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A Developmental Psychopathology Model

of Childhood Traumatic Stress and Intersection with


Anxiety Disorders
Robert S. Pynoos, Alan M. Steinberg, and John C. Piacentini

Empirical findings regarding childhood traumatic stress lifecycle of the individual, family, group, and society. A
are placed within a developmental life-trajectory model developmental psychopathology approach recognizes the
that incorporates a tripartite etiology of posttrauma dis- intricate matrix of intrinsic factors, developmental matu-
tress. This approach recognizes an intricate matrix of ration and experience, life events, and evolving familial
child-intrinsic factors, developmental maturation and ex- and social ecologies that contribute to proximal and distal
perience, life events, and evolving family and social
outcomes. A developmental psychopathology framework
ecologies. Of central developmental importance in the
field of traumatic stress is the ontogenesis of appraisal, recognizes the intimate theoretical relationship between
emotional response, emotional and physiological regula- adaptive and maladaptive outcomes and between pathol-
tion, and consideration of protective action with regard to ogy and normality (Cicchetti and Cohen 1995). Figure 1
danger. The complexity of traumatic situations and their presents an updated developmental life-trajectory schema
aftermath suggests the relevance of multiple stress diathe- (Pynoos et al 1995; Steinberg and Ritzmann 1990), orga-
ses in understanding individual variability in proximal nizing selected current clinical and research knowledge
and distal effects. Neurobiological systems that subserve about childhood traumatic stress.
danger mature over childhood and adolescence. Neuro- This schema indicates that there are multiple sources of
physiological and neurohormonal studies among trauma- acute posttrauma distress, falling into three major categories.
tized children and adolescents suggest potential neurode- Whereas the contribution of traumatic experience(s) has been
velopmental stage-related vulnerabilities within these
well recognized, both associated proximal secondary adver-
systems. Advances in child development and traumatic
stress provide tools for investigating proximal and distal sities and proximal trauma and loss reminders introduce
interplay of psychopathology, disturbances in the acqui- additional stress diathesis. Aspects of the appraisal and
sition and maintenance of developmental competencies, response to danger and resistance and vulnerability mediate
and life-trajectory outcomes. A developmental psychopa- acute distress. Resilience refers to early effective efforts at
thology model suggests different avenues by which dan- adjustment and recovery. A developmental psychopathology
gerous circumstances, childhood traumatic experiences, model places equal importance on proximal development,
and posttraumatic stress disorder (PTSD) can intersect proximal psychopathology, and their interactions as out-
with other anxiety disorders over the life span. Biol comes of early adjustment. Ongoing adjustment takes place
Psychiatry 1999;46:1542–1554 © 1999 Society of Biolog- in an interactive matrix encompassing distal trauma remind-
ical Psychiatry ers, distal secondary stresses, distal development and distal
pathology. Child-intrinsic factors and the ecology of the child
Key Words: Developmental psychopathology, PTSD, operate throughout the schema. This model suggests a revi-
child trauma, anxiety sion of the acute-chronic typology to a more developmentally
sound approach. Repeated or sequential traumatic experi-
Introduction ences should be analyzed in regard to emerging developmen-
tal contexts. These contexts generate new sources of trau-

D anger, trauma, fear and anxiety are embedded in the


human condition. There is a wide spectrum of ap-
praisal, response, and adaptation to danger within the
matic distress, situation-specific reminders, secondary
stresses, and new efforts at adjustment, which carry addi-
tional implications at each occurrence for acquisition of
developmental competencies and prolongation or new onset
From the Trauma Psychiatry Service and Child and Adolescent OCD and Anxiety
Disorders Program, Department of Psychiatry and Biobehavioral Sciences,
of psychopathology.
University of California at Los Angeles. Advances in the developmental epidemiology of traumatic
Address reprint requests to Robert S. Pynoos, UCLA, Ste. 2235, 300 Medical Plaza,
Department of Psychiatry, Los Angeles, CA 90024.
stress support the adoption of such a complex developmental
Received March 31, 1999; revised August 30, 1999; accepted September 24, 1999. perspective. This literature points to several important con-

© 1999 Society of Biological Psychiatry 0006-3223/99/$20.00


PII S0006-3223(99)00262-0
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siderations. First, by using refined typologies of exposure, well-being of a significant other whose whereabouts or
there is evidence of differential exposure rates through the safety are unknown. After the cessation of threat, addi-
course of childhood and adolescence. Age, sex, and child- tional traumatic moments can include efforts to assist the
intrinsic factors interact with evolving ecologies of the injured, emergency medical procedures and surgery,
family, school, peer group, community, and society. Second, abrupt separations from family members, and reunion with
careful review of rates of exposure across age groups sug- agitated or terrified parents or school personnel.
gests that children or adolescents may experience a highly
variable series of exposures occurring at different develop-
mental periods (Boney-McCoy and Finkelhor 1995). Third, Appraisal and Response to Danger
studies of the impact of different forms of exposure are This theoretical framework assigns a prominent role to the
becoming more interdependent as we document, for exam- ontogenesis of human appraisal, reaction, and response to
ple, the interaction of extrafamilial and intrafamilial violence, danger. A modern approach to the theory of anxiety must
and their respective environments of chronic danger and recognize three interrelated mental operations: 1) estima-
pathogenic family disturbance (Foy et al 1996; Lynch and tion of the nature and magnitude of external and internal
Cicchetti 1998). dangers, 2) emotional and physiological reaction and their
regulation, and 3) estimation of the type, degree, and
efficacy of protective intervention. These operations are
Traumatic Stress strongly rooted in neurobiological development, experien-
Empirical studies among acutely traumatized school-age tial history, and, for children in particular, availability of
children and adolescents have found that their traumatic and reliance on adults as auxiliary agents with regard to
experiences involve complex sensory, physiological, emo- danger and tolerance of anxiety. Over time, these basic
tional, and cognitive experiences of multiple moments processes become modified or rigidified, related to sec-
with different vantage points of concern (Pynoos et al ondary reappraisals, secondary efforts at regulating re-
1997a). newed or new emotional and physiological reactions, and
There may be different moments and types of phys- reconsideration, planning, and enactment of preventive
iological alarm and serial or simultaneous onset of and protective intervention for the future.
extreme negative emotions, as well as frightening ac- Early life corresponds to a period when contextual
celerations in physiological and emotional reactions. estimation of danger and protective intervention rests with
Emotional reactions can range from terror over the parent(s) or caretakers. The infant is equipped with alarm
external danger, to extreme helplessness over failure of reactions, relatively uninhibited defensive mechanisms,
protective action, to extreme shame over loss of bodily and evolved care-eliciting behaviors. Ontogenesis of am-
function. Cognitions can include sudden shifts in alert- bulatory exploratory behavior in toddlers coincides with
ness and attention; radical challenges to expectancy increasing maturation of the hippocampus and orbitofron-
sets; extreme uncertainty about event parameters, in- tal cortex that relates to spatial mapping and contextual
cluding confusions and misappraisals; attributions of discrimination. The early stages of appraisal of danger rely
intent, responsibility, and efficacy of actions by self or on social referencing to attachment figures (Klinnert et al
others; and catastrophic intraevent cognitions regarding 1983) and an amygdala-related capacity for recognizing
personal consequence. Witnessing of threat to signifi- facial expression of emotion. The preschool child responds
cant others may be accompanied by suppression of to limited natural clues that elicit fearful responses, relies
one’s fear for self and unalleviated empathic distress, on a protective shield provided by others, and utilizes
whereas immediate threat or injury to a child may emerging catastrophic emotions that enable him or her to
engender moments of estrangement. Radical shifts in act more self-protectively against threats of bodily injury.
attention may occur after injury or sexual violation, Preschool children begin to consciously include safety of
away from vigilance to external threat toward concern parents in their schemas of danger and their own self-
for the extent and personal consequences of injury or protection. School age children develop an increasing
violation. appreciation of dangerous circumstances, envision more
Children often experience the alarm and fear expres- self-efficacy (with conscious themes of courage and cow-
sions, agitated behavior, cries of distress, and ineffective ardliness), are engaged in skill and safety training, and
or potentially endangering behavior of adult caretakers. experience a sense of culpability and ineffectualness when
They may witness mutilating injuries and grotesque death protective action fails. By midadolescence, there is pre-
of family members and friends, experiencing horror and dominant reliance on self and peer appraisal of threat,
acute grief reactions, even while the threat to the child motivation, consequence, and protection, with accompa-
continues. There may also be intense worry about the nying struggles over decisions to directly intervene and
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Figure 1. Developmental psychopathology model of childhood traumatic stress.

