Journal of Traumatic Stress, Vol. 22, No. 5, October 2009, pp.
399–408 ( C 2009)
A Developmental Approach to Complex PTSD: Childhood and Adult Cumulative Trauma as Predictors of Symptom Complexity
Department of Child and Adolescent Psychiatry, New York University School of Medicine and Nathan S. Kline Institute for Psychiatric Research, New York, NY
Bradley C. Stolbach
La Rabida Children’s Hospital Chicago Child Trauma Center and Department of Psychiatry, University of Chicago Pritzker School of Medicine, Chicago, IL
Judith L. Herman
Victims of Violence Program, Cambridge Health Alliance, and Department of Psychiatry, Harvard Medical School, Cambridge, MA
Bessel van der Kolk
Trauma Center at Justice Resource Institute, Brookline, MA
Department of Psychiatry and Biobehavioral Sciences, University of California-Los Angeles, Los Angeles, CA
Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, NY
Department of Child and Adolescent Psychiatry, New York University School of Medicine and Nathan S. Kline Institute of Psychiatric Research, New York, NY Exposure to multiple traumas, particularly in childhood, has been proposed to result in a complex of symptoms that includes posttraumatic stress disorder (PTSD) as well as a constrained, but variable group of symptoms that highlight self-regulatory disturbances. The relationship between accumulated exposure to different types of traumatic events and total number of different types of symptoms (symptom complexity) was assessed in an adult clinical sample (N = 582) and a child clinical sample (N = 152). Childhood cumulative trauma but not adulthood trauma predicted increasing symptom complexity in adults. Cumulative trauma predicted increasing symptom complexity in the child sample. Results suggest that Complex PTSD symptoms occur in both adult and child samples in a principled, rule-governed way and that childhood experiences signiﬁcantly inﬂuenced adult symptoms. Individuals with a trauma history rarely experience only a single traumatic event but rather are likely to have experienced several episodes of traumatic exposure (Kessler, 2000). This phenomenon has been frequently reported among survivors of childhood abuse, domestic violence, and those who have been witnesses to or targets of genocide. Exposure to sustained, repeated or multiple traumas, particularly in the childhood years, has been proposed to result in a complex symptom presentation that includes not only posttraumatic stress symptoms, but also other symptoms reﬂecting disturbances predominantly in affective and interpersonal
Correspondence concerning this article should be addressed to: Marylene Cloitre, Trauma and Resilience Research Program, NYU Child Study Center, 215 Lexington Avenue, New York, NY 10016. E-mail: email@example.com.
2009 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20444
Published on behalf of the International Society for Traumatic Stress Studies. symptom complexity. Frewen & Lanius. 1995). absent or psychiatrically disturbed parents) result in impairment in developmental processes related to the growth of emotion regulation and associated skills in effective interpersonal behaviors (e. Stewart. 2000. 2008. Briere and colleagues (2008) tested this notion and found that in a community sample of young women (college students). Finkelhor & Dziuba-Leatherman. and aggressive or socially avoidant behaviors. Fourth Edition-Text Revision (DSM-IV-TR. Following a brief phone screen. hospital and community clinics.. and word-of-mouth. We also calculated the combined load of childhood and adulthood trauma to assess the impact the total lifetime accumulation of trauma on symptom complexity. It is unknown and remains to be tested whether after adjustment for child cumulative trauma. American Psychiatric Association [APA]. 1992) and are designated in the Diagnostic and Statistical Manual of Mental Disorders. We wished to build on and extend this research by adopting this algorithm to evaluate a clinical sample of women with histories of childhood abuse. Coid et al. This study addresses the following questions.
. 2000). 2000) and accordingly has substantial implications for evaluation and treatment. 2008). & Green.. Participants were self-referred by means of advertisements in local papers. No women participated in more than one study. which has demonstrated that childhood abuse as well as other childhood adversities (neglect. Roth. Herman.. These symptoms are part of Complex Posttraumatic Stress Disorder (PTSD. as a further test of the principled nature of the relationship between cumulative trauma and symptom complexity. Kaltman. & Spinazzola. Consequently. In general. adulthood trauma contributes to symptom complexity. dissociative symptoms. those found eligible for the study participated in the full assessment procedure.g.g. It has been proposed that an increasing number of different types of traumas is associated with an increasingly greater number of different types of symptoms experienced simultaneously (i. 2000).g. and apparently contradictory symptoms of complex PTSD. we wished to replicate the ﬁndings of Briere et al. Livingston. We hypothesized that the accumulation of adulthood trauma and of childhood trauma would each play a role. Shipman. 2006. In addition. Dong et al.
