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Synthesis, characterization, cellular uptake, apoptosis, cytotoxicity, dna-binding, and antioxidant activity studies of ruthenium(II) complexes.
Focus on Childhood and Adolescent Mental Health
Clinical Significance of a Proposed
Developmental Trauma Disorder Diagnosis:
Results of an International Survey of Clinicians
Julian D. Ford, PhD; Damion Grasso, PhD; Carolyn Greene, PhD;
Joan Levine, MPH; Joseph Spinazzola, PhD; and Bessel van der Kolk, MD
ABSTRACT
Objective: Maltreatment, family violence, and
disruption in primary caregiver attachment in
childhood may constitute a developmental form
of trauma that places children at risk for multiple
psychiatric and medical diagnoses that often are
refractory to well-established evidence-based mental
health treatments. No integrative diagnosis exists to
guide assessment and treatment for these children
and adolescents. This study therefore assessed
clinicians’ ratings of the clinical utility of a proposed
developmental trauma disorder diagnostic framework.
Method: An Internet survey was conducted with
an international convenience sample of 472 selfselected medical, mental health, counseling, child
welfare, and education professionals. Respondents
made quantitative ratings of the clinical significance
of developmental trauma disorder, developmental
trauma exposure, and symptom items and also
posttraumatic stress disorder (PTSD) and other
Axis I internalizing and externalizing disorder
symptom items for 4 clinical vignettes. Ratings
of the discriminability of each developmental
trauma disorder item from PTSD, other anxiety
disorders, affective disorders, and externalizing
behavior disorders, and of each developmental
trauma disorder item’s amenability to existing
evidence-based treatments for those disorders,
also were obtained.
Results: Respondents viewed developmental trauma
disorder criteria as (1) comparable in clinical utility
to criteria for PTSD and other psychiatric disorders;
(2) discriminable from and not fully accounted for by
other disorders; and (3) refractory to existing evidencebased psychotherapeutic treatments.
Conclusions: The exposure and symptom criteria
proposed for a developmental trauma disorder
diagnosis warrant clinical dissemination and scientific
field testing to determine their actual clinical utility in
treating traumatized children with complex psychiatric
presentations.
J Clin Psychiatry 2013;74(8):841–849
© Copyright 2013 Physicians Postgraduate Press, Inc.
Submitted: July 19, 2012; accepted January 17, 2013
(doi:10.4088/JCP.12m08030).
Corresponding author: Julian D. Ford, PhD, University of
Connecticut Health Center, Department of Psychiatry MC1410,
263 Farmington Ave, Farmington, CT 06030 (jford@uchc.edu).
T
he diagnosis of posttraumatic stress disorder (PTSD) was first
introduced in the American Psychiatric Association’s Diagnostic
and Statistic Manual of Mental Disorders, Third Edition, in 19801 to
describe the constellation of problems with intrusive reexperiencing of
traumatic memories, avoidance and emotional numbing, and hyperarousal exhibited by combat veterans and women exposed to domestic
violence or rape.2 Since this formal recognition of a unique constellation of symptoms experienced by trauma survivors in the diagnosis
of PTSD, dramatic scientific progress and clinical innovation has
occurred in the traumatic stress field.3,4
Even before the PTSD diagnosis was formalized, clinicians had
identified subgroups of childhood interpersonal trauma survivors with
symptoms of dysregulation5—including problems in managing extreme
emotion states, disruptive behavior, somatoform symptoms, conflict
in or withdrawal from relationships, and identity impairments—that
are more complex than those of PTSD.6 Substantial evidence indicates
that traumatized children are at risk for developing all of these types
of biopsychosocial dysregulation in addition to, and in the absence of,
PTSD.7 Moreover, there is evidence that the dysregulation experienced
by polyvictimized children and adolescents not only leads to polydiagnosis and polytreatment but also cannot be accounted for fully
by PTSD or other psychiatric disorders.8–10 Dysregulation symptoms
have been shown to comprise a transdiagnostic syndrome specific to
maltreated children.11–13 These findings have spurred the development14 and empirical validation of15–17 treatments designed to treat
children with complex forms of posttraumatic dysregulation. A formal
diagnosis could greatly spur this progress, as is evident in the growth
of the PTSD field since its formal codification.
Scientific and clinical studies suggest that a syndrome described as
developmental trauma disorder18 may fulfill these criteria.5,7 Developmental trauma disorder defines symptoms of affective, somatic,
cognitive, behavioral, interpersonal, and self-identity dysregulation
that constitute a “silent epidemic of neurodevelopmental injuries”19
caused by victimization20 typically beginning early in childhood.21 The
fiscal cost of childhood victimization in the United States—identified
by the Centers for Disease Control22 as the most significant current
public health issue—was $103.8 billion in 2007.23 Children exposed to
multiple forms of victimization—polyvictims—are particularly at risk:
they constituted one-third of children in a nationally representative
sample24 and 75% of children surveyed nationally in traumatic stress
treatment programs.25 The multiple forms of psychobiological dysregulation experienced by many polyvictims extend beyond PTSD8,26–34 and
persist into adulthood.35,36 They also often fail to benefit from evidencebased treatments,37–43 receiving multiple diagnoses as children,8,44
adolescents,45 and adults,46 and complex treatment regimens47,48 that
may lead to adverse reactions.49–51 However, polyvictimized children
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Ford et al
Clinical Points
■ Children in or in need of psychiatric treatment for multiple
comorbid diagnoses should be assessed for a history of
traumatic victimization and disrupted caregiver attachments.
■ The sequelae of childhood traumatic victimization and
disrupted caregiver attachments are a set of symptoms
that clinicians identify as clinically significant and not fully
accounted for by existing psychiatric diagnoses or effectively
treated by existing evidence-based treatments.
