Essay: Complex Trauma in Adolescents: The Developmental Impact of Childhood Abuse and Neglect



Introduction

This study briefly reviews complex trauma and discusses how it manifests in adolescents with a history of childhood abuse and neglect. A history of childhood abuse and neglect often leads to long-term emotional, behavioral and physical dysregulation that do not always fit the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) diagnostic criteria for Posttraumatic Stress Disorder (PTSD). This has led to the proposal of a separate but related diagnosis termed Developmental Trauma Disorder (Cook, Blaustein, Spinazzola & van der Kolk, 2003; van der Kolk, 2005; Najjar, Weller, Weisbrot & Weller, 2008). This diagnosis is based on an assessment of the literature on complex trauma and its long-term mental and physical health consequences. In this study, we will review the following: 1) the scope of complex trauma in terms of its general impact on individuals and society; 2) a description of the phenomenology of complex trauma; 3) the developmental impact of complex trauma on adolescents; and 4) the diagnosis, treatment, and prevention of complex trauma in adolescents.

Complex trauma refers to both the exposures and the developmental impact of long-term exposure to traumatic events during childhood and adolescence. Traumatic exposures are commonly of an interpersonal nature, including childhood physical, sexual, and emotional abuse and neglect. Traumatic exposures can also include repeated surgical procedures, chemotherapy or other adverse events during childhood. Complex trauma has a significant developmental impact across the life-span.

In a large epidemiological survey, the Adverse Childhood Experiences (ACE) study, of more than 17,000 adults from the general population, adverse childhood experiences were much more prevalent than expected with 22% reporting childhood sexual abuse, 10.8 % reporting childhood physical abuse and, 11% reporting childhood emotional abuse (Fellitti, et al., 1998). In the ACE study, the presence of one or more of these childhood adverse events was associated with smoking, obesity, depression, a history of suicide attempt, current substance abuse and addiction, risky sexual behavior, sexually transmitted diseases, heart disease, cancer, emphysema, and diabetes. The individual cost of child complex trauma cannot be assessed, but the cost per year has been estimated at 94 billion dollars per year (Cook, Blaustein, Spinazzola & van der Kolk, 2003).

Complex Trauma during childhood and adolescence has been causally implicated in a host of psychological disorders across the life-span. These disorders include problems with emotional self-regulation, attachment disorders, mood disorders, addictions, eating disorders, somatoforms disorders, sexual disorders, and dissociative disorders (Cook, Blaustein, Spinazzola & van der Kolk, 2003). The presence of exposure to complex trauma during childhood and adolescence also increases vulnerability to further traumatic experiences, increasing the chances of having PTSD after exposure to trauma (van der Kolk, 2005).

Since complex trauma results in a multifaceted array of emotional, behavioral, and physical dysregulation, it is often misdiagnosed as one or more of the co-morbid disorders that may be a part of the Developmental Trauma Disorder pattern. This can lead to inappropriate treatment approaches, distrust of mental health professionals and added human misery (Cook, Blaustein, Spinazzola & van der Kolk, 2003; Gabowitz, Zucker & Cook, 2008). Diagnosis and treatment of complex trauma or Developmental Trauma Disorder must address all of the developmental deficits that arise from complex trauma exposure. In order to be effective, treatment interventions must be phased according to the natural ordering of the normal developmental process (van der Kolk, 2005; Cook, Blaustein, Spinazzola & van der Kolk, 2003). The following sections will discuss these issues in more detail.

