CM E Developmental Trauma Disorder A new, rational diagnosis for children with complex trauma histories.

Bessel A. van der Kolk, MD

hildhood trauma, including obtaining information about childhood EDUCATIONAL OBJECTIVES abuse and neglect, is probably trauma, abuse, neglect, and other expo- 1. Identify emotional triggers Cthe single most important pub- sures to violence. Research has shown and patterns of re-enactment lic health challenge in the United States, that traumatic childhood experiences in traumatized children. a challenge that has the potential to be not only are extremely common but also largely resolved by appropriate preven- have a profound impact on many differ- 2. Discuss the spectrum of de- tion and intervention. Each year, more ent areas of functioning. For example, velopmental derailments sec- than 3 million children are reported to children exposed to alcoholic parents ondary to complex trauma authorities for abuse or neglect in the or domestic violence rarely have secure exposure. US; about 1 million of those cases are childhoods; their symptomatology tends 3. Describe patterns of accom- substantiated.1 Many thousands more to be pervasive and multifaceted and modation in traumatized undergo traumatic medical and surgical is likely to include depression, various children. procedures and are victims of accidents medical illnesses, and a variety of im- and of community violence (see Spin- pulsive and self-destructive behaviors. maintenance organization (HMO) mem- azzola et al., page xxx). However, most Approaching each of these problems bers responded to a questionnaire about trauma begins at home; the vast majority piecemeal, rather than as expressions of adverse childhood experiences, includ- of people (about 80%) responsible for a vast system of internal disorganization, ing childhood abuse, neglect, and fam- child maltreatment are children’s own runs the risk of losing sight of the forest ily dysfunction. Eleven percent reported parents. in favor of one tree. having been emotionally abused as a Inquiry into developmental mile- child, 30.1% reported physical abuse, stones and family medical history is rou- COMPLEX TRAUMA and 19.9% sexual abuse. In addition, tine in medical and psychiatric examina- The traumatic stress fi eld has adopted 23.5% reported being exposed to fam- tions. In contrast, social taboos prevent the term “complex trauma” to describe ily alcohol abuse, 18.8% were exposed the experience of multiple, chronic and to mental illness, 12.5% witnessed their Dr. van der Kolk is professor of psychiatry, prolonged, developmentally adverse mothers being battered, and 4.9% re- Boston University Medical School, Boston, MA; traumatic events, most often of an inter- ported family drug abuse. clinical director, The Trauma Center at Justice personal nature (eg, sexual or physical The ACE study showed that adverse Resource Institute, Brookline, MA; and co-di- abuse, war, community violence) and childhood experiences are vastly more rector, the National Child Traumatic Stress early-life onset. These exposures often common than recognized or acknowl- Network Community Program, Boston. occur within the child’s caregiving sys- edged and that they have a powerful re- Address reprint requests to: Bessel A. van tem and include physical, emotional, lationship to adult health a half-century der Kolk, MD, [ADDRESS]. and educational neglect and child mal- later. The study confi rmed earlier inves- Dr. van der Kolk has no industry relation- treatment beginning in early childhood tigations that found a highly signifi cant ships to disclose. (Cook et al., page xxx, and Spinazzola relationship between adverse childhood et al., page xxx). experiences and depression, suicide at- In the Adverse Childhood Experi- tempts, alcoholism, drug abuse, sexual ences (ACE) study by Kaiser Perman- promiscuity, domestic violence, ciga- ente and the Centers for Disease Control rette smoking, obesity, physical inactiv- and Prevention,2 17,337 adult health ity, and sexually transmitted diseases.