self-regulatory capacities such as difﬁculties with anxious arousal. and well-documented relationship to other types of childhood and adulthood traumas (e. Shipman. 1994. Third. Disturbances in self-regulation account for both overactivation and deactivation/avoidance in emotions and interpersonal behaviors as seen in dysphoria and anger as well as dissociation. & Wraith. First. we wished to test whether regardless of child cumulative adversity and trauma. Second. & Champion. van der Kolk. 2001. We combined data for analysis because there were no differences in the
Journal of Traumatic Stress DOI 10. childhood trauma would contribute more strongly to symptom complexity than adulthood trauma. the associated features of PTSD as described in the DSM-IV-TR (APA. (2008) with a clinical sample of women and determine whether childhood cumulative adversity and trauma was predictive of symptom complexity. Swisher. The research focus on childhood abuse as an example of a type of trauma associated with Complex PTSD results from its high prevalence (e. All participants provided informed consent approved by the institutional review board of the relevant university.. and in interpersonal behaviors that are aggressive or dependent.g. but consistent with developmental theory (Pynoos. Briere. 2000) as “PTSD and its associated features.1002/jts. p. Posttraumatic stress disorder symptoms themselves have been described as a form of a chronic dysregulated emotional response to traumatic reminders as reﬂected in the co-occurring symptoms of hyperarousal/emotional numbing and hypervigilance/poor concentration (e. Understanding the effects of trauma as the result of disturbances or vulnerabilities in self-regulatory capacities is useful as it creates conceptual coherence to the multiple. Childhelp.400
Cloitre et al. we identiﬁed a sample of children presenting at a trauma-focused outpatient clinic. which would suggest that the burden of repeated and multiple adulthood traumas in and of themselves may overwhelm self-regulatory systems. Pelcovitz. most of whom had experienced multiple types of childhood abuse and adversity as well as a various number of adulthood traumas. understanding of complex PTSD has been inﬂuenced by developmental research.. diffuse. Brown. & Dennison. emotional abuse. Sunday. we wished to compare the impact of child cumulative trauma versus adult cumulative trauma on symptom complexity. adulthood cumulative trauma was associated with symptom complexity. anger management. Kaloupek.” The importance of evaluating the effects of multiple traumas in their cumulative form is critical as this circumstance characterizes the experience of the majority of trauma survivors (Kessler. Steinberg.. 2005). Edwards. 465) specify a core set of symptoms of particular salience. Although self-regulatory difﬁculties vary from person to person. 2005. Litz. there
STUDY 1 METHOD
A total of 849 women presenting for treatment of trauma-related symptoms resulting from childhood abuse were assessed as part of a series of four treatment studies over a period of approximately 12 years.. as well as those that are distant and avoidant. 2004).. Zeman. and evaluated the relationship between the range of experienced childhood traumas and types of symptoms similar to those of our adult population. was a linear relationship between the number of trauma types experienced before 18 and symptom complexity.g. & Jennings. Orsillo. 2005). Penza.e. & Weathers. the expression of self-regulatory problems can be measured and predicted in a principle-governed way as related to trauma history. participants enrolled in the studies did not differ from participants who did not enroll. Lastly. typically recurring nature (e.
emotion regulation difﬁculties. This group did not differ from the total group of women on any of the sociodemographic characteristics. 1990).6). Lifetime cumulative trauma index was deﬁned as the sum of the child and adult measures. & Keane. yielding a sample size of N = 582 for the reported analyses. Inventory of Interpersonal Problems ≥1. and 3. If the J–T test indicated that the mean of the outcome changed monotonically with the predictors. both child and adult trauma scores were included in a model to predict symptom complexity.000.
exp. Scarvalone. and 30. adult.5% had earned from $5. the majority had experienced childhood sexual. physical assault. 1990) (2) depression as measured by the Beck Depression Inventory (BDI.2% were either divorced or widowed. Chi-square test for independence was used to assess the association between the child and adult indexes. Weathers. The reliability of these clinical interviews as well as detailed deﬁnitions of childhood and adult events has been reported in previous publications (Cloitre. BDI ≥25 (Beck et al. and interpersonal regulation difﬁculties. 1988).