Defining Complex Trauma

The term complex trauma refers to both exposure to traumatic experiences or events and to the human response to these exposures in terms of developmental, psychological and physical disorder. Exposures leading to complex trauma usually relate to caregivers and the developmental environment (Cook, Blaustein, Spinazzola & van der Kolk, 2003). Examples of these exposures include the following: child physical, emotional and sexual abuse; physical and emotional neglect; seeing domestic violence; and violence in the community. Complex trauma has similarities to PTSD. However, it is much more pervasive and is not restricted to a narrow range of traumatic exposures. Complex trauma shares general symptom patterns with PTSD but does not require exposure to one specific traumatic event that meets the DSM-IV-TR definition (criterion A). Criterion A is very specific in requiring the “experience or witness of an actual or threatened death or serious injury or threat to the physical integrity of self or others”. Children can develop long-tem symptoms meeting other PTSD criteria without exposure to an event that meets criterion A. For example, child sexual or emotional abuse alone, in the absence of the threat of violence, can lead to the complex trauma symptoms of re-experiencing the trauma (PTSD criterion B), avoidance of things that the child associates with the trauma (PTSD criterion C) and increased sympathetic nervous system (SNS) arousal (PTSD criterion D) (Cook, Blaustein, Spinazzola & van der Kolk, 2003; Najjar, Weller, Weisbrot & Weller, 2008). For these reasons, a more general diagnosis for children and adolescents called Developmental Trauma Disorder has been proposed (van der Kolk, 2005).

Complex Trauma in Adolescents: Developmental Impact

Complex trauma has consequences that extend throughout the life-span that impact adolescent development. Complex trauma exposures have been implicated in leading to developmental impairment across seven domains. These are as follows: 1) disruption of normal childhood and adult attachment; 2) impairment of biological regulation; 3) affect or emotional regulation; 4) dissociation or disruption of the normal experiences of consciousness; 5) behavioral problems; 6) cognitive problems; and 7) impairment of self-concept (Cook, Blaustein, Spinazzola & van der Kolk, 2003).

Attachment begins during infancy and extends throughout the life-span. Normal or secure attachment is a result of adequate and consistent attention and emotional attunement from caretakers during infancy and childhood. Normal attachment “provides the scaffolding for the growth of many developmental competencies, including the capacity for self-regulation, the safety with which to explore the environment, early knowledge of agency (i.e., the capacity to exert an influence on the world), and early capacities for receptive and expressive communication” (Cook, Blaustein, Spinazzola & van der Kolk, 2003). Children who have experienced child abuse and neglect tend also to have insecure or abnormal attachment patterns. There are three basic types of insecure attachment, including the following: a) avoidant attachment arising from caretakers who predictably reject or dismiss the child; b) ambivalent attachment from experience with caretakers who have labile responses to the child ranging from anxious, intrusive displays of concern to detachment; and c) disorganized attachment, arising from experience of caretakers as violent and dangerous. Avoidant attachment typically manifests as disinterest in social connection. Ambivalent attachment is characterized by a hypervigilance for signs of rejection accompanied by a longing for social engagement. Disorganized attachment is characterized by “primitive survival-based relational working models that are rigid, extreme, and thematically focused” (Lyons-Ruth & Jacobovitz, as cited in Cook, Blaustein, Spinazzola & van der Kolk, 2003).

These three patterns can lead to various difficulties with social engagement that interfere with adolescent development of social competency and development of peer relationships. This can lead to problems developing a social network for support in coping with the many challenges of adolescence, including balancing the challenges of developing cognitively and physically, while keeping up with school work, family relations, and peer-pressure (Berger, 2005). The disorganized attachment pattern has particularly disturbing features in that primitive survival-based relational working models can include dependence on coercive control that may lead to bullying and violence. The passive manifestation of these primitive models involves helplessness and low self-esteem, potentially leading to chronic depressive symptoms. These attachment patterns can result in development problems with emotional self-regulation, inability to use language to deal with relationship issues, and inability to cope with stress, antisocial personality disorder, borderline personality disorder, and chronic PTSD symptoms (Cook, Blaustein, Spinazzola & van der Kolk, 2003).

Biological dysregulation from exposure to child abuse and neglect can include problems with development of neurological structures essential for executive function. Executive function refers to the neurological development of working memory and decision making processes that normally occur during adolescence. These developments are necessary for “autonomous functioning and engagement in relationships” (Cook, Blaustein, Spinazzola & van der Kolk, 2003). Other biological consequences of childhood trauma include somatization, asthma, pelvic pain, eating disorders, and autoimmune disorders. These can all interfere in adolescent development by limiting full and healthy participation in the project of developing social connections, academic success, participation in sports, and healthy physical development.

