Complex trauma events, or chronic interpersonal traumas that begin early in life, are thought to result in profound disruptions, well beyond the symptoms of PTSD. Complex trauma events may be especially toxic for children and adolescents, whose regulatory systems are more vulnerable. This study provides empirical support for the previously unexamined hypothesis that complex trauma events result in broad systemic difficulties, not simply higher levels of PTSD symptoms. This study also offers evidence for a dimensional conceptualization of traumatic events, with acute noninterpersonal trauma residing on one end of the spectrum and complex trauma on the other. 346 treatmentseeking children and adolescents who had experienced a traumatic event were included in this study. Results indicated that children exposed to a complex trauma event had significantly higher levels of trauma-related and generalized difficulties as compared to those exposed to other, less severe traumatic events. Children exposed to successively more severe traumatic events were also reported to have increasingly higher levels of difficulties. The evidence of including an impaired caregiving system, operationalized as the child being removed from the home following the onset of the traumatic event, into the definition of complex trauma was examined, but not supported. The results demonstrate the validity of the concept of complex trauma and point to the need for a diagnostic construct related to complex trauma for children and adolescents. Wamser, Rachel, UMSL, 2012 8 Complex Trauma in Children and Adolescents A substantial number of children and adolescents experience traumatic events such as sexual, physical, or emotional abuse, neglect, domestic violence, natural disasters, school or community violence and serious car accidents and other accidents. It is the unfortunate reality that some of these youth receive more than their fair share, experiencing severe, multiple, prolonged traumas. In fact, one nationally representative sample of over two thousand children found that 22% of surveyed children had experienced four or more different kinds of victimization within a single year (Finkelhor, Ormrod, & Turner, 2007). This suggests that the experience of extensive and repeated trauma is not all uncommon, yet this subset of survivors have not received little attention to their unique needs. Decades of research, however, have been devoted to examining the impact of single types of maltreatment (i.e., sexual or physical abuse) and consistently demonstrate the toxicity of various traumatic events. Childhood traumatic experiences have been linked to a variety of physical and mental health problems, risky and selfinjurious behaviors, negative parenting outcomes, revictimization, and perpetration of interpersonal violence (Abram, Teplin, Longworth, McClelland, & Dulcan, 2004; Anda, 2006; Banyard, Williams, & Siegel, 2003; Felitti et al., 1997; Walsh, Blaustein, Knight, Spinazzola, & van der Kolk, 2007; Whitfield, Dube, Anda, & Felitti, 2003). Clearly, these well-documented symptoms extend far beyond the confines of the diagnostic construct Posttraumatic Stress Disorder (PTSD) even for acute traumatic events. When considering the impact of poly-victimization, then PTSD may be insignificant. A diagnosis of PTSD requires the direct or indirect exposure to a traumatic event that involves an actual or perceived threat to the physical integrity of an individual or others (criterion A1; APA, 2000). Traumatic events commonly observed in childhood Wamser, Rachel, UMSL, 2012 9 include, but are not limited to: child sexual or physical abuse, neglect, domestic violence, life-threatening illness, school or community violence, unexpected death of a family member or close friend, natural disaster, motor vehicle accident or other serious accident. Thus, a wide range of events are captured under the heading of a traumatic event. But would the experience of learning of a friend's non-fatal car accident be expected to result in an identical symptom presentation as chronic sexual abuse perpetrated by one's biological father? According to the PTSD framework, yes. Despite qualitative differences in terms of the degree of involvement, severity, and chronicity of the traumatic event, with the diagnostic construct of PTSD, all traumatic events are assumed to potentially result in the same sequelae. Yet, common sense and clinical lore suggests that survivors of severe traumatic events will have a more complicated symptom presentation. This is affirmed by research. Researchers consistently find that characteristics of the traumatic event are related to a more complicated symptom presentationtypically with non-PTSD symptoms. For example, interpersonal traumas, such as abuse and domestic violence, appear to be particularly harmful, resulting in long-lasting, severe, and more generalized symptoms than non-interpersonal traumas such as motor vehicle accidenets (Briere & Jordan, 