■ Developmental trauma disorder may provide a parsimonious,
single efficient diagnosis to guide the treatment of
traumatized children who present with multiple psychiatric
diagnoses.
have been shown to benefit when provided with treatments
that address the adverse impact of victimization on selfregulation.15,52–58 Similarly, adults with histories of childhood
victimization have been found to benefit from treatments
designed to enhance their ability to regulate emotions and
impulsivity.16,17,59–61
However, before undertaking the massive changes in
mental health systems required by instituting a new diagnosis, it is essential to show that the costs and effort are justified
by the incremental clinical utility of a proposed diagnosis.62
Draft criteria for adding a disorder to DSM-5 have been formulated,63 requiring that new diagnoses must be prevalent,
confer significant morbidity, and lack efficient diagnoses or
effective treatment. They also identify tests of face validity
(eg, by surveying clinicians) as key to demonstrating clinical utility. If clinicians consistently evaluate the criteria of
a proposed diagnosis or practice as highly useful for conveying unique information about patients that can facilitate
treatment planning and monitoring, then it would seem that
the diagnosis or practice will actually be used in practice.
Although clinician ratings alone cannot validate a diagnosis
or its criteria, they can provide guidance in selecting criteria that are most likely to be both informative and actually
adopted in practice.64–66
Therefore, the present study was designed to evaluate
developmental trauma disorder with regard to 2 other fundamental criteria for diagnoses62: clinical utility (“a helpful guide
to clinical practice”62[p561]) and discriminability from other
psychiatric disorders. These criteria require that practicing
clinicians judge a diagnosis to be value-added by enabling
them to parsimoniously and accurately characterize clinically
significant problems more accurately than existing diagnoses.
On the basis of clinical research literature summarized above,
we expected that the types of trauma (ie, childhood victimization involving disruption of primary caregiver bonds) and
dysregulation of emotion, bodily processes, cognition, behavior, relationships, and identity postulated for developmental
trauma disorder would be consistently judged by clinicians
to be useful for clinical formulations and treatment planning,
distinctive in relation to existing psychiatric disorders and
their criteria, and refractory to the available evidence-based
pharmacotherapy and psychotherapy treatment models.
METHOD
Procedure
Clinicians providing mental health, counseling, social
work, or pediatric services to children or families were
invited to participate in an anonymous Internet survey
using a snowball sampling approach. Initially, invitations
were sent to organizations and agencies in the public systems
sampled in the Patterns of Youth Mental Health Care in Public
Service Systems study67 and in a large national consortium
of traumatic stress treatment providers for children in the
United States (the National Child Traumatic Stress Network)
and an international professional organization representing
traumatic stress clinicians and researchers (the International Society for Traumatic Stress Studies). The survey was
posted on an encrypted SurveyMonkey site using a protocol
approved by the Institutional Review Board of the University
of Connecticut Health Center.
Sample
Respondents included 472 child-serving professionals:
34% psychologists, 29% social workers, 27% counselors, 13%
marriage and family therapists, 7% psychiatrists, 6% educators, 6% child protective services workers, 4% case managers,
and 4% pediatricians or pediatric nurses. They represented
a range of professional experience, with 27% reporting more
than 20 years, 27% reporting 10–19 years, and 41% reporting
less than 10 years.
A number of respondents (23%) were from countries
other than the United States: Australia, Canada, Israel, the
Netherlands, and Sweden. Respondents were predominantly
female (78%) and white (80%), and included 6% self-identified
as Hispanic. The median age was 45 years old.
Responses for each section of the survey were included
in analyses only for respondents who included all items in
that section. Respondents who completed each section were
generally comparable to others except in being more likely
to be psychologists than from other disciplines for vignette
1 (χ21 = 5.92), discriminability (χ21 = 5.45), and independence
(χ21 = 7.07) ratings and in being more likely to be counselors
than from other disciplines for the treatment response ratings
(χ21 = 6.60); all P values < .05.
Measures
The clinician survey consisted of primarily forced-choice
questions designed to require 45–60 minutes to complete.
After a 1-page introduction, institutional review board–
approved passive consent notification, and brief survey of
demographics, an explanation of the first 2 ratings—clinical
utility (usefulness for case formulation, treatment planning,
and professional communication for this child) and significance (extent to which improvement in this symptom is of
significance when the therapeutic gain/outcomes for this child
are assessed)—was provided with specific anchors on 9-point
rating scales. Each of the next 4 sections began with a detailed
1-page case vignette (see Table 1 for a summary), followed
by a list of 39–42 features (6 types of developmental trauma
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Clinician Survey for Developmental Trauma Disorder
for establishing clinical utility62,69,70
with 9-point Likert scale ratings. The
Vignette 1: 15-year-old obese aggressive Latina
items were based on a childhood comChildhood sexual, physical, and emotional abuse; parental domestic violence
plex PTSD formulation developed by
≤ 20 out-of-home placements since age 8
Diagnoses: posttraumatic stress disorder, reactive attachment disorder, associative disorder,
a group of content-matter experts
intermittent explosive disorder, bipolar disorder
from the National Child Traumatic
Described as vengeful, impulsive, reckless, having extreme mood swings, having an explosive
Stress Network and provisionally
temper, self-harming
Describes self as “garbage, worthless, reject”
