Julian D. Ford

Complex Trauma in Children and Adolescents

The present paper highlights seven primary domains of impairment observed in children exposed to complex trauma. These phenomenologically based domains have been identified based on the extant child clinical and research literatures, the adult research on Disorders of Extreme Stress Not Otherwise Specified (Pelcovitz et al, 1997; van der Kolk, Pelcovitz, Roth, Mandel, McFarlane, & Herman, 1996; van der Kolk, Roth, et al., in press), and the combined expertise of the NCTSN Complex Trauma Taskforce.

Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice.

Children and adolescents who are exposed to traumatic events are helped by numerous child-serving agencies, including health, mental health, education, child welfare, first responder, and criminal justice systems to assist them in their recovery. Service providers need to incorporate a trauma-inform

Understanding Interpersonal Trauma in Children: Why We Need a Developmentally Appropriate Trauma Diagnosis

Childhood exposure to victimization is prevalent and has been shown to contribute to significant immediate and long-term psychological distress and functional impairment. Children exposed to interpersonal victimization often meet criteria for psychiatric disorders other than posttraumatic stress disorder (PTSD). Therefore, this article summarizes research that suggests directions for broadening current diagnostic conceptualizations for victimized children, focusing on findings regarding victimization, the prevalence of a variety of psychiatric symptoms related to affect and behavior dysregulation, disturbances of consciousness and cognition, alterations in attribution and schema, and interpersonal impairment. A wide range of symptoms is common in victimized children. As a result, in the current psychiatric nosology, multiple comorbid diagnoses are necessary-but not necessarily accurate-to describe many victimized children, potentially leading to both undertreatment and overtreatment. Related findings regarding biological correlates of childhood victimization and the treatment outcome literature are also reviewed. Recommendations for future research aimed at enhancing diagnosis and treatment of victimized children are provided.

Randomized trial of cognitive-behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse.

The authors conducted a randomized clinical trial of individual psychotherapy for women with posttraumatic stress disorder (PTSD) related to childhood sexual abuse (n = 74), comparing cognitive-behavioral therapy (CBT) with a problem-solving therapy (present-centered therapy; PCT) and to a wait-list (WL). The authors hypothesized that CBT would be more effective than PCT and WL in decreasing PTSD and related symptoms. CBT participants were significantly more likely than PCT participants to no longer meet criteria for a PTSD diagnosis at follow-up assessments. CBT and PCT were superior to WL in decreasing PTSD symptoms and secondary measures. CBT had a significantly greater dropout rate than PCT and WL. Both CBT and PCT were associated with sustained symptom reduction in this sample.

Child Maltreatment, other Trauma Exposure, and Posttraumatic Symptomatology among Children with Oppositional Defiant and Attention Deficit Hyperactivity Disorders

Consecutive child psychiatric outpatient admissions with disruptive behavior or adjustment disorders were assessed by validated instruments for trauma exposure and posttraumatic stress disorder (PTSD) symptoms and other psychopathology. Four reliably diagnosed groups were defined in a retrospective case-control design: Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), comorbid ADHD-ODD, and adjustment disorder controls. ODD and (although to a lesser extent) ADHD were associated with a history of physical or sexual maltreatment. PTSD symptoms were most severe if (a) ADHD and maltreatment co-occurred or (b) ODD and accident/illness trauma co-occurred. The association between ODD and PTSD Criterion D (hyperarousal/hypervigilance) symptoms remained after controlling for overlapping symptoms, but the association of ADHD with PTSD symptoms was largely due to an overlapping symptom. These findings suggest that screening for maltreatment, other trauma, and PTSD symptoms may enhance prevention, treatment, and research concerning childhood disruptive behavior disorders.

Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness

Interrater reliability, internal consistency, test-retest reliability, and convergent validity were examined for the Trauma History Questionnaire (THQ), the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale (CAPS), and the PTSD Checklist (PCL) in 30 clients with severe mental illnesses. Interrater reliability for the THQ and CAPS was high, as was internal consistency of CAPS and PCL subscales. The test-retest reliability of the THQ was moderate to high for different traumas. PTSD diagnoses on the CAPS and PCL showed moderate test-retest reliability. Lower levels of test-retest reliability for PTSD diagnoses were related to psychosis diagnoses and symptoms. However, when more stringent criteria for PTSD were used on the CAPS, it had excellent test-retest reliability across all clients. CAPS and PCL diagnoses of PTSD showed moderate convergent validity. The results support the reliability of trauma and PTSD assessments in clients with severe mental illness.