The third domain of impairment from childhood and adolescent complex trauma is affect regulation. This includes impaired self-regulation of emotions and problems identifying and expressing internal states, experiences and desires (Cook, Blaustein, Spinazzola & van der Kolk, 2003). Since normal adolescence is a time for developing identity and self-understanding, crystallization of vocational aspirations, as well as the ability for social engagement (Berger, 2005; ), these impairments make normal adolescent development relatively untenable for children with complex trauma. Consequences of the impaired self-regulation may include social isolation and alienation. This pattern, combined with tendencies to use coercive attachment strategies and primitive, explosive emotional self-expression, may explain the last two decades’ history of significant violence in schools. Impairment of emotional self-regulation also leads to an inability to self-soothe and therefore mange normal environmental stress. This can lead to avoidance of social engagement as a means of self-regulation and a vicious cycle of social developmental failure, leading eventually to chronic depressive symptoms or major depressive disorder (Cook, Blaustein, Spinazzola & van der Kolk, 2003).

The fourth domain of developmental impairment from complex trauma relates to disruption the normal ability to integrate the flow of everyday events into a continuous, time sequenced experience that can be remembered and used for future reference. This disruption leads to dissociation. Dissociation means that contents of a person’s external and internal sensory, cognitive and emotional experience are not naturally linked, because traumatic events prevented normal processing or led to regressive experiences, where more primitive levels of processing take over, which cannot link experiences as we would expect (Cook, Blaustein, Spinazzola & van der Kolk, 2003). This can lead to thought and emotions related to an experience that are not connected, emotions that seem to come without any narrative memory content of an experience, and somatic sensations that are disconnected from any memories. Dissociation is also thought to be the source of unconscious repetitions of traumatic behavior, like acting out the traumatic experiences in play or getting into situations where the same trauma can happen again without knowing why or being aware of the risks.

The fifth domain of impairment from complex trauma during childhood is behavioral control. This involves a large array of problems including impulsivity, aggression, and oppositional behavior. It also includes behaviors directed toward providing the self-soothing that is missing from lack of development of affect-regulation. These include behaviors like cutting, eating disorders, compulsive sexual behavior, and substance abuse (Cook, Blaustein, Spinazzola & van der Kolk, 2003). These developmental disorders all tend to manifest, or are exacerbated, during adolescence, and can thus be thought of as adolescent developmental manifestations of disorders arising from childhood or adolescent exposure to trauma.

The sixth domain of impairment from complex trauma exposure is that of cognition. Cognitive function develops significantly during adolescence with more abstract thinking and formal operational thought and hypothetical deductive reasoning developing (Berger, 2005). These abilities to use logical thought to organize experience are essential for moving through adolescence into a more independent adult role. The abilities to successfully understand and derive logical implications from general principles (deductive reasoning), as well as make inferences from experiential data (inductive reasoning), are essential for academic success, and for successful functioning as an independent adult. Exposure to complex trauma in childhood and adolescence interferes with cognitive development by interfering with the development of the ability to perform normal developmental abstract cognitive tasks and to pay attention (Cook, Blaustein, Spinazzola & van der Kolk, 2003).

The last domain of impairment from complex trauma is that of self-concept. Development of self-concept begins with secure attachment where, as Bowlby (as cited in Cook, Blaustein, Spinazzola & van der Kolk, 2003) noted, “Over time, a child consolidates and internalizes a secure, stable, and integrated sense of identity.” All of the five developmental impairments noted above, from attachment to cognition, serve to work against the development of a secure sense of self or identity. They can lead to repeated failures in social engagement and ongoing psychosocial development and to a sense of self that is “ineffective, helpless, deficient and unlovable” (Cook, Blaustein, Spinazzola & van der Kolk, 2003).

