Cognitive Psychology Discussion Paper

    Cognitive Psychology Discussion Paper

    Alex grew up in a violent and abusive home. His father drank to intoxication each night and neglected Alex until he turned three, at which point his father began to physically abuse Alex regularly. Alex’s mother screamed at him any time he cried as a child, and she rarely held or tried to soothe him. What types of behaviors would one possibly see from Alex during childhood? Describe the possible effects of the abuse in terms of the HPA axis, including brain structures and neurotransmitters. How might a psychologist approach working with Alex to address any maladaptive behaviors you identified?

    Compose a post of one to two paragraphs.


    van, d. K. (2005). Developmental trauma disorder. Psychiatric Annals, 35(5), 401-408. Retrieved from

    C M E

    Childhood trauma, including abuse and neglect, is probably the single most important public health challenge in the United States, a challenge that has the po- tential to be largely resolved by appropriate

    prevention and intervention. Each year, more than 3 mil- lion children are reported to authorities for abuse or neglect in the US; about 1 million of those cases are substantiated.1 Many thousands more

    Dr. van der Kolk is profes-

    sor of psychiatry, Boston

    University Medical School,

    Boston, MA; clinical director,

    The Trauma Center at Justice

    Resource Institute, Brookline,

    MA; and co-director, the Na-

    tional Child Traumatic Stress

    Network Community Pro-

    gram, Boston.

    Address reprint requests

    to: Bessel A. van der Kolk, MD,

    16 Braddock Park, Boston,

    MA 02116.

    Dr. van der Kolk has no in-

    dustry relationships to disclose.

    The following members

    of the National Child Trau-

    matic Stress Network DSM-

    V task force contributed

    to the development of the

    proposed diagnosis of devel-

    opmental trauma disorder:

    Marylene Cloitre, PhD; Julian

    Ford, PhD; Alicia Lieberman,

    PhD; Frank Putnam, MD;

    Robert Pynoos, MD; Glenn

    Saxe, MD; Michael Scheerin-

    ga, PhD; Joseph Spinazzola,

    PhD; Allan Steinberg, MD;

    and Martin Teicher, MD, PhD.



    Developmental Toward a rational diagnosis for children with complex trauma histories.

    Bessel A. van der Kolk, MD

    Trauma Disorder

    402 PSYCHIATRIC ANNALS 35:5 | MAY 2005

    undergo traumatic medical and surgical procedures and are victims of accidents and of community violence (see Spinaz- zola et al., page 433). However, most trau- ma begins at home; the vast majority of people (about 80%) responsible for child maltreatment are children’s own parents.

    Inquiry into developmental milestones and family medical history is routine in medical and psychiatric examinations. In contrast, social taboos prevent obtain- ing information about childhood trauma, abuse, neglect, and other exposures to violence. Research has shown that trau- matic childhood experiences not only are extremely common but also have a profound impact on many different areas of functioning. For example, children ex- posed to alcoholic parents or domestic vi- olence rarely have secure childhoods; their symptomatology tends to be pervasive and multifaceted and is likely to include depression, various medical illnesses, and a variety of impulsive and self-destructive behaviors. Approaching each of these problems piecemeal, rather than as expres- sions of a vast system of internal disorga- nization, runs the risk of losing sight of the forest in favor of one tree.

    COMPLEX TRAUMA The traumatic stress field has adopted

    the term “complex trauma” to describe the experience of multiple, chronic and prolonged, developmentally adverse trau- matic events, most often of an interper-

    sonal nature (eg, sexual or physical abuse, war, community violence) and early-life onset. These exposures often occur within the child’s caregiving system and include physical, emotional, and educational ne- glect and child maltreatment beginning in early childhood (Cook et al., page 390, and Spinazzola et al., page 433).

    In the Adverse Childhood Experi- ences (ACE) study by Kaiser Permanente and the Centers for Disease Control and Prevention,2 17,337 adult health mainte- nance organization (HMO) members re- sponded to a questionnaire about adverse childhood experiences, including child- hood abuse, neglect, and family dysfunc- tion. Eleven percent reported having been emotionally abused as a child, 30.1% re- ported physical abuse, and 19.9% sexual abuse. In addition, 23.5% reported being exposed to family alcohol abuse, 18.8% were exposed to mental illness, 12.5% witnessed their mothers being battered, and 4.9% reported family drug abuse.

