Complex Trauma Treatments

Running Head: COMPLEX TRAUMA TREATMENTS

Complex Trauma: Diagnosis, Symptoms, and Treatments Rhonda D. Williams University of Calgary

Complex Trauma Treatments

Children and adolescents who suffer from complex trauma have been exposed to multiple and chronic traumatic events throughout their lives. There are a wide range of stress reactions for children and adolescents with complex trauma symptomatology. Younger children exhibit stress resulting from exposure from a traumatic event by displaying more overt aggression and destructiveness. They also re-enact their experiences in their play and art. Adolescents tend to react similar to adults and are able to see more of the long-term consequences of the traumatic event and are able to reflect more on their own role in what happened. Regardless of age, children exposed to chronic and repeated exposure to abuse and maltreatment may develop personality changes, suicidal or self-harm behaviours, depression, or other psychological disorders (Dyregrov & Yule, 2006). Complex PTSD extends beyond the classic symptoms of PTSD experienced by children and adolescents to include difficulty regulating extreme emotional states, dissociation, medically unexplained bodily stress, and profoundly negative cognitions about themselves, others, relationships and their world views (Gleiser, Ford, & Fosha, 2008). Children and adolescents with affect regulation impairments often have difficulty with emotional self-regulation, labelling and expressing feelings, problems knowing and describing internal states and communicating wishes and needs (van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Exposure to trauma impairs development, severely impacting children and adolescents. Treatment intervention should focus on building normative competencies and establish connections to external resources that support resiliency building (Kinniburgh et al., 2005). Treatment for complex trauma in

Complex Trauma Treatments youth should focus on phase-oriented, evidence-based approaches. Trauma-focused cognitive behavioural therapy, eye movement desensitizing and reprocessing and the attachment, self-regulation, and competency framework address pressing issues associated with children and adolescents who have experienced complex trauma. This paper will describe issues surrounding the definition of complex trauma, symptoms, predictive and protective factors, issues of attachment and three specific treatment approaches to complex trauma: Trauma-focused cognitive behavioural therapy, eye movement desensitizing and reprocessing and the attachment, self-regulation, and competency framework. Method A search of Medline, Psychology and Behavioral Sciences Collection and PsycInfo for journal articles published between 2004 and 2010 examining the definition,

symptomatology and treatment of complex trauma and complex posttraumatic stress was conducted. The search terms and keywords used in the initial computerized database search were: complex trauma and adolescents, complex trauma and children, complex PTSD and children and adolescents, and attachment and trauma. In order to narrow the search results, the search terms, treatment, cognitive behavioural therapy, and EMDR were added to the search. From the database searches, twenty-two articles were chosen for this literature review because they met the criteria for inclusion and they provided descriptive information and quantitative data. Journal articles that focused on assessment procedures and biological information were not included in the paper due to the limited scope of the literature review.

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Definitions CPTSD/DESNOS Complex trauma refers to a type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts (Courtois, 2004, p.412). In the DSM IV-TR (APA, 2000) an extreme stressor is one that involves experience with event that involves actual or threatened death or injury, witnessing or learning about the death or injury of another person close to them. Examples of extreme stressors include physical abuse, sexual abuse, emotional abuse, neglect, severe accidents, death of a loved one, natural or man-made disasters, lifethreatening illness, ethnic cleansing, witnessing domestic violence, war or terrorism (Cook et al., 2005; Gleiser, Ford & Fosha, 2008). A diagnosis of PTSD simply does not capture the developmental impact complex trauma has on children and adolescence when exposed to multiple traumatic events such as the examples listed above (Cook et al., 2005). Rather, the disorder of extreme stress not otherwise specified (DESNOS) identifies symptoms of dysregulation in consciousness, emotion, behavioural selfmanagement, bodily functioning, self-perception, interpersonal functioning, and a sense of purpose in life related to the chronic and repetitive nature of complex trauma (Ford, Courtois, Steele, van der Hart, & Nijenhuis, 2005). The diagnosis of DESNOS was conceptualized based on identified seven problem areas associated with early interpersonal trauma: difficulty in affect regulation, attention and consciousness, selfperception, perception of the perpetrator, relationships with others, somatisation and/or medical problems, and systems of meaning (Courtois, 2004; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005).