The relationships between the potential predictors (child. To assess the additional effect of each predictor after controlling for the other. & Brown. Published on behalf of the International Society for Traumatic Stress Studies. The adult cumulative trauma index was the sum of four different types of adulthood traumas: sexual assault. Posttraumatic stress disorder symptoms were evaluated using the Clinician-Administered PTSD Scale (CAPS. TSI-dissociation ≥1. whereas everywhere else two-sided tests were used.1% had earned more than $30.g. 20. and (4) dissociation as measured by the Trauma Symptom Inventory (TSI) Dissociation subscale (Briere & Runtz. the Childhood Maltreatment Interview Schedule (Briere. Negative Mood Regulation Scale ≤90 (Catanzaro & Mearns. 1995). Nagy.8% Hispanic. and total trauma indexes) and the outcome (symptom complexity) were assessed as follows. 1996). Spielberger. intimacy. 1996). we next estimated the effect of the predictors on the outcome. 26.000 to $30. Ureno. and 53.5% were single.90 (Horowitz et al.80 (Briere.5% Asian American. which examines difﬁculties (either being too high or two low) on six dimensions of interpersonal functioning (sociability. 1997)...000. Education varied with 12.1 (SD = 10. & Difede. Jonckheere– Terpstra (J–T) test (Jonckheere. The cutoff points for the six symptoms were CAPS ≥80 (Weathers. emotional abuse. only women for whom both childhood and adulthood data were available were included. one-sided.
Exposure to trauma and childhood adversity was assessed using two clinician-administered instruments. the most common adulthood trauma was sexual assault. cumulative logistic regression was used to model the odds for being at a more severe level of the outcome variable. 1988). Approximately 26% were either married or living with a signiﬁcant other. 2001.05. & Villasenor. Emotion regulation difﬁculties were evaluated by (1) general emotion regulation self-efﬁcacy as measured by the Negative Mood Regulation Scale (Catanzaro & Mearns. physical abuse. 1999). and emotional abuse. For the purposes of this investigation. which were based on guidelines provided in the empirical literature.
Journal of Traumatic Stress DOI 10. 1991). Of the 582 participants. Symptom complexity was deﬁned as the number of symptoms a person had. Rosenberg. The sample was comprised of 45. anger exp ≥35 (Spielberger.Childhood and Adult Cumulative Trauma as Predictors of Symptom Complexity sociodemographic characteristics. Table 1 provides the frequency of women reporting each type of childhood and adulthood trauma. The results are interpreted as the ratio of the odds for being at a more severe level of symptom complexity for every unit increase of the predictor variable. physical. Beck. assertiveness. during kidnapping or captivity. repeated physical assault by a spouse or live-in partner).1% were of other ethnicities. by an acquaintance or partner). 24. Cohen. repeated sexual assault (e. & Kaloupek.1002/jts. the average age was 36. and domestic violence (e. 1990). neglect.. The child cumulative trauma index was the sum of ﬁve indicators of childhood adversities and trauma: sexual abuse. Interpersonal problems were measured with the Inventory of Interpersonal Problems (Horowitz. 1995). rather than nominal factors). the odds for being at a more severe level of symptom complexity were modeled as a function of each predictor individually.7% having more than college training.. Because the outcome is a count between 0 and 6 and thus could not be considered as a continuous Gaussian variable. or symptom characteristics across the four study samples. To assess the effect of each predictor regardless of the level of the other. 1992) to assess adulthood traumas.6% had earned from $15. 22. Blake. 64. To test for equality of the mean of the outcome at different levels of the predictors against an ordered alternative (because the levels of the predictors were ordinal. 1991). The measure of complex PTSD included in this analysis was comprised of six symptoms in three domains: PTSD symptoms. and control) and a total score is computed.8% African American. trauma histories. Edelman. Ruscio. Steer.g. & Han.000.8% had earned less than $5. Signiﬁcance of J–T tests was judged at level α = .
. Baer. 1992) to assess childhood events and the Sexual Assault and Additional Interpersonal Violence Schedule (Resick & Schnicke. Earnings of participants for the year previous to the study were as follows: 20.000. (3) anger expression difﬁculties as measured by the anger expression subscale (An/Ex) from the State-Trait Anger Expression Inventory (anger
Trauma Characteristics and Symptoms
Among the 582 women.7% Caucasian women. and 23. and 9. 1954) was employed.000 to $15. responsibility. and not living with mother (due to impairment or absence/abandonment).3% having a high school diploma or less. 10.1% having ﬁnished college or some college training. submissiveness. that exceeded a prespeciﬁed level of severity. Cloitre.
