Renewing the Battle

In 2001, the Cummings Foundation convened a group of child psychiatrists, public policy experts, and representatives from the Department of Justice, Department of Health and Human Services, and Congressional staff to consider the deplorable state of services to traumatized children, a service sector that consumes billions of taxpayer dollars with very little to show for it. Led by Senator Edward Kennedy's office, this initiative led to the establishment of the Congressionally mandated National Child Traumatic Stress Network (NCTSN), which, during the past nine years, has welded together 53 clinics and academic institutions nationwide to develop and implement effective interventions for traumatized children and adolescents. Soon, the researchers and clinicians working in the NCTSN ran into the same problems Herman, van der Kolk, and their numerous colleagues had confronted a decade earlier: while children can develop plain PTSD symptoms as a result of a single traumatic incident, the children who'd sustained prolonged abuse, neglect, and violence—the vast majority of children treated in the NCTSN—suffered from something that went beyond PTSD.

These very troubled children with histories of abuse weren't easily pigeonholed into any other existing diagnoses: the standard treatment system wasn't working—it just didn't fit the circumstances of abused children, any more than it had worked for adults with histories of chronic childhood abuse. These children often collected impressive diagnostic records—four, five, six, and more different diagnoses before they reached their teens; the more traumatic stressors, the larger the number of diagnoses. As a result, they received treatments geared to one or another diagnosis, like bipolar disease or conduct disorder—consisting of medications, behavioral modification, exposure therapy—that often didn't work, or even caused more damage.

Alicia Lieberman, director of the Child Trauma Research Project at San Francisco General Hospital, remembers one 18-month-old referred to her during the mid-'80s by a child care center because he was so hard to manage. He regularly ran away, bit and pushed other children, refused to take naps, and often sat in a corner crying and rocking. The last straw came when he threw a chair through the window, bit the teacher who tried to restrain him, and then ran away. In addition, Lieberman soon discovered, he woke up at night screaming, cried for his mother in daycare, and alternated between being sad and despairing or angry and defiant.

In Lieberman's office, the boy clung fearfully to his mother's jacket, unwilling to leave her side, to which his mother responded harshly, "ÔStop manipulating me. You're just pretending to be shy!'" Asked about her son's extreme nail-biting—Lieberman could see he bit his nails to the quick—the mother said brusquely, "He just does that to bug me." He was frightened by any loud noise. When a bell rang outside the office, Lieberman had to take him outside to see that it was only a bell to calm him down.

There were obvious attachment problems, Lieberman said—the mother rejected the child and attributed malicious motives to his behavior. When asked about her own background, the mother revealed that she'd had a lifelong history of childhood abuse and chaotic, unstable relationships as an adult. She'd become pregnant with her son when her boyfriend raped her at gunpoint. He then abandoned her when she told him she was pregnant. Now she was convinced that the boy was the father's genetic double—a small version of her rapist. The boy had witnessed a lot of domestic violence between his mother and a succession of partners. His bruises made it clear that he was being knocked around, and he certainly was being emotionally maltreated.

"This boy started me thinking about the whole problem of comorbidity with trauma," Lieberman said. "He could meet the criteria for depression, anxiety, oppositional defiant disorder, and PTSD. But if we only picked one of the disorders, we wouldn't be alert to the wide range of symptoms—we wouldn't be seeing the whole child. This case made me think that we needed to move beyond single diagnoses to something that could encompass different domains at once."

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Joel4th  - Whole-Hearted Agreement -From a patient's view   |Registered |2010-09-05 22:45:20 I am not a Psychiatrist or Psychologist, but a 46 year old that has recently become disabled by the long-term result of Child-hood Trauma from a Vietnam Veteran Father who abused my sisters and abandoned myself and my brothers. Also, complicating the dysfunction was the Army's Protection of the Abuser and the furious pace of constantly moving. Begining in my 30's My Mental Health was brought to a breaking point as a result of "Work-Place Bullying" so prevalent in Civil Engineering. Eventually PTSD like symptoms and Panic attacks completely disabled me 2 years ago. Obtaining a Diagnosis was nearly imposible because I have Multiple Problems and Doctors would not put anything in writing to support my case. An MHMR Psychologist diagnosed me as having "P.D.D. or A.S.D., but I belive your Diagnosis fits better. - I recommend specific study of Children in Military Families,who are Moved too often. jfreess   |2010-06-29 13:16:26 Very good article, well-written and thought-provoking.

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