Addressing Complex Trauma Across the Lifespan

Editor’s note: This text-based course is an edited transcript of the webinar, Addressing Complex Trauma Across the Lifespan, presented by Patrice Berry, Psy.D., LCP.

Learning Outcomes

• After this course, participants will be able to define complex Trauma and understand how it can present across the lifespan.
• After this course, participants will be able to identify the appropriate assessment tool to match the setting. 
• After this course, participants will be able to identify clinical approaches to consider with children, families, and adults that present with complex trauma.

  Introduction

One disclaimer that I want to give is that I will be going over larger programs that you may need an additional certification for, so this course will not give an exhaustive explanation of the different training. This topic applies to almost any setting, and you will encounter individuals with complex trauma if you have not already. These individuals are often difficult to engage, and taking different approaches can help them meet their treatment objectives. This course does assume a foundational knowledge of the Adverse Childhood Experiences study and a basic understanding of trauma-informed care. This care goes from looking at what is wrong to looking at what happened to you. This is important because it is often that the history of the person is not considered. Going into that detailed history can often give you a better understanding of how to help an individual. 

Complex Trauma

According to the National Child Traumatic Stress Network, “the term Complex Trauma describes both children's exposure to multiple traumatic events, often of an invasive, interpersonal nature, and the wide-ranging, long-term impact of this exposure.” That exposure can be emotional, social, cognitive, behavioral, or physical. It is not an official diagnosis within the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and people often refer to it as complex post-traumatic stress disorder (PTSD). However, it is not an official diagnosis. Experts tried to work on including developmental trauma or complex trauma within the DSM-5, and instead lowered some of the restrictions for kids. This is because practitioners realized that kids were not meeting full criteria for PTSD, and it did not fully describe all that was going on with the individual. Maybe it will be included in the future. 

Clinical Presentation Across Lifespan

Early Childhood (0-5)

• Developmental delays
• Difficulty separating from caregiver 
• Crying and/or frequent screaming 
• Difficulty with appetite
• Nightmares
• Dysregulated behaviors

In early childhood, you may notice developmental delays. These children have had significant neglect during their early years, so there may be speech delays, cognitive delays, or issues with sensory processing. They may have difficulty separating from their caregiver, or there may be excessive crying or frequent screaming that goes beyond what you would expect for that age range. This may be a child who is difficult to console, and you may see issues with appetite. In working with their social worker and treatment team, you can see how to address those issues. The child may also be experiencing nightmares, which is one of the DSM criteria for PTSD. That is a re-experiencing symptom where kids often do present dysregulated behavior and maybe a little all over the place. Often you will get complaints from daycares, or if they are able to engage in preschool programming, they may struggle within those environments.

School Age (6-12)

• Commonly misdiagnosed as ADHD
• Tantrums
• Difficulty accepting limits and “no”
• Express emotional issues (depression or anxiety) as behavioral issues
• Physical and/or verbal aggression
• Academic problems
• Social withdrawal or poor boundaries
• Hypervigilance/Fearful
• Guilt/Shame

Research shows that children in their school-age years are commonly misdiagnosed with Attention Deficit Hyperactivity Disorder (ADHD) because you may see similar behavioral dysregulation. I describe this to families by telling them that dysregulation that comes from ADHD is a prefrontal cortex, which is a frontal lobe issue, whereas trauma is from an overactive amygdala. If it is more of an emotional dysregulation, that may be trauma-related whereas ADHD is a frontal lobe issue. Watch for individuals with complex trauma who are prescribed stimulant medication because you may see an increase in negative behaviors, and that is when families should talk with their prescribing physician to discuss options. I have had families want to see if they could get used to the medication. However, I always advise them to immediately discuss their options with their provider because the medication stimulates the entire brain. 

Regarding a child with complex trauma, they may have an increase in behaviors at times. That is why it is important to get a good assessment of what is going on. Someone can have ADHD and trauma symptoms and it is important to get some of the trauma symptoms under control. This is because regulating those emotions can help before going forward, and that is when you should work closely with their prescribing physician. You may see tantrums for a variety of different issues, especially in difficulty accepting limits or being told no. That is when you might see an increase in physical aggression or behavioral issues anytime a limit is set. You may get a referral to your office if the family is having difficulty managing the child's behavior. They may be more likely to express emotional issues such as depression or anxiety. 

