Since PTSD was added to the DSM in 1980, professionals treating children with histories of attachment difficulties and early and chronic trauma have struggled to fit them into the definition, without much success. PTSD was originally developed to describe the problems of veterans returning from Vietnam. It was also suitable to describe the lingering deleterious effects of single event traumas such as rape, disasters, life-threatening accidents, and other overwhelming experiences that were so horrifying, the individual felt their life to be in danger and they were powerless to stop.
Judith Herman, M.D. in her seminal book, Trauma and Recovery (Basic Books, Penguin Books Group; New York, NY 1992, 1997) coined the term complex Trauma, or complex PTSD. She was after a more accurate description of chronic trauma such as that which is found in prisoners of war, victims of ongoing intimate partner violence, and chronically abused and neglected children. What differentiated these victims from those with PTSD was that the trauma was interpersonal in nature, and perpetrated by those who the person was utterly depended on, causing a “trauma bond” to develop. The complications caused by repeated and prolonged abuse were not ameliorated with the interventions used for single event PTSD. Indeed, chronically abused children did not even fit the diagnostic criteria.
Yet even the term, complex PTSD did not really address the multitude of difficulties observed in very young children who had experienced severe neglect and abuse at the hands of their caregivers; the very people these children had to depend on for their very survival. Researchers were beginning to apply attachment theory , developed by John Bowlby, as a basis for the myriad developmental difficulties. They observed that children with a secure attachment followed a normal developmental trajectory, while those with disorganized attachments (dangerous, obtrusive or neglectful caregiver) fared the worst. In other words, a disorganized attachment was traumatic!
Mental health practitioners and researchers were isolating a common core of symptoms and behaviors in children who had, as a common denominator, chronic and severe neglect and abuse at the hands of caregivers. The effects were so severe that they disrupted, in a profound way, normal child development across the spectrum, and involved disturbed early attachment relationships. Clearly, more research was desperately needed as well as a more precise name for what they were seeing.
Indeed, it was found that most trauma has to do with attachment relationships characterized by abuse, neglect, mental illness of a caregiver, violence in the home; in other words, living in a home where there is no protection. For example, a child may be involved in a traumatic event, but the effect will be mitigated by a loving and effective caregiver who protects and provides safety and structure for that child, whereas a child with no protection will be terrorized. Imagine if this happens to this unfortunate child repeatedly.
In 2008 The National Association of State Mental Health Program Directors (NASMHPD) and the Medical Directors Council petitioned the APA to include a proposed diagnosis of Developmental Trauma Disorder, which would capture the reality of the chronically traumatized children and teens they were seeing, in the upcoming version of the new DSM V. The consensus proposal was spearheaded by Bessel van der Kolk, M.D. and Robert Pynoos, M.D. Many of us who are parents, therapists or caregivers to these children will recognize what is included in this new diagnostic criteria.
Developmental Trauma Disorder
A. 1. Direct experience or witness to repeated and severe episodes of
A.2. Significant disruptions of protective caregiving as a result of repeated
changes in the primary caregiver, repeated separations from the primary
caregiver, or exposure to severe and persistent emotional abuse.
A.3. Persistent neglect
B. Affective and Physiological Dysregulation The child has an impaired ability to regulate arousal.• • •
B.1. Inability to modulate, tolerate, or recover from extreme states (anger, fear, shame, etc.) including extreme or prolonged tantrums or becoming immobilized.
B. 2. Disturbances in the regulation of bodily functions such as eating or sleeping. Over-reactivity or under-reactivity to touch and sounds, becoming disorganized during transitions.
B. 3. Diminished awareness or dissociations of sensations, emotions, and body states. Child may seem spacey. May be unaware of being thirsty, tired, hungry, or in pain.
C. Behavioral and Attentional Dysregulation
C.1. Preoccupation with threat or impaired capacity to perceive threat and
misreading of safety or danger cues. Sees and reacts to threat where none
actually exists. Exaggerated startle response.
C. 2. Impaired capacity to self-protect or increased risk/thrill seeking.
C.3. Maladaptive attempts to self soothe; rocking, excessive masturbation, escapism into computer games, isolation.
C.4. Habitual or intentional self-harm.
C.5. Inability to sustain attention and concentration. Difficulties in setting
goals and goal directed behavior. Some children and teens can’t imagine a future. Many complain of constant agitation and ‘static’ in their brains.
D. Self and Relational Dysregulation. Impaired competencies in their sense of self, personal identity, and involvement in relationships.
D 1. Intense preoccupation with the safety of the parent/caregiver or other loved ones. Difficulties tolerating reunion after separation.
D.2. Persistent negative self concept. Feeling defective, bad, helpless, ineffective despite successes and evidence to the contrary. Resists compliments and reassurances.
D. 3. Extreme and persistent distrust, defiance, and lack of reciprocal behavior. Assumes ill will from others.
D. 4. Reactive physical or verbal aggression toward peers, caregivers, and others. Paranoia about the motives of others is common. “Everyone hates me. Others are out to get me.”
D. 5. Insecurity. Inappropriate (excessive or promiscuous attempts to get intimate contact, not limited to physical or sexual) or excessive reliance on peers or adults to feel safe and reassured.
D. 6. Delayed or impaired capacity to regulate empathy. May be overly responsive to other’s distress at the expense of the self, or demonstrate a coldness, distance, or lack of empathy to the distress of another. Lack of, “emotional bandwidth.”
Unfortunately, the request for inclusion of the above diagnostic criteria in the DSM V was denied citing insufficient evidence! However Developmental Trauma is now recognized as a more accurate description among those who actually work with and live with our children. Great strides are being made in identifying and finding treatments for our chronically traumatized children, such as neurofeedback, yoga, art and occupational therapies. The first priority is to reframe the symptoms and behaviors of our hurt children as natural responses to trauma, and not willful misbehavior. And we must start listening to what they have to say. and to recognize that they crave respect. Therein lies the hope. The challenge is getting the word out to the people can help.
Copyright 2017 Melinda Charles San Antonio Center for Childhood Trauma and Attachment, LLC. All rights reserved.