titled “developmental trauma disorStrengths: determined, studious, articulate
der.”18 Survey items corresponded
Vignette 2: 13-year-old adopted white girl
to developmental trauma disorder
Biological mother diagnosed with substance use disorder; adoptive mother ill/died; childhood
criteria: A (6 items, each representing
sexual and physical abuse by babysitters/temporary caregivers
13 crisis hospitalizations for suicide/self-harm
a type of interpersonal victimization;
Diagnoses: bipolar disorder; intermittent explosive disorder; reactive attachment disorder;
ie, physical assault victim or witness;
attention-deficit disorder, hyperactive subtype; oppositional defiant disorder; substance use
sexual trauma; separation from or
disorder
Described as isolative, controlling, explosive, sexualized, intrusive, vindictive, narcissistic
absence of a primary caregiver; emoDescribes self as “disgusting, wish I was dead”
tional abuse by a primary caregiver;
Strengths: engaging, self-reliant, reading
neglect by a primary caregiver), B (9
Vignette 3: 11-year-old adopted African American boy
items, each representing a symptom
Childhood physical abuse and possible sexual abuse, parental domestic violence, biological mother
diagnosed with substance use disorder and had termination of parental rights when son was age
of emotion or somatic dysregula2—but mother now seeks renewed contact
tion), C (7 items, each representing
Diagnoses: reactive attachment disorder, social anxiety disorder, major depressive disorder/
a symptom of cognitive or behavioral
dysthymic disorder, conduct disorder, substance use disorder
Described as manipulative, unpredictable, having separation anxiety, callous, isolative, defiant
dysregulation, including self-harm
Describes self as “confused, guilty, hopeless”
and self-soothing), and D (7 items,
Strengths: intelligent, popular, affectionate
each representing a symptom of
Vignette 4: 7-year-old Asian American boy of Cambodian descent
relational-dysregulation or selfWitnessed parents being assaulted, brother’s murder, grandfather’s dissociative violence
Diagnoses: pervasive developmental disorder, schizophrenia, child disintegrative disorder,
dysregulation, including expectancy
stereotypic movement disorder, attention-deficit disorder, developmental coordination disorder
of betrayal and abandonment and
Symptoms: stereotypic self-harm/soothing, command/threat hallucinations, unpredictable rage,
belief that self is permanently damrelates to objects not people, wanders off
Described as odd, in his own world, spaced out, distractible, uncoordinated, a loner
aged). Each vignette was also rated on
Describes self as “quiet, happy by myself, I see lots of pictures in my mind”
an additional 11–14 symptom items
Strengths: follows rules and routines, good at math, computers, and video games
taken from DSM-IV criteria for likely
alternative or comorbid disorders
and 23 proposed developmental trauma disorder symptoms,
(which were purposefully varied to be appropriate to each
followed by 10–13 symptoms of DSM-IV disorders characcase vignette).
terizing each composite child) that were separately rated for
The vignettes were written by the first author and indeclinical utility and clinical significance. Sample items for the
pendently judged by 6 experienced clinicians (with 100%
developmental trauma features and developmental trauma
agreement) to represent (1) PTSD with dissociative and reacdisorder symptoms included experienced or witnessed viotive attachment features; (2) anxiety and affective disorders;
lent assault, actual or threatened sexual violation, repeated
(3) conduct/ oppositional-defiant disorder, attention-deficit/
separation from primary caregiver(s), inability to recover
hyperactivity disorder (ADHD), and substance abuse disfrom dysphoric states, and persistent inability to experience
orders; and (4) autism-spectrum and psychotic disorders.
positive affect.
Vignettes (available by request from J.D.F.) are summarized
The second section of the survey did not refer to a cliniin Table 1.
cal vignette but asked 116 questions based on 4 ratings of
The next set of questions elicited ratings regarding the disthe extent to which each of the 29 developmental trauma
criminability of the 29 developmental trauma disorder items
disorder features was discriminable (not at all to completely
from (1) PTSD and from each of 3 classes of psychiatric dis“distinct”) from the symptoms of (1) PTSD, (2) other anxiorders; (2) other anxiety disorders; (3) affective (depression
ety disorders, (3) depression or bipolar disorder, and (4)
and bipolar) disorders; and (4) ADHD, oppositional-defiant,
attention-deficit, oppositional-defiant, or conduct disorand conduct disorders. Each developmental trauma disorder
ders. In addition, another 115 items elicited ratings of the
symptom was then rated for the strength of agreement (from
(1) extent of overlap with any other psychiatric disorder
1 = complete disagreement to 9 = complete agreement) with
and (2) perceived effectiveness of existing evidence-based
the statement, the symptoms “provide information about a
pharmacotherapies or psychotherapies for each of those 4
child that is not fully provided in any existing diagnosis.”
sets of children’s psychiatric disorders in remediating each of
Finally, each developmental trauma disorder symptoms
the 23 developmental trauma disorder symptoms.
response to evidence-based treatments for PTSD, anxiety
Items were constructed by following the template used in
disorders, mood disorders, and externalizing disorders was
prior expert consensus surveys66,68 and drawing on guidelines
rated on 9-point Likert scales.
Table 1. Summary Description of the 4 Case Vignettes
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3.65–7.78
3.88–7.58
3.04–6.03
4.02 (2.79)–7.57 (1.61)
4.26 (2.89)–7.35 (1.74)
3.39 (2.70)–5.68 (2.67)
3.80–6.73
4.65–6.70
3.83–7.28
4.13 (2.71)–6.49 (1.96)
4.95 (2.46)–6.45 (2.04)
4.15 (2.59)–7.02 (2.09)
5.97–7.49
5.68–8.03
4.05–7.17
6.23 (2.27)–7.31 (1.61)
5.92 (2.12)–7.73 (1.48)
4.32 (2.36)–6.94 (2.02)
Existing DSM-IV/DSM-5 disorder symptoms
Developmental trauma disorder criterion A events
Developmental trauma disorder dysregulation symptom
Affective/somatic
6.14 (2.18)–6.92 (1.66)
Cognitive/behavioral
6.2 (1.88)–7.23 (1.57)
Relational/self
5.55 (2.04)–7.28 (1.72)
aRange from lowest to highest mean for that symptom/item domain.