For adoption and foster care, it is often that when a child comes out of a honeymoon period, families will often feel that the behavioral issues are intentional. I view that as survival behavior, and it can be difficult for them to let go of that because it may have kept them safe in a different environment. Individuals with complex trauma may have had to fight for food or fight their siblings within their families of origin, so giving up that physical aggression may make them feel unsafe. That is why having a good understanding of the child's history is important. You may see academic problems and difficulties with learning, and that is when you want to work with the school to make sure they are not only focusing on academics but also on relationships. You may see complete social withdrawal, difficulty engaging with peers, formation of superficial relationships, or struggle with having deeper relationships. They may be hypervigilant, fearful, or jumpy, which are symptoms of PTSD. There also may be guilt and shame related to their trauma if they start to understand their experience in a different way. There may be self-blame, shame, and low self-esteem with that as well. 

Adolescence (13-18)

• Depression and/or Anxiety
• Anger
• Feelings of loneliness/social withdrawal
• At-Risk Behaviors (e.g. running away, unsafe sexual behaviors, substance abuse)
• Poor peer relationships
• Poor academic performance, lack of academic motivation, and/or frequent referrals
• Legal problems

With adolescents, we see an increase in depression or anxiety, and their emotions begin to be expressed as anger. There may also be an increase in feeling lonely, as well as social withdrawal. They may begin to engage in risk behaviors and often get involved with the juvenile justice setting. These actions include running away, substance abuse, stealing, or unsafe sexual behavior. They have poor peer relationships and are seemingly addicted to drama. They may recreate the chaos that they feel in their different relationships. With those individuals, I try to have them increase their ability to calm because they are used to chaos, not positive interactions within a relationship. There also may be poor academic performance, lack of academic motivation, or frequent referrals from school. This is often when the school’s social worker gets involved. We take their history and find out if we need to switch to a trauma-informed approach or refer them to other programs. There may be legal problems around this age as well. 

Adults (19+)

• Behavioral Issues: impulsivity, substance abuse, treatment interfering/self-sabotaging behaviors
• Emotional Issues: (e.g. affect lability, rage, depression, and panic)
• Social Issues: poor boundaries, frequent drama/conflict, domestic violence (victim and/or aggressor)
• Somatization

Adults often present with similar behavior issues, but now you may start to see ingrained patterns that can be difficult to break. You will see impulsivity, substance use or abuse, treatment-interfering behaviors, or self-sabotaging behaviors. They may also engage in behaviors that damage their relationships, as well as emotional issues and difficulty regulating their effect. They may display rage, depression, or panic. You may see poor social boundaries or frequent drama and conflict. There may be some domestic violence where they could be the victim or the aggressor. There may also be an increase in somatization, where there are frequent physical issues and complaints. The more Adverse Childhood Experiences (ACEs) the individual had in the past will usually mean more medical issues. Trauma has an impact on the physical body, and I want to mention The Body Keeps the Score by Dr. Bessel van der Kolk. It talks about how trauma and the body can be linked and how people have found healing with that. These individuals may present to a medical hospital, but not to counseling or other social services. That is where the social worker, being aware of the background, can often help the person get the right type of treatment. 

Borderline Personality Disorder versus Complex Trauma

An individual can present both borderline personality disorder (BPD) and complex trauma. Some research has shown that individuals with complex trauma can have a higher rate of being diagnosed with personality disorders, but there is other research that shows significant differences. If someone does not have certain symptoms then they may meet criteria for a trauma-related disorder and not borderline personality disorder. The DSM criteria for borderline personality disorder starts with frantic efforts to avoid real or imagined abandonment, a pattern of unstable or intense interpersonal relationships, and identity disturbance, so that is where there may be an unstable sense of self. There can be impulsivity in a few different areas involving self-damaging or suicidal behavior, whether it be gestures, threats, or self-harm. They may experience highs and lows that go over a long period of time. This is more of a personality shift versus a biological mood that you may see within a mood disorder. Chronic feelings of emptiness, inappropriate and intense feelings of anger, difficulty controlling anger, transient paranoid ideation, or severe dissociative symptoms may be prominent as well. 

