Developmental Trauma
and Pediatric Psychology
Bradley C. Stolbach, PhD
Program Director, Chicago Child Trauma Center
La Rabida Children's Hospital
Lead Technical Advisor
Midwest Region Complex Trauma Training and Technical Assistance
Center, NCTSN Complex Trauma Treatment Network
Associate Professor of Clinical Pediatrics
The University of Chicago Pritzker School of Medicine
Midwest Regional Conference on Pediatric Psychology
Milwaukee, Wisconsin, April 26, 2012
Conflict of Interest Disclosure Statement
I, Bradley C. Stolbach, have no conflicts
of interest to disclose.
I am, however, willing to entertain offers. Interested parties, please see
me after the presentation.
Trauma Symptoms in Pediatric Burn Patients
Admitted to an Urban Burn Center
n = 40
70% reported clinical levels of Posttraumatic Stress Symptoms
PTSS LEVELS
N
No or few trauma symptoms
12
30
Moderate/Consistent with Partial PTSD
20
50
Severe/Consistent with Full PTSD
8
Stolbach, Fleisher, Gazibara, Gottlieb, Mintzer, & West, 2007
%
20
Trauma History
65% reported history of prior trauma exposure including 52.5%
who had experienced two or more prior traumas
M = 1.55 prior trauma exposures Range = 0-6 prior trauma exposures
Potentially Traumatic Event
Burn
Death or serious injury of loved one
Witnessed neighborhood violence
Victim of neighborhood violence
Domestic violence
Physical abuse
Natural disaster
Other bad accident
Seen dead body
Sexual abuse
Homelessness
N
40
19
16
7
6
4
3
2
2
2
1
Percentage
of Sample
100
47.5
32.5
17.5
15
10
7.5
5
5
5
2.5
Stolbach et al., 2007
Prior trauma exposure was correlated with level of trauma symptoms
experienced by children following burns (p < .05), while “objective”
estimates of burn severity (e.g., TBSA) and child characteristics were
not.
Burn Only
Prior Trauma
Non-clinical levels of
PTSS
N=7
N=5
Clinical levels of PTSS
N=7
N = 21
75% of children with clinical PTSS had prior trauma history
86% (18/21) of children with histories of 2 or more prior traumas
experience clinical levels of PTSS
Results suggest that prior trauma exposure increase the risk for PTSD
and that all pediatric medical trauma patients should be screened for
history of other trauma.
Stolbach et al., 2007
American Academy of Pediatrics
Statement on Early Childhood Adversity,
Toxic Stress and the Role of the Pediatrician
All health care professionals should adopt [an]
ecobiodevelopmental framework as a means of
understanding the social, behavioral, and economic
determinants of lifelong disparities in physical and mental
health. Psychosocial problems and the new morbidities
should no longer be viewed as categorically different from the
causes and consequences of other biologically based health
impairments.
Garner, Shonkoff et al., 2011
This Just In…..
4/26/12
"Exposure to Violence During Childhood is Associated with
Telomere Erosion from 5 to 10 Years of Age: A Longitudinal
Study," Idan Shalev, Terrie Moffitt et al. Molecular Psychiatry,
April 24th. doi:10.1038/mp.2012.32
The new report in the journal Molecular Psychiatry shows that a
subset of those children with a history of two or more kinds
of violent exposures have significantly more telomere loss
than other children. Since shorter telomeres have been
linked to poorer survival and chronic disease, this may not
bode well for those kids.
This Just In…..
The findings suggest a mechanism linking cumulative childhood
stress to telomere maintenance and accelerated aging, even
at a young age. It appears to be an important way that
childhood stress may get "under the skin" at the fundamental
level of our cells.
"An ounce of prevention is worth a pound of cure," said Moffitt,
who is the Knut Schmidt Nielsen Professor of Psychology and
Neuroscience. "Some of the billions of dollars spent on
diseases of aging such as diabetes, heart disease and
dementia might be better invested in protecting children
from harm."
Adverse Childhood Experiences Study (ACES)*
Physical abuse by a parent
Emotional abuse by a parent
Sexual abuse by anyone
An alcohol and/or drug abuser in the household
An incarcerated household member
Someone who is chronically depressed, mentally ill, institutionalized, or suicidal
Domestic violence
Loss of a parent
Emotional neglect
Physical neglect
Felitti et al. 1998
Adverse Childhood Experiences Study (ACES)*
Felitti et al. 1998
There is no such thing as
an event, especially
when children are
involved.
The Co-Occurring Nature of Trauma
“Individuals with a trauma history rarely experience only a single traumatic
event, but rather are likely to have experienced several episodes of traumatic
exposure.”
Cloitre et al., 2009
(Retrospective studies, e.g., Kessler, 2000; Stewart et al., 2008;
Coid et al., 2001; Dong et al., 2004 )
Finkelhor et al. (2009)
Nationally Representative Sample (n=4549)
Nearly 40% had experienced two or more types of direct victimization in the past year.
NCTSN Core Data Set (2012)
Children Served in the National Child Traumatic Stress Network (n=11,138)
Fewer than 24% had experienced only one type of trauma or ACE.
Over 40% had experienced 4 or more.
Percentage of Children & Adolescents
Trauma Exposure in Children Served in the National Child Traumatic
Stress Network
Single vs. Multiple Trauma Types
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
76.9%
Single
Multiple
23.2%
Single
Multiple
NCTSN Core Data Set
September 2010
Percent
Percentage of Children in the NCTSN Core Data Set
Experiencing Cumulative Traumas
© 2011 by Fairbank & Briggs-King
Trauma Exposure
30%
25%
20%
15%
10%
5%
0%
1
2
3
4
5
6
7
Total # Types of Traumatic Stressors Experienced
Mean = 2.59
70.9% Experienced 2 or More
Stolbach et al., 2009
Traumatic Stressors
Sexual Abuse
55%
Witnessed Domestic Violence
39%
Physical Abuse
27%
Traumatic Loss
26%
Witnessed Physical or Sexual Abuse
26%
Witnessed Community Violence
19%
Motor Vehicle Accident
13%
Other Medical Trauma (other than burns) 12%
Victim of Extrafamilial Violent Crime
7%
Burns
7%
Fire
7%
Witnessed Homicide
5%
Other trauma types include dog attack, school violence, abduction, torture,
witnessing serious injury, hurricane
Stolbach et al., 2009
Trauma Exposure
90% experienced at least one form of interpersonal
trauma.
63% experienced at least one form of family violence.
58% experienced at least one form of ongoing traumatic
stress.
Stolbach et al., 2009
Other Adverse Experiences
30%
25%
20%
15%
10%
5%
0%
0
1
2
3
4
5
6
7
8
9
Total # Types of Adverse Experiences
Mean = 2.65
59% Experienced 2 or More
Stolbach et al., 2009
Other Adverse Experiences
Impaired Caregiver
Neglect
Placement in Foster Care
Death of Significant Other (not TL)
Unresolved Trauma History in Caregiver
Exposure to Drug Use or Criminal Activity
in Home
Emotional Abuse
Exposure to Prostitution or other Developmentally
Inappropriate Sexual Behavior in Home
Substitute Care (not foster care)
Incarcerated Family Member
Homelessness
54%
37%
30%
26%
24%
23%
22%
Stolbach et al., 2009
18%
17%
16%
7%
La Rabida Chicago Child Trauma Center
Total Trauma and Adverse Experiences
14%
12%
10%
8%
6%
4%
2%
0%
n=214
1
3
5
7
9
11
13
Total # Types of Trauma and ACEs
Mean = 5.26
63% Experienced 4 or More
Stolbach et al, 2009
There is no such thing as
an individual, especially
when children are
involved.