5.94–7.06
6.02–7.37
5.36–7.44
Vignette 2 (n = 279)
Mean (SD), Range
95% CI
5.35 (2.38)–6.87 (2.02) 5.08–7.10
5.43 (3.00)–7.82 (3.05) 5.12–8.03
Vignette 1 (n = 437)
Mean (SD), Range
95% CI
6.35 (1.76)–7.89 (1.66) 6.19–8.04
8.04 (1.23)–8.39 (1.19) 7.93–8.49
Table 2. Clinician Ratings of Clinical Utility for Features of Existing Disorders and Developmental Trauma Disordera
Vignette 3 (n = 236)
Mean (SD), Range
95% CI
5.13 (3.01)–7.89 (1.50) 4.76–8.07
6.31 (2.55)–7.84 (1.67) 6.00–8.04
Vignette 4 (n = 214)
Mean (SD), Range
95% CI
6.42 (2.46)–8.00 (1.26) 6.10–8.16
3.61 (3.02)–7.97 (1.71) 3.22–8.19
Ford et al
Statistical Analyses
Consistent with the approach of prior consensus surveys,66,71 ratings were aggregated
based on mean scores and 95% confidence intervals (CIs). The distribution of ratings for
clinical utility and significance was organized in 3 categories: first line (95% CI ≥ 6.5), indicating a consistent high level of perceived utility or significance; second line (95% CI, 3.5–6.5),
indicating moderate perceived utility or significance; and third line (95% CI < 3.5), indicating unacceptable clinical utility or significance. Discriminability ratings were dichotomized,
with items that were considered discriminable from PTSD if 95% CI ≥ 4 (expecting some
overlap with PTSD) and from other anxiety or affective or externalizing behavior disorders if
95% CI ≥ 5. A more conservative requirement (95% CI ≥ 6) was used to identify items that
were considered not accounted for by other diagnoses. Developmental trauma disorder items
were classified as refractory to treatment if they were rated as, at most, partially remediable
by available evidence-based treatments (95% CI ≤ 6).
RESULTS
Clinical Utility Ratings
Table 2 displays the range of clinical utility ratings for existing psychiatric disorders, developmental trauma disorder event items, and each domain of developmental trauma disorder
symptoms. The highest-rated specific items for vignette 1 (a 15-year-old Latina diagnosed
with PTSD, reactive attachment disorder, dissociative disorder, intermittent explosive disorder, and bipolar disorder) were suicidality (95% CI, 8.2–8.4), all developmental trauma
disorder event items (95% CI, 7.9–8.5), and PTSD symptoms (intrusive reexperiencing,
hypervigilance, anger, negative affect; 95% CI, 7.0–8.0). Two dissociative symptoms, fugue
and depersonalization/derealization, were highly rated (95% CI, 7.0–7.4), as were developmental trauma disorder criterion B items (affect dysregulation; 95% CI, 7.0–7.1), criterion C
items (risky behavior, reactive aggression, self-harm; 95% CI, 7.3–7.4), and criterion D items
(self permanently damaged, expectancy of betrayal and victimization, impaired interpersonal
boundaries; 95% CI, 7.0–7.4).
In vignette 2 (a 13-year-old white girl diagnosed with bipolar disorder, reactive attachment
disorder, intermittent explosive disorder, attention-deficit/hyperactivity disorder, oppositional defiant disorder, and substance use disorder), clinical utility ratings were highest for
developmental trauma disorder criterion B (dysregulated anger; 95% CI, 7.4–7.7) and criterion C (self-harm, risky behavior, aggression, self-soothing; 95% CI, 7.1–8.0). Developmental
trauma disorder sexual trauma (95% CI, 6.8–7.4), criterion B (sleep and eating problems;
95% CI, 7.0–7.4), and criterion D (impaired interpersonal boundaries, expectancy of betrayal
and victimization, self permanently damaged; 95% CI, 6.7–7.1) items had moderate clinical
utility, as did 3 DSM-IV symptoms of mania (95% CI, 6.7–7.1), dysphoria (95% CI, 6.9–7.3),
and substance abuse (95% CI, 6.9–7.4).
Vignette 3 (an 11-year-old African American boy diagnosed with reactive attachment
disorder, social anxiety disorder, major depressive disorder/dysthymic disorder, conduct disorder, and substance use disorder) clinical utility ratings were highest for separation anxiety
and dysphoria (95% CI, 7.0–8.1). Developmental trauma disorder criterion A (separation from
primary caregivers and criterion D (expectancy of irresolvable loss) had moderately strong
clinical utility (95% CI, 6.9–7.4), as did developmental trauma disorder criterion B (emotional
disengagement and anger items) (95% CI, 6.7–7.3). School avoidance, rule violations, indifference to caregivers, and developmental trauma disorder criterion C symptoms (aggression,
risky behavior, self-soothing) also had moderate clinical utility (95% CI, 6.5–7.0).
Vignette 4 (a 7-year-old Asian-American boy diagnosed with autism spectrum, psychotic,
and related disorders) clinical utility ratings were low for developmental trauma disorder
features, except for exposure to violence (95% CI, 7.0–7.5) and self-soothing, impaired
expression of emotions, problems with anger, and self-harm (95% CI, 6.5–7.2). Clinical utility
ratings were highest for autism spectrum symptoms (95% CI, 7.3–8.3), PTSD flashback and
concentration problems (95% CI, 7.0–7.5), and psychotic symptoms (95% CI, 6.7–7.3).
