Sunday, June 28, 2009

Trauma Conference Part Two

On the second day of the conference, the general speakers were:
Glenn Saxe speaking on Complexity Theory
Dan Hughes speaking about the use of the body in therapy
And
Bessel van der Kolk on Developmental Trauma Disorder

Glenn Saxe is one of my favorite theorists and writers. His book, Saxe, Glenn; Ellis, B. Heidi; and Kaplow, Julie B. Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach (2006, The Guilford Pres)s does the best job of any I have read to conceptualize a model for working both with the child themselves and with the system around the child.

At this presentation Dr. Saxe was talking about his latest fascination, complexity theory, which is the science that investigates how schools of fish or flocks of birds maintain their complex, moving patterns with out a leader or a plan. Dr. Saxe is using this theory to look at the complex patter of a traumatized child in his or her social systems, and stated that the theories will help us understand which changes will be most powerful, and where we could intervene to gain the most effect.

Daniel Hughes has long been an inspiration of mine, and was part of our beginning down the journey towards trauma informed care. His book: Hughes, Daniel. (1998). Building the bonds of attachment: Awakening love in deeply troubled children. Jason Aronson served as our guide book as we invented this new model. More recently, I have appreciated his newest books: Attachment Focused Family Therapy, (W.W. Norton & Co.; 1 edition May, 2007) and Attachment-Focused Parenting: Effective Strategies to Care for Children (Norton Professional Books, March 2009). At the conference Dr. Hughes was emphasizing the role of non-verbal communication within therapy. In fact he wondered why we call it "non-verbal" communication- 80% of our communication is what he would term "body communication". Since trauma is held in the body, it is essential that the therapist deliberately use all body communication to facilitate and deepen the therapeutic process. This includes:
Matching vitality and affect of client
Congruent with verbal communication
Awareness of other’s nonverbal meaning
Clear, nonambiguous expressions
Flowing- gradual, regulated, changes
Gaze- direct, warm, open, interested, responsive
Voice- variable, responsive, relaxed, open, animated
thoughtful, alive, empathic.
Gestures- animated, expansive, dramatic, responsive
Posture- open, moving/leaning forward

Dr. Hughes showed some wonderful videos to illustrate his points. However, he was especially prod of the picture with which he began his slide show- a lovely picture of his daughter and her daughter in attuned communication.

Bessel van der Kolk then presented on his work on establishing a new diagnostic category for the upcoming DSM V- that of Developmental Trauma Disorder. Dr. van der Kolk started by relating the history of the trauma diagnosis- noting that there is a new phrase for the effect of war on soldiers in each war, and it reflects the weapon predominated in that war (such as "shell shock"). The PTSD diagnosis was created in the aftermath of the Vietnam war, in an attempt to get funding and medical care for the veterans, and has proved effective for adults who experience trauma in adulthood.
However, there has been recognition of the profound difference between adult onset PTSD and the clinical effects of interpersonal violence on children, as well as the need to develop effective treatments for these children. It has become evident that the current diagnostic classification system is inadequate for the tens of thousands of traumatized children receiving psychiatric care for trauma-related difficulties.
PTSD is a frequent consequence of single traumatic events. Research supports that PTSD, with minor modifications, also is an adequate diagnosis to capture the effects of single incident trauma in children who live in safe and predictable caregiving systems. Even as many children with complex trauma histories exhibit some symptoms of PTSD, research shows that the diagnosis of PTSD does not adequately capture the symptoms of children who are victims of interpersonal violence in the context of inadequate caregiving systems. In fact, multiple studies show that the majority meet criteria for multiple other DSM diagnoses.

Therefore, the goal of introducing the diagnosis of Developmental Trauma Disorder is to capture the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma and thereby guide clinicians to develop and utilize effective interventions and for researchers to study the neurobiology and transmission of chronic interpersonal violence. Whether or not they exhibit symptoms of PTSD, children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems are ill-served by the current diagnostic system, as it frequently leads to no diagnosis, multiple unrelated diagnoses, an emphasis on behavioral control without recognition of interpersonal trauma and lack of safety in the etiology of symptoms, and a lack of attention to ameliorating the developmental disruptions that underlie the symptoms. Most children exhibited posttraumatic sequelae not captured by PTSD: at least 50% had significant disturbances in affect regulation; attention & concentration; negative self-image; impulse control; aggression & risk taking. These findings are in line with the voluminous epidemiological, biological and psychological research on the impact of childhood interpersonal trauma of the past two decades that has studied its effects on tens of thousands of children. Because no other diagnostic options are currently available, these symptoms currently would need to be relegated to a variety of seemingly unrelated co-morbidities, such as bipolar disorder, ADHD, PTSD, conduct disorder, phobic anxiety, reactive attachment disorder and separation anxiety.

Suggesting that an alternative diagnosis was necessary to capture the spectrum of coherent symptoms of children exposed to interpersonal violence and disruptions in caregiving, van der Kolk (2005) proposed the creation of a Developmental Trauma Disorder diagnosis and described the broad domains of impairment and distress that characterize these children and adolescents.

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:
A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
A. 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:
B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization
B. 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)
B. 3. Diminished awareness/dissociation of sensations, emotions and bodily states
B. 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:
C. 1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues
C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking
C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation)
C. 4. Habitual (intentional or automatic) or reactive self-harm
C. 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:
D. 1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation
D. 2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness
D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers
D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other adults
D. 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
D. 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.

(Material adapted from:
Proposal To Include A Developmental Trauma Disorder Diagnosis For Children And Adolescents In Dsm-V, Bessel A. van der Kolk, MD, Robert S. Pynoos, MD, 2009)

At the conference Dr. van der Kolk discussed the complex political process that is involved in changing the DSM. The proposed new diagnosis would create sweeping changes, in that it postulates that early childhood trauma is actually at the root of other diagnosis, such as Borderline Personality Disorder. Many grants, insurance payments, and other funding streams are shaped by the DSM, and such a profound change might threaten many established programs. This change has at the time of the conference been rejected by the DSM committee. It will be fascinating to watch the process and the evolution of our understanding.

I highly recommend this trauma conference, which is held every year in Boston. It is the only conference of the many I attend which so effectively combines science, social issues, advocacy and clinical practice, and brings us the most current thinking in our field.

3 comments:

Arthur Becker-Weidman, PhD said...

Very nice summary of the material. Thanks. It is unfortunate that it appears that the APA will not be including DTD in the new DSM-V nor making any reference to Complex Trauma.

Art Becker-Weidman
www.Center4FamilyDevelop.com

Landon said...

Thank you for the summary. I found it interesting. I am part of an adolescent treatment center in Missouri that focuses on trauma, attachment and mood regulation. www.caloteens.com

-Landon

Patricia Wilcox, LCSW said...

Thanks for your responses. Landon, I'd like to learn more about your place- if you are interested in exchanging more information email me at patw@klingberg.com.