Developmental trauma disorder: pros and cons of including formal criteria in the psychiatric diagnostic systems
1Department of child and adolescent psychiatry University Basel, Schanzenstrasse 13, CH-4056, Basel, Switzerland
2Center of clinical psychology and rehabilitation University Bremen, Grazer Strasse 6, DE-28329, Bremen, Germany
3Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Steinhövelstrasse 5, DE-89075, Ulm, Germany
BMC Psychiatry 2013, 13:3 doi:10.1186/1471-244X-13-3
The electronic version of this article is the complete one and can be found online at:http://www.biomedcentral.com/1471-244X/13/3
|Received:||4 January 2012|
|Accepted:||29 November 2012|
|Published:||3 January 2013|
© 2013 Schmid et al.; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article reviews the current debate on developmental trauma disorder (DTD) with respect to formalizing its diagnostic criteria. Victims of abuse, neglect, and maltreatment in childhood often develop a wide range of age-dependent psychopathologies with various mental comorbidities. The supporters of a formal DTD diagnosis argue that post-traumatic stress disorder (PTSD) does not cover all consequences of severe and complex traumatization in childhood.
Traumatized individuals are difficult to treat, but clinical experience has shown that they tend to benefit from specific trauma therapy. A main argument against inclusion of formal DTD criteria into existing diagnostic systems is that emphasis on the etiology of the disorder might force current diagnostic systems to deviate from their purely descriptive nature. Furthermore, comorbidities and biological aspects of the disorder may be underdiagnosed using the DTD criteria.
Here, we discuss arguments for and against the proposal of DTD criteria and address implications and consequences for the clinical practice.
Comorbidity; Developmental psychopathology; Developmental trauma disorder (DTD); Dissociation, Post-traumatic stress disorder (PTSD)
Inclusion of post-traumatic stress disorder (PTSD) in psychiatric diagnostic systems represents an important milestone since a clear connection between traumatic experiences and mental disorders have not been established previously [1–3]. Clinicians in the field of child and adolescent psychiatry and clinical psychology have to face acute traumatized children and victims of different shades and forms of chronic child abuse, maltreatment and neglect.
In the clinical setting, the effects of neglect, maltreatment, and abuse are noticeable which has prompted the need for a diagnosis capable of creating the connection between developmental and psychopathological aspects.
In children and adolescents, the usefulness of diagnostic criteria of PTSD is limited because the characterization of the condition is based on symptoms in adults. Because most symptoms are subjective and require verbal description by the patient, the diagnosis of PTSD in younger children remains challenging. In the presence of distinct, well-defined traumata and their effects, the diagnosis of PTSD can be readily made; childhood traumatization and neglect tend to be more complex and may entail a multitude of psychosocial risk factors. Therefore, various proposals for diagnostic criteria have been published which include developmental psychology factors [4–7].
Most traumatic experiences in children and adolescents occur in their immediate social environment [5,8,9]. Families with neglected, maltreated, or abused children often carry a number of additional risk factors, such as mental disorders in parents, poverty, cramped living conditions, or social isolation [5,10,11]. Moreover, childhood traumatization leads to a significantly higher risk of suffering other traumata in adult life [12,13].
Many severely maltreated, sexually abused, or neglected children who had suffered repeated traumatic events (i.e., chronic or sequential traumatization) do not fulfill the diagnostic criteria of PTSD in the strict (adult) sense. Frequently, affected children experience a multitude of other psychopathological symptoms [14–16] that often persist into adulthood, thus making a more systematic description of the particular symptoms necessary. Terr’s concept , one of the most influential proposals for the improvement of diagnostic processes, categorized traumata into single, well-defined, more public traumata such as accidents, natural disasters, and wartime experiences (type I), and a series of related, sequential traumata such as neglect, maltreatment, and sexual abuse often committed secretly and over longer time periods by persons close to the victim (type II). While type I traumatization often produces the classic psychopathological symptoms of PTSD, sequential traumatization may result in impaired development of personality and heterogeneous psychopathological symptoms. Dissociation, low self-efficacy, impaired regulation of emotion, somatization, and disturbed perception of self and others are all among the symptoms caused by chronic traumatization .
Repeatedly traumatized patients tend to exhibit a typical pattern of successive disorders, i.e., regulatory disorder during infancy, attachment disorders with or without disinhibition at preschool age, hyperkinetic conduct disorder at school age, or combined conduct and emotional disorders during adolescence. In later years, personality disorders are common and often accompanied by substance abuse, self-harm, and affective disorders. It is assumed that the same fundamental deficiencies (like impaired regulation of emotion, low self-efficacy, tendency towards dissociation) have variable consequences at different developmental stages of the patient, thus resulting in typical age-related psychopathological symptoms  (see Figure 1).
Figure 1. Development heterotopia of trauma.
Most literature reviews in this field focus on cross-sectional studies. Longitudinal studies are rare as they are difficult to conduct and constrained by ethical limitations. There are only a few highly important studies supporting the relevance of interpersonal trauma for developmental psychopathology from childhood to adulthood [4,14,18].
Empirical evidence of the course of PTSD indicates that severe sequential traumatization mostly begins in childhood showing an inverse correlation between the age of onset of traumatization and the severity of symptoms. This gave rise to the need of improved understanding of developmental aspects in children and adolescents with a complex trauma history .
In an effort to establish a rational diagnosis in severely traumatized children, several authors postulated a refined list of criteria [1,17,19]. To separate these criteria from those for PTSD, the term ‘developmental trauma disorder’ (DTD) was suggested  (see list of symptoms below).
List of symptoms: consensus of proposed diagnostic criteria for developmental trauma disorder
In the present paper, the suitability and limitations of the criteria postulated in the diagnosis of DTD are reviewed, and implications and consequences for clinical practice are discussed.
Proposed diagnostic criteria and symptom clusters
To include DTD in the DSM-V algorithm for separated diagnosis, van der Kolk et al. proposed the following criteria (organized into three symptom clusters) in addition to the defined symptoms of PTSD (see List of Symptoms below):
· Symptoms of emotional and physiological dysregulation/dissociation
· Problems with conduct and attention regulation
· Difficulties with self-esteem regulation and in managing social connections.
In the following, these symptom clusters are addressed in more detail.
Symptoms of emotional and physiological dysregulation/dissociation
Chronic activation of neurobiological systems involved in the regulation of stress and emotion appears to potentiate activation of the relevant neurotransmitters and neuroendocrinological systems. This has also been implicated in severe emotional dysregulation [21,22]. Several studies reported clear differences in the aptitude of children with and without traumata in regulation and recognition of emotion [23–25].
Subjects with difficulties in regulation of emotion react faster and more fiercely to emotional stimuli and require more time to calm down after an emotional reaction. This was particularly evident in studies with adult borderline patients [26–28]. Moreover, negative emotional reactions in everyday life seem to be more easily triggered in those patients [29,30].
The child or adolescent has experienced or witnessed multiple or prolonged extremely stressful traumatic events over a period of at least one year beginning in childhood or early adolescence, including:
1) Direct experience or witnessing of repeated and severe episodes of interpersonal violence, and
2) Significant disruptions of protective care giving as a 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:
1) Inability to modulate, tolerate, or recover from extreme affect states (e.g. fear, anger, shame), including prolonged and extreme tantrums, or immobilization,
2) Disturbances in regulation of bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions),
3) Diminished awareness/dissociation of sensations, emotions, and bodily states, and/or
4) 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:
1) Preoccupation with threat or impaired capacity to perceive threat, including misreading of safety and danger cues,
2) Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking,
3) Maladaptive attempts at self-soothing (e.g. rocking and other rhythmical movements, compulsive masturbation),
4) Habitual (intentional or automatic) or reactive self-harm, and/or
5) Inability to initiate or sustain goal-directed behavior.
D. Self and relational deregulation
The child exhibits impaired normative developmental competencies in his/her sense of personal identity and involvement in relationships, including at least three of the following:
1) Intense preoccupation with safety of the caregiver or other loved ones (including precocious care giving) or difficulty tolerating reunion with them after separation,
2) Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness,
3) Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers,
4) Reactive physical or verbal aggression toward peers, caregivers, or other adults,
5) Inappropriate (excessive or promiscuous) attempts to achieve intimate contact (including but not limited to sexual or physical intimacy), or excessive reliance on peers or adults for safety and reassurance, and/or
6) 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. Post-traumatic spectrum symptoms
The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, and D.
F. Duration of disturbance
Persistence of symptoms in criteria B, C, D, and E for 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:
1) 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,
2) 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,
3) 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,
4) 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, and/or
5) 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, severe headache (including migraine), or chronic pain or fatigue.