Take note that some of these symptoms are similar to complex trauma, but there are some specific differences. In looking at the two, they both have an impact on the self and the identity. But within borderline personality disorder, it is about an unstable sense of self, while complex trauma includes a chronic, negative self-image. An individual with BPD may have days where they feel good about themselves, but changes in relationships bring down their sense of self. With complex trauma there is a negative self-image in which they almost always feel badly about themselves. Often they cannot remember a time when they felt positively about themselves. These individuals may have had histories of emotional abuse when the negative things that they play in their mind are things that someone else has said about them. They may have someone else's voice internalized as their own. 

Within both cases, you also can see interpersonal issues. With borderline personality disorder, it is more so about fear of abandonment, as well as unstable relationships due to black and white thinking. With complex trauma there is the chronic avoidance of relationships and isolation, and not feeling like they ever belong within the family. I often see this with individuals who have been adopted and teenagers going into adulthood. They may feel like they do not have a place in the world. They do not go back and forth from love to hate because they often do not feel love from their family. I describe that as there being no bottom to their cup. Regarding individuals with complex trauma, it does not matter how much love you put in their cup because everything just pours out. This can relate to a family that might describe how they spent all day with one foster child, but then that child did not feel cared for the minute they spent time with another child. Also, both BPD and complex trauma have issues with emotion regulation. Within borderline personality disorder, there tends to be more impulsivity and difficulty with regulating mood. With complex trauma, it is ineffective coping and reactive anger. It is chronic difficulty versus not having the right skills. That is why there are treatments that can be effective for both. 

Assessment

There are many different types of assessments that look at trauma and a person's history. If you have time to do a thorough social history and ask specific questions, then that would be preferred. You also want to give someone a nonverbal way to share their story in case some are not comfortable talking. I have worked with many patients for a period of time who disclosed their past trauma later on. It may be difficult for them during that initial intake because of an underlying feeling that they will not be understood or will be judged. I think a detailed intake is a great place to start if you have the time. If you are a foster care social worker, you are going to get that detailed social history. If you are working in an outpatient setting, you will be able to get a thorough understanding. 

On the other hand, if you have a larger caseload and are only able to do a brief screening, I recommend the Adverse Childhood Experiences Scale. It lists 10 different adverse life experiences that someone may have went through, ranging from divorce to physical or sexual abuse. It is important to ask about negative life events versus trauma because people may not view what they went through as trauma; they see it as normal, or they somehow have found a way to cope. That is why using the Adverse Childhood Experiences Scale can be a good way to do a screening. If you are in a setting where you have to do a screening, such as the juvenile justice setting, every student undergoes this to see what their ACEs is. Individuals with lower ACEs typically have less of the behavioral, emotional, social, or cognitive problems. Individuals with higher ACEs can bring up some of those problems and may end up requiring additional support. 

There are symptom checklists to look at, such as the Trauma Symptom Checklist for Children, as well as others for adults. There is a checklist for parents, where they fill it out for their young children. You can also do a more comprehensive assessment by using a Child and Adolescent Needs and Strengths assessment. I see these done within social services, or with a child that has been referred to residential treatment. This is because you are then able to take the time and get a more comprehensive assessment of the child's trauma. I like how that assessment includes their strengths because individuals who have been through complex trauma are also resilient. Those strengths may present in ways that cause issues for them because they may be good at advocating for themselves, but it comes off in an aggressive way. That is where we might tweak their expression of that particular strength because there is always traumatic growth that we can move towards. Even though the person has had those difficult life experiences and cannot change the past, they can turn it into positive change and they need help and support in doing that. 