Complex Trauma Treatments Co-morbidity Children and youth with complex trauma related symptoms have been traditionally viewed as mentally ill rather than responding to the traumatic events (Griffin, Martinovich, Gawron, & Lyons, 2009). Many of the symptoms associated with complex trauma are often categorized by their co-morbid conditions rather than being recognized as essential components to complex trauma symptomatology (Courtois,

2004). Children exposed to abuse, loss of a caregiver or maltreatment are often diagnosed with a variety of psychological disorders (e.g. Attention Deficit Hyperactivity Disorder, Anxiety Disorders, Eating Disorders, Communication Disorders, Oppositional Defiant Disorder, Conduct Disorder, Reactive Attachment Disorder and Separation Anxiety Disorder). However, each of these disorders only capture a limited aspect of the relational and self-regulation deficits these children exhibit (Cook et al., 2005). Cloitre et al. (2009) propose that diagnosing and labelling a person with multiple psychiatric disorders increases the risk the patient feeling stigmatized. Multiple diagnoses can also lead to complexity and difficulties articulating priorities and goals within the treatment programs. In contrast, a single diagnosis addressing complex trauma presents an empirically based, conceptually coherent and unifying approach reducing the negative impacts of multiple labels on individuals. This would also simplify clinical decisionmaking and guide treatment goals and strategies (Cloitre et al., 2009). Symptoms The symptoms related to experiencing complex trauma can have long-lasting and varied impacts on children and adolescents. A study conducted by Cloitre and her colleagues (2009) investigated the relationship between cumulative trauma and symptom complexities in women with histories of multiple or repeated forms of maltreatment and

Complex Trauma Treatments abuse in childhood. An overall additive effect in the study found women who experienced more complex trauma symptoms in adulthood (more severe than single-

event trauma) were also more impacted in affect and interpersonal domains (Cloitre et al., 2009). Cohen, Mannarino, & Deblinger (2006) classify trauma symptoms into four main categories: affective, behavioural, cognitive, and physical. Affective symptoms include anger, depression, fear, and mood dysregulation. Traumatized youth are frequently disconnected from their own emotional states and are unable to identify the link between their emotions and bodily states. Often youth with self-dysregulation are biased towards negative affect states (e.g. isolation, shame, guilt) due to internalizing responsibility for the occurrence of traumatic events in their lives. Children and adolescents struggling with self-regulation also have a tendency to misinterpret emotions expressed by others as dangerous or negative (e.g. blame, anger), leading to isolating/avoidant behaviours or explosive reactions. After intense emotional states, traumatized youth often struggle to calm down and may rely on maladaptive coping strategies such as substance abuse or self-harm as a way to regulate themselves. (Cohen et al., 2006; Kinniburgh, Baustein, Spinazzola, & van der Kolk, 2005). Behavioural symptoms include avoidance of things that remind the individual of the traumatic experiences (Cohen et al., 2006). Behavioural regulation difficulties often manifest themselves as poor impulse control, self-destructive behaviour, aggression towards others, pathological self-soothing behaviours, eating disorders, sleeping disorders, substance abuse, excessive compliance, oppositional behaviour, difficulty

Complex Trauma Treatments understanding and complying with rules and a re-enactment of trauma in play or actions (Kinniburgh et al., 2005). Cognitive symptoms focus on distorted cognitions about themselves, others, the

traumatic events or their world view. Blaming themselves for the occurrence of the event is one of the most common irrational beliefs held by children (Cohen et al., 2006). Children many also experience difficulties with dissociation, attention regulation and executive functioning, planning and anticipating, understanding responsibility, language development, orientation in time and space and learning difficulties (van der Kolk, Roth, Pelcovitz, Sunday, and Spinazzola, 2005). Physical symptoms are related to the chronic stress experiences by children who have experienced complex trauma. These children often have elevated heart rates and blood pressure along with greater muscle tension and somatization (Cohen et al., 2006). Children may also experience impairments in sensorimotor development, coordination and balance (van der Kolk et.al, 2005). Others have expanded the categories of symptoms to include the domains of attachment, self-concept and developmental levels (Kinniburgh et al., 2005; van der Kolk et al., 2005). Youth with attachment deficits often struggle setting appropriate boundaries with others, tend to distrust or are suspicious of others, may engage in social isolation, may exhibit interpersonal difficulties, often struggle with attuning to others emotional states and also have difficulty with perspective taking. Issues surrounding a youths selfconcept often focus on a lack of a continuous, predictable sense of self, a poor sense of separateness, disturbances in body image, low self-esteem and feelings of shame and guilt (van der Kolk et al., 2005). Developmental stages are important for children and

