Content uploaded by Joseph Spinazzola
Author content
All content in this area was uploaded by Joseph Spinazzola on Aug 10, 2018
Content may be subject to copyright.
2 PSYCHIATRIC ANNALS 35:5 | MAY 2005
C
M
E
The term complex trauma refers to
a dual problem of exposure and
adaptation.3,4 Complex trauma
exposure is the experience of multiple or
chronic and prolonged, developmentally
adverse traumatic events, most often of
an interpersonal nature (eg, sexual or
physical abuse, war, community vio-
lence) and early-life onset. These ex-
posures 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., see page xxx).3
According to the National Child
Abuse and Neglect Data System devel-
oped by the Children’s Bureau of the US
Department of Health and Human Ser-
vices (DHHS), 903,000 cases of child
maltreatment were substantiated in the
United States in 2001 — and this num-
ber is thought to be an underestimate.3
The Third National Incidence Study of
Child Abuse and Neglect,4 an epidemio-
logical study, estimated the incidence of
children at risk of harm through abuse
and neglect to be 2,815,600 in 1993.
Considering that complex trauma may
take many other forms in addition to
maltreatment (eg, chronic exposure to
community violence, loss of a primary
caregiver in early childhood), it is un-
deniable that child complex trauma is a
prevalent public health problem.
A growing body of research has
clearly substantiated that complex trau-
ma exposure leads to chronic problems
across multiple domains of self-regula-
tion: affective, behavioral, physiologi-
cal, cognitive/perceptual, relational,
and self-attributional.3 While affected
children often meet criteria for posttrau-
matic stress disorder (PTSD), expres-
sions of psychopathology typically ex-
tend beyond the symptoms captured by
that disorder, and often include psychi-
atric disorders and functional defi cits in
the areas of attachment, anxiety, mood,
eating, substance abuse, attention and
concentration, impulse control, disso-
ciation, somatization and chronic medi-
cal problems, sexual behavior and de-
velopment, and learning and scholastic
performance. For example, in a study of
sexually and physically abused boys and
girls ages 7 to 13, PTSD was only the
fourth most common diagnosis, follow-
ing separation anxiety, oppositional defi -
ant, and conduct disorders.5 Both clinical
consensus and research have shown that
the adverse effects of complex trauma
exposure can be lasting; adult survivors
of complex trauma have been found to
continue to exhibit signifi cant defi cits in
many domains of functioning and meet
criteria for a wide range of psychiatric
National Survey of Complex Trauma
Exposure, Outcome, and Intervention for
Children and Adolescents
Joseph Spinazzola, PhD; Julian D. Ford, PhD; Marla Zucker, PhD; Bessel van der Kolk, MD; Susan
Silva, PhD; Stefanie Smith, PhD; and Margaret Blaustein, PhD
EDUCATIONAL OBJECTIVES
1. Identify the three most com-
mon forms of trauma exposure
reported for children served by
the National Child Traumatic
Stress Network.
2. Discuss the domains of impair-
ment reported by practicing
clinicians to be exhibited by a
majority of children exposed to
complex trauma.
3. Describe two intervention mo-
dalities reported by practicing
clinicians to be most effective
in treatment with children
impacted by complex trauma.
Dr. Spinazzola is [TITLE], The Trauma Cen-
ter at Justice Resource Institute, Brookline, MA.
Dr. Ford is [TITLE], University of Connecticut
School of Medicine, Department of Psychia-
try, Farmington, CT. Dr. Zucker is [TITLE], The
Trauma Center. Dr. van der Kolk is professor of
psychiatry, Boston University Medical School,
Boston; clinical director, The Trauma Center;
and co-director, National Child Traumatic
Stress Network Community Program, Boston.
Dr. Silva is [TITLE], Duke University Medical
Center and Duke Clinical Research Institute,
Durham, NC. Dr. Smith is [TITLE] and Dr. Blaus-
tein is [TITLE], The Trauma Center.