2 PSYCHIATRIC ANNALS 00:0 | MONTH 200X In addition, the more adverse childhood ior by anticipating their caregivers’ re- child’s response is likely to mimic that experiences reported, the more likely sponses to them.8 This interaction allows of the parent — the more disorganized a person was to develop heart disease, them to construct what Bowlby called the parent, the more disorganized the cancer, stroke, diabetes, skeletal frac- “internal working models.”9 A child’s child.13 tures, and liver disease. internal working models are defi ned by However, if the distress is over- Isolated traumatic incidents tend to the internalization of the affective and whelming, or when the caregivers them- produce discrete conditioned behavioral cognitive characteristics of their primary selves are the source of the distress, and biological responses to reminders relationships. Because early experiences children are unable to modulate their of the trauma, such as those captured in occur in the context of a developing arousal. This causes a breakdown in the posttraumatic stress disorder (PTSD) brain, neural development and social their capacity to process, integrate, and diagnosis. In contrast, chronic maltreat- interaction are inextricably intertwined. categorize what is happening. At the ment or inevitable repeated traumatiza- As Don Tucker has said: “For the human core of traumatic stress is a breakdown tion, such as occurs in children who are brain, the most important information in the capacity to regulate internal states. exposed to repeated medical or surgical for successful development is conveyed If the distress does not ease, the relevant procedures, have a pervasive effects on by the social rather than the physical en- sensations, affects, and cognitions can- the development of mind and brain. vironment. The baby brain must begin not be associated — they are dissociated Chronic trauma interferes with neuro- participating effectively in the process into sensory fragments14 — and, as a re- biological development (Ford, see page of social information transmission that sult, these children cannot comprehend xxx) and the capacity to integrate senso- offers entry into the culture.”10 what is happening or devise and execute ry, emotional and cognitive information Early patterns of attachment affect appropriate plans of action. into a cohesive whole. Developmental the quality of information processing When caregivers are emotionally ab- trauma sets the stage for unfocused re- throughout life.11 Secure infants learn to sent, inconsistent, frustrating, violent, sponses to subsequent stress,3 leading to trust both what they feel and how they intrusive, or neglectful, children are dramatic increases in the use of medical, understand the world. This allows them likely to become intolerably distressed correctional, social and mental health to rely on both their emotions and their and unlikely to develop a sense that the services.4 People with childhood histo- thoughts to react to any given situation. external environment is able to provide ries of trauma, abuse and neglect make Their experience of feeling understood relief. Thus, children with insecure at- up almost the entire criminal justice provides them with the confi dence that tachment patterns have trouble relying population in the US.5 Physical abuse they are capable of making good things on others to help them and are unable and neglect are associated with very happen and that, if they do not know to regulate their emotional states by high rates of arrest for violent offenses. how to deal with diffi cult situations, they themselves. As a result, they experience In one prospective study of victims of can fi nd people who can help them fi nd excessive anxiety, anger, and longings abuse and neglect, almost half were ar- a solution. to be taken care of. These feelings may rested for nontraffi c-related offenses by Secure children learn a complex vo- become so extreme as to precipitate dis- age 32.6 Seventy-fi ve percent of perpe- cabulary to describe their emotions, sociative states or self-defeating aggres- trators of child sexual abuse report to such as love, hate, pleasure, disgust, and sion. “Spaced out” and hyperaroused have themselves been sexually abused anger. This allows them to communicate children learn to ignore either what they during childhood.7 how they feel and to formulate effi cient feel (their emotions), or what they per- These data suggest that most interper- response strategies. They spend more ceive (their cognitions). sonal trauma on children is perpetuated time describing physiological states such When children are unable to achieve by victims who grow up to become per- as hunger and thirst, as well as emotional a sense of control and stability, they be- petrators or repeat victims of violence. states, than do maltreated children.12 come helpless. If they are unable to grasp This tendency to repeat represents an Under most conditions, parents are what is going on and unable do anything integral aspect of the cycle of violence able to help their distressed children about it to change it, they go immedi- in our society. restore a sense of safety and control. ately from (fearful) stimulus to (fi ght/ The security of the attachment bond fl ight/freeze) response without being TRAUMA, CAREGIVERS, AND AFFECT mitigates against trauma-induced terror. able to learn from the experience. Sub- TOLERANCE When trauma occurs in the presence of sequently, when exposed to reminders of Children learn to regulate their behav- a supportive, if helpless, caregiver, the a trauma (eg, sensations, physiological