Complex Trauma Treatments adolescents because these are times when they must negotiate through key tasks built on past experiences. Competency is gained when children are successful in new developmental tasks, across the domains of emotional, cognitive, intrapersonal and interpersonal, and build a sense of achievement, increasing self-esteem (Kinniburgh et al., 2005). Predictive and Protective factors In addition to the complexities of symptoms experienced with complex trauma, several predictive factors are associated with developing complex PTSD. Repeated exposure to stressful and traumatic events, along with a variety of different types of trauma experienced are consistently associated with the development of complex PTSD. Other factors include problems with family cohesion, lack of social supports, the female gender, prior psychiatric problems, prior exposure to trauma and a strong acute response (Boyer, Hallion, Hammell and Button, 2009; Pine & Cohen, 2002). The possession of strengths builds resiliency in youth and has a positive effect of

their ability to cope with the impact of complex trauma (Griffin, Martinovich, Gawron & Lyons, 2009). The more strengths and resources a child or youth possesses, the greater chance they will have a higher level of functioning and is less likely to engage in highrisk behaviour. The development of secure attachments in relationships with caregivers builds a safe and stable base for youth, resulting in positive social, emotional and behavioural skills and coping mechanisms. Secure attachments can still be formed even after a child experiences complex trauma. This allows the child to build resiliency and gain competency with each success achieved in a variety of domains (Kinniburgh et al., 2005).

Complex Trauma Treatments Attachment Adolescence represents a developmental phase in which an individuals attachment figures expands to include friends and romantic relationships. The development of secure versus insecure attachments appears to be multi-factorial and strongly influenced by familial and environmental factors. Secure attachment in adolescence is associated with a wide range of positive indicators and is formed when caregivers are consistent, promote skill development, and provide safety (Kinniburgh et al., 2005; Shumaker, Deutsch & Brenninkmeyer, 2009). Insecure attachment is closely

associated with internalizing and externalizing disorders, personality disorders and social problems (Shumaker et al., 2009). When caregivers are emotionally absent, inconsistent, violent, neglectful, or dealing with their own unresolved trauma and loss, they can not be a source of stability and security for their children. Under these conditions, children and adolescents can become distressed and feel unsafe, often resulting in the development of insecure attachments (van der Kolk, & Courtois, 2005). The most problematic attachment is a disorganized attachment pattern. In children, this pattern consists of erratic behaviour in relation to caregivers (e.g. alternatively clingy, dismissive and aggressive), while in adolescents, behaviours manifest that are extreme, rigid and dissociative. Often their behaviour revolves around themes of coercive control (e.g. hostility, blaming and rejection) to helplessness (e.g. dejection, abandonment and betrayal)(van der Kolk et al., 2005). Attachment is also significant predictor of resiliency among high-risk populations. However, the majority of maltreated and abused youth have insecure attachment patterns. Youth who receive inconsistent, neglectful, or rejecting caregiving tend to manage overwhelming experiences using maladaptive coping strategies such as dissociation,

Complex Trauma Treatments aggression and avoidance. These youth fail to acquire more sophisticated emotional management skills (Kinniburgh et al., 2005). Youth with unresolved attachment states (disorganized attachment) are at greater risk for deficiencies in certain cognitive processes (specifically areas of broad attention, cognitive efficiency, and working memory) compared to peers with resolved attachments (Webster, Hackett and Joubert, 2009). Treatments Current trends emerging in modern approaches for complex trauma in children

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focus on efficacy and efficiency. Some researchers are attempting to reduct in the amount of sessions required for treatment within group setting to promote commitment and attendance (Dyregrov & Yule, 2006). There is also an emphasis on teaching coping strategies to both children and caregivers and have trauma-informed treatment integrate strength building approaches to yield optimal outcomes (Griffin, Martinovich, Gawron, & Lyons, 2009). Webster, Hackett and Joubert (2009) also recommend a comprehensive treatment plan that addresses both cognition and relational experiences with attachment figures (e.g. caregivers) to improving the overall functioning of adolescents with a history of complex trauma. The Complex Trauma Workgroup of the National Child Traumatic Stress Network has identified six core components intervention should focus on when designing an individualized program for a child or adolescent with complex trauma histories (van der Kolk, Roth, Pelcovitz, Sunday and Spinazzola, 2005). Good treatment should be sequential, phase-oriented, and flexible, adapting to the individual needs of each child (e.g. developmental level, age, gender, etc.). The core components emphasize internal and environmental safety, self-regulation (affect, physiological, cognition, and