    The ACE study showed that adverse childhood experiences are vastly more common than recognized or acknowledged and that they have a powerful relationship to adult health a half-century later. The study confirmed earlier investigations that found a highly significant relationship be- tween adverse childhood experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domes- tic violence, cigarette smoking, obesity, physical inactivity, and sexually transmit- ted diseases. In addition, the more adverse childhood experiences reported, the more likely a person was to develop heart dis- ease, cancer, stroke, diabetes, skeletal frac- tures, and liver disease.

    Isolated traumatic incidents tend to produce discrete conditioned behavioral and biological responses to reminders of the trauma, such as those captured in the posttraumatic stress disorder (PTSD) diagnosis. In contrast, chronic maltreat- ment or inevitable repeated traumatiza- tion, such as occurs in children who are exposed to repeated medical or surgical

    procedures, have a pervasive effects on the development of mind and brain.

    Chronic trauma interferes with neuro- biological development (Ford, see page 410) and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole. Developmental trauma sets the stage for unfocused responses to subsequent stress,3 leading to dramatic increases in the use of medical, correc- tional, social and mental health services.4 People with childhood histories of trau- ma, abuse and neglect make up almost the entire criminal justice population in the US.5 Physical abuse and neglect are associated with very high rates of arrest for violent offenses. In one prospective study of victims of abuse and neglect, almost half were arrested for nontraffic- related offenses by age 32.6 Seventy-five percent of perpetrators of child sexual abuse report to have themselves been sexually abused during childhood.7

    These data suggest that most inter- personal trauma on children is perpetu- ated by victims who grow up to become perpetrators or repeat victims of violence. This tendency to repeat represents an in- tegral aspect of the cycle of violence in our society.


    Children learn to regulate their behav- ior by anticipating their caregivers’ re- sponses to them.8 This interaction allows them to construct what Bowlby called “internal working models.”9 A child’s in- ternal working models are defined by the internalization of the affective and cogni- tive characteristics of their primary rela- tionships. Because early experiences oc- cur in the context of a developing brain, neural development and social interac- tion are inextricably intertwined. As Don Tucker has said: “For the human brain, the most important information for suc- cessful development is conveyed by the social rather than the physical environ- ment. The baby brain must begin partici-


    1. Identify emotional triggers and patterns of re-enactment in traumatized children.

    2. Discuss the spectrum of de- velopmental derailments sec- ondary to complex trauma exposure.

    3. Describe patterns of accom- modation in traumatized children.

    PSYCHIATRIC ANNALS 35:5 | MAY 2005 403

    pating effectively in the process of social information transmission that offers entry into the culture.”10

    Early patterns of attachment affect the quality of information processing through- out life.11 Secure infants learn to trust both what they feel and how they understand the world. This allows them to rely on both their emotions and their thoughts to react to any given situation. Their experience of feeling understood provides them with the confidence that they are capable of making good things happen and that, if they do not know how to deal with difficult situations, they can find people who can help them find a solution.

    Secure children learn a complex vo- cabulary to describe their emotions, such as love, hate, pleasure, disgust, and anger. This allows them to communicate how they feel and to formulate efficient re- sponse strategies. They spend more time

    describing physiological states such as hunger and thirst, as well as emotional states, than do maltreated children.12

    Under most conditions, parents are able to help their distressed children re- store a sense of safety and control. The security of the attachment bond mitigates against trauma-induced terror. When trau- ma occurs in the presence of a supportive, if helpless, caregiver, the child’s response is likely to mimic that of the parent — the more disorganized the parent, the more disorganized the child.13

    However, if the distress is overwhelm- ing, or when the caregivers themselves are the source of the distress, children are unable to modulate their arousal. This causes a breakdown in their capacity to

    process, integrate, and categorize what is happening. At the core of traumatic stress is a breakdown in the capacity to regu- late internal states. If the distress does not ease, the relevant sensations, affects, and cognitions cannot be associated — they are dissociated into sensory fragments14 — and, as a result, these children cannot comprehend what is happening or devise and execute appropriate plans of action.

    When caregivers are emotionally ab- sent, inconsistent, frustrating, violent, intrusive, or neglectful, children are likely to become intolerably distressed and unlikely to develop a sense that the ex-

    t e r n a l environment is able to provide relief. Thus, children with insecure at- tachment patterns have trouble relying on others to help them and are unable to regulate their emotional states by themselves. As a result, they experience excessive anxiety, anger, and longings to be taken care of. These feelings may become so extreme as to precipitate dis- sociative states or self-defeating aggres- sion. “Spaced out” and hyperaroused children learn to ignore either what they

    feel (their emotions), or what they per- ceive (their cognitions).

