Psychiatr News February 2, 2007
Volume 42, Number 3, page 20
© 2007 American Psychiatric Association
Developmental Trauma Merits DSM Diagnosis, Experts Say
Mark Moran
Complex trauma is a precursor to a host of biological and psychological
problems not captured in any DSM diagnosis. Symptoms can interfere
with developmental tasks, complicating the clinical picture as children
mature.
| |
Bessel van der Kolk, M.D.: "These children have come to organize
their neurobiology and psychology in response to seeing the world as a
threatening and overwhelming place."
Photo: Courtesy of Bessel van der Kolk, M.D.
|
|
Denise (not her real name), now living with her maternal grandmother, is an
11-year-old girl who was assaulted by her father in the first year of her
life.
The abuse required her to undergo multiple reconstructive surgeries.
Removed from her parents' home, she has had a relatively normal upbringing in
her grandmother's care; with the exception of some difficulty eating related
to surgery on her jaw, the physical symptoms related to abuse have been
manageable.
But Denise's emotional development has been less smooth, according to child
trauma expert Julian Ford, Ph.D., an associate professor of psychiatry at the
University of Connecticut School of Medicine, who described the case.
Unable to form friendships with adults or peers, she has developed an
intensely private inner world. And in situations requiring her to interact
with others, Denise is prone to sudden outbursts of rage so extreme she has
had to be removed temporarily from her grandmother's home, Ford told
Psychiatric News.
"[T]he determination that we are somehow missing many children who we
cannot fully and accurately diagnose [with the current diagnostic criteria]
has just crystallized in the last few years."
Or consider "Michael," a 2-year-old boy who witnessed the
shooting death of a parent and was then left alone with the body for days
before being discovered.
"For a child who doesn't even have the language or cognitive capacity
that would be available to an older child, how will such an episode
reverberate over the course of his development?" asked child-trauma
expert Steven Marans, Ph.D., director of the National Center for Children
Exposed to Violence located at Yale University's Yale Child Study Center and a
professor of child psychiatry at Yale. "What will happen to his capacity
to form trusting relationships with new adoptive parents?"
Michael's and Denise's stories—composites of real events in the lives
of thousands of children who are subject to trauma every year—are among
those that form the clinical background for what trauma experts call
"complex trauma" or "developmental trauma."
The terms have been coined to address the kinds of questions Marans raises
and to capture the multifaceted nature of sequelae experienced by children
when violence, neglect, and fear form the fabric of their early existence.
Trauma experts say horrors of the sort experienced by Denise and Michael
have a pervasive impact on the developing brain, resulting in wide-ranging
behavioral and neurobiological symptoms including depression, attention
disorders, various somatic illnesses, interpersonal problems, and impulsive
and self-destructive behaviors. Moreover, the symptoms are liable to interfere
with sequential developmental tasks, creating new difficulties with each
succeeding stage of development and complicating the clinical picture as the
child matures.
While knowledge about the effect of developmental trauma is familiar to
clinicians and researchers who are steeped in the study of childhood trauma,
it runs counter to the traditional way in which DSM-IV describes
trauma—embodied in the diagnosis of posttraumatic stress disorder
(PTSD)—as an isolated traumatic incident producing discrete behavioral
and biological responses to discrete triggers.
"Historically, PTSD was derived as a diagnosis for Vietnam
Warvets," said psychiatrist Bessel van der Kolk, M.D., medical director
of the Trauma center in Boston and a professor of psychiatry at Boston
University School of Medicine. "It was a very good description of
one-time trauma, but when we look at trauma among women in abusive
relationships or kids who are abused by parents or an institution, we see an
entirely different clinical picture.
"Traumatized kids who come to the attention of schools and social
service agencies overwhelmingly experience trauma in the context of intimate
relationships," van der Kolk said. "These children have come to
organize their neurobiology and psychology in response to seeing the world as
a threatening and overwhelming place, the result of being assaulted by their
environment or as a coping mechanism to deal with their internal
dysregulation."
Seeing One Tree Instead of Forest
In recent years, leaders in the treatment of child trauma—including
Ford, van der Kolk, and Robert Pynoos, M.D., who is director of the National
Child Traumatic Stress Network (NCTSN)—have spearheaded a project with
colleagues nationwide to support the introduction of a new diagnosis in
DSM that more completely accounts for the sequelae of developmental
trauma.
They say that in the absence of a diagnosis that accurately captures the
pervasive nature of disturbances related to early childhood trauma, children
tend to receive a hodgepodge of labels for any number of symptoms—PTSD
and attention deficit, conduct, and mood disorders—that are treated as
separate conditions.
