for suicidal ideation when providing medical forensic care after disclosure of acute or nonacute sexual abuse/assault. Forensic nurses must feel confident in their abilities to assess suicide risk and provide appropriate intervention and referrals. A thorough understanding of the relationship between sexual abuse and suicidal ideation and behaviors can assist the forensic nurse in the development of practice behaviors to better identify, intervene, and prevent suicidal ideation and behaviors among youth experiencing sexual abuse.
Book
Full-text available
Children and adolescents face many challenges in today’s fast changing society and constantly have to overcome increasing levels of adversity in order to achieve success. Enhancing the ability of young people to cope with adversity by training in resilience skills has been the objective of several interventions and programs in the past years. Resilience programs promote the development of protective and preventive factors, both at a personal and social level, that can help to overcome socio-emotional challenges in a positive and adaptive way. Past work has shown the importance of training resilience of youth by leveraging on relevant activities they typically perform in formal and informal learning environments. This Frontiers Research Topics eBook presents 20 peer reviewed papers published in Frontiers in Psychiatry on promoting resilience in young people, with a particular focus on evidence-based resilience programs in promoting mental well-being in youth, both in the short and long term. Several contributions present evaluations of existing and new resilience programs for children and young people.
Article
Full-text available
This article describes the development and validation of the Race-Related Stressor Scale (RRSS), a questionnaire that assesses exposure to race-related stressors in the military and war zone. Validated on a sample of 300 Asian American Vietnam veterans, the RRSS has high internal consistency and adequate temporal stability. Hierarchical regression analyses revealed that exposure to race-related stressors accounted for a significant proportion of the variance in posttraumatic stress disorder (PTSD) symptoms and general psychiatric symptoms, over and above (by 20% and 19%, respectively) that accounted for by combat exposure and military rank. The RRSS appears to be a psychometrically sound measure of exposure to race-related stressors for this population. Race-related stressors as measured by the RRSS appear to contribute uniquely and substantially to PTSD symptoms and generalized psychiatric distress.
Article
Full-text available
Background: This study was designed to determine lifetime prevalence of psychiatric disorders among twins who reported childhood sexual abuse (CSA), and to compare these rates with those among non-abused co-twins. The contribution of familial and individual-specific factors to reported sexual abuse was also examined. Method: Information about lifetime psychopathology and substance use was obtained by structured telephone interviews with 5995 Australian twins. Twins who reported a history of childhood sexual abuse (CSA) were contrasted on lifetime psychopathology with subjects without such a history; in addition, comparisons were made between same-sex twin pairs discordant for CSA. Results: A history of CSA was reported by 5.9% of the women and 2.5% of the men. In the sample as a whole, those reporting CSA were more likely to receive lifetime diagnoses of major depression, conduct disorder, panic disorder and alcoholism, and were more likely to report suicidal ideation and a history of suicide attempt. Abused women, but not men, were also more likely to report social phobia. When comparisons were restricted to non-abused co-twins, no differences in psychopathology were seen. However, rates of major depression, conduct disorder and suicidal ideation were higher if both co-twins were abused than if the respondent alone reported CSA. Model-fitting indicated that shared environmental factors influenced risk for reported CSA in women, but not in men. Conclusion: The association between CSA and psychopathology arises at least in part through the influence of shared familial factors on both risk of victimization and risk of psychopathology.
Article
Objective: To provide clinicians with current information on prevalence, risk factors, outcomes, treatment, and prevention of child sexual abuse (CSA). To examine the best-documented examples of psychopathology attributable to CSA. Method: Computer literature searches of Medline and PSYCInfo for key words. All English-language articles published after 1989 containing empirical data pertaining to CSA were reviewed. Results: CSA constitutes approximately 10% of officially substantiated child maltreatment cases, numbering approximately 88,000 in 2000. Adjusted prevalence rates are 16.8% and 7.9% for adult women and men, respectively. Risk factors include gender, age, disabilities, and parental dysfunction. A range of symptoms and disorders has been associated with CSA, but depression in adults and sexualized behaviors in children are the best-documented outcomes. To date, cognitive-behavioral therapy (CBT) of the child and a nonoffending parent is the most effective treatment. Prevention efforts have focused on child education to increase awareness and home visitation to decrease risk factors. Conclusions: CSA is a significant risk factor for psychopathology, especially depression and substance abuse. Preliminary research indicates that CBT is effective for some symptoms, but longitudinal follow-up and large-scale "effectiveness" studies are needed. Prevention programs have promise, but evaluations to date are limited.