The Attachment Behavioral System
 Attachment: an evolved behavioral system that functions to
promote the protection and safety of the attached person
 Attachment system is activated strongly by internal and
external stressors or threats.
 It is through healthy attachment (i.e., a behavioral system that
effectively protects and comforts the infant or child) that a
child develops the capacity for emotional and behavioral selfregulation, as well as a coherent self.
Attachment
Internal Working Models: complementary
representations of the self and the attachment figure
These models reflect the child’s appraisal of, and
confidence in, the self as acceptable and worthy of
care and protection, and the attachment figure’s
desire, ability, and availability to provide protection
and care. – Solomon & George, 1999
Children and Trauma
The child trapped in an abusive environment is faced
with formidable tasks of adaptation. She must find a
way to preserve a sense of trust in people who are
untrustworthy, safety in a situation that is unsafe,
control in a situation that is terrifyingly unpredictable,
power in a situation of helplessness. Unable to care
for or protect herself, she must compensate for the
failures of adult care and protection with the only
means at her disposal, an immature system of
psychological defenses.
Judith Herman, 1992
Children and Trauma
 Defining Dissociation
 “…a complex psychophysiological process…that
produces an alteration in the person’s consciousness.
During this process, thoughts, feelings and
experiences are not integrated into the individual’s
awareness in the normal way.” – Putnam, 1985
 “a mechanism by which some of the systems of
experience and some of the somatic apparatuses are
disintegrated from the rest of the personality”
- Sullivan, 1929
Children and Trauma
Defining Dissociation
 “In the service of protecting the self from
unbearable experiences, those who have the
mental agility to do so are able to segregate
various aspects of their experiences.”
– Allen, 1993
Dissociation and Attachment Disorganization
Disorganized children may construe what they have repeatedly
experienced in their attachment interactions as:
1) their being responsible for the fear and/or aggression they
perceive in the attachment figure when they approach him or
her;
2) the attachment figure being the cause of their extreme
experience of fear;
3) the attachment figure being able to comfort them;
4) their being able to comfort the attachment figure;
5) both victims of some unseen, inexplicable outside danger.
- Liotti, 1999
Dissociation and Attachment Disorganization
Frightened and helpless >
Victim
Cause of other’s fear and helplessness >
Persecutor
Comforting the frightened other >
Rescuer
Liotti, 1999
The Trauma Response
Peritraumatic Dissociation
 “In the service of protecting the self from
unbearable experiences, those who have the
mental agility to do so are able to segregate
various aspects of their experiences.”
– Allen, 1993
The Trauma Response
Traumatic memory is not processed or
interpreted
Traumatic memory is stored in visual or
somatosensory (including affective) impressions
The Trauma Response
 Development of Posttraumatic Symptoms
 Although rendered unconscious…by the dissociative
process, these mental elements are not thereby removed
from the sum total of mental contents…[They have] the
potential of being subsequently recalled to consciousness
under special circumstances. Furthermore they have the
capacity in their unconscious state to intrude on and
affect consciousness in a variety of disguises that may
take the form of ego-alien symptoms.”
- Nemiah, 1993
Some Basic Assumptions About
Psychological Traumatization
Traumatic experiences are those which overwhelm an individual’s
capacity to integrate experience in the normal way. (e.g., Putnam,
1985)
Following exposure to trauma, if integration does not occur, traumatic
experience(s) are split off and an individual alternates between
functioning as if the trauma is still occurring and functioning as if the
trauma never occurred. (e.g., Nijenhuis et al., 2004)
Although traumatic memories and associations remain inaccessible to
consciousness much of the time, they have the power to shape an
individual’s daily functioning and behavior. (e.g., Allen, 1993)
Continuum of Adverse Outcomes Following Exposure to
Potentially Traumatic Events
DID
DDNOS
Simple PTSD
Persistent Trauma-Related
Distress
Complex PTSD
DTD
Secondary Structural Dissociation
ASD
Primary Structural Dissociation
Trauma-related structural dissociation of the personality
Nijenhuis, van der Hart & Steele (2004)
Tertiary
Structural
Dissociation
The Case of Gabriela

Abused at age 10 by aunt and aunt’s boyfriend (1 incident),
who were convicted and sentenced to 14- and 30-year
sentences for abusing numerous other victims

Participated in Forensic Interview and subsequent
apparently effective short-term abuse-focused therapy at
CAC

At age 16, disclosed sexual abuse by male cousin (6 years
older) from age 6 to age 10

Returned to CAC in Park Forest for services after disclosure
The Case of Gabriela

Assessed and appeared to have simple PTSD except for the
fact that she reported having no memory of having been in
previous therapy at CAC

Academic “over-achiever”

Highly conflictual relationship with mother who has
extensive history of childhood sexual abuse

Minimal contact with father
The Case of Gabriela




In treatment, identifies “different parts” of self:
“Everyday Self”, “Angry Self”, “Happy Self”, “Sad/depressed
Self”
Has numerous discussions with therapist about sex, dating,
boys, and the fact that she is not sexually active and is not
interested in being sexually active
In subsequent session, casually mentions her boyfriend,
with whom she has been sexually active
Is surprised that therapist did not know about boyfriend and
has no memory of prior statements to therapist about lack
of interest in sexual activity
Posttraumatic Stress Disorder
A. Event
B. Reexperiencing
C. Avoidance/Numbing/Amnesia
D. Hyperarousal
DSM-IV PTSD Criterion A
Exposure to traumatic event in which both of the
following were present
Experienced, witnessed, or was confronted with an
event or events that involved actual or threatened
death or serious injury, or a threat to the physical
integrity of self or others
The person’s response involved intense fear,
helplessness, or horror
Proposed DSM-5 PTSD Criterion A
The person was exposed to the following event(s): death or threatened
death, actual or threatened serious injury, or actual or threatened
sexual violation, in one or more of the following ways:
Experiencing the event(s) him/herself
Witnessing the event(s) as they occurred to others
Learning that the event(s) occurred to a close relative or close
friend
Experiencing repeated or extreme exposure to aversive details
of the event(s) (e.g., first responders collecting body
parts; police officers repeatedly exposed to details of
child abuse)
Met Full Criteria for PTSD
73.5
Percent
100
90
80
70
60
50
40
30
20
10
0
NO
Yes
24.5
Pynoos et al., 2008
Limitations of PTSD Diagnosis for Children
• Conceptualized from an adult perspective
• Identified as diagnosis via Vietnam vets and adult rape victims
• Focuses on single event traumas
• Fails to recognize chronic/multiple/on-going traumas
• Is not developmentally sensitive and does not reflect the impact of
trauma on brain development
• Many traumatized children do not meet full diagnostic criteria
• Does not direct clinical attention to attachment history and attachmentrelated injuries
Beyond Posttraumatic Stress Disorder
Complex Trauma, Type II Trauma, Betrayal Trauma,
Developmentally Adverse Interpersonal Trauma and
Maltreatment, ACEs, Extreme Stress Not Otherwise
Specified….
have profound effects on development, functioning,
personality, and the capacity to live, love, and be loved.
These effects are not accounted for in our current
diagnostic classification system, nor are they addressed
in standard simple PTSD treatment approaches.
Beyond Posttraumatic Stress Disorder
Developmental Trauma Disorder (van der Kolk, 2005)
proposes that following exposure to multiple, chronic adverse
interpersonal stressors, including neglect, emotional abuse,
violence, children develop symptoms of dysregulation across
multiple areas :
Affective (emotional)
Somatic (physiological, motoric, medical)
Behavioral (re-enactment, cutting)
Cognitive (dissociation, confusion)
Relational (clinging, oppositional, distrustful)
Self-attribution (self blame, hate)
“The interactions of developmental interferences,
unresolved chronic traumatic reactions, and chronic
adaptations to trauma are serious, often devastating,
and repeated or serial trauma often leaves no time
for recovery and continues to affect later
developmental periods.”
