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Complex Trauma in Children and Adolescents

May 2005
Psychiatric Annals 35(5):390-398

DOI:10.3928/00485713-20050501-05

Authors:

Joseph Spinazzola

Foundation Trust

Alexandra Cook

The Trauma Center at JRI

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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.

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Is Racism Like Other Trauma Exposures? Examining the Unique Mental Health Effects of Racial/Ethnic Discrimination on Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), and Generalized Anxiety Disorder (GAD)

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Nov 2024

Although scholars have increasingly drawn attention to the potentially traumatic nature of racial/ethnic discrimination, diagnostic systems continue to omit these exposures from trauma definitions. This study contributes to this discussion by examining the co-occurrence of conventional forms of potentially traumatic experiences (PTEs) with in-person and online forms of racism-based potentially traumatic experiences (rPTEs) like racial/ethnic discrimination. Additionally, we investigated the unique association of rPTEs with posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD), accounting for demographics and other PTEs. Participants were (N = 570) 12-to-17-year-old (Mage = 14.53; 51.93% female) ethnoracially minoritized adolescents (54.21% Black; 45.79% Latiné). Youth completed online surveys of PTEs, in-person and online rPTEs, and mental health. Bivariate analyses indicated that youth who reported in-person and online rPTEs were more likely to experience all conventional PTEs. Accounting for demographics and conventional PTEs, in-person and online rPTEs were significantly associated with PTSD (in-person: aOR = 2.60, 95% CI [1.39, 4.86]; online: aOR = 2.74, 95% CI [1.41, 5.34]) and GAD (in-person: aOR = 2.94, 95% CI [1.64, 5.29]; online: aOR = 2.25, 95% CI [1.24, 4.04]) and demonstrated the strongest effect sizes of all trauma exposures. In-person, but not online, rPTEs were linked with an increased risk for MDD (aOR = 4.47, 95% CI [1.77, 11.32]). Overall, rPTEs demonstrated stronger associations with PTSD, MDD, and GAD compared to conventional PTEs. Findings align with racial trauma frameworks proposing that racial/ethnic discrimination is a unique traumatic stressor with distinct mental health impacts on ethnoracially minoritized youth.

They Should Look After Me: Micro-process Analysis of a Meaning Complex in an Abused Child

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Oct 2024

Caring for others in the narratives of abused children is contradictory. Their perceptions are altered because the abusing adults often distorts this reality. By studying their narratives from a semiotic and dialogical perspective, the transformation of meaning can be appreciated moment by moment. In this paper, a path of psychological growth in which difficulties unfold as dynamics of relational tensions is presented. For this purpose, sequential events of individual psychotherapy sessions between a seven-year-old girl and a therapist are analyzed focusing on her relational world. Aspects of the transformation of the child’s meanings about the care provided by family members and her relational network are displayed. It is concluded that the child can elaborate on the notion of care although she does so with a high level of tension and ambivalence of meaning. Finally, the scope and limitations of this methodological approach for psychotherapeutic practice are discussed.

What is important to young people in care during adolescence? A qualitatively driven photo-elicitation study

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Dec 2024

A feature of being a young person in care is that your life is overseen by a range of professionals, who make decisions that affect you. There is a lack of research into the experiences of young people in care to inform these decisions from the perspective of the young people. A need for research that allows young people in care to contribute to the literature about what is important to them during adolescence was established. This exploratory study used a participant-led, photo-elicitation methodology with six young people (13–15 years) who lived in foster care. A photo-elicitation interview was conducted in which participants brought photographs of what was important to them which they then discussed. Data were analysed using Interpretative Phenomenological Analysis. Participants described their experiences as being embedded in the place they lived, with their development being shaped by the possibilities this provided. Participants described what was important to them as: being seen and heard; a part of their place and being with others; finding space to escape to; relationships with their pets; and getting to know themselves. Discussion of how this relates to existing knowledge, and relevant clinical implications and future research directions, are discussed based on this analysis.

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Leandra Perrotta

Do Changing Times Call for Changing Definitions?: Dynamic Definitions of Disengagement as a Response to Trauma from the COVID Pandemic

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Nov 2024

Scholars have noted changes in student engagement following the return to university classes after the COVID-19 lockdowns. The purpose of this study was to describe the perceptions of higher education instructors regarding student engagement over the past three years. The research team shared a link to an electronic questionnaire to recruit participants (n=108). Questions focused on common signs of disengagement and asked faculty about changes they perceived in students’ engagement prior to, during, and following the lockdowns. Following the return to classes, late work was perceived most often to signify disengagement. Behaviors participants interpreted as “student disengagement” are consistent with previously proposed definitions of post-traumatic stress. Although more research is needed to fully understand the phenomenon of student disengagement, it is likely educational practices within institutions of higher learning need to change to meet the needs of today’s students.