Discriminability Ratings
Developmental trauma disorder items of separation, loss, neglect, and emotional abuse
were rated as distinguishable from PTSD criterion A, but developmental trauma disorder
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Clinician Survey for Developmental Trauma Disorder
Table 3. Discriminability of Developmental Trauma Disorder Events and Symptoms From DSM-IV Disorders (n = 225)
PTSD
Anxiety Disorders
Developmental Trauma Disorder
Events and Symptom
Mean (SD)
95% CI
Mean (SD)
95% CI
Criterion A: exposure
Violent assault
2.77 (2.78) 2.42–3.11
NA
Sexual violation
2.91 (2.80) 2.56–3.26
NA
Repeated caregiver separation
5.41 (2.99) 5.04–5.78*
NA
Absence of reliable caregiver
5.42 (3.05) 5.05–5.80*
NA
Emotional abuse by caregiver(s)
4.57 (3.01) 4.20–4.94*
NA
Emotional/physical neglect
4.80 (3.05) 4.42–5.18*
NA
Criterion B: affective and physiological dysregulation
Anger outbursts and irritability
3.71 (2.58) 3.38–4.04
4.75 (2.30) 4.45–5.04
Inability to recover/dysphoria
4.31 (2.67) 3.98–4.65
5.05 (2.40) 4.74–5.35
Inability to feel positive affect
4.53 (2.61) 4.20–4.86* 5.20 (2.29) 4.91–5.50
Impaired expressive emotion
4.69 (2.76) 4.33–5.04* 5.44 (2.38) 5.13–5.74*
Avoidance of emotion expression
4.27 (2.58) 3.94–4.61
5.49 (2.38) 5.18–5.80*
Eating or urination/defecation
4.75 (2.77) 4.39–5.11* 4.86 (2.41) 4.55–5.17
Somatoform pain
4.32 (2.73) 3.97–4.67
4.41 (2.45) 4.09–4.72
Aversion to touch
4.02 (2.73) 3.67–4.37
5.17 (2.48) 4.85–5.49
Criterion C: attentional and behavioral dysregulation
Preoccupation with threats
3.28 (2.73) 2.93–3.63
4.41 (2.49) 4.09–4.73
Reactive aggression
3.58 (2.67) 3.24–3.92
5.27 (2.63) 4.93–5.61
Avoidance due to perceived threat
3.06 (2.68) 2.72–3.40
4.24 (2.65) 3.89–4.58
Risk taking or reckless behavior
4.91 (2.71) 4.56–5.25* 6.47 (2.47) 6.15–6.79*
Nonsuicidal self-harm
4.65 (2.80) 4.29–5.01* 5.46 (2.55) 5.13–5.79*
Maladaptive self-soothing
4.30 (2.72) 3.95–4.65
4.57 (2.46) 4.24–4.89
Criterion D: self and relational dysregulation
Belief that self was damaged
3.71 (2.90) 3.33–4.08
6.10 (2.55) 5.76–6.43*
Belief self permanently damaged
3.89 (2.87) 3.52–4.25
5.67 (2.61) 5.33–6.01*
Expectancy of betrayal
4.17 (2.77) 3.82–4.53
5.58 (2.57) 5.25–5.91*
Expectancy of victimization
3.78 (2.81) 3.43–4.14
5.30 (2.54) 4.98–5.63
Indiscriminate physical contact
5.37 (2.73) 5.01–5.72* 6.35 (2.46) 6.03–6.67*
Overidentification with others’ distress 5.17 (2.62) 4.84–5.51* 5.55 (2.51) 5.23–5.88*
Expectancy of irresolvable loss
5.04 (3.04) 4.65–5.43* 5.71 (2.73) 5.35–6.06*
*Lower bound of 95% CI ≥ 4.00 for PTSD or ≥ 5.00 for all other disorders.
Abbreviations: NA = not applicable, PTSD = posttraumatic stress disorder.
items of violence and victimization were not (Table 3). Developmental trauma disorder symptoms rated as distinguishable
from PTSD included several criterion B items: impaired
positive and negative affect, affect tolerance and expression,
emotion regulation, and bodily functions and pain). Other
developmental trauma disorder symptoms distinguishable
from PTSD were criterion C risky behavior, self-harm, and
self-soothing and criterion D impaired physical and emotional boundaries and expectancy of irresolvable loss.
Several developmental trauma disorder symptoms were
rated as distinguishable from anxiety disorders: criterion B
impaired/avoided emotional expression; criterion C reckless behavior, self-harm, and aggression; and all criterion D
symptoms. All criterion C attention/behavioral dysregulation
symptoms were rated as distinguishable from affective disorders, except self-harm and self-soothing, as were all criterion
D symptoms, except self as permanently damaged. Aversion
to touch was the only criterion B item rated as distinguishable from affective disorders.
Several developmental trauma disorder symptoms were
rated as distinguishable from externalizing disorder symptoms, including all developmental trauma disorder criterion
D symptoms, except impaired physical boundaries, as well
as criterion B aversion to touch and avoidance of emotional
expression, and criterion C avoidance of and preoccupation
Depression
Mean (SD)
95% CI
NA
NA
NA
NA
NA
NA
Externalizing Disorders
Mean (SD)
95% CI
NA
NA
NA
NA
NA
NA
4.09 (2.28)
3.67 (2.67)
3.20 (2.67)
4.58 (2.41)
4.63 (2.47)
4.32 (2.59)
4.32 (2.39)
5.82 (2.47)
3.80–4.39
3.32–4.01
2.86–3.55
4.26–4.88
4.31–4.95
3.98–4.66
4.01–4.63
5.50–6.14*
3.43 (2.39)
3.91 (2.46)
4.58 (2.35)
4.92 (2.37)
5.63 (2.42)
5.11 (2.52)
5.19 (2.49)
6.10 (2.33)
3.13–3.74
3.59–4.22
4.27–4.88
4.61–5.22
5.31–5.94*
4.79–5.44
4.87–5.51
5.80–6.41*
5.64 (2.52)
6.02 (2.47)
5.52 (2.57)
5.90 (2.55)
4.17 (2.49)
4.42 (2.44)
5.31–5.96*
5.70–6.34*
5.19–5.86*
5.57–6.23*
3.84–4.49
4.10–4.74
5.63 (2.49)
5.24 (2.50)
5.79 (2.48)
3.76 (2.83)
4.21 (2.52)
4.41 (2.51)
5.31–5.96*
4.92–5.57
5.47–6.11*
3.39–4.13
3.88–4.54
4.08–4.74
5.70 (2.60)
4.69 (2.63)
5.44 (2.54)
5.36 (2.53)
6.38 (2.42)
5.38 (2.48)
5.29 (2.63)
5.36–6.04*
4.35–5.03
5.11–5.77*
5.03–5.69*
6.06–6.69*
5.06–5.70*
4.95–5.64
6.16 (2.61)
5.51 (2.56)
5.63 (2.56)
5.90 (2.53)
5.08 (2.54)
6.02 (2.41)
6.17 (2.55)
5.82–6.51*
5.12–5.84*
5.30–5.97*
5.57–6.23*
4.74–5.41
5.71–6.34*
5.84–6.51*
with threats. No criterion B affect items or criterion C behavior dysregulation symptoms were rated as distinguishable
from externalizing disorder symptoms.
