north dakota conference what is complex trauma · posttraumatic stress disorder (ptsd) re...

Hilary Hodgdon, Ph.D. – Complex Trauma in Children 1

Complex Trauma in Children: Complex Trauma in Children: Developmental Impact and Current Approaches Developmental Impact and Current Approaches

to Treatmentto Treatment

Presentation by:Presentation by:

Hilary Hilary HodgdonHodgdon, Ph.D. , Ph.D.

The Trauma CenterThe Trauma Center

ScheduleSchedule

�� 99--10:30: Morning session I10:30: Morning session I

�� 10:3010:30--10:45: Break10:45: Break

�� 1111--12: Morning session II12: Morning session II

�� 1212--1: Lunch1: Lunch

�� 11--2:30: Afternoon session I2:30: Afternoon session I

�� 2:302:30--2:45: Break2:45: Break

�� 2:452:45--4: Afternoon session II4: Afternoon session II

�� 4: Evaluations, 4: Evaluations, CEUCEU’’ss Handed outHanded out


Workshop GoalsWorkshop Goals

�� Think trauma: Beyond the DSMThink trauma: Beyond the DSM

�� Complex Trauma: Etiology, Complex Trauma: Etiology,

Developmental Impact, ExpressionsDevelopmental Impact, Expressions

�� Overview of Complex Trauma TreatmentsOverview of Complex Trauma Treatments

What is trauma?What is trauma?



Per the DSMPer the DSM--IVIV--TR:TR:

A A ““traumatic eventtraumatic event”” must involve;must involve;

�� Actual or threatened death, serious injury, or Actual or threatened death, serious injury, or

threat to physical integrity (objective threat to physical integrity (objective

component).component).

�� Response of intense fear, helplessness or Response of intense fear, helplessness or

horror (subjective component).horror (subjective component).


Over time, gradual trend towards expanding the Over time, gradual trend towards expanding the

scope of what is considered a traumatic event.scope of what is considered a traumatic event.

�� DSMDSM--V:V:

�� A1:A1:

•• Experiencing the event.Experiencing the event.

•• Witnessing the eventWitnessing the event

•• Learning that the event occurred to a close relative or close Learning that the event occurred to a close relative or close

friend.friend.

•• Experiencing repeated or extreme exposure to aversive Experiencing repeated or extreme exposure to aversive

details of the details of the event(sevent(s).).

�� Also proposed to throw out A1 criteria altogether.Also proposed to throw out A1 criteria altogether.



�� Acute:Acute:

�� Single incident:Single incident:

•• Car accidentCar accident

•• Sexual assaultSexual assault

�� ChronicChronic

�� Repeated: Repeated:

•• Physical abusePhysical abuse

•• Exposure to DVExposure to DV

What about acts of omission?

• Physical or emotional neglect.

• Multiple attachment or placement disruptions

• Chaotic early environment

• Impaired care giving

0000

5555

10101010

15151515

20202020

25252525

30303030

35353535

40404040

LossLossLossLoss

DVDVDVDV

EmotionalEmotionalEmotionalEmotional

NeglectNeglectNeglectNeglect

Physical AbusePhysical AbusePhysical AbusePhysical Abuse

Sexual AbuseSexual AbuseSexual AbuseSexual Abuse

Community ViolenceCommunity ViolenceCommunity ViolenceCommunity Violence

Sexual Assault/RapeSexual Assault/RapeSexual Assault/RapeSexual Assault/Rape

Illness/MedicalIllness/MedicalIllness/MedicalIllness/Medical

Serious Injury/AccidentSerious Injury/AccidentSerious Injury/AccidentSerious Injury/Accident

Natural DisasterNatural DisasterNatural DisasterNatural Disaster

KidnappingKidnappingKidnappingKidnapping

School ViolenceSchool ViolenceSchool ViolenceSchool Violence

Most Commonly Reported Most Commonly Reported

TraumasTraumas

Pynoos et al., 2010


Posttraumatic Stress Disorder Posttraumatic Stress Disorder

(PTSD)(PTSD)�� ReRe--experiencingexperiencing: (1): (1)

�� Recurrent, intrusive distressing Recurrent, intrusive distressing recollection (may be repetitive recollection (may be repetitive play)play)

�� Recurrent, distressing dreamsRecurrent, distressing dreams

�� Acting or feeling as if event is Acting or feeling as if event is recurringrecurring

�� Psychological distress on Psychological distress on exposure to cuesexposure to cues

�� Physiological reactivity on Physiological reactivity on exposure to cuesexposure to cues

�� Increased arousalIncreased arousal (2) (2)

�� Difficulty falling or staying asleepDifficulty falling or staying asleep

�� Irritability or outbursts of angerIrritability or outbursts of anger

�� Difficulty concentratingDifficulty concentrating

�� HypervigilanceHypervigilance

�� Exaggerated startle responseExaggerated startle response

�� Avoidance or NumbingAvoidance or Numbing (3)(3)�� Efforts to avoid thoughts, Efforts to avoid thoughts,

feelings, conversations feelings, conversations associated with traumaassociated with trauma

�� Efforts to avoid activities, Efforts to avoid activities, places, or people associated places, or people associated with traumawith trauma

�� Inability to recall important Inability to recall important aspect of traumaaspect of trauma

�� Diminished interest or Diminished interest or participation in significant participation in significant activitiesactivities

�� Feeling of detachment or Feeling of detachment or estrangement from othersestrangement from others

�� Restricted range of affectRestricted range of affect�� Sense of foreshortened Sense of foreshortened

futurefuture

Does PTSD Capture the Impact of Does PTSD Capture the Impact of

Trauma?Trauma?