Address reprint requests to: Joseph Spinaz-
zola, PhD, 227 Babcock Street, Brookline, MA
02446; or e-mail: spinazzola@traumacenter.
org.
This project was supported by the Sub-
stance Abuse and Mental Health Services Ad-
ministration National Child Traumatic Stress
Initiative, including grants U79 SM 54587 and
UD1 SM56111.
[DISCLOSURES]
PSYCHIATRIC ANNALS 35:5 | MAY 2005 3
disorders beyond PTSD.6
Although the prevalence of PTSD
and associated psychiatric disorders in
traumatized children has been estimated
in community7,8 and clinical or high-risk
populations,9,10 the prevalence of self-
regulatory problems related to child-
hood complex trauma exposure has been
studied in regard to only specifi c, limited
problems in clinical samples (eg, suicid-
ality,11,12 early childhood regulatory and
attachment disorders13).
The National Child Traumatic Stress
Network (NCTSN) was created in 2001
to address the widespread effects of
trauma on children’s lives in the United
States. Funded by DHHS through the
Substance Abuse and Mental Health
Services Administration (SAMHSA),
the NCTSN brings together leading aca-
demic clinical research institutions and
front-line community service providers
delivering inpatient, outpatient, residen-
tial, school- and home-based, homeless,
and juvenile justice services to children
and families in urban, suburban, and
rural communities. Although many of
these programs always recognized psy-
chological trauma and PTSD as impor-
tant factors in the lives and treatment
of the children and families whom they
serve, the NCTSN has provided the fi rst
national mandate for them to develop
and disseminate effective services for
this population. With the onset of this
network, clinicians and researchers have
begun to share observations that many
of the children and families being served
had experienced multiple types of often
severe and persistent trauma1 and were
exhibiting a wide array of subsequent
symptoms, behaviors, and diffi culties
consistent with fundamental problems
with self-regulation.2 In response, the
Complex Trauma Workgroup (CTWG)
of the NCTSN was established to better
understand and address the mental health
needs of this large but often overlooked
subset of traumatized children and their
families.
In 2002, the CTWG conducted a sur-
vey to assess clinicians’ perceptions of
the extent and nature of complex trauma
exposure and sequelae in children and
families receiving treatment services at
network sites. The survey also assessed
the types and perceived effectiveness of
interventions used with children affected
by complex trauma. This article provides
a summary of this study and its results.
METHOD
Measures
The survey was developed based on
a review of the literature and collective
clinical and research experience through
a multi-level survey design, including
an expert consensus by members of the
CTWG and review and approval by the
National Center for Child Traumatic
Stress (NCCTS) of the NCTSN. The
survey was completed by clinicians who
were asked to provide aggregate data on
their child trauma caseloads. As the unit
of analysis in this study is the clinician
and not the child, interrelations among
child demographic, trauma exposure,
and symptom variables could not be ex-
amined.
The survey asked respondents to de-
scribe the size, demographics, trauma his-
tories, and symptomatic and functional
problems of their child/family caseloads
in the 12-month period between January
1 and December 31, 2002. Respondents
also were asked to identify intervention
modalities employed with these patients
and to select those modalities they con-
sidered most and least effective in treat-
ment of complex trauma.
Participants/Procedure
The survey was sent to 118 clinicians
at 34 eligible network sites; 62 clini-
cians (range = 1 to 6 respondents per
site) from 25 sites returned the survey,
refl ecting a response rate of 74% for
sites and 53% for clinicians. Survey dis-
semination followed a representative,
but not random, sampling procedure.
Specifi cally, NCTSN regional liaisons
solicited names of up to fi ve direct child
service clinicians per site from the di-
rectors of the 36 Category II (academic
institutions) and Category III (commu-
nity provider agencies) Network sites in
existence at the time of the survey. No
information about survey content was
provided to site directors. Directors were
asked to select clinicians with caseloads
of 10 or higher who could address the
range of service settings and types of-
fered at the site.