7 (33) 35.34 1.4 (206) 1.94 24. The mean number of different types of childhood trauma was 3. TSI = Trauma Symptom Inventory.5 (9) 5.3 (54) 4.0 (SD = .71 SD 23. suggesting that the measures are related but not highly overlapping in shared variance (i.
Table 2 identiﬁes the proportion of women at each level of cumulative trauma in childhood (see last column) and at each level of adulthood cumulative trauma (see bottom row) as well as their joint distribution. which is the sum of child and adult trauma.36 – NMR −.93).29 to .7 (74) 7.4 (14) 8.8 (51) 12.0 (0) 0.58). Descriptive Information and Correlations among Symptom Measures in Adult Sample (N = 582)
Correlations Among Symptom Measures Measures PTSD BDI An/Ex NMR TSI Dissociation IIP M 66. ranged from a very small percentage who had experienced only one type of trauma (5.16) and the mean number of different types of adult trauma was 1.60 .27 – IIP .6 (44) 11.46 −.7 (4) 8.9 (121) 36.8 (51) 20.e.9 (17) 22.0%) to those with as many as eight types of trauma (0. Percentages for each cell were computed relative to the total sample of 582.0 (582) 0 1 2 3 4 Total
Note.2 (1) 2.
.63 % Exceeding clinical cutoff 31. χ 2 (16.4 (14) 1.10 31.58 .34 −.45 1. IIP = Inventory of Interpersonal Problems.20 Adulthood traumas Sexual assault Physical assault Domestic violence Chronic sexual assault N 288 131 80 65 % 50.402
Cloitre et al.56 77.75 11.
Analyses of Symptom Complexity
The mean symptom complexity score (number of different types of symptoms above the cutoff ) was 1.0 (0) 0.
Summary statistics are provided in Table 3 for all symptom measures as well as the percentage of women above the clinical cutoff for that symptom and the correlations among the symptom measures.0 (0) 0.10 91.
Table 1.19 10. Child and adult trauma were associated.60).1 (SD = 1. Correlations among symptoms were in the moderate range (.1002/jts.
Table 3.42 – SCL Dissociation .95) with a range of 0 to 6. Published on behalf of the International Society for Traumatic Stress Studies.38
Table 2..01. The number of lifetime trauma types was 4.0 (35) 5.1 (SD = 1.05 9. BDI = Beck Depression Inventory. p < .34 21.37 .5%).3 (25) 35.2 (42) 4. NMR = Negative Mood Regulation.98 77.4 (8) 4.22 34.0 35.4 36.87 17.57 – Anger .50 −.1 (210) 19. a measure explains between 8% and 36% of the variability in another).62 45.48 –
Note.6 (27) 2.94 (SD = 1.8 (208) 2. An/Ex = Anger Expression.0 (29) 7. Table 4 provides the distribution of symptom
Journal of Traumatic Stress DOI 10.8 (116) 14.6 PTSD – BDI .06 0.45 . N = 582) = 35.5 29.5 (131) 0.2 (1) 0.29 1.6 (33) 0. PTSD = Posttraumatic Stress Disorder.5 (3) 0. Distribution of Number of Types of Traumas in Childhood and Adulthood for Adult Sample (N = 582)
Adulthood trauma % (N) Childhood trauma % (N) 1 2 3 4 5 Total 5.45 .6 39.0 (0) 0.5 (9) 1.3 (25) 9.34 −. Frequencies by Type of Trauma in Childhood and Adulthood in Adult Sample (N = 582)
Childhood traumas Sexual abuse Physical abuse Neglect Emotional abuse Did not live with mother N 380 451 246 417 185 % 67.8 41.4 (84) 100. whereas the majority (67.1.13 13. The total number of types of lifetime trauma.60 .0%) experienced from three to ﬁve types.5 (67) 6.
