PEDIATRICS

Understanding Developmental Trauma

Its lifelong impact on health

BY NORM THIBAULT, PHD, LMFT

There is a very small window in the early life of humans to learn to trust the world around us. The process of bonding to caregivers – attachment - is our most important task during this time, and one that will have a resonating impact throughout our life. The sensitive period for attachment, when our brains are most malleable, begins in pregnancy and continues up to about 24 months post-birth. Prenatally, epigenetic research is helping us understand how the environment of the birth mother and experiences of the birth father can shape the way that genes are expressed later in life. During this time of development, significant events happen neurologically as sensory, language and higher cognitive function pathways are formed in the brain.

At the outset of life, infants have one significant survival task: to determine if the world is safe or dangerous. When the world is safe, infants will strive towards social engagement. When the world is unsafe they will be defensive in nature and learn to not trust their environment, nor those around them. These two systems, social engagement and social defense, are impacted by the caregiving the infant receives. When caregiving is appropriate, responsive, and timely, the infant learns to trust and becomes more willing to socially engage. Significant research posits that “early experiences with sensitive, nurturing caregivers promotes a pattern of brain development supportive of emotional resilience, empathy and cognitive flexibility.” When caregiving is lacking, misinterpreted or abusive, the infant’s social defensive system will engage in an effort to protect and survive, thus showing up as hypervigilance, being slow to trust and quick to become defensive.

Ultimately, children develop neurologically in the context of relationships, yet most trauma begins at home – the vast majority of people responsible for child maltreatment are the children’s own parents. We know what happens when children are programmed to explore their world in a healthy environment. When a toddler strays away from a caregiver and then becomes frightened or hurt, it returns to the caregiver for safety, comfort and reassurance. But, what if the caregiver is the one who is frightening or harmful? Who or where does a toddler turn to for safety or comfort?

When caregivers are not in tune with the needs of their child or when they are abusive to their children, it may create a situation wherein the children involved become distressed. This type of anxiety can reach a point that a child loses trust in the ability of others to care for them or to provide relief. These children cannot regulate their own emotional states, and consequently learn that they cannot depend on others to assist them when in emotional distress.

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Neurologically speaking, the amygdala seeks to protect us from harm. In children who have experienced caregiver abuse or neglect, it is typically overactive. The neural substrate between the amygdala and the lower prefrontal cortex is not engaged in a way that inhibits reactivity or impulsivity. Therefore, children respond to situations in ways that are interpreted as anti-social or inattentive; they demonstrate significant levels of anxiety or anger, which typically lead to unhealthy or socially inappropriate responses. There is no space to learn or apply experience because they transition so quickly from stimulus to response. Oftentimes these children are then given pejorative labels, such as “Oppositionaldefiant” or “Conduct-disordered.” Simultaneously, they are frequently diagnosed with Attention-Deficit Hyperactivity Disorder, when in fact, they are simply demonstrating hypervigilance in order to stay safe, as dictated by their amygdala.

This dichotomy between caregivers as “guardians” and as “abusers” creates a confusing predicament for the child in regard to caregiver loyalty. This may ultimately manifest itself as behaviors designed to keep the child safe, and at the same time, keep the family intact. Ironically, a child cannot remove itself from a home in order to protect itself, and it typically does not want to see its family separated, either. When these children are then compared to normative standards of behavior, they fall short and their coping mechanisms are often misinterpreted by professionals in a deleterious way.

This lack of an appropriate interpretation is of significant concern because vital concepts around chronic interpersonal trauma are not taught to mental health students in most graduate schools. A 2013 study on enhancing adoptioncompetence among mental health professionals determined that less than 25% of adoptive families found that their mental health professional was adoption-competent. Further, some reported that experiences with clinicians who were uneducated in these important concepts actually damaged their families. Most important among these findings is that treatment without an appropriate diagnosis ultimately leads to an incorrect or incomplete diagnosis, and thus, an incorrect or incomplete treatment plan.

Development trauma disorder

In 2009, Bessel van der Kolk, MD, and Robert S. Pynoos, MD, submitted a paper to the American Psychiatric Association which introduced a new diagnosis by addressing “the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma.” Their hope was that this new diagnosis – Developmental Trauma Disorder (DTD) - would be incorporated in the DSM-V.

Diagnoses in the DSM-IV were far from perfect in diagnosing children who have problems resulting from child abuse, neglect, death of loved ones or traumatic medical experiences. Most of the common disorders used in the DSM-IV to identify symptoms associated with interpersonal trauma fail to adequately conceptualize the impact of development in the context of ongoing danger, maltreatment, and inadequate caregiving systems. For example: • Reactive Attachment Disorder (RAD) is limited to early childhood and occurs in the context of “pathogenic care.” However, many children adopted at birth have symptoms of RAD yet have never struggled with pathogenic care. • PTSD, which began as “Battle Fatigue” in World War I, captures the fearfulness, worry and avoidance involved with trauma, but not the emotional liability and disorganized attachment beliefs of DTD. • Oppositional Defiant Disorder and Conduct Disorder involve anger, distrust and conflict, but don’t address guilt, shame, anxiety, dissociation and depressed mood seen in DTD.

Drs. van der Kolk and Pynoos’ efforts were ultimately rejected by the American Psychiatric Association for inclusion in the DSM-V. This was a missed opportunity. The vast majority of people responsible for child maltreatment are the children’s own parents. Understanding Developmental Trauma to page 264

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One of the major concerns about diagnosing and treating developmental trauma involves its contrast with traditional, behavioral methods of parenting and treatment. Many parents, teachers and providers utilize behavioral means, which are based on principles of loss. When the child makes a mistake, they lose something, such as a privilege or activity. When they do well, they gain privileges or rewards. Behavioral methods typically do not work with children who have suffered developmental trauma, because losing something only serves to reinforce that authority figures cannot be trusted. If a teacher or practitioner is focused on behavioral compliance in the home or classroom, the child (who cannot regulate its emotional state), is destined to failure because such compliance is contrary to their instinct to social defensiveness and ultimate safety. Children who have suffered developmental trauma are at a significant disadvantage when compared to peers, because the very behaviors that they have incorporated to stay safe and survive are considered anti-social and rebellious in nature. This shows up in social, educational and clinical environments where the child is punished and shamed for trying to cope in the only way it knows. Making matters more difficult is the proclivity to prescribe medications to inhibit these behaviors. With neurological damage comes a need for neurological healing, which involves dampening the defensive amygdala and healing the social engagement system. This happens primarily through safe and trusting relationships, not medication. The most reliable healing mechanism we know of is engagement with people we can trust and attach with.

Dr. Stephen Porge’s seminal research on Polyvagal Theory provides an excellent lens to view the importance of safety in relationships in regard to healing. According to Dr. Porges, social behaviors are neural exercises that promote neurophysiological states supporting mental and physical health. Trauma and abuse lower the threshold to trigger defensive behaviors that

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