Two of the 36 sites solicited were inel-
igible due to a lack of active clinicians in
2002. Eight of the nine eligible Category
II sites provided survey data, one site de-
clining to participate. Of the 25 eligible
Category II [SHOULD THIS BE III?]
sites solicited, 17 provided data, one was
unable to respond in time due to local
IRB requirements, four declined partici-
pation or did not respond, and clinicians
at three sites failed to complete the sur-
vey. Participating sites were located in
19 states distributed throughout the con-
tinental US and the District of Columbia.
The geographic distribution and types of
communities and programs represented
by participating sites were comparable
to those of the entire NCTSN, and rep-
resent a cross-section of child and fam-
ily service programs and patients that
is consistent with the national sample
of service programs represented in the
SAMHSA Center for Mental Health
Services14 evaluation of comprehensive
community mental health services for
children and their families.
RESULTS
Caseload Size and Demographics
Reported caseload size ranged from
four to 150, with a mean of 27.4 (SD =
23.3). Aggregate data were provided on
4 PSYCHIATRIC ANNALS 35:5 | MAY 2005
a sample of 1,699 children, constituting
approximately 15% of the total popula-
tion of children directly served by the
NCTSN during a typical year. Demo-
graphic characteristics of the children
and families represented in this survey
are shown in the Table (see page xxx)
and are consistent with those served by
the entire NCTSN. Child patients de-
scribed by respondents were comparable
to children receiving community mental
health services nationally,21 with some
exceptions. They were more likely to
be 5 or younger (25% versus 8%); less
likely to be adolescents (35% versus
62%); more likely to be black (30% ver-
sus 17%); more likely to be female (57%
versus 38%); and more likely to be in
foster placement (18% versus less than
10%). The majority of children received
child trauma specialty services (63%) or
a combination of general mental health
and specialized trauma services (27%),
in an outpatient mental health clinic set-
ting (79%).
Trauma Exposure
The majority of patients described by
clinicians (77.6%) had been exposed to
multiple and/or prolonged trauma, with
a mean number of three (SD = 1.8, range
= 1-11) trauma exposure types (Figure
1, see page xxx). Within a given type,
multiple incidents or chronic ongoing
exposure may have occurred. Initial ex-
posure was reported to occur early, with
an average age of onset of 5 years (SD
= 2.8). Moreover, although one-third of
the sample was adolescent, 93% of cli-
nicians reported average trauma onset
before age 8, and 98% by age 11.
Interpersonal victimization uniform-
ly emerged as the most prevalent form
of trauma exposure, with the locus of
impact typically in the home (Figure
1, see page xxx). Specifi cally, psycho-
logical maltreatment (ie, verbal abuse,
emotional abuse or emotional neglect)
and traumatic loss were reported to have
occurred for more than half of all child
patients, and dependence on an impaired
caregiver (ie, parental mental illness or
substance abuse), domestic violence,
and sexual maltreatment/assault for
more than 40% of the children treated.
Neglect (physical, medical, or educa-
tional) and physical maltreatment or as-
sault were reported to have occurred for
approximately 30% of child patients. Al-
most one in fi ve children was described
as having been directly exposed to war
or terrorism within the US. Forms of
trauma exposure not involving interper-
sonal victimization were less often re-
ported; fewer than 10% of child patients
had been exposed to serious accidents,
medical illness or disaster.
Complex Posttraumatic Sequelae
TABLE.
