Developmental Trauma: What You Can’t See…

 

What you can’t see, can hurt you.

I'm grateful to Carolyn de Lorenzo for her Bustle post on Complex PTSD (C-PTSD), featured in the July 2 ACEsConnection Daily Digest: What Is Complex PTSD? There Isn’t Nearly Enough Awareness Around This Illness.  She defines it as trauma "experienced over extended periods of time... before the age of 18 without reliable adult support.”

Yet digging further, the root cause of C-PTSD is usually something deeper, "developmental trauma." Developmental trauma isn't only over extended time or before age 18.  It also doesn't begin during the cognitive, "post-verbal" era of life starting at age two or three, when we start to form thoughts, consciously recall events, and have words to describe them.

Developmental trauma occurs between the moment of conception, and before the onset of conscious verbal thought at age two or three. That's actually a very long time for a fetus and an infant. And, it's pre-cognitive, pre-verbal, and can't be recalled.  Yet it floods the in utero brain and body with stress chemicals and at birth, stress on baby and mother makes attachment difficult or impossible.  Traumatic dysregulation of cells harms development of the brain, nervous system, and body itself--from scratch.

Dr. Bessel van der Kolk, MD (above) and leaders in brain science and attachment are calling for a hard look at developmental trauma, and its inclusion in the American Psychiatric Association (APA)'s official Diagnostic and Statistical Manual (DSM). Dr. Allan Schore calls it “trauma in the first 1000 days," conception to age two. 

Developmental Trauma Disorder (DTD) was identified by van der Kolk in 2005, but the psychiatric Powers That Be deny it exists. [FN1]  “Clearly our field would like to ignore social realities,” Dr. van der Kolk says, “and study genes…”

 When I first learned I had developmental trauma, it felt like the trauma began "when the sperm hits the egg." It felt like every cell of my body was out of tune, as I wrote in my recent book, "Don't Try This Alone: The Silent Epidemic of Attachment Disorder," at https://www.amazon.com/dp/1976120128  It occurs as a continual process, not discrete incidents, while a baby has not developed a thinking brain able to recall incidents.  Frequently it occurs before there are any discrete incidents.
  
It used to be called Complex PTSD or "early trauma” in the decades before the brain's development during the "first 1,000 days" was understood. Now that we know more about brain development, we see that most C-PTSD actually begins in utero or before the age of two as developmental trauma.
 
How many children have extended trauma over time when under 18, yet enjoyed a wonderful home while their mother was carrying them or nursing them after birth?  Yes, that could happen if a child were born in nurturing family A, had no trauma until age four, then the parents died, and the child was adopted at four by another family B. which abused it.
 
But that's not the usual situation.  In most adoptions, for example, when a gestating mother is giving up her child, she's lived under huge stress from the moment she learned she was pregnant.  And, as in situations of poverty and racism, when a child suffers trauma after the onset of memory at ages two-three, that child and its mother were usually suffering a terrible environment from before that child's conception.
 

But “no one can see it” usually means “it never happened.”  As I’ve said, “No one beat me or raped me. What’s wrong with me?”  Try getting that treated by a doctor. Yet I was sick as a dog.

Insecure Attachment as the Cause

Allan Schore 2

Neuroscientists Dr. Daniel Siegel, MD, Dr. Bruce Perry MD and others detail how attachment failures cause developmental trauma in this video: www.youtube.com/watch?v=jYyEEMlMMb0 [FN2]

DTD is a “Relational Trauma, trauma in the context of a relationship” as Dr. Allan Schore (left), father of attachment theory in the U.S., identified it in the 1990s. [FN3] Only relational processes can explain DTD, not incidents.

Yet all the American Psychiatric Association (APA) can fathom is Post-Traumatic Stress Disorder (PTSD) — since it’s caused by a visible incident such as war injury or rape. Developmental trauma has no incident. It’s ingrained in brain and visceral tissue, with no obvious “big bang,” so some call it “little ‘t’ trauma,” as opposed to visible PTSD “Big ‘T’ Trauma.”