Complex Trauma Treatments behavioural), self-reflective information processing (executive functioning), traumatic

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experiences integration, relational engagement, and positive affect enhancement (van der Kolk, Roth et al., 2005). In 2002, the Complex Trauma Workgroup (CTWG) conducted a survey to assess clinician views on the nature and treatment of complex trauma (Spinazzola et al., 2005). When clinicians were asked to report the effectiveness of treatment approaches used in their own facilities or practice, only individual and family therapy were perceived as effective. The crucial element of treatment identified was the involvement of caregivers in the childs treatment. They also noted the individuation of treatment through combining techniques or tailoring interventions to suit the childs specific needs was the most impactful. The survey also showed a lack of clinical consensus on effective treatments for child trauma victims. These finding suggest most treatment approaches have not been successfully adapted to fully address the needs of a youth exposed to complex trauma or clinicians are not aware of effective strategies to use with this population (Spinazzola et al., 2005). Phase-Oriented, Evidence-Based Treatments As suggested earlier by Spinazzola and his colleagues (2005), effective treatment for children and adolescents with complex trauma symptomatology is implemented in a phase-oriented model. Ford, Courtois, Steele, van der Hart and Nijenhuis (2005) emphasize the importance of using a phase-orientated integrative model to guide the treatment of posttraumatic self-dysregulation by enhancing the recognition (rather than avoidance) of posttraumatic self-dysregulation in tolerable ways in order to promote more proactive self-regulation. The early stage of treatment focuses on the development

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of safety, education, skill building, affect regulation, and treatment alliance. The second phase of treatment focuses on processing traumatic events in enough detail and resolution to allow the individual to function more productively. This phase is engaged in once the individual has developed enough coping strategies and affects regulation skills to deal with the stress of remembering the trauma. The final phase of phase-orientated treatment focuses on life restructuring and consolidation to allow the individual to function less impacted by the trauma they experiences in their past (Courtois, 2004; Ford et al., 2005). Evidence-based treatment has also been identified as an important practice for the development of trauma-informed strategies to help trauma exposed youth (Boyer, Hallion, Hammell, & Button, 2009). Evidence-based practice incorporates current research with the clinicians professional expertise to administer systematic assessment, develop well defined treatment goals and implement core treatment components, addressing the clients unique circumstances (Amaya-Jackson & DeRosa, 2007). Several different phase-orientated model focus on treatment for complex trauma with children and adolescents (Ford, Courtois, Steele, van der Hart & Nijenhuis, 2005). Trauma-Focused Cognitive Behavioural Therapy Evidence-based trauma treatments such as CBT work with the children and adolescents to reprocess traumatic events, ultimately regaining control in their lives (Griffin, Martinovich, Gawron & Lyons, 2009). Trauma-focused cognitive behavioural therapy (TF-CBT) is a specific protocol used to help children and adolescents identify and understand the relationship between thoughts, emotions and behaviour, while learning components of psychoeducation, relaxation, affect modulation, cognitive coping and processing, trauma narratives, mastery of trauma reminders, parenting skills, conjoint child-parent sessions, and enhancing future safety and development (Dyregrov & Yule,

Complex Trauma Treatments 2006; Little, Akin-Little & Gutierrez, 2009). Trauma-focused cognitive behavioural therapy (TF-CBT) has been successful in treating children and youth with complex

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trauma symptoms. TF-CBT consists of six core values: its component based, respectful, adaptable, values family involvement, the therapeutic relationship is key to restoring trust and functioning, and focuses on self-efficacy (Cohen, Mannarino & Deblinger (2006). In a study conducted by Cohen, Deblinger, Mannarino and Steer (2004) focused on child sexual abuse, TF-CBT reduced PTSD symptoms, depression and behavioural problems when compared to child-centered treatment. Cohen and her colleagues (2006) also conducted a follow up study and confirmed children treated with TF-CBT had significantly fewer symptoms of PTSD and described less shame than the children who had been treated with child-centered treatment at both 6 and 12 months following the treatment program. The caregivers who had been treated with TF-CBT also continued to report less severe abuse-specific distress during the follow-up period than those who had been treated with child-centered therapy. Multiple traumas and higher levels of depression at pre-treatment were positively related to the total number of PTSD symptoms at post-treatment for children assigned to the child-centered treatment condition only (Cohen et al., 2006). Eye Movement Desensitization and Reprocessing Eye movement desensitization and reprocessing (EMDR) is a process that requires children and adolescents engage in a series of thought patterns (both positive and negative) when desensitized the individual to the stressful response associated with a traumatic memory (Ahmad & Sundelin-Wahlsten, 2008). The protocol is modified for children by allowing for modified scales (less numbers on the Likert scale or the use of faces to demonstrate different emotions) based on the developmental level and age of the