Pynoos, quoted in Stolbach, 2007
Infants and young children exposed to cumulative, chronic traumatic events
show disturbances and deficits in emotional, social, and cognitive
competencies that are not encompassed by the existing criteria for
diagnosing PTSD. One major reason for this situation is that the existing
diagnostic criteria for PTSD do not incorporate developmentally appropriate
constructs of infancy and early childhood. A second problem is that the
current definition of PTSD is predicated on the occurrence of a single
traumatic event, whereas pervasive and recurrent traumatization is often
the norm for children living in high-risk families and communities. For
millions of young children, repeated exposure to traumatic events takes the
form of co-occurring physical abuse, domestic violence, community
violence, and accidents such as falls, burns, dog bites and near-drownings
that occur as the byproduct of severe neglect. Developmental
competencies are derailed in [numerous] domains.
Lieberman, Ghosh Ippen, & Van Horn, 2008
Cumulative Risk Increases Lifetime DSM Diagnoses
in 5 Different Diagnostic Categories
(Mood, Anxiety, Conduct, Substance Abuse, Impulsive)
CRS = 0
CRS = 3
CRS = 1
CRS ≥ 4
CRS = 2
5 DSM Categories
4 DSM Categories
3 DSM Categories
2 DSM Categories
1 DSM Category
OhioCanDo4Kids.Org
Putnam et al., 2008
No DSM Diagnosis
Contribution of Childhood Adversity to Diagnostic Complexity
as manifest by the number of Lifetime DSM Diagnostic
Categories for individuals with CRS = 0 and CRS ≥ 4
(DSM Categories = Mood, Anxiety, Conduct, Substance Abuse, Impulsive
Disorders)
5 DSM Categories
4 DSM Categories
CRS = 0
(N=2806)
CRS ≥ 4
(N=252)
3 DSM Categories
2 DSM Categories
1 DSM Category
OhioCanDo4Kids.Org
Putnam et al., 2008
No DSM Diagnosis
Children’s Posttraumatic Reactions:
Risk for Misdiagnosis and Mislabeling
Children presenting with complex trauma-related symptoms are
at risk of being misdiagnosed with a variety of disorders and
functional difficulties particularly when a comprehensive
assessment for complex trauma issues is not conducted
 ADHD
 Depressive Disorders
 Oppositional Defiant Disorder
 Conduct Disorder
 Reactive Attachment Disorder
 Psychotic Disorders
 Specific Phobias
 Learning/ academic difficulties
 Juvenile Delinquency
Research has shown that traumatic childhood
experiences not only are extremely common, but also
have a profound impact on many different areas of
functioning. For example, children exposed to
alcoholic parents or domestic violence rarely have
secure childhoods; their symptomatology tends to be
pervasive and multifaceted and is likely to include
depression, various medical illnesses, and a variety of
impulsive and self-destructive behaviors. Approaching
each of these problems piecemeal, rather than as
expressions of a vast system of internal
disorganization, runs the risk of losing sight of the
forest in favor of one tree.
van der Kolk, 2005
“Of course being in a family where you get beaten
up by the people who are supposed to take care
of you would be different from getting burned or
being in a fire or something. Why do they have
only one diagnosis?”
Eva Griffin-Stolbach (age 8), personal communication,
January 2009
Creating and testing a scientifically derived, accurate, and useful
diagnosis is no small task. It requires not only a true and deep
understanding of the clinical presentations and needs of the
children we serve, but also the cooperation and collaboration
of experts with diverse perspectives who must be prepared to
set aside strongly held beliefs about child development,
attachment, and trauma, and allow empirical data to dictate
the outcome of the process. If we are successful, the payoff
will be tremendous for the many children affected by complex
trauma. Just as the creation of PTSD in the DSM-III
transformed the health care system for individuals exposed to
traumatic stress and led to an explosion of specialized
research and practice, the inclusion in the DSM-V of a clinically
accurate and useful diagnosis for children whose development
has been shaped by complex trauma will be a powerful
catalyst for transformation of the systems that serve children.
Stolbach, 2007
It will change the way clinicians, who must learn the
contents of the DSM, are trained. It will make it
possible for new and better research on intervention
to take place and will lead to the development of
“Well Supported and Efficacious” treatments for the
pervasive developmental effects of complex trauma.
It will enable clinicians to get paid for providing
treatment for developmental trauma symptoms.
Finally, and most importantly, it will make it possible
for thousands of children to get the help they need in
order to heal during their childhoods, so that their
lives will not be structured by the traumatic past and
their healthy development may proceed.
Stolbach, 2007
Developmental Trauma Disorder DSM V “Task Force”
Led by Bessel van der Kolk, MD and Robert Pynoos, MD
Grew out of NCTSN Complex Trauma Work Group following
Complex Trauma White Paper
NCTSN Complex Trauma Survey
Psychiatric Annals, May 2005
Developmental Trauma Disorder DSM V “Task Force”
Data collection and analysis to guide proposed field trial(s).
Illinois Childhood Trauma Coalition hosted first collaborative
research meeting in January 2008.
Research collaborators include:
The Trauma Center at JRI (van der Kolk, Spinazzola, Dekel,
D’Andrea)
Northwestern Mental Health Services and Policy Program (Kisiel,
Fehrenbach, McClelland, Griffin, Burkman)
Chicago Child Trauma Center (Stolbach, Dominguez)
University of Colorado at Boulder (Silvern, Schulz-Heik, McClintic)
Julian Ford, Alicia Lieberman, Frank Putnam
Developmental Trauma Disorder DSM V “Task Force”
ISTSS, Chicago, November 2008
Teleconference Presentations to DSM-V Sub-Work Group
12/19/08 (van der Kolk, Herman, Pynoos)
UCONN Meeting 1/16/09
NCTSN Consensus Proposal Submitted to DSM-V 2/1/09
ISTSS, Atlanta, November 2009
Privately Funded Field Trial Currently Underway
PROPOSAL TO INCLUDE A DEVELOPMENTAL TRAUMA DISORDER
DIAGNOSIS FOR CHILDREN AND ADOLESCENTS IN DSM-V
Bessel A. van der Kolk, MD
Robert S. Pynoos, MD
Dante Cicchetti, PhD Marylene Cloitre, PhD
Wendy D’Andrea, PhD Julian D. Ford, PhD Alicia F. Lieberman, PhD
Frank W. Putnam, MD Glenn Saxe, MD Joseph Spinazzola, PhD
Bradley C. Stolbach, PhD Martin Teicher, MD, PhD
February 1, 2009
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 illserved 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.
CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER
A. Exposure. The child or adolescent has experienced or witnessed multiple or
prolonged adverse events over a period of at least one year beginning in
childhood or early adolescence, including:
A. 1. Direct experience or witnessing of repeated and severe episodes of
interpersonal violence; and
A. 2. Significant disruptions of protective caregiving as the result of repeated
changes in primary caregiver; repeated separation from the primary
caregiver; or exposure to severe and persistent emotional abuse
B. Affective and Physiological Dysregulation. The child exhibits impaired
normative developmental competencies related to arousal regulation,
including at least two of the following:
B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g.,
fear, anger, shame), including prolonged and extreme tantrums, or
immobilization
B. 2. Disturbances in regulation in bodily functions (e.g. persistent
disturbances in sleeping, eating, and elimination; over-reactivity or underreactivity to touch and sounds; disorganization during routine transitions)
B. 3. Diminished awareness/dissociation of sensations, emotions and bodily
states
B. 4. Impaired capacity to describe emotions or bodily states
C. Attentional and Behavioral Dysregulation: The child exhibits impaired
normative developmental competencies related to sustained attention,
learning, or coping with stress, including at least three of the following:
C. 1. Preoccupation with threat, or impaired capacity to perceive threat,
including misreading of safety and danger cues
C. 2. Impaired capacity for self-protection, including extreme risk-taking or
thrill-seeking
C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical
movements, compulsive masturbation)
C. 4. Habitual (intentional or automatic) or reactive self-harm
C. 5. Inability to initiate or sustain goal-directed behavior
D. Self and Relational Dysregulation. The child exhibits impaired normative
developmental competencies in their sense of personal identity and
involvement in relationships, including at least three of the following:
D. 1. Intense preoccupation with safety of the caregiver or other loved ones
(including precocious caregiving) or difficulty tolerating reunion with them
after separation
D. 2. Persistent negative sense of self, including self-loathing, helplessness,
worthlessness, ineffectiveness, or defectiveness
D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in
close relationships with adults or peers
D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other
adults
D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate
contact (including but not limited to sexual or physical intimacy) or
excessive reliance on peers or adults for safety and reassurance
D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of
empathy for, or intolerance of, expressions of distress of others, or
excessive responsiveness to the distress of others
E. Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom
in at least two of the three PTSD symptom clusters B, C, & D.
F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6
months.
G. Functional Impairment. The disturbance causes clinically significant
distress or impairment in at least two of the following areas of functioning:
•
•
•
•
•
Scholastic: under-performance, non-attendance, disciplinary problems, drop-out, failure to
complete degree/credential(s), conflict with school personnel, learning disabilities or
intellectual impairment that cannot be accounted for by neurological or other factors.
Familial: conflict, avoidance/passivity, running away, detachment and surrogate
replacements, attempts to physically or emotionally hurt family members, non-fulfillment of
responsibilities within the family.
Peer Group: isolation, deviant affiliations, persistent physical or emotional conflict,
avoidance/passivity, involvement in violence or unsafe acts, age-inappropriate affiliations or
style of interaction.
Legal: arrests/recidivism, detention, convictions, incarceration, violation of probation or other
court orders, increasingly severe offenses, crimes against other persons, disregard or
contempt for the law or for conventional moral standards.
Health: physical illness or problems that cannot be fully accounted for physical injury or
degeneration, involving the digestive, neurological (including conversion symptoms and
analgesia), sexual, immune, cardiopulmonary, proprioceptive, or sensory systems, or severe
headaches (including migraine) or chronic pain or fatigue.
Table 1. Data Sources
Dataset
Contributors
N
Sample Source
NCTSN Survey
Spinazzola, Ford, J.D., Zucker, van der Kolk,
Silva, Smith, & Blaustein
1699
Clients at NCTSN
sites
NCTSN Core Data
Set
Pynoos, Ostrowski, Fairbank, Briggs-King,
Steinberg, Layne, & Stolbach
4435
Clients at NCTSN
sites
CANS Dataset
McClelland, Fehrenbach, Griffin, Burkman, &
Kisiel.
7668
All Illinois Foster Care
system
CCTC Dataset
Stolbach, Dominguez, & Rompala
172
Western Michigan
Dataset
Ford (In press)
Richardson, Henry, Black-Pond, & Sloane
209
All PTSD criterion Aexposed
Foster care
Ford, O’Connor, & Hawke
397
Juvenile Justice
Ford, Hawke, & Chapman
1825
Ghosh Ippen and
Lieberman
Ghosh Ippen, Harris, Van Horn, & Lieberman
89
Child psychiatry
inpatients
Juvenile Detention
Centers
Preschoolers exposed
to domestic violence
Table 5. CCTC Data: Correlations between DTD Criterion A Exposure and Symptom
Measures
Mean for DTD
Criterion Aa
Exposed
Children
Symptom Measure
Mean for NonDTD Criterion
Ab Exposed
Children
r =
P<
.245
.277
ns
ns
ns
ns
ns
ns
.05
.05
Self Report
UCLA PTSD Reaction Index for DSM-IV (n=111)
Children’s Depression Inventory (n=121)
Reynolds Children’s Manifest Anxiety Scale (n=114)
Trauma Symptom Checklist for Children (n=111)
Children’s DES & Posttraumatic Symptom Inventory (n=114)
DICA ADHD, Depression, Separation Anxiety, PTSD (n=90-114)
DICA Conduct Disorder Symptoms
DICA Dysthymia Symptoms
Caregiver Report
UCLA PTSD Reaction Index for DSM-IV – Parent Version (n=135)
Child Behavior Checklist Internalizing (n=156)
Child Behavior Checklist Externalizing (n=156)
Child Behavior Checklist Total (n=156)
Child Dissociative Checklist (n=150)
Children’s Sexual Behavior Inventory (n=70)
Clinician Report (n=110)
Child Complex Trauma Symptom Checklist PTSD Items
Child Complex Trauma Symptom Checklist Non-PTSD Items
Child Complex Trauma Symptom Checklist Dissociation Items
c
Clinical Dissociation Summary Variable (n=157)
a
2.16
1.54
1.20
.42
23.70
61.86
65.63
66.27
10.92
73.60
24.82
62.06
60.49
62.21
7.77
57.32
.227
.181
.232
.339
ns
ns
.005
.05
.001
.005
11.05
23.38
3.38
9.78
13.22
1.84
.394
.355
ns
.005
.001
% Clinical
% Clinical
58%
35%
.229
.005
Ongoing traumatic stress in combination with neglect, emotional abuse, and/or impaired caregiver
b
Ongoing traumatic stress alone, isolated traumatic stress alone or in combination with neglect, etc.
c
CDES>24 or CDC>11 or CCTSCL Dissociation>4 or CCTSCL Top 5 Dissociation>1
Complex Trauma Histories, PTSD, and
Developmental Trauma Disorder
Symptoms in Traumatized Urban Children
Bradley C. Stolbach, Ph.D.
Renee Z. Dominguez, Ph.D.
Vikki Rompala, L.C.S.W.
Tanja Gazibara, B.A.
Robert Finke, Ph.D.
Chicago Child Trauma Center Complex Trauma Database
Previous Findings
Stolbach, Dominguez, Rompala, & Gazibara, 2008
In this trauma-exposed and highly traumatized sample, PTSD does not differentiate
children with Complex Trauma Histories from other children.
Children with Complex Trauma Histories appear to have more difficulty than other
children in the areas of
Behavioral Dysregulation (CBCL Externalizing, CSBI, CDC)
Dissociation
General Numbing of Responsiveness (Dysthymia)
Cloitre, Stolbach, Herman, van der Kolk, Pynoos, Wang, & Petkova, 2009
Childhood cumulative trauma predicted symptom complexity in the child sample and
was a stronger predictor than adulthood cumulative trauma in the adult sample.
Goals of Current Study
Use existing data to examine the newly proposed
Developmental Trauma Disorder Consensus Criteria.
Identify symptoms that differentiate children with
histories of proposed DTD Criterion A exposure from
other children.
Stolbach et al., 2009
Demographics
214 trauma-exposed children referred to CCTC after
experiencing 1 or more PTSD Criterion A stressor(s)
Age Range = 3-17
96 Male
118 Female
170
21
18
9
Mean Age = 9 yrs., 9 mos.
