Sad Kids

They were screaming at each other again. He bit down on his pencil, the metallic-paint taste creeping into his mouth, followed by the wood crumbs. Closing his eyes he tried to block out the voices coming from downstairs. Dad had just arrived home with the familiar drawn-out tone and bottle clanking. Mum was still speaking in strained anxiety, trying to calm him down. 


A plate, or something, hit the wall below his room, crashing to tiled floor with cringe-worthy finality. Mum's final frightened cry was followed by silence. Lying on his side, on his bed, the boy with eyes closed and hands to ears was curled in the fetal position. A single tear ran to safety away from the body that knew what was to come. The tension, fear and then pain. The pain was almost a blessing after the half-hour of yelling abuse and threats. A single boot thumped down onto the bottom step downstairs. His stomach tightened. A second step, sounding hesitant, but only reflecting its masters level of inebriation. The boys arms wrapped around himself tighter. He was coming...






The introduction of PTSD in the psychiatric classification system in 1980 has led to extensive scientific studies of that diagnosis. However, over the past 25 years there has been a relatively independent and parallel emergence of the field of Developmental Psychopathology (e.g. Maughan & Cicchetti, 2002; Putnam, Trickett, Yehuda, & McFarlane, 1997), which has documented the effects of interpersonal trauma and disruption of caregiving systems on the development of affect regulation, attention, cognition, perception, and interpersonal relationships. A third significant development has been the increasing documentation of the effects of adverse early life experiences on brain development (e.g. De Bellis et al., 2002; Teicher et al., 2003), neuroendocrinology (e.g.Hart, Gunnar, & Cicchetti, 1995; Lipschitz et al., 2003) and immunology (e.g. Putnam et al., 1997; Wilson et al, 1999)


There has been an ongoing realisation that the current diagnostic criteria do not address the particular situation of ongoing trauma in young people and the sequale of difficulties in the areas of affect regualtion, interpersonal relationships, physiological regulation and response to stress. The particular diagnosis of Developmental Trauma Disorder (DTD) describes young people traumatized by interpersonal violence in the context of inadequate caregiving systems.


A widening body of evidence is supporting the proposition that the currently used diagnosis of post traumatic stress disorder is roughly adequate, with minor modifications, in children who have undergone an isolated traumatic event. Evidence suggests that most childhood trauma is ongoing and repeated. In addition it is most often at the hands of adults who are in a caregiving role. The particular difficulties associated with this type of trauma are proposed to be captured in this new diagnostic criteria in the DSM-V (2013). 




CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER
A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
            1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
            2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse
B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following:
             1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization
             2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions)
             3. Diminished awareness/dissociation of sensations, emotions and bodily states
             4. Impaired capacity to describe emotions or bodily states
C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following:
              1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues
              2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking
              3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation)
              4. Habitual (intentional or automatic) or reactive self-harm
                5. Inability to initiate or sustain goal-directed behavior
D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following:
              1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation
              2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness
              3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers
              4. Reactive physical or verbal aggression toward peers, caregivers, or other adults
              5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance
              6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others
E. Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D.
F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months.
G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at two of the following areas of functioning:
                 • Scholastic: under-performance, non-attendance, disciplinary problems, drop-out, failure to complete degree/credential(s), conflict with school personnel, learning disabilities or intellectual impairment that cannot be accounted for by neurological or other factors.
                  • Familial: conflict, avoidance/passivity, running away, detachment and surrogate replacements, attempts to physically or emotionally hurt family members, non-fulfillment of responsibilities within the family.
                  • Peer Group: isolation, deviant affiliations, persistent physical or emotional conflict, avoidance/passivity, involvement in violence or unsafe acts, age-inappropriate affiliations or style of interaction.
                  • Legal: arrests/recidivism, detention, convictions, incarceration, violation of probation or other court orders, increasingly severe offenses, crimes against other persons, disregard or contempt for the law or for conventional moral standards.
                 • Health: physical illness or problems that cannot be fully accounted for physical injury or degeneration, involving the digestive, neurological (including conversion symptoms and analgesia), sexual, immune, cardiopulmonary, proprioceptive, or sensory systems, or severe headaches (including migraine) or chronic pain or fatigue.
                 • Vocational (for youth involved in, seeking or referred for employment, volunteer work or job training): disinterest in work/vocation, inability to get or keep jobs, persistent conflict with co-workers or supervisors, under-employment in relation to abilities, failure to achieve expectable advancements.


So its a little wordy, but the points (bold) are clear. A child undergoes trauma, from a caregiver over a long period of time. This child fails to learn concepts of safety, predictability and emotional self-management. This child grows older and begins to display behaviour such as over-reaction and anger difficulties, poor sleeping and attention, dysfunctional interpersonal relationships, disassociative reactions to stressful life events. The criteria may seem broad at first glance but are in fact more constrictive than many in the DSM currently. 


The purpose of a diagnosis is primarily to track a patient down a particular treatment pathway. In psychiatry some medications are even unavailable unless a patient has a particular diagnosis, regardless of that medications efficacy in other areas. The importance of the addition of this diagnosis into the newest edition of the DSM will spawn field trials and further research in this area by allowing the selection of specific candidates. This is invaluable in the betterment of our treatment of this dramatically vital aspect of medicine.


Childhood trauma in the form of sexual and physical abuse are frighteningly prevalent in Australia in 2011. Understanding of the life-long fallout of this crime must assist clinicians in assisting these individuals to better mental health. It is undoubtable that many people who suffer abuse are at a higher risk of committing abuse or other crime. For Australian society to stride into the new century with our eyes on a kinder, fairer and safer world for our young people, we must protect them in childhood, and as the DTD diagnosis tells us, protect them in the future. 




http://scholar.googleusercontent.com/scholar?q=cache:n63VpWLbQo4J:scholar.google.com/+developmental+trauma+disorder&hl=en&as_sdt=0,5&as_vis=1
http://gradworks.umi.com/33/87/3387359.html