Prevalence of Psychiatric Disorders in Abused Prevalence of Psychiatric Disorders in Abused Children Children (Ackerman et al., 1998)(Ackerman et al., 1998)

�� Generalized Anxiety DisorderGeneralized Anxiety Disorder……………….59%.59%

�� Oppositional Defiant DisorderOppositional Defiant Disorder……………….36%.36%

�� Simple PhobiaSimple Phobia……………………………………………………36%36%

�� Posttraumatic Stress DisorderPosttraumatic Stress Disorder……………….34%.34%

�� ADHDADHD……………………………………………………………………..29%..29%

�� Conduct DisorderConduct Disorder…………………………………………..21%..21%

�� DysthymiaDysthymia…………………………………………………………..19%..19%


Does PTSD Capture the Impact of Does PTSD Capture the Impact of

Trauma?Trauma?

�� Prevalence:Prevalence:

�� 44thth ((AkermanAkerman et al., 1998)et al., 1998) or 10or 10thth (Copeland et al, 2007)(Copeland et al, 2007)

most common diagnosis among traumamost common diagnosis among trauma--

impacted kids.impacted kids.

�� CoCo--morbidity:morbidity:

�� Over 80% of kids and 90% of adults with Over 80% of kids and 90% of adults with

PTSD have at least one other Axis I PTSD have at least one other Axis I

diagnosis. diagnosis. ((CloitreCloitre et al., 2009)et al., 2009)

Thinking beyond the DSMThinking beyond the DSM

�� Consideration of:Consideration of:

�� Trauma types not captured by A1.Trauma types not captured by A1.

�� Cumulative impact of multiple or prolonged Cumulative impact of multiple or prolonged

trauma exposure.trauma exposure.

�� Developmental timing.Developmental timing.

�� Context of traumatic experience.Context of traumatic experience.


Beyond A1:Beyond A1:

Emotional MaltreatmentEmotional Maltreatment�� Definition:Definition: ““persistent or extreme thwarting of the childpersistent or extreme thwarting of the child’’s s

basic emotional needsbasic emotional needs”” including including ““parental acts that are parental acts that are harmful because they are insensitive to the childharmful because they are insensitive to the child’’s s developmental level.developmental level.””

--Barnett, Manly, & Barnett, Manly, & CicchettiCicchetti, 1993, 1993

�� Includes Includes (English & LONGSCAN, 1997):(English & LONGSCAN, 1997):

�� Verbal abuse: insults, threats, belittling.Verbal abuse: insults, threats, belittling.�� Emotional abuse: bullying, terrorizingEmotional abuse: bullying, terrorizing�� Excessive or inappropriate demands on performance.Excessive or inappropriate demands on performance.�� Emotional neglect: shunning, withdrawal of affection or love.Emotional neglect: shunning, withdrawal of affection or love.�� Intentional social deprivation or isolation.Intentional social deprivation or isolation.

�� American Academy of Pediatrics:American Academy of Pediatrics:�� ““Most challenging and prevalent form of child abuse and Most challenging and prevalent form of child abuse and

neglect.neglect.””

EM: PrevalenceEM: Prevalence

�� Impacts over 1.1 million children each year. Impacts over 1.1 million children each year. (Fourth (Fourth

Nat. Incidence Study of Child Abuse and Neglect, 2010)Nat. Incidence Study of Child Abuse and Neglect, 2010)

�� Most commonly reported trauma in NCTSN Most commonly reported trauma in NCTSN

clients. clients. (Spinazzola et al., 2009; Spinazzola et al., In Press)(Spinazzola et al., 2009; Spinazzola et al., In Press)

�� Found to be present in over 50% of child welfare Found to be present in over 50% of child welfare

cases, but officially noted in only 9% of cases. cases, but officially noted in only 9% of cases. ((TrickettTrickett, Mennen, Kim, & Sang, 2009), Mennen, Kim, & Sang, 2009)

�� Community samples find rates ranging from 21Community samples find rates ranging from 21--

80%. 80%. ((ChamberlandChamberland et al., 2005; Clement & et al., 2005; Clement & ChamberlandChamberland, 2007), 2007)


Impact on Mental HealthImpact on Mental Health

�� Minnesota Mother Child Interaction Minnesota Mother Child Interaction Project. Project. ((EgelandEgeland and colleagues, 1987, 1983, 1989)and colleagues, 1987, 1983, 1989)

�� PTSDPTSD�� EM predicts PTSD EM predicts PTSD sxssxs when other forms of when other forms of

abuse are controlled for. abuse are controlled for. ((TaussingTaussing & & CulhaneCulhane, 2010), 2010)

�� Internalizing BehaviorsInternalizing Behaviors

�� AnxietyAnxiety

�� DepressionDepression

�� Suicidal Ideation and BehaviorsSuicidal Ideation and Behaviors

�� Low SelfLow Self--EsteemEsteem

Impact on Mental HealthImpact on Mental Health

�� Activating effect of EM on PA:Activating effect of EM on PA:�� 160 maltreated adolescents.160 maltreated adolescents.

�� Official record that was cross validated.Official record that was cross validated.

