Developmental Trauma Disorder
In 2009, professionals researching and treating Complex Trauma in children proposed a new diagnosis of Developmental Trauma Disorder be included in the Diagnostic and Statistical Manual to capture the dysfunctions experienced by children and adolescents exposed to chronic traumatic stress. Some of these children did not meet the criteria for Post-Traumatic Stress Disorder (PTSD), the disorder in the DSM-IV that most closely relates. Others had been diagnosed with a laundry list of unrelated disorders because their symptoms and behaviors meet the criteria for everything from Oppositional Defiance Disorder to Autism Spectrum Disorders. Yet these children’s problems have developed in the context of trauma and developmental disruptions. Because no other diagnostic options are available, the symptoms professionals see often lead them to diagnosing unrelated disorders such as bipolar disorder, ADHD, conduct disorder, RAD, autism, and a host of anxiety disorders.
Dr. Bessel van der Kolk and the staff at The Trauma Center at JRI have been researching “Disorders of Extreme Stress” in children for a decade. Together with the National Child Traumatic Stress Network, they proposed the inclusion of Developmental Trauma Disorder into the DSM-5, to be published in 2012. At this point the proposal is being considered and research trials are underway. The disorder has not yet been included in the drafts of this manual. However, professionals treating attachment disorder and trauma in children are supporting this diagnosis and are more frequently using it to describe what they see in many clients.
A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
- Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
- Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse.
B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following:
- Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization.
- Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions.)
- Diminished awareness/dissociation of sensations, emotions and bodily states.
- Impaired capacity to describe emotions or bodily states.
C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning or coping with stress, including at least three of the following:
- Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues.
- Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking.
- Maladaptive attempts at self-soothing (e.g. rocking and other rhythmical movements, compulsive masturbation).
- Habitual (intentional or automatic) or reactive self-harm.
- Inability to initiate or sustain goal-directed behavior.
D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following:
- Intense preoccupation with safety of caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation.
- Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness.
- Extreme and persistent distruct, defiance or lack of reciprocal behavior in close relationships with adults or peers.
- Reactive physical or verbal aggression toward peers, caregivers, or other adults.
- Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance.
- Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others.
E. Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters (B, C, & D).
F. Duration of disturbance (symptoms in DTD Criteria B, C, D. and E) at least 6 months.
G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at least two of the following areas of functioning:
- Scholastic: under-performance, non-attendance, disciplinary problems, drop-out, failure to complete degree/credential(s), conflict with school personnel, learning disabilities or intellectual impairment that cannot be accounted for by neurological or other factors.
- Familial: conflict, avoidance/passivity, running away, detachment and surrogate replacements, attempts to physically or emotionally hurt family members, non-fulfillment of responsibilities within the family.
- Peer Group: isolation, deviant affiliations, persistent physical or emotional conflict, avoidance/passivity, involvement in violence or unsafe acts, age-inappropriate affiliations or style of interaction.
- Legal: arrests/recidivism, detention, convictions, incarceration, violation of probation or other court orders, increasingly severe offenses, crimes against other persons, disregard or contempt for the law or for conventional moral standards.
- Health: physical illness or problems that cannot be fully accounted for, physical injury or degeneration, involving the digestive, neurological (including conversion symptoms and analgesia), sexual, immune, cardiopulmonary, proprioceptive, or sensory systems, or severe headaches (including migraine) or chronic pain and fatigue.
- Vocational (for youth involved in, seeking or referred for employment, volunteer work or job training): disinterest in work/vocation, inability to get or keep jobs, persistent conflict with co-workers or supervisors, under-employment in relation to abilities, failure to achieve expectable advancements.
To learn more about Developmental Trauma Disorder and Dr. van der Kolk’s research:
Understanding Interpersonal Trauma in Children: Why We Need a Developmentally Appropriate Trauma Diagnosis – D’Andrea, Ford, Stolbach, Spinazzola & van der Kolk, 2012
When Age Doesn’t Match Stage: Challenges and Considerations in Services for Transition-Age Youth with Histories of Developmental Trauma -Blaustein, Kinniburgh, Focal Point: Youth, Young Adults, & Mental Health. Trauma-Informed Care, 29, 17-20, 2015