Julian Ford, PhD, ABPP
Professor, Department of Psychiatry, University of Connecticut. Farmington, CT. Director, The Center for the Treatment of Developmental Trauma Disorders, a part of the National Child Traumatic Stress Network (www.nctsn.org).
Dr. Ford has no financial relationships with companies related to this material.
CCPR: We’re all familiar with posttraumatic stress disorder—what is developmental trauma disorder?
Dr. Ford: Developmental trauma disorder (DTD) combines symptoms from a traumatic event with additional symptoms from the disruption or loss of a critical primary caregiving relationship. This is more complicated than posttraumatic stress disorder (PTSD). For instance, after a car accident a child may have PTSD symptoms (eg, intrusive re-experiencing, hypervigilance), but if a parent dies in that same accident, the child also loses a critical relationship. The symptoms are more profound and varied than for 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 the trauma is the result of abuse, family or community violence, hate crimes, or armed conflict.
CCPR: DTD is not listed in the DSM-5.
Dr. Ford: That’s true. A 2009 task force proposal to include DTD in the DSM-5 documented that 95% of children in the Illinois child welfare system had trauma-related symptoms but did not qualify for a PTSD diagnosis (www.tinyurl.com/395puf9v). Still, DTD didn’t make it in. The International Classification of Diseases 11th Revision (ICD-11) has a complex PTSD diagnosis for adults. It resembles DTD but omits many symptoms. For example, problems in relationships are limited to detachment or withdrawal. DTD includes that, but adds insecurity, conflict, over-involvement, and too little or too much empathy. There’s nothing like DTD in DSM-5 or ICD-11 for children and adolescents.
CCPR: How common is DTD?
Dr. Ford: We don’t really know. However, the population at risk for DTD is substantial. National surveys of adolescents in the US and other high-income countries report that one in four girls and one in 14 boys have been sexually abused (Finkelhor D et al, J Adolesc Health 2014;55(3):329–333). Surveys also report that over one in five children have been physically abused, one in three have been emotionally abused, and one in six have experienced physical or emotional neglect (Stoltenborgh M et al, Child Abuse Review 2015;24(1):37–50). 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 (www.tinyurl.com/4s6nrxj4).
CCPR: What are the criteria for DTD?
Dr. Ford: There are four criteria described in our work and in the task force proposal (Editor’s note: See “Consensus Proposed Criteria for Developmental Trauma Disorder” at www.thecarlatreport.com/devtrauma): 1. A traumatic event involving victimization combined with disruption of attachment; 2. symptoms of emotional and/or bodily dysregulation; 3. attentional and behavioral dysregulation; and 4. profoundly negative self-concept and difficulty relating to others (Ford JD et al, Acta Psychiatr Scand 2022;145(6):628–639; www.tinyurl.com/4t5zkpwj).
CCPR: What are the symptoms of emotional and bodily dysregulation?
Dr. Ford: Kids may overreact to situations or become numb, shut down, or even dissociate. They can’t think through what to do to solve the problem or protect themselves. They may experience bodily problems such as pain, gastrointestinal upset, or headaches that do not respond to medical treatment. Somatic dysregulation is not included in PTSD or complex PTSD but is a symptom of DTD.
CCPR: What about attention and behavioral problems?
Dr. Ford: Some kids might want to achieve a goal but can’t get started or stay focused. This might be mistaken for ADHD or a learning disability. While the child could also have either of those things, the DTD aspect is the result of being preoccupied with threat, not a lack of motivation, ability, or intelligence. Behaviorally, the child might self-harm as an attempt at self-soothing when they are frightened, frustrated, or disappointed. Kids with DTD are super-survivors, but their constant focus on survival makes it tough to deal with ordinary life, learning, and relationships, partly due to the absence of a secure and stabilizing caregiver bond.
CCPR: What types of relationship challenges would we see with DTD?
Dr. Ford: Kids with DTD see themselves as damaged and unfixable. They may protect themselves from becoming close to others by being aggressive and may be diagnosed with oppositional defiant disorder (ODD). Many kids in the juvenile justice system have DTD; some seem callous and unemotional or unable to trust others. They might be labeled as delinquent or incorrigible, but many care deeply about others and have positive core values. They are quick to protect themselves, hiding their vulnerability and reacting aggressively to perceived injustice or hypocrisy. Other kids become overly empathic caretakers. Many have difficulty keeping boundaries, indiscriminately seeking attachment. One boy I met would try to hug you no matter what. This is at-risk behavior for victimization—perpetrators go after those kids.
CCPR: Do cultural and social determinants play a role in DTD?
Dr. Ford: Systemic racism and inequities add to adversity. Poverty and homelessness have a traumatic impact. Although more affluent White children and families have advantages that can reduce their risk of trauma, DTD can occur when a child of any race, ethnicity, or background experiences victimization and disrupted attachment bonds.
CCPR: Moving to diagnosis, how do we differentiate DTD from reactive attachment disorder (RAD), dissociative disorders, and PTSD?
Dr. Ford: There is overlap. Children with RAD often have developmental trauma. Teenagers are rarely diagnosed with RAD, so that’s one way DTD fills a gap. Kids with DTD may have dissociative disorders, but the withdrawal in kids with DTD is a pervasive primary response to any stressor. Kids with PTSD are often preoccupied with threat, but children with DTD have more trouble maintaining a sense of internal security. PTSD in the DSM-5 focuses on hyperarousal. DTD is about protective withdrawal, which includes emotional shutdown, dissociation, self-protective aggression, trouble completing things, and difficulty socializing with peers or adults.
