Conceptualizing complex and developmental trauma

According to the Diagnostic and Statistical Manual of Mental Disorders 5, (5^th ed., American Psychiatric Association, 2013), “trauma and stressor related disorders are specific to exposure to a traumatic or stressful event” (p.265). More specifically

posttraumatic stress disorder relative to adults, adolescents, and children over 6 years, is defined as “exposure to actual or threatened death, serious injury, or sexual violation” (p.

52 271). For children under age 6, the same definition applies, however with more detailed diagnostic criteria.

Two types of traumas are articulated: Type I, or single incident traumas including natural disasters, and Type II or man-made disasters, inclusive of interpersonal trauma (Terr, 1990). Complex trauma is a Type II trauma. It is a relatively new concept that evolved from the term psychological trauma. It has been recognized as a multifaceted problem that disrupts functioning on a systemic level involving both the body and the mind (van der Kolk, 2005). For three decades the concept of psychological trauma expanded to include increasingly complex symptomologies. The notion of complex trauma does more justice to the experiences and the sequelae for children in care, but trauma, historically studied only in adult populations, has been studied more from a children’s perspective, only in recent years - however social workers have been aware of developmental sequelae since the early 1900’s (Addams, 1912).

The definitions of childhood complex trauma have been many, however each definition takes into account the same key characteristics which are; a child’s exposure to severe stressors from ongoing abuse, beginning in childhood and repeated over time, and perpetrated by a caregiver whose role it is to protect children (Boyd Webb, 1999; Bussey

& Wise, 2007; Cook et al. 2005; Mannarino & Cohen, 2011; Steele & Malchiodi, 2012;

Terr, 1990; van der Kolk, 2005). Complex trauma is a multifaceted problem that disrupts children’s personal and social functioning on many different levels, including biological (e.g., hypervigilance), psychological (e.g., dissociation) and social (e.g., compromised attachment and relationships). These levels of trauma and their impacts have a powerful effect on children’s physical and mental health throughout their lives, especially as young

53 adults and as adults many years later. Such harmful impacts are evident in my practice experiences whereby adults with mental health and addictions issues predominantly disclose histories of childhood sexual abuse, supporting Knight’s (2015) finding that adult survivors of childhood trauma account for the majority of clients seeking treatment.

The impacts of complex trauma include increasing situational risks as evidenced by the fact that people with histories of trauma, abuse, and neglect make up almost the entire prison population in the United States (van der Kolk, 2005). It is also evidenced in the field of psychiatry, for which the patient-client population is over-represented with adults who experienced trauma as children, and then went through a lifetime of

diagnostic labels that were rooted in their early childhood experiences (Sinason, 2011).

This is in keeping with epidemiological studies, which show that children exposed to trauma are vulnerable to a range of psychological, behavioural, and emotional problems, social maladjustment and academic failure (Allnock & Hynes, 2011). Statistics on childhood trauma support its prevalence but also support the multiple types of

victimization, or polyvictimization, which predict the highest rates of trauma symptoms (Mannarino & Cohen, 2011).

Such evidence is testimony to the lasting effects of childhood trauma, and highlights the dire necessity of early intervention with developmentally appropriate interventions, which could change the negative trajectory of traumatized children’s futures. It has been within my own work with traumatized children that I have developed an interest in researching interventions that go beyond traditional talk therapies, which are now known to be less than effective with children. Children learn through their natural language of play, which helps them to explore, and to express emotions including

54 pain (Pehrsson & Aguilera, 2007; Schaefer & O’Conner, 1983). One developmentally and neurologically appropriate form of intervention can be found within the field of play therapy whereby certified play therapists intervene with high-risk children, who have experienced complex trauma (Reyes & Asbrand, 2005). In my experience with the use of play in therapy, I have witnessed its powerful effects. The activities give ‘voice’ as they speak children’s language and offer opportunities for expression of their traumatization, while providing opportunities for children to master their traumas, and to regain hope for their future.

