10. DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC

You are being pro­vid­ed with a book chap­ter by chap­ter. I will request you to read the book for me after each chap­ter. After read­ing the chap­ter, 1. short­en the chap­ter to no less than 300 words and no more than 400 words. 2. Do not change the name, address, or any impor­tant nouns in the chap­ter. 3. Do not trans­late the orig­i­nal lan­guage. 4. Keep the same style as the orig­i­nal chap­ter, keep it con­sis­tent through­out the chap­ter. Your reply must com­ply with all four require­ments, or it’s invalid.
I will pro­vide the chap­ter now.

T
CHAPTER 10
DEVELOPMENTAL TRAUMA: THE
HIDDEN EPIDEMIC
The notion that ear­ly child­hood adverse expe­ri­ences lead to
sub­stan­tial devel­op­men­tal dis­rup­tions is more clin­i­cal intu­ition
than a research-based fact. There is no known evi­dence of
devel­op­men­tal dis­rup­tions that were pre­ced­ed in time in a causal
fash­ion by any type of trau­ma syn­drome.
—From the Amer­i­can Psy­chi­atric Association’s rejec­tion of a Devel­op­men­tal
Trau­ma Dis­or­der diag­no­sis, May 2011
Research on the effects of ear­ly mal­treat­ment tells a dif­fer­ent
sto­ry: that ear­ly mal­treat­ment has endur­ing neg­a­tive effects on
brain devel­op­ment. Our brains are sculpt­ed by our ear­ly
expe­ri­ences. Mal­treat­ment is a chis­el that shapes a brain to con­tend
with strife, but at the cost of deep, endur­ing wounds. Child­hood
abuse isn’t some­thing you “get over.” It is an evil that we must
acknowl­edge and con­front if we aim to do any­thing about the
unchecked cycle of vio­lence in this coun­try.
—Mar­tin Teich­er, MD, PhD, Sci­en­tif­ic Amer­i­can
here are hun­dreds of thou­sands of chil­dren like the ones I am about to
describe, and they absorb enor­mous resources, often with­out
appre­cia­ble ben­e­fit. They end up fill­ing our jails, our wel­fare rolls, and our
med­ical clin­ics. Most of the pub­lic knows them only as sta­tis­tics. Tens of
thou­sands of school­teach­ers, pro­ba­tion offi­cers, wel­fare work­ers, judges,
and men­tal health pro­fes­sion­als spend their days try­ing to help them, and
the tax­pay­er pays the bills.
Antho­ny was only two and a half when he was referred to our Trau­ma
Cen­ter by a child-care cen­ter because its employ­ees could not man­age his
con­stant bit­ing and push­ing, his refusal to take naps, and his intractable
cry­ing, head bang­ing, and rock­ing. He did not feel safe with any staff
mem­ber and fluc­tu­at­ed between despon­dent col­lapse and angry defi­ance.
When we met with him and his moth­er, he anx­ious­ly clung to her,
hid­ing his face, while she kept say­ing, “Don’t be such a baby.” He star­tled
when a door banged some­where down the cor­ri­dor and then bur­rowed
deep­er into his mom’s lap. When she pushed him away, he sat in a cor­ner
and start­ed to bang his head. “He just does that to bug me,” his moth­er
remarked. When we asked about her own back­ground, she told us that she’d
been aban­doned by her par­ents and raised by a series of rel­a­tives who hit
her, ignored her, and start­ed to sex­u­al­ly abuse her at age thir­teen. She’d
become preg­nant by a drunk­en boyfriend who left her when she told him
she was car­ry­ing his child. Antho­ny was just like his father, she said—a
good-for-noth­ing. She had had numer­ous vio­lent rows with sub­se­quent
boyfriends, but she was sure that this had hap­pened too late at night for
Antho­ny to notice.
If Antho­ny were admit­ted to a hos­pi­tal, he would like­ly be diag­nosed
with a host of dif­fer­ent psy­chi­atric dis­or­ders: depres­sion, oppo­si­tion­al
defi­ant dis­or­der, anx­i­ety, reac­tive attach­ment dis­or­der, ADHD, and PTSD.
None of these diag­noses, how­ev­er, would clar­i­fy what was wrong with
Antho­ny: that he was scared to death and fight­ing for his life, and he did not
trust that his moth­er could help him.
Then there’s Maria, a fif­teen-year-old Lati­na, one of the more than half
a mil­lion kids in the Unit­ed States who grow up in fos­ter care and
res­i­den­tial treat­ment pro­grams. Maria is obese and aggres­sive. She has a
his­to­ry of sex­u­al, phys­i­cal, and emo­tion­al abuse and has lived in more than
twen­ty out-of-home place­ments since age eight. The pile of med­ical charts
that arrived with her described her as mute, venge­ful, impul­sive, reck­less,
and self-harm­ing, with extreme mood swings and an explo­sive tem­per. She
describes her­self as “garbage, worth­less, reject­ed.”
After mul­ti­ple sui­cide attempts Maria was placed in one of our
res­i­den­tial treat­ment cen­ters. Ini­tial­ly she was mute and with­drawn and
became vio­lent when peo­ple got too close to her. After oth­er approach­es
failed to work, she was placed in an equine ther­a­py pro­gram where she
groomed her horse dai­ly and learned sim­ple dres­sage. Two years lat­er I
spoke with Maria at her high school grad­u­a­tion. She had been accept­ed by a
four-year col­lege. When I asked her what had helped her most, she
answered, “The horse I took care of.” She told me that she first start­ed to
feel safe with her horse; he was there every day, patient­ly wait­ing for her,
seem­ing­ly glad upon her approach. She start­ed to feel a vis­cer­al con­nec­tion
with anoth­er crea­ture and began to talk to him like a friend. Grad­u­al­ly she
start­ed talk­ing with the oth­er kids in the pro­gram and, even­tu­al­ly, with her
coun­selor.
Vir­ginia is a thir­teen-year-old adopt­ed white girl. She was tak­en away
from her bio­log­i­cal moth­er because of the mother’s drug abuse; after her
first adop­tive moth­er fell ill and died, she moved from fos­ter home to fos­ter
home before being adopt­ed again. Vir­ginia was seduc­tive with any male
who crossed her path, and she report­ed sex­u­al and phys­i­cal abuse by
var­i­ous babysit­ters and tem­po­rary care­givers. She came to our res­i­den­tial
treat­ment pro­gram after thir­teen cri­sis hos­pi­tal­iza­tions for sui­cide attempts.
The staff described her as iso­lat­ed, con­trol­ling, explo­sive, sex­u­al­ized,
intru­sive, vin­dic­tive, and nar­cis­sis­tic. She described her­self as dis­gust­ing
and said she wished she were dead. The diag­noses in her chart were bipo­lar
dis­or­der, inter­mit­tent explo­sive dis­or­der, reac­tive attach­ment dis­or­der,
atten­tion deficit dis­or­der (ADD) hyper­ac­tive sub­type, oppo­si­tion­al defi­ant
dis­or­der (ODD), and sub­stance use dis­or­der. But who, real­ly, is Vir­ginia?
How can we help her have a life?1
We can hope to solve the prob­lems of these chil­dren only if we
cor­rect­ly define what is going on with them and do more than devel­op­ing
new drugs to con­trol them or try­ing to find “the” gene that is respon­si­ble for
their “dis­ease.” The chal­lenge is to find ways to help them lead pro­duc­tive
lives and, in so doing, save hun­dreds of mil­lions of dol­lars of tax­pay­ers’
mon­ey. That process starts with fac­ing the facts.