"Learning to 'waltz' rather than 'wrestle' … " : a novel, ultra-brief intervention supporting early child-caregiver relationships

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Importance of Community Context in Understanding Substance Use Among Adolescents With Allegations of Maltreatment

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This study examined the association between community disadvantage and substance use among adolescents referred to child protective services (CPS) and the interaction role of race/ethnicity in the association between community disadvantage and adolescent substance use. Findings revealed that higher county-level alcohol/drug mortality rates were associated with a higher risk of substance use across non-Hispanic Black, non-Hispanic white, and Hispanic adolescents. An interaction test showed that the association between county-level alcohol/drug mortality rates and risk of substance use was particularly stronger for non-Hispanic Black adolescents compared to non-Hispanic white adolescents. However, county-level vacant housing rates and low median household income did not show a significant association with adolescent substance use across all racial/ethnic groups. Results suggest that practitioners should screen for community-level substance risk levels to prevent substance use among historically marginalized racial-ethnic adolescents involved in CPS.

Intergenerational Transmission of Posttraumatic Orientation to Bodily Signals Following Child Maltreatment

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Nov 2024
J INTERPERS VIOLENCE

Recent studies have indicated that CM (child maltreatment) may influence individuals' perception of their bodies, often resulting in a posttraumatic orientation to bodily signals (OBS). Given the intricate relationship between bodily and interpersonal experiences, it is hypothesized that posttraumatic OBS may be intergenerationally transmitted. However, knowledge regarding this phenomenon, and its underlying mechanisms, remains limited. Two studies tested (a) the link between CM and posttraumatic OBS, mediated by posttraumatic stress (PTS) symptoms and attachment security, and (b) the intergenerational transmission of a posttraumatic OBS following CM among dyads of parents and their young adult offspring. The first study included 445 young adults (mean age = 352, SD = 10.2), and the second study included 393 dyads (parents’ mean age = 58, SD = 5.91; offspring's mean age = 27, SD = 3.91). The participants completed self-reported questionnaires. Study 1 found that posttraumatic OBS was associated with CM, through the mediation of PTS symptoms (indirect effect = 0.15, p = .005), and insecure attachment (indirect effects between 0.132 and 1.44, p < .006). The second study found two pathways of intergenerational transmission. The first pathway showed indirect paths between parents’ CM exposure and offspring’s posttraumatic OBS, through parents’ reaction to CM (PTS symptoms, anxious attachment, and avoidant attachment) and posttraumatic OBS (indirect effects between 0.006 and 0.013, p < .039). The second pathway revealed indirect links between parents’ CM exposure and offspring’s posttraumatic OBS, through parents’ and offspring’s reaction to CM (indirect effects between 0.006 and 0.56, p < .015). The study’s findings add empirical evidence that posttraumatic OBS is a significant implication of CM. The second study illuminates the intergenerational transmission of a posttraumatic OBS following parental CM exposure, uncovering PTS symptoms, and insecure attachment styles as potential underlying mechanisms.

"Break the walls of silence": Perceptions of intrafamilial parental abuse survivors concerning the presence of the other parent during the abuse

Thesis

Full-text available

Sep 2023

Aviv Hazan

Parental abuse is a wide-ranging social phenomenon that leads to important consequences on survivor's life, from their childhood to their adult lives. This phenomenon is being extensively investigated, especially regarding its prevalence, consequences and the identity of the perpetrators. Furthermore, few studies have examined the retrospective perceptions of the survivors in relation to the presence of others during the abuse, and in particular there are few qualitative findings regarding how the survivors of abuse perceive the presence of another parent in the shadow of the abuse.

Moral Injury Among Youth: Historical Accounts, Current Research and Future Directions

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Oct 2024

This manuscript explores the definition and historical context of Moral Injury (MI), detailing its psychological and spiritual impact on individuals, including youth populations. Morals are our beliefs and understanding of what is right and wrong. They are often informed by cultural and social norms and typically encompass values and responsibilities that individuals use to judge whether an action is right or wrong. MI is a psychological phenomenon that can unfold when there is a loss of trust in these beliefs or others' ability to keep our shared moral agreements. Traditionally associated with military personnel, MI has evolved to include other populations, including youth and family systems. This piece explores moral development among youth populations and how injuries to moral codes are particularly salient in youth populations and family systems. Special attention is given to MI's unique manifestations and implications in childhood and adolescence. The manuscript concludes with a call to action for further research that prioritizes and integrates youths' own voices in understanding and addressing MI.

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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.

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Article

Full-text available

May 1991

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)

Early sexual abuse and lifetime psychopathology: A co-twin-control study

Article

Full-text available

Feb 2000

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.

Parent—Child Interaction Therapy

Book

Jan 1995

Ten-year research update review: Child sexual abuse

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Mar 2003
J AM ACAD CHILD PSY

Frank W. Putnam

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.

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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.

Maltreated children's language and speech development: Abused, neglected, and abused and neglected

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Oct 1991
First Lang

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.

The classroom performance and behavior of sexually abused females

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Dec 1994
DEV PSYCHOPATHOL

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.

Mental Health Assessment of Infants, Toddlers, and Preschoolers in a Service Program and a Treatment Outcome Research Program

Article

Dec 1998
INFANT MENT HEALTH J

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

Relation of dissociative phenomena to levels of cerebrospinal fluid monoamine metabolites and beta-endorphin in patients with eating disorders: A pilot study

Article

Nov 1993
PSYCHIAT RES

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.