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 relationship between abuse and psychiatric diagnoses was investigated in two groups of physically abused adolescents, 57 living in homes with interparental violence and 32 in homes without such violence, and in 96 nonabused adolescents living in nonviolent homes. Adolescents in the first group were found to be at greater risk for depression, separation anxiety disorder, post-traumatic stress disorder, and oppositional defiant disorder than were those in the second group. Adolescents in the first group also appeared more vulnerable to anxiety and depression.

Professionals in the child trauma field, eager to bring best practices to children and their families who have suffered from traumatic life events, have developed a number of evidence-based treatments (EBTs) and promising practices available for adoption and implementation into community practice. Clinicians and researchers alike have raised questions about "if, when, and how" these EBTs can be applied to some of the more complex trauma presentations seen in real world practice. The authors take an evidence-based practice approach, including critical appraisal of clients' unique needs and preferences, utilizing applicable trauma treatment core components and current EBTs, and emphasizing monitoring strategies of client progress, particularly when needing to adapt EBTs for select clients.

Despite the proliferation of empirically supported treatments in child mental health and the intensive resource investments agencies and training programs make to prepare clinicians, there are no clear guidelines to direct the selection of treatments. Specifically in the treatment of traumatized youth, there is no current mandate to adopt a developmental trauma framework to guide clinical decision making. The authors argue that this lack of knowledge and guiding framework can significantly impair therapists' abilities to address the complexities chronically traumatized children and families experience that may call for tailoring or adapting treatment models. It is proposed that cultivating a lifelong leaming approach, driven by critical thinking, to review the latest scientific knowledge base and to utilize evidence-based trauma-informed assessment is essential. With this knowledge, clinicians are better equipped to engage in critical appraisal as they formulate case conceptualizations and treatment recommendations for traumatized youth and their families. Recommendations for promoting an evidence-based practice approach in the field of child and adolescent traumatic stress applicable to both graduate programs and continuing education for seasoned clinicians are proposed.

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