Complex Trauma Treatments child(Ahmad & Sundelin-Wahlsten, 2008). However, children who have experienced complex trauma often struggle identifying their emotions and articulating their internal state with others. This could be a huge drawback for EMDR protocols. In fact, the authors reported that almost always the children required help to explain negative feelings and cognitions and differentiate between them. Despite this criticism, Ahmad and Sundelin-Wahlsten (2008) suggest that EMDR might be an effective way to teach children how to identify his/her thoughts and emotions in specific situations. A meta-analysis was conducted to determine the magnitude of treatment effects for children with PTSD symptoms between children receiving EMDR and children

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receiving control treatments (Rodenburg, Benjamin, Roos, Meijer, & Stams, 2009). The results of the meta-analysis indicate a medium strength effect size, providing evidence EMDR is beneficial for children to engage in the treatment for PTSD symptoms. When children treated with EMDR were compared to the children treated with established trauma treatments (CBT), EMDR adds a small but significant incremental value (Rodenburg et al., 2009, p.604). The meta-analysis also showed fewer treatment sessions were associated with better treatment outcomes. However, individual factors were not identified in relation to better treatment outcomes. In future studies, it is important to investigate which type of trauma treatment best suits the various types of traumatic experiences. Further, the treatment of EMDR needs to investigate future research in both clinical and non-clinical settings to study the effectiveness of resource-focused interventions in comparison with other researched methods with a larger sample size. The inclusion of alternating bilateral stimulation into EMDR procedures also needs further investigation to test its efficacy in the treatment model (Leeds, 2009).

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Attachment, Self-Regulation, and Competency The attachment, self-regulation, and competency (ARC) model is a componentbased framework focusing on the treatment of complex trauma with children and adolescents addressing individual developmental needs within their social context (Kinniburgh, Baustein, Spinazzola & van der Kolk, 2005). ARC is not a prescribed manualized treatment protocol, but rather a guide to trauma-informed treatment practices that is individualized and flexible to the needs of each person. Although it is important to process traumatic memories and experiences, ARC focuses on the developmental skill deficits associated with exposure to traumatic events. ARC also focuses on building resiliency in youth by strengthening trust and security within the caregiving system, building skills, and stabilizing internal distress (Kinniburgh et al., 2005). In the ARC model, the attachment (interactions and relationship) between the child and the caregiver has a major impact on the development of identity, early working models of self and others, and emotional regulation (Kinniburgh et al., 2005). ARC focuses on two overarching goals for attachment-focused intervention: building healthy attachments with caregivers and creating a safe environment for healthy recovery. These goals are achieved through four core principles focusing on creating a consistent and structured environment through the use of routines and rituals, increasing the caregivers ability to manage intense emotions (caregiver affect management), improving childcaregiver emotional attunement, and increasing the use of praise and reinforcement to create a strength-based approach rather than focusing on deficits (Kinniburgh et al., 2005).

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ARC focuses on three primary regulatory skills for complex trauma. These skills are the acquisition of affect knowledge and the ability to accurately identify ones own feelings and read the emotional cues of others, the ability to safely express and communicate emotions, and the ability to modulate and shift within an emotional experience and return to a comfortable state of arousal (Kinniburgh et al., 2005). The final component to the ARC model emphasizes four general principles in developmental competency. Caregivers and treatment staff should focus on creating opportunities for mastery, connections with peers, adults and the community, build on strengths to promote a positive self-concept, and teach the child to evaluate outcomes to foster a sense of control and self-efficacy. The ARC model can be best summarized by the final sentence written by Kinniburgh and her colleagues (2005): ARC has been developed in response to these challenges as an intervention framework designed to address the array of developmental vulnerabilities experienced by the complexly traumatized child by building or restoring developmental competencies, identifying and enhancing internal, familial, and systemic resources, and providing a foundation for continued growth. (Kinniburgh et al., 2005, p. 430). The ARC framework addresses almost all affect, cognition, behavioural, and physiological address in complex trauma literature. It provides a very structured guideline for treatment that is flexible and can be individualized for a child in their specific setting. Discussion Complex trauma and complex PTSD severely impact functioning levels in children and adolescents. Although chronic and multiple traumatic experiences are seen