Dissociation may be described as a loss of outward perception and trance-like state of mind, which is accompanied by a loss of coenesthesia and sense of time, spatial orientation, facial expression, perception of pain, and often a feeling of derealization. Dissociative disruptions may also involve the loss of memory of own and observed external actions. As shown in recent experiments , both learning and assimilation of new information are strongly inhibited in dissociated states. Lynchet al. demonstrated that reducing dissociation tendency improves the success of outpatient psychotherapy.
While approximately 10% of the general population reacts with a stronger tendency to dissociation in response to trauma, 50% of affected individuals may suffer from chronic dissociation when faced with repeated traumatization [33,34]. Apart from the genetic disposition, susceptibility of reacting to traumatic experiences with dissociation is markedly influenced by the frequency and nature of traumatic experiences. Furthermore, dissociation tendency is a predictor for the development of PTSD in response to traumatic experiences [35,36].
Maltreated or sexually abused schoolchildren have a much stronger tendency towards dissociation than non-maltreated children . Extreme familial psychosocial stress and a tense family atmosphere are both factors that appear to potentiate this tendency [38,39].
Somatization, body and sensory perception
Among chronically traumatized individuals, body perception is frequently impaired . Good body perception is necessary for recognizing, processing, and expressing emotions . In traumatized individuals, perception of pain during tense conditions is diminished [42,43], and auditory perception is impaired . Overall, body perception, sensory perception, experience of pleasure, and ability to focus on positive sensory perceptions such as taste and music are clearly underdeveloped in affected individuals.
Studies show a clear relationship between early experiences of neglect/malnutrition and somatic diseases (e.g. high blood pressure, coronary heart disease, diabetes) in adulthood . Furthermore, there is increasing evidence that PTSD is not only associated with a higher vulnerability for comorbid mental disorders but also with an increased incidence of (psycho-) somatic disorders [46,47]. Many traumatized children suffer from severe sleep disorders [48,49].
Self-injury, high risk behavior, and sexual abnormalities
Non-suicidal self-injury  and suicidal behavior [51,52] constitute the symptoms most strongly linked with traumatization, particularly sexual abuse. More than 80% of patients with a history of self-injury report traumatic events in their earlier lives . Given the high prevalence of self-injuries among adolescents, periodical and repetitive self-injuring behavior should be regarded separately since it is unlikely that the majority of adolescent self-injurers share a history of traumatic events. Interestingly, repetitive self-injury has been reported more often in adults with a childhood history of sexual abuse, whereas intermittent self-injury appears to be more frequently associated with physical abuse in childhood . Nonetheless, a meta-analysis of 45 studies on the association of sexual abuse and self-injury only found a relatively weak relationship between self-injury and sexual abuse indicating that sexual abuse ceased to explain the variance in self-injurious behavior if the studies were controlled for other psychiatric risk factors . Other studies described a relationship between self-injury and traumatization [55,56]. A recent review suggests that the association of child maltreatment and self-injury varies according to the type of maltreatment . Weierich and Nock showed that PTSD symptoms mediate the relation between sexual abuse and self-injury . Self-injury probably functions as a support of emotion regulation and disrupts dissociative states and the emotional tension related to regulation of emotion . Neurobiologically, self-injury can be seen as an attempt to alter the state of the autonomic nervous system that has been pushed to an extreme state by reminders of traumatic events .
Glassman et al.  found that traumatization leads to self-injury, particularly when shame and self-criticism transform into self-hate. Among all psychological disorders, post-traumatic syndromes are most closely related to suicidal ideation and are associated with the highest suicide rates. PTSD symptoms like flashbacks, nightmares and intrusions were reported to be significantly associated with tension, dissociation and self-injury [53,58]. The literature concerning the association between a history of traumatic events and suicidal behavior is particularly consistent. Recent data from the World Mental Health survey (21 countries, n=55’299) showed a strong relationship between childhood adversities (odds ratio [OR] for suicide attempt after sexual abuse: 5.7) and suicidal behavior, such as suicidal ideation or attempts .
Children who have experienced sexual abuse seem to be more preoccupied with their sexuality, show more sexualized behavior, and may exhibit compulsive masturbating behavior [61,62]. Several reviews suggest that impulsive high-risk-behavior in adolescents (e.g. unprotected sexual intercourse, risky behavior in traffic, carrying arms) often occurs in young individuals who have been traumatized . In particular, early substance abuse is likely alongside impulsivity and psychosocial risk factors .
Difficulties with executive functions and the regulation of attention
Studies in heavily deprived Romanian orphans showed that without a minimum of stimulation during the sensitive phase of development, cognitive development is sustainably impaired [65–67]. Executive functions, such as attention span, distractibility, and the ability for serial structuring and making plans are particularly affected. However, there is a clear distinction between these traits and the symptoms of attention deficit hyperactivity disorder (ADHD) [67,68]. The work group around Michael Rutter analyzed the intelligence profiles of traumatized and neglected Romanian residential care children after adoption by families in the United Kingdom and noticed that these children show deficits in their executive functions [65,68]. On the neuropsychological level, self-regulation of more complex behaviors and future orientated planning in daily life appear to be limited or impaired, because complex traumatized children have learned to focus on the next moment to survive and not to overlook broader timeframes [17,19]. Some studies showed different significant problems in working memory in students following sexual abuse and childhood trauma [69,70]. Endo and colleagues  found that dissociative children meet criteria of ADHD whereas non maltreated children with ADHD do not show dissociative symptoms.
Difficulties in self-regulation and establishment of relationships
Eighty percent of all traumatized (physically abused) children show a disorganized style of attachment [72–74]. Abused and neglected children often develop highly insecure representations of attachment [75,76] and show promiscuous and non-selective behavior in their attachment to adults [67,77]. Other studies found that exposure to interpersonal trauma leeds to social isolation. Attachment is an important resilience factor for preventing the development of a mental disorder after traumatization. Emotional support provided directly following a traumatizing experience reduces the risk of developing PTSD [35,36]. Moreover, positive relationships enhance the success of psychosocial interventions .
Perception of social situations is altered in traumatized children because they are highly sensitized to potentially threatening stimuli. Dodge and Schwartz  showed that traumatized children tend to interpret neutral behavior of other people as hostile and react to more aggressive behavior with fear or even dissociation. Furthermore, abused children react stronger and more impulsive to negative facial expressions, especially to those of anger [23,81–83]. This hypersensitivity to potentially threatening stimuli often leads to aggressive reactions in affected individuals[80,84,85]. Probably reduced grey matter in the visual cortex represents a neurobiological correlate of difficulties in the recognition and interpretation of emotions and social skills .
Traumatized individuals often develop feelings of self-reproach, guilt, and shame . Development of a healthy self-image is substantially impaired in traumatized subjects. The impact of abuse and neglect on the development of self-esteem (self-insufficiency, defectiveness) has been addressed in longitudinal studies [85,88]. Kim and Cicchetti reported that feelings of shame caused by traumatization were responsible for interpersonal problems in adulthood .
Several studies have addressed empathy, theory of mind, and the ability for mentalization in traumatized and heavily neglected children [89,90]. The ability of taking the perspectives of others was diminished, increasing with the length of the children being in conditions of deprivation . When studying mentalization , the ability to take the perspective of others in emotional situations involving pressure was of main interest. Under such circumstances, deficient regulation of emotion and lacking ability to take others perspectives are additive.
Because of scientific discussion among the long term consequences of childhood trauma and the criteria of development trauma disorders a discussion among pros and cons of the introduction of such a diagnosis in the revision of DSM-V and ICD-11 started (see Table 1).
Table 1. Arguments for and against the introduction of development trauma disorder in the psychiatric diagnostic systems
Arguments for and against a systematic diagnosis of DTD
Arguments in favor of formalized DTD diagnostic criteria
The following arguments support the initiative to include DTD as a distinct mental disorder in diagnostic systems:
· More specific diagnosis: The diagnosis of PTSD does not sufficiently take into account the symptoms of traumatized patients. The postulated DTD diagnostic criteria comprise a range of symptoms seen to occur after complex and repeated traumatization. For the diagnosis of DTD, traumatic experience is essential but not exclusive, and genetic and biopsychosocial origins of the disorder must be ruled out to specify the interaction between neurobiology, epigenetics and transgenerational traumatic life events and their consequenses for the development of mental disorders. The existence of specific and validated DTD diagnostic criteria may sensitize professionals and the general public to the drastic consequences of child abuse, neglect, and traumatization. Moreover, the establishment of measures for e.g. child protection, policy making would be expedited.
· Course of mental disorders: The supporters of this initiative argue that more emphasis should be placed on developmental aspects of disorders caused by traumatization. The few longitudinal studies available indicate that more than 60% of adults with psychiatric disorders suffered from psychopathological symptoms during adolescence, and 77% exhibited symptoms before the age of 18 years [87,92]. Furthermore, PTSD frequently becomes chronic. In a longitudinal study in adolescents with PTSD, 48% of patients still met the criteria for PTSD three to four years later.