�� Matched comparison group.Matched comparison group.

�� Controlled for other forms of abuse.Controlled for other forms of abuse.

�� Results:Results:

•• PM accounted for largest amt of unique variance of PM accounted for largest amt of unique variance of

Internalizing & Externalizing Problems on YSR. Internalizing & Externalizing Problems on YSR.

•• PA was only related to Externalizing Problems PA was only related to Externalizing Problems

when PM was added to prediction when PM was added to prediction –– suppressor suppressor

effect. effect. (McGee, Wolfe & Wilson, 1997)(McGee, Wolfe & Wilson, 1997)


Emotional Maltreatment: Emotional Maltreatment:

Results from the NCTSN Results from the NCTSN

CORE Data SetCORE Data Set

Introduction: Core Data Set Introduction: Core Data Set

(CDS)(CDS)�� Quality Improvement InitiativeQuality Improvement Initiative

�� NetworkNetwork--wide data collection to address:wide data collection to address:�� Who is served?Who is served?

�� What types of problems, symptoms, needs do What types of problems, symptoms, needs do youth have?youth have?

�� What types of trauma have youth experienced?What types of trauma have youth experienced?

�� What types of treatment are provided?What types of treatment are provided?

�� To what extent and in what ways do youth To what extent and in what ways do youth improve during treatment?improve during treatment?

�� Ensure that Network interventions are Ensure that Network interventions are systematically measured, disseminated, and systematically measured, disseminated, and recognized.recognized.


What is in the CDS?What is in the CDS?�� Data collected on over 14,000 youth from 56 NCTSN Data collected on over 14,000 youth from 56 NCTSN

sites between 2004 and 2010:sites between 2004 and 2010:�� Demographic and living situation informationDemographic and living situation information

�� Trauma history and detailTrauma history and detail

�� Indicators of severityIndicators of severity

�� Clinical evaluationClinical evaluation

�� Treatment Treatment

�� Standardized Assessment MeasuresStandardized Assessment Measures

PTSD SymptomsPTSD Symptoms�� UCLA PTSD Reaction IndexUCLA PTSD Reaction Index

�� Trauma Symptom Checklist for ChildrenTrauma Symptom Checklist for Children--Alternate (also taps Alternate (also taps associated difficulties: depressive symptoms, anxiety)associated difficulties: depressive symptoms, anxiety)

Behavioral and Emotional DifficultiesBehavioral and Emotional Difficulties�� Child Behavior ChecklistChild Behavior Checklist

�� CDS measures: administered at treatment entry, end of CDS measures: administered at treatment entry, end of treatment (if short term) or every 3 monthstreatment (if short term) or every 3 months

Baseline Use of ServicesBaseline Use of ServicesBaseline Use of ServicesBaseline Use of ServicesBaseline Use of ServicesBaseline Use of ServicesBaseline Use of ServicesBaseline Use of ServicesMA (N=546)MA (N=546) NCTSN (N=13,542)NCTSN (N=13,542)++

Educational SectorEducational Sector

Special Class/School*Special Class/School*

School Counselor/Psych/SW*School Counselor/Psych/SW*

51.7%51.7%

31.1.1%31.1.1%

16.7%16.7%

26.2%26.2%

Mental /State InstitutionMental /State Institution

Residential TX*Residential TX*

Detention Center*Detention Center*

Case Management*Case Management*

Outpatient TherapyOutpatient Therapy

Psychiatrist*Psychiatrist*

43.8%43.8%

7.9%7.9%

56.7%56.7%

31.4%31.4%

17.6%17.6%

3.7%3.7%

2.8%2.8%

25.7%25.7%

28.3%28.3%

11.9%11.9%

General MedicalGeneral Medical

Primary Care MD/Pediatrician*Primary Care MD/Pediatrician* 23.5%23.5% 17.8%17.8%

Child WelfareChild Welfare

Social Services*Social Services*

Foster Care*Foster Care*

Treatment Foster CareTreatment Foster Care

57.9%57.9%

13.8%13.8%

3.7%3.7%

36.1%36.1%

21.4%21.4%

5.7%5.7%

CDS September 2010

++++Remaining Centers*p <.05 for all comparisons*p <.05 for all comparisons


Study of Emotional MaltreatmentStudy of Emotional Maltreatment�� Subset of 5,616 youth (2,379 males, 3237 females).Subset of 5,616 youth (2,379 males, 3237 females).

�� Looked at kids who experienced:Looked at kids who experienced:�� Only:Only:

•• Physical abusePhysical abuse

•• Sexual abuseSexual abuse

•• Emotional abuseEmotional abuse

�� Any combination of the above:Any combination of the above:

•• Physical and sexual abusePhysical and sexual abuse

•• Physical and emotional abusePhysical and emotional abuse

•• All three types.All three types.

•• Etc.Etc.

�� Compared impact of trauma types for:Compared impact of trauma types for:�� Internalizing and externalizing symptomsInternalizing and externalizing symptoms

�� PTSD SymptomsPTSD Symptoms

�� Functional impairmentFunctional impairment

�� Clinically significant difficulties in a range of areas.Clinically significant difficulties in a range of areas.

EM Impact: CBCL TotalEM Impact: CBCL Total

57

58

59

60

61

62

63

64

65

66

CBCL Ext. CBCL Int.

