Whether due to COVID, conflict, climate, or common car crashes, children often lose their caregiver at the same time they experience trauma. Our podcast with Julian Ford will help you understand the proposed diagnostic criteria and ideas for intervention for this complex developmental trauma disorder.
Published On: 05/15/2023
Duration: 29 minutes, 55 seconds
Transcript:
Dr. Feder: Developmental trauma disorder also known as DTD combines the disruption from a traumatic event with the loss of primary caregiving relationships. This is more complicated than posttraumatic stress disorder (PTSD). The symptoms are more profound and varied than PTSD because the child experiences both a threat to their safety and the loss of security and sense of protection from a caregiver. It’s even worse when trauma is the result of abuse, family or community violence, hate crimes, or armed conflict.  In this podcast, Mara and I will discuss the proposed criteria for developmental trauma disorder, how to differentiate it from similar conditions, assessment, treatment, and more. Dr. Julian Ford joins us today to help unpack this topic. 
Welcome to The Carlat Psychiatry Podcast.
This is another special episode from the child psychiatry team. 
I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice and the newer, Prescribing Psychotropics.
Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice. 

So how common is developmental trauma disorder? Well we don’t really know, however, the population at risk for developmental trauma disorder is substantial. National surveys of adolescents in the US and other high income countries report that one in four girls and one in fourteen boys have been sexually abused, over one in five have been physically abused, one in three have been emotionally abused, and one in six have experienced physical or emotional neglect. Also, one in four adolescents and one in six preschool children in the US are exposed to family violence, and one in four children lose a loved one or close friend to violence, or are exposed to violence in the community or at school.

Dr. Ford is developmental trauma disorder listed in the DSM-5?

Dr. Ford: Nope. It has not gotten into the DSM-5. Meanwhile, the International Classification of Diseases has, in its most recent edition, the 11th revision, it has a complex PTSD diagnosis for adults which is similar but somewhat different. But no. Developmental trauma disorder exists only in the minds of many, many clinicians who see children who have these difficulties and in the studies that we’ve done that are intended to provide evidence so when there is a DSM-5 version 5.1 or 5.2, we hope that it will be included.

Dr. Feder: So with no official DSM-diagnosis, what is the criteria used to assess or diagnose for developmental trauma disorder? 

Dr. Ford: So, the first criterion, criterion A is exposure to victimization trauma which could include abuse, other forms of maltreatment and includes emotional as well as physical and sexual abuse potentially, violence exposure.  Criterion B are emotional and somatic dysregulation symptoms. criterion C is attentional and behavioral dysregulation. The final symptom criterion is criterion D. That is relational and self-dysregulation.

Dr. Feder: Is Criteria A limited to abuse and violence or does it extend to disruptions in secure attachment bonds?

Dr. Ford: Yes. So, any kind of exposure to victimization, that is interpersonal trauma. And then also, exposure to fundamental disruptions in secure attachment bonds. So, that could be the result of being separated from a primary caregiver, having a primary caregiver who is significantly impaired and is unable to provide the conditions that make it possible for a child to develop a secure attachment bond. And any way in which the attachment bond with a primary caregiver is disrupted.

Dr. Feder: What are the symptoms of emotional and bodily dysregulation?

Dr. Ford: So, that’s just classically when kids have a difficult time regulating intense emotions, sometimes when they become very emotionally numb and shut down. But it also extends to dysregulation of the body, since there’s so much involvement of the body in emotions and dysregulation of the body’s ability to manage and to respond and protect the child from stress.

So, emotion and somatic dysregulation _00:15:00_ can include dissociation, as well; and that’s something that has gotten added onto PTSD, but it not in the adult complex PTSD in the ICD-11. So, there’s emotion dysregulation as one set of symptoms, which also include bodily aspects of emotions.

Dr. Feder: How about attention and behavioral problems?

Dr. Ford: So, these are the kinds of dysregulation when a child is basically having difficulties with impulses, with basically being very preoccupied with a sense of either being in danger or, in some cases, these are kids who are absolutely disregarding any kind of danger, whatsoever. Sometimes, they will avoid being aware of danger as a way of just kind of digging their head into the sand and trying to carry on in spite of situations in the past or currently that are quite dangerous.