"Approaching each of these problems piecemeal, rather than as
expressions of a vast system of internal disorganization, runs the risk of
losing sight of the forest in favor of one tree," said van der Kolk.
"What you call someone has large implications for how you treat someone,
even though you may be describing the same phenomenology [using different
terms]."
He noted, for instance, that because of the emotional dysregulation that
traumatized children frequently display—as well as self-harming
behaviors they may adopt as a coping mechanism—they are too often
diagnosed with bipolar disorder and treated exclusively with drugs and
behavior management.
But van der Kolk and other leaders in the field say that such an approach
is an example of how an overly simplified diagnosis can lead to inadequate
treatment and a poor outcome.
"Looking at developmental trauma can help us to think more
realistically about both the complexity of presenting problems and the depth
or extent of clinical services that need to be in play, not only in the
consulting room but in the work with parents and teachers," Marans told
Psychiatric News. "It makes a big difference whether you base a
diagnosis solely on the presentation of particular symptoms or on a more
complex view of how the symptoms are affecting development over
time."
In his article "Developmental Trauma Disorder: A New Rational
Diagnosis for Children With Complex Trauma Histories," in the May 2005
Psychiatric Annals, van der Kolk argued the case for a new diagnostic
entity and described implications for treatment.
"The diagnosis of PTSD is not developmentally sensitive and does not
adequately describe the effect of exposure to childhood trauma on the
developing child," he wrote. "Because infants and children who
experience multiple forms of abuse often experience developmental delays
across a broad spectrum, including cognitive, language, motor, and
socialization skills, they tend to display very complex disturbances, with a
variety of different, often fluctuating, presentations."
At the Trauma Center in Boston, van der Kolk said, treatment of severely
traumatized children can involve theater groups, yoga, and breathing and
sensory integration exercises aimed at enhancing self-regulation. A focus of
therapy is improving heart rate variability, which reflects disruption of the
body's sympathetic-parasympathetic balance caused by chronic trauma.
In the Psychiatric Annals article, he explained that treatment of
chronically traumatized children should focus on three primary areas:
establishing the child's capacity to regulate his or her internal states of
arousal, learning to negotiate safe interpersonal attachments, and integration
and mastery of the body and mind.
"Mastery is most of all a physical experience," he wrote,
"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."
Steep Costs to Treat Separate Symptoms
Ford said that while clinicians and researchers working with traumatized
children have long recognized the developmental nature of trauma, it has only
recently been synthesized and articulated for a larger audience of
clinicians.
"Research and clinical work has been going on for two or three
decades," he told Psychiatric News. "The integration of
that information and the determination that we are somehow missing many
children who we cannot fully and accurately diagnose [with the current
diagnostic criteria] has just crystallized in the last few years."
Today much of the work on developmental trauma is being advanced by NCTSN.
The network consists of 70 member centers and is funded by the center for
mental Health services, part of the Substance Abuse and Mental Health Services
Administration.
Ford described an agenda for the future that includes collecting case
studies of children who have experienced profound trauma, which would be
provided by clinicians nationally and internationally; refinement of criteria
for diagnosing complex trauma disorder; and development of
structured-interview instruments and rating scales that clinicians can use in
everyday practice.
Van der Kolk noted that the effort to create a diagnostic category for
developmental trauma disorder is supported by state child welfare agency
directors who see the costs of treating the isolated symptoms of severely
traumatized children. According to a white paper titled "Complex Trauma
in Children and Adolescents" by the NCTSN, these costs include an
estimated $24 billion or more a year spent on hospitalization, chronic health
problems, mental health care, child welfare, law enforcement, and the judicial
system.
Indirect expenses, estimated at $69 billion, include such items as special
education, adult mental health and health care, the consequences of juvenile
delinquency and adult criminality, and lost productivity, according to the
NCTSN.
"State child service commissioners say to us, 'You are describing the
children who are costing us $5 billion a year and absorbing most of the money
that states spend on kids,' " van der Kolk told Psychiatric
News. "They say that once we have a diagnosis [that encompasses all
of the complex difficulties of traumatized children], we can develop treatment
programs that would really make a difference."
"Developmental Trauma Disorder: A New Rational Diagnosis for
Children With Complex Trauma Histories" is posted at
<www.traumacenter.org/PsychiatricAnnals3a.pdf>.
"Complex Trauma in Children and Adolescents" is posted at
<www.nctsn.org>.
Get information about faster international access.
Privacy Policy
Copyright © 2007
American Psychiatric Association.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
| 