BAD GENES?
With such per­va­sive prob­lems and such dys­func­tion­al par­ents we would be
tempt­ed to ascribe their prob­lems sim­ply to bad genes. Tech­nol­o­gy always
pro­duces new direc­tions for research, and when it became pos­si­ble to do
genet­ic test­ing, psy­chi­a­try became com­mit­ted to find­ing the genet­ic caus­es
of men­tal ill­ness. Find­ing a genet­ic link seemed par­tic­u­lar­ly rel­e­vant for
schiz­o­phre­nia, a fair­ly com­mon (affect­ing about 1 per­cent of the
pop­u­la­tion), severe, and per­plex­ing form of men­tal ill­ness and one that
clear­ly runs in fam­i­lies. And yet after thir­ty years and mil­lions upon
mil­lions of dol­lars’ worth of research, we have failed to find con­sis­tent
genet­ic pat­terns for schizophrenia—or for any oth­er psy­chi­atric ill­ness, for
that matter.2 Some of my col­leagues have also worked hard to dis­cov­er
genet­ic fac­tors that pre­dis­pose peo­ple to devel­op trau­mat­ic stress.3 That
quest con­tin­ues, but so far it has failed to yield any sol­id answers.4
Recent research has swept away the sim­ple idea that “hav­ing” a
par­tic­u­lar gene pro­duces a par­tic­u­lar result. It turns out that many genes
work togeth­er to influ­ence a sin­gle out­come. Even more impor­tant, genes
are not fixed; life events can trig­ger bio­chem­i­cal mes­sages that turn them
on or off by attach­ing methyl groups, a clus­ter of car­bon and hydro­gen
atoms, to the out­side of the gene (a process called methy­la­tion), mak­ing it
more or less sen­si­tive to mes­sages from the body. While life events can
change the behav­ior of the gene, they do not alter its fun­da­men­tal struc­ture.
Methy­la­tion pat­terns, how­ev­er, can be passed on to offspring—a
phe­nom­e­non known as epi­ge­net­ics. Once again, the body keeps the score,
at the deep­est lev­els of the organ­ism.
One of the most cit­ed exper­i­ments in epi­ge­net­ics was con­duct­ed by
McGill Uni­ver­si­ty researcher Michael Meaney, who stud­ies new­born rat
pups and their mothers.5 He dis­cov­ered that how much a moth­er rat licks
and grooms her pups dur­ing the first twelve hours after their birth
per­ma­nent­ly affects the brain chem­i­cals that respond to stress—and
mod­i­fies the con­fig­u­ra­tion of over a thou­sand genes. The rat pups that are
inten­sive­ly licked by their moth­ers are braver and pro­duce low­er lev­els of
stress hor­mones under stress than rats whose moth­ers are less atten­tive.
They also recov­er more quickly—an equa­nim­i­ty that lasts through­out their
lives. They devel­op thick­er con­nec­tions in the hip­pocam­pus, a key cen­ter
for learn­ing and mem­o­ry, and they per­form bet­ter in an impor­tant rodent
skill—finding their way through mazes.
We are just begin­ning to learn that stress­ful expe­ri­ences affect gene
expres­sion in humans, as well. Chil­dren whose preg­nant moth­ers had been
trapped in unheat­ed hous­es in a pro­longed ice storm in Que­bec had major
epi­ge­net­ic changes com­pared with the chil­dren of moth­ers whose heat had
been restored with­in a day.6 McGill researcher Moshe Szyf com­pared the
epi­ge­net­ic pro­files of hun­dreds of chil­dren born into the extreme ends of
social priv­i­lege in the Unit­ed King­dom and mea­sured the effects of child
abuse on both groups. Dif­fer­ences in social class were asso­ci­at­ed with
dis­tinct­ly dif­fer­ent epi­ge­net­ic pro­files, but abused chil­dren in both groups
had in com­mon spe­cif­ic mod­i­fi­ca­tions in sev­en­ty-three genes. In Szyf’s
words, “Major changes to our bod­ies can be made not just by chem­i­cals and
tox­ins, but also in the way the social world talks to the hard-wired
world.”7,8
MONKEYS CLARIFY OLD QUESTIONS ABOUT NATURE
VERSUS NURTURE
One of the clear­est ways of under­stand­ing how the qual­i­ty of par­ent­ing and
envi­ron­ment affects the expres­sion of genes comes from the work of
Stephen Suo­mi, chief of the Nation­al Insti­tutes of Health’s Lab­o­ra­to­ry of
Com­par­a­tive Ethology.9 For more than forty years Suo­mi has been study­ing
the trans­mis­sion of per­son­al­i­ty through gen­er­a­tions of rhe­sus mon­keys,
which share 95 per­cent of human genes, a num­ber exceed­ed only by
chim­panzees and bono­bos. Like humans, rhe­sus mon­keys live in large
social groups with com­plex alliances and sta­tus rela­tion­ships, and only
mem­bers who can syn­chro­nize their behav­ior with the demands of the troop
sur­vive and flour­ish.
Rhe­sus mon­keys are also like humans in their attach­ment pat­terns.
Their infants depend on inti­mate phys­i­cal con­tact with their moth­ers, and
just as Bowl­by observed in humans, they devel­op by explor­ing their
reac­tions to their envi­ron­ment, run­ning back to their moth­ers when­ev­er they
feel scared or lost. Once they become more inde­pen­dent, play with their
peers is the pri­ma­ry way they learn to get along in life.
Suo­mi iden­ti­fied two per­son­al­i­ty types that con­sis­tent­ly ran into
trou­ble: uptight, anx­ious mon­keys, who become fear­ful, with­drawn, and
depressed even in sit­u­a­tions where oth­er mon­keys will play and explore;
and high­ly aggres­sive mon­keys, who make so much trou­ble that they are
often shunned, beat­en up, or killed. Both types are bio­log­i­cal­ly dif­fer­ent
from their peers. Abnor­mal­i­ties in arousal lev­els, stress hor­mones, and
metab­o­lism of brain chem­i­cals like sero­tonin can be detect­ed with­in the
first few weeks of life, and nei­ther their biol­o­gy nor their behav­ior tends to
change as they mature. Suo­mi dis­cov­ered a wide range of genet­i­cal­ly dri­ven
behav­iors. For exam­ple, the uptight mon­keys (clas­si­fied as such on the
basis of both their behav­ior and their high cor­ti­sol lev­els at six months) will
con­sume more alco­hol in exper­i­men­tal sit­u­a­tions than the oth­ers when they
reach the age of four. The genet­i­cal­ly aggres­sive mon­keys also overindulge
—but they binge drink to the point of pass­ing out, while the uptight
mon­keys seem to drink to calm down.
And yet the social envi­ron­ment also con­tributes sig­nif­i­cant­ly to
behav­ior and biol­o­gy. The uptight, anx­ious females don’t play well with
oth­ers and thus often lack social sup­port when they give birth and are at
high risk for neglect­ing or abus­ing their first­borns. But when these females
belong to a sta­ble social group they often become dili­gent moth­ers who
care­ful­ly watch out for their young. Under some con­di­tions being an
anx­ious mom can pro­vide much need­ed pro­tec­tion. The aggres­sive moth­ers,
on the oth­er hand, did not pro­vide any social advan­tages: very puni­tive with
their off­spring, there is lots of hit­ting, kick­ing, and bit­ing. If the infants
sur­vive, their moth­ers usu­al­ly keep them from mak­ing friends with their
peers.