Demographic Characteristics of Children* Represented in
the NCTSN Complex Trauma Survey
n % of Sample
Child trauma client age
0-2 59 3.5
3-5 382 22.5
6-11 646 38.0
12-15 418 24.6
16-21 194 11.4
Child trauma client race
White 955 56.2
Black or African
American
507 29.8
Asian 35 2.1
Mixed 115 6.8
Other 19 1.1
Unknown 68 4.0
Child trauma client ethnicity
Hispanic or Latino 369 21.7
Not Hispanic or
Latino
1295 76.2
Unknown 35 2.1
Child trauma client gender
Female 967 56.9
Male 732 43.1
Family status
Intact biological 362 21.3
Divorce/stepparent(s) 213 12.5
Divorce/single parent 533 31.4
Adoptive home 77 4.5
Foster home 309 18.2
Living with relatives 152 8.9
Unknown 17 1.0
*n = 1699
PSYCHIATRIC ANNALS 35:5 | MAY 2005 5
Clinicians reported that a large per-
centage of the children being served were
exhibiting several forms of posttraumat-
ic sequelae not captured by the symp-
toms of PTSD, other anxiety disorder, or
mood disorder (Figure 2, see page xxx).
Notably, 50% or more were reported to
exhibit signifi cant disturbances in the
following domains: affect regulation, at-
tention and concentration, negative self-
image, impulse control, and aggression
or risk taking. In addition, approximate-
ly one-third of the sample demonstrated
problems with somatization, conduct or
oppositionality, age-inappropriate sexu-
al interest, activity or avoidance, attach-
ment, or dissociation.
Treatment Approaches
The fi ve most common modalities re-
ported as being used with children who
had experienced complex child trauma
were: weekly individual therapy (77.8%),
coping or self-management skills coach-
ing (62.2%), parent–child or family ther-
apy (56%), play therapy (54.9%), and
expressive therapies (41.3%). Clinicians
were also asked to rank the three most
and least effective modalities for treat-
ment of children who had been exposed
to complex trauma based on the subset
of modalities in practice at their setting
and direct clinical observation and/or
empirical demonstration of treatment
outcomes at their site.
Despite the wide array of interven-
tions reported as available, no clear con-
sensus emerged regarding the relative
effectiveness of available modalities.
Notably, fi ve of the seven modalities
identifi ed by respondents as most ef-
fective — play, group, expressive, and
multisystemic therapies and self-man-
agement skills coaching — were also
ranked by respondents among the seven
least effective interventions with this
population. Only individual and family
therapy were perceived to be effective
intervention modalities by a majority
of respondents (78% and 57%, respec-
tively).
Consistent with the positive evalu-
ation of family therapy modalities, the
majority of respondents spontaneously
identifi ed the active involvement of care-
givers in children’s treatment as a cru-
cial element in treatment. Many clini-
cians also noted the utility of combined
approaches to intervention, as well as
the need to tailor intervention services
to children’s specifi c needs based on
contextual factors, which include devel-
opmental stage, sociocultural context,
and the availability of environmental
resources. Finally, several clinicians
pointed to the importance of coordinat-
ing services across service sectors (eg,
schools, mental health, social services).
DISCUSSION
This survey provides a preliminary
description of the types of complex child
trauma exposures and their sequelae
and treatment, as reported by clinicians
representing both the leading academic
clinical research institutions and com-
munity providers, in the child traumatic
stress fi eld nationally. Although the sur-
vey was not intended to represent the
broader children’s mental health servic-
es system, the clinicians surveyed and
their programs and patients were similar
in geographic distribution, demographic
0
10
20
30
40
50
60
Emotional Abuse
Loss
ImpairedCaregiver
Domestic Violence
Sexual Abuse
Neglect
Physical Abuse
War/Ter rori sm (U. S.)
Inju ry/Accident
Illness/Medical
Disaster
War/Terrorism (Int'l
)
Forced Displacem en t
% of Sample
Figure 1. Prevalence of trauma exposure types in children represented in the survey.
0
10
20
30
40
50
60
70
Affect dysr egulation
Attent ion/Concentration
Negative self- im ag e
Impulse control
Aggression/risk-taking
Somatization
Clinginess
ODD/Conduct disorders
Sexual Problems
Attachment Problems
Dissociation
Fears insocial situations
Substance Abuse/ Dependence
% of Sample
Figure 2. Prevalence of posttraumatic sequelae in children represented in the survey.