CCPR: What about borderline personality disorder?
Dr. Ford: Borderline personality disorder is characterized by fear of rejection, which leads to ambivalent enmeshment in relationships. In complex PTSD and DTD, patients feel unsafe and vulnerable, and their symptoms are efforts to protect themselves and others above all else (Ford JD and Courtois CA, Bord Personal Disord Emot Dysregul 2021;8:16). 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.
CCPR: So patients often have combinations that include DTD?
Dr. Ford: Yes. DTD can be comorbid with any other child psychiatric disorder, including depression, bipolar disorder, anxiety disorders, and disruptive behavior disorders such as ODD and disruptive mood dysregulation disorder (Ford JD et al, J Ch Adol Trauma 2021. Epub ahead of print). You need to recognize the DTD or it will be difficult to treat the other conditions.
CCPR: How do you assess for DTD?
Dr. Ford: 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. We’ve developed a validated structured interview that is free (www.complextrauma.org). There’s a version for adult caregivers, too, so that clinicians can get the caregiver’s perspective on the child’s symptoms in addition to the child or youth’s self-description.
CCPR: We typically need a DSM diagnosis for the medical record. What should we use?
Dr. Ford: Most kids with DTD meet criteria for PTSD, anxiety disorder, or depression. I use diagnoses that are less stigmatizing but describe the child’s symptoms. I hesitate to use conduct disorder or ODD diagnoses because they can lead to labeling a kid as “bad.” Some children may not recognize their daily experiences as traumatic (for example, in instances of maltreatment or family or community violence), but they still have DTD symptoms. Still, symptoms can be subtle. Kids with DTD may shut down under stress and it seems like a natural response. Whatever diagnosis you use, include DTD in your clinical formulation and treatment plan to help the child address 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.
CCPR: What do you think about kids or teens who experience a potentially traumatizing event, such as non-consensual sex, but do not show any symptoms of DTD or PTSD?
Dr. Ford: Look for less obvious ways in which they are hypervigilant, avoidant, self-blaming, dissociating, or living with hidden emotional turmoil. It’s entirely possible for kids to not have any clear symptoms related to such experiences. They may be resilient and find 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 constitutes acceptable or unacceptable behavior.
CCPR: Is there treatment for DTD?
Dr. Ford: I am developing a treatment, but right now the strongest evidence for treating DTD-like symptoms is trauma-focused cognitive behavioral therapy (TFCBT). There is an excellent introduction to TFCBT available online (www.tfcbt.org). For kids at school, there is a program called Cognitive Behavioral Intervention for Trauma in Schools. For young children, there’s abuse-focused cognitive behavioral therapy. And then there’s child-parent psychotherapy (CPP), a wonderful treatment for infants and very young children and their caregivers. You can learn CPP at www.childparentpsychotherapy.com. All these approaches help the child or youth develop a story about traumatic events that helps them and their parent or caregiver make sense of what happened. This way they don’t have to avoid thinking about it, they understand that it’s not happening again, and they have new ways to respond for healthier relationships. (Editor’s note: Long-term psychodynamic therapy, as well as eye movement desensitization and reprocessing, is also used for traumatic disorders. See: Strauss MB. Treating Trauma in Adolescents: Development, Attachment, and the Therapeutic Relationship. New York, NY: Guilford Press; 2017.)
CCPR: Tell us about the treatment that you are developing.
Dr. Ford: It’s called Trauma Affect Regulation: Guide for Education and Therapy (TARGET). It helps kids and adults shift from reacting to reminders of traumas to focusing on their core values and life goals. The most important thing is to identify adaptive strengths and build on those. We’re trained to do the opposite—to find deficits and build structures to overcome them. One young man I worked with was detached in therapy, talking on his phone with friends. I was patient. One day he said “I’ve got this video I want to show you” of teenage girls at school fighting. My first thought was “I cannot watch this.” But this was a test to see if I would see things through his eyes. He was focused on aggression and avoidance, but he had remarkable perceptive abilities. That gave us a basis to begin working together.
CCPR: Is there a role for medication to support the treatment of DTD?
Dr. Ford: Like with PTSD, there are no FDA-approved medications for children with DTD-like symptoms. Treatment focuses on trauma, the caregiver-child relationship, and building on the child’s strengths. However, there are often problems that medication might help, such as concentration, impulsivity, or sleep. Antidepressants or mood stabilizers can help when DTD symptoms occur in combination with severe depression or extreme highs and lows.
CCPR: What’s the prognosis of DTD if it’s not adequately treated?
Dr. Ford: That is a serious concern. We haven’t done a longitudinal study; however, these kids could be heading for behavioral disorders that become labeled antisocial; depression that leads to self-harm or suicide; or difficulties with boundaries, empathy, and aggression in relationships.
CCPR: But there’s hope for better outcomes.
Dr. Ford: Yes. If you identify and treat the DTD, you can help kids understand how they’ve been affected by trauma, teach them that it doesn’t make them defective, and help them understand that they can learn to protect themselves and feel safe in ways that help them live a happier and more functional life.
CCPR: Thank you for your time, Dr. Ford.
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