themes of hero and antihero. Throughout these stages of increased motivational understanding add new dimen-
development, false alarms, under-estimations of danger, sions to the appraisal of threat over childhood and
and narrow escapes are mediated by child-parent interac- adolescence (Saarni and Harris 1991).
tions. Major parent-child transitions that occur over these Secondary appraisals, emotional and physiological reg-
periods include renegotiations of risk parameters and ulation, and considerations of prevention and protective
authority over decision making. intervention extend over years and are typically highly
Emotional and physiological responses not only serve to interactional social processes in childhood (Fivush 1991).
warn of external danger or initiate protective action, but also They rely on co-construction and assistance from parents,
may constitute a perceived internal threat. Children often siblings, school personnel, and peers; new information;
report becoming frightened by the intensity, acceleration, and and subsequent experience. Appropriate assistance can
duration of alarm reactions, physiological arousal, somatic facilitate recovery from failed developmental expectan-
sensations, and extreme negative emotions, for example, a cies, readdressing issues of accountability and integrating
7-year-old child who says, “My heart was beating so fast I the complex experience into veridical memory represen-
thought it was going to break.” Disturbing bodily sensations tations for use in future appraisals and response to danger.
associated with traumatic experiences can lead to enduring In humans, there is a long developmental delay in
responses to trauma reminders due to interoceptive condi- achieving inhibitory modulation of some basic defensive
tioning (Craske 1997), for example, a 10-year-old boy’s mechanisms. For example, it takes approximately 8 years
renewed nausea at olfactory reminders of witnessing his for children to reach mature prepulse inhibition of the
mother’s rape. The metacognition of emotions, the startle reflex, passing through a preschool period during
emergence of self-conscious negative emotions, and an which there is instead an exaggerated prepulse facilitation
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Figure 1. Continued.

(Pynoos et al 1997b). At this age, we have found that span, depending on alterations in family circumstances
children begin to actively entertain thoughts of personally and social ecology, and future developmental transitions.
addressing, disarming, or directly harming the source of The media may serve as an unrecognized source of trauma
danger. This is in contrast to the preschool child’s inter- reminders (Nader et al 1993). Compounding posttrauma
vention thoughts of escaping from danger and searching distress, there may be an additional set of loss reminders
for external protection. that evoke a different range of negative emotions, includ-
ing extreme sadness, anger over the loss, separation
anxieties, and worries about the future.
Proximal Trauma and Loss Reminders Psychological and physiological reactivity to reminders
Trauma reminders derive from trauma-specific features of contributes to the periodic or phasic nature of renewed
the child’s experience. They are ubiquitous in the after- traumatic anxiety and avoidant behavior and, perhaps, to a
math of trauma. Because of the complexity of a traumatic transition from phasic to tonic physiological arousal. The
experience and its occurrence in a natural setting, there unexpected nature and often-unrecognized occurrence of
may be a large number of cues, whose previous more reminders may reevoke a sense of unpreparedness and
neutral or even positive associations are now superseded lack of control. Features of one-trial aversive learning
by associations with the traumatic experience(s). There (Garcia et al 1986), fear-conditioning (Armony and Le-
may be widely different patterns of frequency among Doux 1997), and context-related anxiety (Davis et al 1997)
types of reminders, ranging from relatively infrequent to have been proposed to explain different mechanisms
daily, with diminished or increased recurrence over the life underlying the longevity, fear, and anxiety-provoking
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nature of reminders. These paradigms point to different Resistance, Vulnerability, Resilience,