6 PSYCHIATRIC ANNALS 35:5 | MAY 2005
characteristics (with notable exceptions
discussed below), and service/program
types to the providers and patients in-
cluded in the largest national study of
community mental health services for
children.14 The survey results, therefore,
provide a basis for clinical hypotheses
about the nature and extent of trauma
exposure and posttraumatic sequelae
experienced by children receiving psy-
chiatric services in the US, which can be
more defi nitively tested in subsequent
epidemiological studies.
The results are striking in suggest-
ing a substantial prevalence of children
in mental health services who have had
multiple, chronic, and early-onset trauma
exposures and severe biopsychosocial
impairment. Moreover, interpersonal
traumas, and in particular psychological
maltreatment, traumatic loss, and family
violence, were the most commonly re-
ported types of trauma exposures. Inter-
estingly, these experiences do not neces-
sarily meet the “Criterion A” defi nition
for a traumatic event from the Diag-
nostic and Statistical Manual of Mental
Disorders, fourth edition (DSM-IV),15
which requires, in part, an experience
involving “actual or threatened death or
serious injury, or a threat to the physi-
cal integrity of self or others.” Children
exposed to these prevalent types of inter-
personal adversity thus typically would
not qualify for a PTSD diagnosis unless
they also were exposed to experiences or
events that qualify as “traumatic,” even
if they have symptoms that would other-
wise warrant a PTSD diagnosis.
This fi nding has several implica-
tions for the diagnosis and treatment of
traumatized children and adolescents.
Non-Criterion A forms of childhood
trauma exposure, such as psychological
or emotional abuse and traumatic loss,
have been demonstrated to be associated
with PTSD symptoms and self-regula-
tory impairments in children16,17 and
into adulthood.18 Thus, classifi cation of
traumatic events may need to be defi ned
more broadly, and treatment may need
to address directly the sequelae of these
interpersonal adversities, given their
prevalence and potentially severe nega-
tive effects on children’s development
and emotional health.
Notably, exposure to terrorism and
war was reported to have occurred for a
substantially larger subset (as many as
one in fi ve child patients) than has been
reported previously in surveys of child
mental health samples in the US.19 This
fi nding may be related to the recency
of the September 11, 2001, terrorist at-
tacks, as well as the presence of several
NCTSN sites in New York, NY. Howev-
er, it also may refl ect the importance of
recognizing exposure to war and terror-
ism as potentially traumatic stressors for
children in the US.
The relatively low prevalence esti-
mates of exposure to noninterpersonal
traumas such as accidents, disasters, or
severe illness are consistent with fi nd-
ings from community epidemiological
samples but lower than those reported
in child mental health and urban juve-
nile justice detention center samples.20
These fi ndings highlight the greater risk
that children receiving mental health
services have of experiencing complex
interpersonal trauma compared with
noninterpersonal trauma. It also, how-
ever, raises the possibility that clinicians
treating children with extensive trauma
histories and severe biopsychosocial im-
pairments may overlook potential types
of trauma that seem less important be-
cause they are accidental or caused by
larger natural forces. Noninterpersonal
trauma should not be overlooked in a
thorough screening or assessment, even
with children who have prominent histo-
ries of more complex trauma.
Clinicians surveyed commonly re-
ported symptoms and behaviors in their
child patients that were consistent with
complex adaptations to trauma. Results
suggest that between approximately
one-third and one-half (or more) of
these children had impairments in the
six domains of self-regulation typically
disrupted by complex trauma: affect
dysregulation, information processing
(eg, attention/concentration diffi culties,
dissociation), self-concept (eg, negative
self-image), behavior (eg, aggression,
risk-taking, conduct or oppositionality
problems), relationships (eg, attachment
problems), and biology (eg, somatiza-
tion). One limitation of this study was
that symptoms of PTSD were not in-
cluded in the survey, thus making it
impossible to compare the frequency
of complex adaptations to trauma to
PTSD symptomatology. Nevertheless,
it is clear that a large percentage of the
children and adolescents receiving men-
tal health and related services across the
country may have experienced complex
trauma exposures and adaptations.
