While working at a mental health clinic in Harlem years ago, I got used to hearing the most traumatic stories I could have ever imagined. They were the normal way to live for many of my clients.
One day a woman in her 40s, who lived in a drug den and had gone through a frightful marriage before her husband was imprisoned, asked me how she could know if her son was traumatized. As a then-inexperienced clinician, I took out the last version of the DSM (Diagnostic and Statistical Manual of Mental Disorders) off my shelf the same way a cowboy would take out his pistol from his belt, ready to shoot off a diagnosis.
The last version of the DSM at that time was the IV edition of the handbook produced by the American Psychiatric Association (APA) and used by healthcare professionals in the United States and many other countries as the authoritative guide to the diagnosis of mental disorders. It only included Posttraumatic Stress Disorder (PTSD) — under Anxiety Disorders — and made no difference between applying the criteria to adults and children. It did include, however, an explanation of how it could be difficult for children to report many of the symptoms listed.
I was not really able to help the woman that day, and felt the same frustration that had become the regular experience of my days, confronting the incapacity of helping so many traumatized people with so little understanding of the phenomena of trauma. When I couldn’t bear the frustration anymore, I joined a two year postgraduate clinical program in Trauma Studies.
One of the first things I remember learning during my formation as a trauma therapist was that the phenomenon of psychological traumatization, even though identified and studied centuries ago, had been dismissed several times by the psychiatric community, until Vietnam veterans created “rap groups” — an informal discussion group, often supervised by a trained leader, that met to discuss shared concerns or interests. The groups spread through the country and the evidence of the consequences of war on the veterans’ mental health became undeniable. That’s when, after a few years of research, the first official acknowledgment of trauma as a mental disorder was approved by the inclusion of the diagnosis of PTSD in the DSM version III in 1980.
In these 40 years, the number of research papers exposing the countless ways that someone can develop trauma — beyond the criteria of being exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence — has exploded. And yet, there is no diagnosis accepted for any type of complex trauma — as in, for those exposed to prolonged toxic stress instead of a single event — even when there have been several attempts to have one in the DSM. For example, Bessel van der Kolk –one of the most important promoters of trauma studies— proposed the inclusion of DESNOS (Disorders of Extreme Stress Not Otherwise Specified) into the DSM-5 but it was not accepted.
Trauma Studies in Children
It has been forty years since PTSD appeared, and still, we lack a good way to know if a child is traumatized beside the narrow point of view of the PTSD diagnosis. It has become evident and undeniable that children and adolescents experience high rates of potentially traumatic experiences at home and other circumstances, and that they are very vulnerable to developing developmental issues if traumatized during childhood; many of those alterations could be irreversible.
Bessel van Der Kolk also made a study for what he called Developmental Trauma Disorder (DTD) focusing on the traumatization that happens while the child is developing, and offered it as an option for a more complex manifestation of PTSD. Still, the APA has not accepted several propositions for diagnosing children.
Actually, the “world” has adopted the term Complex Trauma (C-PTS) as if it was official, and it’s commonly used in literature and across platforms. But Developmental Trauma is still an unheard-of concept by most, which is a terrible pity, since it is the one syndrome that affects children and that without prevention or treatment can have irreversible consequences in the life of the adult.
It has been argued that when a child is exposed to extreme stress during prolonged periods of time, they frequently do not meet the criteria for a PTSD diagnosis because the symptoms are different. Families with neglected or abused children often carry a number of additional risk factors, such as mental disorders in parents, poverty, threatening living conditions, loss or absence of a parent, social isolation, domestic violence, parent’s addiction or lack of family cohesion in general.
Trauma in children has different characteristics than in adults because the dysregulation of the nervous system created by the activation of the defenses while at risk, in a system that is still developing, causes more permanent damage. On top of that, the defenses triggered in a child who has little possibility to defend him/herself, brings a sense of defeat, defectiveness, and hopelessness that will mold the kid’s personality, sense of self, identity, and behavior. The alterations suffered in a child’s brain due to the toxic stress, high levels of cortisol, and loss of homeostasis from the traumatization affect learning, mood, motivation, cognitive functions, impulse control, disconnection and disengagement, just to name a few.
Trauma Indicators in Children
A child develops trauma if they get exposed to developmentally-adverse traumatic events, most often of an interpersonal nature. These are some ways to find out whether or not the circumstances have affected the nervous system of the child enough as to assume traumatization:
- One of the most important indicators of trauma in a child is the way he/she manages his/her emotions. Is the child able to control his/her anger? Are they aggressive — or on the contrary, very passive?
- One good tool to measure traumatization is something called the Window of Tolerance. Everyone has a certain tolerance to experience emotional states. We can go up and down emotionally without suffering from our emotions. We can get angry without screaming or breaking stuff, or we can get sad or disillusioned without losing the desire to live:
- When emotions are either too intense that they make the child act in extreme ways, or when the tolerance to emotions is so narrow that the child feels overwhelmed easily, you can say that the child has little tolerance to affect and that that may be an indicator of the sequela of traumatization. I remember a 6-year-old child that felt complete disconsolate when the aunt didn’t want to buy him coffee at dinner. “I wish I could die,” whispered the kid, and he meant it.
- Another indicator is how fearful the kid is. If you notice that the reactions are not congruent with the level of risk, you may also consider the possibility of trauma. I remember seeing a 3-year-old kid going absolutely ballistic, when he saw someone giving his mother a massage at a spa. The kid reacted as if he was witnessing his mother’s assassination. Two adults had to contain the child because the mother just went on relaxing and enjoying her massage, while the child was not able to control himself and wanted to attack the masseur.
- Most children who suffer from trauma will have the tendency to shut down. They may be extremely quiet and disconnected. They may avoid other kids or games. They may also show strange behavior, if they go to unfamiliar environments. For example, they may wet the bed every time they sleep in grandma’s house. They may also have learning disabilities and delayed development. They may act younger than their age compared with other kids.
In general, a kid suffering from trauma will have bizarre behavior that is not congruent with their environment. I’m describing developmental trauma. If the kid suffered from a clearly traumatizing event, then he may have PTSD symptoms and the criteria for the diagnosis will apply the same way as for adults, except for children younger than 6.
Learning about the type of situations that can damage a child could prevent traumatization. Finding out if the child is already suffering from trauma can alter his/her life if there is an intervention in time. Identifying the cause, manifestations, symptoms, and alterations that traumatization produces could stop you from confusing symptoms with temperament or personality, as it happens in many cases; kids are called introverts, lazy, quiet, or fearful instead of shutdown or withdrawn; kids are called aggressive, disobedient, hyperactive, or inattentive instead of hypervigilant or dysregulated. All those judgements on the behavior of the children create shame and hurt their identity instead of helping recognize that the kids need help stabilizing their nervous system.