Complex Trauma & Developmental Trauma Disorder
Recent and current work and research regarding complex (developmental) trauma and Developmental Trauma Disorder in children and young people, including the ARC framework of intervention.
Complex Trauma and its Effects on Child Development.
Dr Arthur Becker-Weidman discussing how trauma suffered in early childhood shapes children’s brain development, in his Grand Rounds presentation at NYU Langone Medical Center on 09 November 2012.
For more information visit the Center for Family Development.
Complex Trauma & DTD
Complex trauma refers to both the exposure of children to traumatic events, and the effects of this exposure on the development of children and their future lives as adults. Complex trauma refers to the experience, in early childhood, of severe, sustained and developmentally detrimental traumatic experiences. These traumatic events are often experienced by the child within their closest attachment relationships, such as those with their primary caregivers, and include physical, sexual and emotional abuse, neglect, separation and loss, and witnessing domestic or community violence.
In a study cited by van der Kolk (2005), the results of previous investigations were confirmed in finding "a highly significant relationship between adverse childhood experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, cigarette smoking, obesity, physical inactivity and sexually transmitted diseases. In addition, the more adverse childhood experiences reported, the more likely a person was to develop heart disease, cancer, stroke, diabetes, skeletal fractures and liver disease." Van der Kolk also states that "People with childhood histories of trauma, abuse and neglect make up almost the entire criminal justice population in the US."
It is estimated that the direct and indirect costs of child abuse and neglect and the consequences of complex trauma amount to over $100 billion in the USA each year, and there is no doubt that equivalent costs are incurred within the UK and other countries. Many children and young people with complex trauma histories are living in the care system, and the poor outcomes associated with looked after children (in areas such as education, teenage pregnancy, homelessness, substance misuse, mental health and the criminal justice system) led to the Government'sEvery Child Matters agenda in 2003.
In order to work effectively with children who have suffered complex trauma, the effects of trauma on the developing child must be understood. Many of the articles and links in this and other sections of the site provide information regarding these effects. Essentially, the impact of trauma on the developing child is global - it affects every area of the child's development and functioning. The National Child Traumatic Stress Network (NCTSN) Workgroup on Complex Trauma identify 7 domains of impairment in children exposed to complex trauma: attachment; biology; affect (emotional) regulation; dissociation; behavioural control, cognitive processes; and self-concept. A more comprehensive breakdown of these domains is provided in the paper Complex Trauma in Children and Adolescents. Foster carers and other members of staff will recognise the children they care for in the examples given of impairment within these domains.
The fact that complex trauma impacts globally on a child's development makes it significantly different to the more recognisable post-traumatic stress disorder, and no single formal diagnosis yet exists that incorporates the effects of complex trauma and its effect on development. Many children with complex trauma histories are diagnosed with conditions such as ADHD, oppositional defiance disorder, conduct disorders, anxiety disorders, communication disorders, learning difficulties, autistic spectrum disorders and so on. However, as Cook, Spinazzola, Ford et al (2005)point out, "Each of these diagnoses captures a limited aspect of the traumatized child's complex self-regulatory and relational impairments."
Therefore, an overarching diagnosis of developmental trauma disorder (DTD) has been proposed by members of this task force (van der Kolk, Pynoos, Cicchetti, Cloitre, D'Andrea, Ford, Lieberman, Putnam, Saxe, Spinazzola, Stolbach & Teicher 2009) for inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), due to be published in 2013. "This provisional diagnosis is based on the concept that multiple exposures to interpersonal trauma, such as abandonment, betrayal, physical or sexual assaults, or witnessing domestic violence, have consistent and predictable consequences that affect many areas of functioning." (van der Kolk 2005)
Some of the articles and other documents produced by the task force are provided in pdf form on this page. Many others can be found on the Trauma Centre at Justice Resource Institute website, of which Bessel van der Kolk is the Medical Director and founder, and Joseph Spinazzola is the Executive Director.
The model of working with traumatised children and young people that Phoenix is developing is firmly rooted in attachment and trauma theory, and correlates strongly with the ARC treatment framework, also developed by clinicians at the Trauma Centre, and laid out by Margaret Blaustein and Kristine Kinniburgh in their 2010 book Treating Traumatic Stress in Children and Adolescents (available from the Phoenix resource library for foster carers and staff to access).
ARC Treatment Framework
The Attachment, Self-Regulation and Competency (ARC) treatment framework was developed as a way of working with children and young people who have experienced complex developmental trauma. It is intended to be a flexible tool that can be adapted to different work settings and home environments, and we are currently in the process of looking at how the ARC framework can inform our training programme, therapeutic care planning and assessment frameworks. Kinniburgh, Blaustein & Spinazzola provide an accessible overview of the ARC intervention framework.
van der Kolk, B., McFarlane, A. & Weisaeth, L. (Eds) (2007) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society (2007), New York: The Guildford Press
Blaustein, M. & Kinniburgh, K. (2010) Treating Traumatic Stress in Children and Adolescents: How to Foster Resilience through Attachment, Self-Regulation, and Competency, New York: The Guildford Press
Briere, J.N. & Lanktree, C.B. (2012) Treating Complex Trauma in Adolescents and young adults, Sage Publications Inc
Courtois, C.A. & Ford, J.D. (Eds) (2009) Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide, New York: The Guildford Press
Webb, N.B. (Ed) (2006) Working with Traumatized Youth in Child Welfare, New York: The Guildford Press
Perry, B.D. & Szalavitz, M. (2006) The Boy Who Was Raised as a Dog: and other stories from a child psychiatrist's notebook: what traumatized children can teach us about loss, love and healing, New York: Basic Books
Tomlinson, P. & Philpot, T. (2008) A Child's Journey to Recovery: Assessment and Planning with Traumatized Children, London: Jessica Kingsley Publishers
Thomas, M. & Philpot, T. (2009) Fostering a Child's Recovery: Family Placement for Traumatized Children, London: Jessica Kingsley Publishers
Pughe, B. & Philpot, T. (2007) Living Alongside a Child's Recovery: Therapeutic Parenting with Traumatized Children, London: Jessica Kingsley Publishers
Archer, C. (1999) First Steps in Parenting the Child Who Hurts: Tiddlers and Toddlers, London: Jessica Kingsley Publishers
Archer, C. (1999) Next Steps in Parenting the Child Who Hurts: Tykes and Teens, London: Jessica Kingsley Publishers
Miles, L. (2010) Holding On and Hanging In: The story of a boy, his foster family and their journey from trauma to healing, London: BAAF
Cairns, K. (2002) Attachment, Trauma and Resilience: Therapeutic caring for children, London: BAAF
Levy, T.M. & Orlans, M. (1998) Attachment, Trauma and Healing: Understanding and Treating Attachment Disorder in Children and Families, Washington: CWLA Press