So, the attentional focus toward or away from threats and then impulsive behavior, but also self-harming behavior, difficulties with self-soothing. That’s an important behavioral challenge for kids. Again, because in the absence of a secure caregiver bond, kids learn that they have to soothe themselves when they’re distressed. But that can become quite problematic.

These kinds of behavioral difficulties lead to a symptom that is often overlooked and that is when kids have a real difficulty with setting goals and sticking with whatever actions it takes to achieve the goals. That kind of difficulty is often considered only a learning disability – and it may be a learning disability. We’re not in any way challenging that. But it can also be the result of being so preoccupied with this sense of being under threat and not protected that that’s what really interferes with the ability to set goals and to achieve goals. It’s not a lack of motivation. It’s not a lack of intelligence. It’s simply being survival-oriented.

Mara: Dr. Ford, how does developmental trauma disorder impact a child’s self-image? And what types of relationship challenges can we expect to see?

Dr. Ford: Kids really start to see themselves as fundamentally damaged, as having something wrong with them that can never be fixed. So, this is similar to depression in a sense of worthlessness, but it’s actually much more profound in many ways because it’s fundamentally a sense that there’s something wrong with me that can never be fixed. I’m not just worthless, but I’m broken.

And then their relationships, and the difficulties in relationships that children have when they are experiencing developmental trauma disorder include on the one hand, protecting themselves by being aggressive. So, many times kids who are diagnosed with oppositional defiant disorder, they are kids who often have experienced profound trauma and in many cases, they’re not oppositional of defiant or aggressive because they’re in any way, shape or form wanting to hurt anyone, or because they’re fundamentally antisocial, it’s because they’re trying to make sure that they protect themselves by any means necessary. And that’s a reactive kind of aggression that we see that’s often related to experiencing trauma.

These are also kids who very often have a difficult time with empathy, with taking the perspective of others and so, they can seem very callous and unemotional and indifferent and that can lead them to be shunted off into the juvenile justice system. And we know that, unfortunately, many of the kids who end up in the juvenile justice system are unempathic and seem callous on the surface, but that’s largely because they’ve learned that they cannot trust others and they have to first take care of themselves.

Other kids actually become overly empathic, and they become overly involved and they become the caretakers for adults. So, this difficulty with empathy can cut two ways and similarly, kids with developmental trauma disorder often have difficulties keeping boundaries, so they can be absolutely unwilling to let anybody get close or they can also at times be indiscriminately seeking attachment.

I remember a little boy who I met at our children’s psychiatric hospital and the staff said, now, when meet him he’s a really nice kid; but you’re going to have to be careful, _00:20:00_ because he’s like a heat-seeking missile. He’s going to try to hug you no matter what. He’s just going come for you. And there’s a kid who just doesn’t have good boundaries in a sense, and that it’s very sweet in some ways and poignant but he’s a real at-risk for victimization because perpetrators will go after those kinds of kids, tragically.

Mara: Do cultural and social determinants play a role in developmental trauma disorder?

Dr. Ford: We’ve found that with the 500 or so kids who we’ve assessed using in our two studies so far, that it doesn’t make any difference whether they’re black or white, whether they’re Latinx or not Hispanic. It doesn’t matter what their family’s socio-economic background is, they’re all equally potentially at risk for developing these kinds of symptoms, if they’ve experienced these two fundamental conditions of victimization and attachment disruption.

So, you think then, of course, for children who are growing up in communities or countries where there is violence, where there’s war, where there is an absence of adults who can really fully protect them, those are kids who are going to be at more risk for these kinds of symptoms just simply because their overall environment is posing such a great risk of victimization and their caregivers are often required to do so much that it’s impossible to fully care for and sometimes even to have the quiet and the space to be able to develop a close, secure attachment.

Dr. Feder: Dr. Ford, when diagnosing patients, how do we differentiate developmental trauma disorder from reactive attachment disorder (RAD), dissociative disorders, and PTSD?

