Instead, these children showed pervasive, complex, often extreme, and sometimes contradictory patterns of emotional and physiological dysregulation. Their moods and feelings could be all over the place—rage, aggressiveness, deep sadness, fear, withdrawal, detachment and flatness, and dissociation—and when upset, they could neither calm themselves down nor describe what they were feeling. To soothe themselves, they'd engage in chronic masturbation, rocking, or self-harming activities (biting, cutting, burning, and hitting themselves, pulling their hair out, picking at their skin until it bled). They often had physical problems—sleep disturbances, headaches, bad digestion, unexplained pain, oversensitivity to touch or sound—as well as difficulties with language processing and fine-motor coordination. They were clingy and dependent, even with the person who abused them. They often loathed themselves, felt defective and worthless, and distrusted other people. Not surprisingly, they couldn't concentrate, performed poorly in school, and made few, if any, friends. "These kids have serious problems with affect regulation, dissociation, attention, concentration, risk-taking, aggression, impulse control, and self- image—they hate themselves," says van der Kolk. "But they don't have PTSD."

Studying a similar group of young adults at New York University, researcher Marylene Cloitre found that emotional abuse and neglect—the absence, failure, or distortion of the child's relationship to a primary caregiver—did as much, if not more, damage than actual physical abuse. "The severity of a particular trauma—assault, accident, whatever—determined PTSD symptoms," van der Kolk says, "but the child's relationship to the abuser determined everything else—anger, suicidality, self-injury, disturbed relationships, tendency to be revictimized." At the heart of emotional abuse or neglect is a failure of parental attachment and attunement, not to mention overt hostility, worse in its way then physical abuse because it does such a number on the developing brain and nervous system of a child. "You need presence, you need mirroring, you need someone out there who knows what you see, so you can know what you know, and speak what you speak," says van der Kolk, before quoting attachment pioneer, John Bowlby: "ÔWhat cannot be communicated to the mother by the child cannot be communicated to the self of the child.'" If a child doesn't get this sense of "presence" from a trusted adult, she can't connect with her own felt inner experience and, ultimately, can't develop a sense of her own authentic self.

Van der Kolk illustrates the lesson with the example of an alcoholic father beating a child, who later says to his mother, "Daddy hit me. I hope that he'll just go away and never come home again." The mother, afraid to leave her husband or even rock the domestic boat, simply denies what happened—"No, no, Daddy really loves you a lot—he's just had a bad day and is tired." In such a situation, particularly if there are lots of such situations, "You lose the capacity for internal representation of what really happened, for finding words that represent your felt, physical experience. Your capacity to feel your inner realness is impaired." Such children are left with a bone-deep sense that "something is very wrong with the way I am." It's this damage done to a chronically abused child's budding sense of personal identity and coherent selfhood that particularly distinguished this "trauma syndrome" from garden-variety PTSD.

In 2005, the complex trauma task force, chaired by van der Kolk, began working in earnest on constructing a new diagnosis, called Developmental Trauma Disorder (DTD), which, they hoped, would capture the multifaceted reality experienced by chronically abused children and adolescents—a kind of "DESNOS, Jr.," only with more emphasis on developmental and attachment issues. Finally, in January 2009, they submitted to the DSM Trauma, PTSD, and Dissociative Disorders Sub-Work Group, an elaborate criteria set (DSM-speak for symptom list) for DTD: exposure to prolonged trauma, causing pervasive impairments of psychobiological dysregulation (of emotions and bodily functions, of awareness and sensations, of attention and behavior, of their sense of self and their relationships), as well as at least two symptoms of standard PTSD, and multiple functional impairments (with school, family, peer group, the law, health, and jobs or job training). They also requested support for a field trial to develop accurate assessment tools, test the criteria, and address still-unanswered questions. With their proposal, they included supporting evidence from 130 research papers representing 100,000 children.

According to van der Kolk, the DSM committee responded that the complex trauma task force had "inundated" them with too much data, but not the right kind: they needed to submitother kinds of data concerning 17 issues, including possible genetic transmission, environmental risk factors, temperamental antecedents, bio-markers, familial patterns, treatment response, and so on—almost none of which, van der Kolk notes, is known about any currently existing psychiatric diagnosis. After a two-week, night-and-day, largely sleepless extravaganza of work, spearheaded by Wendy d'Andrea, a post-doctoral student at the Trauma Center, the NCTSN task force resubmitted the proposal, with an even bigger barrage of supporting materials, including combined data on 20,000 traumatized children gathered from various sources—among them, 4,500 children from the NCTSN, 7,000 from the Illinois child welfare system, and almost 2,000 collected by Julian Ford from a juvenile justice center. Participating Chicago NCTSN director Bradley Stolbach did the preliminary analysis, which convincingly showed that kids suffering from long-term trauma are indeed different from those suffering single-incidence trauma. In addition to the data on these 20,000 children, they analyzed and submitted more than 300 research articles. They also enclosed a joint letter from the National Association of State Mental Health Directors, representing 53 states, urging DSM to adopt the new diagnosis. Says van der Kolk, "I'd guess that we gave DSM more documentation supporting DTD than ever before provided for any other psychiatric diagnosis."

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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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