Dr. Norm Thibault, LMFT
One of the common challenges that adoptive families face is receiving adequate treatment for the complexities of issues that their adoptive children may be experiencing. A 2013 study by the Donaldson Adoption Institute indicated that fewer than 25% of adoptive parents who sought mental health services felt that their mental health professional was adoption-competent. A number of the families that we have worked with at Three Points Center have experienced the same challenge.
In my opinion, there are three particular reasons for this and each are interrelated: 1) There is no adequate diagnosis in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (also known as the DSM-V, published by the American Psychiatric Association) that adequately conceptualizes what our children experience. The DSM-V is used by most therapists, social workers, psychologists and psychiatrists to allow us to speak the same language when describing a mental illness. So, if it’s not in that book, it’s not typically acknowledged. Because of this lack of clinical recognition 2) the symptoms and issues that our children experience are therefore not taught in most graduate school mental health programs to new clinicians, and 3) Insurance companies will not cover what is really going on with these children and families because it is not correctly conceptualized, coded, and diagnosed. This is an enormous issue for adoptive families and an even larger embarrassment to all of professional mental health.
In this brief, I wish to address the first concern, which is the current problem with mental health diagnoses in regards to what our adoptive children have experienced. With apologies to George Box, “All diagnoses are wrong, but some are useful.”
Some common diagnoses used with our students include Pervasive Developmental Disorders, Oppositional Defiant Disorder, Conduct Disorder, Reactive Attachment Disorder, Affective Disorders, Anxiety Disorders, Attention-Deficit Hyperactivity Disorder, Post-Traumatic Stress Disorder, and Borderline Personality Disorder. Each of these may characterize certain symptoms that our students demonstrate, but none of them systemically addresses the developmental aspect of trauma that children experience, and none take into account the profound impact of being traumatized by birth or foster-parents. It has been noted that about 80% of maltreatment experienced by children is inflicted by their own parents. According to Julian Ford, PhD, a psychologist with the University of Connecticut, “There is no diagnosis for children that more than partially addresses the symptoms associated with these impairments in self-regulation” that are experienced by many of our adopted children.
To this end, Bessel van der Kolk, MD, a Boston University Psychiatrist has proposed a diagnosis called “Developmental Trauma Disorder” or DTD. This diagnosis includes symptoms that differentiate it from Post-Traumatic Stress Disorder, (which is commonly used for our children but is simply an off-shoot from the “Battle-Fatigue” symptoms of WWI and hasn’t been much modified since). Dr. van der Kolk states, “While PTSD is a good definition for acute trauma in adults, it doesn’t apply well to children, who are often traumatized in the context of relationships. Because children’s brains are still developing, trauma has a much more pervasive and long-range influence on their self-concept, on their sense of the world, and on their ability to regulate themselves.”
Three Points Center embraces Dr. van der Kolk’s work and his Developmental Trauma Disorder. We believe it to be the most accurate clinical way to define and conceptualize what our students experience.
There are four diagnostic areas involved in DTD, each with a set of criteria that help to define it:
1. Exposure
a. Multiple or chronic exposure to one or more forms of developmentally adverse interpersonal trauma (eg, abandonment, betrayal, physical assaults, sexual assaults, threats to bodily integrity, coercive practices, emotional abuse, witnessing violence and death).
b. Subjective experience (eg, rage, betrayal, fear, resignation, defeat, shame).
2. Triggered pattern of repeated dysregulation in response to trauma cues
a. Dysregulation (high or low) in presence of cues. Changes persist and do not return to baseline; not reduced in intensity by conscious awareness.
b. Affective.
c. Somatic (eg, physiological, motoric, medical).
d. Behavioral (eg, re-enactment, cutting).
e. Cognitive (eg, thinking that it is happening again, confusion, dissociation, depersonalization).
f. Relational (eg, clinging, oppositional, distrustful, compliant).
g. Self-attribution (eg, self-hate, blame).
3. Persistently Altered Attributions and Expectancies
a. Negative self-attribution.
b. Distrust of protective caretaker.
c. Loss of expectancy of protection by others.
d. Loss of trust in social agencies to protect.
e. Lack of recourse to social justice/retribution.
f. Inevitability of future victimization.
4. Functional Impairment
a. Educational.
b. Familial.
c. Peer.
d. Legal.
e. Vocational.
For those who work with adopted children who have suffered various forms of Complex Trauma, these symptoms will seem self-evident. Unfortunately, most clinicians will not understand them or recognize them.