aspects of the response, corresponding to extreme cata- and Adjustment
strophic expectancies (in regard to naturalistic dangers and
noxious physical states), bouts of fear, and chronic appre- This schema discriminates between resistance and resilience,
hensions over recurrence and associated dangers. Our concepts that are often confused in the child stress literature.
report demonstrating time-dependent sensitization of the Resistance may entail positive or negative mental health
acoustic startle reflex, bidirectional abnormal behavior in attributes that check the production of acute posttrauma
a fear-provoking environment, and dysregulation of ag- reactions. For example, a lack of empathy related to conduct
gression in mice after weekly exposures to a situational disorder when witnessing the distress of others may be
reminder (Pynoos et al 1996) indicates the powerful protective. Resilience, on the other hand, refers to the
multidimensional impact of reminders. capacity to respond to different levels of distress with
effective efforts at recovery. Resistance and vulnerability
factors mediate or moderate the impact of trauma, proximal
Proximal Secondary Stresses reminders, and proximal secondary stresses on the type and
There is a striking increase in risk of psychiatric disorder severity of acute posttrauma distress. Different aspects of
among children associated with accumulation of adverse child-intrinsic factors may mediate the impact of these three
life events (Tiet et al 1998). Traumatic events are com- components. The strength and reliance on affiliative attach-
monly associated with a cascade of secondary stresses. ment represent a critical developmental vulnerability in
They constitute additional sources of distress and increase childhood to witnessing threat or harm to a parent or family
the risk of comorbidity of posttraumatic stress reactions member, to being without parental protection, or to being the
with other adverse reactions. They complicate efforts at victim of a violent betrayal of affiliative expectancies when
adjustment and may interfere with normal opportunities the parent is the agent of the trauma. In young children, there
for developmental maturation, or initiate maladaptive is also vulnerability to fear acquisition by witnessing parental
coping responses that, over time, may be associated with response during the event or upon reunion. Temperament and
chronic psychopathology other than posttraumatic stress anxiety sensitivity may be especially relevant with regard to
disorder (PTSD). Secondary adversities or stresses may trauma reminders, including reactivity, attributions of con-
substantially interfere with the availability of support to trollability, catastrophizing of bodily sensations, cognitive
the child from parents, family, school, and community. discrimination, ability to calm down, or capacity to be
Parental loss is associated with risk of impaired care- comforted by efforts at safety improvements or parental
taking, disruption of the school community is associated reassurances. Intrinsic factors that mediate childhood stress in
with lost educational opportunities, and community disor- general are particularly relevant with regard to secondary
ganization and unemployment are associated with in- adversities (Rutter 1985). These include a positive relation-
creases in intrafamilial violence, parental substance abuse, ship with a competent adult, skill at learning and problem
and juvenile delinquency (Pynoos et al 1998). solving, engaging personality, competence and perceived
efficacy by self or society, high IQ score, positive school
experience, mastery motivation, and previous successful
Distress coping experiences (Masten et al 1990).
Distress is the acute subjective registration of the effects of a With regard to child-extrinsic factors, different aspects of
traumatic experience or reactivity to reminders and chal- parent behavior and family, school, and social ecology may
lenges of secondary stresses. There is compelling evidence moderate each of the three components (Pynoos et al, in
that by school age, children experience the full range of acute press). In situations of imminent danger, parental overreac-
posttraumatic stress and grief reactions (for review see tion, uncertainty, or conflict may exacerbate children’s anx-
Pfefferbaum 1997). In addition, posttrauma distress may iety over appropriate protective action. Adult or parental
include fears of recurrence, guilt and shame, ongoing worries decisions that result in separation of children from parents
about a significant other, and reactivation of posttraumatic can measurably increase children’s posttrauma distress. Re-
reactions associated with previous adverse life experiences. sponding to the distress of a traumatized child requires
Distress encompasses 1) the registration of personal conse- parental skills, for example, to address reactivity to reminders
quences, 2) causal attributions to self and other (including and behavioral regressions. Parental responsiveness can be
introduction of fear into a primary attachment relationship), mediated by parent-intrinsic factors, especially anxiety sen-
and 3) failure of developmental expectancies arising from sitivity, prior trauma and loss experiences, and reactivity to
physical helplessness at moments of irreversible harm, of reminders. Maternal trauma-related avoidance and overt
social referencing of catastrophic emotions to prevent injury, parental anxious responses to trauma reminders and fears of
and of beliefs in a socially modulated world. recurrence increase young children’s posttrauma distress.
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Variations in parental proactive interventions, such as secur- disorder secondary to intrafamilial abuse and violence
ing a bookcase that fell in the child’s room during an (World Health Organization 1990). There is a dose of
earthquake, can be critical to alleviate a child’s ongoing exposure association in which the severity of traumatic
apprehensions and sleep disturbance. exposure is strongly correlated with the risk for PTSD
Adjustment refers to the child’s ability to tolerate, manage, (Foy et al 1996; Goenjian et al 1995), with preexisting
or alleviate ongoing psychological, physiological, behavioral, anxiety increasing the severity of PTSD within exposure
and developmental disturbances. Effective adjustment in- groups (La Greca et al 1998). Continuous ratings rather
cludes the achievement of adequate understanding of the than categorical diagnosis have proven to be more sensi-
experience and subsequent reactions and, as two outcome tive to dose of exposure relationships and in identifying
measures, resumption of age-related developmental progres- mediating and moderating factors. Subjective appraisal of
sion and acquisition of developmental competencies, as well threat to self and others, intensity of internal arousal, and
as recovery from traumatic-stress-related symptoms. We appropriateness of behavior of self and others further
would emphasize the importance to adjustment of veridical contribute to risk. There is also evidence of an additive
reappraisals of danger, renewed efforts at emotional and effect of multiple and multimodal exposures to violence
physiological regulation, and evolving thoughts and plans of among adolescents (Kilpatrick et al 1995). There is evi-
future protective intervention. dence of an interplay of PTSD and grief in childhood,
Several elements of these adjustment processes rely on the leading to complicated bereavement, identified as a risk
maturation of key neurobiological mechanisms. Animal stud- factor among adults for psychiatric and physical morbidity
ies suggest that decreased conditioned-fear responses rely on (Prigerson et al 1997). Bereavement carries its own
active new learning to achieve conditioned inhibition and independent risks of subsequent depression and anxiety.
modulation of contextual reactivity. Such new learning is, in Multiple stress diatheses following traumatic experi-
part, governed by evolving functions of the prefrontal cortex ences are needed to understand the prevalence of psychi-
that permit more complex stimulus representation and greater atric comorbidity. High rates of comorbid PTSD and
capacity for stimulus analysis (Armory and LeDoux 1997). A depression have been found among preadolescents and
recent report suggests that fear conditioning and escape adolescents after catastrophic natural or transportation
behavior may operate through different anatomical pathways disasters and violence (Goenjian et al 1995; Yule and
within the amygdala (Amorapanth et al 1999), introducing Udwin 1991). Brent et al (1996) demonstrated that after
considerations of the role of maturing capacities for protec- adolescent peer suicide, risk of depression among friends
tive intervention in mediating ongoing emotional regulation is most associated with a family or personal history of
and reactivity to reminders. Considerations of protective depression, while PTSD, the incidence of which increased
intervention rely on maturing capacities for information over the 3-year follow-up, is associated with features of
processing and motor behavior. As pointed out by Korn and exposure to the suicide. Our studies after the earthquake in
Faber (1996), escape behaviors have short latencies, which Armenia found a dose of exposure-related chronic sepa-
leave minimal time for complex treatment of sensory infor- ration anxiety disorder among a significant percentage
mation and analysis of environmental parameters, paralleling (7.4%) of early adolescent youth (Goenjian et al 1995), an
the preschool child’s limited use of appraisal and consider- age group where this disorder is quite uncommon. Studies
ation of intervention other than escape. of the contribution of trauma-specific features, prior ex-
Parents can play a critical role in facilitating the use of periences, and anxiety sensitivity to the persistence of
more advanced cognitive strategies in children’s future separation anxiety or new-onset anxiety disorders, espe-
review of past traumatic experiences. Alternatively, par- cially phobias, are needed.
ents may contribute to disruption of this process because
of their own anxious preoccupations or, at the extreme, by
misleading explanations or a conspiracy of silence. The
adjustment and recovery in adolescence may rely much Proximal Development
more critically on opportunities provided by parents and Proximal development encompasses the achievement of
society for constructive means to address their interven- proximal developmental tasks that contribute to the onto-
tion preoccupations, including career opportunities. genesis of developmental competencies (Cicchetti 1989),
successful navigation of interpersonal and intrafamilial
developmental transitions (Rutter 1988), and normal bio-
Proximal Psychopathology logical maturation. Recently acquired developmental
Figure 1 includes a list of the range of child and adolescent achievements are particularly vulnerable to disruption
psychiatric disorders that have been reported after trau- (Rutter 1988), including periods of relative neurobiologi-
matic exposures and loss. ICD 10 includes an attachment cal cortical restructuring and neurophysiological consoli-
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dation (Pynoos et al 1997b). Selected aspects of proximal detrimental contributions of massive trauma in adoles-
development are highlighted below. cence. After the Armenia earthquake, adolescents mani-
There can be general effects on allocation of attentional fested an acceleration in their understanding of morality
resources and selective impact on age-related cognitive and communal values, and increased empathic understand-
developmental tasks. Selective attention can be skewed ing and depth of pride and remorse over moral behavior.
toward trauma-related new information or incident-spe- At the same time, these adolescents demonstrated pro-
cific new fears (Yule et al 1992). Early childhood con- found disturbances in conscience functioning, including
frontations with violence can interfere with preschool loss of moral willpower and negative moral expectancies
achievement of narrative coherence (Osofsky 1993). Sleep of self, other, and social institutions (Goenjian et al 1999).
disturbances may interfere with daytime learning (Pynoos The investigation of the developmental neurobiology of
et al 1987) and potentially with sleep-related consolidation traumatic stress is in its infancy, with only a few isolated
of learning. Sleep disturbances associated with child studies among children. The interpretation of findings will
physical abuse appear to persist over many years (Clod et need to placed in the context of three broad areas of
al 1997). Specific interference with learning may have neurodevelopment: 1) maturation of brain structures, 2)
quite different proximal developmental impact, with the functional physiological correlates, and 3) associated ma-
marginal student at greatest academic risk (Yule and turing cognition, emotional regulation, and behavioral
Udwin 1991) and school failure increasing the risk of responses (Pynoos et al 1997b). Studies of early childhood
secondary psychiatric morbidity. maltreatment, especially physical abuse and neglect
The generation of multiple intense negative emotions can (Galvin et al 1997; Perry et al 1995; Teicher et al 1997)
challenge maturing mechanisms of emotional regulation, have focused on early alterations in structure of brain
including the preschool task of increasing differentiation of regions and modification of neurotransmitter systems,
basic emotions, school-age elaboration on affective expres- such as catecholamine systems, that are functional early in
sion, and adolescent efforts to achieve a more sophisticated life and may have trophic effects on brain development.
understanding of the origins and consequences of negative Quantitative EEG findings of increased left hemispheric
emotions (Saarni and Harris 1991). In adolescence, trauma- coherence and MRI findings of volumetric reduction in the
