Developmental Trauma is a political issue that has caused controversy among professionals, particularly those revising the 2013 Diagnostic & Statistical Manual. The Long Shadow of Trauma, a lead article in the March/April 2010 issue of Psychotherapy Networker (www.spychotherapynetworker.org) chronicles the politicization of developmental trauma as a diagnosis. Mary Sykes Wylie, the senior editor of the magazine, describes in great detail the focused efforts of many professionals to get Developmental Trauma Disorder included in the revised DSM V (Diagnostic Statistical Manual of the American Psychiatric Association).
Developmental Trauma & Politics
(DSM) is the “professional Bible” published by American Psychiatric Association. Mental health professions use this manual to diagnose clients so that they can get reimbursed for treating their patients.
In the article, Wylie talks about the challenges of including trauma diagnoses in the DSM. She describes how it took a motley crew of Vietnam vets, anti-war activists group groups and some sympathetic psychiatrists to finally get the post-traumatic stress diagnosis (PTSD) included in the DSM III.
When the work began for the DSM IV R 2000 revision, traumatologist Bessel van der Kolk and the PYSD Committee attempted to expand the definition of PTSD. They wanted to include a new diagnosis, DESNOS, which involves experiences of extreme stress, not otherwise specified. While the committee voted 19 to 2 to approve the DESNOS diagnosis, somewhere up the line it was taken out. This was the first indication that trauma was being politicized.
When the revisions began for the new DSM V, van der Kolk and his colleagues again led the charge. This time they sought to include Developmental Trauma Disorder as a diagnostic category. van der Kolk and his colleagues organized a task force complex trauma to conduct research and collect research that could help make their case.
Most all of van der Kolk’s team specialized in working with traumatized children. Their research showed that less than 25% of kids exposed to multiple and/or prolonged interpersonal trauma actually met the criteria for PTSD. Even though these kids have serious problems regulating their emotions, suffer from dissociation, aggression, impulse control and poor self-image, according to van der Kolk, But they dont have PTSD. Other research showed that emotional abuse and neglect connected to the absence, failure or distortion of the child’s primary relationship, mostly with the mother, was just as much or more harmful than actual physical abuse.
In 2005 van der Kolk’s task force began a concerted effort to get the new diagnosis, Developmental Trauma Disorder, included in the DSM V. In early 2009, his task force submitted a formal request to the DSM Trauma, PTSD, and Dissociative Disorder Sub-Work Group to develop specific diagnostic criteria from DTD. To support their request, van der Kolk’s task force presented data from over 130 clinical research The Work-Group was overwhelmed and then told van der Kolk that it was the wrong data and sent his team to work on collecting and presenting even more data. According to van der Kolk this was the most documentation ever provided in support of any other psychiatric diagnosis.
Again the overall subcommittee chair wrote van der Kolk and his colleagues the following, the consensus is that it is unlikely that DTD can be included in the main part of the DSM V in its present form because of the current lack of evidence in support of the diagnosis. They did not dispute the evidence but saw it a irrelevant, and saw it as more clinical intuition than a research-based fact.
The Political Outcome
The DSM subgroup confirmed their bias by stating that the range of symptoms covered in the proposed criteria was too broad. It was so broad that it would supersede not only PTSD, it would supersede ALL internalizing and externalizing disorders that appeared following interpersonal trauma and poor rearing. They reasoned that any early any problem that followed childhood mistreatment would have to receive this new diagnosis.
The DSM subgroup feared that this “new kid on the block” would dramatically upset their apple cart. It would make them rethink all diagnoses that they are accustomed to using in their clinical practice. And worse case scenario, the Developmental Trauma Disorder even replace ALL of the diagnoses they typically give clients.
Well, we couldn’t agree more! On pages 2-3 of the Introduction to our Healing Developmental Trauma (2010) book, we state, “Using our expanded definition of shock, trauma and stress, much of the Diagnostic and Statistic Manual (DSM) of the American Psychiatric Association might be viewed as a handbook describing disorders that are caused by the impact of developmental shock, trauma and stress on the human Mind-body.”
The Political Struggle Between Clinicians & University Researchers
Our understanding of the research on developmental shock, trauma and stress has moved us far beyond where the entrenched mainstream of psychology and psychiatry currently resides. The end result is a professional struggle between two groups: 1) the clinical practitioners and 2) shapers of the DSM who are mostly university researchers. It is important to acknowledge that the researchers use prepackaged responses to their rating scales rather than the clinical encounters to reach their conclusions. The criticism is that these research findings do not lead to better diagnoses by the clinician in the trenches.
The heart of the rejection, according to van der Kolk lies in political realities. He said, The most likely explanation: academic laboratories are funded to
study particular disordersIf you say that your disorder is part of a larger picture, which includes elements from several other diagnoses, then youd have
to rearrange your lab, your concepts, your funding, and your rating scales-and you also have to confront the fact that if children are terrified and abandoned by caregivers, this will affect their brains, minds, and behavior. This seems too much to ask.
The tragedy of this position by the members of the DSM sub committee is that while these professionals were not willing to risk sacrificing their reputations or their positions, they were willing to sacrifice the over one million children who are confirmed to be abused and neglected each year plus the countless millions of adults who cannot be treated for their disorder. Unrecognized and untreated developmental trauma from prolonged acute and subtle child abuse and neglect costs the U. S. over $107 billion a year, a very conservative estimate. This makes it the largest under-treated public health problem in this country.
Van der Kolk believes it will take a massive public crusade against child maltreatment to alter the political realities that are blocking change. He added, We need someone important in public life to have the courage to stand up and take a very visible stand on something like this it has a huge impact on science and society. He adds, We dont seem ready to acknowledge that the greatest danger to our women and children isnt Al-Qaeda, but the people who are supposed to love and take care of them.
Clinicians & Practitioners Continue to Advocate for the Rights of Children
Our book, Healing Developmental Trauma, may not help clinicians get paid for treating developmental, shock, trauma or stress. We do hope it will provide beginning and experienced clinicians and social workers learn better ways to recognize the symptoms of each of these new diagnostic categories and learn effective ways to intervene in the lives of their clients and patients.
We believe our book represents a paradigm shift in our understanding of developmental shock, trauma and stress and will at some later time be part of the force for change in the way we help people heal the long term effects of these developmental disorders.