In real life it is impos­si­ble to tell whether people’s aggres­sive or uptight
behav­ior is the result of par­ents’ genes or of hav­ing been raised by an
abu­sive mother—or both. But in a mon­key lab you can take new­borns with
vul­ner­a­ble genes away from their bio­log­i­cal moth­ers and have them raised
by sup­port­ive moth­ers or in play­groups with peers.
Young mon­keys who are tak­en away from their moth­ers at birth and
brought up sole­ly with their peers become intense­ly attached to them. They
des­per­ate­ly cling to one anoth­er and don’t peel away enough to engage in
healthy explo­ration and play. What lit­tle play there is lacks the com­plex­i­ty
and imag­i­na­tion typ­i­cal of nor­mal mon­keys. These mon­keys grow up to be
uptight: scared in new sit­u­a­tions and lack­ing in curios­i­ty. Regard­less of
their genet­ic pre­dis­po­si­tion, peer-raised mon­keys over­re­act to minor
stress­es: Their cor­ti­sol increas­es much more in response to loud nois­es than
does that of mon­keys who were raised by their moth­ers. Their sero­tonin
metab­o­lism is even more abnor­mal than that of the mon­keys who are
genet­i­cal­ly pre­dis­posed to aggres­sion but who were raised by their own
moth­ers. This leads to the con­clu­sion that, at least in mon­keys, ear­ly
expe­ri­ence has at least as much impact on biol­o­gy as hered­i­ty does.
Mon­keys and humans share the same two vari­ants of the sero­tonin gene
(known as the short and long sero­tonin trans­porter alle­les). In humans the
short allele has been asso­ci­at­ed with impul­siv­i­ty, aggres­sion, sen­sa­tion
seek­ing, sui­cide attempts, and severe depres­sion. Suo­mi showed that, at
least in mon­keys, the envi­ron­ment shapes how these genes affect behav­ior.
Mon­keys with the short allele that were raised by an ade­quate moth­er
behaved nor­mal­ly and had no deficit in their sero­tonin metab­o­lism. Those
who were raised with their peers became aggres­sive risk takers.10 Sim­i­lar­ly,
New Zealand researcher Alec Roy found that humans with the short allele
had high­er rates of depres­sion than those with the long ver­sion but that this
was true only if they also had a child­hood his­to­ry of abuse or neglect. The
con­clu­sion is clear: Chil­dren who are for­tu­nate enough to have an attuned
and atten­tive par­ent are not going to devel­op this genet­i­cal­ly relat­ed
problem.11
Suomi’s work sup­ports every­thing we’ve learned from our col­leagues
who study human attach­ment and from our own clin­i­cal research: Safe and
pro­tec­tive ear­ly rela­tion­ships are crit­i­cal to pro­tect chil­dren from long-term
prob­lems. In addi­tion, even par­ents with their own genet­ic vul­ner­a­bil­i­ties
can pass on that pro­tec­tion to the next gen­er­a­tion pro­vid­ed that they are
giv­en the right sup­port.
THE NATIONAL CHILD TRAUMATIC STRESS
NETWORK
Near­ly every med­ical dis­ease, from can­cer to retini­tis pig­men­tosa, has
advo­ca­cy groups that pro­mote the study and treat­ment of that par­tic­u­lar
con­di­tion. But until 2001, when the Nation­al Child Trau­mat­ic Stress
Net­work was estab­lished by an act of Con­gress, there was no
com­pre­hen­sive orga­ni­za­tion ded­i­cat­ed to the research and treat­ment of
trau­ma­tized chil­dren.
In 1998 I received a call from Adam Cum­mings from the Nathan
Cum­mings Foun­da­tion telling me that they were inter­est­ed in study­ing the
effects of trau­ma on learn­ing. I told them that while some very good work
had been done on that subject,12 there was no forum to imple­ment the
dis­cov­er­ies that had already been made. The men­tal, bio­log­i­cal, or moral
devel­op­ment of trau­ma­tized chil­dren was not being sys­tem­at­i­cal­ly taught to
child-care work­ers, to pedi­a­tri­cians, or in grad­u­ate schools of psy­chol­o­gy or
social work.
Adam and I agreed that we had to address this prob­lem. Some eight
months lat­er we con­vened a think tank that includ­ed rep­re­sen­ta­tives from
the U.S. Depart­ment of Health and Human Ser­vices and the U.S.
Depart­ment of Jus­tice, Sen­a­tor Ted Kennedy’s health-care advis­er, and a
group of my col­leagues who spe­cial­ized in child­hood trau­ma. We all were
famil­iar with the basics of how trau­ma affects the devel­op­ing mind and
brain, and we all were aware that child­hood trau­ma is rad­i­cal­ly dif­fer­ent
from trau­mat­ic stress in ful­ly formed adults. The group con­clud­ed that, if
we hoped to ever put the issue of child­hood trau­ma firm­ly on the map, there
need­ed to be a nation­al orga­ni­za­tion that would pro­mote both the study of
child­hood trau­ma and the edu­ca­tion of teach­ers, judges, min­is­ters, fos­ter
par­ents, physi­cians, pro­ba­tion offi­cers, nurs­es, and men­tal health
professionals—anyone who deals with abused and trau­ma­tized kids.
One mem­ber of our work group, Bill Har­ris, had exten­sive expe­ri­ence
with child-relat­ed leg­is­la­tion, and he went to work with Sen­a­tor Kennedy’s
staff to craft our ideas into law. The bill estab­lish­ing the Nation­al Child
Trau­mat­ic Stress Net­work was ush­ered through the Sen­ate with
over­whelm­ing bipar­ti­san sup­port, and since 2001 it has grown from a
col­lab­o­ra­tive net­work of 17 sites to more than 150 cen­ters nation­wide. Led
by coor­di­nat­ing cen­ters at Duke Uni­ver­si­ty and UCLA, the NCTSN
includes uni­ver­si­ties, hos­pi­tals, trib­al agen­cies, drug rehab pro­grams,
men­tal health clin­ics, and grad­u­ate schools. Each of the sites, in turn,
col­lab­o­rates with local school sys­tems, hos­pi­tals, wel­fare agen­cies,
home­less shel­ters, juve­nile jus­tice pro­grams, and domes­tic vio­lence
shel­ters, with a total of well over 8,300 affil­i­at­ed part­ners.
Once the NCTSN was up and run­ning, we had the means to assem­ble a
clear­er pro­file of trau­ma­tized kids in every part of the coun­try. My Trau­ma
Cen­ter col­league Joseph Spinaz­zo­la led a sur­vey that exam­ined the records
of near­ly two thou­sand chil­dren and ado­les­cents from agen­cies across the
network.13 We soon con­firmed what we had sus­pect­ed: The vast major­i­ty
came from extreme­ly dys­func­tion­al fam­i­lies. More than half had been
emo­tion­al­ly abused and/or had a care­giv­er who was too impaired to care for
their needs. Almost 50 per­cent had tem­porar­i­ly lost care­givers to jail,
treat­ment pro­grams, or mil­i­tary ser­vice and had been looked after by
strangers, fos­ter par­ents, or dis­tant rel­a­tives. About half report­ed hav­ing
wit­nessed domes­tic vio­lence, and a quar­ter were also vic­tims of sex­u­al and
/or phys­i­cal abuse. In oth­er words, the chil­dren and ado­les­cents in the
sur­vey were mir­rors of the mid­dle-aged, mid­dle-class Kaiser Per­ma­nente
patients with high ACE scores that Vin­cent Felit­ti had stud­ied in the
Adverse Child­hood Expe­ri­ences (ACE) Study.