related negative self-attributions and painful emotions may corpus collosum (Teicher et al 1997) raise questions about
contribute to excessive concerns about social evaluation and the effects of early abuse on cortical differentiation and
social avoidance. Dysregulation of aggression and hostile lateralization. Perry et al (1995) have proposed that
emotions, including revenge, can disrupt the maturing capac- childhood trauma, by differentially effecting maturation of
ity for restraint of aggression, appropriate use of instrumental brain subsystems, through use-dependent modifications,
aggression, and assertiveness (Atkins et al 1993). Autono- sets these subsystems’ relative contributions to future
mous strivings may be subverted by trauma-related avoid- appraisal and response to danger.
ance, leading to lost developmental opportunities, or be Studies that have examined the effects of school-age
accelerated by trauma-generated adventuresome pursuits that and preadolescent trauma have begun to document neuro-
lie beyond the child or adolescent’s developmental capabili- hormonal and neurophysiological alterations. De Bellis et
ties. The latter may increase risk of subsequent traumatic al (1994) found low basal and CRF-stimulated ACTH
exposures. Changes in future expectancies and perceived levels among sexually abused girls. Goenjian et al (1996)
narrowing of developmental opportunities can adversely reported low basal cortisols and hypersuppression after
effect adolescent emerging ambition, initiative, and dexamethasone among adolescent survivors of the Arme-
motivation. nian earthquake. Perry et al (1995) have reported post-
Critical parent-child transitions can be accelerated or trauma bidirectional autonomic changes, primarily in heart
impeded, as, for example, the chronic separation among rate. Tachycardia appears to be most related to witnessing
the Armenian adolescents is likely to interfere with their and direct threat without physical violation, while lowered
age-appropriate adjustment in the balance of independence heart rate is associated with sexual abuse, physical pene-
and dependence. Posttrauma irritable, anxious, avoidant, tration, and dissociative phenomena. Ornitz and Pynoos
or withdrawn behavior, physical disability or disfigure- (1989) found a significantly reduced level of normal
ment, and preoccupation with trauma-related material may prepulse inhibition of startle response among school-aged
profoundly affect current peer interactions. Peer rejection, children exposed to catastrophic violence. We are cur-
in part mediated by school milieu, carries its own inde- rently evaluating the influence of trauma-related alter-
pendent risk for disturbed social adjustment and subse- ations in startle modulation on information processing, an
quent psychopathology (Asher and Coie 1992). investigation that needs to consider the complex develop-
A recent study of the dimension of moral development mental course of endogenous event-related potentials (Py-
illustrates the inherent opposition of constructive and noos et al 1997b).
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These findings point to a number of critical questions in mation, and experience. They have the capacity to pow-
the developmental neurobiology of traumatic stress. Do erfully influence future career choices, preferences for
danger-related changes in neurotransmitters have a neuro- geographical residence, and parenting behavior. Lack of
trophic influence on cortical development in infancy and adequate schematization of protective intervention may
early childhood? How, when, and by what means do compromise self-preservative and self-caring functions in
phasic autonomic reactions become more tonic? Are children (Hartman and Burgess 1989) and interfere with
volumetric changes in brain regions attributable to a adult protective behavior (Wyatt et al 1992).
stress-related “toxicity” or to diminishment in trophic
factors, such as stress-related changes in BDNF mRNA
activity (Rasmusson and Charney 1997)? To what extent Distal Trauma Reminders and Secondary
do neurohormonal alterations represent vulnerability to Stresses
adapation to danger, trauma, and other life stresses? Our The influence of distal trauma reminders may depend on
preliminary startle modulation studies raise the issue of the extent to which they are embedded in the circum-
varying impacts of traumatic exposures during periods of stances of everyday life. The more they involve intricacies
relative neural plasticity or consolidation, including the of interpersonal interactions, bodily sensations, and inter-
possibility of neurophysiological regression, in addition to nal affective states, the more difficult they are to identify
lack of maturation. Furthermore, the slow developmental as sources of renewed arousal, anxiety, or avoidance.
progression in the acquisition of startle modulation under- Distal reminders may appear during parenthood, leading to
scores the prolonged neurodevelopmental maturation and overly anxious, protective, or authoritarian behavior. Dis-
vulnerability of major inhibitory pathways that relate to tal secondary stresses may be a continuation of stresses
the human capacity to appraise and respond to danger. that occurred in the immediate aftermath of the trauma or
may arise out of new developmental challenges or life
circumstances. They range from the need for future
Distal Development medical treatment and accommodation to disability, con-
Prospective longitudinal studies tracking the distal devel- tact of an abusive parent or relative with children of the
opmental outcome of child and adolescent traumatic ex- next generation, or the challenge of self-revelation to
periences have yet to appear. One important personality explain trauma-related behavior to intimate persons in
axis affected by trauma is that of fear, courage, and one’s later life.
fearlessness (Rachman 1980). The child literature includes
reports of oscillations toward each of the extremes among
Distal Pathology
severely traumatized children (Gislason and Call 1982).
The incorporation of shifts on this axis into character can A developmental psychopathology model of PTSD under-
result in enduring personality traits, including chronic scores the complex iterative impact on developmental
fearfulness, compulsive heroism, or under reactivity to progression and distal pathology of repeated victimization
high-risk situations. in childhood, a review of which is beyond the scope of this
Traumatic experiences can skew expectancies about the paper. Nonetheless, even among heterogeneous outcomes,
world, the safety and security of interpersonal life, and there is a role for systematic review of trauma history and
forecasts about the future. Such expectancies conceptually determination of comorbid PTSD. A residential treatment
map onto a schema of risk, danger, injury, loss, safety, study, for example, showed that history of earlier trauma,
security, protection, and intervention. Especially in child- diagnosis of PTSD, and current reactivity to trauma
hood, these expectancies, once organized, tend to operate reminders explained otherwise unexplained aggressive
outside of conscious awareness and resist dramatic change and avoidant behaviors among adolescents with mood and
(Cicchetti and Cohen 1995). disruptive behavioral disorders (Doyle and Bauer 1989). A
Negative self-attributions that arise out of the original prospective study following adolescent Cambodian refu-
experience(s), may, if uncorrected, also become embedded gees into young adulthood found a waxing and waning
in character. Adult studies suggest that these negative course of PTSD, continuity of PTSD related to traumatic
self-images are vulnerable to reactivation after future exposure, and current depression associated with current
traumatic exposure (Foa and Riggs 1994) and compromise secondary stresses (Sack et al 1996). Clark and Kirisci
efforts at adjustment. These attributions may also influ- (1996) found significant detrimental effects of chronic
ence the degree to which one is willing to rely on others PTSD on the quality of life among adolescents, with
for danger appraisal, support with emotional regulation, disturbances in health functioning, social competence, and
and protective intervention. Intervention themes can re- school performance. A recent HMO retrospective study
main relatively fixed or evolve with maturity, new infor- among adults suggests that witnessing family violence,
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childhood victimization, and childhood exposure to severe progression in fears and anxieties, age-related repetitive
household dysfunction are risk factors for the leading behaviors, and play and mental activities (Carter et al
causes of death in adults (Felitti et al 1998). 1995; Craske 1997). The field of childhood traumatic
Retrospective studies have suggested the importance stress would suggest that a more comprehensive model
of a developmental path analysis in understanding the would place the intersection of these two lines of
association of child and adolescent traumatic experi- progression within the psychology and developmental
ences, child and adolescent PTSD, and adult PTSD. neurobiology of maturing capacities to appraise, emo-
Findings include the association of childhood physical tionally regulate, and respond to real dangers in the
abuse with increased risk of chronic PTSD after late- world.
adolescent or young-adulthood combat exposure (Zaidi As more epidemiological information about age- and
and Foy 1994), the chronicity of PTSD into adulthood gender-related traumatic exposures becomes available, it
associated with sequential childhood physical abuse and would be fruitful to map the epidemiology of anxiety
sexual abuse (Rodriguez et al 1998), and the greater risk disorders against a background of this information. Trau-
of developing PTSD in adulthood associated with a matic experiences and losses have been considered, among
history of multiple traumatic events (Robin et al 1997; nonshared environments, as being potentially salient in
Yehuda et al 1995). explaining variance in childhood and adolescent psycho-
There is suggestive evidence of potential neurobio- pathology (Pike and Plomin 1996). Family and twin
logical changes extending into adulthood. These include studies have suggested an important role for nonshared
tonic autonomic and catecholamine activity alterations environments in the etiology and course of anxiety disor-
(Perry et al 1995); HPA axis alterations, including ders (Kendler et al 1992a, 1992b). Prospective population
increased glucocorticoid receptor numbers in adult studies of child and adolescent anxiety disorders need to
survivors of childhood sexual abuse (Stein et al 1997); incorporate ongoing systematic screening for traumatic
a pattern of low cortisol response to adult sexual trauma exposures, using typologies congruent with developmental
after earlier sexual assault history (Resnick et al 1995); and environmental risks. For example, the peak incidences
and reduced left hippocampal volume in adults with (and surprisingly high prevalence) of serious near-drown-
histories of childhood physical, sexual abuse, or both ing, burns, and dog bites are between infancy and five
(Bremner et al 1997; Stein et al 1997). It will be years of age, the latter two exposures having been reported
important to prospectively study the effects of these to be associated with PTSD and, over time, with childhood
changes on the appraisal and response to danger and phobic disorder (Gislason and Call 1982; Stoddard et al
future traumatic experiences. 1989). Consistent with our model, the report of traumatic
exposure should be complemented with information about
secondary adversities and the ecology of trauma
Intersection of Childhood Traumatic Stress, reminders.
PTSD, and Other Anxiety Disorders As we incorporate more rigorous prospective informa-
This developmental model suggest different avenues by tion about trauma exposures, it will become possible to
which dangerous circumstances, childhood traumatic examine the concordance of specific traumatic features
experiences, and PTSD can intersect with other anxiety and symptom profile of later anxiety disorder, as well as to
disorders over the life span. Recent adult studies have examine the mediating role of child-intrinsic factors in-
begun to describe how difficult it is to ascertain the cluding different forms of anxiety sensitivity (Stein et al
impact of prior trauma and chronic PTSD among 1999). For example, Bouwer and Stein (1997) reported
patients presenting with predominant Panic, OCD, or that a significant subpopulation of adults with panic
other primary anxiety profiles. Given the emerging disorder had a history of traumatic suffocation experi-
developmental epidemiology of child and adolescent ences. These included school age and adolescent near-
traumatic exposures and the prevalence of anxiety drowning and political torture by suffocation. Fear and
disorders in childhood (Costello and Angold 1994), it is symptom profiles included respiratory phenomena and
important to begin to better characterize their potential nocturnal panic. The severity of the exposures presented in
points of intersection. Last et al (1992) have suggested the case material would suggest the likelihood of acute
that the age-of-onset data of childhood anxiety disor- traumatic reactions, reactivity to reminders, and ongoing
ders points to a developmental progression (simple interactions with proximal psychopathology and develop-
phobia followed by separation anxiety, overanxious or ment prior to the onset of young adult panic disorder
general anxiety disorder, obsessive-compulsive disor- (Pynoos et al, in press). Such complex interactions may
der, social phobia, and panic, with or without agora- contribute to the development and maintenance of an
phobia), which others have mapped against a normative increased alarm propensity.
Child Development, PTSD, Child Trauma, Anxiety BIOL PSYCHIATRY 1551
1999;46:1542–1554