These seven domains of impairment characterize the damage from exposure to complex trauma. The basic theme is that survival in the traumatic environment has required postponement of developmental progress. These developmental problems loom like a mountain of troubles that can seem insurmountable from the point of view of treatment and prevention. However, there are effective treatments for complex trauma. Next, we will examine diagnosis and treatment of complex trauma in adolescents.

Diagnosis, Treatment, and Prevention of Complex Trauma in Adolescents

As mentioned above, care must be taken to avoid diagnosing the results of complex trauma as simply one or more co-morbid disorders commonly encountered in complex trauma. A history of exposure to complex trauma can lead to symptoms in adolescents that may appear to be depressive or anxiety disorders, eating disorders, Attention Deficit Disorder (ADD), or Oppositional Defiant Disorder (ODD). Particular care must be taken when making diagnoses in the presence of a history of complex trauma (Gabowitz, Zucker & Cook, 2008). The diagnostic category of Developmental Trauma Disorder provides a framework through which complex trauma can be identified and diagnosed (Cook, Blaustein, Spinazzola & van der Kolk, 2003; van der Kolk, 2005). According to van der Kolk (2005), Developmental Trauma Disorder is assessed by investigating the following: 1) “chronic exposure to one or more forms of developmentally adverse interpersonal trauma (e.g., abandonment, betrayal, physical assaults, sexual assaults, threats to bodily integrity, coercive practices, emotional abuse, witnessing violence or death”; 2) “triggered patterns of repeated dysregulation in response to trauma cues”; 3) “persistently altered attributions and expectancies”; and 4) “functional impairment”. The second characteristic above refers to the seven domains of impairment but also centers on the concept of “triggered dysregulation”, where dysregulation is evoked by some sort of environmental reminder of the original traumatic situation. For example, experiencing extreme anxiety when made the center of attention, along with a pattern of social disengagement through attempts to remain invisible in social situations, could point to parental lashing out during childhood or adolescent attempts to win parental approval by showing off. The third characteristic above concerning altered attributions and expectancies manifests as pervasive lack of trust of care takers, institutions and others in general, a sense of being doomed to future victimization and a sense of self as bad, flawed and unlovable. Functional impairment can be in any domain, including school, social engagement, work, or family. Where possible, referral of clients with a history of trauma for neuropsychological assessment can be very helpful in avoiding misdiagnosis (Gabowitz, Zucker & Cook, 2008). Neuropsychological assessment provides detailed information on cognitive and developmental domains in which an adolescent has impairments, as well as strengths, and can help in creating specific treatment plans that target specific developmental areas in which the client needs help. Where possible, assessment should include interviewing the child and the parents or caretakers. Perrin, Smith & Yule (2000) present details of how best to interview adolescent clients about traumatic events. These strategies include allowing the adolescent client to describe as much of the trauma that they can on their own and to avoid prompting the client while they are telling the story. Once the story is told then the counselor can go back and ask questions. This is consistent with effective practices for adolescent counseling described by Edgette (2002). Symptom severity at the initial assessment visit and improvement during treatment can be tracked with self-report instruments like the Impact of Events Scale, Revised (IES-R), which is a 22-item scale that has three subscales measuring PTSD symptoms of avoidance, intrusion, and hyperarousal. The IES-R has been shown to work well for assessing change in trauma symptoms (Weiss, 2004).

Treatment for Developmental Trauma Disorder in children and adolescents follows a phased approach to avoid overwhelming the client with too much information and learning challenges at one time (Cook, Blaustein, Spinazzola & van der Kolk, 2003; van der Kolk, 2005). The initial phase requires establishing safety for the client before moving on to treatment of developmental issues. Establishing safety involves working with community services and institutions, like child protective services and the courts, to establish an environment that is free of ongoing exposure to trauma. Safety is an aspect of the counseling relationship, as well as the home and school environment. During the safety phase, it will also be important for the counselor to establish the beginnings of a working counseling relationship with the adolescent client. This can be accomplished with the right mixture of “authenticity and candor” and by keeping the client interested in moving forward with the process using methods developed specifically for adolescent clients (Edgette, 2002). Establishing a therapeutic relationship with individuals exposed to complex trauma may also serve to begin the process of supporting the capacity for secure attachments.