(44.9%)
(55.1%)
Black/African American
White/European American
Hispanic/Latino
“Biracial”/“Multiracial”
(79.4%)
(10.9%)
( 8.4%)
( 4.2%)
Stolbach et al., 2009
Self-Report Measures – Ages 8+
Children’s Depression Inventory (CDI, Kovacs)
UCLA Reaction Index for PTSD (PTSD-RI, Pynoos et al)
Trauma Symptom Checklist for Children (TSCC, Briere)
Children’s Dissociative Experiences Scale & Posttraumatic
Symptom Inventory (CDES/PTSI, Stolbach et al)
Revised Children’s Manifest Anxiety Scale (RCMAS, Reynolds)
Diagnostic Interview for Children and Adolescents (DICA, Reich)
Stolbach et al., 2009
Self-Report Measures
DICA Modules
• ADHD
• Oppositional Defiant Disorder
• Conduct Disorder
• Depression
• Dysthymia
• Separation Anxiety Disorder
• PTSD
• Somatization
Stolbach et al., 2009
Caregiver-Report Measures – All Ages
Child Behavior Checklist (CBCL, Achenbach & Rescorla)
UCLA Reaction Index for PTSD (RI – Parent, Pynoos et al)
Child Sexual Behavior Inventory (CSBI, Friedrich)
Child Dissociative Checklist (CDC, Putnam)
Stolbach et al., 2009
Clinician Report – All Ages
Following completion of trauma-focused assessment clinicians answer 3
questions:
Does child meet criteria for PTSD?
Does child have symptoms related to complex trauma history and
not accounted for by PTSD?
Does child meet criteria for any other DSM diagnoses?
and complete 74-Item Symptom Checklist (Ford et al, 2007)
Includes all DSM PTSD symptoms and 57 other items
Rating of 5 Most Clinically Significant Symptoms
Stolbach et al., 2009
Limitations of Data
Study was designed and approved, and data collection began
after publication of DTD concept, but well before the
proposed Developmental Trauma Disorder Consensus
Criteria were put forward.
DTD could not be assessed prospectively. Measures were not
designed to capture DTD symptoms. For the purpose of the
current study, items were identified that correspond with
some of the proposed criteria. Some of the proposed
symptoms had as few as one corresponding item and some
measures/items were only available for a subset of the
sample.
Stolbach et al., 2009
Trauma Exposure
30%
25%
20%
15%
10%
5%
0%
1
2
3
4
5
6
7
Total # Types of Traumatic Stressors Experienced
Mean = 2.59
70.9% Experienced 2 or More
Stolbach et al., 2009
Traumatic Stressors
Sexual Abuse
55%
Witnessed Domestic Violence
39%
Physical Abuse
27%
Traumatic Loss
26%
Witnessed Physical or Sexual Abuse
26%
Witnessed Community Violence
19%
Motor Vehicle Accident
13%
Other Medical Trauma (other than burns) 12%
Victim of Extrafamilial Violent Crime
7%
Burns
7%
Fire
7%
Witnessed Homicide
5%
Other trauma types include dog attack, school violence, abduction, torture,
witnessing serious injury, hurricane
Stolbach et al., 2009
Trauma Exposure
90% experienced at least one form of interpersonal
trauma.
63% experienced at least one form of family violence.
58% experienced at least one form of ongoing traumatic
stress.
Stolbach et al., 2009
Other Adverse Experiences
30%
25%
20%
15%
10%
5%
0%
0
1
2
3
4
5
6
7
8
9
Total # Types of Adverse Experiences
Mean = 2.65
59% Experienced 2 or More
Stolbach et al., 2009
Other Adverse Experiences
Impaired Caregiver
Neglect
Placement in Foster Care
Death of Significant Other (not TL)
Unresolved Trauma History in Caregiver
Exposure to Drug Use or Criminal Activity
in Home
Emotional Abuse
Exposure to Prostitution or other Developmentally
Inappropriate Sexual Behavior in Home
Substitute Care (not foster care)
Incarcerated Family Member
Homelessness
54%
37%
30%
26%
24%
23%
22%
Stolbach et al., 2009
18%
17%
16%
7%
Proposed DTD Criterion A
A. Exposure. The child or adolescent has experienced or
witnessed multiple or prolonged adverse events over a period
of at least one year beginning in childhood or early
adolescence, including:
A. 1. Direct experience or witnessing of repeated and severe
episodes of interpersonal violence; and
A. 2. Significant disruptions of protective caregiving as the result
of repeated changes in primary caregiver; repeated
separation from the primary caregiver; or exposure to severe
and persistent emotional abuse
Proposed DTD Criterion A Exposure
35%
30%
25%
20%
15%
10%
5%
0%
Episodic
Traumatic
Stress Only
Exposure
does not
include DTD
Criterion A1
or A2
DTD
Criterion A1
DTD
Criterion A2
DTD
Criterion A1
& A2
Stolbach et al., 2009
Results
Correlations Between DTD Criterion A Exposure
and Measures
Self Report
DICA Past Major Depressive Episode (r = .245, p < .05)
DICA Dysthymia symptoms (r = .436, p < .001)
DICA Conduct Disorder (r = .200, p < .05)
CDI, PTSD Measures, RCMAS not correlated or negatively
correlated with DTD Criterion A exposure
Stolbach et al., 2009
Correlations Between DTD Criterion A
Exposure and Measures
Caregiver Report
Child Dissociative Checklist Total (r = .185, p< .01)
Child Sexual Behavior Inventory (r = .248, p < .05)
Child Behavior Checklist Externalizing (r = .182, p < .01)
CBCL Internalizing and Total CBCL not correlated
UCLA Reaction Index not correlated
Stolbach et al., 2009
Correlations Between DTD Criterion A Exposure
and Clinician Report
PTSD*
Stolbach et al., 2009
Other Trauma
Related Symptoms***
Additional
Diagnoses*
Correlations Between DTD Criterion A Exposure
and Clinician Report
SCL-PTSD
Items*
SCL-Other
Items***
SCL-Dissociation
Items*
Stolbach et al., 2009
B. Affective and Physiological Dysregulation. The child exhibits impaired
normative developmental competencies related to arousal regulation,
including at least two of the following:
B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g.,
fear, anger, shame), including prolonged and extreme tantrums, or
immobilization
B. 2. Disturbances in regulation in bodily functions (e.g. persistent
disturbances in sleeping, eating, and elimination; over-reactivity or underreactivity to touch and sounds; disorganization during routine transitions)
B. 3. Diminished awareness/dissociation of sensations, emotions and bodily
states
B. 4. Impaired capacity to describe emotions or bodily states
DTD Cluster B Symptoms by Criterion A Exposure
DTD A +
84.3%
Problems managing/tolerating angry affect
Problems managing/tolerating anxious affect 65.4%
DTD A 46.5%***
42.4%**
Difficulty knowing and describing internal states
68.6%
31.7%***
Avoidance or dissociation of negative/painful affect
76.5%
55.0%**
Emotional unresponsiveness
39.2%
19.8%**
Difficulty labeling and expressing
feelings and internal experience
72.5%
34.7%***
Difficulty communicating wishes and desires
60.8%
19.0%***
Stolbach et al., 2009
C. Attentional and Behavioral Dysregulation: The child exhibits impaired
normative developmental competencies related to sustained attention,
learning, or coping with stress, including at least three of the following:
C. 1. Preoccupation with threat, or impaired capacity to perceive threat,
including misreading of safety and danger cues
C. 2. Impaired capacity for self-protection, including extreme risk-taking or
thrill-seeking
C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical
movements, compulsive masturbation)