Mean C

BCL S

core

SA PA EM SA + PA EM + SA EM + PA All Three

Spinazzola et al., Under Review



0

5

10

15

20

25

30

35

PTSD-RI Overall

PTSD-R

I Tota

l Score


EM Impact: PTSD TotalEM Impact: PTSD Total

EM Impact: EM Impact:

Clinician Rated ProblemsClinician Rated Problems

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Academic

Problems

Behavior

Problems

Attachment

Problems

Self-Injury Substance Abuse

% C

linic

ally S

ignific

ant




EM Impact: EM Impact:

Clinician Rated SymptomsClinician Rated Symptoms

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Acute Stress DO Dissociation Generalized Anxiety Depression

% C

lin

icall

y S

ign

ific

an

t



Cumulative Impact of Cumulative Impact of

Trauma:Trauma:

The Adverse Childhood The Adverse Childhood

Experiences (Experiences (ACEsACEs) Study) Study

Vincent Vincent FelittiFelitti

Robert Robert AndaAnda


Adverse Childhood Experiences Adverse Childhood Experiences

Study (ACES)*Study (ACES)*

Felitti et al. 1998;

0000

2222

4444

6666

8888

10101010

12121212

14141414

1111

2222

3333

4444

5555

6666

7777

8888

9999

10+10+10+10+

Percentage of Children Percentage of Children

Experiencing Cumulative TraumasExperiencing Cumulative Traumas


Adverse Childhood Experiences and Adverse Childhood Experiences and

OutcomeOutcome�� Increased presence of childhood adverse Increased presence of childhood adverse

experience leads to increased risk of:experience leads to increased risk of:�� DepressionDepression

�� Drug addictionDrug addiction

�� Alcohol use/abuseAlcohol use/abuse

�� Adult sexual assaultAdult sexual assault

�� Adult domestic violence (perpetrator and victim)Adult domestic violence (perpetrator and victim)

�� Early onset sexuality and sexual promiscuityEarly onset sexuality and sexual promiscuity

�� Teen pregnancy and paternityTeen pregnancy and paternity

�� SuicidalitySuicidality

�� ObesityObesity

�� Cigarette useCigarette use

�� General health problemsGeneral health problems

ACE Study (Felitti et al., 1998)

0

5

10

15

20

25

30

35

Perc

ent W

ith H

ealth P

roble

m (%

)

0 1 2 3 4 or more

ACE Score

Considers Self

An Alcoholic

Ever Attempted

Suicide

Sexually Assaulted as

an Adult (Women)

ACE Score and Alcoholism, Suicide Attempts, or

Sexual Assault


7 5

14

1

8 7

21

2

10 10

32

4

1410

36

10

1712

51

18

0

10

20

30

40

50

60

Current

smoker

Severe Obesity Two or more

wks. of

depressed

mood in last yr.

Ever attempted

suicide

Pre

vale

nce (%

)

0 ACE

1 ACE

2 ACE's

3 ACE's

4 or more

ACE's

Felitti, et al (1998)

ACE Score and Health Risks

3

6

0

3

66

11

1

5

910

19

1

6

1011

22

2

6

13

16

28

3

7

17

0

5

10

15

20

25

30

Considers

self an

alcoholic

Ever used

illicit drugs

Ever

injected

drugs

Had 50 or

more

intercourse

partners

Ever had a

sexually

transmitted

disease

Pre

vale

nce (%

)

0 ACE

1 ACE

2 ACE's

3 ACE's

4 or

more

ACE's

ACE Score and Health Risks


Estimates of the Population Attributable Risk* (PAR)

of Adverse Childhood Experiences for

Selected Outcomes in Women

Mental Health: PAR Current depression 54%

Depressed affect 41%Suicide attempt 58%

Drug Abuse:Alcoholism 65%Drug abuse 50%

IV drug abuse 78%

Promiscuity 48%

Crime Victim:Sexual assault 62%Domestic violence 52%

Developmental Developmental

ConsiderationsConsiderations


Trauma and Development:Trauma and Development:

Layers of InfluenceLayers of Influence

The Developmental Unfolding of The Developmental Unfolding of

Trauma ImpactTrauma Impact

““A A ‘‘developmental analysisdevelopmental analysis’’ presupposes presupposes

change and novelty, highlights the critical change and novelty, highlights the critical

role of timing the organization of behavior, role of timing the organization of behavior,

underscores multiple determinants, and underscores multiple determinants, and

cautions against expecting invariant cautions against expecting invariant

relations between causes and outcomes.relations between causes and outcomes.””

-- CicchettiCicchetti & & TothToth, 2008, 2008


6 6 –– 13 years13 yearsMiddle Childhood/LatencyMiddle Childhood/Latency

Life StageLife Stage Approximate AgeApproximate Age

InfancyInfancy Birth Birth –– 2 years2 years

ToddlerToddler 2 2 –– 3 years3 years

Early ChildhoodEarly Childhood 3 3 –– 6 years6 years

AdolescenceAdolescence 13 13 –– 18 years18 years

Developmental Stages

Developmental TimingDevelopmental Timing

U.S. DHHS, ACF, 2012


Developmental TimingDevelopmental Timing

U.S. DHHS, ACF, 2012

Developmental TimingDevelopmental Timing�� Importance of timing Importance of timing -- 2 Levels:2 Levels:

•• What is impacted (What is impacted (““Developmental Task).Developmental Task).

•• How impact is expressed (disruption, symptoms).How impact is expressed (disruption, symptoms).

