What is Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder?

If you’ve read the earlier pages of this section, it will be obvious why some adopted children might be diagnosed with Post-Traumatic Stress Disorder, or PTSD. Symptoms of PTSD in children include, but are not limited to: extreme emotional reactions, possibly including angry outbursts related to specific trauma triggers; obsessive repetitive play around traumatic themes; sleep disturbances; unusual or excessive fears.

But many traumatized children do not reveal the impact of their early history in such obvious or easily identifiable ways. Recently, a new diagnostic category has been proposed for inclusion in the upcoming editions of the DSM – Complex Post-Traumatic Stress Disorder, or C-PTSD. C-PTSD aims to better describe and enumerate the many profound and overlapping effects of chronic and ongoing trauma in the absence of consistent care. Symptoms of C-PTSD include persistent difficulties with:

1 Attachment – Uncertainty about the reliability and predictability of the world; difficulty with boundaries; distrust and suspiciousness; social isolation; interpersonal difficulties; difficulty attuning to other people's emotional states and points of view.

    Many of our traumatized children do not accept discipline, invade other people’s personal space, distrust others, and lack friends.

2 Biology – hypersensitivity to physical contact; analgesia; somatization; problems with coordination, balance, and body tone; increased medical problems, including metabolic differences, and autoimmune and endocrine imbalances, allergies, asthma.

    Many of our traumatized children stiffen when touched, do not feel pain, exaggerate small pains, and take longer than is typical to learn how to ride a bike, skate or perform other movements requiring bilateral co-ordination. Many of our traumatized children’s metabolisms are seriously compromised, with imbalances of essential vitamins (such as the B vitamins), minerals (such as zinc, calcium and magnesium), neurotransmitters (such as serotonin, histamine, dopamine, and norepenephrine), and hormones (such as oxytocin and melatonin) contributing to irritability, anger, and even violent behavior, as well as sleep difficulties, premature puberty, depression, and other problems. Many of our children suffer from ongoing gastrointestinal disturbances; research shows that rat pups separated from their mothers show colonic dysfunction[i] and the gut-brain connection is well-established in humans, so it is safe to assume that traumatized children may be particularly vulnerable to GI dysfunction for the same reasons. Many of our children suffer from autoimmune disorders such as PANDAS. Many of our children have eczema or allergies. For more detailed information about these neurobiological issues, please refer to the Nutrition and Bio-medical section, under “Treatment” at this site.

3         Affect or emotional regulation – easily-aroused high-intensity emotions; difficulty with self-soothing; difficulty describing feelings and internal experience; chronic and pervasive depressed mood or sense of emptiness or deadness; chronic suicidal preoccupation, overinhibition or excessive expression of anger.

Many of our children explode into a violent rage at the smallest provocation (for example, the word “no” or even, “Let’s discuss this later.”) Many of our children will cry for an hour over a trivial remark or brood for days about an imagined slight. Many of our children can’t articulate what they feel; when asked what they feel, they say they “don’t know.” Some of our children are “too good,” wearing a mask of fake happiness. Some of our children seem to recognize few feelings except anger.

4        Dissociation – distinct alterations in states of consciousness; amnesia; depersonalization; and derealization.

Many of our children repeatedly dissociate when confronted with trauma triggers, such as an adult’s angry voice or facial expression, a parent leaving the child with a sitter or at daycare, the sight (or even the thought) of babies, or diapers, or dolls, or a car seat restraint. Dissociation may not always be obvious to the untrained eye; some children use television viewing as a way of dissociating.

5        Behavioral control –  poor modulation of impulses; self-destructive behavior; pathological self-soothing; aggressive behavior; sleep disturbances; eating disorders; substance abuse; oppositional behavior; excessive compliance; communication of trauma through behavior or play.

Many of our children fire before they aim; they do things before they think about the effects their actions might have on others or even themselves. They interrupt, butt into line, grab, push, or say the first thing that pops into their heads. Some of our children self-harm in large or small ways (cutting, hitting) or engage in pathological attempts to self-soothe, such as picking skin, rocking, head banging, chewing on their lips, masturbating. Many of our children are aggressive, particularly with parents but not only with parents. They hit, pinch, kick, bite, and throw large objects. Many of our children suffer from nightmares, night terrors, bruxism (tooth grinding), restless leg, and night waking. Some of our children suffer from eating disorders even as infants and toddlers; many more develop eating disorders as they mature. Older children are prone to drug and alcohol abuse. Many of our children refuse to do as they are asked to do. Others show a false front and deny their own wishes and feelings in an effort not to rock the boat. Finally, many of our children live out the type of trauma they have suffered, either in their play, or simply in their day-to-day interactions with others.

6        Cognition – difficulties in attention regulation and executive functioning; problems focusing on and completing tasks; reduced curiosity; problems with object constancy; difficulty planning and anticipating; problems with cause/effect thinking; difficulty understanding own role in what happens to them; learning difficulties; problems with language development; acoustic, visual, and other sensory perceptual problems; impaired visual-spatial skills.

Many of our children are diagnosed with ADHD because they cannot pay attention when they are supposed to pay attention and they cannot plan tasks effectively. Some of our children seem dulled-down and lack the urge to explore their world. Many of our children have not fully integrated the idea of “object permanence.” If they can’t see someone, they don’t know or believe on a deep level that she is still there (with obvious implications for attachment.) Many of our children don’t understand the idea of cause and effect, especially as it pertains to them; they do not grasp that if they hit someone, that person will not want to be their friend. Many of our children suffer from learning disabilities. Many of our children show delayed development of language skills. Many of our children cover their eyes in bright light, cover their ears at a medium-loud noise (yet scream themselves), find it terrifying (or unusually thrilling) to spin, swing, or hang upside down. Many of our children struggle to complete puzzles or read maps or learn how to tell time.

7        Self-concept – lack of a continuous and predictable sense of self; low self-esteem; feelings of shame and guilt; disturbances of body image; poor sense of separateness; generalized sense of being ineffective in dealing with one's environment; belief that one has been permanently damaged by the trauma.[ii]

Many of our children doubt their own reality; they chatter nonsense constantly partly as a way of helping themselves believe that they exist. Many of our children believe they are bad, unworthy, wrong, or at fault for every negative thing that has ever happened to them. Some of our children imagine they are fat when they are not, or believe they are much smaller or less powerful than they are. Many of our children cannot see where they leave off and others begin, and as a result, they constantly invade others’ personal space, either literally (waving a book two centimeters from someone else’s nose, clinging to a parent at an inappropriate or even dangerous moment, such as when the parent is standing at the stove) or metaphorically, with constant demands for attention. Some of our children can’t believe they could ever do anything to reduce their powerfully negative feelings, and some of our children fear that they are “damaged goods,” “trash,” “garbage,” or “unfixable” and that if they show their bad sides, their adoptive parents may send them back to the orphanage or to another foster home.