· Enhance research: Establishment of formal diagnostic criteria for DTD is expected to stimulate research efforts in this area (e.g., epidemiological studies, developmental-psychopathological research). Cross-sectional and longitudinal studies on psychosocial risks and comorbidities during childhood and adolescence should be encouraged.
· Explain comorbidities: From a clinical point of view, the diagnosis of DTD focuses on traumatization as the psychopathological trigger of mental disorders . Several well-designed studies clearly demonstrated such correlations. Post-traumatic symptoms may occur together with other mental disorders. As many as 80% of PTSD patients meet the criteria for another disorder [95–98]. In an evaluation of the ‘Dunedin longitudinal study’, Koenen et al.  showed that all subjects meeting the criteria for PTSD in young adulthood had suffered from mental disorders at a young age. Conversely, other mental disorders may be present before PTSD or may develop after its occurrence [15,87,92]. In particular, victims of sequential traumatization have an inherently high risk of developing a complex syndrome of disorders that often go hand-in-hand with single symptoms of PTSD without fulfilling the complete clinical picture of PTSD . In children and adolescents, comorbidities with ADHD, anxiety disorder, suicidal thoughts, and a trend towards affective disorders is highly prevalent [1,98].
· Enable effective treatment: By selectively treating trauma symptoms, patients can be stabilized, and concomitant illnesses (like anxiety disorder or depression) can be addressed. The effectiveness of therapeutic interventions in traumatized children and adolescents has been well documented in recent years [99–103]. Spinazzola et al. pointed out that more attention should be given to naturalistic studies in inpatients suffering from psychosocial stress being at risk of suicide.
Patients with severe interpersonal traumatization in childhood are the hardest to treat and have the poorest prognosis. Treatment may be constrained by insufficient understanding of the underlying illness, and patients often cannot be reached by the psychosocial care system. Moreover, the degree of traumatization affects treatment success. Therefore, it is important to take the nature and severity of traumatic experiences into account when developing a treatment plan. With a more specific diagnosis, treatment options can be tailor-made.
· Social and legal aspects: Many victims of neglect, child abuse, and maltreatment live on the edge of society and depend on social services for most of their lives. Failures at school and in youth welfare institutions are common . Clear definition of trauma-related symptoms could help to change attitudes towards delinquent or aggressive adolescents and facilitate the initiation of treatment .
Several studies have addressed the enormous healthcare costs arising from traumatization, such as medical treatment costs, early retirement, inability to work, need for social benefits, and even imprisonment [107,108]. If the consequences of childhood traumatization were officially recognized, patients would benefit from improved social acceptance of their difficulties. Moreover, inclusion of mental disorders arising from complex traumatization in the official diagnostic systems would assist patients in obtaining compensation and legal support (court, victim aid). Many traumatized patients develop chronic mental disorders with serious impairment of their working ability and social interactions. Early and effective intervention is necessary to help patients to maintain a normal life style.
Arguments against formalized DTD diagnostic criteria
The following arguments question the usefulness of including DTD as a distinct mental disorder in diagnostic systems:
· Conflicting DSM and ICD diagnostic systems: Formal DTD diagnostic criteria are thought to weaken the power of existing diagnostic systems, such as DSM-IV-TR and ICD-10. Both diagnostic systems were strictly designed to exclude any theory about the etiology of the mental disorders and confine themselves to a clear and operationalizable description of the symptoms and disorders. Since Axis V of the multiaxial diagnostic system covers psychosocial risk factors, aspects associated with chronic exposures to traumatic events are included in existing systems. In addition, critics claim that there is no clear distinction between symptoms and syndromes, and that DTD criteria overlap with those of some established and some discussed diagnoses. Many symptoms of borderline personality disorder or attachment disorder are included in the list of DTD symptoms, thus impeding the distinction between these disorders. Similarly, DTD criteria overlap with those of attachment disorders, conduct disorder, multiple complex development disorders (MCDD)  or the criteria for borderline disorder in childhood and adolescence . Although, all of these diagnosis have a high prevalence among people with traumatic life events, problems with validity and reliability [110,111] and high comorbidities with other mental disorders. Some diagnosis like multiple complex trauma disorder and borderline personality disorder in childhood are not part of the diagnostic systems.
· Monocausality: concerning the diagnosis of DTD, monocausality is assumed, but this has not been proven . DTD diagnosis favors a psychosocial explanation for the etiology of the disorders and neglects the biological explanations of the biopsychosocial model to understand the development of mental disorders. DTD is frequently manifested as a mixture of symptoms and syndromes, and a unidirectional relationship between traumatic experiences and the development of a confined syndrome remains is based on a widespread of actual research in the field of psycho traumatology. Moreover, genetic/biological causes of the symptom pattern may be ignored when diagnosing DTD. Critics of a formal DTD diagnosis point out that those similar symptoms may be present in individuals who did not have any traumatic experiences. In line with this, 20% to 30% of patients with borderline personality disorder, whose criteria are similar to those of complex PTSD, had not suffered from any traumatic experience . By explaining complex symptom patterns by a single cause, other disorders that require treatment may remain untreated. Focussing on trauma etiology it might be possible that other comorbid diagnosis like ADHD will not be taken into account and missed to treat with evidenced based interventions. Furthermore, assumption of traumatization as the single cause of the disorder may result in too much importance being attached to identifying the causative traumatic experience, thus ignoring positive life experiences that would facilitate a resource-orientated therapeutic relationship, especially with the parents.
· Selectivity: Certain children who had been severely traumatized do not develop any mental disorder . Of course this is a weak argument because skeptics can argue in the same way against the classic PTSD diagnosis.According to Malinosky-Rummell and Hansen, 80% of adults who had been physically abused during childhood showed no mental disorder in adulthood . However, Collishaw et al. found considerably weaker psychopathological resilience in a follow-up analysis of adults who had experienced maltreatment during childhood. Furthermore a study of the Dunedin birth cohort (in ) suggested that the risk of developing a mental disorder increases with repeated traumatization. Individuals who did not develop any symptoms were found to have good peer relations, success at school and work, and stable relationships. Current research into resilience increasingly focuses on dynamic factors, such as behavior and attitude, which enhance individual or familial resilience , and their correlation with genetic factors. Conversely, non-traumatized individuals may develop similar symptoms. The formal DTD criteria do not explain this phenomenon. In addition, there is a relatively high overlap with existing and well-established mental disorders (e.g., borderline disorder, attachment disorder with disinhibition, etc.).
· Inverse correlation: Diagnosing DTD implies that emotional dysregulation is caused by traumatic experiences but ignores the fact that the reverse relationship also exists. Emotional dysregulation is accompanied by a higher risk of traumatization. It is well established that subjects with impaired emotional control may adversely respond to environmental factors, thus reinforcing the present symptoms . This correlation was described in the transactional model by Fruzzetti et al. . Furthermore, children with externalizing disorders have a four times higher risk of being abused .
· Age sensitivity: Although the proposed diagnostic criteria are meant to take the age and developmental status of the patient into account, symptoms are not sufficiently stipulated age-sensitive. But of course this is a problem of every diagnosis in childhood and adolescence – regarding the actual debate among assessing symptoms of attention deficit and hyperactivity disorder ADHD in childhood, adolescence and adulthood . Furthermore the criteria claim to be development-oriented, however they fail to specify the symptoms for different age groups. Thus, no distinction is being made between young children and adolescents with respect to emotional and physiological regulation. This is due to the limited knowledge about the course of trauma-related symptoms and the methodical problems in longitudinal studies to address the same construct in different age groups with other psychometric methods. Additionally clinical studies are limited by ethical restraints.
· Treatment: The main purpose of accurately diagnosing psychopathological conditions in children and adolescence is the endeavor to treat them effectively. Critics of the introduction of formal DTD diagnostic criteria argue that comorbidities may remain untreated because too much emphasis is placed on trauma-related aspects of the condition. This can provoke misinterpretations of biological symptoms with the consequence that effective psycho-pharmaceutical treatment options stay unused.
· Disadvantages of trauma-focused diagnostic explorations: For inexperienced professionals the concentration on trauma-related symptoms in the diagnostic process may result in a pressure to detect traumatic life events. This kind of exploration might have a negative influence on the therapeutic relationship, especially to parents of multi-problem families. It can be difficult to combine a trauma-focused exploration style with solution focused interventions. But without the development of a sustainable therapeutic relationship every treatment will fail. Another negative aspect of trauma-focused diagnostic exploration could be that patients will be pushed in an implicit or explicit way to remember or to talk about traumatic events. It is even possible that some trauma-focused exploration styles provoke false memories of biographical life events with several negative consequences .