This survey also showed the lack of
clinical consensus on effective treat-
ments for child trauma victims. Indi-
vidual and family therapy were the only
modalities unequivocally ranked as ef-
fective. Family therapy’s designation
as an effective approach to treatment is
consistent both with the frequent occur-
rence of intrafamilial trauma in these
children’s lives and clinicians’ belief
that family involvement was crucial to
achieving positive outcomes. The sur-
vey did not ask about particular models
of individual (eg, cognitive-behavior,
psychodynamic) or family (eg, strate-
gic, behavioral) therapy, so the survey
fi ndings may be due to clinicians’ use
of specifi c approaches or extend across
the different models of individual and
family therapy. More detailed examina-
tion of clinicians’ perceptions of specifi c
models of individual and family therapy
for children’s complex trauma adapta-
tions is warranted, and to that end the
CTWG has identifi ed core components
for interventions with children (Cook et
PSYCHIATRIC ANNALS 35:5 | MAY 2005 7
al., see page xxx).
Ratings for other therapeutic mo-
dalities (eg, home-based, play, expres-
sive, group, pharmacologic) were more
equivocal. These modalities tended to be
more specifi c in their application than
individual or family therapy, controver-
sial among clinicians and researchers,
and less familiar to child mental health
clinicians without specialized training.
These fi ndings suggest either that most
treatment modalities have yet to be suc-
cessfully adapted for this population, or
else that clinicians have not been made
aware of potentially effective approach-
es that could contribute to a multi-com-
ponent intervention.
Related to the demographic char-
acteristics of the survey sample, the
substantial proportion of child patients
served by NCTSN sites who are in fos-
ter care (almost one in fi ve) is an indica-
tion of the importance of identifying and
treating the sequelae of complex trauma
among children who are likely to have
experienced not only abuse and neglect
but also multiple disruptions and losses
of relationships with primary caregiv-
ers.
Furthermore, the greater representa-
tion of young children (5 or younger) in
this survey compared to that reported by
the comprehensive evaluation of child
community mental health services is
consistent with an increasing emphasis
in the past decade21 on identifying and
treating mental health problems early
enough to prevent or mitigate chronic
developmental and psychosocial im-
pairment. The NCTSN specifi cally ad-
dressed this mandate to treat young
children by funding a network of sites
within the larger national network that
provides treatment and assessment for
traumatized infants, toddlers, and pre-
schoolers. The fi nding further suggests
that complex trauma can and should be
identifi ed in early childhood, both to
enhance treatment outcomes for young
children and to reduce the severity and
chronicity of self-regulatory problems
that are evident for school-age and ado-
lescent patients in the survey’s fi ndings.
SUMMARY
The survey results overwhelmingly
indicate that complex trauma exposure
and posttraumatic adaptation involving
self-regulatory impairment are prevalent
in the caseloads of child and family cli-
nicians who work with traumatized pa-
tients. These results suggest that mental
health professionals need assessment and
treatment strategies, tools, and protocols
for use with this population that they can
integrate into their existing practices.
REFERENCES
1. Terr L. Too Scared to Cry: Psychic Trauma
in Childhood. New York, NY: Basic Books;
1990
2. Herman JL. Complex PTSD: a syndrome in
survivors of prolonged and repeated trauma. J
Trauma Stress. 1992;5(3):377-391.
3. Cook A, Blaustein M, Spinazzola J, van der
Kolk B, eds. Complex trauma in children and
adolescents. National Child Traumatic Stress
Network, Complex Trauma Task Force. 2003.
Available at: http://www.nctsnet.org/nctsn_
assets/pdfs/edu_materials/ComplexTrauma_
All.pdf. Accessed April 13, 2005.
4. Third National Incidence Study of Child
Abuse and Neglect (NIS-3). 2001. Available
at: http://www.healthieryou.com/cabuse.html.