33.1002/jts.g.7 1.9 1.9 1.04–1. The relationships appear linear. the prediction of lifetime cumulative trauma became nonsigniﬁcant. The effects of child and adult trauma on symptom complexity seem additive (rather than.13. Gorst-Unsworth.8 1.0 1.0 M 4 SD M 1. these analyses yielded the same pattern of results. 2005. however.0 2.0 1. Cumulative childhood trauma was strongly associated with symptom complexity. A cumulative logistic regression analysis indicated that child trauma was associated with higher symptom complexity. 95% CI = 1.0
0.3 1. Given that adulthood cumulative trauma was not related to symptom complexity in the J–T test.0 1.4 2.51.3 2. interactive).9 2 SD 1.3 2.9 2.0 M 0.02).3 1. e..8 2.4 1. the relationship between cumulative life trauma and symptom complexity remained signiﬁcant ( p = .0 1.4 2.8 SD 1. to symptom complexity.9 2.3 2.9 1.
STUDY 2 METHOD
Children and adolescents (N = 152) presenting to a child trauma clinic for trauma-focused evaluation and treatment services were
Journal of Traumatic Stress DOI 10. Figure 1 shows the relationship between symptom complexity and both child and adult trauma together.4 2.01. p < .8 2.4 1. we repeated the above set of analyses controlling for race/ethnicity and earnings. The three-dimensional ﬁgure also provides a visual representation of the joint relationship of adult and childhood cumulative trauma
Figure 1. Z = 1. Cumulative logistic regression analysis also showed that lifetime trauma (the total of child and adult trauma) was associated with higher symptom complexity.0 M 2.24.Childhood and Adult Cumulative Trauma as Predictors of Symptom Complexity
Table 4. The lifetime cumulative trauma was signiﬁcantly related to symptom complexity.3 1.0 1. a regression analyses was not performed.8 2.0 4. 95% CI = 1. i. but when adult cumulative trauma was entered as a control variable. when childhood cumulative trauma was entered into the model along with the lifetime variable.e. Symptom Complexity: Number of Symptoms above the Clinical Cutoff as a Function of Child Cumulative Trauma and Adult Cumulative Trauma (N = 582)
Adult cumulative trauma 0 Child cumulative trauma 1 2 3 4 5 Total M 1. whereas the relationship between adulthood trauma and symptom complexity was not signiﬁcant.9
0. OR = 1.30.
.1 2.1 1. Three-dimensional representation of relationship of child and adult cumulative trauma to current symptom complexity.9 M 0.6 3 SD 0.8 2. OR = 1.0 2.1
complexity scores by levels of childhood and adulthood cumulative trauma.41. Rutter. Z = 2. Published on behalf of the International Society for Traumatic Stress Studies. p < .0 2.8 2.. The ﬁgure shows the results of model-ﬁtting symptom complexity on smooth functions of the two predictors.2 1.17.0 1.0 2.3 2. p = .9 1.8 1. each additional type of childhood trauma increased the odds of greater symptom complexity by about 17%. & Turner.9 2.6 1.0 1 SD 1. Because there is evidence that racial/ethnic disparities and poverty are adversities that may contribute to negative mental health outcomes (e.01.2 2.9 1.8 2.5 1.01.4 2.0 2.6 2.3 3.10.9 Total SD 1. As expected. with a steeper slope associated with child trauma (reﬂecting the stronger relationship with symptom complexity) compared to adulthood trauma.03–1.2 2. 1996).. p < .g.05. van Velsen.7 2. p < . Z = 2.
22. the Checklist’s dissociation items showed good internal reliability (Cronbach’s alpha = . 44. and not living with mother (due to placement in foster or other substitute care). The range of child cumulative adversity and trauma Index ranged from 1 through 7..1002/jts. N = 152) = 9. 2008.