There is considerable controversy with respect to implementing formal DTD diagnostic criteria; based on existing empirical studies the correlation between traumatic experiences and related symptoms is not in question among experts. Studies focusing on the neurobiology of mental disorder in childhood have clearly identified traumatization as an important cause .
The current debate on the need for a formal definition of DTD criteria highlights the important role of traumatization and neglect in the development of complex psychopathological disorders that are difficult to treat. Awareness of long-term outcomes of child abuse and neglect may strengthen the acceptance of initiatives to protect children from maltreatment and improve attitudes towards ‘difficult’ adolescents who live at the edge of society. A better understanding of the effects of traumatization might lead to improved psychosocial treatment options for these children and adolescents and may help to prevent from participation restrictions in the society.
The arguments for and against implementing formal DTD diagnostic criteria are convincing, and the debate can only be resolved conclusively based on the emergence of new information. Sophisticated neurobiological and genetic studies are needed because traumatization is known to affect prenatal factors, such as endocrinological processes during and after pregnancy, or even genotype [121–124]. Moreover, longitudinal studies are necessary because DTD is not a static but a rather dynamic condition, undergoing changes in its manifestation over time. An innovative method using a developmental-heterotopic approach has been described by Fegert et al. and Schmid et al.[4,125,126].
In addition, clusters of mental disorders should be identified, and interaction of psychosocial and biological aspects in the development of these clusters should be addressed. Such an approach would help to explain the pervasive nature of trauma-related psychopathological disorders.
Trauma experts working in specialized institutions that deal exclusively with traumatized individuals tend to be the main supporters of a formal definition of DTD diagnostic criteria, while professionals working in the general clinical and psychiatric setting remain critical for the reasons stipulated above. Regardless of the outcome of the ongoing debate, treatment of severely traumatized children and adolescents should be improved substantially. Although trauma outpatient clinics offering symptom-specific treatment will be of help, general psychotherapeutic professionals also need to be trained in this area since many traumatized children are encountered in the clinical setting. Therapeutic concepts currently available for hospitalized patients are grossly inadequate to address the dramatic squeal in severely traumatized children. Trauma-specific concepts of outpatient treatment with possible inpatient interval treatment should be developed and implemented [101,127–129], taking the specific needs of children and adolescents into account as well as the need of their parents, foster parents or residential care staff. It is important to be able to combine both treatment needs: to maintain a “save place” and to have the possibility to do effective (prolonged) exposure therapy. For severely traumatized patients a combination of a skill training and trauma therapeutic exposure treatment is currently regarded to be the best approach[101,103] with the least drop-out rates. The trauma system therapy as a model of combined milieu therapeutic, systemic / family centered and psychotherapeutic intervention is a very promising and, as the first results show, successful treatment approach for children and adolescents suffering from complex trauma or developmental trauma disorder . The psychotherapeutic skill training focuses on the capacities to cope with dissociation, emotion regulation problems, situations of extreme stress and tension as well as intrusions, disgust and social problems [101,103,127]. The additive skill training will help to overcome tension and dissociation during the exposure therapy and is a kind of precondition for exposure therapy with complex traumatized patients with fewer capacities to cope with stress, tension and dissociation . The dialectical behavior therapy and their adaptions for adolescents [132,133] are the best evaluated treatment concepts to improve these skills. For such treatment concepts to be effective, specialized wards are needed, which will probably require inpatient treatment for a greater catchment area and build a network of outpatient therapists cooperating with this specialized ward.
As many severely traumatized children and adolescents cannot stay in their families of origin, psychiatric liaison services for adolescents in residential care institutions and youth welfare services should be implemented. These liaison services can help to reach more burdened children, reduce inpatient child- and adolescent psychiatric treatment days and improve continuity in residential and foster care placements . Youth welfare concepts should be sensitized to trauma symptoms and try to promote and enhance resilience factors, self-efficacy and social and emotion-regulation skills . In conclusion, the available arguments for and against the implementation formal diagnostic criteria for DTD cannot be appraised conclusively based on current research. The main advantage appears to be improved sensitization to trauma outcomes and more tailor-made treatment options, but this may also be achieved by a descriptive approach. A dimensional diagnostic system comprising the relevant domains, such as relationship / attachment representation, assessing interpersonal trust, emotion regulation, affinity to dissociation / sensual perception, and lacking expectation of self-efficacy, could also be envisaged. Specific symptom scales for emotion regulation, attachment/ interpersonal trust, self-efficacy and dissociation may be effective in predicting the outcome of psychotherapeutic treatment. These symptom scales may show relevant aspects of developmental psychopathology, can support the diagnostic process, and help to develop individualized treatment concepts with specific guidelines for the arrangement of the therapeutic alliance. Probably the sensitization to trauma symptoms and the interpersonal learning history of a patient can prevent drop-out and improve the therapeutic outcome.
The authors declare that they have no competing interests.
JMF and FP contributed equally to this work. This paper is based on a former German publication by MS, JMF, FP. (2010) Traumaentwicklungsstörung: Pro und Contra. Kindheit & Entwicklung, 19 (1), 47–63. All authors read and approved the final manuscript.
Dr. Marc Schmid is chief psychologist at the department of child and adolescent psychiatry at the University Basel (Switzerland). Head of the center for the psychiatric and psychotherapeutic liaison services with youth welfare institutions and the EQUALS project.
Prof. Dr. Franz Petermann is Director of the center of rehabilitation and clinical psychology and professor for psychological diagnostics and intervention at the University Bremen (Germany).
Prof. Dr. Jörg M. Fegert is Medical Director of the department for child and adolescent psychiatry at the University of Ulm (Germany). Professor Fegert is member of diverse academic advisory boards of the German government among family affairs, research, child abuse and neglect.
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- Classen CC, Palesh OG, Aggarwal R: Sexual revictimization: a review of the empirical literature.Trauma Violence Abuse 2005, 6(2):103-129. PubMed Abstract | Publisher Full Text
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- van der Kolk BA: Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories.Psychiatr Ann 2005, 35(5):401-408.
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- Maercker A, Karl A: Lifespan-developmental differences in physiologic reactivity to loud tones in trauma victims: a pilot study.Psychol Rep 2003, 93(3 Pt 1):941-948. PubMed Abstract
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- Martin J, Hiscock H, Hardy P, Davey B, Wake M: Adverse associations of infant and child sleep problems and parent health: an Australian population study.Pediatrics 2007, 119(5):947-955. PubMed Abstract | Publisher Full Text
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- Navalta CP, Polcari A, Webster DM, Boghossian A, Teicher MH: Effects of childhood sexual abuse on neuropsychological and cognitive function in college women.J Neuropsychiatry Clin Neurosci 2006, 18(1):45-53. PubMed Abstract | Publisher Full Text
- Savitz J, Jansen P: The Stroop Color-Word Interference Test as an indicator of ADHD in poor readers.The Journal of Genetic Psychology: Research and Theory on Human Development 2003,164(3):319-333.
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- Schmid M: Entwicklungspsychopathologische Grundlagen einer Traumapädagogik.Trauma & Gewalt 2008, 2(4):288-309. PubMed Abstract
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Developmental Trauma Disorder: Distinguishing, Diagnosing, And The DSM
In 2001, the Cummings Foundation convened a group of child psychiatrists, public policy experts, and representatives from the Department of Justice, Department of Health and Human Services, and Congressional staff to consider the deplorable state of services to traumatized children. This initiative led to the establishment of the Congressionally mandated National Child Traumatic Stress Network (NCTSN).
In order to study the symptomatology of the children seen within the NCTSN, Boston psychiatrist and trauma expert Bessel van der Kolk and his colleague Joseph Spinazzola organized a complex trauma task force. Between 2002 and 2003 they conducted a survey (via clinician reports) of 1,700 children receiving trauma-focused treatment and experiencing the effects of child abuse at 38 different centers across the country.
They found more evidence of what two decades of research had already revealed: Nearly 80% of the surveyed kids had been exposed to multiple and/or prolonged interpersonal trauma, and of those, fewer than 25% met the diagnostic criteria for Post-Traumatic Stress Disorder (PTSD).
Instead, these children showed pervasive, complex, often extreme, and sometimes contradictory patterns of emotional and physiological dysregulation. Their moods and feelings could be all over the place—rage, aggressiveness, deep sadness, fear, withdrawal, detachment and flatness, and dissociation—and when upset, they could neither calm themselves down nor describe what they were feeling.
In 2005, the complex trauma task force—chaired by van der Kolk—began working in earnest on constructing a new diagnosis, called Developmental Trauma Disorder, which, they hoped, would capture the multifaceted reality experienced by chronically abused children and adolescents.