Complex Trauma Treatments as stressors and identified under the DESNOS diagnostic criteria, the developmental impact of complex trauma is not directly addressed (APA, 2000). In light of this inaccuracy of diagnostic criteria, van der Kolk (2005) has proposed a new diagnostic

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criteria that takes into account the cumulative impact trauma has on development, affect and interpersonal domains. Developmental Trauma Disorder encompasses the complex symptoms of chronically abuse and maltreated children and adolescents (Cloitre et al., 2009). Once a new diagnostic criteria is acknowledged throughout the fields of psychology and psychiatry, a clearer vision of complex trauma will be established, allowing clinicians to better explore and implement focused treatment plans (Cloitre et al., 2009). Children and adolescents with multiple psychiatric diagnoses who have experienced complex trauma may change to one diagnosis that explains all their symptoms under one umbrella rather than using multiple co-morbid disorders to explain their psychological complexities. Although there are numerous treatment programs adapted to focus on the treatment of complex PTSD, trauma-focused cognitive behavioural therapy and eye movement desensitizing and reprocessing treatment are the most commonly used. Both of these approaches integrate some form of exposure to traumatic memories to desensitize the child from fear and anxiety. The attachment, self-regulation, and competency (ARC) framework approaches the issues associated with complex trauma differently. Rather than utilizing short therapy sessions, the ARC framework is flexible to the environment the child is currently. This allows for a more extensive approach to help build secure attachments, self-regulatory skills, and competency in a wide variety of domains. The exposure to a therapeutic approach is much longer compared to individual

Complex Trauma Treatments or group therapy sessions once or twice a week. In fact, these therapy sessions could be

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integrated within the ARC model as part of the psychoeducational component. The ARC model works on building supports and resources around a trauma-impacted youth to help develop resiliency.

Complex Trauma Treatments References

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Ahmad, A. & Sundelin-Wahlsten, V. (2008). Applying EMDR on children with PTSD. European Child and Adolescence Psychiatry, 17, 127-132. doi:10.1007/s00787077-0646-8 Amaya-Jackson, L. & DeRosa, R.R. (2007). Treatment considerations for clinicians in applying evidence-based practice to complex presentations in child trauma. Journal of Traumatic Stress, 20(4), 379-390. dio:10.1002/jts.20266 Boyer, S.N., Hallion, L.S., Hammell, C.L., & Button, S. (2009). Trauma as a predictive indicator of clinical outcome in residential treatment. Residential Treatment for Children & Youth, 26, 92-104. dio:10.1080/08865710902872978 Cloitre, M., Stolbach, B.C., Herman, J.L., van der Kolk, B., Pynoos, R., Wang, J., & Petkova, E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22(5), 399-408. doi:10.1002/jts.20444 Cohen, J.A., Deblinger, E., Mannarino, A.P., & Steer, R.A. (2004). A multisite, randomized controlled trail for children with sexual abuse-related symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 393402. doi:10.1097/01.Chi.0000111364.94169.f9 Cohen, J.A., Mannarino, A.P., & Deblinger. E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: The Guilford Press. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390-398.

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Courtois, C.A. (2004). Complex trauma, complex reactions: Assessment and treatment. Psychotherapy: Theory, Research, Practice, Training, 41(4), 412-425. doi:10.1037/0033-3204.41.4.412 Deblinger, E., Mannarino, A.P., Cohen, J.A., Steer, R.A. (2006). A follow-up study of a multisite, randomized, controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 1474-1484. doi:10.1097/01.chi.0000240839.56114.bb Dyregrov, A. & Yule, W. (2006). A review of PTSD in children. Child and Adolescent Mental Health, 11 (4), 176-184. doi:10.1111/j.1475-3588.2005.00384.x Ford, J.D., Courtois, C.A., Steele, K., van der Hart, O., & Nijenhuis, E.R.S. (2005). Treatment of complex posttraumatic self-dysregulation. Journal of Traumatic Stress, 18(5), 437-447. doi:10.1002/jts.20051 Gleiser, K., Ford, J.D., & Fosha, D. (2008). Contrasting exposure and experiential therapies for complex posttraumatic stress disorder. Psychotherapy Theory, Research, Practice, Training, 45(3), 340-360. doi:10.1037/a0013323 Griffin, G., Martinovich, Z., Gawron, T., & Lyons, J.S. (2009). Strengths moderate the impact of trauma on risk behaviors in child welfare. Residential Treatment for Children & Youth, 26, 105-228. doi:10.1080/08865710902872994 Kinniburgh, K.J., Blaustein, M., Spinazzola, J., & van der Kolk, B.A. (2005). Attachment, self-regulation, and competency. Psychiatric Annals, 35(5), 424-430. Leeds, A.M. (2009). Resources in EMDR and other trauma-focused psychotherapy: A