    When children are unable to achieve a sense of control and stability, they become helpless. If they are unable to grasp what is going on and unable do anything about it to change it, they go immediately from (fearful) stimulus to (fight/flight/freeze) response without being able to learn from the experience. Subsequently, when ex- posed to reminders of a trauma (eg, sen- sations, physiological states, i m a g e s ,

    sounds, situ- ations), they tend to be- have as if they were traumatized all over again — as a catastrophe.15 Many problems of traumatized children can be understood as efforts to minimize objec- tive threat and to regulate their emotional distress.16 Unless caregivers understand

    Secure children learn a complex vocabulary to describe their emotions, such as love, hate, pleasure, disgust, and anger.

    404 PSYCHIATRIC ANNALS 35:5 | MAY 2005

    the nature of such re-enactments, they are likely to label the child as “oppositional,” “rebellious,” “unmotivated,” or “antiso- cial.”


    Young children, still embedded in the here-and-now and lacking the capacity to see themselves in the perspective of the larger context, have no choice but to see themselves as the center of the universe. In their eyes, everything that happens is related directly to their own sensations. Development consists of learning to mas- ter and “own” one’s experiences and to

    learn to experience the present as part of one’s personal experience over time.17 Piaget18 called this “decentration”: mov- ing from being one’s reflexes, move- ments, and sensations to having them.

    Predictability and continuity are critical for a child to develop a good sense of cau- sality and learn to categorize experience. A child needs to develop categories to be able to place any particular experience in a larger context. Only then will he or she be able to evaluate what is happening and en- tertain a range of options with which they can affect the outcome of events. Imagin- ing being able to play an active role leads to problem-focused coping.15

    If children are exposed to unmanage- able stress and if the caregiver does not take over the function of modulating the child’s arousal, as occurs when children are exposed to family dysfunction or vio- lence, the child will be unable to organize and categorize experiences in a coherent fashion. Unlike adults, children do not have the option to report, move away or otherwise protect themselves; they depend on their caregivers for their very survival.

    When trauma emanates from within the family, children experience a crisis of loyalty and organize their behavior to sur- vive within their families. Being prevent- ed from articulating what they observe and experience, traumatized children will organize their behavior around keeping the secret, deal with their helplessness with compliance or defiance, and accli- mate in any way they can to entrapment in abusive or neglectful situations.19

    When professionals are unaware of children’s need to adjust to traumatizing environments and expect that children should behave in accordance with adult standards of self-determination and au- tonomous, rational choices, these mal- adaptive behaviors tend to inspire revul- sion and rejection. Ignorance of this fact is likely to lead to labeling and stigmatiz- ing children for behaviors that are meant to ensure survival.

    Being left to their own devices leaves chronically traumatized children with deficits in emotional self-regulation. This results in problems with self-defi- nition as reflected by a lack of a con- tinuous sense of self, poorly modulated affect and impulse control, including aggression against self and others, and uncertainty about the reliability and pre- dictability of others, expressed as dis- trust, suspiciousness, and problems with intimacy, resulting in social isolation.20 Chronically traumatized children tend to suffer from distinct alterations in states of consciousness, including amnesia, hypermnesia, dissociation, depersonal- ization and derealization, flashbacks and


    Developmental Trauma Disorder

    A. Exposure

    • Multiple or chronic exposure to one or more forms of developmentally ad- verse interpersonal trauma (eg, abandonment, betrayal, physical assaults, sexual assaults, threats to bodily integrity, coercive practices, emotional abuse, witnessing violence and death).

    • Subjective experience (eg, rage, betrayal, fear, resignation, defeat, shame).

    B. Triggered pattern of repeated dysregulation in response to trauma cues

    Dysregulation (high or low) in presence of cues. Changes persist and do not return to baseline; not reduced in intensity by conscious awareness.

    • Affective.

    • Somatic (eg, physiological, motoric, medical).

    • Behavioral (eg, re-enactment, cutting).

    • Cognitive (eg, thinking that it is happening again, confusion, dissociation, depersonalization).

    • Relational (eg, clinging, oppositional, distrustful, compliant).

    • Self-attribution (eg, self-hate, blame).

    C. Persistently Altered Attributions and Expectancies

    • Negative self-attribution.

    • Distrust of protective caretaker.

    • Loss of expectancy of protection by others.

    • Loss of trust in social agencies to protect.

    • Lack of recourse to social justice/retribution.

    • Inevitability of future victimization.

    D. Functional Impairment

    • Educational.