Most traumas begin at home as the vast majority of people (almost 80%) responsible for child maltreatment are children’s own parents (van der Kolk, 2005).

When trauma stems from within a child’s caregiving system beginning early in childhood the traumatized child will organize their behaviour around the expectation of, or

prevention of, abandonment or victimization while keeping the abuse a secret (Herman, 1997). For example a child who becomes aggressive to protect himself cannot simply stop acting out when the danger has passed. S/he remains in hypervigilant mode, which is most often misread by caring adults as an aggressive personality. Similarly, a child who tells a lie as a way to protect himself from an abusive parent cannot stop lying simply by being removed from that home, nor can a child who is taught to steal as a way to please adults stop doing so because of removal from this environment. These apparently unreasonable patterns have their own logic but are still very difficult for caregivers to comprehend. Ignorance of the effects of trauma on a child may lead to labels such as:

oppositional, rebellious, unmotivated, detached, and antisocial. In addition, it can also lead to stigmatization for behaviours that are meant to ensure survival (van der Kolk,

55 2005). In my experience, the majority of mental health or behavioural management referrals on children in care are for behavioural issues such as aggression, defiance and lying, which did not subside following removal. It is important to recognize that in social work practice history, the functional school recognized this paradoxical pattern of

function in apparent dysfunction (Dunlap, 2011; Jani & Reisch, 2011; Towle, 1957).

Initially, clinical exploration of the more direct effects of trauma was prompted by studies of war veterans. Traumatized soldiers from WWI were diagnosed with war

neuroses, including the phenomena labeled shell shock (Bailey, 1918). Work with these veterans propelled the field of social work into a recognized specialty prompting the development of a new education curriculum to prepare social workers to treat returning veterans in WWII (Bransford & Bakken, 2003). It was the diagnosis of Vietnam veterans that contributed to the formulation and inclusion of posttraumatic stress disorder (PTSD) in the DSM, 3^rd ed. (APA, 1980). At the same time there was an increased societal awareness of violence against women and children, which specifically highlighted the trauma of child abuse and its post-trauma effects (Herman, 1997).

Clinical exploration of psychological trauma continued, with increased knowledge and practice wisdom from the vantage point of trauma as experienced by children and as impacting mental health and development. Subsequently, researchers found that the effects of child abuse trauma, although fitting a posttraumatic model, also evidenced differences in breadth, depth, and developmental impacts (Cook et al, 2005).

Changes were proposed for DSM-IV to reflect these findings by adding a new category of developmental trauma disorder (Cohen, Mannarino & Anthony, 2010). However DSM-IV-TR (2000) instead included a lengthy definition of a traumatic stressor but with

56 more specific criterion than its predecessor. Gil (2010) criticized this definition as being too limiting, too incomplete, or too misleading. It was also criticized for the limited acknowledgement of the differential effects of trauma on children and youth. Thus PTSD remained primarily an adult diagnosis until May 2013, when DSM-5 was released, in which childhood trauma was more clearly recognized and articulated. However,

publication of DSM-5 has sparked debate, thus increased the ongoing research into our understanding, assessment, and treatment of trauma. Scholarship that expands ahead of various iterations of the DSM, informs policy and practice. In this latest revision, PTSD symptom criteria are elaborated and expanded to reflect the different effects of trauma on children, including reduced diagnostic thresholds for children under six years old

(Wakefield, 2013). A critical component of progress will be the dissemination of research findings to those best placed to intervene with traumatized children as well as those working with traumatized children contributing to the research findings. I would suggest the majority of those would be social workers, both in clinical practice and in child protection, which are at the frontline of services for children. These social workers are in prominent positions to implement practice-based evidence, and expert practice wisdom interventions, which eventually evolve into evidence-based practices. A feedback loop needs to be acknowledged and is required in this field so that not only does research and practice inform policy but policy also informs practice, and wise practice informs research, policy, and the practice of others.

