Complex Trauma in Children and Adolescents

Exposure to Trauma

It is now well established that children and adolescents are exposed to potentially traumatic events (PTEs) at significant rates, that most children have some distress following exposure to a PTE, that a nontrivial percentage of exposed children develop significant emotional and behavioral problems related to PTEs, and that exposure increases risk for a variety of subsequent problems.

Prevalence rates of exposure vary between studies due to a number of factors, including the type of PTE exposure assessed, the specificity of the screening questions, whether children are asked the questions directly, whether the design is retrospective, and the nature of the sample. For example, studies using multiple, behaviorally descriptive questions typically yield higher rates for sexual and physical abuse than those using a single, general gate question. Studies employing samples of children residing in inner-city areas report much higher rates of exposure to serious community violence than do other groups. Until quite recently, studies tended to focus on one or a few types of potentially traumatic events, making it difficult to ascertain the cumulative burden of exposure. More recent studies that have screened for multiple traumas find that it is common for children who are exposed to one type of trauma to be exposed to others, with a substantial percentage having been exposed to four or more traumas.

In terms of impact, studies also vary for similar reasons, including what outcomes are assessed; how outcomes are measured; whether the design is prospective or cross-sectional; and whether self-report, parent report, official report, or a combination of sources for outcomes is used. The degree and nature of impact tends to differ based on the source of the information. In general children report higher levels of posttraumatic stress, anxiety, and depression than caregivers. Overall, the results converge in finding that a significant percentage of exposed youth develop a posttraumatic stress response such as posttraumatic stress disorder (PTSD) and have higher rates of emotional and behavioral problems than nonexposed children. Predictors for negative outcomes include severity (e.g., sexual penetration, injury), perception of life threat, and duration. Prior exposure to trauma increases the likelihood of negative impact for a particular event, and a history of more traumas is associated with worse outcomes.

Definitions

There is currently no consensus definition of the term complex trauma. In part this is due to the use of the term trauma to describe both PTEs and their impact. In terms of defining the events, an unresolved question is what events are included. PTE was originally defined, as described in the Diagnostic and Statistical Manual [Page 146]of Mental Disorders, Third Edition (DSM-III), as an event outside ordinary human experience that was associated with a threat to life and limb. Now that it is known that even conservatively defined traumas are relatively common, rareness is no longer a relevant criterion. The objective threat criterion was abandoned as it became widely accepted that such often nonviolent experiences as child sexual abuse were subjectively experienced as threatening. Direct exposure is no longer considered necessary, as individuals who know someone who died violently or offspring of trauma-exposed individuals can develop PTSD.

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