● Interpersonal difficulties: Trauma symptoms may contribute to negative interpersonal interactions and social isolation. Certain symptoms may manifest in behaviors that alienate peers, such as callous or unemotional interactions, a lack of trust, limited empathy, a lack of boundaries, and abrasive and Diagnosing Childhood Trauma This chapter has emphasized the various ways in which childhood trauma symptoms elude existing diagnostic and assessment tools. Two major trauma-related diagnoses, however, are recognized in treating children. The DSM-5 lists specific posttraumatic stress disorder (PTSD) criteria for children age six or younger. The second diagnosis, developmental trauma disorder, although not included in the DSM-5, is widely accepted among national childhood trauma experts (National Child Traumatic Stress Network [NCTSN], 2017; van der Kolk, 2014; van der Kolk et al., 2009). Posttraumatic Stress Disorder in the DSM-5 The DSM-5 offers a new developmental subtype of PTSD for children age six years or younger (PTSD in preschool children; American Psychological Association [APA], 2013). This represents the “first developmental subtype of an existing disorder,” suggesting an increasing awareness of the unique experiences of children (Scheeringa, 2021, p. 1). The general criteria for this subtype are the same as for the adult diagnosis, with minor tweaks and subtle changes Developmental Trauma Disorder Although the DSM-5 PTSD subtype for children age six or younger represents a step toward tailoring trauma diagnoses to the complexities of the developing child, many experts believe it still falls short (van der Kolk, 2014). The NCTSN reports that fewer than 25% of the children receiving trauma treatment meet criteria for PTSD (D’Andrea et al., 2012). Numerous trauma authorities contend that the simplicity of the DSM-5 criteria does not adequately address childhood trauma. Advocates of this position have proposed developmental trauma disorder (DTD) as a viable alternative diagnosis and solution to this issue (van der 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
aggressive externalizing behaviors (D’Andrea et al., 2012). At times, these behavioral manifestations of trauma symptoms may result in antisocial behaviors, school disruptions, and legal troubles (D’Andrea et al., 2012). to be more “behaviorally anchored and developmentally sensitive” (Scheeringa, 2021, p. 1). It is no longer required that children react with extreme distress to the traumatic event. This shift takes into account some children’s inability to verbalize their reactions in the same way as adults (APA, 2013; Scheeringa, 2021). Additionally, re-experiencing symptoms are not required to be “distressing,” as some children express trauma through play—which may not look distressing—and exhibit emotional numbness rather than distress (Scheeringa, 2021). Children age six or younger need only to display one symptom in either the avoidance or negative alterations criterion. Many of the symptoms within these domains are difficult to detect in children. For instance, many children are just starting to identify and shape their interests and affective vocabulary, so detecting true manifestations of symptoms such as “loss of interest” or “restricted range of affect” is challenging (Scheeringa, 2021). Similarly, the symptoms “sense of a foreshortened future” and “inability to recall an important aspect of the event” were deleted (Scheeringa, 2021). 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 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).
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