in Child Welfare - The Trauma Center

8 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013The Heart of the Matter: Complex Trauma in Child WelfareJoseph Spinazzola, Ph.D., Mandy Habib, Psy.D., Angel Knoverek, Ph.D., LCPC, Joshua Arvidson, MSS, LCSW, JanNisenbaum, MSW, Robert Wentworth, MSW, Hilary Hodgdon, Ph.D., Andrew Pond, LICSW, and Cassandra Kisiel, Ph.D.OverviewComplex trauma involves chronic or repeated,typically early-onset exposure to two or moreof the following forms of trauma exposure:sexual, physical or emotional abuse, domesticviolence, or neglect, as well as severe caregiverimpairment and school/community violence(Kisiel et al., 2009). A national sample of over2,200 children in child welfare found thatover 70% met exposure criteria for complextrauma (Greeson et al, 2011). A substantialsubset of children—typically those withthe fewest social and economic resources,and those living amidst poverty, crime orcultural minority status (Cohen, 2007)—haveexperienced all of these forms of exposure.Complex trauma impacts multiple coredomains of functioning: children’s physiologyand brain development; their ability toidentify, tolerate, control and appropriatelyexpress emotions, impulses and bodilysensations; to concentrate, learn and engage ingoal-directed behavior; to form a positive andcohesive sense of self, meaningful values andhopeful future outlook; to cultivate secure andhealthy attachment bonds, sustain intimaterelationships, safely negotiate conflict andcommunicate their needs; and to interpretsocial cues accurately, set healthy personalboundaries and differentiate safe fromthreatening situations and interactions withpeers and adults (Cook et al, 2005; Kisielet al, 2009; Spinazzola et al, 2005). By thetime they reach adolescence, many complexlytraumatized youth are already caught in avortex of intense somatic, behavioral andemotional dysregulation in which dailylife is fraught with an ever-expanding hostof traumatic reminders and subtle falsealarms that activate extremes of hyper- andhypo-arousal. Like “live wires,” complexlytraumatized youth can become chargedwith heightened vigilance and physiologicalreactivity at levels that are emotionallyoverwhelming and debilitating to the immunesystem. Like “walking dead,” they canretreat or slip into extended periods of severewithdrawal, emotional constriction, avoidanceand numbing of consciousness induced viacoping strategies that include dissociation,binge eating or substance dependence.The legacy of unresolved complex traumais staggering, and has been causally linkedwith increasingly dire outcomes across thelifespan that collectively place an enormouseconomic burden on society, conservativelyestimated at over $200,000 per impactedchild and over 100 billion per year (Fang et al,2012). Long-term outcomes include scholasticfailure, dropout and unemployment; earlypregnancy, sexually transmitted disease,rape and domestic violence; chronic mentaland physical illness, health risk behaviors,The legacy of unresolved complex trauma is staggering, and has beencausally linked with increasingly dire outcomes across the lifespanthat collectively place an enormous economic burden on society,conservatively estimated at over $200,000 per impacted child and over100 billion per yeardisability and premature mortality (Edwardset al, 2004; Felitti et al, 1998, Ford et al,2010).Psychological maltreatment: Thesleeping giant of complex traumaPsychological maltreatment has beenrecognized by the American PediatricAssociation as the most prevalent form ofchild maltreatment and thus far the mostoverlooked despite substantial evidence ofits deleterious impact at levels comparableto more readily recognizable forms ofmaltreatment such as physical and sexualabuse (Hibbard et al, 2012). Psychologicalmaltreatment is comprised of various overtand subtle forms of chronic emotional abuseand neglect, including prolonged verbalabuse, terrorizing, shunning, and socialisolation. A recent study on a large sampleof over 5,000 children and adolescents fromthe Core Dataset of the NCTSN revealedpsychological maltreatment to have equal orsignificantly greater association than physicalor sexual maltreatment to 27 out of 30frequency and severity symptom, diagnosticand risk indicators assessed (Spinazzola etal, 2011). Psychologically maltreated youthwere the most likely to exhibit significantinternalizing, attachment and substanceabuse problems and the most likely todevelop anxiety and depressive disorders. Alsonotable was that exposure to psychologicalmaltreatment resulted in equal levels of PTSDsymptom severity compared to physical orsexual abuse. The child welfare system canserve as a critical gatekeeper of suspectedThe term complex trauma wasintroduced by a special taskforceof the National Child TraumaticStress Network (NCTSN) to helpmultidisciplinary service providersbetter understand and respondto the multifaceted relationshipbetween children’s exposure tomultiple traumatic events and thewide-ranging, long-term impactof this exposure (Complex TraumaTaskforce, Cook et al, 2003, 2005,2007). The complex trauma constructdiffers in important ways fromother conceptual frameworksof child maltreatment. Whereas“polyvictimization” addresses thecircumstances of children’s exposureto multiple, often inter-relatedtraumatic forms of trauma (Finkelhoret al., 2007, 2009), complex traumaspeaks to the cascading interplaybetween trauma exposure, impactand (mal)adaptation. Moreover,unlike “Complex PosttraumaticStress Disorder,” introduced in anattempt to characterize a broaderand more pronounced symptom-setexhibited in a subset of traumatizedadults (Herman, 1992), the complextrauma construct was formulated inrealization that the PTSD diagnosisneither typically nor sufficientlycaptures the cardinal featuresof disturbance observed in youthexposed to prolonged and severemaltreatment, violence, and neglect(Ackerman et al., 1998; Spinazzola etal., 2005).and reported psychological maltreatmentin children and families with its power andauthority to open the door to thoroughinvestigation of its presence and impact inreported youth.