C. 4. Habitual (intentional or automatic) or reactive self-harm
C. 5. Inability to initiate or sustain goal-directed behavior
DTD Cluster C Symptoms by Criterion A Exposure
Over or under-estimation of risk
DTD A + DTD A 34.0%
9.3%***
Total Score for CSBI
54.3%
29.0%*
Inability to self-soothe
54.9%
21.8%***
Self-injurious behavior
39.2%
15.0%**
Problems with capacity to plan and anticipate
Problems with age-appropriate capacity
to focus on and complete tasks
39.2%
18.0%**
51.0%
Stolbach et al., 2009
23.0%***
D. Self and Relational Dysregulation. The child exhibits impaired normative
developmental competencies in their sense of personal identity and
involvement in relationships, including at least three of the following:
D. 1. Intense preoccupation with safety of the caregiver or other loved ones
(including precocious caregiving) or difficulty tolerating reunion with them
after separation
D. 2. Persistent negative sense of self, including self-loathing, helplessness,
worthlessness, ineffectiveness, or defectiveness
D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in
close relationships with adults or peers
D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other
adults
D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate
contact (including but not limited to sexual or physical intimacy) or
excessive reliance on peers or adults for safety and reassurance
D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of
empathy for, or intolerance of, expressions of distress of others, or
excessive responsiveness to the distress of others
DTD Cluster D Symptoms by Criterion A Exposure
DTD A +
DTD A –
Feelings of being damaged or defective
52.9%
24.8%***
Low feelings of self-esteem, self-confidence or self-worth
74.5%
39.6%***
Distrust of others
62.7%
40.6%***
Physically attacks people
15.4%
4.6%*
Volatile interpersonal relationships
47.1%
15.0%***
Interpersonal boundary issues
47.1%
13.0%***
Difficulty attuning to other people’s emotional states
33.3%
8.9%***
Difficulty with perspective taking
47.1%
13.0%***
Stolbach et al., 2009
% Meeting DTD Symptom Criteria
by Criterion A Exposure
35%
30%
25%
20%
15%
10%
5%
0%
Episodic
Traumatic
Stress Only
Exposure
does not
include DTD
Criterion A1
or A2
DTD
Criterion A1
DTD
Criterion A2
DTD
Criterion A1
& A2***
Stolbach et al., 2009
Histories of Trauma Exposure in Former Child
Soldiers in Uganda
Abduction
Exposure to Armed Combat
Physical Assault
Witnessed Killing
Community Violence
Rape by Rebels
Physical Abuse
Sexual Assault in Community
99%
92%
90%
88%
56%
26%
26%
24%
Klasen et al., 2011
PTSD, MDD & DTD
in Former Child Soldiers in Uganda
Posttraumatic Stress Disorder
Major Depressive Disorder
Developmental Trauma Disorder
PTSD Only
MDD Only
DTD Only
Two Diagnoses
All Three
None
33%
36%
78%
1%
3%
32%
30%
17%
17%
Klasen et al., 2011
Complex Trauma Exposure and Symptoms in Child Welfare:
Evidence for Developmental Trauma Disorder
Cassandra Kisiel, Ph.D.
Tracy Fehrenbach, Ph.D.
Gary McClelland, Ph.D.
Kristine Burkman, B.A.
Gene Griffin, JD, Ph.D
Mental Health Services and Policy Program
Northwestern University Feinberg School of Medicine
Trauma Groups by DTD Symptom Criteria - Overall
4
3.5
3
p<.001
2.1
No A1/A2
2.5
A1 Only***
p<.05
1.7
2
1.3
1.5
A1 and A2
1.2
1.4
1.3
1
p<.01
4.4
4.7
0.5
5.0
0
A2 Only***
2.1
2.5
B: Affect &
Physio
*
1.7 *
2.3
=
=
C: Atten &
Behav
2.5
1.7
D: Self &
Relat
E: Postraum
Spectrum
G: Funct
Impair
Kisiel et al., 2009
* p < .05
** p <.01
*** p < .001
Corrected Rates of Placement Change by Trauma Profile:
Two Years Following Assessment
Trauma Groups
Incident Rate Ratio
Significance
No A1 or A2
1.00
A1 Only
1.027
p = .369
A2 Only
1.128
p < .01
A1 & A2
1.203
p < .001
Kisiel et al., 2009
Developmental Trauma Disorder: Results from the
National Child Traumatic Stress Network
Sarah A. Ostrowski, PhD
Western Kentucky University
Ernestine Briggs-King, PhD, John A. Fairbank, PhD
National Center for Child Traumatic Stress
Duke University School of Medicine
Robert Pynoos, MD, Alan Steinberg, PhD
National Center for Child Traumatic Stress
UCLA
Bradley Stolbach, PhD
La Rabida Children’s Hospital
Descriptive Information
DTD Criterion A
Exposed
Children
[N (%)]
Non-DTD Criterion A
Exposed
Children
[N (%)]
Total Sample
1804 (28.8)
4459 (71.2)
Male
797 (44.2)
2223 (50.1)
Female
1004 (55.7)
2214 (49.9)
Caucasian
1064 (59.0)
1814 (40.7)
African American
484 (26.8)
1670 (37.5)
Hispanic
439 (24.6)
1049 (24.2)
Public Insurance
1241 (68.8)
2796 (62.7)
Ostrowski et al., 2009
Sample: DTD+ versus non-DTD Children
• Criterion A
– A1.
• Selected those children who reported experiencing any type of
chronic interpersonal stressor [abuse/maltreatment (sexual,
physical, emotional), DV, and/or extreme interpersonal
violence]
– A2.
• Selected those children who reported chronic neglect, and/or
impaired caregiving
• Non-DTD
– Did not meet Criterion A1 and A2
• Other traumas (e.g., war/terrorism, illness, serious
injury/accident, natural disaster, kidnapping)
Cluster B: Affective and Physiological
Dysregulation
***p<.001
***p<.001
***p<.001
***p<.001
Ostrowski et al., 2009
Cluster C. Attentional and Behavioral
Dysregulation.
***p<.001
***p<.001
Ostrowski et al., 2009
Cluster D. Self and Relational Dysregulation
***p<.001
***p<.001
***p<.001
Ostrowski et al., 2009
Criterion E. PTSD Symptoms
Symptom Measure
Mean for DTD+
Children
Mean for
DTDChildren
t =
p=
Total Score
28.738
23.914
-6.825
.000***
Cluster B (Re-experiencing)
8.228
6.822
-8.290
.000***
Cluster C (Avoidance)
10.650
8.569
-8.415
.000***
Cluster D (Hyperarousal)
10.045
8.524
-8.605
.000***
Self Report
UCLA PTSD Reaction Index for DSM-IV
Ostrowski et al., 2009
Summary
• Children who experienced ongoing interpersonal
violence in combination with disruptions in protective
caregiving were characterized by high levels of
symptoms and developmental impairment
– Consistent with the proposed DTD criteria
– Results remained statistically significant even
when controlling for PTSD symptom severity
Ostrowski et al., 2009
Key Developmental Capacities Affected by
Complex Trauma
Ability to modulate, tolerate, or recover from extreme affect states
Regulation of bodily functions
Capacity to know emotions or bodily states
Capacity to describe emotions or bodily states
Capacity to perceive threat, including reading of safety and danger cues
Capacity for self-protection
Capacity for self-soothing
Ability to initiate or sustain goal-directed behavior
Coherent self, Identity
Capacity to regulate empathic arousal
Trauma Histories of Incarcerated Girls
Witnessed Community Violence
70%
Motor Vehicle Accident
70%
Witnessed Domestic Violence
70%
Traumatic Loss
70%
Sexual Abuse/Assault
60%
Witnessed Physical Abuse
60%
Witnessed Physical or Sexual Abuse
60%
Dog Attack
60%
Witnessed School Violence
60%
Victim of Extrafamilial Violent Crime
50%
Witnessed Homicides (all at least 2)
40%
Physical Abuse
40%
Burns
30%
Fire
20%
Other trauma types include natural disaster, abduction, torture
Trauma Exposure
100% experienced at least one form of family violence.