    • Familial.

    • Peer.

    • Legal.

    • Vocational.

    PSYCHIATRIC ANNALS 35:5 | MAY 2005 405

    nightmares of specific events, school problems, difficulties in attention regu- lation, disorientation in time and space, and sensorimotor developmental disor- ders. The children often are literally are “out of touch” with their feelings, and often have no language to describe in- ternal states.21

    When a child lacks a sense of predict- ability, he or she may experience diffi- culty developing object constancy and inner representations of their own inner world or their surroundings. As a result, they lack a good sense of cause and ef- fect and of their own contributions to what happens to them. Without internal maps to guide them, they act instead of plan and show their wishes in their be- haviors, rather than discussing what they want.15 Unable to appreciate clearly who they or others are, they have problems enlisting other people as allies on their

    behalf. Other people are sources of ter- ror or pleasure but are rarely fellow hu- man beings with their own sets of needs and desires.

    These children also have difficulty appreciating novelty. Without a map to compare and contrast, anything new is potentially threatening. What is familiar tends to be experienced as safer, even if it is a predictable source of terror.15

    Traumatized children rarely discuss their fears and traumas spontaneously. They also have little insight into the re- lationship between what they do, what they feel, and what has happened to them. They tend to communicate the nature of their traumatic past by repeating it in the form of interpersonal enactments, both in

    their play and in their fantasy lives.


    Posttraumatic stress disorder (PTSD) is not the most common psychiatric diag- nosis in children with histories of chronic trauma (Cook et al., see page 390). For example, in one study of 364 abused chil- dren,22 the most common diagnoses in or- der of frequency were separation anxiety disorder, oppositional defiant disorder, phobic disorders, PTSD, and ADHD.22 Numerous studies of traumatized children find problems with unmodulated aggression and

    impulse control,23,24 at- tentional and dissociative problems,25 and difficulty negoti- ating relationships with caregivers, peers, and, later in life, intimate partners.26

    A history of childhood physical and sex- ual assault is associated with a host of other psychiatric diagnoses in adolescence and adulthood. These may include substance abuse, borderline and antisocial personal- ity, or eating, dissociative, affective, so- matoform, cardiovascular, metabolic, im- munologic, and sexual disorders.27

    The results of the Diagnostic and Statistical Manual of Mental Disorders, fourth ediction (DSM-IV),28 Field Trial suggested that trauma has its most perva- sive impact during the first decade of life and becomes more circumscribed (ie, more like “pure” PTSD) with age.29 The diagnosis of PTSD is not developmen- tally sensitive and does not adequately describe the effect of exposure to child- hood trauma on the developing child. Because infants and children who ex-

    p e – r i e n c e multiple forms of abuse often experience devel- opmental delays across a broad spec trum, including cog nitive, language, motor, and social- ization skills,30 they tend to dis- play very complex disturbances, with

    A history of childhood physical and sexual assault is associated with a host of other psychiatric diagnoses in adolescence and adulthood.

    406 PSYCHIATRIC ANNALS 35:5 | MAY 2005

    a variety of different, often fluctuating, presentations.

    However, because there currently is no other diagnostic entity that describes the pervasive effects of trauma on child development, these children are given a range of “comorbid” diagnoses, as if they occurred independently from the PTSD symptoms. None of these do justice to the spectrum of problems of traumatized children, and none provide guidelines on what is needed for effec- tive prevention and intervention. By relegating the full spectrum of trauma- related problems to seemingly unrelated “comorbid” conditions, fundamental trauma-related disturbances may be lost to scientific investigation, and clinicians may run the risk of applying treatment approaches that are not helpful.


    The question of how best to organize the very complex emotional, behavioral, and neurobiological sequelae of child- hood trauma has vexed clinicians for sev- eral decades. Because DSM-IV includes a diagnosis for adult onset trauma, PTSD, this label often is applied to traumatized children as well. However, the majority of traumatized children do not meet di- agnostic criteria for PTSD31 (Cook et al., see page 390), and PTSD cannot capture the multiplicity of exposures over critical developmental periods.

    Moreover, the PTSD diagnosis does not capture the developmental effects of childhood trauma: the complex disrup- tions of affect regulation; the disturbed attachment patterns; the rapid behavioral regressions and shifts in emotional states; the loss of autonomous strivings; the ag- gressive behavior against self and others; the failure to achieve developmental com- petencies; the loss of bodily regulation in the areas of sleep, food, and self-care; the altered schemas of the world; the anticipa- tory behavior and traumatic expectations;

    the multiple somatic problems, from gas- trointestinal distress to headaches; the apparent lack of awareness of danger and resulting self endangering behaviors; the self-hatred and self-blame; and the chron- ic feelings of ineffectiveness.

