The term “trauma” has both a medical and a psychiatric definition.  Medically, trauma refers to a serious or critical “bodily injury, wound, or shock” (Neufeldt, 1988).  In psychological terms, trauma assumes a different meaning, referring to a “painful emotional experience, or shock, often producing a lasting psychic effect” (Neufeldt, 1988).

Various adverse events experienced in childhood and adolescence can have a detrimental effect on the health, well-being and development of affected children and adolescents (Brooks-Gunn and Duncan, 1997; Rutter, 1999).  Traumatic events often involve a life-threat, severe physical injury, threat to psychological control or physical or psychological integrity, loss of a primary caretaker, or loss of one’s community or social environment.  Traumatic events may occur as episodes of (a) physical and sexual abuse or assault, (b) natural or man-made disasters and catastrophes, (c) physical injuries or incapacitation, such as from motor vehicle or bicycle accidents, animal attacks, or other serious accidents, (d) chronic, severe, or painful medical conditions or invasive or  painful medical procedures, (e) witnessing or experiencing family or community violence, (f) traumatic loss of family members, friends and other significant attachment figures, and (g) exposure to war,  terrorism, kidnappings, political oppression and forced displacement. Traumatic events can be single or repeated events or chronic exposure to or experience of a condition.  Many types of trauma include both acute and longer-term components (e.g., acute physical injuries, such as burns, that result in chronic pain, disfigurement or disability or repeated episodes of childhood abuse.

Exposure to traumatic events is common in children and adolescents.  In 1998 an estimated 200,000 children were victims of physical child abuse, 100,000 were victims of sexual abuse, and 225,000 were victims of multiple forms of child maltreatment. (U.S. Department of Health and Human Services, 2000a).  Each year approximately 140,000 children and adolescents receive treatment for bicycle-related head injuries; almost 20,000 children are hospitalized because of burns, and 5 of every 100,000 children, aged 0-10, are hospitalized for dog bites (Sosin, et al., 1996;  Sacks, Kresnow, and Houston, 1996; Quinlan and Sacks, 1999).

During the event and its immediate aftermath, traumatic events can produce feelings of panic, helplessness, uncontrollable fear or terror and lead to a range of both acute and chronic traumatic stress reactions.  The American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) recognizes a number of psychiatric syndromes associated with exposure to stressful and traumatic events including Post Traumatic Stress Disorder, Acute Stress Disorder, and Adjustment Disorder.  The impact of trauma on the functioning of children and adolescents can be pervasive.  Effects of trauma can include dysphoric emotional states and emotional dysregulation, such as depression, anxiety, and chronic or impulsive outbursts of anger; suicide attempts; behavior problems, such as antisocial behavior and substance abuse; cognitive and motivational distortions, including hopelessness, chronic shame or guilt; learning and academic problems resulting from learning, memory, and attentional difficulties; and interpersonal problems (Leavitt and Fox, 1993; Briere, et al., 1996; Eckenrode, Laird, and Doris, 1993; Gunnar, 2000; Perry and Pollard, 1998; Pollack, Cicchetti, and Klorman, 1998; Shonk and Cicchetti, 2001; Trickett and Schellenbach, 1998). A number of other serious syndromes and pervasive personality distortions are associated with exposure to serious or chronic stress and trauma, including Dissociative Disorders and Borderline Personality Disorder.  And yet, many children and adolescents are able to cope effectively with the aftereffects of their trauma exposure through their own resilience, and with support of family and others, and may even derive positive benefits from their experiences.

The severity and chronicity of the stress reactions following exposure to traumatic events can vary greatly. Of particular significance to children and adolescents are the effects on development (Cichetti and Toth, 1997; Kaufman and Henrich, 2000; Garbarino, Eckenrode, and Powers, 1997; Pynoos, et al., 1999).  Exposure to trauma can delay, distort or arrest normal developmental processes in children and adolescents. Developmental effects are a function of the age at which a child is exposed to traumatic events, the developmental issues that they are addressing at the time, the significance of the type of trauma for current and later developmental stages, and how this exposure may affect resources needed for later developmental tasks.

Considerable progress has been made in understanding the prevalence, characteristics, risk factors, and consequences of trauma in children and adolescents.  However, knowledge is unevenly developed across  areas of child trauma and many fundamental questions have not been adequately addressed, such as which children will experience the most detrimental effects of trauma exposure, the impact of trauma on developmental processes across the stages of development,  and determination of the underlying biological, psychological, and social processes that must be targeted by effective interventions (Pfefferbaum, 1997).
 

Intervention in the aftermath of trauma is perhaps the most significant clinical issue in child and adolescent mental health.  Promising interventions for child trauma have been identified (James, 1989; Cohen, Berliner, and March, 2000; Deblinger and Heflin, 1996; March, et al., 1998; Lieberman, Silverman and Pawl, 2000; Marmar, Weiss, and Pynoos, 1995; Pynoos, et al., 1998), but much needs to be done to provide these services to children and their families.  The scientific evidence-base is not strong on many critical intervention issues, such as what types of interventions maximize trauma recovery, which children and which types of trauma exposure are effectively treated by different types of intervention approaches, and how intervention approaches should best address developmental issues.

Of particular concern for receipt of intervention services are children in child service systems with high rates of trauma exposures, such as the child welfare and child protective services systems, the juvenile justice system, hospitals and emergency clinics, child rehabilitation services, and service systems for refugee children. (Rosenfeld, et al., 1997; Dubner and Motta, 1999; Clausen, et al., 1998; Crimmins, et al., 2000; Erwin, et al., 2000).  These systems provide services to large numbers of children.   In 1998, more than 1.8 million reports of child abuse and neglect were investigated by child protective services and 900,000 children were categorized as victims of abuse and/or neglect or at risk for maltreatment. (U.S. Department of Health and Human Services, 2000a).  Every day in the U.S. nearly 600,000 children and adolescents are in the child welfare system -- with almost half in non-relative foster care and almost 10 percent in institutional care.  (U.S. Department of Health and Human Services, 2000b). In 1997 approximately 125,000 juveniles were in detention (Gallagher, 1999). Approximately 100,000 refugees are admitted into the U.S. every year, many are families arriving from war zones, fleeing political oppression or victims of torture. (U.S. Department of Health and Human Services, 2000c).

In addition to these specialty child service systems, schools are the largest child service system and in every school there will be children whose ability to perform competently is compromised by unrecognized and untreated traumatic stress.  Some progress has been made in developing procedures to identify children affected by exposure to traumatic events and provide trauma-focused treatment in school settings (Muris, et al., 2000; McNally, 1996; March, et al., 1998). Development and implementation of effective identification, assessment  and treatment approaches in these child service settings would have a significant impact on the mental health of children.

The National Child Traumatic Stress Initiative is designed to address these child trauma issues by  providing Federal support for a national effort to improve treatment and services for child trauma, to expand availability and accessibility of effective community services, and to promote better understanding of clinical and research issues relevant to providing effective interventions for children and adolescents exposed to traumatic events.
 

APPENDIX B

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