he immediate and long-term consequences of children's exposure to maltreatment and other traumatic experiences are multifaceted. Emotional abuse and neglect, sexual abuse, and physical abuse, as well as witnessing domestic violence, ethnic cleansing, or war, can interfere with the development of a secure attachment within the caregiving system. Complex trauma exposure results in a loss of core capacities for self-regulation and interpersonal relatedness. Children exposed to complex trauma often experience lifelong problems that place them at risk for additional trauma exposure and cumulative impairment (eg, psychiatric and addictive disorders; chronic medical illness; legal, vocational, and family problems). These problems may extend from childhood through adolescence and into adulthood (see van der Kolk, page xxx). DIAGNOSTIC ISSUES The diagnosis of posttraumatic stress disorder (PTSD) does not capture the developmental effects of complex trauma exposure. Children exposed to maltreatment, family violence, or loss of their caregivers often meet diagnostic criteria from the Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV), 38 for depression, attention-defi cit/hyperactivity disorder (ADHD), oppositional defi ant disorder (ODD), conduct disorder, anxiety disorders, eating disorders, sleep disorders, communication disorders, separation anxiety disorder, and reactive attachment disorder. Each of these diagnoses captures a limited aspect of the traumatized child's complex self-regulatory and relational impairments. A comprehensive review of the literature on complex trauma suggests seven primary domains of impairment observed in exposed children: attachment, biology, affect regulation, dissociation (ie, alterations in consciousness), behavioral regulation, cognition, and self-concept. 1 Sidebar 1 (see page xxx) provides a list of each domain, along with examples of associated symptoms.