After safety is established, the next phase involves helping the client develop emotional regulation skills. These skills can include relaxation exercises and other cognitive methods for regulating anxiety and emotional arousal (Najjar, Weller, Weisbrot & Weller, 2008; Perrin, Smith & Yule, 2000). Other aspects of affect regulation training include the ability to correctly identify and name emotional content and identifying and countering intrusive thoughts related re-experiencing of traumatic events (Brier & Scott, 2006). As affect regulation training progresses, clients are helped to establish social engagement in order to practice and master interpersonal skills.

The next phase in treating complex trauma involves processing past traumatic events and constructing meaningful narratives that allow these events to become personal history, rather than current intrusive unprocessed or dissociated fragments of traumatic experience. This can take several forms including exposure therapy, which involves experiencing the trauma in a safe environment by telling the story over and over again, using visualization of the event, and drawing pictures of the event. During these sessions, the counselor must be careful to allow some level of arousal in order to process the trauma but not so much that the client dissociates affect from memory. In order to accomplish this, the client is helped to mobilize resources for affect regulation learned in earlier phases of the treatment (Brier & Scott, 2006). Other methods such as eye movement desensitization and reprocessing (EMDR) have also shown promise in helping adolescents process traumatic experiences, in that they can be quicker and involve less experience of negative affect (Farkas, Cyr, Lebeau & Lemay, 2010).

The last phase of treatment for childhood and adolescent complex trauma is that of “enhancing resiliency and integration into social network” (Cook, Blaustein, Spinazzola & van der Kolk, 2003; van der Kolk, 2005). This involves the client’s learning skills, activities and strategies to prevent future exposure to trauma and to establish social network for support and social enjoyment. The ability to experience pleasurable activities along with friends provides a healing element and an arena for practicing new interpersonal skills. Establishing social networks can also entail working with trauma related material that may interfere with relational functions (Brier & Scott, 2006). This may involve working through automatic responses having strong emotional content that may interfere with creating new relationships. The approach to working with these is similar to working through traumatic experiences. The relational response must be activated during counseling sessions and worked through by helping the client manage the level of affect, using self-regulation skills learned at an earlier phase, and examine the fact that the trauma is not actually happening again, rather that they are in a condition of relational safety. Brier and Scott (1990) and others (Cook, Blaustein, Spinazzola & van der Kolk, 2003; van der Kolk, 2005; Najjar, Weller, Weisbrot & Weller, 2008; Perrin, Smith & Yule, 2000) describe in detail many aspects of trauma therapy too lengthy to detail here. Therapy for complex trauma is a long-term effort requiring specialized skills, the ability to establish strong rapport with the adolescent client, and mobilize resources in the home and community with respect to safety issues.

Summary

Exposure to childhood and adolescent abuse and neglect leading to developmental impairment and long-term mental and physical health issues is more common that once thought. This phenomenon, defined as complex trauma, can lead to significant and pervasive developmental impairment across the seven dimensions that make up normal human development. Complex trauma can be operationalized and identified as a newly proposed diagnostic category under the name Developmental Trauma Disorder. This disorder more accurately identifies the symptom pattern associated with complex trauma than do the diagnostic criteria for PTSD. During assessment of clients exposed to childhood and adolescent trauma, care must be taken to avoid misdiagnosing the client with one or more of the co-morbid disorders with symptoms that overlap with Developmental Trauma Disorder but missing the diagnosis of the overall trauma related disorder. This can lead to inappropriate and ineffective treatment efforts. Finally, while the developmental impairments associated with complex trauma may seem insurmountable, treatment based on a phased approach that establishes safety and then moves through emotional regulation training, processing of traumatic experiences and interpersonal trauma, and establishment of resiliency and social connection have been shown to be successful in treating adolescents with complex trauma.