Insecure attachment and attachment disorder generally are the cause of developmental trauma, not vice versa, Dr. van der Kolk detailed in his May 2005 Psychiatric Annals pdf  noted above and in FN1.  He also emphasized this in his terrific May 10, 2013 speech at Yale: Youtube.com/watch?v=N2NTADxDuhA   Van der Kolk lists DTD’s symptoms as relational and chronic: inability to concentrate or regulate feelings; chronic anger, fear and anxiety; self-loathing; aggression; and self-destructive behavior. [FN4A]

 He’s also shown it’s at the root of borderline personality disorder and bipolar disorder, and  implies it’s at the root of most cases mis-diagnosed as  ADHD/ADD.  Again, see his Yale speech for this: Youtube.com/watch?v=N2NTADxDuhA

Working with the National Center for Child Traumatic Stress Complex Trauma Network (NCTSN), van der Kolk reports that he ran a survey of 40,000 children nationally being treated for multiple traumas. Most of them  “do not meet the criteria for PTSD… (as) the majority of issues are not specific traumas, but issues in their attachment relationships,” he says.

Van der Kolk describes studies by his colleague Dr. Marylene Cloitre, on attachment problems as the cause of DTD.  “Marylene looked at chronic complex trauma symptoms, then she did child attachment interviews, Dr. Mary Main’s interviews, in which I hope all of you have been trained, because they are very very helpful to see what were peoples’ experiences of their childhoods,” he said [referring to the Adult Attachment Interview (AAI)]. [FN4B]

Dr. Cloitre found “that pure PTSD symptoms are a function of specific traumatic incidents, but the other symptoms she identified – affect dysregulation, mood regulation, anger expression, chronic suicidality, self-injury, disturbance in relations with self and others… do not occur in PTSD.  They are rather a function of a disturbed attachment relationship,” van der Kolk repeated.

Yet psychiatry, he says, “is not good at treating attachment difficulties. There is very little treatment” of it.  Innovative somatosensory healing programs at van der Kolk’s Trauma Center in Boston using “theater programs, yoga, martial arts for kids, etc. — to get them inter-personally attuned — are not standard treatment even though we do statistical research and publish it,” he notes.

The Body Keeps the Score

Bessel Book bodykeepsscoreBecause DTD happens before we have a thinking brain, the body is forced to store all the memories as somatic trauma. “There is somatization. The body keeps the score,” he says, the title of his latest book, “this is a somatic experience, and you become a terrified organism. Your immune system changes, your stress hormone system changes and your perception of your body changes.”

PTSD’s existence was hard to get recognized at first, too. It took Dr. van der Kolk and friends a chunk of the 1970s and ’80s to get the government to stop insisting that war trauma didn’t exist. Doctors finally established the diagnosis PTSD by showing that Vietnam vets were re-living discrete terrifying incidents from the past.

But “in fact there was no basis for any opinion about the prevalence” of any childhood trauma, even of childhood sexual abuse, before the 1995-1998 Adverse Childhood Experiences (ACE) Study,  study co-director Dr. Vincent J. Felitti, MD, notes. “That’s because such information is almost completely protected by shame and secrecy, by families, and by individuals.  Doctors also have been inhibited by our own ignorance and major gaps in our training, from asking into certain areas of patient history.”

“We were astonished to find that the percent of the general public who suffer from traumatic experiences in childhood and adolescence is far higher than imagined… Two-thirds (64-67%) of middle class subjects had one or more types of childhood trauma, and 38-42% had two or more types. One in six had an ACE Score of 4 or more; one in nine had an ACE Score of 5 or more.”  In less privileged populations the numbers are far higher.

Similarly, Dr. van der Kolk describes a patient in the 1980s who could not recall if she were sexually abused, yet drew portraits of her family with menacing genitals. “So we went to the textbook — Freedman,  Kaplan, & Sadock’s  ‘Comprehensive Textbook of Psychiatry’ — with which I sat for my board exam in psychiatry.  It said:  ‘Incest is very rare; it happens in 1 out of 1.1 million women.’   At the time there were about 200 million Americans, so I thought, ‘Hmm… About 100 million women, 110 women are incest victims; how come 47 of them are in my office?’/” [FN4 Yale video.]

“The text says it is also very benign,” he went on quoting it: ‘There’s no agreement about the role of father-daughter incest as a source of psychopathology. The act offers an opportunity to test a fantasy whose consequences are found to be gratifying and pleasurable…In many cases it allows for a better adjustment to the external world.  The large majority of them are none the worse for the experience ’. ”  [FN7]

Developmental Trauma: Psychiatrists Still in Denial

Shrink knitting my brainBut even today, until DTD is in the APA’s official Diagnostic and Statistical Manual of Mental Disorders (DSM), most mental health professionals will not diagnose or treat it, and no insurance company will cover it.

So in 2012 Dr. van der Kolk’s NCTSN network submitted data on 200,000 children around the world to the APA to document DTD.  He spoke on DTD before the National Association of State Mental Health Directors, which treats 6.1 million patients a year with a $29 billion budget, and they wrote to the APA urging that DTD be included in the next DSM-5 in 2013.