PSYCHIATRIC ANNALS 00:0 | MONTH 200X 3 states, images, sounds, situations), they do not have the option to report, move “out of touch” with their feelings, and tend to behave as if they were trauma- away or otherwise protect themselves; often have no language to describe in- tized all over again — as a catastrophe.15 they depend on their caregivers for their ternal states.20 Many problems of traumatized children very survival. When a child lacks a sense of predict- can be understood as efforts to minimize When trauma emanates from within ability, he or she may experience diffi - objective threat and to regulate their the family, children experience a crisis culty developing of object constancy emotional distress.16 Unless caregivers of loyalty and organize their behavior and inner representations of their own understand the nature of such re-enact- to survive within their families. Being inner world or their surroundings. As a ments, they are likely to label the child prevented from articulating what they result, they lack a good sense of cause as “oppositional,” “rebellious,” “unmoti- observe and experience, traumatized and effect and of their own contribu- vated,” or “antisocial.” children will organize their behavior tions to what happens to them. Without around keeping the secret, deal with internal maps to guide them, they act, THE DYNAMICS OF CHILDHOOD their helplessness with compliance or instead of plan, and show their wishes TRAUMA defi ance, and acclimate in any way they in their behaviors, rather than discussing Young children, still embedded in the can to entrapment in abusive or neglect- what they want.15 Unable to appreciate here-and-now and lacking the capacity ful situations.18 clearly who they or others are, they have to see themselves in the perspective of When professionals are unaware of problems enlisting other people as allies the larger context, have no choice but children’s need to adjust to traumatiz- on their behalf. Other people are sources to see themselves as the center of the ing environments and expect that chil- of terror or pleasure but are rarely fel- universe. In their eyes, everything that dren should behave in accordance with low human beings with their own sets of happens is related directly to their own adult standards of self-determination needs and desires. sensations. Development consists of and autonomous, rational choices, these These children also have diffi culty learning to master and “own” one’s ex- maladaptive behaviors tend to inspire re- appreciating novelty. Without a map to periences and to learn to experience the vulsion and rejection. Ignorance of this compare and contrast, anything new is present as part of one’s personal experi- fact is likely to lead to labeling and stig- potentially threatening. What is familiar ence over time.17 Piaget[REFERENCE] matizing children for behaviors that are tends to be experienced as safer, even if called this “decentration”: moving from meant to ensure survival. it is a predictable source of terror.15 being one’s refl exes, movements, and Being left to their own devices leaves Traumatized children rarely dis- sensations to having them. chronically traumatized children with cuss their fears and traumas spontane- Predictability and continuity are criti- defi cits in emotional self-regulation. ously. They also have little insight into cal for a child to develop a good sense This results in problems with self-defi - the relationship between what they do, of causality and learn to categorize ex- nition as refl ected by a lack of a con- what they feel, and what has happened perience. A child needs to develop cat- tinuous sense of self, poorly modulated to them. They tend to communicate the egories to be able to place any particular affect and impulse control, including nature of their traumatic past by repeat- experience in a larger context. Only then aggression against self and others, and ing it in the form of interpersonal en- will he or she be able to evaluate what uncertainty about the reliability and pre- actments, both in their play and in their is happening and entertain a range of dictability of others, expressed as dis- fantasy lives. options with which they can affect the trust, suspiciousness, and problems with outcome of events. Imagining being able intimacy, resulting in social isolation.19 CHILDHOOD TRAUMA AND