Leaving RAD Behind

By: Nichole Noonan on October 4, 2018

Almost half of the nation’s children have experienced at least one or more types of serious childhood trauma, according to the National Survey of Children’s Health. For some children, the trauma happens during critical developmental stages and is so prevalent that it physically changes their brain structure, inhibits their ability to attach and develop relationships and stunts their developmental growth past toddlerhood.

The effects of early childhood trauma impact us all as a society. Some traumatized children, when not appropriately treated, are at high-risk for incarceration, psychological impairment and economic non-productivity into adulthood. “If we want to remedy societal problems—gangs, suicide, and the like—we need to understand from where these issues stem,” said Robert W. McBride, LCSW. “At their core, such people often suffer from the effects of early trauma and lack of attachment.”

Few people know about the serious impacts of childhood trauma. And even fewer know what to do about it.

Without effective early intervention, the cycle of childhood trauma will continue to persist for generations. We believe we can help to end that cycle at the Institute for Attachment and Child Development (IACD). As we continue to push ahead toward that mission, we are leaving the diagnosis of reactive attachment disorder (RAD) behind in recognition of the true root of the effects of childhood trauma.

Few people know about the serious impacts of childhood trauma. And even fewer know what to do about it.

We will continue to provide children and their families with the same family-based treatment model that has transformed the lives of children for nearly 40 years. From now on, however, the organization will call and diagnose the problem what it is and what we’ve been treating all along. In our IACD Executive Director Forrest Lien’s presentation at the Mayo Clinic 31st Annual Social Work Symposium on September 12, he presented developmental trauma disorder (DTD) as the appropriate diagnosis of the disorder we treat.

IACD Executive Director Forrest Lien’s presentation at the Mayo Clinic 31st Annual Social Work Symposium, he presented developmental trauma disorder (DTD) as the appropriate diagnosis of the disorder we treat.

Why a diagnosis makes a difference

To begin to fix a problem, one must first understand it. Our society lacks greater awareness and effective treatment for childhood trauma due to lack of understanding. This is primarily because the root and effects of childhood trauma have not been appropriately defined—at least, not officially.

“If you are unable to understand the cause of a problem, it is impossible to solve it.” – Naoto Kan

The current diagnosis most commonly used to identify the effects of early childhood trauma in the Diagnostic and Statistical Manual of Mental Disorders (DSM V)—the resource used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders—is RAD. RAD does not adequately describe the origin of the problem, however. Children who experienced early trauma often go misdiagnosed and without effective early intervention as a result.

Thankfully, we are one step closer to awareness in this country due to the diligence and research of Dr. Bessel van der Kolk, a highly regarded psychiatrist and researcher in the field of trauma, and his colleagues. In 2005, the psychiatry journal Annals of Clinical Psychiatry published van der Kolk’s article “Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories”. Van der Kolk and his colleagues proposed the addition of DTD to the The Diagnostic and Statistical Manual of Mental Disorders (DSM V) in 2009. Unfortunately, the diagnosis was not accepted. 

The simple word “development” is the most pivotal difference between the diagnoses of RAD and DTD. The definition of RAD does not explain how childhood trauma impacts development and, therefore, does not grasp the full complexity of the disorder or explain thorough symptoms. Many clinicians do not know how to properly assess or treat the effects of childhood trauma as a result. “Most clinicians are taught in graduate school about healthy child development and attachment,” said Institute for Attachment and Child Development Executive Director Forrest Lien. “But they’re not taught interventions to deal with early childhood trauma.”

Adults often mistake a child’s DTD for a “normal” developmental stage and presume that the child will outgrow it. Clinicians often diagnose traumatized children with attention-deficit disorder, bipolar disorder, oppositional defiant disorders and other more commonly known diagnoses. A child’s DTD often goes misdiagnosed and mistreated.

Many clinicians and foster and adoptive parents extremely familiar with traumatized children deem DTD the accurate diagnosis, despite its rejection into the DSM V. Bremness and Polzin noted (2014), “If we are still to use DSM V, we might go as far to say that if the Editors of DSM V wanted only one trauma diagnosis, then arguably it should have been developmental trauma disorder” (para. 3). Likewise, the Institute for Attachment and Child Development no longer waits for the inclusion of DTD into the next DSM revision in order to properly acknowledge it.

