Child Psychiatrists at NYU Langone Raise the Standard of Care for Treating Complex Childhood Trauma

Glenn Saxe, MD, the Arnold Simon Professor of Child and Adolescent Psychiatry, chair of the Department of Child and Adolescent Psychiatry, director of the Child Study Center, and founder of Trauma Systems Therapy, reviews trauma assessment and treatment protocols at NYU Langone.

A clinician’s recognition that a child’s symptoms may have a traumatic origin can be life changing for the child. Once this origin is recognized, a course of treatment can be implemented that gets to the bottom of the child’s problems and sets the stage for a happier, healthier, and more successful life. Traumatic stress in children may present like other psychiatric illnesses, and the failure to recognize it can have tragic consequences.

“If you don’t ask the right questions to understand the context of the child’s emotional state, it’s easy to give a child a diagnosis that misses the nature of their core problem,” explains Glenn Saxe, MD, the Arnold Simon Professor of Child and Adolescent Psychiatry, chair of the Department of Child and Adolescent Psychiatry, and director of the Child Study Center at NYU Langone Medical Center. “You have to look beyond the symptoms and see the context in which they are expressed, and then the diagnosis may look very different.

“Diagnosing trauma requires a moment-by-moment assessment of each episode to see what patterns
emerge,” he adds. “It may look like there is no rhyme or reason to the child’s shifting emotional states until you dig down deep to find out what is really happening in the moment.”

The child may be having a flashback brought on by a subtle reminder of a past trauma, such as a teacher’s angry glance or tone of voice, he explains. After the traumatic experience, the child may have repeated flashbacks and behavior disruptions in school, but if no one is looking for the patterns, the child may receive treatment for a very different problem.

The number of children affected by trauma is significant. About 15 to 43 percent of girls and 14 to 43 percent of boys go through at least one trauma. Of the children and teens who have had a trauma, 3 to 15 percent of girls and 1 to 6 percent of boys develop post-traumatic stress disorder (PTSD), according to the National Center for PTSD, part of the U.S. Department of Veterans Affairs. These rates vary on the basis of the type and/or numbers of trauma that a child has experienced.

These rates are probably higher, since most children with a history of complex trauma are misdiagnosed and mistreated, says Jennifer Havens, MD, associate professor of child and adolescent psychiatry and vice chair for public psychiatry at NYU Langone. “This is a huge tragedy. These children have been or are being abused, and they come to a hospital reporting symptoms and are not assessed properly, if at all,” says Dr. Havens.

“An assessment often should involve finding the most horrific experience and attaching it to symptoms,” Dr. Havens says. Instead, these kids are typically given antipsychotic medications. “It is akin to coming into the emergency room with a heart attack and leaving with a diagnosis of diabetes and a prescription for insulin. If you give them a pill, they will think there is a medical solution to the problem, but there isn’t.”

Dr. Saxe adds that clinicians often need to dig deeper: “Often nothing is working because there are things going on that no one is asking about,” he notes. “Ask the questions. Be curious. We need to try to understand the reality of these children’s lives.”

Child psychiatrists at NYU Langone are specifically trained to diagnose complex trauma and have spearheaded efforts to develop systematic trauma assessment and treatment protocols that clinicians anywhere can use. In particular, Trauma Systems Therapy (TST), an approach that Dr. Saxe pioneered, is now used in 13 states, and its reach is spreading outside the United States.

TST addresses childhood traumatic stress comprehensively by taking a child’s support system and social environment into account. The flexible protocol allows clinicians to match the correct interventions to the child’s social environment to maximize the chance of a successful outcome. “Some treatments oversimplify trauma and don’t address the complexity of the child’s environment,” Dr. Saxe says.

TST focuses on trauma-related symptoms and perpetuating factors in the child’s social environment or care system. The protocol helps the child to gain control over their emotions and behavior. It diminishes ongoing stresses and threats in the social environment through the use of skill-based psychotherapy, home and community-based care, advocacy, and/or medication.

“We give clinicians in any setting the skills, tools, and training to do it without us, and this includes scaling up and sustaining their program,” says Dr. Saxe. His department recently received three grants totaling $7 million to improve the way traumatized children in the United States, including those in the juvenile system and the foster care/child welfare system, are assessed, diagnosed, and treated.