But the APA refused and in June 2013, issued DSM-5 without mention of developmental trauma. Van der Kolk in his Yale video ridicules the APA for asking only two questions on child trauma in preparing DSM-5: “1. Can we assume life was pretty good growing up? and  2. Was anyone in your family a drug addict or an alcoholic?”

“Clearly our field would like to ignore social realities,” van der Kolk responds, “and study genes or biological functions — because for us to actually find out how the environment shapes the brain, would get us into very difficult situations.”

The APA refusal letter actually made a veiled dig against the Adverse Childhood Experience (ACE) Study and denied that “childhood adverse experiences” are a “substantive” problem – which is outrageous.  Dr. van der Kolk read that letter at Yale in May 2013 and let ’em have it:

APA:  “The consensus was there was just too little evidence to include DTD in the DSM-5. There have not been any published accounts about children with this disorder.”
Dr. vdK aside: “No, because it’s not in the textbooks!”

APA: “The notion that childhood adverse experiences lead to substantive developmental reduction is more clinical intuition than a research-based fact. “
Dr. vdK aside: “We submitted research data on 200,000 children from around the world to substantiate our diagnosis.”

APA: “The statements made cannot be backed up by prospective studies.”
Dr. vdK aside: “Actually, they can.”

Dr. van der Kolk could make a lot more money as a TV comedy star, after dealing with this idiocy for a lifetime. Despite the tragedy, his psychiatrist audience also had a good laugh — the APA is that absurd.

Developmental trauma is the “invisible” part of “the Silent Epidemic of Attachment Disorder.” [FN8]. DTD can happen as a by-product when a mother or her child are beaten or sexually abused – but it also happens on a wide-spread basis with no visible incident.

Perhaps 20-40% of our population goes through life never knowing they even have DTD. That’s why many of them go on to become leaders of industry and government. That’s why Dr. van der Kolk has said that the US Congress is “dissociated,”  or they’d feel the simple human compassion to know that sending youth to war brings back a flood of PTSD suicides.  (To me that means more than 50% of Congress has attachment problems, which is why they made a career of trying to control others. ) [FN9]

A version of this post first appeared at https://attachmentdisorderheal...evelopmental-trauma/

Footnotes

FN1  van der Kolk, Bessel, MD, “Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories,” Psychiatric Annals 35:5, 401-408, May 2005   www.traumacenter.org/products/pdf_files/preprint_dev_trauma_disorder.pdf
This article also details how developmental trauma is attachment-based:  “Early patterns of attachment inform the quality of information processing throughout life [11]. Secure infants learn to trust both what they feel and how they understand the world…. (more),” he reports.
But “When caregivers are emotionally absent, inconsistent, frustrating, violent, intrusive, or neglectful, children are liable to become intolerably distressed and unlikely to develop a sense that the external environment is able to provide relief. Thus, children with insecure attachment patterns have trouble relying on others to help them, while unable to regulate their emotional states by themselves. As a result, they experience excessive anxiety, anger and longings to be taken care of. These feelings may become so extreme as to precipitate dissociate states or self-defeating aggression…”
Dr. van der Kolk has been Medical Director of The Trauma Center in Boston for 30 years (www.traumacenter.org).

FN2  Daniel Siegel, MD, et.al, “Trauma, Brain & Relationship: Helping Children Heal,” www.youtube.com/watch?v=jYyEEMlMMb0
Introductory video on Attachment Disorder and how development of the mind-body system can cause trauma. Copies at www.postinstitute.com/dvds.

FN3  Schore, Allan N., PhD, “Effects of Early Relational Trauma on Right Brain Development, Affect Regulation, & Infant Mental Health,” 2001, www.trauma-pages.com/a/schore-2001b.php

FN4A  van der Kolk, Bessel, MD: Video, Yale University, May 10, 2013, “Childhood Trauma, Affect Regulation, and Borderline Personality Disorder,” http://acesconnection.com/vide...egulation-borderline