0-5 Key Developmental Tasks Trauma’s Impact

Development of visual and auditory perception

Attachment to primary caregiver

Recognition of and response to emotional cues

Avoidance of contact

Attachment to primary caregiver Heightened startle response

Confusion about what’sdangerous and who to go to for protection

Fear of being separated from familiar people/places


School-Aged Children (6-12)

KeyKey DevelopmentalDevelopmental TasksTasks TraumaTrauma’’ss ImpactImpact

Manage fears, anxieties, Manage fears, anxieties,

and aggressionand aggression

EmotionalEmotional DysregulationDysregulation

Sustain attention for Sustain attention for

learning and problem learning and problem

solvingsolving

LearningLearning ProblemsProblems

Control impulses Control impulses andand

managemanage physicalphysical

responses responses toto dangerdanger

SpecificSpecific anxietiesanxieties andand fearsfears

AttentionAttention seekingseeking

ReversionReversion toto youngeryounger

behaviorsbehaviors

Adolescence (13-21)

KeyKey DevelopmentalDevelopmental TasksTasks TraumaTrauma’’ss ImpactImpact

Think abstractlyThink abstractly Difficulty imagining or Difficulty imagining or

planning planning

for the futurefor the future

Anticipate and consider the Anticipate and consider the

consequences of behaviorconsequences of behavior

OverOver-- or underestimating or underestimating

dangerdanger

Accurately judge danger Accurately judge danger

and safetyand safety

Inappropriate aggressionInappropriate aggression

Modify and control behavior to Modify and control behavior to

meet longmeet long--term goalsterm goalsReckless and/or selfReckless and/or self--

destructive destructive

behaviorsbehaviors


ContextContext

�� EnvironmentEnvironment�� IntraIntra--familial trauma most common.familial trauma most common.

•• Accounts for over 80% of child welfare reports.Accounts for over 80% of child welfare reports.

�� Linked to Linked to –– disruptions in selfdisruptions in self--regulation, empathy regulation, empathy development, ability to trust, etc.development, ability to trust, etc.

�� PerpetratorPerpetrator�� TrickettTrickett et al. (2001) profiles study: sexual abuse by et al. (2001) profiles study: sexual abuse by

father / close family member = worse outcomes in father / close family member = worse outcomes in adolescence than when perpetrator was outside the adolescence than when perpetrator was outside the family.family.

�� Reaction to disclosureReaction to disclosure�� Having an adult who believes you and takes action = Having an adult who believes you and takes action =

one of the strongest predictors of positive outcomes.one of the strongest predictors of positive outcomes.

Trauma and Children Trauma and Children

�� Most commonly reported (and also Most commonly reported (and also impactfulimpactful) ) types of traumatic exposure (i.e. emotional types of traumatic exposure (i.e. emotional abuse) in kids not covered by A1 criteria.abuse) in kids not covered by A1 criteria.

�� PTSD not most common diagnosis in traumaPTSD not most common diagnosis in trauma--impacted kids.impacted kids.

�� Majority of traumaMajority of trauma--impacted kids exhibit a range impacted kids exhibit a range of coof co--morbid symptoms morbid symptoms –– results in kids being results in kids being labeled with multiple diagnoses.labeled with multiple diagnoses.

�� Consideration of Consideration of cumulative impact,cumulative impact,developmental stage and contextdevelopmental stage and context is essential.is essential.


Complex TraumaComplex Trauma

DSMDSM--IV Field Trial for PTSD IV Field Trial for PTSD van van derder KolkKolk, , PelcovitzPelcovitz, Roth & Mandel, 1994, Roth & Mandel, 1994

0

10

20

30

40

50

60

70

80

90

100

Complex PTSD or DESNOS

PTSD only

0-4 5-8 9-13 14-19 20-25 >26

N=75 N=92 N=56 N=62 N=16 N=27

AGE AT ONSET OF TRAUMA (years)

PE

RC

EN

T E

ND

OR

SE

ME

NT


Complex Trauma: ExposureComplex Trauma: Exposure

�� Complex Trauma TaskforceComplex Trauma Taskforce found:found:�� Multiple and/or chronic exposure Multiple and/or chronic exposure –– the rule the rule

rather than the exception:rather than the exception:

•• Ave number of exposure types: 3Ave number of exposure types: 3

•• 94% of clinicians reported 94% of clinicians reported aveave # of exposure types # of exposure types to be more than one.to be more than one.

•• Represents over 77% of child clients in NCTSN Represents over 77% of child clients in NCTSN sample.sample.

�� Early exposure common:Early exposure common:•• Average age of onset: 5 yearsAverage age of onset: 5 years

�� Context of exposure most frequently within Context of exposure most frequently within family system.family system.

(Spinazzola et al., 2005)(Spinazzola et al., 2005)

Prevalence of Multiple TraumasPrevalence of Multiple Traumas

14141414

72727272

0000

10101010

20202020

30303030

40404040

50505050

60606060

70707070

80808080

90909090

100100100100

Percent

Percent

Percent

Percent Single TraumaSingle TraumaSingle TraumaSingle Trauma

Multiple TraumasMultiple TraumasMultiple TraumasMultiple Traumas


Complex Trauma: ExpressionsComplex Trauma: Expressions�� Less than 25% of kids in CTT survey met PTSD criteria.Less than 25% of kids in CTT survey met PTSD criteria.