to play an active role leads to problem- Chronically traumatized children tend to PSYCHIATRIC ILLNESS focused coping.15 suffer from distinct alterations in states Posttraumatic stress disorder (PTSD) If children are exposed to unmanage- of consciousness, including amnesia, is not the most common psychiatric able stress and if the caregiver does not hypermnesia, dissociation, depersonal- diagnosis in children with histories of take over the function of modulating ization and derealization, fl ashbacks and chronic trauma (Cook et al., see page the child’s arousal, as occurs when chil- nightmares of specifi c events, school xxx). For example, in one study of 364 dren are exposed to family dysfunction problems, diffi culties in attention regu- abused children,21 the most common di- or violence, the child will be unable to lation, disorientation in time and space, agnoses in order of frequency were sepa- organize and categorize experiences in a and sensorimotor developmental disor- ration anxiety disorder, oppositional de- coherent fashion. Unlike adults, children ders. The children often are literally are fi ant disorder, phobic disorders, PTSD,

4 PSYCHIATRIC ANNALS 00:0 | MONTH 200X TABLE 1 and ADHD.21 Numerous studies of traumatized children fi nd problems with Developmental Trauma Disorder unmodulated aggression and impulse control,22,23 attentional and dissociative A. Exposure problems,24 and diffi culty negotiating • Multiple or chronic exposure to one or more forms of developmentally adverse relationships with caregivers, peers, and, interpersonal trauma (eg, abandonment, betrayal, physical assaults, sexual as- later in life, intimate partners.25 saults, threats to bodily integrity, coercive practices, emotional abuse, witnessing A history of childhood physical and violence and death). sexual assault is associated with a host • Subjective experience (eg, rage, betrayal, fear, resignation, defeat, shame). of other psychiatric diagnoses in adoles- B. Triggered pattern of repeated dysregulation in response to trauma cues cence and adulthood. These may include Dysregulation (high or low) in presence of cues. Changes persist and do not return substance abuse, borderline and antiso- to baseline; not reduced in intensity by conscious awareness. cial personality, and eating, dissociative, • Affective affective, somatoform, cardiovascular, • Somatic (eg, physiological, motoric, medical) metabolic, immunological, and sexual • Behavioral (eg, re-enactment, cutting) disorders.26 • Cognitive (eg, thinking that it is happening again, confusion, dissociation, deper- The results of the DSM-IV Field Trial sonalization). suggested that trauma has its most per- • Relational (eg, clinging, oppositional, distrustful, compliant). vasive impact during the fi rst decade of • Self-attribution (eg, self-hate, blame). life and becomes more circumscribed C. Persistently Altered Attributions and Expectancies (ie, more like “pure” PTSD) with age.27 • Negative self-attribution. The diagnosis of PTSD is not devel- • Distrust of protective caretaker. opmentally sensitive and does not ad- • Loss of expectancy of protection by others. equately describe the effect of exposure • Loss of trust in social agencies to protect. to childhood trauma on the developing • Lack of recourse to social justice/retribution. child. Because infants and children who • Inevitability of future victimization. experience multiple forms of abuse often D. Functional Impairment experience developmental delays across • Educational. a broad spectrum, including cogni- • Familial. tive, language, motor, and socialization • Peer. skills,28 they tend to display very com- • Legal. plex disturbances, with a variety of dif- • Vocational. ferent, often fl uctuating, presentations. However, because there currently is no other diagnostic entity that describes of applying treatment approaches that not meet diagnostic criteria for PTSD29 the pervasive effects of trauma on child are not helpful. (Cook et al., see page xxx), and PTSD development, these children are given a cannot capture the multiplicity of expo- range of “comorbid” diagnoses, as if they A NEW DIAGNOSIS: sures over critical developmental peri- occurred independently from the PTSD DEVELOPMENTAL TRAUMA ods. symptoms. None of these do justice to DISORDER Moreover, the PTSD diagnosis does the spectrum of problems of traumatized The question of how to best organize not capture the developmental effects of children, and none provide guidelines on the very complex emotional, behavioral, childhood trauma: the complex disrup- what is needed for effective prevention and neurobiological sequelae of child- tions of affect regulation; the disturbed and intervention. By relegating the full hood trauma has vexed clinicians for attachment patterns; the rapid behav- spectrum of trauma-related problems to several decades. Because DSM-IV in- ioral regressions and shifts in emotional seemingly unrelated “comorbid” condi- cludes a diagnosis for adult onset trau- states; the loss of autonomous strivings; tions, fundamental trauma-related dis- ma, PTSD, this label often is applied to the aggressive behavior against self turbances may be lost to scientifi c inves- traumatized children as well. However, and others; the failure to achieve de- tigation, and clinicians may run the risk the majority of traumatized children do velopmental competencies; the loss of