Dr. Ford: So, reactive attachment disorder also is typically a diagnosis for younger children. But these are kids who may be teenagers and still are having fundamental attachment problems. They rarely get diagnosed with reactive attachment disorder, even when they have significant attachment problems. So, that’s one way in which DTD can fill a gap.

They’re also different than kids who have primary dissociative disorders. Now, they may have significant dissociation, but this is not a disorder where we’re presuming that there is a fundamental fragmentation of the self in the way that is the case for most dissociative disorders, not just dissociative identity disorder, but even depersonalization or derealization disorders.

These are kids who dissociate very often, not always, but they dissociate in a sense where they’re not so much fragmenting_00:25:00_ into different personality states, but they are shifting their focus of awareness or it is shifting, actually, without them consciously determining it. And they simply go away. And it’s that kind of withdrawal that is not jut an intentional withdrawal to avoid, but literally where they go within themselves and they’re just not present. That’s the kind of dissociation that we see in developmental trauma disorder.

DTD is different from PTSD in that it’s not primarily based on a state of hyperarousal. There is hypervigilance, but it’s primarily based upon a withdrawal – a protective withdrawal which doesn’t always look like avoidance. Sometimes it looks like aggression. Sometimes it looks like just an inability to complete things or to be social with other kids or with other people.

So, it’s fundamentally different from PTSD in that it’s not just a preoccupation with threat and making sure that you don’t get taken by surprise again as, unfortunately, kids with PTSD are preoccupied with. It’s really a sense that you not only have to be concerned about threat - threats from the external world, but you also have to do whatever it takes in order to calm yourself, soothe yourself, maintain some sense of internal security and that’s different than any of those other disorders.

Dr. Feder: Borderline personality disorder is characterized by fear of rejection which leads to ambivalent enmeshment in relationships, while in complex PTSD and DTD patients feel unsafe and vulnerable and their symptoms are efforts to protect themselves and others above all else. The combination of borderline and developmental or complex trauma syndromes is most difficult to treat, although distinguishing their different effects may provide a path to better outcomes.  

Dr. Ford, do patients often have combinations that include developmental trauma disorder? 

Dr. Ford: That’s exactly right, Josh, and actually two of the papers that we’ve written are on comorbidity and the interesting thing is that DTD is comorbid with pretty much every other child psychiatric disorder. Not for every child, but in many, many cases. Very often, these are kids who meet criteria for depression, for anxiety disorders, for some of the disruptive behavior disorders.

The important thing that we found is that these are kids where any of those other disorders’ symptoms may be quite significant. But what’s not taken into account clinically, if you don’t consider the potential impact of trauma on these kids is that much of the emotional difficulty they’re having – if it’s anxiety or depression or the behavioral difficulties they’re having, if it’s oppositional defiance or even ADHD – those problems are very real, and they very often require some specialized treatment for those disorders.

Mara: When assessing for developmental trauma disorder ask about trauma and disrupted relationships. Catalog emotional and bodily symptoms, attentional and behavioral problems, and difficulties with sense of self and relating to others. Dr. Ford has developed a validated structured interview which we will link in the transcript to this podcast. Definitely check it out. There’s a version for adult caregivers, too, so that clinicians can get their perspective on their child’s symptoms in addition to the child or youth’s self-description. 

Some children may not recognize their daily experiences as traumatic , but they still have developmental trauma disorder symptoms. Still, symptoms can be subtle. Kids with developmental trauma disorder may shut down under stress and it seems like a natural response. 

For kids or teens who experience a potentially traumatizing event, such as nonconsensual sex, but do not show any symptoms of developmental trauma disorder or PTSD, look for less obvious ways in which they are hypervigilant, avoidant, self-blaming, dissociating, or living with hidden emotional turmoil. It’s possible for kids to not have any clear symptoms related to such experiences. They may be resilient and have found ways to compartmentalize the traumas so that they do well or even excel in the visible parts of their life. If they have neurodevelopmental problems, they may not have the perspective to understand what’s acceptable behavior or not. 

Dr. Feder, since providers typically need a DSM diagnosis for the patient’s medical record and developmental trauma disorder is not classified as an official disorder in the DSM-5, what should clinicians use?