Overall, 26 of the 29 developmental trauma disorder event
and symptom criteria were rated as distinguishable from
at least 1 of the 4 classes of psychiatric disorders (PTSD,
anxiety, affective, externalizing). Anger outbursts, inability to recover from negative affect states, and maladaptive
self-soothing were the only developmental trauma disorder
criteria that were not rated as discriminable from any of the
other disorders.
Ability of Other Psychiatric Disorders to Account
for Developmental Trauma Disorder Symptoms
Although developmental trauma disorder symptoms may
be distinguishable from other disorders’ symptoms, those
disorders may be able to account for developmental trauma
disorder symptoms as a result of their having similar if not
exactly identical symptoms. Using this more conservative
standard for evaluating the uniqueness of symptoms proposed for developmental trauma disorder, raters identified
7 developmental trauma disorder symptoms as probably not
accounted for by any other psychiatric disorder (Table 4).
Most prominently, these included developmental trauma disorder criterion D symptoms (beliefs about self as permanently
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Table 4. Ability of Psychiatric Disorders to Account for Developmental
Trauma Disorder Symptoms (n = 218)
Developmental Trauma Disorder Symptom
Criteriona Mean (SD)
95% CI
Symptoms probably not accounted for by other diagnoses (95% CI > 6.0)
Belief that self is permanently damaged
D
7.04 (2.47)
6.71–7.36
Expectancy of irresolvable attachment loss
D
6.96 (2.55)
6.62–7.30
Expectancy of betrayal
D
6.94 (2.46)
6.61–7.26
Belief that self was damaged by trauma
D
6.94 (2.54)
6.60–7.27
Expectancy of victimization
D
6.86 (2.50)
6.53–7.20
Overidentification with others’ distress
D
6.59 (2.23)
6.29–6.89
Maladaptive self-soothing
C
6.39 (2.61)
6.04–6.73
Symptoms potentially not accounted for by other diagnoses (95% CI > 4.5)
Reactive aggression due to perceived threats
C
6.22 (2.64)
5.87–6.57
Impaired attention due to perceived threats
C
6.18 (2.65)
5.83–6.53
Aversion to touch
B
6.17 (2.63)
5.82–6.52
Indiscriminate seeking of physical contact
D
6.12 (2.51)
5.78–6.45
Impairment in expressive emotion skills
B
6.06 (2.39)
5.74–6.37
Avoidance of emotion expression
B
5.97 (2.40)
5.66–6.29
Inability to recover from dysphoric states
B
5.91 (2.44)
5.59–6.23
Persistent inability to experience positive affect
B
5.67 (2.55)
5.33–6.00
Nonsuicidal self-harm
C
5.66 (2.67)
5.30–6.01
Avoidance due to perceived threats
C
5.57 (2.76)
5.21–5.94
Somatoform pain (medically unexplainable)
B
5.07 (2.66)
4.72–5.42
Extreme risk taking or reckless behavior
C
4.97 (2.69)
4.62–5.33
aCorresponding developmental trauma disorder criteria for the 3 criteria: criterion B
(affective and physiological dysregulation), criterion C (attentional and behavioral
dysregulation), and criterion D (self and relational dysregulation).
Table 5. Developmental Trauma Disorder Symptom Responsiveness to Existing Evidence-Based Treatments (n = 141)
PTSD Evidence-Based
Treatment
Developmental Trauma
Disorder Symptom
Mean (SD)
95% CI
Criterion B: affective and physiological dysregulation
Anger outbursts and irritability
5.93 (2.10) 5.60–6.27
Inability to recover/dysphoric
5.44 (2.21) 5.08–5.80*
Inability to feel positive affect
5.24 (2.18) 4.88–4.60*
Impaired expressive emotion
5.12 (2.28) 4.75–5.50*
Avoid emotion expression
5.39 (2.22) 5.03–5.75*
Eating or urination/defecation
4.60 (2.54) 4.19–5.02*
Somatoform pain
4.91 (2.38) 4.53–5.30*
Aversion to touch
4.90 (2.53) 4.48–5.31*
Criterion C: attentional and behavioral dysregulation
Preoccupation with threats
5.88 (2.19) 5.52–6.24
Reactive aggression
5.79 (2.30) 5.42–6.17
Avoidance of perceived threats
5.99 (2.25) 5.62–6.36
Risk taking or recklessness
5.05 (2.31) 4.67–5.43*
Nonsuicidal self-harm
5.48 (2.28) 5.10–5.85*
Maladaptive self-soothing
5.45 (2.33) 5.07–5.83*
Criterion D: self and relational dysregulation
Belief that self was damaged
5.61 (2.62) 5.18–6.04
Belief self permanent damaged
5.56 (2.58) 5.14–5.98*
Expectancy of betrayal
4.99 (2.41) 4.59–5.38*
Expectancy of victimization
5.25 (2.30) 4.87–5.62*
Indiscriminate physical contact
4.60 (2.57) 4.18–5.02*
Overidentification with others’
4.43 (2.39) 4.04–4.82*
distress
Expectancy of irresolvable loss
4.56 (2.71) 4.12–5.01*
*Upper bound of 95% CI < 6.00.