PSYCHIATRIC ANNALS 00:0 | MONTH 200X 5 bodily regulation in the areas of sleep, children with complex histories. In an children. After having become aroused, food, and self-care; the altered schemas attempt to more clearly delineate what these children have a great deal of dif- of the world; the anticipatory behavior these children suffer from and to serve fi culty restoring homeostasis and return- and traumatic expectations; the multiple as a guide for rational therapeutics this ing to baseline. Insight and understand- somatic problems, from gastrointestinal taskforce has started to conceptualize a ing about the origins of their reactions distress to headaches; the apparent lack new diagnosis provisionally called de- seems to have little effect. of awareness of danger and resulting self velopmental trauma disorder (Sidebar, In addition to the conditioned physi- endangering behaviors; the self-hatred see page xxx). This proposed diagnosis ological and emotional responses to and self-blame; and the chronic feelings is organized around the issue of triggered reminders characteristic of PTSD, chil- of ineffectiveness. dysregulation in response to traumatic dren with complex trauma develop a Interestingly, many forms of interper- reminders, stimulus generalization, and view of the world that incorporates their sonal trauma, in particular psychological the anticipatory organization of behavior betrayal and hurt. They anticipate and maltreatment, neglect, separation from to prevent the recurrence of the trauma expect the trauma to recur and respond caregivers, traumatic loss, and inappro- effects. with hyperactivity, aggression, defeat, or priate sexual behavior, do not necessar- This provisional diagnosis is based freeze responses to minor stresses. Cog- ily meet DSM-IV “Criterion A” defi ni- on the concept that multiple exposures nition in these children also is affected tion for a traumatic event. This criteria to interpersonal trauma, such as aban- by reminders of the trauma. They tend requires, in part, an experience involving donment, betrayal, physical or sexual as- to become confused, dissociated, and “actual or threatened death or serious in- saults, or witnessing domestic violence, disoriented when faced with stressful jury, or a threat to the physical integrity have consistent and predictable conse- stimuli. They easily misinterpret events of self or others.”[REF] Children ex- quences that affect many areas of func- in the direction of a return of trauma posed to these common types of inter- tioning. These experiences engender in- and helplessness, which causes them to personal adversity thus typically would tense affects, such as rage, betrayal, fear, be constantly on guard, frightened, and not qualify for a PTSD diagnosis unless resignation, defeat, and shame, and ef- overreactive. they also were exposed to experiences or forts to ward off the recurrence of those In addition, expectations of a return events that qualify as “traumatic,” even emotions, including the avoidance of ex- of the trauma permeate their relation- if they have symptoms that would other- periences that precipitate them or engag- ships. This is expressed as negative self- wise warrant a PTSD diagnosis. ing in behaviors that convey a subjective attributions, loss of trust in caretakers, This fi nding has several implications sense of control in the face of potential and loss of the belief that some some- for the diagnosis and treatment of trau- threats. These children tend to reenact body will look after them and making matized children and adolescents. Non- their traumas behaviorally, either as per- feel safe. They tend to lose the expecta- Criterion A forms of childhood trauma petrators (eg, aggressive or sexual acting tion that they will be protected and act exposure — such as psychological or out against other children) or in frozen accordingly. As a result, they organize emotional abuse and traumatic loss avoidance reactions. Their physiological their relationships around the expecta- — have been demonstrated to be asso- dysregulation may lead to multiple so- tion or prevention of abandonment or ciated with PTSD symptoms and self- matic problems, such as headaches and victimization. This is expressed as ex- regulatory impairments in children30 and stomachaches, in response to fearful and cessive clinging, compliance, opposi- into adulthood.31 Thus, classifi cation of helpless emotions. tional defi ance, and distrustful behavior. traumatic events may need to be defi ned Persistent sensitivity to reminders They also may be preoccupied with