Trauma-Related Disorders

All children have to be deceived if they are to grow up without trauma.

—Kazuo Ishiguro

Clinical Description

Many children grow up with the scars of physical or sexual abuse, domestic violence, or other traumas. Natural disasters, war, and serious illness with painful procedures are other sources of trauma. It is impossible to grow up without some bad things happening. However, for some children, the horrors they have had to endure have left serious emotional scars.

Posttraumatic stress disorder (PTSD) is an emotional disorder that occurs following an overwhelming and frightening event that threatened serious bodily harm. It results in a re-experiencing of the traumatic event and avoidance of situations that activate traumatic memories. In infants and young children, neglect or maltreatment may result in emotional consequences as well (Table 19.1). Reactive attachment disorder (RAD) is characterized by disturbed and distrusting social relatedness caused by grossly pathogenic care. This disorder results in the child displaying severe inhibition and hypervigilance in social interactions (inhibited type) or
indiscriminate attachment and familiarity with any adult who is nice to them (disinhibited type). Children who are traumatized often are quite reactive and stress sensitive, tend to perceive the world as a dangerous place, and tend to interpret other people’s behavior as menacing or aggressive.

Table 19.1. DSM-IV-TR Criteria for Posttraumatic Stress Disorder

Trauma exposure	The child has been exposed to an event that involved threatened death or serious injury to him/herself or others. The child’s response to the trauma was expressed by disorganized or agitated behavior (or intense fear, helplessness, and horror).
Trauma re-experience (1 or more)	Repetitive play of trauma themes in young children. Recurrent intrusive distressing recollections of the event (images, thoughts, or perceptions) for others. Frightening dreams or recurrent dreams of the event. Trauma-specific reenactment in young children. Acting or feeling like the traumatic event was recurring, e.g., flashbacks. Intense psychological distress or physiological reactivity on exposure to something that resembles the traumatic event.
Trauma avoidance (3 or more)	Efforts to avoid thoughts, feelings, activities that prompt recollection of the trauma. Inability to recall aspects of the trauma. Diminished interest or feelings of detachment. Restricted range of affect. Sense of foreshortened future.
Increased arousal (2 or more)	Difficulty falling or staying asleep. Irritability or outbursts of anger. Difficulty concentrating. Hypervigilance and/or exaggerated startle response.
Adapted from American Psychiatric Association (2000), Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text revision. Washington, DC. American Psychiatric Association.

Clinical Vignette

Sylvia is a 5-year-old girl who was adopted from an orphanage in Europe at the age of 3. Her biological parents were both substance abusers, and Sylvia had lived on the streets with them, exposed to neglect and unknown traumas, until she was 2, at which time she arrived at the orphanage, poorly nourished and “famished.” Sylvia quickly made friends at the orphanage, calling all of the women who worked there “Mama.” When she was adopted by parents from the United States, she called her new mother “Mama” right away and seemed to attach immediately. Sylvia has been well cared for by her parents and has been in very good day-care when her parents are at work. Difficulties with severe temper tantrums when she does not get her way prompted the day-care provider to suggest referral. When you meet her, Sylvia is a beautiful, blue-eyed girl who immediately takes your hand to walk to your office. She is chatty and has mild articulation errors, but otherwise seems to be developing well. You play together, and she directs the action of dolls in the dollhouse repeatedly being attacked by “burglars”. When it gets time for her to leave your office and the toys with which you have been playing, she begins to pout, cry, and refuse to go with her mother. You are concerned about Sylvia’s trauma history and her symptoms of RAD, disinhibited type.

Epidemiology

Trauma is a common occurrence in our communities. The National Center on Child Abuse and Neglect reported in 2000 that over 3 million children per year are referred to child protective services for abuse or serious neglect. One-third of these cases are substantiated and half of these (over half a million) are so severe that the children are removed from their homes. Community violence, domestic violence, natural disasters, accidents, and other events may be so severe as to leave permanent scars on the child’s developing personality. In inner cities, children may be exposed to shootings or stabbings (up to 40% according to Schwab-Stone). September 11th was a national trauma, which affected children in the vicinity much more intensely.

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