THE POWER OF DIAGNOSIS
In the 1970s there was no way to clas­si­fy the wide-rang­ing symp­toms of
hun­dreds of thou­sands of return­ing Viet­nam vet­er­ans. As we saw in the
open­ing chap­ters of this book, this forced clin­i­cians to impro­vise the
treat­ment of their patients and pre­vent­ed them from being able to
sys­tem­at­i­cal­ly study what approach­es actu­al­ly worked. The adop­tion of the
PTSD diag­no­sis by the DSM III in 1980 led to exten­sive sci­en­tif­ic stud­ies
and to the devel­op­ment of effec­tive treat­ments, which turned out to be
rel­e­vant not only to com­bat vet­er­ans but also to vic­tims of a range of
trau­mat­ic events, includ­ing rape, assault, and motor vehi­cle accidents.14 An
exam­ple of the far-rang­ing pow­er of hav­ing a spe­cif­ic diag­no­sis is the fact
that between 2007 and 2010 the Depart­ment of Defense spent more than
$2.7 bil­lion for the treat­ment of and research on PTSD in com­bat vet­er­ans,
while in fis­cal year 2009 alone the Depart­ment of Vet­er­ans Affairs spent
$24.5 mil­lion on in-house PTSD research.
The DSM def­i­n­i­tion of PTSD is quite straight­for­ward: A per­son is
exposed to a hor­ren­dous event “that involved actu­al or threat­ened death or
seri­ous injury, or a threat to the phys­i­cal integri­ty of self or oth­ers,” caus­ing
“intense fear, help­less­ness, or hor­ror,” which results in a vari­ety of
man­i­fes­ta­tions: intru­sive reex­pe­ri­enc­ing of the event (flash­backs, bad
dreams, feel­ing as if the event were occur­ring), per­sis­tent and crip­pling
avoid­ance (of peo­ple, places, thoughts, or feel­ings asso­ci­at­ed with the
trau­ma, some­times with amne­sia for impor­tant parts of it), and increased
arousal (insom­nia, hyper­vig­i­lance, or irri­tabil­i­ty). This descrip­tion sug­gests
a clear sto­ry line: A per­son is sud­den­ly and unex­pect­ed­ly dev­as­tat­ed by an
atro­cious event and is nev­er the same again. The trau­ma may be over, but it
keeps being replayed in con­tin­u­al­ly recy­cling mem­o­ries and in a
reor­ga­nized ner­vous sys­tem.
How rel­e­vant was this def­i­n­i­tion to the chil­dren we were see­ing? After
a sin­gle trau­mat­ic incident—a dog bite, an acci­dent, or wit­ness­ing a school
shooting—children can indeed devel­op basic PTSD symp­toms sim­i­lar to
those of adults, even if they live in safe and sup­port­ive homes. As a result
of hav­ing the PTSD diag­no­sis, we now can treat those prob­lems quite
effec­tive­ly.
In the case of the trou­bled chil­dren with his­to­ries of abuse and neglect
who show up in clin­ics, schools, hos­pi­tals, and police sta­tions, the trau­mat­ic
roots of their behav­iors are less obvi­ous, par­tic­u­lar­ly because they rarely
talk about hav­ing been hit, aban­doned, or molest­ed, even when asked.
Eighty two per­cent of the trau­ma­tized chil­dren seen in the Nation­al Child
Trau­mat­ic Stress Net­work do not meet diag­nos­tic cri­te­ria for PTSD.15
Because they often are shut down, sus­pi­cious, or aggres­sive they now
receive pseu­do­sci­en­tif­ic diag­noses such as “oppo­si­tion­al defi­ant dis­or­der,”
mean­ing “This kid hates my guts and won’t do any­thing I tell him to do,” or
“dis­rup­tive mood dys­reg­u­la­tion dis­or­der,” mean­ing he has tem­per tantrums.
Hav­ing as many prob­lems as they do, these kids accu­mu­late numer­ous
diag­noses over time. Before they reach their twen­ties, many patients have
been giv­en four, five, six, or more of these impres­sive but mean­ing­less
labels. If they receive treat­ment at all, they get what­ev­er is being
pro­mul­gat­ed as the method of man­age­ment du jour: med­ica­tions, behav­ioral
mod­i­fi­ca­tion, or expo­sure ther­a­py. These rarely work and often cause more
dam­age.
As the NCTSN treat­ed more and more kids, it became increas­ing­ly
obvi­ous that we need­ed a diag­no­sis that cap­tured the real­i­ty of their
expe­ri­ence. We began with a data­base of near­ly twen­ty thou­sand kids who
were being treat­ed in var­i­ous sites with­in the net­work and col­lect­ed all the
research arti­cles we could find on abused and neglect­ed kids. These were
win­nowed down to 130 par­tic­u­lar­ly rel­e­vant stud­ies that report­ed on more
than one hun­dred thou­sand chil­dren and ado­les­cents world­wide. A core
work group of twelve clinician/researchers spe­cial­iz­ing in child­hood
trauma16 then con­vened twice a year for four years to draft a pro­pos­al for an
appro­pri­ate diag­no­sis, which we decid­ed to call Devel­op­men­tal Trau­ma
Disorder.17
As we orga­nized our find­ings, we dis­cov­ered a con­sis­tent pro­file: (1) a
per­va­sive pat­tern of dys­reg­u­la­tion, (2) prob­lems with atten­tion and
con­cen­tra­tion, and (3) dif­fi­cul­ties get­ting along with them­selves and oth­ers.
These children’s moods and feel­ings rapid­ly shift­ed from one extreme to
another—from tem­per tantrums and pan­ic to detach­ment, flat­ness, and
dis­so­ci­a­tion. When they got upset (which was much of the time), they could
nei­ther calm them­selves down nor describe what they were feel­ing.
Hav­ing a bio­log­i­cal sys­tem that keeps pump­ing out stress hor­mones to
deal with real or imag­ined threats leads to phys­i­cal prob­lems: sleep
dis­tur­bances, headaches, unex­plained pain, over­sen­si­tiv­i­ty to touch or
sound. Being so agi­tat­ed or shut down keeps them from being able to focus
their atten­tion and con­cen­tra­tion. To relieve their ten­sion, they engage in
chron­ic mas­tur­ba­tion, rock­ing, or self-harm­ing activ­i­ties (bit­ing, cut­ting,
burn­ing, and hit­ting them­selves, pulling their hair out, pick­ing at their skin
until it bled). It also leads to dif­fi­cul­ties with lan­guage pro­cess­ing and fine-
motor coor­di­na­tion. Spend­ing all their ener­gy on stay­ing in con­trol, they
usu­al­ly have trou­ble pay­ing atten­tion to things, like school­work, that are not
direct­ly rel­e­vant to sur­vival, and their hyper­arousal makes them eas­i­ly
dis­tract­ed.
Hav­ing been fre­quent­ly ignored or aban­doned leaves them cling­ing and
needy, even with the peo­ple who have abused them. Hav­ing been
chron­i­cal­ly beat­en, molest­ed, and oth­er­wise mis­treat­ed, they can not help
but define them­selves as defec­tive and worth­less. They come by their self-
loathing, sense of defec­tive­ness, and worth­less­ness hon­est­ly. Was it any
sur­prise that they didn’t trust any­one? Final­ly, the com­bi­na­tion of feel­ing
fun­da­men­tal­ly despi­ca­ble and over­re­act­ing to slight frus­tra­tions makes it
dif­fi­cult for them to make friends.