In January 2009, they submitted to the Diagnostic and Statistical Manual (DSM) Trauma, PTSD, and Dissociative Disorders Subwork Group an elaborate criteria set (DSM-speak for symptom list) for Developmental Trauma Disorder: Exposure to prolonged trauma, causing pervasive impairments of psychobiological dysregulation (of emotions and bodily functions, of awareness and sensations, of attention and behavior, of their sense of self and their relationships), as well as at least two symptoms of standard PTSD, and multiple functional impairments (with school, family, peer group, the law, health, and jobs or job training).
According to van der Kolk, the DSM committee responded that the complex trauma task force had “inundated” them with too much data about Developmental Trauma Disorder, but not the right kind: They needed to submit other kinds of data concerning 17 issues, including possible genetic transmission, environmental risk factors, temperamental antecedents, bio-markers, familial patterns, treatment response, and so on.
The DSM subcommittee, chaired by Matthew Friedman, executive director of the National Center for PTSD, wrote that “the consensus is that is it unlikely that Developmental Trauma Disorder can be included in the main part of DSM-5 in its present form because of the current lack of evidence in support of the diagnosis and the lack of prospective testing of your proposed diagnostic criteria.”
The complex trauma task force argued that this was a proposed diagnosis, which didn’t officially exist yet, and so—in that great Catch-22 tradition of DSM—couldn’t qualify for the funding for the kind of research the DSM subcommittee wanted to see. But their argument was still unconvincing.
Though temporarily stymied, the NCTSN task force is by no means defeated. They’ve been able to raise the money for a Developmental Trauma Disorder field trial and enlisted the sites that are able to carry out the required research.
“We’re still going ahead full throttle,” says van der Kolk. “I feel very optimistic.”
Young children are especially susceptible to exposure to trauma. Rates of abuse and neglect among this population are staggering. This article presents a review of relevant literature, including research findings specific to early childhood vulnerability to trauma, symptoms associated with traumatic events, diagnostic validity of early childhood trauma, and treatments for young children. In the past, misconceptions about the mental health of young children have hindered accurate diagnosis and treatment of trauma-related mental illness. Due to the prevalence of trauma exposure in early childhood, counselors are encouraged to become familiar with ways that clients and families are impacted and methods for treatment. Implications for future research also are presented.
Keywords: early childhood, trauma, treatment, mental health, mental illness
Children from birth to age 5 are at a particularly high risk for exposure to potentially traumatic events due to their dependence on parents and caregivers (Lieberman & Van Horn, 2009; National Child Traumatic Stress Network, 2010). Traumatic events are incidents that involve the threat of bodily injury, death or harm to the physical integrity of self or others and often lead to feelings of terror or helplessness (National Library of Medicine, 2013). The American Psychological Association (APA) Presidential Task Force on Posttraumatic Stress Disorder (PTSD) and Trauma in Children and Adolescents (2008) indicated that traumatic events include suicides and other deaths or losses, domestic or sexual violence, community violence, medical trauma, vehicle accidents, war experiences, and natural and manmade disasters. With more than half of young children experiencing a severe stressor, they are especially susceptible to accidents, physical trauma, abuse and neglect, as well as exposure to domestic or community violence (National Child Traumatic Stress Network, 2010).
Over 20 years ago, Straus & Gelles (1990) estimated that three million couples per year engage in severe in-home violence toward each other in the presence of young children. The Administration on Children, Youth, and Families (2003) reported that in 2001, 85% of abuse fatalities occurred among children younger than 6 years of age, and half of all child victims of maltreatment are younger than 7. More recently, the Child Welfare Information Gateway (2014) indicated that 88% of child abuse and neglect fatalities occurred among children 7 years of age and younger. Often, there is an overlap between domestic violence and child physical and sexual abuse (Osofsky, 2003). In addition to domestic violence, young children also are vulnerable to community violence.
A study conducted by Shahinfar, Fox, and Leavitt (2000) suggested that the majority of young children enrolled in Head Start experienced violence in their communities. Young children also are exposed to traumatic stressors such as accidental burns or falls resulting in hospitalization or death (Grossman, 2000). It is common for children to experience more than one traumatic event (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008).
Young children birth to age 5 are especially vulnerable to adverse effects of trauma due to rapid developmental growth, dependence on caregivers and limited coping skills. However, despite decades of statistical data, counselors generally have limited knowledge of the impact of traumatic events on younger children in comparison to older children and adolescents (De Young, Kenardy, & Cobham, 2011). Reasons for this disparity in knowledge include a historical resistance to the notion that early childhood mental health is important and concerns about diagnosing young children with mental disorders.
Research in early childhood mental health has developed rapidly over the past 20 years. Practitioners and researchers who work with this population continue to contribute to the understanding of trauma and early childhood mental health. However, the broader counselor population seems less informed which hinders referrals for this vulnerable population of young children. For example, a counselor may work with a victim of domestic violence who has young children. However, due to the counselor’s limited knowledge of early childhood trauma and the impact of domestic violence, the counselor may not consider support services for the children. The present article examines the history and diagnostic validity of trauma-related mental illnesses in young children, the symptoms of trauma in early childhood, the longitudinal impact of early childhood trauma, the protective and risk factors associated with trauma in early childhood, and current and emerging treatments for this vulnerable population.
Mental Health, Trauma and Young Children: A Historical Perspective
Historically, researchers have spent little time and energy researching the effects of trauma exposure in early childhood. A widely held misconception has been that infants and young children lack the perception, cognition and social maturity to remember or understand traumatic events (Zeanah & Zeanah, 2009). Additionally, mental health counselors have been hesitant to diagnose trauma-related mental illness as a result of the associated stigmas that plague young children. In some cases when a child is diagnosed with mental illness, society focuses on the diagnosis and not the child.
Today it is widely accepted that children have the capacity to perceive and remember traumatic events. From birth, the tactile and auditory senses of a child are similar to those of an adult, which suggests that a child can experience stressful events (De Young et al., 2011). At 3 months of age, a child’s visual sensory development increases exponentially. A study by Gaensbauer (2002) suggested that infants as young as 7 months of age can remember and reenact traumatic events for up to 7 years. By 18 months of age, children begin to develop autobiographical memory; however, it is unlikely that memories from before that age can be recalled verbally (Howe, Toth, & Cicchetti, 2006). Researchers have demonstrated that infants and young children have the perceptual ability and memory to be impacted by traumatic events (De Young et al., 2011; Howe et al., 2006).
While research findings have confirmed that traumatic events can impact children, clinicians without proper training in early childhood mental health may have difficulty diagnosing trauma-related mental illness in childhood. Children younger than 5 years of age typically experience rapid developmental changes that often are misinterpreted or not fully accounted for which hinders proper diagnosis and intervention (Zero to Three, 2005). Given time and insurance reimbursement constraints, there can be difficulties observing children’s behaviors across settings (Carter, Briggs-Gowan, & Davis, 2004). Although verbal skills develop rapidly in early childhood, children may lack the communication skills necessary to accurately express their thoughts, emotions and experiences (Cohen, 2010). When conducting assessments, mental health professionals rely on parental feedback, inventories and reports from multiple sources, thus increasing the accuracy of the assessment (Carter, Briggs-Gowan, Jones, & Little, 2003).
There is a lack of psychometrically sound diagnostic tools for directly assessing trauma symptoms in children (Strand, Pasquale, & Sarmiento, 2011). Those tools currently available do not appropriately consider the developmental levels of young children (Carter et al., 2004; Egger & Angold, 2006; Strand et al., 2011). However, there are well-designed instruments for early childhood that utilize indirect assessments such as clinician observations and parent/teacher reports (Yates et al., 2008).
Diagnostic tools and assessments developed for children over age 5 are not suitable for assessing young children. For example, young children may not fully understand the directions or the vocabulary used in certain assessment tools. Furthermore, the diagnostic criteria for specific mental health issues (e.g., PTSD) are not developmentally appropriate for children younger than 5 (Scheeringa & Haslett, 2010). The APA Presidential Task Force on PTSD and Trauma in Children and Adolescents (2008) argues that children are not being appropriately identified or diagnosed as having trauma histories and do not receive adequate help.
From a historical perspective, mental health counselors as well as society as a whole have hesitated to acknowledge the plight that young children face in terms of trauma exposure. Several historical factors have contributed to counselors’ general lack of knowledge and expertise regarding this population. However, recent advances in research and in the counseling profession, such as the new American Counseling Association division, the Association for Child and Adolescent Counseling, have begun to broaden counselor knowledge in this area.
Symptoms of Trauma in Early Childhood
Trauma reactions can manifest in many different ways in young children with variance from child to child. Furthermore, children often reexperience traumas. Triggers may remind children of the traumatic event and a preoccupation may develop (Lieberman & Knorr, 2007). For example, a child may continuously reenact themes from a traumatic event through play. Nightmares, flashbacks and dissociative episodes also are symptoms of trauma in young children (De Young et al., 2011; Scheeringa, Zeanah, Myers, & Putnam, 2003).
