● A clinician who focuses on the vacillating mood swings may misdiagnose the child or adolescent as having bipolar disorder. ● Physiological distress from chronic child maltreatment may look like the symptoms of panic disorder. ● If the child is restless or inattentive at school (possibly because of recurring trauma nightmares or hypervigilance), school officials may label the child with a learning disability or attention-deficit/hyperactivity disorder (ADHD). ● Frequent affective outbursts or temper tantrums may be classified as disruptive mood dysregulation disorder. ● If the clinician attends only to frequent, aggressive outbursts, they may believe the child has a conduct disorder. ● Children who are overly familiar with strangers because their sexual abuse histories have distorted their understanding of boundaries may be labeled with disinhibited social engagement disorder. ● Some children with physical abuse histories may be combative or argumentative with adults such as teachers and may then be labeled as having oppositional defiant disorder (ODD). ● If persistent negative affect and feelings of despair are presented, the clinician may believe the child is suffering from major depressive disorder (MDD). ● Unresolved trauma may contribute to explosive outbursts, which could result in an inaccurate diagnosis of intermittent explosive disorder (IED). ● If a clinician fails to make a connection between a child’s self-injurious behaviors and their trauma-fueled diminished self-worth, the clinician may focus on a classification of nonsuicidal self-injury. ● Dissociative symptoms, unstable relational patterns, and self-destructive behaviors may be categorized into a borderline personality disorder diagnosis, when all are actually symptoms of current, ongoing trauma. Note : Adapted from van der Kolk, B. A. (2014). The body keeps the score. Viking. In all these examples, an awareness and assessment of trauma history can be all that separates an accurate diagnosis from an inaccurate diagnosis. Conversely, because trauma exposure can be a causative or contributing factor to many DSM-5 disorders, individuals who have experienced trauma may also accurately fit other diagnostic criteria. However, many of the disorders provided as “misdiagnoses” in this section are treated with pharmaceutical interventions, which do not directly address the underlying trauma. Because children may hide or deny their own trauma Attachment The psychobiological concept of attachment refers to “an emotional bond in which a person seeks proximity to the attachment object and uses them as a safe haven during times of distress and as a secure base from which to explore the world” (Fraley, 2019, p. 404). At a basic evolutionary level, attachment improves the helpless infant’s chances of survival, as human infants are wholly dependent on caregivers. This system is activated in response to danger or fear as well as by separation or threat of separation from the attachment figure. Humans have evolved in such a way that infants and young children will adaptively seek proximity to and maintain contact with a parental figure, even if the caregiver is abusive, hostile, or insensitive (Rincón-Cortés & Sullivan, 2014). The following sections will highlight the characteristics of both healthy and unhealthy attachments and frame the absence of a responsive attachment figure as a traumatic experience that could influence child development and well-being.
histories, or adapt their behaviors to fit their abusive environments, clinicians need to be able to turn on their “trauma ears” or put on their “trauma lenses” to effectively intervene with children. This diagnostic sensitivity will be discussed in greater detail later in the course in the section on trauma-informed care. Case Example Jessica brought her eight-year-old son Lee for treatment regarding his ADHD diagnosis. Lee’s school psychologist and his pediatrician both agreed on the diagnosis based on observations reported by Lee’s teacher and Jessica. Lee struggled in the classroom and the teacher was clearly frustrated by Lee’s inability to sit still and his frequent disruptions of the class, as well as his noncompliant response to rules. The teacher was also worried about Lee’s inability to concentrate and its potential effects on his academic achievement. Jessica reported that Lee was also hyperactive at home and that he had difficulty sleeping— observations that also overlapped onto ADHD criteria. Within the first few sessions with Lee, the underlying role of his trauma history became apparent. Jessica reported that during the first three years of Lee’s life, she struggled with addiction and was in and out of treatment. She had been sober for the past five years and assumed that Lee could not still be affected by that time in their lives. Eventually, through work with Lee and Jessica together, Lee expressed that he had difficulty sleeping because he had frequent nightmares about his mother using drugs. He also reported that he would often worry about his mother while at school (which further explained to his difficulty concentrating). Although Jessica was sober, she still attended regular meetings, and Lee was aware that her sobriety was an ongoing effort. Jessica also reported that Lee had always been sensitive to yelling and loud noises, which she worked to connect to the days when she was using drugs and frequently hosted parties in her home when Lee was upstairs sleeping. Lee’s loud and active school classroom likely triggered a hyperarousal that then presented as hyperactivity in the room. Linking Lee’s symptoms to his trauma history reframed the function and cause of the symptoms, resulting in treatment targets focused on trauma rather than on ADHD. Lee and Jessica worked together to reconstruct trauma narratives, and Jessica was able to give voice to Lee’s worries while also conveying safety. Lee’s teacher was also informed about Lee’s trauma history and, with trauma psychoeducation, was able to facilitate trauma-informed classroom changes that alleviated the frequent triggering of Lee’s trauma symptoms. Healthy Attachment Healthy attachment occurs when caregivers demonstrate sensitivity, an ability to perceive, accurately interpret, and appropriately respond to a child’s signals (Woodhouse, 2018). As children explore their worlds and receive stimulus inputs, they rely on their caregivers to be responsive in helping them to make sense of their environments. When caregivers are emotionally attuned, they provide “subtle physical levels of interaction” that give the child a sense of “being met, understood” and feeling safe (van der Kolk, 2014, p. 115). Caregivers may use gaze, touch, language, or other cues to provide reliable, developmentally appropriate, and caring responses. In turn, the child reacts, and a reciprocal process, termed “serve and return,” is enacted (Harvard University, Center on the Developing Child, 2022). These interactions are fundamental to the mind’s development. The caregiver’s consistent, congruent, and engaged interaction and presence enable the child’s healthy
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