Multidisciplinary Model

With treatment, I think it is best to take a multidisciplinary model to look at all the different people within their life and their home. Within the school you want to be able to collaborate with teachers whenever possible. You can do this by having teachers do updated reports periodically. If they are involved with social services, you want to make sure you are communicating with their social worker. I recommend that individuals with complex trauma be in some type of therapy because it does affect them across the lifespan. There may be times where the trauma is seemingly resolved at age six or seven, but then at around nine or 10 they need to go back to therapy. They do not have to stay in therapy forever, but I want them to view therapy in a positive light, like going to the doctor for an annual checkup. There may be times when they need to attend therapy again and de-stigmatize it. It is to remind them that they are not wrong or crazy. The skills that individuals acquired previously may not work after a period of time, so they can go back to therapy and learn new skills. When I meet with individuals with complex histories of trauma, I prepare families with the knowledge that they can discontinue therapy for a time. However, something may happen in life where they need to return. 

Some states have community-based services and I am licensed in the State of Virginia, so we have intensive home-based and school-based services that are available. There are other states that do not have those types of resources available, so you will have to research the resources that are available within your area. This is important because there are times when social services will approve certain programs that aren't approved by insurance. Are there any intensive programs that are within the child's home? At times, people do need to go to higher levels of care. In Virginia, we try to limit referrals to higher levels of care because it is the assumption that kids do best within their home. However, there are times when kids are not able to be stabilized within their home and need that referral to a higher level of care. 

You also want to make sure that you are collaborating with their doctor because these individuals can present with a variety of physical symptoms. I do not want to call something somatic without checking with doctors, and then realize the patient has a vitamin D deficiency or sleep apnea. If eating is an issue, I rely on the doctor to help the different treatment providers understand whether or not the individual is in a healthy range. We will most likely intervene more if they are not healthy at that time and collaborate with their psychiatrist. Many individuals with histories of trauma, especially kids and teens, can have sensory issues that are triggered by different things. I have worked with some people who use headphones and that allowed them to do things in their community without becoming overwhelmed with sensory input. Regarding individuals with complex trauma, you will want to be mindful of these factors in your office or the different settings they are involved in. Are they too stimulating? There may be too much going on in their classroom. Within trauma-informed schools, they will often recommend teachers still decorate their classroom in a fun way, but have it be more organized and predictable. For younger children with developmental delays, physical therapy could be helpful. If they have some issues with motor skills, they may need physical therapy. 

Neurosequential Model of Therapeutics

Another treatment model is the Neurosequential Model of Therapeutics. It was developed by Bruce Perry to address the impact of early trauma on brain organization. It is a bottom-up model that describes how the brain develops from the brainstem to the limbic system, as well as the different areas of the brain that are impacted by complex trauma. If an affected individual is in their thirties or forties and they have a trauma trigger, they may revert to lower levels of the brain that were not fully developed. It is useful to have a multidimensional lens and a useful picture to assess someone's strengths and vulnerabilities. Bruce Perry also talks about how viewing the client through this lens allows the treatment team to develop interventions to meet their specific needs. This particular model talks about movement and how that repetition can help individuals regulate lower levels of the brain that may not be as well-developed. It is an evidence-based, developmentally sensitive and trauma-informed program. 

The brain develops from the bottom-up, and the majority of brain organization takes place within the first four years. Starting with the brainstem, we describe that as the primitive brain that is responsible for basic survival skills. That is where the fight, flight or freeze part of the brain is. From the brainstem we move up to the midbrain, which is where the motor skills are developed. If someone has motor issues, they may have originated in the brainstem and the midbrain was not fully developed. There may be issues within the limbic system because that is after the midbrain. The next part of the brain with traditional development is the limbic system, which is the emotional center. If you are working with someone that has a lot of emotional reactivity and certain triggers, they may be getting stuck in the limbic area of their brain. The last part of the brain to develop is the cortex, which is where reasoning and judgment happen. If I am working with a 12-year-old, there could be times when they emotionally revert to age two or three. Someone's developmental age may change based on the situation. 