Article
This article reviews the four major components of trauma-focused cognitive behavioral therapy (CBT) for children and adolescents: exposure, cognitive processing and reframing, stress management, and parental treatment. For each component, background, description, and the current empirical support for including each of these components in the treatment of traumatized children is presented. Although there is growing empirical support for the efficacy of traumafocused CBT in decreasing psychological symptomatology, there are inadequate data to indicate the relative contribution of the individual CBT components. Suggestions for future clinical and research directions are also discussed.
Article
Seventy-four preschool-age maltreated children's receptive and expressive language, speech skills, general language and cognitive abilities were assessed to investigate the language, speech and cognitive skills of abused, neglected, and abused and neglected children. While all three groups were delayed, neglect was the type of maltreatment most strongly associated with both expressive and receptive language delays and overall language delay. The three groups did not differ in general cognitive development. The most important feature of our data, relative to a Vygotskian perpective, is that language development is particularly vulnerable in an environment devoid of parent-child social language exchange.
Article
Examined the association among child maltreatment, socioeconomic status (SES), visual self-recognition, and emotional responses to mirror images. Children were assessed cross-sectionally at 18, 24, and 30 mo. The nonmaltreated children spanned 2 SES groups (lower and middle), and the maltreated children came from the lower SES. Maltreated children did not differ from the lower- or middle-SES comparison children in the development of visual self-recognition. Differences between the samples were observed in the quality of affective reactions to mirror self-images. Hierarchical loglinear modeling was used to test for associations among the variables of self-recognition, age, SES, maltreatment, and affective reactions to mirror images (positive, negative, and neutral, as well as coy affective responses). Results are discussed in terms of the complex interactions among these variables, indicating that the ontogenesis of self-knowledge is determined by multiple interrelated influences. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
This study examines the relationship of child sexual abuse to classroom academic performance and behavior in a sample of 6–16-year-old girls. Half of the sample was sexually abused by a family member. The other half is a demographically similar nonabused comparison group. Measures of academic performance include school records, teacher's ratings of classroom behavior and performance, and parental reports of school performance. Possible mediators of the impact of sexual abuse on classroom performance and behavior – cognitive capability, perceived competence, and behavior problems–are also measured. Results can be summarized as follows, (a) A history of sexual abuse does predict academic performance: Abuse is directly negatively related to ratings of classroom social competence, competent learner, and overall academic performance and positively related to school avoidant behavior, but is not related to grades, (b) Sexual abuse is negatively related to cognitive ability and positively related to measures of behavior problems indicating depression, destructiveness, and dissociation, (c) Cognitive ability and perceived competence predict the more “academic” aspects of academic performance—grades, ratings as a competent learner, and overall academic performance. Behavior problems predict ratings as a competent learner, classroom social competence, school avoidant behavior, and overall academmic performance.
Article
This article describes the mental health assessment in preparation for treatment conducted in two University-based clinical programs that offer dyadic child-parent psychotherapy as the treatment modality. The Infant-Parent Program is a mental health program serving children between birth and 3 years of age and their families when the parent-child relationship is jeopardized by risk factors in the parent, child, or family circumstances. The Child Trauma Research Project is an intervention outcome research program serving preschool- aged children and their mothers when the child witnessed domestic violence. The programs share a similar assessment approach emphasizing the importance of a working alliance, spontaneous parental reports, and observation of child-parent interaction in a variety of settings. However, their different functions in terms of clinical service and research dictate appropriate modifications in their respective assessment procedures. The two assessment protocols and their rationale will be described in the context of the clinical and research goals of the programs. © 1997 Michigan Association for Infant Mental Health
Article
Dissociation is made manifest by a failure to integrate thoughts, feelings, memories, and actions into a unified sense of consciousness. Although dissociation is presumed to be a special state of consciousness manifested by state-dependent memory and physiology, the psychobiology of dissociation is poorly understood. In this study, we examined cerebrospinal fluid levels of the major monoamine metabolites and β-endorphin in patients with eating disorders (11 with anorexia nervosa, 16 with bulimia nervosa), while they were acutely ill. Dissociative capacity was measured using the Dissociative Experiences Scale (DES). We provide evidence that neurochemical changes in dopaminergic, serotonergic, and opioid systems may be associated with the clinical expression of dissociation in patients with eating disorders during the acute phase of their illness. These preliminary results are compatible with previous studies of neurochemical disturbances in the eating disorders and suggest that future work in dissociation should specifically include examination of these neurobiologic systems.