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.