I work with some people who have certain triggers and revert to different areas of the brain. Some examples of interventions for this include music and repetitive movements. I have a friend that would use jump rope because that repetitive movement helps develop those lower areas of the brain for motor skills. There are some interventions that use yoga or mindfulness cards that can include the entire family. Eye movement desensitization and reprocessing (EMDR) is an example of one of the larger systems that helps reprocess traumatic memories from the affected part in order to prevent flashbacks. It is an effective treatment that has been shown to help work on lower areas of the brain that may not be developed. Drumming can be great as well because of the repetitive movement. Some people benefit from equine therapy or a therapy dog that was specifically trained to help the individual. Maybe the dog helped predict their flashbacks or can tell when they are about to have a panic attack. If some people have companion animals when they are having a difficult moment, it can help calm them. Art therapy and drama therapy are additional examples of interventions that can help develop the lower regions of the brain. 

Rolling with Resistance

Working with individuals with complex trauma are often my more difficult cases. But I understand, which does not excuse their behavior but helps me explain it. This is because when I take this approach and decide to roll with resistance, it keeps me from getting frustrated with the individual I am working with. I train and supervise mental health professionals, and I work with my staff on not working harder than their client. This is because it is often that I see mental health professionals get frustrated when they want the client to do more than they are willing. If we meet clients where they are, maybe they will move to a different level down the road. However, getting frustrated with them because they are not doing what I want them to do will often hurt treatment because relationships are one of the most important things in working with trauma survivors. I like to remind myself that both the client and their families are doing the best that they can. My concern is that they are still not being safe, or maybe their best is causing problems for them. Are they willing to learn some different skills?

As a clinician, you want to be aware of your own triggers and reactions. This is because individuals with complex trauma can read emotions extremely well. They will be able to find that trigger and push it to see what happens within the relationship. As the social worker, that is when you use the skills we teach our clients to regulate your emotions and appropriately respond. It is fine to say, "In this room, I will never disrespect you, so I'd really appreciate you making sure to not be disrespectful of me.” I define respect as an appropriate tone, not name-calling, and not taking personal hits. I remember talking with someone about how they did not have to like the person that they were working with, but they did need to respect them. It is important to set limits and boundaries because sometimes clients push those buttons to get a reaction.

My belief is that I have to agree to be manipulated because if I can see manipulation coming, I can change my response and then the person does not get what they wanted. But we are all human and that is where I have to manage my emotions after the session. If it is a very difficult client and I am in outpatient practice, I may schedule a shorter session with that client. If they are not responding to redirection, maybe I bring the parent in to see how I can adjust things to be emotionally safe for both the client and myself. Make sure to be flexible because a big part of trauma-informed care is giving the client some choice. For individuals with complex trauma I typically have a range of three to four things I might try, but if I present all of those things and the client declines them, I can ask them what they want to do. I present these options early into treatment so I can learn what clients like. Maybe some will want to pick an appropriate song and listen while we talk about it, if they are willing. We can also pull up the lyrics if it is a song that is really important to them. Being flexible with your treatment is helpful because inflexibility can lead to triggering the emotional part of the brain that is often overactive within individuals with complex trauma. 

It is also important to not give up. There is a difference between telling parents that the client is not a good fit for you, versus canceling treatment because the client will not talk. I have received clients after another professional discharged them without having a final session. It is difficult to engage these clients in treatment because they may learn that if they do not engage, they can get out of it. As a social worker it is important to try and meet people where they are and not lose hope. Not losing hope could mean redefining what success means for this client because your goals for them might be different from their own. We want to keep a nonjudgmental posture because these clients are very good at picking up when they are being judged. There is a difference between providing feedback on behavior versus judging the client. Always keep a nonjudgmental attitude towards the person. I might have concerns about specific behaviors, and you may have to be intentional in separating the two because these individuals are riddled with guilt and shame. That is often when I see them have difficulty accepting responsibility for their behavior. It goes between believing they did nothing wrong to thinking they are worthless and hopeless. 

In regards to individuals with complex trauma, be consistent with scheduling, predictable in sessions and following through with appointments. When I went on vacation, I knew that I would have to rebuild the relationship because of the break in consistency. Through preparing myself for that, it helped me not be as frustrated with having to restart the therapeutic process. If we were working on deep topics before I had a planned vacation, we would come back with a check-in in order to build those relationships again. If you have to refer to another provider or terminate services, make sure to do appropriate discharge planning.