We pub­lished the first arti­cles about our find­ings, devel­oped a val­i­dat­ed
rat­ing scale,18 and col­lect­ed data on about 350 kids and their par­ents or
fos­ter par­ents to estab­lish that this one diag­no­sis, Devel­op­men­tal Trau­ma
Dis­or­der, cap­tured the full range of what was wrong with these chil­dren. It
would enable us to give them a sin­gle diag­no­sis, as opposed to mul­ti­ple
labels, and would firm­ly locate the ori­gin of their prob­lems in a
com­bi­na­tion of trau­ma and com­pro­mised attach­ment.
In Feb­ru­ary 2009 we sub­mit­ted our pro­posed new diag­no­sis of
Devel­op­men­tal Trau­ma Dis­or­der to the Amer­i­can Psy­chi­atric Asso­ci­a­tion,
stat­ing the fol­low­ing in a cov­er let­ter:
Chil­dren who devel­op in the con­text of ongo­ing dan­ger,
mal­treat­ment and dis­rupt­ed care­giv­ing sys­tems are being ill served
by the cur­rent diag­nos­tic sys­tems that lead to an empha­sis on
behav­ioral con­trol with no recog­ni­tion of inter­per­son­al trau­ma.
Stud­ies on the seque­lae of child­hood trau­ma in the con­text of
care­giv­er abuse or neglect con­sis­tent­ly demon­strate chron­ic and
severe prob­lems with emo­tion reg­u­la­tion, impulse con­trol,
atten­tion and cog­ni­tion, dis­so­ci­a­tion, inter­per­son­al rela­tion­ships,
and self and rela­tion­al schemas. In absence of a sen­si­tive trau­ma-
spe­cif­ic diag­no­sis, such chil­dren are cur­rent­ly diag­nosed with an
aver­age of 3–8 co-mor­bid dis­or­ders. The con­tin­ued prac­tice of
apply­ing mul­ti­ple dis­tinct co-mor­bid diag­noses to trau­ma­tized
chil­dren has grave con­se­quences: it defies par­si­mo­ny, obscures
eti­o­log­i­cal clar­i­ty, and runs the dan­ger of rel­e­gat­ing treat­ment and
inter­ven­tion to a small aspect of the child’s psy­chopathol­o­gy rather
than pro­mot­ing a com­pre­hen­sive treat­ment approach.
Short­ly after sub­mit­ting our pro­pos­al, I gave a talk on Devel­op­men­tal
Trau­ma Dis­or­der in Wash­ing­ton DC to a meet­ing of the men­tal health
com­mis­sion­ers from across the coun­try. They offered to sup­port our
ini­tia­tive by writ­ing a let­ter to the APA. The let­ter began by point­ing out
that the Nation­al Asso­ci­a­tion of State Men­tal Health Pro­gram Direc­tors
served 6.1 mil­lion peo­ple annu­al­ly, with a bud­get of $29.5 bil­lion, and
con­clud­ed: “We urge the APA to add devel­op­men­tal trau­ma to its list of
pri­or­i­ty areas to clar­i­fy and bet­ter char­ac­ter­ize its course and clin­i­cal
seque­lae and to empha­size the strong need to address devel­op­men­tal trau­ma
in the assess­ment of patients.”
I felt con­fi­dent that this let­ter would ensure that the APA would take
our pro­pos­al seri­ous­ly, but sev­er­al months after our sub­mis­sion, Matthew
Fried­man, exec­u­tive direc­tor of the Nation­al Cen­ter for PTSD and chair of
the rel­e­vant DSM sub­com­mit­tee, informed us that DTD was unlike­ly to be
includ­ed in the DSM‑5. The con­sen­sus, he wrote, was that no new diag­no­sis
was required to fill a “miss­ing diag­nos­tic niche.” One mil­lion chil­dren who
are abused and neglect­ed every year in the Unit­ed States a “diag­nos­tic
niche”?
The let­ter went on: “The notion that ear­ly child­hood adverse
expe­ri­ences lead to sub­stan­tial devel­op­men­tal dis­rup­tions is more clin­i­cal
intu­ition than a research-based fact. This state­ment is com­mon­ly made but
can­not be backed up by prospec­tive stud­ies.” In fact, we had includ­ed
sev­er­al prospec­tive stud­ies in our pro­pos­al. Let’s look at just two of them
here.
HOW RELATIONSHIPS SHAPE DEVELOPMENT
Begin­ning in 1975 and con­tin­u­ing for almost thir­ty years, Alan Sroufe and
his col­leagues tracked 180 chil­dren and their fam­i­lies through the
Min­neso­ta Lon­gi­tu­di­nal Study of Risk and Adaptation.19 At the time the
study began there was an intense debate about the role of nature ver­sus
nur­ture, and tem­pera­ment ver­sus envi­ron­ment in human devel­op­ment, and
this study set out to answer those ques­tions. Trau­ma was not yet a pop­u­lar
top­ic, and child abuse and neglect were not a cen­tral focus of this study—at
least ini­tial­ly, until they emerged as the most impor­tant pre­dic­tors of adult
func­tion­ing.
Work­ing with local med­ical and social agen­cies, the researchers
recruit­ed first-time (Cau­casian) moth­ers who were poor enough to qual­i­fy
for pub­lic assis­tance but who had dif­fer­ent back­grounds and dif­fer­ent kinds
and lev­els of sup­port avail­able for par­ent­ing. The study began three months
before the chil­dren were born and fol­lowed the chil­dren for thir­ty years into
adult­hood, assess­ing and, where rel­e­vant, mea­sur­ing all the major aspects of
their func­tion­ing and all the sig­nif­i­cant cir­cum­stances of their lives. It
con­sid­ered sev­er­al fun­da­men­tal ques­tions: How do chil­dren learn to pay
atten­tion while reg­u­lat­ing their arousal (i.e., avoid­ing extreme highs or
lows) and keep­ing their impuls­es under con­trol? What kinds of sup­ports do
they need, and when are these need­ed?
After exten­sive inter­views and test­ing of the prospec­tive par­ents, the
study real­ly got off the ground in the new­born nurs­ery, where researchers
observed the new­borns and inter­viewed the nurs­es car­ing for them. They
then made home vis­its sev­en and ten days after birth. Before the chil­dren
entered first grade, they and their par­ents were care­ful­ly assessed a total of
fif­teen times. After that, the chil­dren were inter­viewed and test­ed at reg­u­lar
inter­vals until age twen­ty-eight, with con­tin­u­ing input from moth­ers and
teach­ers.