FN4B  Cloitre, Marylene, et. al, (NYU Child Study Center, Department of Psychiatry, New York University Medical College,  marylene.cloitre@nyumc.org), “Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories,”   Journal of Traumatic Stress, 2008 Jun;21(3):282-9. doi: 10.1002/jts.20339.  Abstract: Despite the consistent documentation of an association between compromised attachment and clinical disorders, there are few empirical studies exploring factors that may mediate this relationship. This study evaluated the potential roles of emotion regulation and social support expectations in linking adult attachment classification and psychiatric impairment in 109 women with a history of childhood abuse and a variety of diagnosed psychiatric disorders. Path analysis confirmed that insecure attachment was associated with psychiatric impairment through the pathways of poor emotion regulation capacities and diminished expectations of support. Results suggest the relevance of attachment theory in understanding the myriad psychiatric outcomes associated with childhood maltreatment and in particular, the focal roles that emotion regulation and interpersonal expectations may play. http://www.ncbi.nlm.nih.gov/pubmed/18553408

FN5   Vincent J. Felitti, MD;  Robert F. Anda, MD, MS;  “The Lifelong Effects of Adverse Childhood Experiences,” Chapter 10 of Chadwick’s “Child Maltreatment,” Sexual Abuse and Psychological Maltreatment, Encyclopedic Vol 2 of 3, STM Learning, Inc., Saint Louis, p.203-215; March, 2014

FN7  Freedman, Alfred M., Kaplan, Harold I., & Sadock, Benjamin J.,  “Comprehensive Textbook of Psychiatry,” 2nd Edition, Williams and Wilkins Co., Baltimore, 1975; 2609 pages.  Now in 9th edition; known since 4th edition as “Kaplan and Sadock’s.”

FN8  Lanius, Ruth A., MD; Vermetten, Eric; Pain, Claire; Editors, “The Impact of Early Life Trauma on  Health and Disease: The Hidden Epidemic,” Cambridge University Press, 2010. “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician,” American Academy of Pediatrics,  2012 (New York Times 1-7-12), and many more.

FN9  van der Kolk, Bessel, MD, “What Neuroscience Teaches Us About the Treatment of Trauma,” June 6, 2012 webcast, National Institute for the Clinical Application of Behavioral Medicine  (NICABM) : Most of Congress is “dissociated,” van der Kolk told this 2012 globally-televised webcast, or they’d feel the simple human compassion to know that sending youth to war brings back a flood of PTSD suicides. We already knew from Korea and Vietnam that “for every solider that will die on the battlefield, there will be 30 suicides, as is happening right now,” van der Kolk said.  But “society dissociates from the reality of it and then Congress says, ‘Oh, gosh, isn’t that amazing!’  No it’s not amazing, that’s what happens!”
Short promo clip: http://www.nicabm.com/nicabmbl...rvivors-in-the-past/
Link to buy video, mp3 audio, transcripts: http://www.nicabm.com/trauma-2012-new/
On Congress, see also http://www.theatlantic.com/pol...e-of-poverty/371857/

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Brilliant article

Bessel van der Kolk love your work it is life changing. ACEs N.E.A.R Science enabling many to Reconnect the Disconnect. Change the content change the outcome. Much respect for all your doing. 

As a fellow developmental/complex trauma survivor may I thank you for your excellent blog and your heartfelt and encouraging book.



However, from a European/British perspective I think you are being somewhat pessimistic about the recognition of Developmental Trauma. In this part of the world the APA-sponsored DSM does not hold sway. We also take seriously the World Health Organisation’s International Classification of Diseases [ICD]. On 18 June the WHO released Revision 11 of the ICD



http://www.who.int/news-room/d...ication-of-diseases-(icd-11)



It includes a recognition of Complex Trauma which is compatible with Bessel van der Kolk’s Developmental Trauma [indeed van der Kolk often uses the terms inter-changeably]. It has already started to enter public discourse in the UK – most recently by Dr Bryony Farrant, Chief Psychologist to the state-sponsored Independent Inquiry into Child Sexual Abuse in an interview on the BBC [25 May 2018]. She agreed strongly that official recognition of Complex Trauma would be helpful not only to patients but also to General Practitioners and psychological professionals, and that both treatment and wider support was needed. Some limited treatment is now available on our National Health Service. There is still a long way to go here but we are making some progress.



All power to your campaigning work.



Simon Partridge, Complex Trauma Survivor and Activist

      I'm wondering if this may be a relevant factor in the APA's decision not to support Dr. van der Kolk, et al.'s 2005 proposed diagnostic construct... (although I recently learned that 'Co-Dependency' is now a "Contested Construct" in the UK).       

     During a 'medical malpractice' investigation I worked on in the 1980's, I learned that Psychiatry and Neurology used to be a 'joint sub-specialty' of medicine, until about 1972. Why did these two sub-specialties 'separate' ? 