ret- more broadly, and treatment may need interferes with the development of emo- ribution and revenge. to address directly the sequelae of these tional regulation and causes long-term All of these problems are expressed interpersonal adversities, given their emotional dysregulation and precipitous in dysfunction in multiple areas of func- prevalence and potentially severe nega- behavior changes. Their over- and un- tioning: educational, familial, peer-re- tive effects on children’s development derreactivity is manifested on multiple lated, legal, and work-related. and emotional health. levels: emotional, physical, behavioral, The Complex Trauma taskforce of cognitive, and relational. They have TREATMENT IMPLICATIONS the National Child Traumatic Stress fearful, enraged, or avoidant emotional In the treatment of traumatized chil- Network has been concerned about the reactions to minor stimuli that would dren and adolescents, there often is a need for a more precise diagnosis for have no signifi cant effect on secure painful dilemma of whether to keep them

6 PSYCHIATRIC ANNALS 00:0 | MONTH 200X Health and Human Services, Administration in the care of people or institutions who Because these children are prone to ex- on Children, Youth and Families. 2003. Avail- are sources of hurt and threat, or whether perience anything novel, including rules able at: http://www.acf.dhhs.gov/programs/ cb/publications/cm01/outcover.htm. Accessed to play into abandonment and separation and other protective interventions, as April 13, 2005. distress by taking the child away from punishments, they tend to regard teach- 2. Felitti VJ, Anda RF, Nordenberg D, et al. Re- familiar environments and people to ers and therapists who try to establish lationship of childhood abuse and household 15 dysfunction to many of the leading causes whom they are intensely attached but safety as perpetrators. of death in adults. The Adverse Childhood who are likely to cause further substan- Experiences (ACE) Study. Am J Prev Med. tial damage.15 Treatment must focus on Integration and Mastery 1998;14(4):245-258. three primary areas: establishing safety Mastery is most of all a physical ex- 3. Cicchetti D, Toth SL. Developmental psy- chopathology and disorders of affect. In: and compentence, dealing with traumat- perience: the feeling of being in charge, Cicchetti D, Cohen DJ, eds. Developmental ic re-enactments, and integration and calm, and able to engage in focused ef- Psychopathology, Vol. 2: Risk, Disorder, and master of the body and mind. forts to accomplished goals. Children Adaptation. New York, NY: John Wiley & Sons; 1995:369-420. who have been traumatized experience 4. Drossman DA, Leserman J, Nachman G, et Establishing Safety and the trauma-related hyperarousal and al. Sexual and physical abuse in women with Competence numbing on a deeply somatic level. functional or organic gastrointestinal disor- ders. Ann Intern Med. 1990;113(11):828- Complexly traumatized children need Their hyperarousal is apparent in their 833. to be helped to engage their attention in inability to relax and in their high degree 5. Teplin LA, Abram KM, McClelland GM, pursuits that do not remind them of trau- of irritability. Dulcan MK, Mericle AA. Psychiatric disor- ma-related triggers and that give them a Children with “frozen” reactions need ders in youth in juvenile detention. Arch Gen Psychiatry. 2002; 59(12):1133-1143. sense of pleasure and mastery. Safety, to be helped to re-awaken their curiosity 6. Widom CS, Maxfi eld MG. A prospective ex- predictability, and “fun” are essential and to explore their surroundings. They amination of risk for violence among abused for the establishment of the capacity to avoid engagement in activities because and neglected children. Ann N Y Acad Sci. 1996 Sep 20;794:224-237. observe what is going on, put it into a any task may unexpectedly turn into a 7. Romano E, De Luca RV. Exploring the rela- larger context, and initiate physiological traumatic trigger. Neutral, “fun” tasks tionship between childhood sexual abuse and and motoric self-regulation. and physical games can provide them adult sexual perpetration. J Fam Violence. 1997;12(1):85-98. Before addressing anything else, with knowledge of what it feels like to 8. Schore A. Affect Regulation and the Origin of these children need to be helped how be relaxed and to feel a sense of physical the Self: The Neurobiology of Emotional De- to react differently from their habitual mastery. velopment. Hillsdale, NJ: Lawrence Erlbaum fi ght/fl ight/freeze reactions.15 Only after Associates; 1994. 