| Complex Post-traumatic Stress Disorder |
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C-PTSD is characterized by chronic difficulties in many areas of Emotional and Interpersonal functioning. Symptoms include:
ASSESSMENT OF COMPLEX TRAUMA IN CHILDREN Children exposed to complex trauma (chronic maltreatment, Abuse , Neglect , witnessing Domestic Violence , etc.) often evidence impairment in several domains. Cook et al. (2000, 2003) describe symptoms and behavioral characteristics in seven domains: # Attachment - Uncertainty about the reliability and predictability of the world, distrust and suspiciousness, Social Isolation , interpersonal difficulties, difficulty attuning to other people's emotional states and points of view # Biology - Hypersensitivity to physical contact, Analgesia , Somatization , increased medical problems # Affect or emotional regulation - easily-aroused high-intensity emotions, difficulty deescalating, difficulty describing feelings and internal experience, chronic and pervasive depressed mood or sense of emptiness or deadness, chronic suicidal preoccupation, overinhibition or excessive expression of anger # Dissociation - distinct alterations in states of consciousness, Amnesia , Depersonalization and Derealization # Behavioral control - poor modulation of impulses, Self-destructive Behavior , aggressive behavior, sleep disturbances, Eating Disorders , Substance Abuse , oppositional behavior, excessive compliance # Cognition - difficulties in attention regulation and executive functioning, problems focusing on and completing tasks, difficulty planning and anticipating, Learning Difficulties , problems with language development # Self-concept - lack of a continuous and predictable sense of self, low self-esteem, feelings of shame and guilt, generalized sense of being ineffective in dealing with one's environment, belief that one has been permanently damaged by the trauma After exposure to complex trauma, children and their families should receive a comprehensive trauma assessment that examines functioning in all domains of impairment. This comprehensive assessment should include behavioral and play observations, clinical interviews with children and primary caretakers, collateral information from day care or school personnel, child protection workers, and pediatricians (if applicable), and the results of structured assessment instruments. Information about the traumatic events the child and family experienced, trauma-related symptoms, pre-exposure and post-exposure development, and emotional and social functioning should also be gathered. Trauma History and Caretakers The impact of trauma on children varies depending on many factors, including the type and circumstances of the trauma, participants, sequence of events, the age at which the child was exposed, the child’s history of previous trauma exposure and loss, the availability of attachment figures, and aftermath of the traumatic event. For this reason, it is imperative that clinicians gather very detailed information about the child’s recent and past trauma exposure (Bosquet, 2004). There is also very strong evidence that caregiver trauma history and functioning significantly impact young children’s reactions and recovery from trauma (Appleyard & Osofsky, 2003). For this reason, clinicians should obtain a thorough assessment of caregiver’s trauma history and trauma-related symptomatology. Trauma-Related Symptoms Children and caregivers exposed to trauma often suffer from some of the characteristic symptoms of post-traumatic stress disorder. Children may reexperience the trauma through nightmares and post-traumatic play, they may show avoidance and numbing in the form of constricted play, social isolation, and developmental regression, and they may suffer from hyperarousal manifested as hypervigilence and difficulty sitting still. A comprehensive assessment should gather information about these symptoms through play and behavioral observations, clinical interviews, and structured assessment instruments. Some examples of structured assessment instruments are: UCLA PTSD Reaction Index for DSM-IV (Pynoos et al., 1998) is a self-report measure that screens for exposure to a wide range of traumatic events and symptoms of PTSD. Versions for children (ages 7-12), adolescents (ages 13-18) and parents are available, and the measure has been translated into Spanish. Research is under way to examine the psychometric properties of the measure. Traumatic Events Screening Instrument – Parent Report - Revised (TESI-PR-R - Ghosh Ippen et al., 2002) is a 24-item measure used with parents of children aged 0 to 6 years. It screens for a wide range of exposures including accidents, abuse, witnessing community and domestic violence, and terrorism. It also screens for the presence of traumatic responses in young children. The TESI-PR-R is a revised form of the Traumatic Events Screening Instrument (TESI), a reliable and valid measure designed to assess trauma history in older children (Ribbe, 1996). The TESI-PR-R was revised to be developmentally sensitive to the types of trauma that young children may experience. Research is under way to examine the psychometric properties of the revised measure. The TESI-PR-R is available in Spanish. The Life Stressor Checklist-Revised (LSC-R; Wolfe & Levin, 1991) is a 31-item self-report measure for adults that assesses lifetime exposure to trauma and the incidence and impact of stressful life events on current functioning. Data support the validity of the LSC-R (Kimerling et al., 1999). The LSC-R is available in Spanish. The Davidson Trauma Scale (DTS; Davidson, 1996) is a self-report measure designed to assess posttraumatic stress disorder. The scale consists of 17 symptoms rated for frequency and severity. Research indicates that the measure is internally consistent, reliable, and valid and that it distinguishes between groups with and without PTSD diagnoses (Davidson, Tharwani, & Connor, 2002). The DTS is available in Spanish. Development & Social/Emotional Functioning Children exposed to trauma often suffer from developmental disruption, behavior problems, and attachment problems and show impaired school, peer, and family functioning. A comprehensive assessment will gather information about functioning in these areas through play and behavioral observations, clinical interviews, and structured assessment instruments. TREATMENT Treatment for C-PTSD requires a multi-modal approach, as noted by The National Child Traumatic Stress Network (2003). van der Kolk et al. (2005) suggest that treatment for C-PTSD should differ from treatment for PTSD in several important ways. While treatment for PTSD focuses on the impact of specific past events and the processing of specific trauma memories, treatment for C-PTSD should also include a focus on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six core components of complex trauma treatment have been identified by Cook, Spinazzola, Ford and Lanktree (2005): # Safety # Self-regulation # Self-reflective information processing # Traumatic experiences integration # Relational engagement # Positive affect enhancement Treatment for those experiencing C-PTSD should address each dimension. Children who have experienced complex trauma caused by chronic maltreatment can be treated effectively with Cognitive Behavioral Therapy interventions, education, EMDR and other approaches. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), developed by Cohen, Deblinger, and Mannarino (2004), is a highly effective, evidence-based treatment for children with complex trauma. TF-CBT targets posttraumatic, depressive, and anxiety symptoms and addresses cognitive distortions associated with the trauma. TF-CBT works with both children and their caretakers, and includes the following core components:
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