Abbreviation: PTSD = posttraumatic stress disorder.
Other Anxiety Disorder
Evidence-Based
Treatment
Mean (SD)
95% CI
Depressive Disorder
Evidence-Based
Treatment
Mean (SD)
95% CI
Externalizing Disorder
Evidence-Based
Treatment
Mean (SD)
95% CI
5.22 (2.26)
4.77 (2.13)
4.88 (2.17)
4.98 (2.18)
5.07 (2.22)
4.80 (2.36)
4.91 (2.33)
4.85 (2.41)
4.85–5.59*
4.42–5.12*
4.52–5.23*
4.62–5.34*
4.70–5.43*
5.51–5.20*
4.53–5.29*
4.45–5.24*
5.52 (2.04)
5.86 (1.97)
6.17 (2.02)
5.60 (2.12)
5.55 (2.12)
4.92 (2.34)
4.77 (2.30)
4.30 (2.38)
5.18–5.85*
5.54–6.19
5.84–6.50
5.25–5.95*
5.20–5.90*
4.53–5.30*
4.40–5.16*
3.91–4.69*
5.51 (2.03)
5.13 (2.09)
5.13 (2.13)
5.02 (2.18)
4.80 (2.21)
4.53 (2.33)
4.11 (2.21)
3.99 (2.37)
5.18–5.85*
4.79–5.47*
4.78–5.48*
4.66–5.38*
4.43–5.16*
4.14–4.91*
3.75–4.48*
3.60–4.39*
5.40 (2.32)
4.98 (2.31)
5.74 (2.32)
4.49 (2.32)
4.91 (2.27)
5.38 (2.17)
5.02–5.78*
4.60–5.36*
5.36–6.12
4.10–4.87*
4.53–5.28*
5.02–5.73*
4.72 (2.44)
4.53 (2.42)
4.83 (2.33)
4.87 (2.27)
5.90 (2.11)
5.49 (2.15)
4.32–5.12*
4.13–4.93*
4.44–5.21*
4.49–5.24*
5.56–6.25
5.14–5.85*
4.52 (2.30)
4.62 (2.34)
4.45 (2.33)
5.45 (2.32)
5.48 (2.19)
4.97 (2.32)
4.14–4.91*
4.23–5.00*
4.06–4.83*
5.07–5.84*
5.11–5.84*
4.59–5.35*
4.14 (2.57)
4.53 (2.51)
4.45 (2.51)
4.66 (2.40)
4.06 (2.55)
4.49 (2.40)
3.72–4.57*
4.12–4.95*
4.03–4.86*
4.26–5.05*
3.64–4.48*
4.09–4.88*
4.46 (2.49)
4.97 (2.48)
4.62 (2.37)
4.71 (2.30)
4.14 (2.52)
4.45 (2.39)
4.05–4.87*
4.56–5.38*
4.23–5.01*
4.33–5.09*
3.72–4.56*
4.05–4.85*
3.93 (2.41)
4.25 (2.43)
4.18 (2.42)
4.11 (2.36)
4.61 (2.46)
4.16 (2.32)
3.53–4.33*
3.84–4.65*
3.78–4.58*
3.72–4.50*
4.20–5.02*
3.78–4.55*
4.16 (2.65)
3.72–4.60*
4.58 (2.59)
4.15–5.00*
3.90 (2.48)
3.49–4.31*
damaged and irresolvable loss, betrayal, and victimization
in relationships), as well as the criterion C maladaptive selfsoothing symptom.
Another 12 developmental trauma disorder symptoms
were rated as potentially not accounted for by any other
psychiatric disorder: 6 criterion B affective and somatic
dysregulation symptoms, 5 criterion C attentional and
behavioral dysregulation symptoms, and 1 criterion D
relational dysregulation symptom (Table 5). Thus, only 4
of the 23 developmental trauma disorder symptoms (17%)
were rated as potentially (1 symptom; 95% CI lower bound
between 4.1 and 4.5) or likely (3 symptoms; 95% CI lower
bound between 3.5 and 4.0) accounted for by any other psychiatric disorder.
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Clinician Survey for Developmental Trauma Disorder
Developmental Trauma Disorder Symptom
Refractoriness/Responsiveness to Existing
Evidence-Based Treatments
With the following exceptions, raters consistently viewed
developmental trauma disorder symptoms as not well ameliorated by evidence-based treatments for PTSD or other
internalizing or externalizing disorders (Table 5). Evidencebased treatments for PTSD were rated as effective for anger
problems, sleep disturbance, preoccupation with threats,
aggression and avoidance in reaction to perceived threats,
and beliefs that the self was damaged by trauma. Evidencebased treatments for other anxiety disorders were rated as
effective in treating only the developmental trauma disorder
symptoms of sleep disturbance and avoidance of perceived
threats. Evidence-based treatments for depressive disorders
were rated as effective in enhancing affect regulation, positive affect, and sleep and reducing nonsuicidal self-harm.
Evidence-based treatments for externalizing disorders were
rated as generally ineffective for developmental trauma
disorder symptoms. Collectively, existing evidence-based
treatments were rated as generally effective for only 39%
(9 of 23) of the developmental trauma disorder symptoms.