. 1987). the UCLA PTSD Reaction Index for DSM-IV. Race/ethnicity distribution was 76. Nijenhuis. Child report was utilized for internalizing symptoms (e. the child cumulative adversity and trauma index was comprised of seven predictors: sexual abuse.001. Children aged 7 and above provided assent. All children were assessed by licensed clinical social workers.1% of boys and 28. The frequency of each of the seven different types of child cumulative traumas are presented (with additional information by gender when differences emerged) are as follows: sexual abuse (60%. 17. neglect (47%)..8% three types. 7. November 17.. with a mean of 3. Achenbach & Rescorla. Symptom measures included in this analysis were selected to parallel the symptom domains in Study 1 and included child self-report (ages 7–17) and caregiver-report (all ages.3% African American.2% Hispanic. p = .g.1 years of age (SD = 3. 11. Reich. Children and families served at the clinic were typically at or below poverty level. 2004).. and through clinician report using the 10 Dissociation items from the Child Complex Trauma Symptom Checklist (Ford et al. witnessing sexual or physical abuse. Children’s Depression Inventory >65.404
Cloitre et al. law enforcement. Stolbach. personal communication. 11. For the Child Complex Trauma Symptom Checklist. & Herjanic. Dominguez. For the current study. Participants were referred by a variety of sources including children’s advocacy centers. child protective service investigators. caregiver report for externalizing and other behavioral symptoms. 2008). aggressive behavior. parent version and child/adolescent version (Steinberg. clinicians completed the Trauma/Loss History Proﬁle (Pynoos & Steinberg. 5.08. Dissociative symptoms were assessed through self-report using the Children’s Dissociative Experiences Scale (Stolbach. review of child welfare. Stolbach et al. witness to domestic violence (44%). child welfare caseworkers. Based on information gathered from these measures. regardless of whether age and gender terms were signiﬁcant.5% of girls). Clinical dissociation was deﬁned as meeting one or more of the following criteria: Children’s Dissociative Experiences Scale >24 or Child Dissociative Checklist >11 or Child Complex Trauma Symptom Checklist Dissociation >4 or Child Complex Trauma Symptom Checklist Top 5 dissociation >1. 2004). and the Diagnostic Interview for Children and Adolescents PTSD and Psychosocial Stressors sections (Reich.1% four types. licensed clinical psychologists. The mean age of the sample was 10.3% biracial or multiracial..4% two types. There were few gender differences in trauma history and none in sociodemographic. we adjusted for age and gender in the models.2% Caucasian. pediatricians. personal communication. except that because the sample consisted of both genders and ages ranged from 3 to 17 years. and word-of-mouth. 19. PTSD and depression symptoms).99. or advanced trainees under the supervision of licensed clinicians. provided by guidelines in the manual or validation studies for each of the measures. 2000.5). Published on behalf of the International Society for Traumatic Stress Studies. and when appropriate.
assessed. Child Behavior Checklist >65. Rompala. Brymer.75) comparable to that of the 17 DSM PTSD symptom items on the Child Complex Trauma Symptom Checklist (Cronbach’s alpha = . (Stolbach et al.9% six or
Journal of Traumatic Stress DOI 10. 2000). Of the 152 children. Symptom complexity was deﬁned as the number of symptoms (out of these four) that exceeded a prespeciﬁed level of severity. or hospital records. The cutoff points were: PTSD-RI >40. Interpersonal problems and behavioral regulation were measured through caregiver report using the Child Behavior Checklist Externalizing Problems Scale (e. Legal guardians for all participants provided informed consent approved by the institutional review board of the relevant university and the state child welfare department. and witness to sexual or physical abuse (32%). 62. Decker. emotional abuse/impaired caregiver.8% ﬁve types.. witnessing domestic violence.73. χ 2 (1. clinical interview. 2008). 1997. November 16. These 10 dissociation items were reviewed by two leading experts in the ﬁeld of dissociation (E. Pynoos et al. Depressive symptoms were evaluated through self-report using the Children’s Depression Inventory (Kovacs. In a prior study
The data analysis approach was identical to the approach used for Study 1. and 11.
Of the 152 children assessed. physical abuse.0% of boys and 69. 2001). O. Steinberg et al. Welner. All had experienced at least one DSM PTSD Criterion A traumatic stressor (APA. van der Hart.9).g. 2008. through caregiver report using the Child Dissociative Checklist (Putnam et al. neglect. 42... 2008). physical abuse (34%. 2004. and 17. a relatively new measure with no such guidelines. and symptom complexity characteristics. completed by primary caregiver) and clinician report to enhance accuracy of symptom report.1% had experienced one of the seven types of trauma or adversity. emotional abuse (68%). 2000.77). symptom severity. N = 152) = 2. & Pynoos. not living with mother (54%).5% were girls and the remainder was boys. 1993). investigative. 2007).4 (SD = 1. 1992). χ 2 (1.
Trauma history was assessed via self. the severity level was deﬁned as greater than one SD above the sample mean. & Gazibara. rule-breaking behavior.4% of girls). Posttraumatic stress disorder symptoms were evaluated through self-report using the Child/Adolescent Version of the UCLA PTSD Reaction Index for DSM-IV (PTSD-RI. and an aggregate of all reporters for dissociation.and caregiver report using two clinician-administered instruments. p < . 2007).