Complex Trauma Treatments review. Journal of EMDR Practice and Research, 3(3), 152-158. doi:10.1891/1933-3196.3.3.152 Little, S.G., Akin-Little, A., & Gutierrez, G. (2009). Children and traumatic events: Therapeutic techniques for psychologists working in the schools. Psychology in the Schools, 46(3), 199-206. doi:10.1002/pits.20364 Pine, D.S., & Cohen, J.A. (2002). Trauma in children and adolescents: Risk and

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treatment of psychiatric sequelae. Society of Biological Psychiatry, 51, 519-531. doi:10.111/j.1455-3588.2002.00453.m5 Rodenburg, R., Benjamin, A., de Roos, C., Meijer, A.M., & Stams, G.J. (2009). Efficacy of EMDR in children: A meta-analysis. Clinical Psychology Review, 29, 599-606. doi:10.1016/j.cpr.2009.06.008 Shumaker, D.M., Deutsch, R.M., & Brenninkmeyer, L. (2009). How do I connect? Attachment issues in adolescence. Journal of Child Custody, 6, 91-112. doi:10.1080/15379410902894866 Spinazzola, J., Ford, J.D., Zucker, M., van der Kolk, B., Silva, S., Smith, S.F., & Blaustein, M. (2005). Survey evaluates complex trauma exposure, outcome, and intervention among children and adolescents. Psychiatric Annals, 35(5), 433-439. van der Kolk, B., & Courtois, C.A. (2005). Editorial comments: Complex developmental Trauma. Journal of Traumatic Stress, 18(5), 385-388. doi: 10.1002/jts.20046 van der Kolk, B., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18(5), 389-399. doi:10.1002/jts.20047

Complex Trauma Treatments Webster, L., Hackett, R.K., & Joubert, D. (2009). The association of unresolved

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attachment status and cognitive processes in maltreated adolescents. Child Abuse Review, 18, 6-23. doi: 10.1002/car.1053

Assignment 1: Literature Review Self-Evaluation List APSY 605 Winter 2010 Please respond to each of the following items by asking yourself, How successful was I at achieving the following factors in my literature review? Please use the following scale to assign a number to each item: 1=unsuccessful, needs work 2=somewhat successful, approaches but does not meet expectation 3=successful, meets expectation 4=extremely successful, exceeds expectation Write a brief paragraph (not point form) with developed ideas and thoughts for each of your item ratings. How successful were you at 1. Describing your search strategy (databases, keywords, parameters of your search) Self rating: 4 My search strategy was very comprehensive. I began the search in the Psychology and Behavioral Sciences Collection and the PsychInfo database and focused just on a few terms such as complex trauma and adolescents, complex trauma and children, complex PTSD and children and adolescents, and attachment and trauma. In order to narrow the search results, the search terms, treatment, cognitive behavioural therapy, and EMDR were added to the search. I then read some of the articles to get a better basis and expanded my search to include some of the articles I wanted to further explore in some of the readings I did and extended my search to the Medline data base. 2. Describing the big picture via your literature review? Self rating: 3 The topic of complex trauma is relatively new and developing rapidly. I was able to describe the main points pertaining to diagnosis, symptoms and common treatment approaches while still focusing on the ARC model towards the end of the paper. The ARC model was what drew me to the topic in the first place. 3. Identifying the central topic? Self-rating: 3 The central topic of complex trauma was easy to select as a central theme. Initially I struggled when first conceptualizing the topic and wanted to include

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assessments as well. However, I soon realized that only focusing on treatments will give me more than enough information.

