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.

The relative short-term efficacy and long-term benefits of pharmacologic versus psychotherapeutic interventions have not been studied for posttraumatic stress disorder (PTSD). This study compared the efficacy of a selective serotonin reuptake inhibitor (SSRI), fluoxetine, with a psychotherapeutic treatment, eye movement desensitization and reprocessing (EMDR), and pill placebo and measured maintenance of treatment gains at 6-month follow-up. Method: Eighty-eight PTSD subjects diagnosed according to DSM-IV criteria were randomly assigned to EMDR, fluoxetine, or pill placebo. They received 8 weeks of treatment and were assessed by blind raters posttreatment and at 6-month follow-up. The primary outcome measure was the Clinician-Administered PTSD Scale, DSM-IV version, and the secondary outcome measure was the Beck Depression Inventory-II. The study ran from July 2000 through July 2003. Results: The psychotherapy intervention was more successful than pharmacotherapy in achieving sustained reductions in PTSD and depression symptoms, but this benefit accrued primarily for adultonset trauma survivors. At 6-month follow-up, 75.0% of adult-onset versus 33.3% of child-onset trauma subjects receiving EMDR achieved asymptomatic end-state functioning compared with none in the fluoxetine group. For most childhood-onset trauma patients, neither treatment produced complete symptom remission. Conclusions: This study supports the efficacy of brief EMDR treatment to produce substantial and sustained reduction of PTSD and depression in most victims of adult-onset trauma. It suggests a role for SSRIs as a reliable first-line intervention to achieve moderate symptom relief for adult victims of childhood-onset trauma. Future research should assess the impact of lengthier intervention, combination treatments, and treatment sequencing on the resolution of PTSD in adults with childhood-onset trauma.

C hildren who suffer from complex trauma have been exposed to an environment marked by multiple and chronic stressors, frequently within a caregiving system thal is intended to be the child's primary source of safety and stability. The cumulative influence of these experiences is seen on immediate and long-term behavioral. functional, and mental health outcomes. There is growing consensus that early-onset and chronic trauma result in an array o[ vulnerabilities across many different domains of functioning: cognitive, affective, behavioral, physiological, relational, and self-attributional. While, in the course of development, most children have the chance to invest their energies in developing various competencies, complexly traumatized children must focus on survival. These children need a flexible model of intervention that is embedded in a developmental and social context and that can address a continuum of trauma exposures, including ongoing exposure. This model must draw from established knowledge bases about effective treatment while accounting for the skills of clinical practitioners and the needs of individual children. Consensus from experts suggests that effective treatment of complex trauma in youth should address six central goals: safety, self-regulation. self-reflective information processing, traumatic experience integration, relational engagement or attachment, and positive affect enhancement (Cook et aI., see page 390, and van der Kolk. sec page 401).1 Further, there is a need to recognize contextual variables. including developmen-. ,. .

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