�� Most commonly reported problems were:Most commonly reported problems were:

61.5%59.2% 57.9%

53.1%

45.8%

0%

15%

30%

45%

60%

75%

Affect Dysregu

latio

n

Attention/Con

centration

Neg

ative Self-Imag

e

Impu

lse Con

trol

Aggres

sion

/Risk-taking

Complex TraumaComplex Trauma

Cook et al., 2005


Developmental Trauma Disorder (DTD)Developmental Trauma Disorder (DTD)Statement of Purpose

The goal of introducing the diagnosis of Developmental Trauma Disorder is to capture the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma and thereby guide clinicians to develop and utilize effective interventions and for researchers to study the neurobiology and transmission of chronic interpersonal violence.

Whether or not they exhibit symptoms of PTSD, children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems are ill-served by the current diagnostic system, as it frequently leads to no diagnosis, multiple unrelated diagnoses, an emphasis on behavioral control without recognition of interpersonal trauma and lack of safety in the etiology of symptoms, and a lack of attention to ameliorating the developmental disruptions that underlie the symptoms.

- van der Kolk et al.

DTDDTD

A. Exposure:A. Exposure:

A1. Multiple / prolonged trauma in childhood or early A1. Multiple / prolonged trauma in childhood or early adolescence.adolescence.

A2. Disruptions in caretaking.A2. Disruptions in caretaking.

B. Affective and Physiological B. Affective and Physiological DysregulationDysregulation..

C. C. AttentionalAttentional and Behavioral and Behavioral DysregulationDysregulation..

D. Self and Relational D. Self and Relational DysregulationDysregulation..

E. Posttraumatic Spectrum Symptoms.E. Posttraumatic Spectrum Symptoms.

F. 6 month durationF. 6 month duration

G. Functional Impairment.G. Functional Impairment.


AttachmentAttachment

Attachment Attachment -- Human StudiesHuman Studies



�� ““A reciprocal, enduring emotional tie A reciprocal, enduring emotional tie

between an infant and caregiver, each of between an infant and caregiver, each of

whom contributes to the quality of the whom contributes to the quality of the

relationship.relationship.”” ((PapaliaPapalia, Olds, & Feldman, 2002), Olds, & Feldman, 2002)

�� Dyadic: there is a back and forth.Dyadic: there is a back and forth.

�� Parent/caregiver is the Parent/caregiver is the ““secure basesecure base”” from from

which the child explores the world around which the child explores the world around

them.them.

Attachment

Myers, 2007

� Harlow (1971) showed that infants bond with surrogate mothers because of bodily contact and not nourishment.

� They become attached to parents who are soft and warm and who rock, feed, and pat.

� Much of the parent-infant emotional connection occurs because of touch.

� Familiarity is another factor in causing attachment.

� Children like to reread the same books, rewatch the same movies, reenact family traditions.



HarlowHarlow’’s Monkey: Contact Comforts Monkey: Contact Comfort

Secure Attachment

Myers, 2007

� Placed in a strange situation, 60% of children express secure attachment.

� In their mother’s presence, they play comfortably, happily exploring their new environment.

� When she leaves, they are distressed.

� When she returns, they seek contact with her.

� Relaxed and attentive caregiving becomes the backbone of secure attachment.

� Sensitive, responsive mothers, who noticed what their babies were doing and responded appropriately, had infants who exhibited secure attachment.


Insecure Attachment

Myers, 2007

� The other 30% show insecure attachment.

� These children cling to their mothers or caregivers, and are

less likely to explore the environment.

� When she leaves, they either cry loudly and remain upset

or seem indifferent to their mother’s going and returning.

� Being insensitive or unresponsive to child needs is predictive

of insecure attachment.

� Indicates that level of attunement between caregiver and

child is important.

Disorganized AttachmentDisorganized Attachment

�� 80% of maltreated samples display 80% of maltreated samples display

disorganized attachment:disorganized attachment:

�� Combination of approach and avoidance Combination of approach and avoidance

behaviors.behaviors.

�� May appear frightened or dazed.May appear frightened or dazed.

�� Do not have organized response to Do not have organized response to

environment.environment.



Still Face Mother ExperimentStill Face Mother Experiment

Self RegulationSelf Regulation



�� PhysiologicalPhysiological

�� EmotionalEmotional

�� CognitiveCognitive

Physiological Physiological DysregulationDysregulation

�� Somatic expressionsSomatic expressions

�� Sleep disturbanceSleep disturbance

�� Bed wettingBed wetting

�� DysregulatedDysregulated energy statesenergy states


The Modulation Model© for

children

Sympathetic

Arousal: high

activation

Parasympathetic

Arousal: low

activation

With Permission of the Sensorimotor Psychotherapy Institute, Ogden and Minton (2000)

A

R

O

U

S

A

L

Hyperarousal:

Hypoarousal:

“inside our window of

tolerance” (D. Siegel 1999)

Optimal Arousal

Zone: Balanced

autonomic nervous

system

Physiological Physiological DysregulationDysregulation

�� HyperarousalHyperarousal::

�� High energyHigh energy

�� Lack of control over body / Lack of control over body /

attention / concentration.attention / concentration.

�� Can look like: ADHD, ODDCan look like: ADHD, ODD

�� HypoarousalHypoarousal::

�� Chronic low energyChronic low energy

�� Low motivation.Low motivation.