Dr. Feder: Most kids with developmental trauma disorder meet criteria for PTSD, anxiety disorder, or depression. I also encourage clinicians to use diagnoses that are less stigmatizing but describe the child’s symptoms, refraining from using conduct disorder or Oppositional Defiant Disorder diagnoses to try to prevent people labeling a kid as “bad.” Whatever diagnosis you use, include developmental trauma disorder in your clinical formulation and treatment plan to help the child with the emotional or behavioral symptoms and shift their view of themselves and their lives so they feel more confident in themselves, and safer and more secure in their key relationships. 

Mara: Dr. Ford, what treatments are available for developmental trauma disorder?

Dr. Ford: Well, the treatment for kids who’ve experienced psychological trauma that has the strongest evidence base is trauma-focused cognitive behavioral therapy – TFCBT.  There’s another one called Abuse-Focused Cognitive Behavioral Therapy. And then there’s a wonderful treatment for very young children, toddlers and even infants and their caregivers called Child-Parent Psychotherapy. 

All of these approaches focus on helping either the adult in the child-parent psychotherapy approach or the child in the other treatment approaches in developing a story about traumatic events or a traumatic event or events that they’ve experienced. And developing a story that then helps them to make sense of what happened; not to feel terrible about it. These are not treatments that are designed to get kids all emotional or distressed, but instead, to actually help them to sort out things that have happened to them and put them into a story-like form, which can be something they dictate. It can be something they draw, so it can be done with creative arts expression. It doesn’t have to be done verbally.

And what they’re doing is really helping kids to figure out what has happened to me, so that they don’t have to avoid thinking about it or remembering it and so that they have some sense that it’s not happening again now; and that they actually did some things that helped them to get through those experiences which they can draw on now in healthier relationships.

Mara: What have you found to be the most effective approach to treatment? 

Dr. Ford: The most important thing I’ve found in working with children and adolescents who’ve experienced developmental trauma or any kind of traumatic stressors is that the best approach to treatment, regardless of what name we give it, the different evidence-based approaches is to find what the child or the adolescent – find their adaptive strengths and build on those. That’s often exactly the opposite of what we’re trained to do. Where we’re supposed to find their deficits and fix or somehow build something new that will kind of provide an alternative structure that will help them overcome their deficit.

Yeah, kids who’ve experienced developmental trauma, they sometimes do have deficits that they’re not as good sometimes at having relationships. At other times, they’re the best at doing things that you can possibly imagine, and I have yet to work with a kid who has experienced developmental trauma who doesn’t have incredible adaptive strengths. That’s why they’re still around. And building on those strengths.

I’ll give you one quick example and, again, I won’t talk about any one individual in a way that’s personally revealing. But I’ve worked with a number of kids who are very oppositional and they’re always getting into trouble at school, and it just seems like they’re always hanging out with the wrong kinds of kids. So, one young man who I met, he was exactly in that profile. He also pretty much kept detached from pretty much everybody, even though he hung out with the “wrong crowd” (in quotation marks) and _00:45:00_  and what he did in therapy for quite a period of time was he would just come in and then sit and talk on his phone to his friends. Occasionally, he would let me get a word in edgewise. Not very often. And my inner therapist was saying, oh, am I just wasting everybody’s time here; and I guess some other therapist would be able to handle this, but I can’t seem to figure out how to break through.

But I also figured, I guess I just need to be patient. So, I was patient and then one day he came in and he said, oh, I’ve got this video I want to show you. And he showed me a video, in brief, that he had taken of a couple of teenage girls at his high school fighting with each other. And my first thought was, I cannot watch this video. This is not a good thing. But then I also realized that this was a test on his part to see would I be willing to join him in some way in his world and see something through his eyes.

So, I said, I’ll watch the video but I’m going to watch it to learn about how you actually looked at and how you saw this event or these events. And what I learned was that he was a very expert filmer who could very well have a career as a combat photographer. He could be in very dangerous situations and doing an amazing job of filming. He actually did an after the fight interview with each of the girls, too.