Recognition of the needs of high-risk children in DSM-5 will change the

discourse of complex trauma, a major step in reframing the issue. The diagnostic criteria changes will focus attention on identifying high-risk children and promoting reflective

57 clinical exploration and research for developmentally appropriate interventions. In doing so the days of treating complex trauma in children with medication and dismissal will, hopefully, become a thing of the past. In my clinical experience attending to behaviour and reducing behaviour related problems, medicating without benefit of psychotherapies such as talk therapy or active therapies (e.g., play therapy), or dismissal of the presenting issue as not being significant, have more often been the norm than the exception, within the medical field. Take the case of a traumatized child, age 8, who attempted suicide. The psychiatric response was a one-time treatment of Ativan, and return home with no

follow-up. The psychiatrist specifically stated there were no symptoms of PTSD, despite my well-informed insistence. Using DSM-5, this child would have met the specified criteria for diagnosis, thus changing the course of his treatment, and perhaps the predictable symptomatic and developmental trajectory of his future.

The use of PTSD as a diagnosis for trauma is not without its critics. One of the major criticisms is that of its use towards the medicalization of trauma as a condition to be treated pharmacologically, rather than as a normal response to overwhelming

experiences (Burstow, 2003; LeFrançois, 2006; LeFrançois & Coppock, 2014, Mills, 2014; Singh & Chang, 2012). Some see trauma as being adaptive, and are concerned that the western world has pathologized responses and adaptations to abnormal and abusive experiences (Afuape, 2011; Burstow, 2003). Such views see trauma as an opportunity for individuals to develop resilience, resistance, posttraumatic growth and recovery (Brom et al., 2009). Of these, resilience has received significant attention. Resilience is the

capacity to rebound from adversity, strengthened, and to become more resourceful (Bussey & Wise, 2007, p.8), a concept that can be strengthened by protective factors in a

58 child’s life. Resilience is often credited with the successes many victims of traumatic experiences have later in their lives. Other critics of the changes in the DSM-5 fear the potential to increase the prevalence rates of PTSD (Jones, 2011). Still others, such as Cohen, Mannarino & Anthony (2010) say the DSM-IV diagnosis, with revisions, could work well, supporting their position by highlighting established treatments for child PTSD, under conditions where risks are high and needs are often left unmet. Starting with the needs of children and contextual relevance, social workers and play therapists have an opportunity to be child-centred as opposed to diagnostic theory-centred.

Within the conceptualizations of trauma, complex trauma has been identified as one of the most debilitating types, given that it occurs within the confines of a child’s interpersonal relationship with a caregiver. The resulting sequelae have highlighted the need for continued and ongoing study into finding effective interventions for treatment that respects complexity. This need was supported with the release of DSM 5 (2013) in which the needs of high-risk children were recognized, as was the need for effective therapeutic interventions. Far too many children do not get the help they need while they are young enough to ward off the effects of trauma and thus are unable to change the predictable trajectory of trauma effects (Perry, 2009).

2. 2 Historical and political context

This section will review literature concerning the historical and political context of complex trauma by first of all reviewing the history of childhood and how it has been conceptualized and re-conceptualized throughout its development. Depending on the historical timeframe, the political will, and the value of children, the view held of children often changed to realign with societal pressures, and pressures from those who

59 were able to keep the best interests of children in the forefront.

The study of trauma calls to attention the experiences of oppressed people, and therefore is an inherently political enterprise. Because subordination of children

especially has been so deeply embedded in our culture, the use of violence against them (and against women) has only recently been recognized as a violation of human rights.

By the late 1800’s social work as a movement advocated for children’s protection and for the end of child labour, as well as for the end of the sexual exploitation of children as seen in the writings of social work leader and Nobel Prize winner, Jane Addams (Addams, 1912), in A New Conscience and An Ancient Evil. Years later it was the feminist movements that re-focused attention to the widespread sexual abuse of children (Herman, 1997) including interpersonal abuse, arguably, a form of complex trauma.