�� Can look like: DepressionCan look like: Depression



�� Trauma impacted kids display deficits in:Trauma impacted kids display deficits in:

�� Emotion identificationEmotion identification and processingand processing (self (self

and others).and others).

�� Emotion regulationEmotion regulation: ability to modulate : ability to modulate

emotions in response to environmental emotions in response to environmental

demands.demands.

�� Emotional expressionEmotional expression: ability to verbalize what : ability to verbalize what

they are feeling and what they need.they are feeling and what they need.

Emotion IdentificationEmotion Identification

Masten et al., 2008


Emotion IdentificationEmotion Identification

Scared

Sad

Happy

Surprised

Angry Anger

Anger

Anger

Hostile Attribution BiasHostile Attribution Bias


Cognitive Cognitive DysregulationDysregulation

DissociationDissociation

““Disruption in the usually integrated Disruption in the usually integrated

functions of consciousness, memory, functions of consciousness, memory,

identity or perception.identity or perception.””(DSM(DSM--IVIV--TR)TR)


Dissociation: 3 ComponentsDissociation: 3 Components1.1. Absorption:Absorption:

•• Losing contact with current surroundings Losing contact with current surroundings –– this could be due to this could be due to absorption in an activity, flashback, going away in oneabsorption in an activity, flashback, going away in one’’s mind, s mind, etc.etc.

2.2. DerealizationDerealization/Depersonalization:/Depersonalization:•• ““Out of bodyOut of body”” experiences, feeling disconnected from oneexperiences, feeling disconnected from one’’s s

body.body.•• Sensory disturbances.Sensory disturbances.•• Feeling as though things Feeling as though things ““arenaren’’t real.t real.””•• Feeling like a robot, just going through the motions, or like inFeeling like a robot, just going through the motions, or like in a a

movie.movie.

3.3. Amnesia for dissociative states:Amnesia for dissociative states:•• Person engages in a behavior and then has no memory of it.Person engages in a behavior and then has no memory of it.•• ““Coming toComing to”” in the middle of an activity, with no memory of in the middle of an activity, with no memory of

how one got there.how one got there.

(Waller, Putnam, & Carlson, 1996)(Waller, Putnam, & Carlson, 1996)

Dissociative ContinuumDissociative Continuum

DaydreamingSpacing out

Transient Dissociative

Episode

DissociativeDisorder

(DID, DDNOS)

Functional

“Disordered”


What does Dissociation Look Like?What does Dissociation Look Like?

�� Trace like state, Trace like state, ““Out of itOut of it””, or going away in their mind., or going away in their mind.�� Unresponsive/catatonic or internal focus.Unresponsive/catatonic or internal focus.

�� Perception becomes fuzzy, out of focus, or confused.Perception becomes fuzzy, out of focus, or confused.

�� Physical, panic symptomsPhysical, panic symptoms this may precede or continue this may precede or continue throughout a dissociative episode or flashback.throughout a dissociative episode or flashback.

�� Noticeable change in behavior or functioning that is out of Noticeable change in behavior or functioning that is out of character or mismatch with their developmental stage character or mismatch with their developmental stage ––““state shift.state shift.””

�� Conversion symptomsConversion symptoms -- pseudopseudo--seizers, fainting, or other seizers, fainting, or other physical ailments.physical ailments.

�� Amnesia/difficulty remembering the details of an event.Amnesia/difficulty remembering the details of an event.

�� Reenactment of past trauma.Reenactment of past trauma.

�� Retreat into fantasy world and imagination.Retreat into fantasy world and imagination.

Neurobiological Neurobiological

ExpressionsExpressions


Impact of Trauma on the BrainImpact of Trauma on the Brain

Which cells survive and thrive and which ones do Which cells survive and thrive and which ones do

not is determined by a combination of effects not is determined by a combination of effects

involving genes andinvolving genes and experiencesexperiences

At Birth, the brain contains twice as many nerve

cells as there will be at age 6.

Source: Rowe.J. Creating Trauma-Informed CW systems, Chapter 3 p: 33

81

By age 6, the cells which have survived will form

thousands of connections with other cells.

��Brain development Brain development

happens from the bottom happens from the bottom

up: up:

�� From primitive (basic From primitive (basic

survival) survival)

�� To more complex To more complex

(rational thought, (rational thought,

planning, abstract planning, abstract

thinking)thinking)

82

(Continued)


��The brain develops by The brain develops by

forming connections.forming connections.

��Interactions with Interactions with

caregivers are critical tocaregivers are critical to

brain development.brain development.

��The more an The more an

experience is experience is

repeated, the stronger repeated, the stronger

the connections the connections

become.become.

83

Triune BrainTriune Brain

Intellect, executive functioning, language, conscious thought, self awareness. “Wise Mind”

Sensory and emotional experience, implicit memory.“Emotion Mind”

Instinctive responses, unconscious body functions (breathing, digestion, muscle tone, etc.)


��Trauma has biological consequences on the Trauma has biological consequences on the regulation of brain functions.regulation of brain functions.

��These biological effects damage the childThese biological effects damage the child’’s or s or adultadult’’s ability to control himself/herself, calmly s ability to control himself/herself, calmly interact with others, pay attention and learn interact with others, pay attention and learn and take care of his/her lifeand take care of his/her life

Important Brain functions such as frustration

tolerance, ability to pay attention and learn,

sleeping, eating, social relations, and arousal of

the nervous system are regulated by connections

and influence.