Adult anxiety disorder research has continued to sug- Research in childhood anxiety disorders is paralleling
gest the utility of a developmental psychopathology ap- that of childhood traumatic stress in addressing the
proach across the lifecycle. A significant subpopulation of interplay among traumatic experiences, psychopathol-
young and middle-age adults with panic disorder report a ogy, child-parent interactions, and developmental dis-
history of childhood sexual abuse (Stein et al 1996) in turbance. For many children with anxiety disorders,
which the peak incidence is during preadolescence, for including PTSD, the relationship between disorder and
example. This life-trajectory approach is especially rele- impairment is a reciprocal one, with impairment leading
vant in considering the findings of Prigerson et al (1996) to continued exacerbation of anxiety symptoms, which
that childhood physical, sexual, and psychological abuse, in turn results in worse impairment. As an example,
as well as parental loss, are risk factors for the onset of social phobia is often triggered by a traumatic or
late-life anxiety disorders, particularly after becoming a stressful event (Ost 1987) that can then lead to phobic
caretaker of an ill spouse. avoidance and deterioration in the child’s level of social
Child-parent interaction is a critical dimension of non- activity. Decreased peer performance may foster in-
shared environments (Pike and Plomin 1996). Many fea- creased social discomfort, leading to further withdrawal
tures of parent-child interactions that have been described and worsening impairment (Beidel and Morris 1994). A
as moderating the pathogenesis of anxiety disorders in developmental psychopathology model suggests the
children are also evident in dangerous circumstances and mutual importance of lessening psychopathology and
after children’s traumatic exposures. These features in- habilitating developmental competencies, especially in
clude reciprocation of avoidance responses; parental neg- childhood, where lost developmental opportunities and
ative feedback, including being critical; and parental impaired acquisition of skills carry significant indepen-
restriction, which exacerbates children’s anxious and dent risks for adverse life-trajectory outcomes.
avoidant behaviors (Barrett et al 1996; Dadds et al 1996;
Hirshfeld et al 1997). Costanzo et al (1995) have postu-
lated that outcome is mediated by mechanisms involved in This work was presented at the scientific satellite conference, “The Role
the acquisition of developmental competencies, including of Biological and Psychological Factors on Early Development and Their
Impact on Adult Life,” that preceded the Anxiety Disorders Association
disturbances in the child’s sense of control and self-
of America (ADAA) annual meeting, San Diego, March 1999. The
efficacy and overdependence on others to master stimuli, conference was jointly sponsored by the ADAA and the National
leading to greater ambiguity in the child’s sense of agency Institute of Mental Health through an unrestricted educational grant
and effectiveness. These resulting child- or adolescent- provided by Wyeth-Ayerst Laboratories.
intrinsic factors may mediate responses to real danger and
represent an axis of vulnerability to PTSD after traumatic
experiences. References
Fairbanks and McGuire (1993) have provided a power- Amorapanth P, Nader K, Repa JC, LeDoux JE (1999): The fear
ful ethological demonstration of the nonshared environ- arousing and motivational properties of aversive stimuli are
mental impact on siblings of the introduction of real mediated by different systems within the amygdala (abstract).
Soc Neurosci.
danger into the group ecology, mediated by increases in
Armony JL, LeDoux JE (1997): How the brain processes
maternal protectiveness. Among vervet monkeys, all emotional information. Ann N Y Acad Sci 821:259 –270.
mothers, across a spectrum of baseline laissez-faire to high
Asher SR, Coie JD (1992): Peer Rejection in Childhood. New
protectiveness, became more protective toward their in- York: Cambridge University Press.
fants during years when a new male had been introduced Atkins M, Stoff D, Osborne ML, Brown K (1993): Distinguish-
into the group (new males pose a threat of infanticide), as ing instrumental and hostile aggression: Does it make a
compared with long-term resident males. Infants reared difference? J Abnorm Child Psychol 21:355–365.
from the new male groups were more fearful and cautious Barrett PM, Rapee RM, Dadds MM, Ryan SM (1996): Family
when tested 1–3 years later, with longer latency to enhancement of cognitive style in anxious and aggressive
approach a novel object or enter a novel environment. children. J Abnorm Child Psychol 224:187–203.
Using principles of population genetics, these investiga- Beidel DC, Morris TL (1995): Social phobia. In: March JS,
tors are presently evaluating the relative contributions of editor. Anxiety Disorders in Children and Adolescents. New
York: Guilford Press, 181–211.
genetics and nonshared environment to cohort population
Boney-McCoy S, Finkelhor D: (1995) Psychosocial sequelae of
variance in behavioral inhibition. This ethological study
violent victimization in a national youth sample. J Cons Clin
suggests that there can be an interplay of danger and Psychol 63:726 –736.
trauma and exaggerated parental protectiveness in the Bouwer C, Stein DJ (1997): Association of panic disorder with a
developmental course of behaviorally inhibited children history of traumatic suffocation. Am J Psychiatry 154:1566 –
and risk of anxiety disorder. 1570.
1552 BIOL PSYCHIATRY R.S. Pynoos et al
1999;46:1542–1554