Parent Training and Involvement

Parent training and involvement is one of the most important things to consider while working with individuals with complex trauma, especially children and teens. This is because therapists can work on rebuilding the relationship, but that typically occurs over a short period of time. If the parent can get on board with taking a different approach, I have seen progress happen quicker with clients. This way, parents feel less frustrated because if they make changes within their home setting, families have success in reframing behavior. Once again, this is not excusing behavior, but it does help us explain it. One of my favorite examples for this is stealing food. If an individual has had a history of neglect from an early age, we will often refer to that as hoarding food. The word “stealing” has serious consequences while hoarding is more of an impulsive behavior, so families do not get as upset over hoarding. Educating yourself on how to address behaviors without blaming or shaming is important because these individuals already shame themselves in their own minds. We are going to address behaviors, but we are going to do it in a way that targets the behavior and not the person. I recently heard someone say, “Discipline should teach, punishment hurts,” so we want to make sure that we are teaching them about changing their behaviors. 

Having parents explore the root of why certain behaviors are triggering them is important as well. Maybe stealing or lying triggers something that is often from their own childhood. They might be fearful of what that means for the child down the road. When we parent out of fear, we typically make more harsh or rash decisions than when we parent from a more mindful place. Teach parents to recognize their trigger, and then you might find out that their family was always lying for one another in the past. This may have led to the parent saying, "When I'm older and have my own family, they're never going to lie.” One of my interventions I do for lying is not asking a question that you already know the answer to. If the child has cookie crumbs all over their face, do not ask them if they ate a cookie. Even kids without complex trauma are going to say no at times because it is a part of the developmental process for children. That is often why I recommend asking, “Show me your homework,” versus “Did you do your homework?” A parent with a child with complex trauma is going to need to be in constant communication with the school because the child may come home and say, "The teacher said there is no homework for the rest of the year.” The teacher did not say that, so being in communication is going to be very important or the child will continue to hold to that lie. Even when you say, "Hey, I'm emailing the teacher,” they will still say, "Yes, she said it.” I also try to have families use humor when talking with the other professionals, or if they can get into a parent group for those with foster kids. It can often be validating to hear that other people are struggling with the same things. 

When I have parents come in for their first session I often start by talking about typical examples of things kids with histories engage in, and the parents have a look of relief that says, "I thought it was a bad parent. I thought I was a bad person.” Doing that has often helped families disarm some of their defenses in being able to open up to me. I do not have a judgemental attitude towards the parents because I feel that they are doing the best they can. I want to help give them different skills to try because I might recommend something that may not work for their child. It is important to make sure that they are increasing their toolbox because things may work for only a period of time, which is why the relationship with an ongoing provider can be important. They continue to get additional updates, such as getting creative with ways to say yes instead of saying no all the time. With one specific treatment called Trust Based Relational Intervention (TBRI), they talk about ways to deal with children that have issues with food. Parents can have a “yes” table, in which children asking to have nutritious food is always a “yes.” However, it may be yes with a condition. For example, if the parent is cooking dinner and the child asks for a piece of fruit, instead of saying, "No, dinner is almost ready," shift a different way and say, "Okay, you can have it. Set it at the table and you can have it once you finish your dinner.” It is that often the child never eats the banana. If they do, they do not feel like their basic needs are being deprived. 

Regarding children that have histories of significant trauma before the age of four, their brains can easily go into survival mode. That is why I think saying no can be triggering because they are reacting and responding as though this is the individual that is abusing and neglecting them. I have had students that get into rages, saying, "Why don't you care about me? Why won't you feed me?" In some cases they may have just been asking for a snack and they were told no. Now you will have to say no to certain things, but you want to save those no's for big things. The parent may have to let some of the smaller things go, but this is just a different way of thinking about things. We want to focus on safety-related behaviors while letting go of minor annoyances because the child may chew with their mouth open, but they have a history of significant trauma. Instead it would be beneficial to focus on the speed that they eat instead of how they eat, because that might be a safety issue. Focusing on major things and letting go of some minor things can be good for building a relationship because people do not want to be in a relationship with those who always tell them no. With parents, they feel like they should always be mindful of their child. Letting a few minor things go can often be very helpful. 