Source: Rowe.J. Creating Trauma-Informed CW systems, Chapter 3 p: 33

85

86


��On constant alert for dangerOn constant alert for danger

��Quick to react to threats (fight, flight, freeze, Quick to react to threats (fight, flight, freeze,

submissive)submissive)

Exposure to trauma causes the brain to develop

in a way that will help the child survive in a

dangerous world:

Source: Teicher., M. H. (2002). Scars that won't heal: The neurobiology of child abuse. Scientific American, 286 (3),68-75.

89

The stress hormones produced during trauma also

interfere with the development of higher brain

functions.

Emotion Regulation CircuitEmotion Regulation Circuit

Hippocampus:Memory Processing

Amygdala (Alarm):Alerts to danger

Anterior Cingulate


Trauma and the BrainTrauma and the Brain

�� Trauma can have serious consequences for the normal Trauma can have serious consequences for the normal development of childrendevelopment of children’’s brains, brain chemistry, and s brains, brain chemistry, and nervous system.nervous system.

�� TraumaTrauma--induced alterations in biological stress systems induced alterations in biological stress systems can adversely effect brain development, cognitive and can adversely effect brain development, cognitive and academic skills, and language acquisition.academic skills, and language acquisition.

�� Traumatized children and adolescents display changes Traumatized children and adolescents display changes in the levels of stress hormones similar to those seen in in the levels of stress hormones similar to those seen in combat veterans. combat veterans.

�� These changes may affect the way traumatized These changes may affect the way traumatized children and adolescents respond to future stress in children and adolescents respond to future stress in their lives, and may also influence their longtheir lives, and may also influence their long--term term health.health.11

1. Pynoos et al. (1997). Ann N Y Acad Sci;821:176-193

NCTSN, 2008

�� In In early childhood,early childhood, trauma can be trauma can be associated with reduced size of the cortex.associated with reduced size of the cortex.

�� The cortex is responsible for many complex functions, The cortex is responsible for many complex functions, including memory, attention, perceptual awareness, including memory, attention, perceptual awareness, thinking, language, and consciousness.thinking, language, and consciousness.

��Trauma may affect Trauma may affect ““crosscross--talktalk”” between between the brainthe brain’’s hemispheres, including parts of s hemispheres, including parts of the brain governing emotions.the brain governing emotions.

�� These changes may affect IQ, the ability to regulate These changes may affect IQ, the ability to regulate emotions, and can lead to increased fearfulness and a emotions, and can lead to increased fearfulness and a reduced sense of safety and protection.reduced sense of safety and protection.


NCTSN, 2008


Bruce Perry, M.D. Ph.D.

�� In In schoolschool--age childrenage children, trauma undermines , trauma undermines the development of brain regions that would the development of brain regions that would normally help children:normally help children:�� Manage fears, anxieties, and aggressionManage fears, anxieties, and aggression

�� Sustain attention for learning and problem solvingSustain attention for learning and problem solving

�� Control impulses and manage physical responses to danger, Control impulses and manage physical responses to danger, enabling the adolescent to consider and take protective actionsenabling the adolescent to consider and take protective actions

�� As a result, children may exhibit:As a result, children may exhibit:�� Sleep disturbancesSleep disturbances

�� New difficulties with learningNew difficulties with learning

�� Difficulties in controlling startle reactionsDifficulties in controlling startle reactions

�� Behavior that shifts between overly fearful and overly aggressivBehavior that shifts between overly fearful and overly aggressivee


NCTSN, 2008


�� In In adolescentsadolescents,, trauma can interfere with trauma can interfere with development of the prefrontal cortex, the development of the prefrontal cortex, the region responsible for:region responsible for:�� Consideration of the consequences of behaviorConsideration of the consequences of behavior

�� Realistic appraisal of danger and safetyRealistic appraisal of danger and safety

�� Ability to govern behavior and meet longerAbility to govern behavior and meet longer--term goalsterm goals

�� As a result, adolescents who have As a result, adolescents who have experienced trauma are at increased risk for:experienced trauma are at increased risk for:�� Reckless and riskReckless and risk--taking behaviortaking behavior

�� Underachievement and school failureUnderachievement and school failure

�� Poor choicesPoor choices

�� Aggressive or delinquent activityAggressive or delinquent activity

American Bar Association. (January 2004). Adolescence, Brain Development and Legal Culpability.

NCTSN, 2008


““I wasnI wasn’’t thinking!t thinking!””

Peers

Triggers

Emotionallycharged situation

Impulsivity

Bad Decisions

Flight, Fight, Freeze


Brain PlasticityBrain Plasticity

IdentityIdentity


Fragmentation: Fragmentation: ““PartsParts”” of Selfof Self

�� What are our own parts?What are our own parts?�� Professional partProfessional part

�� Family partFamily part

�� Social partSocial part

�� Special talents, roles or Special talents, roles or identities?identities?

�� For our kids, parts of self For our kids, parts of self can be more:can be more:�� Fragmented. Fragmented.

�� Regressed, childish or Regressed, childish or immature.immature.

�� Hostile, angry, or Hostile, angry, or aggressive.aggressive.

Maintaining EmpathyMaintaining Empathy

Questions to ask yourself:

• Is this a “part”?

• How old is the part?

• What does this part need in the moment?

• How can I help this part get it’s

needs met in a safe way?

• Am I getting triggered by this part?

• What can I do in the moment to take care of myself?

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