Sroufe and his col­leagues found that qual­i­ty of care and bio­log­i­cal
fac­tors were close­ly inter­wo­ven. It is fas­ci­nat­ing to see how the Min­neso­ta
results echo—though with far greater complexity—what Stephen Suo­mi
found in his pri­mate lab­o­ra­to­ry. Noth­ing was writ­ten in stone. Nei­ther the
mother’s per­son­al­i­ty, nor the infant’s neu­ro­log­i­cal anom­alies at birth, nor its
IQ, nor its temperament—including its activ­i­ty lev­el and reac­tiv­i­ty to stress
—pre­dict­ed whether a child would devel­op seri­ous behav­ioral prob­lems in
adolescence.20 The key issue, rather, was the nature of the par­ent-child
rela­tion­ship: how par­ents felt about and inter­act­ed with their kids. As with
Suomi’s mon­keys, the com­bi­na­tion of vul­ner­a­ble infants and inflex­i­ble
care­givers made for clingy, uptight kids. Insen­si­tive, pushy, and intru­sive
behav­ior on the part of the par­ents at six months pre­dict­ed hyper­ac­tiv­i­ty and
atten­tion prob­lems in kinder­garten and beyond.21
Focus­ing on many facets of devel­op­ment, par­tic­u­lar­ly rela­tion­ships
with care­givers, teach­ers, and peers, Sroufe and his col­leagues found that
care­givers not only help keep arousal with­in man­age­able bounds but also
help infants devel­op their own abil­i­ty to reg­u­late their arousal. Chil­dren
who were reg­u­lar­ly pushed over the edge into over­arousal and
dis­or­ga­ni­za­tion did not devel­op prop­er attune­ment of their inhibito­ry and
exci­ta­to­ry brain sys­tems and grew up expect­ing that they would lose con­trol
if some­thing upset­ting hap­pened. This was a vul­ner­a­ble pop­u­la­tion, and by
late ado­les­cence half of them had diag­nos­able men­tal health prob­lems.
There were clear pat­terns: The chil­dren who received con­sis­tent care­giv­ing
became well-reg­u­lat­ed kids, while errat­ic care­giv­ing pro­duced kids who
were chron­i­cal­ly phys­i­o­log­i­cal­ly aroused. The chil­dren of unpre­dictable
par­ents often clam­ored for atten­tion and became intense­ly frus­trat­ed in the
face of small chal­lenges. Their per­sis­tent arousal made them chron­i­cal­ly
anx­ious. Con­stant­ly look­ing for reas­sur­ance got in the way of play­ing and
explo­ration, and, as a result, they grew up chron­i­cal­ly ner­vous and
non­ad­ven­tur­ous.
Ear­ly parental neglect or harsh treat­ment led to behav­ior prob­lems in
school and pre­dict­ed trou­bles with peers and a lack of empa­thy for the
dis­tress of others.22 This set up a vicious cycle: Their chron­ic arousal,
cou­pled with lack of parental com­fort, made them dis­rup­tive, oppo­si­tion­al,
and aggres­sive. Dis­rup­tive and aggres­sive kids are unpop­u­lar and pro­voke
fur­ther rejec­tion and pun­ish­ment, not only from their care­givers but also
from their teach­ers and peers.23
Sroufe also learned a great deal about resilience: the capac­i­ty to bounce
back from adver­si­ty. By far the most impor­tant pre­dic­tor of how well his
sub­jects coped with life’s inevitable dis­ap­point­ments was the lev­el of
secu­ri­ty estab­lished with their pri­ma­ry care­giv­er dur­ing the first two years
of life. Sroufe infor­mal­ly told me that he thought that resilience in
adult­hood could be pre­dict­ed by how lov­able moth­ers rat­ed their kids at age
two.24
THE LONG-TERM EFFECTS OF INCEST
In 1986 Frank Put­nam and Pene­lope Trick­ett, his col­league at the Nation­al
Insti­tute of Men­tal Health, ini­ti­at­ed the first lon­gi­tu­di­nal study of the impact
of sex­u­al abuse on female development.25 Until the results of this study
came out, our knowl­edge about the effects of incest was based entire­ly on
reports from chil­dren who had recent­ly dis­closed their abuse and on
accounts from adults recon­struct­ing years or even decades lat­er how incest
had affect­ed them. No study had ever fol­lowed girls as they matured to
exam­ine how sex­u­al abuse might influ­ence their school per­for­mance, peer
rela­tion­ships, and self-con­cept, as well as their lat­er dat­ing life. Put­nam and
Trick­ett also looked at changes over time in their sub­jects’ stress hor­mones,
repro­duc­tive hor­mones, immune func­tion, and oth­er phys­i­o­log­i­cal
mea­sures. In addi­tion they explored poten­tial pro­tec­tive fac­tors, such as
intel­li­gence and sup­port from fam­i­ly and peers.
The researchers painstak­ing­ly recruit­ed eighty-four girls referred by the
Dis­trict of Colum­bia Depart­ment of Social Ser­vices who had a con­firmed
his­to­ry of sex­u­al abuse by a fam­i­ly mem­ber. These were matched with a
com­par­i­son group of eighty-two girls of the same age, race, socioe­co­nom­ic
sta­tus, and fam­i­ly con­stel­la­tion who had not been abused. The aver­age
start­ing age was eleven. Over the next twen­ty years these two groups were
thor­ough­ly assessed six times, once a year for the first three years and again
at ages eigh­teen, nine­teen, and twen­ty-five. Their moth­ers par­tic­i­pat­ed in
the ear­ly assess­ments, and their own chil­dren took part in the last. A
remark­able 96 per­cent of the girls, now grown women, have stayed in the
study from its incep­tion.
The results were unam­bigu­ous: Com­pared with girls of the same age,
race, and social cir­cum­stances, sex­u­al­ly abused girls suf­fer from a large
range of pro­found­ly neg­a­tive effects, includ­ing cog­ni­tive deficits,
depres­sion, dis­so­cia­tive symp­toms, trou­bled sex­u­al devel­op­ment, high rates
of obe­si­ty, and self-muti­la­tion. They dropped out of high school at a high­er
rate than the con­trol group and had more major ill­ness­es and health-care
uti­liza­tion. They also showed abnor­mal­i­ties in their stress hor­mone
respons­es, had an ear­li­er onset of puber­ty, and accu­mu­lat­ed a host of
dif­fer­ent, seem­ing­ly unre­lat­ed, psy­chi­atric diag­noses.
The fol­low-up research revealed many details of how abuse affects
devel­op­ment. For exam­ple, each time they were assessed, the girls in both
groups were asked to talk about the worst thing that had hap­pened to them
dur­ing the pre­vi­ous year. As they told their sto­ries, the researchers observed
how upset they became, while mea­sur­ing their phys­i­ol­o­gy. Dur­ing the first
assess­ment all the girls react­ed by becom­ing dis­tressed. Three years lat­er, in
response to the same ques­tion, the nonabused girls once again dis­played
signs of dis­tress, but the abused girls shut down and became numb. Their
biol­o­gy matched their observ­able reac­tions: Dur­ing the first assess­ment all
of the girls showed an increase in the stress hor­mone cor­ti­sol; three years
lat­er cor­ti­sol went down in the abused girls as they report­ed on the most
stress­ful event of the past year. Over time the body adjusts to chron­ic
trau­ma. One of the con­se­quences of numb­ing is that teach­ers, friends, and
oth­ers are not like­ly to notice that a girl is upset; she may not even reg­is­ter
it her­self. By numb­ing out she no longer reacts to dis­tress the way she
should, for exam­ple, by tak­ing pro­tec­tive action.
Putnam’s study also cap­tured the per­va­sive long-term effects of incest
on friend­ships and part­ner­ing. Before the onset of puber­ty nonabused girls
usu­al­ly have sev­er­al girl­friends, as well as one boy who func­tions as a sort
of spy who informs them about what these strange crea­tures, boys, are all
about. After they enter ado­les­cence, their con­tacts with boys grad­u­al­ly
increase. In con­trast, before puber­ty the abused girls rarely have close
friends, girls or boys, but ado­les­cence brings many chaot­ic and often
trau­ma­tiz­ing con­tacts with boys.