The mean ratings for evidence-based treatment effectiveness ranged from a low of 3.90 (for externalizing disorder
evidence-based treatments and expectancy of irresolvable
loss) to 6.17 (for affective disorder evidence-based treatments and positive affect), indicating an overall view that
evidence-based treatments are, at most, partially effective
with developmental trauma disorder symptoms.
DISCUSSION
Ratings by child-serving clinicians indicated that developmental trauma disorder criteria may have clinical utility
and, despite some overlap, may be discriminable from existing psychiatric diagnoses and their criteria. Clinicians also
consistently rated developmental trauma disorder symptoms
as, at best, only partially remediated by evidence-based child
psychiatry treatments. These findings support the face validity of the developmental trauma disorder criteria as a basis
for a psychiatric diagnosis.5,18 Although many of the proposed developmental trauma disorder symptoms were rated
as overlapping with symptoms of existing child psychiatric
disorders, every proposed developmental trauma disorder
symptom was viewed by the clinical raters as at least somewhat distinct from and not accounted for by some or all of
the descriptively similar internalizing (eg, PTSD, anxiety disorders, depression) and externalizing psychiatric disorders.
The degree of each developmental trauma disorder item’s
clinical utility, discriminability, and independence varied
with the specific clinical features of different cases and different DSM-IV psychiatric disorders. This observation suggests
that a range of developmental trauma disorder symptoms
is necessary to encompass the clinical features of dysregulated polyvictimized children. Additionally, respondents
consistently rated exposure to interpersonal victimization
and disrupted attachment bonds with primary caregivers as
very high in clinical utility and discriminability. This finding
suggests that the combination of polyvictimization and
attachment disruption assessed in developmental trauma
disorder is integral to the proposed syndrome or diagnosis.
Clinicians also rated developmental trauma disorder
symptoms as, at best, only partially remediable by the array
of evidence-based interventions for PTSD and other psychiatric disorders. This outcome suggests that adaptations
or novel treatments based on a developmental trauma disorder framework72 may be needed. An integrative diagnosis
might not only increase diagnostic accuracy and efficiency
but moreover enable clinicians to replace (or reduce) the
plethora of treatments necessitated by multiple comorbid
diagnoses with targeted treatments focused on posttraumatic
psychobiological dysregulation.7
However, several limitations of the study make its findings preliminary and in need of further research. Clinician
ratings were based on hypothetical composite cases that
may not be representative of actual patients rather than on
diagnostic or treatment outcome data from studies of specific patient cohorts. The convenience sample of clinicians
may not be representative of all child-serving clinicians and
professionals. International respondents may not have been
familiar with DSM symptom definitions. Knowledge of psychological trauma and evidence-based treatments for PTSD
(and other child psychiatric disorders) was not assessed,
potentially adding artifact to findings of overlap between
developmental trauma disorder and PTSD symptoms and of
limited perceived efficacy of evidence-based treatments for
developmental trauma disorder symptoms. Monoinformant
comparisons and missing data for many of the ratings also
may have led to undetected response biases.
Further research, therefore, is needed beyond surveying clinicians, including studies to determine (1) whether
victimization-related symptoms are unique to childhood
interpersonal trauma or whether they also apply to some
types of extreme victimization experienced in adulthood
(eg, torture, genocide) or to pervasive noninterpersonal
traumatic stressors, such as chronic life-threatening illness
or loss of family, home, and community in the wake of disasters; (2) whether disturbances in development of attachment
security that are nonviolent, such as severe neglect or the
death or permanent loss of a primary caregiver, result in
similar symptoms; (3) whether and how these symptoms
originate in sensitive developmental periods73 and evolve
as alterations in normal developmental trajectories during
childhood and throughout the subsequent lifespan; and
(4) whether developmental trauma disorder symptoms are
linked to biological vulnerability/resilience processes and
markers.
With regard to clinical utility, it also will be important to
determine how developmental trauma disorder symptoms
are actually used by clinicians and how they empirically perform when scientifically and clinically assessed in children,
including their structure and interrelationships, temporal
stability or patterns of change, convergent and discriminant
validity and comorbidity related to existing psychiatric
diagnoses, predictive utility for both developmental and
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Ford et al
treatment outcomes, and efficiency and acceptability for
use in real-world clinical practice. A first step toward those
ends has begun with a national field trial study testing the
psychometrics and clinical utility of a developmental trauma
disorder structured interview developed based on this survey’s findings. Many additional clinical and scientific studies
will be needed to determine how best to characterize severely
victimized children’s trauma histories and trauma-related
symptoms and impairments.
Author affiliations: Department of Psychiatry, University of Connecticut
School of Medicine (Drs Ford, Grasso, and Greene and Ms Levine) and
The Trauma Center at the Justice Resource Institute (Drs Spinazzola and
van der Kolk).
Potential conflicts of interest: None reported.
Funding/support: The study was funded by a grant from the
Cummings Foundation (Drs Ford and van der Kolk, principal investigators).
Acknowledgments: The authors gratefully acknowledge the contributions
of Bradley Stolbach, PhD, Department of Pediatrics, University of Chicago,
Illinois; Wendy D’Andrea, PhD, Department of Psychology, New School for
Social Research, New York, New York; and the National Child Traumatic
Stress Network Developmental Trauma Disorder Work Group, co-led by
Robert Pynoos, MD, Department of Psychiatry, University of California,
Los Angeles, to the conceptual and clinical framework for this study. None
of the acknowledged individuals have any conflicts of interest to report.
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Editor’s Note: We encourage authors to submit papers for
consideration as a part of our Focus on Childhood and Adolescent
Mental Health section. Please contact Karen D. Wagner, MD, PhD, at
kwagner@psychiatrist.com.
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