Bremner JD, Randall P, Vermetten E, Staib L, Bronen RA, Fivush R (1991): The social construction of personal narratives.
Mazure C, et al (1997): MRI-based measurement of hip- Merrill-Palmer Q 37:59 – 81.
pocampal volume in posttraumatic stress disorder related to Foa EB, Riggs DS (1994): Posttraumatic stress disorder in rape.
childhood physical and sexual abuse: A preliminary report. In: Pynoos R, editor. Posttraumatic Stress Disorder: A
Biol Psychiatry 41:23–32. Clinical Review. Lutherville, MD: Sidron Press, 133–163.
Brent DA, Moritz G, Bridg, J, Perper J, Canobbio R (1996): Foy D, Madvig B, Pynoos R, Camilleri A (1996): Etiological
Long-term impact of exposure to suicide: A three-year factors in development of post-traumatic stress disorder in
controlled follow-up. J Am Acad Child Adolesc Psychiatry children and adolescents. J Sch Psychol 34:133–145.
35:646 – 653.
Galvin MR, Stilwell BM, Shekhar A, Kipta SM, Goldfarb SM
Carter AS, Pauls DL, Leckman JF (1995): The development of (1997): Maltreatment, conscience functioning and dopamine
obsessionality: Continuities and discontinuities. In: Cic- beta hydroxylase in emotionally disturbed boys. Child Abuse
chetti D, Cohen DJ, editors. Developmental Psychopathol- Negl 21:83–92.
ogy: Theory and Models. New York: Wiley, 609 – 632.
Garcia J, Lasiter PS, Bermudez-Rattoni F, Deems A (1986): A
Cicchetti D (1989): How research on child maltreatment has general theory of aversion learning. Ann N Y Acad Sci
informed the study of child development: Perspectives 43:8 –21.
from developmental psychopathology. In: Cicchetti D,
Carlson V, editors. Child Maltreatment: Theory and Re- Gislason IL, Call J. (1982): Dog bite in infancy: Trauma and
search on the Causes and Consequences of Child Abuse personality development. J Am Acad Child Adolesc Psychia-
and Neglect. New York: Cambridge University Press, try 22:203–207.
377– 431. Goenjian AK, Pynoos RS, Steinberg AM, Najarian LM, Asar-
Cicchetti D, Cohen DJ (1995): Manual of Developmental Psy- now JR, Karayan I (1995): Psychiatric co-morbidity in
chopathology. New York: Wiley. children after the 1988 earthquake in Armenia. J Am Acad
Child Adolesc Psychiatry 34:1174 –1184.
Clark DB, Kirisci L (1996): Posttraumatic stress disorder, de-
pression, alcohol use disorders and quality of life in adoles- Goenjian AK, Stilwell BM, Steinberg AM, Fairbanks LA, Galvin
cence. Anxiety 2:226 –233. M, Karayan I, Pynoos RS (1999): Moral development among
adolescents after trauma. J Am Acad Child Adolesc Psychia-
Clod A, Teicher M, Hartman C, Harakal T (1997): Increased try 38:376 –384.
nocturnal activity and impaired sleep maintenance in abused
children. J Am Acad Child Adolesc Psychiatry 36:1236 – Goenjian AK, Yehuda R, Pynoos RS, Steinberg AM, Tashjian
1243. M, Yang RK, et al (1996): Basal cortisol, dexamethasone
suppression of cortisol, and MHPG in adolescents after the
Costanzo P, Miller-Johnson S, Wencel H (1995): Social devel- 1988 earthquake in Armenia. Am J Psychiatry 153:929 –
opment. In: March JS, editor. Anxiety Disorders in Children 934.
and Adolescents. New York: Guildford Press, 82–108.
Hartman CR, Burgess A (1989): Sexual abuse of children:
Costello EJ, Angold A (1995): Epidemiology. In: March JS, Causes and consequences. In: Cicchetti D, Carlson V, editors.
editor. Anxiety Disorders in Children and Adolescents. New Child Maltreatment: Theory and Research on the Causes and
York: Guilford Press, 109 –124. Consequences of Child Abuse and Neglect. New York:
Craske MG (1997): Fear and anxiety in children and adolescents. Cambridge University Press, 95–128.
Bull Menninger Clin 61(2): A4 –A36. Hirshfeld DR, Biederman J, Brody L, Faraone SV, Rosenbaum
Dadds MR, Barrett PM, Rapee RM (1996): Family process and JF (1997): Expressed emotion toward children with behav-
child anxiety and aggression. An observational analysis. J ioral inhibition: Associations with maternal anxiety disorder.
Abnorm Child Psychol 24:715–734. J Am Acad Child Adolesc Psychiatry 36:910 –917.
Davis M, Walker D, Lee Y (1997): Roles of the amygdala and Kendler KA, Neale MC, Kessler RC, Heath AC, Eaves LJ
bed nucleus of the stria terminalis in fear and anxiety (1992a): Generalized anxiety disorder in women: A popula-
measured with the acoustic startle reflex. Ann N Y Acad Sci tion-based twin study. Arch Gen Psychiatry 49:267–272.
821:305–331. Kendler KA, Neale MC, Kessler RC, Heath AC, Eaves LJ
De Bellis MD, Lefter L, Trickett P, Putnam FW (1994): Urinary (1992b): The genetic epidemiology of phobias in women:
catecholamine excretion in sexually abused girls. J Am Acad The interrelationship of agoraphobia, social phobia, situa-
Child Adolesc Psychiatry 33:320 –327. tional phobia and simple phobia. Arch Gen Psychiatry
Doyle JS, Bauer S (1989): Posttraumatic stress disorder in 49:273–281.
children: Its identification and treatment in a residential Kilpatrick DG, Saunders BE, Resnick HS, Smith DW (1995):
setting for emotionally disturbed youth. J Trauma Stress The National Survey of Adolescents: Preliminary Findings
2:275–288. on Lifetime Prevalence of Traumatic Events and Mental
Fairbanks LA, McGuire MT (1993): Maternal protectiveness and Health Correlates. Charleston: Medical University of
response to the unfamiliar in vervet monkeys. Am J Primatol South Carolina, National Crime Victims Research and
30:119 –129. Treatment Center.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Klinnert MD, Campos J, Source JF, Emde RN, Svejda MJ
Edwards V, et al (1998): Relationship of childhood abuse and (1983): Social referencing. In: Plutchik P, Kellerman H,
household dysfunction to many of the leading causes of death editors. The Emotions in Early Development. New York:
in adults: The Adverse Childhood Experiences Study. Am J Academic Press, 123–134.
Prev Med 14:245–258. Korn H, Faber D (1996): Escape behavior— brain stem and
Child Development, PTSD, Child Trauma, Anxiety BIOL PSYCHIATRY 1553
1999;46:1542–1554