9. Bowlby, J. Attachment and Loss, Vol. 3. New children develop the capacity to focus on SUMMARY York, NY: Basic Books; 1980. pleasurable activities without becoming At the center of the therapeutic work 10. Tucker DM. Developing emotions and coriti- disorganized do they have a chance to with terrifi ed children is helping them cal networks. In: Gunnar MR, Nelson CA, eds. Minnesota Symposium on Child Psychol- develop the capacity to play with other realize that they are repeating their early ogy, Vol 24. Hillsdale, NJ: Lawrence Erlbaum children, engage in simple group activi- experiences and helping them fi nd new Associates; 1992:75-128. ties and deal with more complex issues. ways of coping by developing new con- 11. Crittenden PM. Treatment of anxious attach- ment in infancy and early childhood. Dev nections between their experiences, Psychopathology. 1992;4[ISSUE NUM- Dealing With Traumatic emotions and physical reactions. Unfor- BER]:575-602. Re-enactments tunately, all too often, medications take 12. Cicchetti D, White J. Emotion and develop- After a child is traumatized multiple the place of helping children acquire the mental psychopathology. In: Stein N, Lev- enthal B, Trebasso T, eds. Psychological and times, the imprint of the trauma becomes skills necessary to deal with and master Biological Approaches to Emotion. Hillsdale, lodged in many aspects of his or her their uncomfortable physical sensations. NJ: Lawrence Erlbaum Associates; 1990:359- makeup. This is manifested in multiple To “process” their traumatic experienc- 382. 13. Browne A, Finkelhor D. Impact of child sex- ways: fearful reactions, aggressive and es, these children fi rst need to develop a ual abuse: a review of the research. Psychol sexual acting out, avoidance, and uncon- safe space where they can “look at” their Bull. 1986;99(1):66-77. trolled emotional reactions. Unless this traumas without repeating them and 14. van der Kolk BA, Fisler R. Dissociation and 15 the fragmentary nature of traumatic memo- tendency to repeat the trauma is recog- making them real once again. ries: overview and exploratory study. J Trau- nized, the response of the environment is ma Stress. 1995;8(4):505-525. likely to replay of the original traumatiz- REFERENCES: 15. Streeck-Fischer A, van der Kolk B. Down ing, abusive, but familiar, relationships. 1. Child Maltreatment 2001. US Department of will come baby, cradle and all: diagnostic and

PSYCHIATRIC ANNALS 00:0 | MONTH 200X 7 therapeutic implications of chronic trauma ner physical, sexual, psychological, and stalk- on child development. Aust N Z J Psychiatry. ing violence and posttraumatic stress symp- 2000;34(6):903-918. toms in a nationally representative sample of 16. Pynoos RS, Frederick CJ, Nader K, et women. J Trauma Stress. 2004;17(5):413- al. Life threat and posttraumatic stress in 421 school-age children. Arch Gen Psychiatry. 31. Higgins DJ, McCabe MP. Relationships be- 1987;44(12):1057-1063. tween different types of maltreatment during 17. Kegan R. The Evolving Self. Cambridge, MA: childhood and adjustment in adulthood. Child Harvard University Press; 1982. Maltreat. 2000;5(3):261-272. 18. Summit RC. The child sexual abuse ac- commodation syndrome. Child Abuse Negl. 1983;7(2):177-193. 19. Cole PM, Putnam FW. Effect of incest on self and social functioning: a developmental psychopathology perspective. J Consult Clin Psychol. 1992;60(2):174-184. 20. Cicchetti D, White J. Emotion and develop- mental psychopathology. In: In: Stein N, Lev- enthal B, Trebasso T, eds. Psychological and Biological Approaches to Emotion. Hillsdale, NJ: Lawrence Erlbaum Associates; 1990:359- 382. 21. Ackerman PT, Newton JE, McPherson WB, Jones JG, Dykman RA. Prevalence of post traumatic stress disorder and other psychiat- ric diagnoses in three groups of abused chil- dren (sexual, physical, and both). Child Abuse Negl. 1998;22(8):759-774. 22. Lewis DO, Shanok SS. Perinatal diffi culties, head and face trauma, and child abuse in the medical histories of seriously delinquent chil- dren. Am J Psychiatry. 1979;136(4A):419- 423 23. Steiner H, Garcia IG, Matthews Z. Posttrau- matic stress disorder in incarcerated juvenile delinquents. J Am Acad Child Adolesc Psy- chiatry. 1997;36(3):357-365. 24. Teicher MH, Andersen SL, Polcari A, et al. The neurobiological consequences of early stress and childhood maltreatment. Neurosci Biobehav Rev. 2003;27(1-2):33-44. 25. Schneider-Rosen K, Cicchetti D. The rela- tionship between affect and cognition in mal- treated infants: quality of attachment and the development of visual self-recognition. Child Dev. 1984;55(2):648-658. 26. van der Kolk BA. The neurobiology of child- hood trauma and abuse. Child Adolesc Psy- chiatr Clin N Am. 2003;12(2):293-317, ix. 27. van der Kolk BA, Roth S, Pelcovitz D, Mandel FS, Spinazzola J. Disorders of extreme stress: the empirical foundation of a complex adapta- tion to trauma. J Trauma Stress. In press. 28. Culp RE, Heide J, Richardson MT. Mal- treated children’s developmental scores: treat- ment versus nontreatment. Child Abuse Negl. 1987;11(1):29-34. 29. Kiser LJ, Heston J, Millsap PA, Pruitt DC. Physical and sexual abuse in childhood: relationship with post-traumatic stress dis- order. Am Acad Child Adolesc Psychiatry. 1991;30(5):776-783. 30. Basile KC, Arias I, Desai S, Thompson MP. The differential association of intimate part-

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