Toward a better understanding of childhood trauma 

A child who experiences pervasive trauma during his or her early development is at high-risk to live perpetually trapped in a fear-based survival mode of flight, fight or freeze, similar to those with post-traumatic stress disorder. Because the child did not have the opportunity to complete their early development in a healthy way, he or she can also remain cognitively “stuck” in their toddler years. The combination results in a child who lives in constant fear, is easily triggered based on his or her trauma, attempts to maintain complete control of his or her environment to feel safe, has the developmental mindset of a much younger child and distrusts nurturing caretakers. This is developmental trauma disorder.

“Most clinicians are taught in graduate school about healthy child development and attachment,” said Institute for Attachment and Child Development Executive Director Forrest Lien. “But they’re not taught what happens when that process is disrupted by trauma.”

Without effective and early intervention, the child’s maladaptive survival behaviors only becomes more sophisticated. The hurting child grows into a hurting adult. The adult version of DTD is often an adult personality disorder. From childhood through adulthood, the root of the person’s lifelong hurt stems from what happened to them during their earliest developmental years—whether he or she cognitively remembers the events or not.

The treatment of development trauma at the Institute for Attachment and Child Development

The principles deployed in the IACD model to treat the effects of trauma and foster an individual’s ability to attach are primarily based upon the human development and neuroscience research of Erik Erikson, Bessel van der Kolk, Bruce Perry, and Daniel J. Siegel. The IACD model is based on this culmination of trauma and attachment research as well as the knowledge, experience, and education of IACD clinicians. Central to this model is the belief that human relationships are essential to the growth and learning of all individuals; a person’s environment during his early development, as well as his personality, greatly influences his ability to attach to others throughout his lifetime; and that trauma impacts the brain and nervous system and impedes an individual’s ability for healthy attachment.

Congruent with the definition of DTD, the IACD model includes:

  • Professional therapeutic treatment parents in private homes where children learn to feel safe and competent within the context of family
  • Therapy for the children to recognize and overcome their traumatic reenactments and fear-based survival mechanisms
  • Family therapy and parent training with legal guardians so the children can feel safe and competent upon their transitions home
  • Neurofeedback to calm the children’s hyper-vigilant brains

The clinicians and therapeutic treatment parents focus on aiding children in healing from their trauma rather than concentrating upon their behavioral symptoms, in congruence with the theory of DTD. At IACD, children learn to trust healthy caregivers and advance their emotional and neurological development. When children return home, they are prepared to thrive in their own stable, healthy long-term family environments—the best establishment from which to continue healing for a lifetime.

“If we are still to use DSM V, we might go as far to say that if the Editors of DSM V wanted only one trauma diagnosis, then arguably it should have been developmental trauma disorder” -Bremness and Polzin

It is only when children are properly diagnosed and healed that we can begin to truly end the cycle of childhood trauma. According to van der Kolk, “Childhood trauma, including abuse and neglect, is probably the single most important public health challenge in the United States, a challenge that has the potential to be largely resolved by appropriate prevention and intervention” (abstract). At IACD, we will continue to heal children and families, advocate for the inclusion of DTD in the DSM and appeal for appropriate insurance coverage for effective treatment of DTD. We are making great strides here at IACD. Yet, we can move forward more swiftly with the collaboration and support of others. We invite you to join us.

References

Bremness, A., & Polzin, W. (2014). Commentary: Developmental Trauma Disorder: A Missed Opportunity in DSM V. Journal of the Canadian Academy of Child and Adolescent Psychiatry23(2), 142–145

National Survey of Children’s Health. NSCH 2011/12. Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved [10/02/2018] from www.childhealthdata.org.

van der Kolk, B. A. (2005). Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals., 35(5), 401-408. doi:10.3928/00485713-20050501-06

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ABOUT THE AUTHOR: For over 15 years, Nichole has helped to raise awareness of critical nonprofit programs and services in Arizona and Colorado. With a passion for family and healthy child development, Nichole has helped to connect thousands of adoptive and foster parents with one another and with resources and advocacy tools for their families. Nichole earned a Crisis Communication Certification (2017) and is on PRSA’s Association/Nonprofit Social Media Committee. Nichole holds a Bachelor of Arts degree in journalism (University of Arizona) and a Master of Education (Regis University) and has been with IACD since 2012.

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