spinal cord circuitry and function. Curr Opinion Neurobiol Rachman S (1980): Emotional processing. Behav Res Ther
6:826 – 832. 18:51– 60.
La Greca AM, Silverman WK, Wasserstein SB (1998): Chil- Pynoos RS, Ritzmann RF, Steinberg AM, Goenjian A, Prisecaru
dren’s predisaster functioning as a predictor of posttraumatic I (1996): A behavioral animal model of PTSD featuring
stress following Hurricane Andrew. J Cons Clin Psychol repeated exposure to situational reminders. Biol Psychiatry
66:883– 892. 39:129 –134.
Last CG, Perrin S, Hersen M, Kazdin AE (1992): DSM-III-R Pynoos RS, Steinberg AM, Aronson L. (1997a): Traumatic
anxiety disorders in children: Sociodemographic and clin- experiences: The early organization of memory in school-
ical characteristics. J Am Acad Child Adolesc Psychiatry age children and adolescents. In: Appelbaum P, Elin M,
31:1070 –1076. Uyehara L, editors. Trauma and Memory: Clinical and
Lynch M, Cicchetti D (1998): An ecological-transactional Legal Controversies. New York: Oxford University Press,
analysis of children and contents: The longitudinal inter- 272–289.
play among child maltreatment, community violence, and Pynoos RS, Steinberg AM, Ornitz EM, Goenjian AK (1997b):
children’s symptomatology. Dev Psychopathol 10:235– Issues in the developmental neurobiology of traumatic stress.
257. Ann N Y Acad Sci 821:176 –193.
Masten A, Best K, Garmezy N (1990): Resilience and develop- Pynoos RS, Steinberg AM, Wraith R (1995): A developmental
ment: Contributions from the study of children who overcome model of childhood traumatic stress. In: Cicchetti D, Cohen
adversity. Dev Psychopathol 2:425– 444. DJ, editors. Manual of Developmental Psychopathology. New
Nader KO, Pynoos RS, Fairbanks LA, Al-Ajeel M, Al-Asfour A York: Wiley, 72–95.
(1993): A preliminary study of PTSD and grief among the Rasmusson AM, Charney DS (1997): Animal models of rele-
children of Kuwait following the Gulf crisis. Br J Clin vance to PTSD. Ann N Y Acad Sci 821:332–351.
Psychol 32:407– 416. Resnick HS, Yehuda R, Pitman RK, Foy DW (1995): Effect of
Ornitz EM, Pynoos RS (1989): Startle modulation in children previous trauma on acute plasma cortisol level following
with posttraumatic stress disorder. Am J Psychiatry 146:866 – rape. Am J Psychiatry 152:1675–1677.
870.
Robin RW, Chester B, Rasmussen JK, Jaranson JM, Goldman D
Osofsky JD (1993): The New Orleans Violence & Children (1997): Prevalence and characteristics of trauma and posttrau-
Intervention Project. Ment Health 4:2. matic stress disorder in a southwestern American Indian
Ost LG (1987): Age of onset in different phobias. J Abnorm community. Am J Psychiatry 154:1582–1588.
Psychol 96:223–229. Rodriguez N, Van de Kemp H, Foy DW (1998): Posttraumatic
Perry BD, Pollard RA, Blakley TL, Baker WL, Vigilante D stress disorder in survivors of childhood sexual and physical
(1995): Childhood trauma, the neurobiology of adaptation abuse: A critical review of the empirical research. J Child Sex
and use-dependent development of the brain: How states Abuse 7:45.
become traits. Infant Ment Health J 16:271–291. Rutter M (1985): Resilience in the face of adversity. Br J
Pfefferbaum B (1997): Posttraumatic stress disorder in children: Psychiatry 147:598 – 611.
A review of the past ten years. J Am Acad Child Adolesc Rutter M (1988): Epidemiological approaches to developmental
Psychiatry 36:1503–1511. psychopathology. Arch Gen Psychiatry 45:486 – 495.
Pike A, Plomin R (1996): Importance of nonshared environmen- Saarni C, Harris PL (1991): Children’s Understanding of Emo-
tal factors for childhood and adolescent psychopathology. tion. Cambridge, UK: Cambridge University Press.
J Am Acad Child Adolesc Psychiatry 35:560 –570.
Sack WH, Clarke GN, Seeley J (1996): Multiple forms of stress
Prigerson HG, Bierhals AJ, Kasl SV, Reynolds CF, Shear in Cambodian adolescent refugees. Child Dev 67:107–116.
MK, Day N, et al (1997): Traumatic grief as a risk factor
for mental and physical morbidity. Am J Psychiatry 154: Stein MB, Jang KL, Livesley WJ (1999): Heritability of anxiety
616 – 623. sensitivity: A twin study. Am J Psychiatry 156:246 –251.
Prigerson HG, Shear MK, Bierhals AJ, Zonarich DL, Reynolds Stein MB, Koverola C, Hanna C, Terce, MG, McClarity B
CF (1996): Childhood adversity, attachment and personality (1997): Hippocampal volume in women victimized by child-
styles as predictors of anxiety among elderly caregivers. hood sexual abuse. Psychol Med 27:951–959.
Anxiety 2:234 –241. Stein MB, Walker JR, Anderson G, Hazen Al, Ross CA, Eldridge
Pynoos R, Frederick C, Nader KO, Arroyo W, Steinberg A, G, et al (1996): Childhood physical and sexual abuse in
Eth S, et al (1987): Life threat and posttraumatic stress in patients with anxiety disorders and in a community sample.
school-age children. Arch Gen Psychiatry 44:1057–1063. Am J Psychiatry 153:275–277.
Pynoos RS, Goenjian A, Steinberg AM (1998): A public mental Stein MB, Yehuda R, Doverola C, et al (1997): HPA axis
health approach to the post-disaster treatment of children and functioning in adult women who report experiencing severe
adolescents. Child Adolesc Psychiatr Clin North Am 7:195– childhood sexual abuse. Biol Psychiatry 42:680 – 686.
210. Steinberg AM, Ritzmann RF (1990): A living systems approach
Pynoos RS, Kinzie JD, Gordon M (in press): Children, to understanding the concept of stress. Behav Sci 35:138 –
adolescents and families exposed to torture and related 146.
trauma. In: Keane T, Gerrity E, Tuma F, editors. Mental Stoddard FJ, Norman DK, Murphy JM, Beardslee, WR (1989):
Health Consequences of Torture and Related Violence and Psychiatric outcome of burned children and adolescents. J Am
Trauma. Acad Child Adolesc Psychiatry 28:589 –594.
1554 BIOL PSYCHIATRY R.S. Pynoos et al
1999;46:1542–1554