Creating “Felt Safety”

As I mentioned before, TBRI is an intervention that has been developed by Karyn Purvis. There is a treatment protocol and a free chapter available online. It talks about creating physical, emotional, social, and cultural safety. With felt safety, it is a feeling in which you can be physically safe, and still not feel safe. It is often that individuals with complex trauma rarely feel safe, and I want to talk to those clients about the areas of their life where they feel safe. Is it when they are all alone and no one is around? For some people, being alone is when all their thoughts come. They may feel more safe when they are with a trusted caregiver, so it is important to learn about what makes them feel safe and unsafe. 

With physical safety, we may learn that they feel unsafe in their bedroom at night. They may be 15 years old, but maybe bad things happened at night and having a nightlight would help them. This would also help them save face if there are some other children living in the house. Maybe sleeping with the door open could be another safety precaution. "We're going to start sleeping with the door open, just so I can check in at night.” Having the door open with the hallway light on helps get some additional light into the room. Trying to find those creative ways to help clients feel safe when they are physically safe is important. If they are not in a safe situation, we want them to get out of it. However, we want to increase the times that they feel safe when they are physically safe. There are a lot of interventions that you can do around that. 

Creating emotional safety is where we let clients know that emotions are neither good or bad, they just are. Have them get comfortable with their emotions because often they want the emotions to go away. Social safety can be created within their peer group. Some helpful resources include The Deepest Well by Dr. Harris, The Connected Child by Karyn Purvis, and other additional books by Bruce Perry and Daniel Siegel. I have also included video resources. I have families who struggle with finding time to read a whole book, and quick links work better for them. With these links, it may be appropriate for the patient to watch and get an understanding of what is going on with them as well, which can be validating. 

Resources

• The Deepest Well: Healing the Long-Term Effects of Childhood Adversity by Nadine Burke Harris, M.D.
• The Connected Child: Bring hope and healing to your adoptive family by Karyn B. Purvis, David R. Cross, & Wendy Lyons Sunshine
• The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist's Notebook- What Traumatized Children Can Teach Us About Loss, Love, and Healing by Brue D. Perry & Maia Szalavitz
• The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel Van Der Kolk, M.D.
• The Neurosequential Model in Education: Introduction to the NME Series: Trainer's Guide (NME Training Guide) by Bruce D. Perry & Steve Graner
• The Whole-Brain Child: 12 Revolutionary Strategies to Nurture Your Child's Developing Mind by Daniel J. Siegel & Tina Payne Bryson
• The Connected Parent: Real-Life Strategies for Building Trust and Attachment by Lisa Qualls, & Dr. Karyn Purvis
• Attached: The New Science of Adult Attachment and How It Can Help You Find and Keep Love by Amir Levine & Rachel Heller

Video Resources

• Karyn Purvis Institute of Child Development: https://www.youtube.com/channel/UCBW9RKLvTR5C46ey7gy3NuA

•  Survival Brain versus Learning Brain (Jacob Ham): https://www.youtube.com/watch?v=KoqaUANGvpA

• The Repair of Early Trauma: A Bottom Up Approach (Beacon House): https://www.youtube.com/watch?v=FOCTxcaNHeg

• What is Complex PTSD (BetterHelp): https://www.youtube.com/watch?v=NeQ8bgUAnFg

• How Childhood Trauma Affects Health Across a Lifetime (Nadine Burke Harris)

Summary

In summary, we were able to define complex trauma and understand its different presentations across the lifespan in order to avoid misdiagnosis. We then talked about assessing complex trauma and some different clinical approaches that focus on a multidisciplinary approach, including the whole team to create safety and address complex trauma across the lifespan.  For more information regarding culturally competent practice, please review the NASW resource Standards and Indicators for Cultural Competence in Social Work Practice. 

References

Alisic, E. (2012). Teachers' perspectives on providing support to children after trauma: A qualitative study. School   Psychology Quarterly, 27(1), 51–59.

Briere, J. (1996). Trauma Symptom Checklist for Children (TSCC), Professional Manual. Odessa, FL: Psychological   Assessment Resources.

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