80% experienced at least one form of ongoing traumatic
stress.
80% experienced at least one form of traumatic stress prior to
age 6, including 30% who reported exposure to violence
from birth.
Mean # Types of Trauma Experienced = 8.5
Range # Types of Trauma Experienced = 3 - 15
Other Adverse Experiences
Impaired Caregiver
Incarcerated Significant Other
Exposure to Drug Use or Criminal Activity in Home
Neglect
Death of Significant Other (not TL)
Exposure to Prostitution or other Developmentally
Inappropriate Sexual Behavior in Home
Placement in Foster Care
Homelessness
Substitute Care (not foster care)
70%
Mean # Types of Adverse Experiences = 4.8
Range # Types of Adverse Experiences = 2 – 8
70%
70%
60%
60%
50%
40%
30%
20%
Mean Combined Total Types
of Traumatic Stressors +
Other Adverse Childhood Experiences =
13.3
Marie Therese
Fire
Domestic Violence
Impaired Caregiver
Physical Abuse
Sexual Abuse/Assault
Community Violence
School Violence
Extrafamilial Violent Crime Victim
Motor Vehicle Accident
Incarceration
Traumatic Loss
Witnessing Homicide
Homelessness
Employment in Sex Industry
Burn
1
Total Types of Traumatic Stress
Total Types of Adverse Other Experiences
12
4
5
5 - 20
5, 15, 16
7, 15, 16
10
10 - 16
12 - 20
14, 19
17 - 21
18
18, 19
19, 20
19, 20
20
Trauma History Profile: Marie Therese
Age In Years
Trauma/Adverse Experiences
House Fire
Domestic Violence
Physical Abuse
Impaired Caregiver
Neglect
Drug Use or Criminal Activity in Home
Sexual Abuse/Assault
School Violence
Street Violence, Witnessing Homicide
Extrafamilial Violent Crime Victim
Motor Vehicle Accident
Incarceration
Traumatic Loss or Bereavement
Homelessness, Sex Trade Worker
Burn
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Malcolm
Father Incarcerated
Death of Grandmother(s)
School Violence
In and Out of Psychiatric Hospital/Residential Treatment 6 - 12
Exposure to Criminal Behavior in Home
Domestic Violence
7 - 17
Physical Abuse
Witnessing Physical Abuse
7 - 17
Unresolved Trauma in Caregiver
Community Violence
Loss Through Violent Death (Many)
Medical Trauma
Shooting Victim
Motor Vehicle Accident
Extrafamilial Violent Crime Victim
3 mos - 21
5, 17
5 - 18
Total Types of Traumatic Stress
Total Types of Adverse Other Experiences
10
5
7 - 13
7 - 17
7 - 21
8 - 21
8 - 21
8
9
12
17
Trauma History Profile: Malcolm
Age In Years
Trauma/Adverse Experiences
Father Incarcerated
Death of Grandmother(s)
School Violence
Psychiatric Hospitalizations
Drug Use or Criminal Activity in Home
Domestic Violence
Physical Abuse (Direct & Witnessed)
Unresolved Trauma in Caregiver
Community Violence
Loss Through Violent Death
Medical Trauma
Victim of Shooting
Motor Vehicle Accident
Extrafamilial Violent Crime Victim
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Key Messages for Trauma Recovery
1. It is not happening now.
The trauma is over. It is in the past. You are here in the
present.
2. You are safe.
The adults here are responsible for your safety and you
are worthy of care and protection.
3. You are not inherently dangerous/toxic.
What is inside you (thoughts, feelings, dreams, impulses,
etc.) cannot hurt you or others.
4. You are good.
Whatever you have experienced and whatever you have
had to do to survive, you are a good, strong person who
can contribute to your community.
5. You have a future.
Intervention
1. Establishment of safety both in and outside of therapy.
2. Healing injuries related to history of attachment
disorganization, disruption, or loss.
3. Creation of an integrated narrative focused on the child’s
experience of traumatic events through talking, playing,
writing, drawing, etc.
4. Integration of the aspects of the child’s personality, self, or
experiences that have been split off.
5. Educating the child’s caregiver(s) about symptoms and their
meaning, as well as how best to intervene when symptoms
occur.
6. Working with family, school, and others in the child’s life to
support the child’s progress and adapt to changes as the
child heals.
Intervention
1.
2.
3.
4.
5.
6.
Establishment of safety both in and
outside of therapy.
Healing injuries related to history of
attachment disorganization, disruption,
or loss.
Creation of an integrated narrative
focused on the child’s experience of
traumatic events through talking,
playing, writing, drawing, etc.
Integration of the aspects of the child’s
personality, self, or experiences that
have been split off.
Educating the child’s caregiver(s)
about symptoms and their meaning, as
well as how best to intervene when
symptoms occur.
Working with family, school, and
others in the child’s life to support the
child’s progress and adapt to changes
as the child heals.
Core Elements of Child-Parent Psychotherapy
1.
2.
3.
4.
5.
6.
7.
8.
Providing reflective developmental guidance
Providing assistance with problems of living
Helping caregiver provide physical safety
Helping caregiver provide emotional safety
Constructing a joint trauma narrative
Attending to family’s cultural norms and values
Collaborative engagement with family
Reflective supervision
What is a trauma-informed system?
“Trauma-informed” refers to all of the ways in which
a service system is influenced by having an
understanding of trauma, and the ways in which it
is modified to be responsive to the impact of
traumatic stress. A program that is “traumainformed” operates within a model or framework
that incorporates an understanding of the ways in
which trauma impacts an individual’s socioemotional health. This framework should,
theoretically, decrease the risk of retraumatization,
as well as contribute more generally to recovery
from traumatic stress. (Harris & Fallot, 2001)
Key Principles
Trauma awareness:
Trauma-informed systems incorporate an awareness of
trauma into their work. This may include establishing a
philosophical shift, with the overall system taking a different
perspective on the meaning of symptoms and behaviors.
Staff training, consultation, and supervision are important
aspects of organizational change to incorporate trauma
awareness. Practices within the agency should also reflect
an awareness of the impact of trauma, including changes
such as screening for trauma history and increasing access
to trauma-specific services and staff self care to reduce the
impact of vicarious trauma.
Key Principles
Emphasis on safety:
Because trauma survivors are often sensitized to
potential danger, trauma-informed service systems
work towards building physical and emotional safety
for consumers and providers. The system should be
aware of potential triggers for consumers and strive
to avoid retraumatization. Because interpersonal
trauma often involves boundary violations and abuse
of power, systems that are aware of trauma
dynamics establish clear roles and boundaries
developed within a collaborative decision-making
process. Privacy, confidentiality, and mutual respect
are also important aspects of developing an
emotionally safe atmosphere. Diversity is accepted
and respected within trauma-informed settings,
including differences in gender, ethnicity, sexual
orientation, and so on.
Key Principles
Opportunities to rebuild control and empowerment:
Because control is often taken away in traumatic situations,
trauma-informed service settings emphasize the importance
of choice and empowerment for consumers. They create
predictable environments that allow consumers to re-build a
sense of efficacy and personal control over their lives. This
includes involving consumers in the design and evaluation of
services.
Key Principles
Strengths-based approach:
Trauma-informed systems are strengths-based,
versus punitive or pathology driven. This type of
system assists consumers in identifying their own
strengths and developing coping skills. Traumainformed systems are future-focused, and utilize skillbuilding to further develop resiliency.