39 1. Moreover. which includes all of the above symptoms (see van der Kolk.05. Polusny. the relationship between cumulative trauma and symptom complexity was found in a sample of children and adolescents.80.8 47. In childhood. p < . The results of these studies contribute to the growing evidence base for Complex PTSD in that they demonstrate in both children and adults a rule-governed relationship between increasing types of traumatic exposures and the presence of an increasing number of theoretically based and empirically constrained symptoms. Taken together. However. van der Kolk (2005) has proposed a new diagnostic category. these studies suggest that exposure to multiple or repeated forms of maltreatment and trauma in childhood can lead to outcomes that are not simply more severe than the sequelae of single incident trauma.Childhood and Adult Cumulative Trauma as Predictors of Symptom Complexity
Table 5. the childhood cumulative index included prototypical traumatic stressors (sexual abuse.
A signiﬁcant relationship between cumulative trauma and symptom complexity was observed. such events can be argued in many cases to fulﬁll the prototypical characteristic of a trauma. Mean symptom complexity scores by level of cumulative trauma are provided in Table 5. Follette.. the predictor variable in this and other studies of negative outcomes (e. to account for the complex symptom proﬁles of chronically traumatized children. physical abuse) as well as other experiences more broadly understood as maltreatment (neglect.7 behavioral dysregulation (CBCL-Externalizing) Cumulative trauma count (n) 1 (29) 2 (34) 3 (18) 4 (26) 5 (18) ≥ 6 (27)
Symptom complexity M 1.6 Depression (CDI) 50.14 1.g.2
PTSD (UCLA-RI) 28. future research is necessary in characterizing and understanding experiences of maltreatment in contributing to disorders such as Complex PTSD and Developmental Trauma Disorder. This formulation may not include all instances of maltreatment nor sufﬁciently characterize the inﬂuence of maltreatment on psychological disturbances. These latter symptoms were considered in large part because they have been associated with traumatic exposure in developmental studies of children.3 8.
Journal of Traumatic Stress DOI 10.1002/jts.
. The average symptom complexity score was 1. As among the adults.91 1. We included these events as predictors of symptom complexity because they have been shown in disparate studies to be associated with risk for PTSD (e. but of acts of omission as well (such as neglect or abandonment) where the absence or withdrawal of certain resources may create a threat to the child’s survival and physical well-being.67 1.g.. Bechtle. In the adult sample. traumas are comprised not only of acts of commission (such as sexual assault).52 . Thus. Briere et al.2 Dissociation – Interpersonal problems & 3. Interpersonal problems and behavioral dysregulation were measured by the Child Behavior Checklist (CBCL) Externalizing Symptoms Scale. 1999). Thus. whereas the introduction of adult cumulative trauma did not change the outcome.56 1.. the relationship between lifetime trauma and symptom complexity became nonsigniﬁcant. Published on behalf of the International Society for Traumatic Stress Studies. the results of the two studies together suggest that childhood cumulative trauma is associated in a rule-governed way to a complex symptom set and that childhood cumulative trauma signiﬁcantly inﬂuences the presence of these symptoms in adulthood. absence of parent). the analysis of the combined child and adult cumulative trauma index (lifetime trauma) indicated that there was an overall additive effect of the contribution of cumulative trauma to symptom complexity. emotional abuse. but are qualitatively different in their tendency to affect multiple affective and interpersonal domains.12 1.
more types of trauma. child cumulative trauma in children was associated with symptom complexity. which is that they create actual or threat of harm to the person. Recognizing the impact that cumulative trauma has on development beginning in early childhood. the deﬁnition of Complex PTSD articulated in this study represents an integration of the developmental and trauma empirical literature. Depression was measured with the Child Depression Inventory (CDI).42 1. Descriptive Information for Symptom Measures and Symptom Complexity in Child Sample (N = 152)
Symptom scores Measures M SD 15. Summary statistics are provided in Table 5 for all symptom measures along with the percentage of children that exceeded the clinical cutoff for that symptom. 2008.00–1.0 60. OR = 1.0 % at Clinical cutoff 23.76 1.17. Second. Widom. Developmental Trauma Disorder. 2005). the odds for being at a higher level of symptom complexity increased by 17%.56 (SD = 1.24) with a range from 0 to 4. when childhood cumulative trauma was entered into the analyses.02 1.6 1. These data suggest that lifetime cumulative trauma is related to symptom
complexity due to the presence of childhood cumulative trauma.5 – 11. The symptom set under study included both traditional PTSD symptoms as well as symptoms reﬂecting difﬁculties with selfregulatory functions. Several cautions regarding the implications of the study results are warranted. In addition.03
Note. Z = 1. p < . 95% CI = 1. The cumulative logistic regression indicated that for every unit increase in childhood cumulative trauma. Thus.87 SD 1. First.05.37. Posttraumatic stress disorder (PTSD) was measured with the UCLA PTSD Reaction Index (UCLA-RI).
