When Nowhere is Safe: The Traumatic Origins of Developmental Trauma Disorder
October 22, 2018
Over the past 15 years, Developmental Trauma Disorder (DTD) has been formulated and proposed as a diagnosis by clinicians and researchers—and more broadly, as a way to capture the complex psychological, biological, and interpersonal sequelae of children’s exposure to victimization that extend beyond posttraumatic stress disorder (PTSD) (D'Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012; Ford et al., 2013; van der Kolk, 2005). Results of an international survey of pediatric and behavioral health clinicians provided initial support for the clinical utility of the DTD syndrome (Ford et al., 2013). A subsequent multi-site epidemiological field trial has offered validation for the proposed factor structure of this diagnostic construct as well as for the psychometric properties of a diagnostic interview tool to measure DTD (Ford, Spinazzola, van der Kolk, & Grasso, in press). Further analyses of the DTD Field Trial data now are reported in an article in the Journal of Traumatic Stress, demonstrating that children with DTD have a specific profile of past victimization that involves exposure to family and community violence and disruption of primary attachment relationships (Spinazzola, van der Kolk, & Ford, in press). Children with PTSD (and not DTD) had a different trauma history profile that involved exposure to physical assault or abuse. These findings are important as a guide to clinical practice and research with traumatized children, especially in light of research demonstrating that, in addition to PTSD, treatment-seeking children who have experienced victimization often exhibit a number of other internalizing and externalizing problems beyond PTSD (Spinazzola et al., 2005; Spinazzola et al., 2014) that may be best understood and treated using the DTD framework (D’Andrea et al., 2012).
In the DTD Field Trial study, we examined structured interview data with 236 children or their parent. The children ranged in age from 7-18, were 50% female, of diverse ethnocultural backgrounds (51% White non-Hispanic, 30% Black, 16% Latino/Hispanic; 3% Asian American,) and were recruited from outpatient mental health, pediatric and residential treatment settings that represented a mix of urban, suburban and rural communities across four geographical regions in the United States (Mid-Atlantic, Midwest, Northeast, South). Most of the children had experienced at least one traumatic event and were receiving mental health treatment. However, this was not entirely a clinical sample: approximately one-third of the children had no trauma history-- or at most a single incident of accidental or illness-related trauma-- and had no history of mental health treatment. The children were living in varied caregiving settings: with both biological parents (22%), in a step-family (30%), foster/adoptive family (19%), or residential facility (29%).
What we found when we examined the results of interviews with the child and/or an adult caregiver (with the Traumatic Events Screening Inventory for Children), was that both DTD and PTSD were associated with a history physical assault/abuse, family violence, traumatic neglect, emotional abuse, and polyvictimization (exposure to multiple types of victimization) However, children meeting criteria for DTD were more likely than all other children to report community violence exposure and growing up with a caregiver who was impaired by mental illness, substance abuse, or criminal involvement/incarceration. This was the case in multivariate regression analyses that ruled out the effects of other types of trauma/adversity as well as PTSD. In a similar analysis, controlling for the effects of DTD and all types of traumatic experiences, PTSD was found to be uniquely associated only with past physical assault/abuse.
In addition, DTD almost never occurred in the absence of both interpersonal victimization and attachment disruption. Only two children in the sample who had experienced no traumatic events, or only non-interpersonal traumas such as severe accidents or illnesses, met criteria for DTD. Moreover, while some children who had experienced either—but not both— interpersonal victimization or attachment disruption met criteria for DTD, fully 50% of the children who had histories of exposure to both interpersonal victimization and attachment disruptions met full criteria for DTD. Thus, study findings strongly supported the hypothesis that children meeting DTD symptom criteria are highly likely to have experienced both interpersonal victimization and attachment adversity, and that these types of childhood adversity are more closely related to the complex symptoms involved in DTD than to PTSD.
Our findings are consistent with other research suggesting that the combination of interpersonal victimization (and especially, living in dangerous family and community environments) and attachment adversity in childhood has an adverse synergistic effect on psychosocial development (Lowe et al., 2016). DTD involves symptoms that parallel and may co-occur with PTSD, but they also involve survival-like adaptations that extend beyond troubling memories, emotional numbing, emotional distress, and hypervigilance to alterations in the way that children regulate their emotions, behavior, relationships, and sense of self. This is interesting in its mirroring of emerging international research that has identified self/relational dysregulation as a core feature of a complex variant of PTSD in adults (Karatzias et al., 2017).
Therefore, although childhood PTSD and DTD were found to share several traumatic antecedents, DTD appears to warrant further investigation as a framework for the assessment and treatment of children with histories of co-occurring interpersonal victimization and attachment disruption. The specific forms of interpersonal trauma (i.e., family and community violence) and attachment adversity (i.e., impaired caregivers) that were uniquely associated with DTD represent not just the impact of specific traumatic injuries but a child’s entire social ecology that is characterized by persistent exposure to pervasive threat (Lieberman & Van Horn, 2009; McLaughlin & Sheridan, 2016). This finding qualifies and expands on important research on two conceptually relevant paradigms (adverse childhood experiences: Anda et al., 2006; polyvictimization: (Finkelhor, Ormrod, & Turner, 2007) by suggesting that the combination of family and community violence with impaired caregiving may constitute a particularly detrimental risk of impaired self and relational function and development for children over and above the contributions of other traumatic experiences. In fact, the co-occurrence of these three forms of childhood adversity may constitute a “Bermuda triangle” of developmental trauma. While findings from this study await replication with larger-scale, more broadly generalizable, stratified national samples, results from this field trial may reveal what is potentially the most vulnerable subpopulation of complex trauma victims: children and adolescents who endure significant disruption or impairment in their primary caregiving relationships while attempting to develop and thrive in the midst of chronic familial and community violence.
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- What emotional, behavioral, cognitive, and interpersonal symptoms do severely traumatized children experience that go beyond the symptoms of PTSD?
- Why might exposure to ongoing family and community violence in the absence of a stable secure attachment to protective caregivers have an impact that is different than the adverse impact of experiencing a physical assault or physical abuse?
Spinazzola, J. , der Kolk, B. and Ford, J. D. (2018), When Nowhere Is Safe: Interpersonal Trauma and Attachment Adversity as Antecedents of Posttraumatic Stress Disorder and Developmental Trauma Disorder. Journal of Traumatic Stress, 31: 631-642. doi:10.1002/jts.22320
Joseph Spinazzola is the Executive Director of the Foundation Trust and Co-Principal Investigator for the Developmental Trauma Disorder Field Trial.
Julian D. Ford is a Professor of Psychiatry in the University of Connecticut School of Medicine, President-elect of the International Society for Traumatic Stress Studies, and Co-Principal Investigator for the Developmental Trauma Disorder Field Trial.