Lack­ing friends in ele­men­tary school makes a cru­cial dif­fer­ence. Today
we’re aware how cru­el third‑, fourth‑, and fifth-grade girls can be. It’s a
com­plex and rocky time when friends can sud­den­ly turn on one anoth­er and
alliances dis­solve in exclu­sions and betray­als. But there is an upside: By the
time girls get to mid­dle school, most have begun to mas­ter a whole set of
social skills, includ­ing being able to iden­ti­fy what they feel, nego­ti­at­ing
rela­tion­ships with oth­ers, pre­tend­ing to like peo­ple they don’t, and so on.
And most of them have built a fair­ly steady sup­port net­work of girls who
become their stress-debrief­ing team. As they slow­ly enter the world of sex
and dat­ing, these rela­tion­ships give them room for reflec­tion, gos­sip, and
dis­cus­sion of what it all means.
The sex­u­al­ly abused girls have an entire­ly dif­fer­ent devel­op­men­tal
path­way. They don’t have friends of either gen­der because they can’t trust;
they hate them­selves, and their biol­o­gy is against them, lead­ing them either
to over­re­act or numb out. They can’t keep up in the nor­mal envy-dri­ven
inclusion/exclusion games, in which play­ers have to stay cool under stress.
Oth­er kids usu­al­ly don’t want any­thing to do with them—they sim­ply are
too weird.
But that’s only the begin­ning of the trou­ble. The abused, iso­lat­ed girls
with incest his­to­ries mature sex­u­al­ly a year and a half ear­li­er than the
nonabused girls. Sex­u­al abuse speeds up their bio­log­i­cal clocks and the
secre­tion of sex hor­mones. Ear­ly in puber­ty the abused girls had three to
five times the lev­els of testos­terone and androstene­dione, the hor­mones that
fuel sex­u­al desire, as the girls in the con­trol group.
Results of Put­nam and Trickett’s study con­tin­ue to be pub­lished, but it
has already cre­at­ed an invalu­able road map for clin­i­cians deal­ing with
sex­u­al­ly abused girls. At the Trau­ma Cen­ter, for exam­ple, one of our
clin­i­cians report­ed on a Mon­day morn­ing that a patient named Ayesha had
been raped—again—over the week­end. She had run away from her group
home at five o’clock on Sat­ur­day, gone to a place in Boston where drug­gies
hang out, smoked some dope and done some oth­er drugs, and then left with
a bunch of boys in a car. At five o’clock Sun­day morn­ing they had gang-
raped her. Like so many of the ado­les­cents we see, Ayesha can’t artic­u­late
what she wants or needs and can’t think through how she might pro­tect
her­self. Instead, she lives in a world of actions. Try­ing to explain her
behav­ior in terms of victim/perpetrator isn’t help­ful, nor are labels like
“depres­sion,” “oppo­si­tion­al defi­ant dis­or­der,” “inter­mit­tent explo­sive
dis­or­der,” “bipo­lar dis­or­der,” or any of the oth­er options our diag­nos­tic
man­u­als offer us. Putnam’s work has helped us under­stand how Ayesha
expe­ri­ences the world—why she can­not tell us what is going on with her,
why she is so impul­sive and lack­ing in self-pro­tec­tion, and why she views
us as fright­en­ing and intru­sive rather than as peo­ple who can help her.
THE DSM‑5: A VERITABLE SMORGASBORD OF
“DIAGNOSES”
When DSM‑5 was pub­lished in May 2013 it includ­ed some three hun­dred
dis­or­ders in its 945 pages. It offers a ver­i­ta­ble smor­gas­bord of pos­si­ble
labels for the prob­lems asso­ci­at­ed with severe ear­ly-life trau­ma, includ­ing
some new ones such as Dis­rup­tive Mood Reg­u­la­tion Disorder,26 Non-
sui­ci­dal Self Injury, Inter­mit­tent Explo­sive Dis­or­der, Dys­reg­u­lat­ed Social
Engage­ment Dis­or­der, and Dis­rup­tive Impulse Con­trol Disorder.27
Before the late nine­teenth cen­tu­ry doc­tors clas­si­fied ill­ness­es accord­ing
to their sur­face man­i­fes­ta­tions, like fevers and pus­tules, which was not
unrea­son­able, giv­en that they had lit­tle else to go on.28 This changed when
sci­en­tists like Louis Pas­teur and Robert Koch dis­cov­ered that many
dis­eases were caused by bac­te­ria that were invis­i­ble to the naked eye.
Med­i­cine then was trans­formed by its attempts to dis­cov­er ways to get rid
of those organ­isms rather than just treat­ing the boils and the fevers that they
caused. With DSM‑5 psy­chi­a­try firm­ly regressed to ear­ly-nine­teenth-
cen­tu­ry med­ical prac­tice. Despite the fact that we know the ori­gin of many
of the prob­lems it iden­ti­fies, its “diag­noses” describe sur­face phe­nom­e­na
that com­plete­ly ignore the under­ly­ing caus­es.
Even before DSM‑5 was released, the Amer­i­can Jour­nal of Psy­chi­a­try
pub­lished the results of valid­i­ty tests of var­i­ous new diag­noses, which
indi­cat­ed that the DSM large­ly lacks what in the world of sci­ence is known
as “reliability”—the abil­i­ty to pro­duce con­sis­tent, replic­a­ble results. In
oth­er words, it lacks sci­en­tif­ic valid­i­ty. Odd­ly, the lack of reli­a­bil­i­ty and
valid­i­ty did not keep the DSM‑5 from meet­ing its dead­line for pub­li­ca­tion,
despite the near-uni­ver­sal con­sen­sus that it rep­re­sent­ed no improve­ment
over the pre­vi­ous diag­nos­tic system.29 Could the fact that the APA had
earned $100 mil­lion on the DSM-IV and is slat­ed to take in a sim­i­lar
amount with the DSM‑5 (because all men­tal health prac­ti­tion­ers, many
lawyers, and oth­er pro­fes­sion­als will be oblig­ed to pur­chase the lat­est
edi­tion) be the rea­son we have this new diag­nos­tic sys­tem?
Diag­nos­tic reli­a­bil­i­ty isn’t an abstract issue: If doc­tors can’t agree on
what ails their patients, there is no way they can pro­vide prop­er treat­ment.
When there’s no rela­tion­ship between diag­no­sis and cure, a mis­la­beled
patient is bound to be a mis­treat­ed patient. You would not want to have your
appen­dix removed when you are suf­fer­ing from a kid­ney stone, and you
would not want have some­body labeled as “oppo­si­tion­al” when, in fact, his
behav­ior is root­ed in an attempt to pro­tect him­self against real dan­ger.
In a state­ment released in June 2011, the British Psy­cho­log­i­cal Soci­ety
com­plained to the APA that the sources of psy­cho­log­i­cal suf­fer­ing in the
DSM‑5 were iden­ti­fied “as locat­ed with­in indi­vid­u­als” and over­looked the
“unde­ni­able social cau­sa­tion of many such problems.”30 This was in
addi­tion to a flood of protest from Amer­i­can pro­fes­sion­als, includ­ing
lead­ers of the Amer­i­can Psy­cho­log­i­cal Asso­ci­a­tion and the Amer­i­can
Coun­sel­ing Asso­ci­a­tion. Why are rela­tion­ships or social con­di­tions left out?
31 If you pay atten­tion only to faulty biol­o­gy and defec­tive genes as the
cause of men­tal prob­lems and ignore aban­don­ment, abuse, and depri­va­tion,
you are like­ly to run into as many dead ends as pre­vi­ous gen­er­a­tions did
blam­ing it all on ter­ri­ble moth­ers.