T. refugee survivors of torture. 1989). & Mandel. the populations under study were those who had experienced childhood abuse and the range of different types of adult interpersonal traumas was restricted to the common traumas of a civilian population in peacetime. Conversely. Thus. The development of a Clinician-Administered PTSD Scale. The empirical literature has consistently pointed to the predictive power of this variable whereas studies investigating the duration or other characteristics of sustained trauma have yielded little (e. such as somatization and disturbed belief systems. It may simplify clinical decision making and can guide the selection of treatment targets and interventions. Beck. M.. A. D.. diagnosis of complex PTSD as compared to multiple diagnoses in regards to functional impairment or other important outcome variables. single incident events) may not be so much in the duration or the repetitive nature of a particular trauma. 1997) and traumas associated with Complex PTSD often emerge from a history of sustained relational or interpersonal traumas beginning with early life attachments (see Charuvastra & Cloitre. Hooper. Further study is needed to test the relationship between cumulative trauma and measures of additional phenomena. Our participants did not include. or concentration camps.. Comparison of the predictive power of Complex PTSD as compared to multiple comorbidities in regards to important outcomes would help evaluate the beneﬁts of a single streamlined diagnosis.. In summary. for example. the presence of multiple diagnoses can lead to complexity in treatment planning. G. & van der Kolk.. & Green. whereas the corresponding symptom pattern observed in adult subjects is consistent with the concept of Complex PTSD. Kaltman. In addition. It is possible that studies of such populations might show equally powerful effects for adult and childhood cumulative trauma. We propose that diagnosing and labeling a patient with multiple psychiatric disorders increases the risk of the patient feeling and being stigmatized. Steer. war zones. Youth.). difﬁculties in articulating a unifying treatment principle. G. but rather the presence of multiple co-occurring traumatic events (e. L. Weathers. Tests of these proposals would include research assessing the strength and speciﬁcity of the relationship between childhood trauma and Complex PTSD as compared to other disorders (see Herman. 1992). (1996) Beck Depression Inventory. Burlington. The results of this study suggest the importance and value of further research in the characterization and standardization of these proposed disorders.. Perry. greater trauma exposure is associated with more complex symptom presentation. Indeed. witnessing injury or death to others) and the accumulation of such experiences would be expected to increase risk for symptom complexity. L. this study demonstrates that both in children and adults. M. & Brown.g. & Kaloupek. 8. A. Newman. sexual assault. Achenbach. a single diagnosis of Complex PTSD presents an empirically based. actual or threat of injury. A. T. M. Youth. The symptom pattern observed in the child sample is consistent with the concept of a Developmental Trauma Disorder.. Journal of Traumatic Stress. adulthood traumas of sustained nature such as living in a war zone create a life condition that increases risk of exposure to a multiplicity of types of traumatic events (e. disparate disorder unrelated to trauma history. childhood abuse. the impact of sustained and chronic trauma (vs. by delineating those symptoms that are not related to cumulative trauma. 1996. Burlington. further study is needed to demonstrate the speciﬁcity of these complex posttraumatic conditions. childhood sexual abuse. Third. Pelcovitz. T. F. & Notgrass. the current data do not rule out the possibility that the substantial burden of exposure to repeated and multiple types of trauma in such situations could lead deterioration of self-regulatory capacities in individuals without previous trauma histories or self-regulatory difﬁculties. an enduring question regarding the proposed diagnosis of Complex PTSD concerns its utility relative to the strategy of assigning the PTSD diagnosis along with several currently available DSM-IV diagnoses as comorbidities. to rehabilitate developmental competencies. Diagnostic and statistical manual of mental disorders (4th ed. conceptually coherent and uniﬁed set of symptoms that may reduce the stigmatizing impact of being labeled with multiple. Published on behalf of the International Society for Traumatic Stress Studies. Lastly.. political persecution. A. 2008.1002/jts. D. Nagy. 2008).406
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