Kolk, 2014; van der Kolk et al., 2009). Steps in this direction have been seen in the inclusion of a diagnosis for complex PTSD in the ICD-11 (World Health Organization [WHO], 2019). To be diagnosed with DTD, the child must have experienced or witnessed multiple or prolonged adverse events over a period of at least one year. These events specifically include experiencing or witnessing interpersonal traumas and/or significant caregiving disruptions or emotional abuse. In addition to the traumatic qualifier, symptoms are then clustered into the categories of (van der Kolk, 2014; van der Kolk et al., 2009): ● Affective and physiological dysregulation (e.g., inability to modulate or tolerate affect states; disturbances in regulation in bodily functions) ● Attentional and behavioral dysregulation (e.g., impaired normative developmental competencies related to attention, learning, or coping with stress) ● Self and relational dysregulation (e.g., impaired normative developmental competencies in the sense of personal identity and involvement in relationships) ● Posttraumatic spectrum symptoms (i.e., the child exhibits at least one symptom of PTSD) ● Functional impairment (e.g., disturbances in scholastic, familial, occupational, or peer group settings) Although PTSD and DTD may seem similar, DTD is distinct from PTSD in multiple ways. The stressor criterion in DTD specifically requires a caregiving-related stress and/or the presence of interpersonal traumas. Studies have found the symptom presentation of DTD to be uniquely associated with impaired caregiving and prevalent exposure to violent environments (Spinazzola et al., 2018). Additionally, the affect dysregulation in DTD addresses problems in affect modulation and awareness not included in PTSD. The behavioral dysregulation criterion Infant Mental Health Even infants can experience trauma. Infant mental health is a multidisciplinary field that examines early childhood development and recognizes the presence of social-emotional processes as early as infancy (Zeanah, 2009). Some people view infants as simply going through the biological motions of survival, without advanced emotional functioning. This misconception often causes traumatic attachment failures or other traumatic experiences to be dismissed as occurring out of an infant’s perceptual awareness (e.g., “They won’t remember”), minimizing the focus on infant intervention needs. Although infants cannot directly report on their trauma symptoms, physiological evidence suggests that the impact of chronic attachment failures mimics that of more overt traumas (Humphreys & Zeanah, 2015). That being said, due to their limited cognitive, motor, and language skills, infants likely cannot actually experience or show many symptoms of PTSD as described in current diagnostic criteria (DeYoung & Landolt, 2018). Researchers have studied socioemotional traumatic stress of infants by experimentally manipulating parental responsiveness and measuring infants’ behavioral and physiological reactions (Braungart-Rieker et al., 2019; Provenzi et al., 2016). Parents were asked to become unresponsive, with flat affect, while interacting with their children. The infants in the experiments responded with emotionally charged attempts to re-engage the parent, decreased their social/communicative behaviors, and averted their gazes from the parents, all while exhibiting increased physiological stress and arousal (Provenzi et al., 2016). These effects have been shown to carry over into continued parent–child interactions, even when the parent shifts back to a more positive interaction style. In other words, traumatic attachment interactions can impart the long-term consequences in mental health and biological functioning commonly observed in response to trauma. However, for children and parents who generally display a secure attachment style, there appears to
overlaps with many PTSD symptoms, yet DTD focuses more on problems with self-harm, aggression, risk-taking and inhibited exploration, self-soothing, and inadequate goal-directed action (van der Kolk, 2014; van der Kolk et al., 2009). The relational dysregulation in DTD addresses a wider range of problems, including issues with trust, reciprocity, empathy, support-seeking, and related self-attributions. Finally, DTD requires a symptom duration of six months, classifying it as a chronic condition (van der Kolk, 2014; van der Kolk et al., 2009). In fact, there are some children who exhibit signs of DTD and other co-occurring disorders without PTSD being present, suggesting that children who could benefit from trauma-focused treatments may be overlooked due to not meeting PTSD criteria (van der Kolk, 2019). There is continued passionate debate between supporters of the DSM-5 and DTD advocates. Schmid, Petermann, and Fegert (2013) review the current arguments for and against DTD. Those who favor the inclusion of the DTD diagnosis in the DSM suggest that it better conceptualizes the broad range of trauma reactions observed in children and is better at capturing the concepts associated with developmental psychopathology. They believe it clearly addresses severe problem behaviors that stem from trauma and explains comorbidity without resulting in a “smorgasbord of diagnoses” (van der Kolk, 2014, p. 166). Furthermore, they argue that DTD assists in guiding practitioners to provide more informed and effective trauma treatments (Schmid et al., 2013). Conversely, those in opposition claim that DTD conflicts with current diagnostic systems, conflates symptom etiology, underestimates the inverse relationship between other disorders and trauma, and misses the potential for effective pharmaceutical treatments to address comorbid disorders (Schmid et al., 2013). be an increased ability to recover following these periods of unresponsiveness, suggesting that periods of distress can be overcome in the midst of a generally supportive environment (Braungart-Rieker et al., 2019). Clinicians may be in a role to educate parents about the concepts of infant mental health and could potentially mitigate interactions harmful to healthy attachment. When looking for signs of trauma in infants, practitioners should worry less about DSM-5 criteria, as infants do not fit well within symptom domains, and assess for the ways in which trauma may be resulting in developmental shifts—either delays or deviance from normal development (Humphreys & Zeanah, 2015). Case Example Jeff, a young single father struggling with his own depression, entered therapy for help with his 10-month-old infant. His baby would frequently cry, and Jeff felt helpless in his ability to soothe the child. This was Jeff’s first child and he had planned on coparenting with his wife Kristin, who had died from suicide two months earlier, when their infant was 8 months old. Jeff felt unprepared to parent alone and had been experiencing severe grief and depression since Kristin’s death. Jeff reported that Kristin was stifled by her treatment-resistant depression and had not connected emotionally with the baby. Jeff, feeling the same way now, acknowledged that the child had not experience a lot of positive emotion in these first few months of life. Jeff was committed to working on both his depression and his attachment relationship with the baby. While simultaneously focusing on his grief, Jeff was able to improve his ability to help the baby regulate when distressed; engage in shared, positive emotion with the baby; and attune his emotions with the child in a way that eventually reduced the baby’s distress and contributed to improved soothing and regulation.
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Book Code: PYFL4024
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