     If we look back even further, to the time of the Flexner Report, which I've been lead to believe, recommended the German [male-only] model of Medical Education-for the United States, might we have forfeited 'Half the Wisdom of Humankind'... ? ? ?                                                                                                                     My great-grandmother reportedly fled the 'Purge on Midwives' in Mecklenberg Germany in the late 1860's, and came to the US, and continued to 'practice Midwifery'. Later that included a time when 95% of the babies delivered in the United States were delivered by midwives, just about the time the Flexner Report was issued. Fortunately, during one of my undergrad courses, we had to read Barbara Ehrenreich's book: "Witches, Midwives, and Nurses: A History of Women Healers", but it didn't have all the answers to some of my questions. Might Swiss Psychologist Alice Miller have 'stumbled upon' a relevant factor in her book noting the "Parenting Manuals" in use in Germany, when Adolf Hitler was a child ? ? ?     

Does the forthcoming ICD-11 have diagnostic constructs, that address this issue ? ? ?                                                                                                                               

Thank you for this post and your book.  You are right on!

In the case of my CASA youth, who had trauma non stop from 0-12, Neurofeedback was a HUGE help to being able to re-regulate herself.   

Having read Bessel Van der Kolk's work, I also connected her with therapeutic riding and we played a lot of tennis and ping pong (gross motor/ synchronization/ rhythmicity).  But the NF (Neuroptimal) was key as it "talks" to the R brain where the early trauma is stored, lost to conscious memory.

If your own mother can't "relate" to you, how do you learn to relate?  You don't.  You learn to cope.  If you can't practice instinctive "serve & return" w your parent, it is deeply shaming because babies are primed and ready for this, and need it to be well regulated.

Carey S. Sipp (ACEsConnection Staff) posted:

Kathy Brous -

Thank you for this, and for your breakthrough book,"Don't Try This Alone: The Silent Epidemic of Attachment Disorder," at https://www.amazon.com/dp/1976120128  I highly recommend your book. It is an amazing resource.

Also, thank you for putting yourself our there in the world, increasing the likelihood that this story won't be ignored. It is important, powerful, vital, life-changing. It needs to be a wake-up call to the world to be more conscious about procreation, the environment in which pregnant women are living, the homelife of preverbal children and their parents. 

It is no "accident", in my mind, that your post is followed by a post from Robyn Brickell, PhD, in which she asks the seminal question, "Is it ADD or is it Trauma?"  https://www.acesconnection.com...adhd-or-is-it-trauma

There is a lot here, in both your post and Dr. Brickell's. Developmental Trauma, ADD, the self-destructive behaviors that result from developmental trauma, how people can use our wonderful mammalian brains to re-regulate -- l look forward to learning and perhaps sharing more on these topics.

C.

Hi Carey.

Thank you for bringing my attention to Kathy's work!  I look forward to reading it!

I am so happy to hear that my work resonates for you, as well.

One quick correction - I am not a PhD... I am an LMFT (Licensed Marriage and Family Therapist), just want to be sure all of the facts are clear.

Thank you again for your support of ACEs and the impact on life going forward.

Have a great day!

Robyn

Kathy Brous -

Thank you for this, and for your breakthrough book,"Don't Try This Alone: The Silent Epidemic of Attachment Disorder," at https://www.amazon.com/dp/1976120128  I highly recommend your book. It is an amazing resource.

Also, thank you for putting yourself our there in the world, increasing the likelihood that this story won't be ignored. It is important, powerful, vital, life-changing. It needs to be a wake-up call to the world to be more conscious about procreation, the environment in which pregnant women are living, the homelife of preverbal children and their parents. 

It is no "accident", in my mind, that your post is followed by a post from Robyn Brickel, M.A., LMFT, in which she asks the seminal question, "Is it ADD or is it Trauma?"  https://www.acesconnection.com...adhd-or-is-it-trauma

There is a lot here, in both your post and Robyn Brickel’s. Developmental Trauma, ADD, the self-destructive behaviors that result from developmental trauma, how people can use our wonderful mammalian brains to re-regulate -- l look forward to learning and perhaps sharing more on these topics.

C.

Kathy Brous, THANK YOU so much for this post. It certainly enhances my [limited]  understanding of the O'Shay/Paulsen EMDR protocols for trauma that occurred from conception through 3..-when we begin to "verbally integrate memory". Thank You again. Perhaps Dr. van der Kolk's cited comment relates a factor in why the USA is the only 'Non-Signatory Nation' [on earth] to the UN Convention on Children's Rights (and thank you for the Citations at the end of the article). Best Regards !

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