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4. Describing how you conceptualized the problem? Self Rating: 3 I was able to distinguish the problem with current diagnostic criteria and how an unclear definition impacts other aspects of research and treatment models. I needed to give more of the background in symptomatology to allow the reader to better understand the selected treatment approaches and the greater impact complex trauma has on a huge population of children and adolescents. 5. Including current, relevant literature? Self Rating: 4 I used the most current information I could find about the topic. I was able to find numerous articles published in 2009 but did extend my search to 2004. Though reading some articles, I realized the Journal of Traumatic Stress dedicated one entire journal to the topic of complex trauma in 2005. Many of the foundations within the research has stemmed from this wealth of published knowledge. 6. Basing the review mainly on primary research (sources)? Self-Rating: 4 I am a strong believer in only drawing reference from original (or primary) sources. If I came a cross an article in one of the readings I was interested in, I revisited the databases to find the original. There are times when an author will only take a portion of what is written to support their own ideas without portraying the full meaning behind the original author. 7. Critically analyzing the literature (e.g. strengths/weaknesses of previous research, inclusion/exclusion criteria for articles, databases searched)? Self-Rating:3 When reading a research article, I always read about how the investigation was conducted, sample sizes and demographics to see if the results from the study can be generalize or is specific to a particular population. While searching for articles, I used three different data bases for the same searches to gain access to different resources. 8. Providing a well-balanced review, presenting evidence on both (all) sides? Self-Rating: 3 I feel I was able to present a well-balanced review of the various treatment approaches without showing my own biases towards the approach I found to be the most comprehensive and meaningful to children and adolescents with complex trauma. I work in a special education setting and have tried numerous different approaches to complex trauma. I have an understanding of what approaches will actually have a shot at working versus sounding good in theory. 9. Keeping the review free from personal biases (e.g. limiting use of emotional

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language; acknowledging institutional affiliation or funding source)? Self-Rating: 4 I was able to keep the literature review free from personal biases by limiting emotional language and always read the articles to see if the authors had any conflicts of interest regarding funding for the studies they conducted. 10. Identifying the theoretical framework and research question(s) and procedures of reviewed work? Self-Rating: 3 I was able to identify the theoretical frameworks associated with complex trauma as it pertains to children and adolescents. In the treatments I selected to focus on, I was able to describe their procedures to treatment approaches. I also was able to articulate issues of diagnosis, symptoms and types of impairment associated with complex trauma and complex PTSD. 11. Providing sufficient information to support your theoretical framework and research question(s)? Self-rating: 3 Originally I had several more types of treatment researched and written for the paper. However, with the length limitations, I felt I would not be able to describe the theoretical frameworks for each approach in enough detail to clearly and accurately portray treatment ideologies. As a result, I chose to cut several forms of therapy from the paper at the last minute. I feel this was a good decision to allow me the writing space to focus on the three types of treatment I selected. 12. Providing enough information in the literature review to guide all aspects of the research (participants, data collection and analysis)? Self-rating: 2 There are several studies I could have added more detail around the participants within the specific studies. For the most part, I chose studies that pertained to only children and adolescents. I chose to leave out articles I found were not statistically sound (e.g small sample sizes, not representative of the general population, etc). 13. Providing information in this review that would be useful to you? Self-Rating: 4 This review is completely useful to me. As I stated earlier, I work in a special education setting where I am the assistant principal for over 130 coded students. Reading each students psychological files brings to light how many of them have histories of complex trauma. We have some students with up to 6 or 7 different diagnosis. It made me realize that some of them could fix under the umbrella of complex trauma rather than multiple diagnoses addressing co-morbid disorders rather than the root of the difficulties. I am also currently in a group of 40 people focused on implementing aspects of the ARC model within CBE schools to help work with complex trauma students and help build secure attachments with our students. 14. Providing information in this review that would be useful to others?

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Self-Rating: 3 Given the prevalence of complex trauma in the lives of children and adolescents, the information in the literature review would be useful for anyone in the fields of psychology, sociology and education. The information allows a deeper understand to the impairments and struggles associated with complex trauma. The more people are aware of the issues, the more people will look at others through a trauma-informed lens when interacting with some who has experiences complex trauma. 15. Citing references that include diverse and marginalized voices? Self-Rating: 3 The whole area of complex trauma seems to be a diverse and marginalized area of voices. I wanted to bring even more diversity to the discussion of treatment but ran out of writing space. I really felt the issues of symptomatology and attachment needed to be explored to allow the reading insight into the depth of impact complex trauma has on an individual. I was able to include a few articles from the residential setting perspective as those children then to be very marginalized.