As a Clinical Psychologist within a Post Adoption Support Service, I work with children and adolescents who have experienced a number of negative and often frightening early life events including abuse, neglect and the loss of at least one primary caregiver. Despite the resilience that is nothing short of inspirational shown by most, a number of children require additional support from mental health professionals at some point in their lives. Many of these children receive psychiatric diagnoses, sometimes more than one, though others do not meet criteria for any particular diagnostic category – despite clearly struggling across numerous domains of functioning. So what use are these labels for the individuals and families trying to make sense of the difficulties? This problematic question is by no means an original one; clinicians and researchers have debated for years about the potential merits and pitfalls of assigning a specific set of criteria to those struggling with their emotional well-being, and those that work in the field continually seek to refine the diagnostic system, whilst acknowledging its inherent limitations.
In this vein, the term ‘Developmental Trauma’ is increasingly used as a way of conceptualising and describing the distress experienced by individuals exposed to early and chronic trauma. Despite its popularity, the term is not a formal diagnostic category, which leaves me wrestling with a number of questions: how useful is the Developmental Trauma framework in my work? What, if anything, can it do for us as clinicians and ultimately how does it help our young people and their families?
What is Developmental Trauma?
The traditional label given to individuals who experience distress following a traumatic incident is Post Traumatic Stress Disorder (PTSD). However, it has been argued that those individuals exposed to multiple traumas in childhood frequently do not meet the criteria for a PTSD diagnosis. Hence, the problem discussed earlier arises – children either receive no diagnosis (and potentially no access to services) or receive an alternative diagnosis not recognised within the context of trauma, such as Autistic Spectrum Disorder (ASD) or Conduct Disorder. And so it is within this space that the term Developmental Trauma was introduced and was intended to specify the impact of multiple childhood traumas, noting that the difficulties (and perhaps treatment required) differs from that following a single traumatic incident.
Developmental Trauma Disorder was later put forward for inclusion in the latest Diagnostic Statistical Manual (DSM-V), following a definition and set of diagnostic criteria developed by Dr Bessel van der Kolk and his colleagues within the National Child Traumatic Stress Network in 2009. The criteria included the following: exposure to trauma, affective and physiological dysregulation, attentional and behavioural dysregulation, self and relational dysregulation and post traumatic spectrum symptoms. To gain a diagnosis, symptoms would have to be present for 6 months or more and be having a clinically significant impact on the Individuals level of functioning. Despite evidence presented from a number of DSM-V field trials, Developmental Trauma Disorder did not make it into the DSM-5 and there are opposing views as to whether or not it should be re-considered.
The alternative to the DSM-5, the World Health Organisation’s International Classification of Diseases (ICD), is due to release its eleventh edition this year and includes an updated diagnosis of Complex PTSD. This sits alongside PTSD within the ‘disorders specifically associated with stress’ category but, importantly, is distinct. It will include the PTSD symptom clusters and three additional symptom clusters related to difficulties in emotion regulation, a negative sense of self and disturbances in relationships. Early studies have demonstrated that adults meeting criteria for either PTSD or Complex PTSD are significantly different in terms of their type of trauma history and their level of functional impairment (Cloitre et al., 2013), therefore demonstrating the potential value in moving away from the one, limited diagnosis of PTSD. However, Complex PTSD is based on adult psychopathology and its’ applicability to children is yet unknown. Furthermore, it still requires individuals to meet PTSD criteria first, which was a key criticism of the existing classification system.
What are the advantages and disadvantages of these ‘new’ diagnoses?
Diagnosis is often essential for treatment and support. For that reason, one of the strongest arguments in favour of the new diagnoses centres on increasing access to services. This is especially pertinent to the looked after and adopted population who are often victims of childhood trauma and one of the most vulnerable to poor psychosocial outcomes in our society. Several government reports have highlighted that this cohort are often denied services as they may not meet criteria for a mental health diagnosis. The inclusion of Developmental Trauma may alleviate this problem; allowing for greater understanding, reduced stigma and better access to support. Van der Kolk (2014) also argued that without an adequate diagnostic framework, clinicians run the risk of applying ineffective, timely and costly treatments to individuals who may otherwise benefit from a different approach. Therefore, acknowledging distinct trauma-related disorders may also pave the way for greater research and investigation into tailored treatment approaches.
