TRAUMA GROWS UP a new diagnosis for traumatic stress in children by Mara Renz Illustration by Diane Zhou
trauma corrodes the cracks of human experience in both children and adults—yet the age of its victims changes the patterns of the burns left behind. Every year in the United States, millions of children are beaten, sexually abused, or neglected. This trauma can leave children with psychological problems that can affect them for the rest of their lives. Yet in the Diagnostic and Statistical Manual of Mental Disorders (DSM), there isn’t a diagnosis that can fully describe and explain all of these symptoms. As a result, traumatized children are often treated for multiple psychological conditions, including dissociative disorders, attention disorders, mood disorders, and Post Traumatic Stress Disorder (PTSD), which is an anxiety disorder usually associated with soldiers traumatized by war. Features of PTSD include re-experiencing trauma, staying on edge, and going “numb.” In 2000, Congress established the National Child Traumatic Stress Network (NCTSN) to improve access to treatment and services for traumatized children and adolescents. In a paper they released, “Complex Trauma in Children and Adolescents,” it said that, “although the narrowly defined PTSD diagnosis is often used, it rarely captures the extent of the developmental impact of multiple and chronic trauma exposure.” In 2009, the NCTSN created a task force of clinicians to officially propose Developmental Trauma Disorder (DTD), a diagnosis that can explain and describe all of the specific difficulties traumatized children experience, something that the current diagnosis of PTSD just can’t do. Dr. Bessel A. van der Kolk, a leading trauma researcher on the NCTSN task force, said in a paper, that a single traumatic event creates PTSD symptoms, but “chronic trauma interferes with neurobiological development and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole.” If DTD isn’t listed in the manual, a treatment that focuses on DTD won’t be covered by insurance, and without official DSM recognition, funding for research examining DTD is harder to secure. While a single traumatic event for adults is like a sudden windstorm that breaks off a tree’s branch, constant trauma for children is like a constant buffeting of wind that force’s the tree to grow in a completely different shape, as it adapts to it’s harsh environment over time. “Kids adapt to their worlds in ways that make sense,” said Dr. Margaret Blaustein in an interview with the
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Boston Evening Therapy Associates. Dr. Blaustein’s career has focused on understanding and treating chronically traumatized children. She said that when a child develops in a hostile environment, the child’s brain develops in a way that prepares them for more hostility. “They’re very good at picking up on signs of danger—even when there might not be danger around. Very good at protecting themselves— but maybe that prevents them from developing close friendships,” she said. Trauma changes the way a child can think and feel, the way they can interact with the world. These changes persist as they grow up and become adults, according to the Center for Disease Control’s Report on Adverse Childhood Experiences, “traumatic childhood and adolescent experiences literally become ‘biology’ affecting brain structure and function,” which leads to “persistent effects.” Creating a new diagnosis is critical for helping these children. For one thing, although young children are especially at risk for developing psychological difficulties after trauma, they are often not diagnosed with PTSD at all, because eight of the 19 criteria needed for a diagnosis of PTSD requires patients to verbally explain their experience. The American Psychiatric Association’s manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM), defines and describes psychiatric disorder and its framework used by clinicians, insurance companies, and policy makers in the US. The DSM provides a checklist of symptoms and behaviors, which are the criteria doctors, use to decide what disorders a patient might have. The current version, the DSM-IV-TR was last updated in 2000. The next update, the DSM-V, is scheduled for publication in May 2013—it will not include DTD. Politics in the DSM often leads to inappropriate diagnoses and treatment. Until 1974, people could be diagnosed with ‘homosexuality,’ at the time an official psychological disorder in the DSM. The task force tried to get DTD approved for the new manual in 2009, arguing that the current DSM was unable to meet the needs of the millions of abused and neglected children in the US. They said the current manual’s standardswould either lead to a host of unrelated diagnoses that don’t recognize a common source, one that doesn’t fully capture the challenges that the patient faces, or none at all. Dr. Vedat Sar, a past president of the International Society for the Study of Trauma and Dissociation, said in
a paper in the European Journal of Psychotraumatology in 2011 that a diagnosis for developmental or complex PTSD has been proposed in many research papers published by many clinicians and researchers over the past 20 years. Yet no matter how far it gets in the approval process, it always gets dismissed. “The consensus is that it is unlikely that DTD can be included in the main part of DSM-V in its present form because of the current lack of evidence in support of the diagnosis and the lack of prospective testing of your proposed diagnostic criteria” said Mathew Friedman, the DSM subcommittee leader and director of the National Center for PTSD. For the DSM reviewers, the NCTSN’s task force’s presentation of retrospective evidence—which examined over 120,000 cases, analyzed more than 430 different research papers, and revealed a significant difference between people who experienced trauma as children compared to as adults—was simply not enough. The kind of testing that the DSM committee said it needs to see, before seriously considering approving DTD, is difficult to fund without DSM recognition. In fact, a field trial conducted by Dr. Jacob Ham on DTD, Healing Emotions and Achieving Resilience to Traumatic Stress, lost its funding when it became clear that DTD wouldn’t be listed in the DSM-V. According to Friedman, the DSM committee didn’t say the evidence was wrong, but just that it was irrelevant, and that there wasn’t any agreement in the field to prove that DTD could be beneficial to patients and treatment teams. Yet the DSM committee—made up primarily by researchers who don’t treat patients outside of the research setting—also received a letter in the NCTSN’s proposal, that had been jointly written with the National Association of State Mental Health Directors, and which represented every state. According to the 2010 Child Maltreatment study made by the US Department of Health and Human Services, 3.3 million reports of child abuse are made every year in the US. Yet without recognition, these children cannot receive targeted diagnoses and targeted treatment. MARA RENZ B’12.5 is all dappled purple shadow peeling across these half cities.
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