Teicher M, Ito Y, Glod CA, Andersen SL, Dumont N, Yehuda R, Kahana B, Schmeidler J, Southwick SM, Wilson S,
Ackerman E (1997): Preliminary evidence for abnormal Giller EL (1995): Impact of cumulative lifetime trauma and
cortical development in physically and sexually abused recent stress on current posttraumatic stress disorder symp-
children using EEG coherence and MRI. Ann N Y Acad Sci toms in Holocaust survivors. Am J Psychiatry 152:1815–
821:160 –175. 1818.
Tiet QQ, Bird HR, Davies M, Hoven C, Cohen P, Jensen PS, Yule W, Bolton D, Udwin O (1992, June): Objective and
Goodman S (1998): Adverse life events and resilience. J Am subjective predictors of PTSD in adolescence. Presented at
Acad Child Adolesc Psychiatry 37:1191–1200. the World Conference of the International Society for Trau-
World Health Organization Division of Mental Health (1990): matic Stress Studies, Amsterdam.
ICD-10, Mental and Behavioral Disorders. Geneva: DCR Yule W, Udwin O (1991): Screening child survivors for post-
World Health Organization, Division of Mental Health. traumatic stress disorders: Experiences from the “Jupiter”
Wyatt G, Guthrie D, Notgrass C (1992): The differential effects sinking. Br J Clin Psychol 30:131–138.
of women’s child sexual abuse and subsequent sexual assault. Zaidi LY, Foy D (1994): Childhood abuse experiences and
J Cons Clin Psychol 60:167–173. combat-related PTSD. J Trauma Stress 7:33– 42.

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