Furthermore, young children exposed to traumatic events may avoid conversations, people, objects, places or situations that remind them of the trauma (Coates & Gaensbauer, 2009). They frequently have diminished interest in play or other activities, essentially withdrawing from relationships. Other common symptoms include hyperarousal (e.g., temper tantrums), increased irritability, disturbed sleep, a constant state of alertness, difficulty concentrating, exaggerated startle responses, increased physical aggression and increased activity levels (De Young et al., 2011).
Traumatized young children may exhibit changes in eating and sleeping patterns, become easily frustrated, experience increased separation anxiety, or develop enuresis or encopresis, thus losing acquired developmental skills (Zindler, Hogan, & Graham, 2010). There is evidence that traumas can prevent children from reaching developmental milestones and lead to poor academic performance (Lieberman & Knorr, 2007). If sexual trauma is experienced, a child may exhibit sexualized behaviors inappropriate for his or her age (Goodman, Miller, & West-Olatunji, 2012; Pynoos et al., 2009; Scheeringa et al., 2003; Zero to Three, 2005).
The symptoms that young children experience as a result of exposure to a traumatic event are common to many other childhood issues. Many symptoms of trauma exposure can be attributed to depression, separation anxiety, attention-deficit/hyperactivity disorder, oppositional defiant disorder or other developmental crises (see American Psychiatric Association, 2013). It is important for counselors to consider trauma as a potential cause of symptomology among young children.
Long-Term Consequences of Early Childhood Trauma
Recently, researchers have focused on how trauma during early childhood impacts mental and physical health later in life. Symptoms of mental illness can manifest immediately after a trauma, but in some cases symptoms do not emerge until years later. PTSD, anxiety disorders, behavior disorders and substance abuse have all been linked to traumatic events experienced during early childhood (Kanel, 2015). The types and frequencies of traumatic events and whether they were directly or indirectly experienced also can have various effects on physical and mental health later in adulthood. In a review of literature, Read, Fosse, Moskowitz and Perry (2014) described support for the traumagenic neurodevelopmental model. This model proposes that brain functioning changes following exposure to trauma during childhood. These biological factors often lead to psychological issues and physical and mental health concerns in adulthood.
Mental health professionals are often challenged to accurately diagnose PTSD in early childhood, leading to inconclusive reports of the actual prevalence of post-traumatic stress (De Young et al., 2011). Still, there is a clear relationship between PTSD diagnoses and trauma experienced in childhood. For example, higher rates of PTSD are reported among children residing in urban populations where neighborhood violence is prevalent (Crusto et al., 2010; Goodman et al., 2012). Briggs-Gowan et al. (2010) found an association between family and neighborhood violence exposure and oppositional defiant disorder, attention-deficit/hyperactivity disorder, conduct disorder and substance abuse. Additionally, noninterpersonal traumatic events (e.g., car accidents, burns, animal attacks) are associated with PTSD as well as anxiety, phobias, seasonal affective disorder and major depressive disorder (Briggs-Gowan et al., 2010).
Violence exposure is associated with externalizing problems while nonpersonal traumatic events are associated with internalizing problems (Briggs-Gowan et al., 2010). In a more recent study, Briggs-Gowan, Carter, & Ford (2011) found that exposure to neighborhood and family violence in early childhood is associated with poor emotional health and poor performance in school. Low socioeconomic status and traumatic events in early childhood also are correlated with low academic achievement in school (Goodman et al., 2012). Similarly, De Bellis, Woolley, and Hooper (2013) found maltreated children demonstrated poorer neuropsychological functioning and aggregate trauma was negatively related to academic achievement.
According to Schore (2001a), children and adults who experienced relational trauma during infancy are often faced with the struggles of mental disorder due to right brain impairment (p. 239). More recently, Teicher, Anderson, and Polcari (2012) found exposure to maltreatment and other types of stress as a child impacts hippocampal neurons leading to alterations in the brain and potential developmental delays. Additionally, there is evidence of relationships between mistreatment, bullying and accidents in early childhood and the development of delusional symptoms in later childhood (Arseneault et al., 2011). Young children who experience trauma and later use cannabis in adolescence are also at a higher risk for experiencing psychotic symptoms (Harley et al., 2010). Other studies have shown a correlation between early childhood trauma and development of schizophrenia later in life (Bendall, Jackson, Hulbert, & McGorry, 2008; Morgan & Fisher, 2007; Read, van Os, Morrison, & Ross, 2005). Changes in the brain may mediate these relationships between trauma exposure and mental health, as suggested by Schore (2001a, 2001b) and others.
Infants exposed to trauma are often inhibited by emotional and behavioral dysregulation in childhood and as an adult (Ford et al., 2013; Schore, 2001a, 2001b). Dysregulation resulting from trauma is predictive and related to substance use and functionality (Holtmann et al., 2011). For example, findings from a study by Strine et al. (2012) suggested that early childhood trauma and substance abuse are directly correlated. Children who had experienced more than one traumatic event were found to be 1.4 times more likely to become alcohol dependent. Strine et al. (2012) noted that females who experience trauma are more likely than males to abuse or become dependent on alcohol. The relationship between trauma and alcohol use and dependence often stems from untreated psychological distress (Strine et al., 2012).
In addition, there is ample evidence that early childhood trauma impacts later physical health. Some of the most well-known data on this topic come from the adverse childhood experiences study (Edwards et al., 2005). Multiple studies have found that early childhood trauma is associated with autoimmune disorders (Dube et al., 2009), headaches (Anda, Tietjen, Schulman, Felitti, & Croft, 2010), heart disease (Dong et al., 2004), lung cancer (Brown et al., 2010) and other illnesses. In fact, these studies often have found that the more frequent the exposure to early childhood trauma, the higher the risk of poor health outcomes in adulthood (Felitti et al., 1998).
Researchers have found clear evidence that children who experience traumatic events in early childhood are impacted well beyond their youth. Mental health disorders as well as alcohol and substance abuse emerge intermittently with age. Changes in brain functioning and physical health issues are also associated with early childhood trauma.
Risk and Protective Factors
Researchers have begun to explore factors that interact with trauma and the effects they may produce in young children. Environmental and demographic factors as well as parent–child relationships significantly impact outcomes for young children exposed to traumatic events (Briggs-Gowan et al., 2010). These factors may either insulate a child from adverse effects of trauma or increase the child’s risk for developing psychological distress.
Briggs-Gowan et al. (2010) found that symptoms of psychopathology and trauma were related to factors such as economic disadvantage and parent depressive and anxious symptoms. While ethnicity of the minor, parental education level and number of parents were associated with violence exposure, those factors were not associated with symptoms of mental illness. A more recent study found that young children exposed to a traumatic event along with a combination of socio-demographic factors (e.g., poverty, minority status, single parent, parental education less than high school, teenage parenting) are at greater risk for mental illness (Briggs-Gowan et al., 2011). Additionally, Crusto et al. (2010) found that high levels of parental stress are associated with adverse trauma reactions in young children. Parental dysfunction, family adversity, residential instability and problematic parenting can increase the impact of traumatic events as well (Turner et al., 2012). Young children exposed to chronic and pervasive trauma in addition to these risk factors are especially vulnerable to adverse effects (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008).
There are factors that may help protect young children from the negative impact of exposure to trauma. Turner et al. (2012) found that nurturing familial relationships can insulate children from psychological distress associated with traumatic events. Other factors such as safety and stability also might serve as protective factors. Safety implies that the child is free from harm or fear of harm, both physically and socially. Stability indicates consistency in the family environment, while nurturing suggests availability, sensitivity and warmth of caregivers or parents. Well-established, secure parent–child relationships are likely to provide protection from negative effects of trauma experienced by young children. A secure parental attachment has been shown to help children effectively regulate emotional arousal (Aspelmeier, Elliot, & Smith, 2007). Emotional regulation may be a mechanism that protects young children from extreme trauma reactions (De Young et al., 2011). Similarly, Crusto et al. (2010) found that caregiver support and healthy family functioning reduce the risk of psychological distress in young children after a traumatic event.
Early intervention and treatment can minimize the social and emotional impact of a child’s exposure to a traumatic event. Professional counselors should consider making referrals to counselors trained in providing early childhood mental health support. If the professional counselor has difficulties finding a referral source, the counselor’s basic counseling skills can provide the foundation for a safe, secure and trusting relationship between the counselor, family and child. Demonstrating empathy, genuine care and acceptance also fosters rapport among stakeholders (Corey, 2009). Mental health counselors can emphasize strengths and resources for the child and family.