It is particularly troubling that Dr. van der Kolk and his colleagues fought to have this diagnosis included in the Fifth Edition of the DSM but were ultimately denied. (In the interest of transparency, I was a part of the research team that worked on the latest edition of the DSM. I was a Field-Trial Researcher and my area of focus was Borderline Personality Disorder. I did not have input on the inclusion of Developmental Trauma Disorder.)
In their commentary on the failure of the American Psychiatric Association to include this diagnosis in the DSM, Dr. Andrew Bremness and Dr. Wanda Polzin, both of the Child, Adolescent, and Family Mental Health Trauma and Attachment Program in Alberta, Canada, have identified four particular areas that demonstrate the need to have Developmental Trauma Disorder as a diagnosis, as well as strong reasons as to why it needed to be included in the DSM-V:
We see a clear convergence of events currently upon us as to why this field of trauma in children is an important opportunity, we must properly conceptualize in order to forward this area of medicine. This confluence includes: (1) adverse childhood experiences (ACE) outcomes as reported by Felitti et al. (2007; 2008), which so clearly identifies the genesis of chronic medical illness; (2) the imprecision of DSM PTSD criteria for developmental trauma (our only present diagnostic option), which captures only a minority of these trauma cases, as low as 5 to 25% on two large databases…CANS dataset (Illinois DCFS screen of 7,668 foster children) and NCTSN dataset (Pynoos et al. 2008), together totaling over 17,000 children who experienced multiple forms of trauma); and, (3) much greater knowledge of the effect upon neurobiology and developmental psychopathology, following chronic interpersonal trauma.
In an attempt to forward this ‘moment of opportunity’, van der Kolk et al. (2009) sent in their proposal to the DSM-V editors advocating that developmental trauma disorder be included….As pointed out in their proposal, the problem is that following chronic trauma, current clinical practice often reveals no diagnosis, inaccurate diagnosis or inadequate diagnosis…all of which leads to misguided or complete lack of treatment plans. Further, because there is almost always considerable dysregulation of body (sensory and motor), affect (explosive/irritable or frozen/restricted), cognition (altered perceptions of beliefs, auditory and sensory-perceptual flashbacks and dissociation) and behavior (multiple forms of regression), the diagnoses of bipolar, oppositional defiant disorder/conduct disorder, attention deficit hyperactivity disorder (ADHD) or other anxiety disorders are confusingly made. Many of these disorders are co-morbid with developmental trauma disorder anyway, as they tend to cluster in these complex families. But the importance is that the developmental trauma disorder would be primary and thus guide the treatment plan…and further, refine the inclusion (or not) of other co-morbid disorders.
Three Points Center is grateful for the work of these researchers and those who advocate for a better understanding of the complexities involved with our children. Adoption is not just about attachment, although that seems to be what many assume when they hear the word, “adoption.” Most of the children we work with at Three Points Center are attached to their adoptive parents at some level – it may be a disorganized or other type of attachment, but it’s still an attachment. And most of our kids earnestly strive to understand why they respond to situations in the manner they do, and most do wish to draw closer and have better relationships with their parents.
As professionals at Three Points Center, it is clear that our charge is to do everything we can to increase our program knowledge base so that we can improve outcomes for the students and families we work with. We should also be involved in contributing to the greater pool of knowledge accessible to all adoptive families, clinicians, and researchers throughout the world, as we wish to play a significant part in better understanding our kids and families. Advocating for official recognition of Dr. van der Kolk’s Developmental Trauma Disorder is a part of this mission. The entire field of psychology and mental health desperately needs this important information. Helping the adoption community better understand all of the variables involved in the adoption process (be they prior to birth, during birth, and after birth) not only assists in the prevention of mental health concerns, but can also inform our treatment moving forward.
References:
Bremness, A. & Polzin, W. (2014). Commentary: Developmental trauma disorder: A missed opportunity
In DSM V. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 23 (2), 142– 45.
DeAngelis, T. (2007). A new diagnosis for childhood trauma? APA Monitor, 38 (3), 32.
DeAngelis, T. (2007). What the new diagnosis would include. APA Monitor, 38 (3), 33.
DeAngelis, T. (2007). Current trauma diagnoses. APA Monitor, 38 (3), 34.
Felitti V. J., Fink P.J., Fishkin, R. E., & Anda, R. F. (2007). Epidemiologic support of psychoanalytic concepts: Evidence from the Adverse Childhood Experiences (ACE) Study of childhood trauma and violence. Trauma und Gewalt, (2), 18-32.
Pynoos, R., Fairbank, J., Steinberg, A., Amaya-Jackson, L., Gerrity, E., Mount, M., & Maze, J. (2008). The National Traumatic Stress Network: Collaborating to improve the standard of care. Professional Psychology: Research and Practice, 39 (4), 389-395.
van der Kolk, B. (2005). Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401-408.