    Interestingly, many forms of interper- sonal trauma, in particular psychological maltreatment, neglect, separation from caregivers, traumatic loss, and inappro- priate sexual behavior, do not necessar- ily meet DSM-IV “Criterion A” defini- tion for a traumatic event. This criteria requires, in part, an experience involving “actual or threatened death or serious in- jury, or a threat to the physical integrity of self or others.”28 Children exposed to these common types of interpersonal ad- versity thus typically would not qualify for a PTSD diagnosis unless they also were exposed to experiences or events that qualify as “traumatic,” even if they have symptoms that would otherwise warrant a PTSD diagnosis.

    This finding has several implications for the diagnosis and treatment of trauma- tized children and adolescents. Non-Cri- terion A forms of childhood trauma expo- sure — such as psychological or emotional abuse and traumatic loss — have been demonstrated to be associated with PTSD symptoms and self-regulatory impair- ments in children32 and into adulthood.33 Thus, classification of traumatic events may need to be defined more broadly, and treatment may need to address directly the sequelae of these interpersonal adversities, given their prevalence and potentially se- vere negative effects on children’s devel- opment and emotional health.

    The Complex Trauma taskforce of the National Child Traumatic Stress Network has been concerned about the need for a more precise diagnosis for children with complex histories. In an attempt to more clearly delineate what these children suf- fer from and to serve as a guide for ratio- nal therapeutics this taskforce has started to conceptualize a new diagnosis, pro- visionally called developmental trauma

    disorder (Sidebar, see page 404). This proposed diagnosis is organized around the issue of triggered dysregulation in re- sponse to traumatic reminders, stimulus generalization, and the anticipatory orga- nization of behavior to prevent the recur- rence of the trauma effects.

    This provisional diagnosis is based on the concept that multiple exposures to interpersonal trauma, such as aban- donment, betrayal, physical or sexual as- saults, or witnessing domestic violence, have consistent and predictable conse- quences that affect many areas of func- tioning. These experiences engender in- tense affects, such as rage, betrayal, fear, resignation, defeat, and shame, and ef- forts to ward off the recurrence of those emotions, including the avoidance of ex- periences that precipitate them or engag- ing in behaviors that convey a subjective sense of control in the face of potential threats. These children tend to reenact their traumas behaviorally, either as per- petrators (eg, aggressive or sexual acting out against other children) or in frozen avoidance reactions. Their physiological dysregulation may lead to multiple so- matic problems, such as headaches and stomachaches, in response to fearful and helpless emotions.

    Persistent sensitivity to reminders inter- feres with the development of emotional regulation and causes long-term emotional dysregulation and precipitous behavior changes. Children’s over- and underre- activity is manifested on multiple levels: emotional, physical, behavioral, cognitive, and relational. They have fearful, enraged, or avoidant emotional reactions to minor stimuli that would have no significant ef- fect on secure children. After having be- come aroused, these children have a great deal of difficulty restoring homeostasis and returning to baseline. Insight and un- derstanding about the origins of their reac- tions seems to have little effect.

    In addition to the conditioned physi- ological and emotional responses to re- minders characteristic of PTSD, children

    PSYCHIATRIC ANNALS 35:5 | MAY 2005 407

    with complex trauma develop a view of the world that incorporates their betrayal and hurt. They anticipate and expect the trauma to recur and respond with hyper- activity, aggression, defeat, or freeze re- sponses to minor stresses. Cognition in these children also is affected by remind- ers of the trauma. They tend to become confused, dissociated, and disoriented when faced with stressful stimuli. They easily misinterpret events in the direction of a return of trauma and helplessness, which causes them to be constantly on guard, frightened, and overreactive.

    In addition, expectations of a return of the trauma permeate their relationships. This is expressed as negative self-attri- butions, loss of trust in caretakers, and loss of the belief that some somebody will look after them and make them feel safe. They tend to lose the expectation that they will be protected and act ac-

    cordingly. As a result, they organize their relationships around the expectation or prevention of abandonment or victim- ization. This is expressed as excessive clinging, compliance, oppositional defi- ance, and distrustful behavior. They also may be preoccupied with retribution and revenge. All of these problems are expressed in dysfunction in multiple ar- eas of functioning: educational, familial, peer-related, legal, and work-related.