Incorporating existing coping strategies can serve to minimize family stress and foster rapport with the child. Providing information about community support groups or other mental health agencies and resources also can help support and encourage the family. Informing parents and caregivers about symptoms common to young children exposed to traumatic events can foster awareness and allow for adequate support during the treatment process. Counselors can help the family establish or reestablish routines that begin to restore stability for the child, minimizing the adverse effects of the trauma (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008; Clay, 2010).
There are several evidence-based methods available to counselors treating trauma symptoms in young children. Evidence-based approaches are rooted in theory, evaluated for scientific rigor and tend to yield positive results (National Registry of Evidence-Based Programs and Practices, 2012). Trauma-focused cognitive behavioral therapy (TF-CBT) is a popular evidence-based treatment used with children aged 3–18. Based on cognitive behavioral therapy, humanism and family systems theory, TF-CBT includes many therapeutic elements for children and caretakers (Child Welfare Information Gateway, 2012). This form of therapy helps children develop different perceptions and a more adaptive understanding of the traumatic event (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008). Caretakers learn parenting and communication skills as they play active roles throughout the TF-CBT process. Multiple studies demonstrate the effectiveness of TF-CBT in reducing symptoms of trauma in early childhood (see Cohen & Mannarino, 1996, 1997; Deblinger, Stauffer, & Steer, 2001).
While TF-CBT is an established treatment for children and adolescents, there are evidence-based treatments developed specifically for treating trauma in children between birth and 6 years of age. Child–parent psychotherapy (CPP), one of the most widely used interventions for young children, was created to address exposure to domestic violence, although it can treat a variety of traumatic experiences (Lieberman & Van Horn, 2008). In this form of dyadic therapy, the child and the caregiver reestablish safety and security in the parent–child relationship (Lieberman & Van Horn, 2008). CPP is one of the few early childhood treatments validated for use with ethnic minorities (Lieberman & Van Horn, 2008). The primary goal of CPP is to equip parents to meet the psychological needs of their child and maintain a secure relationship after treatment has ended.
Attachment and biobehavioral catch-up (ABC) is another treatment option that is designed primarily for use with young children who have experienced neglect (Dozier, 2003). This approach was developed specifically for low-income families and later adapted for use with foster families. ABC is based on the neurobiology of stress and attachment theory. The goal of ABC is to foster the development of the child’s optimal regulatory strategies by equipping parents with tools for effective response (Dozier, 2003; Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008).
Counselors also can utilize parent–child interaction therapy (PCIT) when working with traumatized youth. PCIT is a structured technique for children ages 2–8 years in which the counselor teaches the parent or caregiver how to interact with the child and set effective limits (Chaffin et al., 2004). In this form of therapy, the counselor often assumes the role of coach, instructing the client on specific skills. Counselors frequently use PCIT when working with children abused by a caregiver. PCIT has been implemented successfully with various populations including Hispanic and Latino clients (Chaffin et al., 2004). The focus of PCIT is on improving the quality of the parent–child relationship as well as child behavior management (Chaffin et al., 2004; McCabe, Yeh, Garland, Lau, & Chavez, 2005).
The treatment interventions previously mentioned are geared toward very young children, all incorporating play as a treatment modality. Since young children do not have extensive vocabularies, they often communicate information about themselves, their trauma and relationships with their caregivers through play (Landreth, 2012). Play therapy intervention research using samples with children between birth and 5 years of age is scant; however, several case studies indicate that play therapy is effective with trauma in early childhood. For example Dugan, Snow, and Crowe (2010) utilized play with a 4 year old exhibiting PTSD symptomology after experiencing Hurricane Katrina in 2005. Anderson and Gedo (2013) provided a case study in which play was used to treat a 3 year old with aggressive behaviors who was separated from his primary caregiver. There also are intervention examples of using play therapy with young children exposed to domestic violence (Frick-Helms, 1997; Kot, Landreth, & Giordano, 1998).
Finally, there are emerging approaches specifically for treating young children exposed to trauma. Tortora (2010) developed Ways of Seeing, a program combining movement and dance therapy with Laban movement analysis to create a sense of regulation and homeostasis for the child exposed to a traumatic event. The Ways of Seeing program does not yet have empirical evidence of its effectiveness. However, it is rooted in attachment theory, multisensory processing, play and sensorimotor psychotherapy. Counselors can use this program to determine how a parent and child experience each other, implement creative interventions for healthy bonding, and renew a sense of efficacy for the parent and child. While much more research is needed, this program appears to be a promising approach to treating trauma in early childhood (see http://www.suzitortora.org/ waysofseeing.html).
Another emerging treatment, known as Honoring Children, Mending the Circle (HC-MC), is based on TF-CBT. The HC-MC approach was developed to address the spiritual needs of young Native American and Alaska Native children exposed to trauma. This method emphasizes preestablished relationships, wellness and healing during the treatment process. Spirituality is a critical component of healing and is integrated throughout the HC-MC approach. The goal of HC-MC is to help the traumatized child attain and reestablish balance (BigFoot & Schmidt, 2007, 2010). Additional research is needed on the efficacy of the HC-MC approach in working with Native American and Alaska Native youth.
A third emerging treatment, Trauma Assessment Pathway, is an assessment-based treatment that focuses on providing triage to young children exposed to traumatic events (Conradi, Kletzka, & Oliver, 2010). In this approach, the counselor uses assessment domains to determine the focus of treatment, provides triage to identify an appropriate pathway for intervention and establishes referrals to community resources if needed (Chadwick Center for Children and Families, 2009). The trauma assessment pathway method, which includes the trauma wheel, is a versatile mode of treatment available for the child and family. However, in many instances counselors may determine that an evidence-based practice, such as CPP, is the most appropriate mode of treatment (see Chadwick Center for Children and Families, 2009).
Each method of treatment offers specific strategies for working with traumatized young children and their families. However, findings from most studies investigating the effectiveness of these treatments are inconclusive (Forman-Hoffman et al., 2013). The strength of evidence for these and many other interventions are relatively low while the magnitudes of treatment effects are small (see Fraser et al., 2013). Common to the treatment models presented is the emphasis on system support, the importance of relationships in the recovery process and developmentally appropriate intervention modalities. These factors likely will serve as integral components of future methods focused on the treatment of traumatized young children.
Discussion and Implications
Young children are at high risk for exposure to traumatic events and are particularly vulnerable for several reasons. They are dependent upon caregivers and lack adequate coping skills. Children also experience rapid development and growth, leaving them particularly impressionable when faced with a traumatic event. Young children benefit from preventive psychoeducation aimed at teaching parents and caregivers about child development and parenting skills (McNeil, Herschell, Gurwitch, & Clemens-Mowrer, 2005; Valentino, Comas, Nuttall, & Thomas, 2013). Counselors who work with this population endeavor to increase protective factors and decrease risk factors while exploring preventive methods, which may reduce young children’s exposure to traumatic events. Similarly, legislators can influence public policy related to enhancing childhood mental health. For example, legislation can address prevention and offer incentives to parents participating in psychoeducation focused on enhancing protective factors and reducing childhood trauma exposure.
In recent years research has emerged that provides an understanding of how trauma impacts young children. Researchers and clinicians know that infants, toddlers and preschoolers have the capacity to perceive trauma and are capable of experiencing psychopathology following a traumatic event. Although these children can experience mental illnesses often associated with older children, adolescents and adults, the symptomology can manifest in various ways. Additionally, professional counselors working with children in a variety of settings should consider the residual impact of traumatic events experienced in early childhood. School-aged children may experience behavioral problems and have difficulty learning and forming relationships as a result of early childhood trauma (Cole, Eisner, Gregory, & Ristuccia, 2013; Cole et al., 2005). A number of studies indicate that trauma is a strong predictor of academic failure (Blodgett, 2012). Therefore, school counselors serving as mediators between academics and wellness should explore ways to advocate for and support students with known or suspected exposure to traumatic events in early childhood. For example, the trauma-sensitive schools initiative provides school counselors with a framework for fostering schoolwide awareness and creating a safe and supportive environment (Cole et al., 2013). School counselors can easily embed these types of preventive measures as part of a comprehensive school counseling program. These efforts will presumably result in increases in student success, wellness and awareness, three outcomes that will benefit all children exposed to traumatic events.
While great strides have been taken recently in understanding and treating early childhood trauma, there are clear gaps in the dissemination of information to counselors. Professional counselors should receive training in specifically designed interventions and attempt to raise public awareness of early childhood trauma in hopes that young children will receive necessary treatment. The findings of this literature review suggest that various methods of treatment might effectively reduce symptoms experienced by traumatized children. Parent–child relationships and other environmental factors also can have significant influence on children’s reaction to trauma.
