A New Take on Childhood Trauma
Expanding the diagnostic frame for childhood trauma
Posted January 6, 2011
Jeannie* was in her mid-thirties when she applied to enter a study for posttraumatic stress disorder (PTSD). She was sure she would meet the criteria: the flyer, which advertised free treatment, was looking for people with both a history of exposure to trauma as well as ongoing struggles such as nightmares, jumpiness, and intrusive thoughts. Jeannie had suffered years of physical and sexual abuse in her childhood and had a substantial range of symptoms. In fact, on interview for the study, she met criteria for seven different mental health diagnoses, including major depression, panic disorder, a specific phobia, historical substance abuse and dependence, and two different personality disorders. The one thing Jeannie didn't meet criteria for - despite having significant posttraumatic symptoms - was PTSD.
"Trauma" is a complex phenomenon. It is so complex that there is little that polarizes the field of traumatic stress more than the very definition of the construct and the description of its outcomes. The definition established by our diagnostic system (1) requires the standard of having witnessed or experienced physical harm or threat to physical integrity - a definition that incorporates stressors as diverse as physical and sexual abuse, motor vehicle accidents, natural disasters, and war and acts of terrorism, but excludes adversities such as chronic neglect, psychological abuse, racism, homelessness, and impairment of caregivers due to mental health or substance use issues.
A child like Manuel* is not captured by this frame. Manuel spent his earliest childhood with a mother who suffered from chronic mental health disturbances. She was inconsistently available and alternatively frightening and disengaged. Manuel was removed from his home at age 5, when his lack of care and his challenging behaviors brought him to the attention of protective authorities. He then spent the next four years shuffling among six different foster homes before being placed in a residential program at age 9. For Manuel, there is no single diagnosis that exists that will capture his inevitable struggles with self-soothing, guardedness in relationships, resistance to authority, learning and attention difficulties, and fragmented sense of self. Like Jeannie, Manuel has been given a laundry list of diagnoses - common ones for children with complex early adversity, including Oppositional Defiant Disorder, Attention Deficit / Hyperactivity Disorder, Generalized Anxiety Disorder, and Major Depression. Manuel can not technically receive a diagnosis of PTSD because our current diagnostic system does not believe that he has experienced trauma.
Rightly or wrongly, diagnosis guides the lens by which individuals are viewed by providers, and often the lens by which they view themselves. However, the study of human behavior and emotion is a nuanced one. As with any - we hope - ever more knowledgeable field, we must continuously reorganize our understanding of "presenting symptoms" into an increasingly complex understanding of the whole person. An understanding of the whole person requires us to pay attention to the roots, rather than just the outcomes. For a physician, establishment of the presence of a fever is only the first step; discerning the cause (A simple bacterial infection? A chronic systemic illness?) is often crucial for the establishment of effective - and lasting - treatment. Similarly, many children may present with attention problems. Although a percentage of those may have a true biologically driven, primary disturbance of attention (i.e., ADHD), it is likely that a substantial proportion - while technically appearing to meet criteria - have attentional problems that are better explained by other factors; for instance, an undiagnosed hearing disturbance, fluctuating emotional distress, or the arousal common among children exposed to trauma.
There is a reason that many diagnoses within the DSM-IV-TR specify the important criterion, "Symptoms are not better accounted for by another diagnosis." In other words, if a child's phobia is due to trauma, or a child's learning disturbance is due to depression, the primary diagnosis trumps. By focusing on primary - or core - etiology, we are able to work with the driving cause, rather than simply with the most obvious behavioral pattern. The challenge, of course, is the need for a system which includes that better, more appropriate diagnosis.
There is, at this point, no question that chronic adversities in childhood have a pervasive impact on both child and adult outcomes, an impact which may include but often goes far beyond the limited diagnosis of PTSD. Numerous studies have pointed to the role of childhood trauma in shifting developmental functioning across domains. Perhaps most notably, the Centers for Disease Control, through its landmark Adverse Childhood Experiences study (2), has definitively established the link among a range of childhood adversities - including many which would not be labeled by the DSM-IV-TR as "traumatic" - and an unfortunately large number of negative adult outcomes, including risk for further victimization, social adversities such as teen pregnancy and paternity, mental health outcomes such as depression and substance use, and significant medical outcomes and risk factors including smoking and obesity.
Research on outcomes associated with trauma exposure highlights the differences between childhood onset (and particularly interpersonal trauma) experiences and adult-onset events in risk for PTSD vs. a more complex array of outcomes. This isn't surprising - it's not difficult to imagine that there are different responses to, for instance, a hurricane, a car accident, childhood abuse, traumatic loss, and war, or that trauma first experienced in adulthood might have a different impact than trauma experienced from the day of birth. This isn't a matter of weighing which trauma matters more; it's about qualitative differences in type of exposure, and ways that any salient experience of childhood - particularly those which provide the overarching fabric of a life - will invariably influence the course of development.
It is this developmental lens that has led experts to propose a new diagnosis, Developmental Trauma Disorder, for the DSM-V. First described by van der Kolk (2005) (3), a consensus statement released this year by leaders within the National Child Traumatic Stress Network (NCTSN) (4) strongly urged the DSM-V committee to consider this diagnosis for inclusion in our next diagnostic manual. Field trials are under way, and research will support - or not - the validity of a more developmental conceptualization. While it will be some time before we have the results, as a clinician who works every day with this population, I have little doubt of the eventual findings.
One of the most pernicious qualities of childhood trauma is often its veil of secrecy: the hiding of the known, and the not seeing of what is. So long as we, as a professional system, refuse to see Jeannie and Manuel and the millions like them, we are complicit in their continued experience - whatever we wish to call it. Personally, I don't much care if we call it trauma or something else; I'm much more interested in how we address it. Here's hoping our field continues to move forward.
*Note: Identifying information has been changed
1 American Psychiatric Association. (200). Diagnostic and statistical manual of mental disorders (4th Edition, Text revision). Washington, DC: Author.
2 See http://www.acestudy.org
3 van der Kolk, B. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401 - 408.
4 van der Kolk, B., Pynoos, R., Cicchetti, D., Cloitre, M., D'Andrea, W., Ford, J., Lieberman, A, Putnam, F., Saxe, G., Spinazzola, J., Stolbach, B., & Teicher, M. (2009, February). Proposal to include a Developmental Trauma Disorder diagnosis for children and adolescents in DSM-V. Unpublished manuscript. Available from http://www.traumacenter.org/announcements/DTD_papers_Oct_09.pdf .