Societal Traumatization and the Legacy of
Imperialism, Attempted Genocide, & Slavery
Just as in cases of individual traumatization,
avoidance of acknowledging and addressing the
traumatic past makes it impossible for integration
to occur.
As long as historical trauma remains taboo, the racial
divisions that pervade every aspect of American life
will persist.
Societal Traumatization and the Legacy of
Imperialism, Attempted Genocide, & Slavery
As trauma professionals, we specialize in helping people to
communicate about and understand that which cannot be
spoken so that they can overcome the horrific past and live
in the present.
Our task in working with traumatized children and their
families is to develop ways of acknowledging and
addressing the historical traumas that have taken place on
this continent and their legacy.
This includes not only the damage done, but the courage,
strength, wisdom, and resilience without which their
cultures would not have survived.
References & Suggested Readings
Allen, J.G. (1993). Dissociative processes: theoretical underpinnings of a working model for
clinician and patient. Bulletin of the Menninger Clinic, 57, 287-308.
Blaustein, M.E. & Kinniburgh, K.M. (2010). Treating Traumatic Stress in Children and
Adolescents: How to Foster Resilience through Attachment, Self-Regulation, and
Competency. New York: The Guilford Press.
Bremner, J.D., Randall, P., Scott, T.M., Bronen, R.A., Seibyl, J.P., Southwick, S.M, Delaney, R.C.,
McCarthy, G., Charney, D.S., & Innis, R.B. (1995). MRI-based measures of hippocampal
volume in patients with PTSD. American Journal of Psychiatry, 152, 973-981.
Bremner, J.D., Randall, P., Vermetten, E. et al. (1997). MRI-based measurement of hippocampal
volume in posttraumatic stress disorder related to childhood physical and sexual abuse: a
preliminary report. Biological Psychiatry, 41, 23-32.
Cloitre, M., Stolbach, B.C., Herman, J.L., van der Kolk, B.A., Pynoos, R.S., Wang, J., & Petkova, E.
(2009). A developmental approach to complex PTSD: child and adult cumulative trauma as
predictors of symptom complexity. Journal of Traumatic Stress, 22, 399-408.
Coid, J., Petruckevitch, A., Feder, G., Chung, W., Richardson, J., & Moorey, S. (2001). Relation
between childhood sexual and physical abuse and risk of revictimization in women: a crosssectional survey. Lancet, 358(9280), 450-454.
Dong, M., Anda, R. F., Felitti, V. J., Dube, S. R., Williamson, D. F., Thompson, T. J., et al. (2004).
The interrelatedness of multiple forms of childhood abuse, neglect, and household
dysfunction. Child Abuse & Neglect, 28(7), 771-784.
References & Suggested Readings
Felitti, V. J., Anda, R. F., Nordenberg, D.F., Williamson, D. F., Spitz, A.M., Edwards, V., et al. (1998).
Relationship of childhood abuse and household dysfunction to many of the leading causes
of death: The Adverse Childhood Experiences (ACE) Study. American Journal of
Preventative Medicine, 14(4), 245-258.
Freud, S. (1917). Mourning and melancholia.
Herman, J.L. (1992). Trauma and Recovery. New York: Basic Books.
Kessler, R.C. (2000). Posttraumatic stress disorder: the burden to the individual and to society.
Journal of Clinical Psychiatry, 61 (Suppl 5), 4-12.
Kisiel, C., Fehrenbach, T., McClelland, G., Burkman, K., & Griffin, E. (2009). Complex trauma
exposure and symptoms in child welfare: Evidence for Developmental Trauma Disorder.
Paper presented at the 25th Annual Meeting of the International Society for Traumatic
Stress Studies, Atlanta, GA, November 7, 2009.
Lewis, M.L. & Ghosh Ippen, C. (2004). Rainbow of tears, souls full of hope: Cultural issues related
to young children and trauma. In J.D. Osofky (Ed.). Young children and trauma: Intervention
and treatment (pp. 11-46). New York: The Guilford Press.
Lieberman, A.F. & Van Horn, P. (2008) Psychotherapy with Infants and Young Children: Repairing
the Effects of Stress and Trauma on Early Attachment. New York: The Guilford Press.
Liotti, G. (1999). Disorganization of attachment as a model for understanding dissociative
psychopathology. In J. Solomon & C. George (Eds), Attachment Disorganization (pp. 291317). New York: Guilford Press.
Nemiah, J.C. (1993). Dissociation, conversion, and somatization. In D. Spiegel (Ed.), Dissociative
Disorders: A Clinical Review (pp. 104-116). Lutherville, MD: Sidran.
References & Suggested Readings
Nijenhuis ERS, van der Hart O, Steele K. Trauma-related structural dissociation of the personality.
Trauma Information Pages Web site. Available at: http://www.trauma-pages.com/nijenhuis2004.php. Accessed November 13, 2004.
Osofsky, J.D. (2004). Young children and trauma: Intervention and treatment. New York: Guilford
Press.
Putnam, F.W. (1985). Dissociation as a response to extreme trauma. In R.P. Kluft, ed. Childhood
Antecedents of Multiple Personality. Washington, DC: American Psychiatric Press; 1985.
Putnam F.W. (1997). Dissociation in Children and Adolescents. New York, NY: Guilford Press
Putnam, F.W., Perry, M., Putnam, K., & Harris, W. (2008). Childhood antecedents of clinical
complexity. Paper presented at the 24th Annual Meeting of the International Society for
Traumatic Stress Studies, Chicago, IL, November 15, 2008.
Pynoos, R., Fairbank, J.A., Briggs-King, E.C., Steinberg, A., Layne, C., Stolbach, B., & Ostrowski, S.
(2008). Trauma exposure, adverse experiences, and diverse symptom profiles in a national
sample of traumatized children. Paper presented at the 24th Annual Meeting of the
International Society for Traumatic Stress Studies, Chicago, IL, November 15, 2008.
Solomon, J. & George, C. (Eds) (1999). Attachment Disorganization (pp. 291-317). New York:
Guilford Press.
Stewart, A., Livingston, M., & Dennison, S. (2008). Transitions and turning points: Examining the links
between child maltreatment and juvenile offending. Child Abuse & Neglect, 32(1), 51-66.
References & Suggested Readings
Stolbach, B.C. (2005). Psychotherapy of a dissociative 8-year-old boy burned at age 3.
Psychiatric Annals, 35(8), 685-694.
Stolbach, B.C. (2007). Developmental trauma disorder: a new diagnosis for children
affected by complex trauma. International Society for the Study of Trauma and
Dissociation News, 25(6): 4-6.
Stolbach, B., Dominguez, R.Z., Rompala, V., & Gazibara, T. (2008). Relationships among
complex trauma histories, dissociation, and symptom profiles in traumatized urban
children. Paper presented at the 25th Annual Meeting of the International Society
for the Study of Trauma and Dissociation, Chicago, IL, November 16, 2008.
Stolbach, B., Dominguez, R.Z., Rompala, V., Gazibara, T., & Finke, R. (2009). Complex
trauma histories, PTSD, and Developmental Trauma Disorder symptoms in
traumatized urban children. Paper presented at the 25th Annual Meeting of the
International Society for Traumatic Stress Studies, Atlanta, GA, November 7, 2009.
van der Kolk, B.A. (2005). Developmental trauma disorder: toward a rational
diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401408.
van der Kolk, B.A., McFarlane, A.C., & Weisaeth, L. (Eds.). Traumatic stress: The effects of
overwhelming experience on mind, body, and society. New York: Guilford Press.
Special Section on Complex Posttraumatic Stress Disorder, Journal of Traumatic Stress,
October, 2005.
bstolbach@larabida.org
www.nctsn.org