A major purpose of this article is to educate counselors about the impact of trauma in early childhood and advocate for appropriate assessment and treatment of these traumatic exposures. While not all counselors choose to work with this vulnerable population, they often work with clients who have extended families with young children. Counselors who work with adult clients can provide psychoeducation about this important issue and initiate referrals to counselors trained to work with early childhood trauma. There is a body of information about trauma in early childhood available for further review. Sources include the National Child Traumatic Stress Network (nctsnet.org), the California Evidence-Based Clearinghouse for Child Welfare (cebc4cw.org), and the Association for Child and Adolescent Counseling (acachild.com). Counselors interested in learning more about this issue can review these online resources.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of
interest or funding contributions for
the development of this manuscript.
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Kristen E. Buss, NCC, is a counselor at Hope-Thru-Horses, Inc. in Lumber Bridge, NC. Jeffrey M. Warren, NCC, is an Assistant Professor at the University of North Carolina-Pembroke. Evette Horton is a clinical instructor at the UNC OBGYN Horizons Program at the University of North Carolina-Chapel Hill. Correspondence can be addressed to Jeffrey Warren, The University of North Carolina-Pembroke, P.O. Box 1510, School of Education, Pembroke, NC 28372, email@example.com.
Complex post-traumatic stress disorder
Complex post-traumatic stress disorder (C-PTSD) also known as developmental trauma disorder (DTD) or complex trauma is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma in the context of dependence, captivity or entrapment (a situation lacking a viable escape route for the victim), which results in the lack or loss of control, helplessness, and deformations of identity and sense of self. Examples include people who have experienced chronic maltreatment, neglect or abuse in a care-giving relationship, hostages, prisoners of war, concentration camp survivors, and survivors of some religious cults. C-PTSD is distinct from, but similar to, post-traumatic stress disorder (PTSD), somatization disorder, dissociative identity disorder, and borderline personality disorder.
Though mainstream journals have published papers on C-PTSD, the category is not formally recognized in diagnostic systems such as Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Statistical Classification of Diseases and Related Health Problems (ICD). It may be included in the upcoming ICD 11. However, the former includes “disorder of extreme stress, not otherwise specified” and the latter has this similar code “personality change due to classifications found elsewhere” (31.1), both of whose parameters accommodate C-PTSD.
C-PTSD involves complex and reciprocal interactions among multiple biopsychosocial systems. It was first described in 1992 by Judith Herman in her book Trauma & Recovery and an accompanying article. Forms of trauma associated with C-PTSD involve a history of prolonged subjection to totalitarian control including sexual abuse (especially child sexual abuse), physical abuse, emotional abuse, domestic violence or torture—all repeated traumas in which there is an actual or perceived inability for the victim to escape.
Child and adolescents
The diagnosis of PTSD was originally developed for adults who had suffered from a single event trauma, such as rape, or a traumatic experience during a war. However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, and a disruption in attachment to their primary caregiver. In many cases, it is the child’s caregiver who caused the trauma. The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child’s development. Currently there is no proper diagnosis for this condition, but the term developmental trauma disorder has been suggested. This developmental form of trauma places children at risk for developing psychiatric and medical disorders.
- Attachment – “problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to other’s emotional states, and lack of empathy”
- Biology – “sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems”
- Affect or emotional regulation – “poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes”
- Dissociation – “amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events”
- Behavioural control – “problems with impulse control, aggression, pathological self-soothing, and sleep problems“
- Cognition – “difficulty regulating attention, problems with a variety of “executive functions” such as planning, judgement, initiation, use of materials, and self-monitoring, difficultyprocessing new information, difficulty focusing and completing tasks, poor object constancy, problems with “cause-effect” thinking, and language developmental problems such as a gap between receptive and expressive communication abilities.”
- Self-concept -“fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self”.
Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization as children as well as prolonged trauma as adults. This early injury interrupts the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.
This can become a pervasive way of relating to others in adult life described as insecure attachment. The diagnosis of dissociative disorder and PTSD in the current DSM-IV TR(2000) do not include insecure attachment as a symptom. Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.
Six clusters of symptoms have been suggested for diagnosis of C-PTSD. These are (1) alterations in regulation of affect and impulses; (2) alterations in attention or consciousness; (3) alterations in self-perception; (4) alterations in relations with others; (5) somatization, and (6) alterations in systems of meaning.
- Difficulties regulating emotions, including symptoms such as persistent dysphoria, chronic suicidal preoccupation, self injury, explosive or extremely inhibited anger (may alternate), or compulsive or extremely inhibited sexuality (may alternate).
- Variations in consciousness, including forgetting traumatic events (i.e., psychogenic amnesia), reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation), or having episodes of dissociation.
- Changes in self-perception, such as a chronic and pervasive sense of helplessness, paralysis of initiative, shame, guilt, self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings
- Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator (caution: victim’s assessment of power realities may be more realistic than clinician’s), becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge, idealization or paradoxical gratitude, a sense of a special relationship with the perpetrator or acceptance of the perpetrator’s belief system or rationalizations.
- Alterations in relations with others, including isolation and withdrawal, persistent distrust, a repeated search for a rescuer, disruption in intimate relationships and repeated failures of self-protection.
- Loss of, or changes in, one’s system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.
C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994. It was neither included in DSM-5. PTSD will continue to be listed as a disorder.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to the relatively large numbers of American combat veterans of the Vietnam War who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse. However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. Such patients were often extremely difficult to treat with established methods.
PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: it is this loss, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.
C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment. DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of C-PTSD, when some adults with C-PTSD become parents and confront their own children’s attachment needs, they may have particular difficulty in responding sensitively especially to their infants’ and young children’s routine distress—such as during routine separations, despite these parents’ best intentions and efforts. Although the great majority of survivors do not abuse others, this difficulty in parenting may have adverse repercussions for their children’s social and emotional development if parents with this condition and their children do not receive appropriate treatment.
Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. C-PTSD better describes the pervasive negative impact of chronic repetitive trauma than does PTSD alone.
C-PTSD also differs from Continuous Post Traumatic Stress Disorder (CTSD) which was introduced into the trauma literature by Gill Straker (1987). It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services.
Traumatic grief or complicated mourning are conditions where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. If a traumatic event was life-threatening, but did not result in death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.
For C-PTSD to manifest, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect.
Attachment theory, BPD and C-PTSD
It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD:
Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.
Anger directed against the self or others is always a central problem in the lives of people who have been violated and this is itself a repetitive re-enactment of real events from the past. Compulsive repetition of the trauma usually is an unconscious process that, although it may provide a temporary sense of mastery or even pleasure, ultimately perpetuates chronic feelings of helplessness and a subjective sense of being bad and out of control. Gaining control over one’s current life, rather than repeating trauma in action, mood, or somatic states, is the goal of healing.
Seeking increased attachment to people, especially to care-givers who inflict pain, confuses love and pain and increases the likelihood of a captivity like that of betrayal bonding,(similar to Stockholm syndrome) and of disempowerment and lack of control. If the situation is perceived as life-threatening then traumatic stress responses will likely arise and C-PTSD more likely diagnosed in a situation of insecure attachment than PTSD.
However, 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was so diagnosed compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that “genetic factors play a major role in individual differences of borderline personality disorder features in Western society.”
In Trauma and Recovery, Herman expresses the additional concern that patients who suffer from C-PTSD frequently risk being misunderstood as inherently ‘dependent‘, ‘masochistic‘, or ‘self-defeating‘, comparing this attitude to the historical misdiagnosis of female hysteria.
The utility of PTSD derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Ford and van der Kolk have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD). For DTD to be diagnosed it requires a
‘history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses of other significant disruption or betrayal of the child’s relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.’
Since C-PTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency’s statutory legal obligations may then need to be enforced.
A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field:
- Identifying and addressing threats to the child’s or family’s safety and stability are the first priority.
- A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
- Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
- All phases of treatment should aim to enhance self-regulation competencies.
- Determining with whom, when and how to address traumatic memories.
- Preventing and managing relational discontinuities and psychosocial crises.
Herman believes recovery from C-PTSD occurs in three stages. These are: establishing safety, remembrance and mourning for what was lost, and reconnecting with community and more broadly, society. Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of “relationship”, however, and can also include relationships with friends, co-workers, one’s relatives or children, and the therapeutic relationship.
Complex trauma means complex reactions and this leads to complex treatments. Hence treatment for C-PTSD requires a multi-modal approach. It has been suggested that treatment for C-PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six suggested core components of complex trauma treatment include:
- Self-reflective information processing
- Traumatic experiences integration
- Relational engagement
- Positive affect enhancement
Multiple treatments have been suggested for C-PTSD. Among these treatments are experiential and emotionally focused therapy, internal family systems therapy, sensorimotor psychotherapy, eye movement desensitization and reprocessing therapy (EMDR), Dialectical behavior therapy (DBT), cognitive behavioral therapy, psychodynamic therapy, family systems therapy and group therapy.