2004; Briere, Kaltman, & Green, 2008; Ford, Stockton, Kaltman, & Green, 2006; van der Kolk, 2005). Interpersonal traumas are partly so toxic as they are intentionally perpetrated by another person, thus, the victim’s views regarding safety, intimacy, and trustworthiness are vulnerable to unhelpful or inaccurate alterations (Janoff-Bullman, 1992). The duration and the number of instances of the traumatic event are also related to outcome. Duration and number of incidents are linked together as traumatic events that are chronic, by their nature, have occurred more than once and conversely, multiple incidents of a Wamser, Rachel, UMSL, 2012 10 traumatic event often occur over an extended period of time. Unsurprisingly, the longer and more frequently the trauma occurs, the more severe and varied the post-traumatic sequelae (Blaauw, Winkel, Arensman, Sheridan, & Freeve, 2002; Mechanic, Uhlmansiek, Weaver, & Resick, 2000). Both of these characteristics may contribute to the survivor feeling overwhelmed, helpless, or that the trauma is inescapable. The age of the victim when the trauma begins is important. Traumatic events that begin in childhood result in a more severe symptom presentation compared to those which begin in adulthood (Cloitre, Scarvalone, & Difede, 1997; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). In sum, all traumatic events are not created equal. Taken together, research would suggest that traumatic events which are interpersonal in nature, chronic or multiple, or begin at an early age are related to a more complex symptom presentation (Herman, 1992; Terr, 1991). Within the current PTSD construct, these differences are not acknowledged and instead are subsumed under a single diagnostic category. PTSD also takes a one-size-fits-all approach to trauma-related symptoms, which is tragic as PTSD is fails to capture the full span of trauma-related sequelae. PTSD is classified as an anxiety disorder and consequently, PTSD describes symptoms of anxiety. Trauma survivors unfortunately have problems beyond that of anxiety. Survivors of childhood sexual abuse, for example, have difficulties in a broad range of domains including serious impairments in affect regulation, self-concept, and interpersonal problems, sexualized behavior, and somatic complaints (Cloitre, Stovall-McClough, Zorbas, & Charuvastra, 2003; Spinazzola, 2005; Stovall-McClough & Cloitre, 2006; Zucker, Spinazzola, Blaustein, & van der Kolk, 2006). These symptoms are notably absent from the list of acceptable symptoms of PTSD. As an anxiety disorder, the construct PTSD is unable to capture these difficulties without violating the organization Wamser, Rachel, UMSL, 2012 11 of the DSM. The non-anxiety symptoms which do not fit are relegated to a variety of “comorbid” conditions, which ostensibly are thought to be unrelated to the trauma. This would be acceptable if few traumatized individuals presented with non-PTSD diagnoses. Unfortunately, non-PTSD symptoms are ubiquitous, with more than 80% of individuals diagnosed with PTSD also receiving a comorbid diagnosis (Foa, Freidman & Keane, 2000). PTSD has one of the highest rates of comorbidity of any DSM diagnostic category (Kessler, Chiu, Demier, Merikangas, & Walters, 2005). This may be problematic, it is implied that some, but not all, of the patient's symptoms may be ascribed to the traumatic experience. Conceptualizing other potential effects of trauma as merely “co-morbid,” as opposed to the “real” trauma disorder may also limit the validity of trauma research; as such co-morbid conditions are often excluded from traumafocused research. In fact, a review of the treatment outcome studies demonstrated that the typical presenting client would be screened out of PTSD studies because of comorbid conditions (Spinazzola, Blaustein, & van der Kolk, 2005). Thus, much of PTSD research may not be even applicable to the typical client. PTSD is, instead, more useful in capturing the effects of single-episode, acute traumas occurring in adulthood (Cloitre, Scarvalone, & Difede, 1997; van der Kolk, 2005). In fact, PTSD is diagnosed more frequently following single instances of trauma than after multiple or chronic traumatic events (Green et al., 2000). Clearly, this does not indicate that individuals who have experienced repeated and severe traumatic events do not present with trauma-related difficulties, but rather, that the PTSD criteria may be insufficient in describing reactions to more severe traumatic events. Since its inception into the DSM in 1980, leaders in the field of traumatic stress have argued that PTSD does not accurately capture the presentation of victims of child abuse, concentration camps, Wamser, Rachel, UMSL, 2012 12 refugee camps, domestic violence, or those that have experienced other repeated and extensive trauma (Herman, 1992; Cook et al., 2005; Courtois, 2004). The shortcomings of PTSD are too great for the most serious of traumas. Diagnostic issues tend to be magnifie