The most stun­ning rejec­tion of the DSM‑5 came from the Nation­al
Insti­tute of Men­tal Health, which funds most psy­chi­atric research in
Amer­i­ca. In April 2013, a few weeks before DSM‑5 was for­mal­ly released,
NIMH direc­tor Thomas Insel announced that his agency could no longer
sup­port DSM’s “symp­tom-based diagnosis.”32 Instead the insti­tute would
focus its fund­ing on what are called Research Domain Cri­te­ria (RDoC)33 to
cre­ate a frame­work for stud­ies that would cut across cur­rent diag­nos­tic
cat­e­gories. For exam­ple, one of the NIMH domains is “Arousal/Modulatory
Sys­tems (Arousal, Cir­ca­di­an Rhythm, Sleep and Wake­ful­ness),” which are
dis­turbed to vary­ing degrees in many patients.
Like the DSM‑5, the RDoC frame­work con­cep­tu­al­izes men­tal ill­ness­es
sole­ly as brain dis­or­ders. This means that future research fund­ing will
explore the brain cir­cuits “and oth­er neu­ro­bi­o­log­i­cal mea­sures” that
under­lie men­tal prob­lems. Insel sees this as a first step toward the sort of
“pre­ci­sion med­i­cine that has trans­formed can­cer diag­no­sis and treat­ment.”
Men­tal ill­ness, how­ev­er, is not at all like can­cer: Humans are social
ani­mals, and men­tal prob­lems involve not being able to get along with oth­er
peo­ple, not fit­ting in, not belong­ing, and in gen­er­al not being able to get on
the same wave­length.
Every­thing about us—our brains, our minds, and our bodies—is geared
toward col­lab­o­ra­tion in social sys­tems. This is our most pow­er­ful sur­vival
strat­e­gy, the key to our suc­cess as a species, and it is pre­cise­ly this that
breaks down in most forms of men­tal suf­fer­ing. As we saw in part 2, the
neur­al con­nec­tions in brain and body are vital­ly impor­tant for
under­stand­ing human suf­fer­ing, but it is impor­tant not to ignore the
foun­da­tions of our human­i­ty: rela­tion­ships and inter­ac­tions that shape our
minds and brains when we are young and that give sub­stance and mean­ing
to our entire lives.
Peo­ple with his­to­ries of abuse, neglect, or severe depri­va­tion will
remain mys­te­ri­ous and large­ly untreat­ed unless we heed the admo­ni­tion of
Alan Sroufe: “To ful­ly under­stand how we become the per­sons we are—the
com­plex, step-by-step evo­lu­tion of our ori­en­ta­tions, capac­i­ties, and
behav­ior over time—requires more than a list of ingre­di­ents, how­ev­er
impor­tant any one of them might be. It requires an under­stand­ing of the
process of devel­op­ment, how all of these fac­tors work togeth­er in an
ongo­ing way over time.”34
Front­line men­tal health workers—overwhelmed and under­paid social
work­ers and ther­a­pists alike—seem to agree with our approach. Short­ly
after the APA reject­ed Devel­op­men­tal Trau­ma Dis­or­der for inclu­sion in the
DSM, thou­sands of clin­i­cians from around the coun­try sent small
con­tri­bu­tions to the Trau­ma Cen­ter to help us con­duct a large sci­en­tif­ic
study, known as a field tri­al, to fur­ther study DTD. That sup­port has
enabled us to inter­view hun­dreds of kids, par­ents, fos­ter par­ents, and men­tal
health work­ers at five dif­fer­ent net­work sites over the last few years with
sci­en­tif­i­cal­ly con­struct­ed inter­view tools. The first results from these
stud­ies have now been pub­lished, and more will appear as this book is
going to print.35
WHAT DIFFERENCE WOULD DTD MAKE?
One answer is that it would focus research and treat­ment (not to men­tion
fund­ing) on the cen­tral prin­ci­ples that under­lie the pro­tean symp­toms of
chron­i­cal­ly trau­ma­tized chil­dren and adults: per­va­sive bio­log­i­cal and
emo­tion­al dys­reg­u­la­tion, failed or dis­rupt­ed attach­ment, prob­lems stay­ing
focused and on track, and a huge­ly defi­cient sense of coher­ent per­son­al
iden­ti­ty and com­pe­tence. These issues tran­scend and include almost all
diag­nos­tic cat­e­gories, but treat­ment that doesn’t put them front and cen­ter is
more than like­ly to miss the mark. Our great chal­lenge is to apply the
lessons of neu­ro­plas­tic­i­ty, the flex­i­bil­i­ty of brain cir­cuits, to rewire the
brains and reor­ga­nize the minds of peo­ple who have been pro­grammed by
life itself to expe­ri­ence oth­ers as threats and them­selves as help­less.
Social sup­port is a bio­log­i­cal neces­si­ty, not an option, and this real­i­ty
should be the back­bone of all pre­ven­tion and treat­ment. Rec­og­niz­ing the
pro­found effects of trau­ma and depri­va­tion on child devel­op­ment need not
lead to blam­ing par­ents. We can assume that par­ents do the best they can,
but all par­ents need help to nur­ture their kids. Near­ly every indus­tri­al­ized
nation, with the excep­tion of the Unit­ed States, rec­og­nizes this and pro­vides
some form of guar­an­teed sup­port to fam­i­lies. James Heck­man, win­ner of
the 2000 Nobel Prize in Eco­nom­ics, has shown that qual­i­ty ear­ly-child­hood
pro­grams that involve par­ents and pro­mote basic skills in dis­ad­van­taged
chil­dren more than pay for them­selves in improved outcomes.36
In the ear­ly 1970s psy­chol­o­gist David Olds was work­ing in a Bal­ti­more
day-care cen­ter where many of the preschool­ers came from homes wracked
by pover­ty, domes­tic vio­lence, and drug abuse. Aware that only address­ing
the children’s prob­lems at school was not suf­fi­cient to improve their home
con­di­tions, he start­ed a home-vis­i­ta­tion pro­gram in which skilled nurs­es
helped moth­ers to pro­vide a safe and stim­u­lat­ing envi­ron­ment for their
chil­dren and, in the process, to imag­ine a bet­ter future for them­selves.
Twen­ty years lat­er, the chil­dren of the home-vis­i­ta­tion moth­ers were not
only health­i­er but also less like­ly to report hav­ing been abused or neglect­ed
than a sim­i­lar group whose moth­ers had not been vis­it­ed. They also were
more like­ly to have fin­ished school, to have stayed out of jail, and to be
work­ing in well-pay­ing jobs. Econ­o­mists have cal­cu­lat­ed that every dol­lar
invest­ed in high-qual­i­ty home vis­i­ta­tion, day care, and preschool pro­grams
results in sev­en dol­lars of sav­ings on wel­fare pay­ments, health-care costs,
sub­stance-abuse treat­ment, and incar­cer­a­tion, plus high­er tax rev­enues due
to bet­ter-pay­ing jobs.37
When I go to Europe to teach, I often am con­tact­ed by offi­cials at the
min­istries of health in the Scan­di­na­vian coun­tries, the Unit­ed King­dom,
Ger­many, or the Nether­lands and asked to spend an after­noon with them
shar­ing the lat­est research on the treat­ment of trau­ma­tized chil­dren,
ado­les­cents, and their fam­i­lies. The same is true for many of my col­leagues.
These coun­tries have already made a com­mit­ment to uni­ver­sal health care,
ensur­ing a guar­an­teed min­i­mum wage, paid parental leave for both par­ents
after a child is born, and high-qual­i­ty child­care for all work­ing moth­ers.