Early Childhood Trauma and Disorders of Extreme Stress as Predictors of Treatment Outcome with Chronic Posttraumatic Stress Disorder

History of early childhood trauma was prevalent and highly correlated with Disorders of Extreme Stress Not Otherwise Specified (DESNOS) in a sample of veterans in inpatient treatment for chronic posttraumatic stress disorder (PTSD). DESNOS predicted reliable change on a variety of measures of psychiatric symptomatology (including PTSD) and psychosocial functioning independently of the effects of PTSD diagnosis and early childhood trauma history. DESNOS also predicted treatment outcome on PTSD and quality of life measures after controlling for the effects of ethnicity, war zone trauma exposure severity, initial level of symptomatic severity or quality of life, Axis I (PTSD and major depression) and Axis II (personality disorder) diagnostic status, and early childhood trauma history. Early childhood trauma was not predictive of outcome. DESNOS appears to play an important role in assessment and treatment planning for psychotherapeutic rehabilitation of chronic PTSD.

Posttraumatic stress disorder in DSM-5: estimates of prevalence and symptom structure in a nonclinical sample of college students.

We empirically investigated recent proposed changes to the posttraumatic stress disorder (PTSD) diagnosis for DSM-5 using a non-clinical sample. A web survey was administered to 585 college students using the Stressful Life Events Screening Questionnaire to assess for trauma exposure but with additions for the proposed traumatic stressor changes in DSM-5 PTSD. For the 216 subjects endorsing previous trauma exposure and nominating a worst traumatic event, we administered the original PTSD Symptom Scale based on DSM-IV PTSD symptom criteria and an adapted version for DSM-5 symptoms, and the Center for Epidemiological Studies-Depression Scale. While 67% of participants endorsed at least one traumatic event based on DSM-IV PTSDs trauma classification, 59% of participants would meet DSM-5 PTSDs proposed trauma classification. Estimates of current PTSD prevalence were .4-1.8% points higher for the DSM-5 (vs. the DSM-IV) diagnostic algorithm. The DSM-5 symptom set fit the data very well based on confirmatory factor analysis, and neither symptom sets factors were more correlated with depression.

COMPLEX TRAUMA AND AGGRESSION IN SECURE JUVENILE JUSTICE SETTINGS

Youth in secure juvenile justice settings (e.g., detention, incarceration) often have histories of complex trauma: exposure to traumatic stressors including polyvictimization, life-threatening accidents or disasters, and interpersonal losses. Complex trauma adversely affects early childhood biopsychosocial development and attachment bonding, placing the youth at risk for a range of serious problems (e.g., depression, anxiety, oppositional defiance, risk taking, substance abuse) that may lead to reactive aggression. Complex trauma is associated with an extremely problematic combination of persistently diminished adaptive arousal reactions, episodic maladaptive hyperarousal, impaired information processing and impulse control, self-critical and aggression-endorsing cognitive schemas, and peer relationships that model and reinforce disinhibited reactions, maladaptive ways of thinking, and aggressive, antisocial, and delinquent behaviors. This constellation of problems poses significant challenges for management, rehabilitation, and treatment of youth in secure justice settings. Epidemiological and clinical evidence of the prevalence, impact on development and functioning, comorbidity, and adverse outcomes in adolescence of exposure to complex trauma are reviewed. Implications for milieu management, screening, assessment, and treatment of youth who have complex trauma histories and problems with aggression in secure juvenile justice settings are discussed, with directions for future research and program development.

Research on Training Counselors and Clinicians

Graduate and mid-career training and supervision are important processes for all human service professions. Practitioners, trainers, and researchers must all acquire and consistently utilize certain skills, attitudes, and knowledge in order to function effectively during their professional careers. Although process and outcome research in psychotherapy and counseling has been extensively reported (e.g., Bergin & Garfield, 1971; Luborsky, Chandler, Auerbach, Cohen, & Bachrach, 1971) parallel research on training counselors and clinicians was almost nonexistent ten years ago (Matarazzo, Wiens, & Saslow, 1966), and rather sparse even five years ago (Matarazzo, 1971). At present, however, the literature encompasses over 100 empirical studies. Although the methods, curricula, and objectives utilized in training are inseparably interdependent in practice, this paper will focus on training methods because that research literature alone merits thorough review before the enormous task of tying together all the research concerning trainings many component processes can be undertaken. Furthermore, research investigating the effects of different training curricula, curriculum content sequences, and curricular materials is, unfortunately, virtually nonexistent in the counselor/clinician training literature (Johnson & Sribbe, 1975; Wexler, 1976). Concerning training objectives, the crucial question of what skills, attitudes, and knowledge