Accessed April 13, 2005.
5. Ackerman PT, Newton JE, McPherson WB,
Jones JG, Dykman RA. Prevalence of post
traumatic stress disorder and other psychiat-
ric diagnoses in three groups of abused chil-
dren (sexual, physical, and both). Child Abuse
Negl. 1998;22(8):759-774
6. van der Kolk BA, Pelcovitz D, Roth S, et al.
Dissociation, somatization, and affect dysreg-
ulation: the complexity of adaptation of trau-
ma. Am J Psychiatry. 1996;153(7 Suppl):83-
93.
7. Costello EJ, Mustillo S, Erkanli A, Keeler G,
Angold A. Prevalence and development of
psychiatric disorders in childhood and adoles-
cence. Arch Gen Psychiatry. 2003;60(8):837-
844
8. Kilpatrick DG, Ruggiero KJ, Acierno R,
et al. Violence and risk of PTSD, major de-
pression, substance abuse/dependence, and
comorbidity: results from the National Sur-
vey of Adolescents. J Consult Clin Psychol.
2003;71(4):692-700.
9. Abram KM, Teplin LA, Charles DR, et al.
Posttraumatic stress disorder and trauma in
youth in juvenile detention. Arch Gen Psy-
chiatry. 2004;61(4):403-410.
10. Kaplan SJ, Pelcovitz D, Salzinger S, et al.
Adolescent physical abuse: risk for adoles-
cent psychiatric disorders. Am J Psychiatry.
1998;155(7):954-959.
11. Kaplan SJ, Pelcovitz D, Salzinger S, et
al. Adolescent physical abuse and risk for
suicidal behaviors. J Interpers Violence.
1999;14(9):976-988.
12. Lipschitz DS, Winegar RK, Nicolaou AL, et
al. Perceived abuse and neglect as risk factors
for suicidal behavior in adolescent inpatients.
J Nerv Ment Dis. 1999;187(1):32-39.
13. Scheeringa MS, Zeanah CH. A relational
perspective on PTSD in early childhood. J
Trauma Stress. 2001;14(4):799-815.
14. SAMHSA Center for Community Mental
Health Services. Annual report to Congress
on the evaluation of the Comprehensive Com-
munity Mental Health Services for children
and their families program. Atlanta, GA,
Macro International Inc., 1998.
15. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders.
4th ed. Washington, DC: American Psychiat-
ric Publishing; 1994.
16. Basile KC, Arias I, Desai S, Thompson MP.
The differential association of intimate part-
ner physical, sexual, psychological, and stalk-
ing violence and posttraumatic stress symp-
toms in a nationally representative sample of
women. J Trauma Stress. 2004;17(5):413-
421
17. Cohen JA. Early mental health interventions
for trauma and traumatic loss in children and
adolescents. In: Litz BT, ed. Early Interven-
tion for Trauma and Traumatic Loss. New
York, NY: The Guilford Press; 2004.
18. Higgins DJ, McCabe MP. Maltreatment and
family dysfunction in childhood and the sub-
sequent adjustment of children and adults. J
Fam Violence. 2003;18(2):107-120.
19. Gurwitch RH, Pfefferbaum B, Leftwich MJT.
The impact of terrorism on children: consid-
erations for a new era. J Trauma Practice.
2002;1(3-4):101-124.
20. Costello EJ, Erkanli A, Fairbank JA, Angold
A. The prevalence of potentially traumatic
events in childhood and adolescence. J Trau-
ma Stress. 2002;15(2):99-112.
21. Mental Health: A Report of the Surgeon Gen-
eral. US Department of Health and Human
Services, Substance Abuse and Mental Health
Services Administration, Center for Mental
Health Services, National Institutes of Health,
National Institute of Mental Health. 1999.
Available at: http://mentalhealth.samhsa.gov/
features/surgeongeneralreport/home.asp. Ac-
cessed April 14, 2005.