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Complex Trauma in Children and Adolescents

Sex differences in stress-related alcohol use.

Examining patterns of adversity in Chinese young adults using the Adverse Childhood Experiences-International Questionnaire (ACE-IQ).

OBJECTIVE
Illicit drug use is identified in Healthy People 2010 as a leading health indicator because it is associated with multiple deleterious health outcomes, such as sexually transmitted diseases, human immunodeficiency virus, viral hepatitis, and numerous social problems among adolescents and adults. Improved understanding of the influence of stressful or traumatic childhood experiences on initiation and development of drug abuse is needed.


METHODS
We examined the relationship between illicit drug use and 10 categories of adverse childhood experiences (ACEs) and total number of ACEs (ACE score). A retrospective cohort study of 8613 adults who attended a primary care clinic in California completed a survey about childhood abuse, neglect, and household dysfunction; illicit drug use; and other health-related issues. The main outcomes measured were self-reported use of illicit drugs, including initiation during 3 age categories: <or=14 years, 15 to 18 years, or as an adult (>or=19 years); lifetime use for each of 4 birth cohorts dating back to 1900; drug use problems; drug addiction; and parenteral drug use.


RESULTS
Each ACE increased the likelihood for early initiation 2- to 4-fold. The ACE score had a strong graded relationship to initiation of drug use in all 3 age categories as well as to drug use problems, drug addiction, and parenteral drug use. Compared with people with 0 ACEs, people with >or=5 ACEs were 7- to 10-fold more likely to report illicit drug use problems, addiction to illicit drugs, and parenteral drug use. The attributable risk fractions as a result of ACEs for each of these illicit drug use problems were 56%, 64%, and 67%, respectively. For each of the 4 birth cohorts examined, the ACE score also had a strong graded relationship to lifetime drug use.


CONCLUSIONS
The ACE score had a strong graded relationship to the risk of drug initiation from early adolescence into adulthood and to problems with drug use, drug addiction, and parenteral use. The persistent graded relationship between the ACE score and initiation of drug use for 4 successive birth cohorts dating back to 1900 suggests that the effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use. Because ACEs seem to account for one half to two third of serious problems with drug use, progress in meeting the national goals for reducing drug use will necessitate serious attention to these types of common, stressful, and disturbing childhood experiences by pediatric practice.

Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study

Adverse childhood experiences (ACEs), peer victimization, and substance use among adolescents

Patterns of adverse childhood experiences and substance use among young adults: A latent class analysis.

Profiles of adverse childhood experiences and impulsivity

Background and objectives E-cigarette use among young people is highly prevalent. Individuals exposed to adverse childhood experiences such as childhood maltreatment (CM) may be at particular risk, as CM has been linked to nicotine dependence. Studies testing the association between CM and e-cigarette use are lacking, including research that examines pathways linking CM to e-cigarette use. Methods Using a community sample of young adults (N = 208; ages 18-21), we examined the relationship between CM and e-cigarette use and explored the potential role of impulsivity in linking CM to e-cigarette use via a series of structural equation models controlling for demographic characteristics. Results CM was significantly associated with lifetime e-cigarette use. Furthermore, CM was associated with negative urgency (NU), whereas NU and sensation seeking were significantly related to lifetime e-cigarette use. NU fully mediated the relationship between CM and lifetime e-cigarette use. Conclusions and scientific significance Our results suggest that young adults with a history of CM might be vulnerable to e-cigarette use and that NU played a significant role in linking CM to lifetime e-cigarette use. Addressing NU in young adults with a history of CM might be a useful avenue for preventing e-cigarette use in this population. (Am J Addict 2019;28:303-310).

Adverse Childhood Experiences and E-Cigarette Use During Young Adulthood.

The last several decades have witnessed growing and converging evidence from randomized controlled trials (RCT’s) that an identifiable set of simple clinical management strategies are effective for those at risk for suicidal thinking and/or suicide attempts. The current article offers a brief review of clinical strategies supported by RCT’s targeting suicidality as “commonalities of treatments that work” and related recommendations for use in the delivery of care for suicidal individuals in generic fashion, regardless of any particular treatment, theoretical orientation, or intervention perspective. The article includes eight recommendations that can be easily adapted across the full range of clinical contexts, institutional settings, and delivery systems, recommendations that help frame a broader clinical narrative for suicide prevention. Recommendations cut across five identifiable domains or clinical strategies for the delivery of care: (1) informed consent discussion that identifies risks of opting out of care and emphasizes the importance of shared responsibility and a collaborative process, (2) an explanatory model that emphasizes the importance of individual self-management skills and targeting the causes of suicide rather than describing suicidality as a function of mental illness, (3) the importance of proactively identifying barriers to care and engaging in targeted problem-solving to facilitate treatment adherence, (4) a proactive and specific plan for management of future suicidal episodes, and (5) reinforcing the importance of taking steps to safeguard lethal means and facilitate safe storage of firearms.

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David Conley

Papers

Patterns of adverse childhood experiences and substance use among young adults: A latent class analysis.

Profiles of adverse childhood experiences and impulsivity

Adverse Childhood Experiences and E-Cigarette Use During Young Adulthood.

A Standard Protocol for the Clinical Management of Suicidal Thoughts and Behavior: Implications for the Suicide Prevention Narrative