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Toward a rational diagnosis for children with complex trauma histories.
Childhood trauma, including abuse and neglect, is probably the single most important public health challenge in the United States, a challenge that has the potential to be largely resolved by appropnate prevention and intervention. Each year, more than 3 million children are reported to authorities for abuse or neglect in the US; about 1 million of those cases are substantiated.1 Many thousands more undergo traumatic medical and surgical procedures and are victims of accidents and of community violence (see Spinazzola et al., page 433). However, most trauma begins at home; the vast majority of people (about 80%) responsible for child maltreatment are children's own parents.
Inquiry into developmental milestones and family medical history is routine in medical and psychiatric examinations. In contrast, social taboos prevent obtaining information about childhood trauma, abuse, neglect, and other exposures to violence. Research has shown that traumatic childhood experiences not only are extremely common but also have a profound impact on many different areas of functioning. For example, children exposed to alcoholic parents or domestic violence rarely have secure childhoods; their symptomatology tends to be pervasive and multifaceted and is likely to include depression, various medical illnesses, and a variety of impulsive and self-destructive behaviors. Approaching each of these problems piecemeal, rather than as expressions of a vast system of internal disorganization, runs the risk of losing sight of the forest in favor of one tree.
COMPLEX TRAUMA
The traumatic stress field has adopted the term "complex trauma" to describe the experience of multiple, chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (eg, sexual or physical abuse, war, community violence) and early-life onset. These exposures often occur within the child's caregiving system and include physical, emotional, and educational neglect and child maltreatment beginning in early childhood (Cook et al., page 390, and Spinazzola et al., page 433).
In the Adverse Childhood Experiences (ACE) study by Kaiser Permanente and the Centers for Disease Control and Prevention,2 17,337 adult health maintenance organization (HMO) members responded to a questionnaire about adverse childhood experiences, including childhood abuse, neglect, and family dysfunction. Eleven percent reported having been emotionally abused as a child, 30.1% reported physical abuse, and 19.9% sexual...