An alternative school of thought advises that trauma is at the heart of many mental health difficulties and that an over-focus on this particular precursor means that clinicians neglect to consider other influences (e.g. biological factors). As a result, individuals may miss out on existing diagnoses and subsequent evidence-based treatments. It has also been criticised that the proposed criteria for the two diagnoses overlap with existing disorders such as Borderline Personality Disorder and Attachment Disorder, and thus undermines the existing structure. In view of this, Marylene Cloitre has proposed adopting a spectrum of trauma-related syndromes which includes PTSD, Complex PTSD and Borderline Personality Disorder (with or without PTSD).
Both standpoints resonate with my personal clinical experience. I have met children who, in my opinion, meet criteria for ASD and would benefit greatly from the support and treatment tailored to this condition, but whose parents have had multiple referrals for a neurodevelopmental assessment rejected and have been offered only attachment-based explanations for their child’s presenting needs. The diagnosis of ASD has only been truly considered when the child is unable to cope with the demands of Secondary School and numerous treatment attempts have failed. On the other hand, I have also met many young people who have numerous diagnoses; none of which appear to be helpful in understanding the distress they are experiencing. The National Institute of Clinical Excellence (NICE) guidelines for treating their diagnoses have not enabled the individuals to move forward with their life and in this case, I have utilised the Developmental Trauma framework to help the young person and their family understand the difficulties and consider a different treatment approach. The Developmental Trauma lens has also been incredibly helpful for children with clear emotional and behavioural difficulties, but who would not meet criteria for any diagnosis.
And so, I go back to my earlier questions; how useful is the Developmental Trauma framework and what can it do for us as clinicians and for the young people that we work with? In my opinion, the Developmental Trauma label can be a useful way of helping individuals to understand and empathise with their own or a loved ones’ trauma-related difficulties. For that reason, it may be a useful addition to the current classification system, particularly if it facilitates greater access to treatment and research in the field. That being said, caution should be given when viewing difficulties through a ‘trauma-only lens’ and using these terms as ‘catch-all’ diagnoses. Occasionally, children and young people miss out on other well-established diagnoses as their experience of early trauma over-shadows other potential influences. As clinicians, we do have the skills to guard against this, and to consider the broader narrative and context around the child. In particular, clinical formulation enables the inclusion of multiple biopsychosocial factors and strengths in order to develop a shared understanding of the child to inform the most appropriate way forward.
Cloitre M., Garvert D. W., Brewin C. R., Bryant R. A., & Maercker A. (2013). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4, 20706. doi:10.3402/ejpt.v4i0.20706
Van der Kolk, B. A. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking Press, 2014.
This is an independent article and the views are not necessarily those of ACAMH.
A beautifully clear and helpful exposition of the issues around diagnosis as well as around Developmental Trauma as a useful (or not) diagnostic and intervention framework. As ever though, when working with clients whose life histories are complex and challenging, a psycho-social approach, rich in curiosity and hypothesis testing would seem the most respectful and useful way forward. A psycho-social approach allows us to acknowledge when ‘diagnosis’ is being used as a gateway to services as well as a key means to understand our client, to help them and their loved ones understand their needs and to increase the likelihood that the interventions we propose are tailored to address the most likely maintaining factors of their distress and psychological challenges.
Thanks so much Catherine for your really useful summary and reflections. Whilst in Sussex and now Suffolk I run an autism clinic. In those with early abuse deprivation AND a diagnosis of autism it is often still difficult to choose between an attachment/ trauma approach adjusted for those on the spectrum, also pending on cognition. I wondered whether you would be aware of any epigenetics research for those target groups? I believe in many severely deprived cases there is a point of no return where too much damage is done in the interpersonal relative relationship area and brain structures responsible for this despite the greater plasticity capacity in the young. recovery will be long term. It would be good to have more insight via a more specific diagnostic approach. Many thanks
Where does the term ‘dysregulated stress response ‘ fit into this picture I wonder. Described by Dr Nadine Burnley Harris I have found this really useful to describe the complex and varying difficulties my adopted son displays and I wonder what you feel about it?
Hi Ann and thanks for your comment. I also find the information about having a dysregulated stress response (following trauma) very helpful in my work. This is captured within the Developmental Trauma framework as one of the seven key components is ‘affective and physiological dysregulation’. Thanks, Catherine.
A very clear and helpful summary of the diagnostic challenges in this field. I need to know more about the boundaries (in dx terms) between ‘developmental trauma’ and other possible explanations. For example, exclusionary criteria.
Important work. Keep it up!!
Hi Dr Frogley,
Really enjoy reading your articles! Always so insightful! Would you mind if I asked you a couple questions regarding my dissertation? Would really love your perspective. Willing to pay for a session to interview you on zoom or via email.