This is one of the more classic examples in my experience where I’m thinking, you know, this is a kid who’s just so focused on conflict and aggression and avoidance, and he was. But he was also a kid who had remarkable abilities to be perceptive, creative abilities. And he wanted to tell stories and he wanted people to understand how he told the story, rather than having to do it in a conventional way. 

Now, that didn’t solve all the problems, but it gave us a basis for then beginning to actually talk and do some work together.

Dr. Feder: Is there a role for medication to support the treatment of developmental trauma disorder? 

Dr. Ford: Well, it’s similar to with PTSD where there is no FDA-approved medication and since developmental trauma disorder isn’t even a formal diagnosis, there clearly is no FDA-approved medication for those symptoms or for that disorder. But I do think even though it can be problematic to just try to medicate the symptoms, the single thing that I’ve seen – I work with child psychiatry residents and fellows here and whenever we talk about medications, the focus is on specific capacities. Medications that can help with not just behaviors, so not just like shutting down aggression like you’re saying or reducing some kind of disruptive behavior.

The medications that help with concentration, so again, that could be because of ADHD-like symptoms or impulsivity. Medication that also helps with sleep. Again, not to in any way suggest that medication to over-sedate kids. That’s something that has to be thought about very carefully. But medication that helps kids function as well as possible. Sometimes antidepressants when some of the symptoms include a profound sense of just loss of interest or just feeling blue and unhappy. I’ve seen medications be helpful for children who have more complex developmental trauma or PTSD symptoms, if they help them in areas of functioning that have been compromised by those or by other disorder symptoms.

In that sense, I think medication can be very helpful. But it’s almost always the case when we talk about cases here with the child psychiatry fellows, we almost always then get back to what can they do to help the child and the caregiver to understand how trauma has had an effect on this child? And how to then take the child’s adaptive strengths and really build on those with the caregiver and the child together. So, they end up having to learn how to do therapy even if they can only do 15-minute med checks and they have to do it briefly. And then they get pretty good at referring to therapists who can do a 50 or a 90-minute hour.

Dr. Feder: What’s the prognosis of developmental trauma disorder if it’s not adequately treated?

Dr. Ford:  Josh, that is a serious concern. We don’t know that because we’ve only done this work with children _00:55:00_ and adolescents so far, so we haven’t done a longitudinal study and followed up. But that is certainly one of the next steps that’s quite important because these are kids who could be heading for any number of problems – conduct disorder that becomes an antisocial personality diagnosis; kids who are very depressed and then become increasingly self-harming or even suicidal; kids who have such extreme difficulties in relationships with boundaries and with empathy and with an attempt to protect themselves through aggression, if necessary. Then if they also have the emotional dysregulation that we’ve been talking about, they can end up diagnosis borderline personality disorder.

So, yes, I think that this constellation of symptoms that we’re calling developmental trauma disorder could lead to some of the most problematic adult conditions and we don’t know that yet. But it is of great concern and we’re hoping that by having this conceptualized as a kind of a syndrome where it’s not just a bunch of random symptoms, but they all fit together and then clinicians can work with kids on the group of symptoms, rather than just on a single symptom here or a single behavior problem there. We’re hoping that that can then help kids to get off those trajectories where they’re heading for a serious psychiatric and sometimes socio legal problems.

Dr. Feder: Before we wrap up, do you have any remaining thoughts on this topic or an overall message for clinicians?

Dr. Ford: I think that the most important thing that we can do is to disseminate DTD as widely as we can possibly to as many clinicians who can use it – not as a diagnosis, but as a framework for understanding the kids that they’re working with so that you don’t miss some of the symptoms that might be related and that might be really important to consider when you’re looking at a kid who just seems to have only disruptive behavioral problems or a kid who just looks like they’re anxious, but they’re not really having intrusive memories.

These are the kids who are often experiencing the effects of trauma and who are adapting in symptomatic ways. If we use the DTD framework as a way to understand some of their adaptations and to help them then build healthy modifications of those adaptations, that’s what I’m hoping for, Josh. And then if it gets to be a diagnosis, that’s frosting on the cake.

Dr. Feder: The newsletter clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust. 

Mara: As always, thanks for listening and have a great day!

__________

The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.