    TREATMENT IMPLICATIONS In the treatment of traumatized chil-

    dren and adolescents, there often is a painful dilemma of whether to keep them in the care of people or institutions who are sources of hurt and threat, or whether

    to play into abandonment and separation distress by taking the child away from fa- miliar environments and people to whom they are intensely attached but who are likely to cause further substantial dam- age.15 Treatment must focus on three primary areas: establishing safety and compentence, dealing with traumatic re- enactments, and integration and master of the body and mind.

    Establishing Safety and Competence Complexly traumatized children need

    to be helped to engage their attention in pursuits that do not remind them of trauma-

    re la ted triggers and that give them a sense of pleasure and mastery. Safety, pre- dictability, and “fun” are essential for the establishment of the capacity to observe what is going on, put it into a larger con- text, and initiate physiological and mo- toric self-regulation.

    Before addressing anything else, these children need to be helped how to re- act differently from their habitual fight/ flight/freeze reactions.15 Only after chil- dren develop the capacity to focus on

    pleasurable activities without becoming disorganized do they have a chance to develop the capacity to play with other children, engage in simple group activi- ties and deal with more complex issues.

    Dealing With Traumatic Re-enactments

    After a child is traumatized multiple times, the imprint of the trauma becomes lodged in many aspects of his or her makeup. This is manifested in multiple ways:

    fearful reactions, ag- gressive and sexual acting out, avoidance, and uncontrolled emotional reactions. Unless this tendency to repeat the trauma is recognized, the response of the environment is likely to replay the original traumatizing, abusive, but familiar, relationships. Because these

    After a child is traumatized multiple times, the imprint of the trauma becomes lodged in many aspects of his or her makeup.

    408 PSYCHIATRIC ANNALS 35:5 | MAY 2005

    children are prone to experience anything novel, including rules and other protective interventions, as punishments, they tend to regard teachers and therapists who try to establish safety as perpetrators.15

    Integration and Mastery Mastery is, most of all, a physical ex-

    perience: the feeling of being in charge, calm, and able to engage in focused efforts to accomplish goals. Children who have been traumatized experience the trauma- related hyperarousal and numbing on a deeply somatic level. Their hyperarousal is apparent in their inability to relax and in their high degree of irritability.

    Children with “frozen” reactions need to be helped to re-awaken their curiosity and to explore their surroundings. They avoid engagement in activities because any task may unexpectedly turn into a traumat- ic trigger. Neutral, “fun” tasks and physi- cal games can provide them with knowl- edge of what it feels like to be relaxed and to feel a sense of physical mastery.

    SUMMARY At the center of therapeutic work with

    terrified children is helping them realize that they are repeating their early expe- riences and helping them find new ways of coping by developing new connections between their experiences, emotions and physical reactions. Unfortunately, all too often, medications take the place of help- ing children acquire the skills necessary to deal with and master their uncomfort- able physical sensations. To “process” their traumatic experiences, these chil- dren first need to develop a safe space where they can “look at” their traumas without repeating them and making them real once again.15

    REFERENCES 1. Child Maltreatment 2001. US Department of

    Health and Human Services, Administration on Children, Youth and Families. 2003. Available at: cations/cm01/outcover.htm. Accessed April 13, 2005.

    2. Felitti VJ, Anda RF, Nordenberg D, et al. Rela- tionship of childhood abuse and household dys- function to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245- 258.

    3. Cicchetti D, Toth SL. Developmental psychopa- thology and disorders of affect. In: Cicchetti D, Cohen DJ, eds. Developmental Psychopathol- ogy, Vol. 2: Risk, Disorder, and Adaptation. New York, NY: John Wiley & Sons; 1995:369-420.

    4. Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with func- tional or organic gastrointestinal disorders. Ann Intern Med. 1990;113(11):828-833.

    5. Teplin LA, Abram KM, McClelland GM, Dul- can MK, Mericle AA. Psychiatric disorders in youth in juvenile detention. Arch Gen Psychia- try. 2002; 59(12):1133-1143.

    6. Widom CS, Maxfield MG. A prospective exam- ination of risk for violence among abused and neglected children. Ann N Y Acad Sci. 1996 Sep 20;794:224-237.

    7. Romano E, De Luca RV. Exploring the re- lationship between childhood sexual abuse and adult sexual perpetration. J Fam Violence. 1997;12(1):85-98.

    8. Schore A. Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Devel- opment. Hillsdale, NJ: Lawrence Erlbaum As- sociates; 1994.

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