Developmental Trauma Merits DSM Diagnosis, Experts Say

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.

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>.▪