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Complex Trauma in Children and Adolescents
CEUs can be earned for this presentation at
~ This presentation is based, in part, upon
~¬†a white paper from the National Child Traumatic Stress Network: ‚ÄúComplex Trauma in Children and Adolescents‚ÄĚ 2003
~ Child-Witnessed Domestic Violence and its Adverse Effects on Brain Development
~ The Adverse Childhood Experiences Study
~ Define complex trauma
~ Define and explore Adverse Childhood Experiences
~ Highlight the cost of complex trauma
~ Examine the impact and diagnostic issues of complex trauma
What is Complex Trauma
~ Exposure to traumatic events plus the short and long term impact of exposure resulting in:
~ Emotional dysregulation
~ Loss of safety
~ Inability to detect or respond to danger cues
~ Inability to detect or respond to internal cues
~ Generalization of cues
More About Complex Trauma
~ Complex Trauma is most likely to develop if the danger is unpredictable and uncontrollable (p.8)
~ The greatest source of danger, unpredictability and uncontrollability is the absence of a caregiver who reliably and responsively nurtures and protects the child.
Adverse Childhood Experiences
~ ACEs measured in the study include:
~ Physical, sexual, emotional abuse
~ Physical or emotional neglect
~ Mother treated violently
~ Substance misuse within household
~ Household mental illness
~ Parental separation or divorce
~ Incarcerated household member
*Could happen anytime prior to 18th birthday
*Two thirds of the 17,000 people in the ACE Study had at least one ACE
Effects of ACEs
~ Psychosocially induced biological alterations (in the brain and the HPA-Axis) related to maladaptation (especially post-traumatic stress disorder) in the context of child-witnessed DV
~ Child-Witnessed Domestic Violence and its Adverse Effects on Brain Development
Effects of ACEs
~ Nearly 60% of women and 35% of men with 4 or more ACEs reported chronic depression
~ The risk of perpetrating violence increased dramatically with the ACE score was over 5
~ Those with at least 4 ACEs had nearly double the chance of being raped later in life.
~ 18% of those with at least 4 ACEs attempted suicide.
National Incidence Study of Child Abuse and Neglect
~ NIS-3 (1996)
~ Harm Standard: 1,553,800
~ Endangerment Standard  2,815,600
~ Emotional (584,100)
~ NIS-4 (2006)
~ Harm Standard: 1,256,600 million (1:58)
~ Endangerment Standard: 2,905,800 (1:25)
~ Significant finding: Emotional (1,173,800)
7 Domains of Impairment
~ Attachment
~ Biology
~ Affect Regulation
~ Dissociation
~ Behavioral Regulation
~ Cognition
~ Self-Concept
As defined by the NCTSN Complex Trauma Taskforce
~ Secure attachment
~ Internalize regulation strategies
~ Identify internal and external cues
~ Learn to use support systems in the face of overwhelming experience
~ Insecure attachment (80% maltreated children)
~ 3 types
~ Avoidant
~¬†Rejecting caregiving‚ÄĒWhat does this look like
~ Disregard and distrust self and others
~ Ambivalent
~ Parents alternate between validation and invalidation/detachment and enmeshment (Borderline-esque)
~ Children become hypersensitive to cues and overgeneralize
~ Children may disconnect to protect
~ Disorganized
~ Lack of co-regulation
~ Erratic behavior in young kids (clingy, dismissive, aggressive)
~¬†Adolescents‚Äô behavior can be extreme, rigid and themed‚ÄĒhelplessness or coercive control (primitive survival)
Consequences of Poor Attachment
~ Life-Long risks for physical and psychosocial dysfunction
~ Increased susceptibility to stress
~ Inability to regulate emotions
~ Extremes in help seeking
Poor Attachment: Symptoms/  Interventions
~¬†Uncertainty about reliability and predictability of the world and their own ‚Äúgut‚ÄĚ
~ Cognitive Processing Therapy
~ Use Mindfulness to
~ Increase self and other awareness
~ Improve ability to communicate wants & needs and ask for help
~ Create structure and stability
~ Correct the behaviors and love the child
Poor Attachment: Symptoms/  Interventions
~ Problems with boundaries
~ Teach about emotional, social and physical boundaries and healthy relationships
~ Examine current relationships
~ Discuss motivations for maintaining poor boundaries
Symptoms /Interventions cont…
~ Interpersonal Difficulties (Trust/Communication/Attachment)
~ Modeling
~ Education
~ Perspective Taking
~ Difficulty interpreting nonverbal cues
~ Practice via group, vignettes, self-report
~ Reduce inappropriate generalization of nonverbal cues
Symptoms / Interventions cont…
~ Difficulty enlisting other people as allies
~ Use interpersonal effectiveness skills (win/win)
~ Examine any fears preventing developing allies (i.e. abandonment, betrayal)
~ Modeling
~ Role Playing
Problems with Biology
~ Sensorimotor developmental issues
~ Hypersensitivity to physical contact
~ Analgesia
~ Problems with coordination and balance
Problems with Affect Regulation
~ Difficulty with emotional self-regulation
~ Difficulty describing feelings and internal experience
~ Problems knowing and describing internal states
~ Difficulty communicating wishes and desires
Behavioral Control Impairments
~ Poor modulation of impulses
~ Self-destructive behavior
~ Aggression
~ Pathological self soothing behaviors
~ Oppositional behavior
~ Difficulty complying with rules
~ Re-enactment of prior trauma in daily behaviors
Problems with Cognition
~ Difficulties in attention regulation
~ Lack of sustained curiosity
~ Difficulty processing new information
~ Deficits in object constancy
~ Problems with orientation to time and space
~ Problems understanding own contribution to what happened to them
The Good News
~ Stressors early or later in life that are predictable, escapable or controllable, or in which responsive caregiver contact is available, and safe opportunities for exploration are reinstated, tend to
~ Increase hippocampal and prefrontal cortex neuronal functioning;
~ Behaviorally enhance curiosity, working memory, anxiety management, and the ability to nurture
Good News cont…
~ Restoration of secure caregiving after early life stressors has a protective effect, reducing long-term biological and behavioral impairment, even if:
~ (a) only visual, not tactile, or symbolic contact with the caregiver is possible
~ (b) the sociophysical environment is severely impoverished
~ (c) the caregiver is not the biological parent
Common Diagnoses (and their functions)
~ Concentration
~ Sitting still
~ Following through
~ Impulse control
~ Conduct Disorder
~ Aggression to people and animals
~ Destruction of Property
~ Deceitfulness, lying, or stealing
~ Serious violations of rules
Diagnoses cont…
~ Oppositional Defiant Disorder
~ Negative/Angry/Resentful
~ Defiant/ Disobedient
~ Hostility toward authority figures
~ Has temper tantrums
~ Is argumentative with adults
~ Blames others for misbehavior
~ Acts touchy and is easily annoyed
~ Is spiteful or vindictive
~ Act aggressively toward peers
~ Has difficulty maintaining friendships
Diagnoses cont…
~ Generalized Anxiety Disorder
~ Constant worrying or obsession about small or large concerns
~ Restlessness and feeling keyed up or on edge
~ Fatigue
~¬†Difficulty concentrating or your mind “going blank”
~ Irritability
~ Muscle tension or muscle aches
~ Trembling, feeling twitchy or being easily startled
~ Trouble sleeping
~ Shortness of breath or rapid heartbeat
Diagnoses cont…
~ Reactive Attachment Disorder
~ Failure to follow others in the room with the eyes
~ Failure to reach out when picked up
~ No interest in playing peekaboo or other interactive games
~ No interest in playing with toys
~ Engaging in self-soothing behavior, such as rocking or self-stroking
~ Calm when left alone
~ Acts aggressively toward peers
~ Watching others closely but not engaging in social interaction
~ Fails to ask for support or assistance
~ Masks feelings of anger or distress
Diagnoses cont…
~ Separation Anxiety Disorder
~ An unrealistic and lasting worry that something bad will happen if parent and child are separated
~ Refusal to go to school in order to stay with the caregiver
~ Refusal to go to sleep without the caregiver being nearby
~ Fear of being alone
~ Nightmares about being separated
~ Bed wetting
~ Complaints of physical symptoms on school days
~ Repeated temper tantrums or pleading
~ Millions of children in the US are abused or neglected each year
~ This maltreatment often leads to negative emotional, social, physical consequences that can last a lifetime
~ When put in context, at the time the behaviors were learned, behavioral issues often make sense
~ Recovery requires learning to trust self, develop a healthy social support system, re-examine learning experiences through a different lens.