Background
List of symptoms: consensus of proposed diagnostic criteria for developmental trauma disorder
Proposed diagnostic criteria and symptom clusters
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· Symptoms of emotional and physiological dysregulation/dissociation
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· Problems with conduct and attention regulation
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· Difficulties with self-esteem regulation and in managing social connections.
Symptoms of emotional and physiological dysregulation/dissociation
A. Exposure
B. Affective and physiological dysregulation
C. Attentional and behavioral dysregulation
D. Self and relational deregulation
E. Post-traumatic spectrum symptoms
F. Duration of disturbance
G. Functional impairment
Somatization, body and sensory perception
Self-injury, high risk behavior, and sexual abnormalities
Difficulties with executive functions and the regulation of attention
Difficulties in self-regulation and establishment of relationships
Discussion
Arguments: pro development trauma disorder | Arguments against development trauma disorder |
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Specific diagnosis for observed symptoms from severely traumatized children | Conflicts the traditional diagnostic systems on constraining on the description of symptoms |
Regards developmental psychopathology and the course of mental disorders | Assumed mono-causality is conflicting bio-psycho-social model of the etiology of mental disorders |
Explains co-morbidity | Underestimates the aspects of inverse correlations of psychopathology and traumatization |
Enables effective treatment for co-morbid disorders | Selectivity underestimates the role of resilience |
Enhances research in the field of developmental psychopathology and trauma related disorders | Higher risk to miss co-morbid disorders and effective (psycho-) pharmaceutical treatment |
Show scientific based arguments for a improvement of child protection, prevention and resources of youth welfare services | Failed to define age-related symptoms |
Explains severe problem behavior, for example reactive aggression, chronic dissociation and self-injury | Trauma focused explorations might lead to a problem focused exploration style |
Arguments for and against a systematic diagnosis of DTD
Arguments in favor of formalized DTD diagnostic criteria
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· More specific diagnosis: The diagnosis of PTSD does not sufficiently take into account the symptoms of traumatized patients. The postulated DTD diagnostic criteria comprise a range of symptoms seen to occur after complex and repeated traumatization. For the diagnosis of DTD, traumatic experience is essential but not exclusive, and genetic and biopsychosocial origins of the disorder must be ruled out to specify the interaction between neurobiology, epigenetics and transgenerational traumatic life events and their consequenses for the development of mental disorders. The existence of specific and validated DTD diagnostic criteria may sensitize professionals and the general public to the drastic consequences of child abuse, neglect, and traumatization. Moreover, the establishment of measures for e.g. child protection, policy making would be expedited.
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· Course of mental disorders: The supporters of this initiative argue that more emphasis should be placed on developmental aspects of disorders caused by traumatization. The few longitudinal studies available indicate that more than 60% of adults with psychiatric disorders suffered from psychopathological symptoms during adolescence, and 77% exhibited symptoms before the age of 18 years [87, 92]. Furthermore, PTSD frequently becomes chronic. In a longitudinal study in adolescents with PTSD, 48% of patients still met the criteria for PTSD three to four years later [93].
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· Enhance research: Establishment of formal diagnostic criteria for DTD is expected to stimulate research efforts in this area (e.g., epidemiological studies, developmental-psychopathological research). Cross-sectional and longitudinal studies on psychosocial risks and comorbidities during childhood and adolescence should be encouraged.
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· Explain comorbidities: From a clinical point of view, the diagnosis of DTD focuses on traumatization as the psychopathological trigger of mental disorders [94]. Several well-designed studies clearly demonstrated such correlations. Post-traumatic symptoms may occur together with other mental disorders. As many as 80% of PTSD patients meet the criteria for another disorder [95‐98]. In an evaluation of the ‘Dunedin longitudinal study’, Koenen et al. [15] showed that all subjects meeting the criteria for PTSD in young adulthood had suffered from mental disorders at a young age. Conversely, other mental disorders may be present before PTSD or may develop after its occurrence [15, 87, 92]. In particular, victims of sequential traumatization have an inherently high risk of developing a complex syndrome of disorders that often go hand-in-hand with single symptoms of PTSD without fulfilling the complete clinical picture of PTSD [14]. In children and adolescents, comorbidities with ADHD, anxiety disorder, suicidal thoughts, and a trend towards affective disorders is highly prevalent [1, 98].
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· Enable effective treatment: By selectively treating trauma symptoms, patients can be stabilized, and concomitant illnesses (like anxiety disorder or depression) can be addressed. The effectiveness of therapeutic interventions in traumatized children and adolescents has been well documented in recent years [99‐103]. Spinazzola et al.[104] pointed out that more attention should be given to naturalistic studies in inpatients suffering from psychosocial stress being at risk of suicide.
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Patients with severe interpersonal traumatization in childhood are the hardest to treat and have the poorest prognosis. Treatment may be constrained by insufficient understanding of the underlying illness, and patients often cannot be reached by the psychosocial care system. Moreover, the degree of traumatization affects treatment success. Therefore, it is important to take the nature and severity of traumatic experiences into account when developing a treatment plan. With a more specific diagnosis, treatment options can be tailor-made.
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· Social and legal aspects: Many victims of neglect, child abuse, and maltreatment live on the edge of society and depend on social services for most of their lives. Failures at school and in youth welfare institutions are common [105]. Clear definition of trauma-related symptoms could help to change attitudes towards delinquent or aggressive adolescents and facilitate the initiation of treatment [106].
Arguments against formalized DTD diagnostic criteria
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· Conflicting DSM and ICD diagnostic systems: Formal DTD diagnostic criteria are thought to weaken the power of existing diagnostic systems, such as DSM-IV-TR and ICD-10. Both diagnostic systems were strictly designed to exclude any theory about the etiology of the mental disorders and confine themselves to a clear and operationalizable description of the symptoms and disorders. Since Axis V of the multiaxial diagnostic system covers psychosocial risk factors, aspects associated with chronic exposures to traumatic events are included in existing systems. In addition, critics claim that there is no clear distinction between symptoms and syndromes, and that DTD criteria overlap with those of some established and some discussed diagnoses. Many symptoms of borderline personality disorder or attachment disorder are included in the list of DTD symptoms, thus impeding the distinction between these disorders. Similarly, DTD criteria overlap with those of attachment disorders, conduct disorder, multiple complex development disorders (MCDD) [109] or the criteria for borderline disorder in childhood and adolescence [28]. Although, all of these diagnosis have a high prevalence among people with traumatic life events, problems with validity and reliability [110, 111] and high comorbidities with other mental disorders. Some diagnosis like multiple complex trauma disorder and borderline personality disorder in childhood are not part of the diagnostic systems.
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· Monocausality: concerning the diagnosis of DTD, monocausality is assumed, but this has not been proven [112]. DTD diagnosis favors a psychosocial explanation for the etiology of the disorders and neglects the biological explanations of the biopsychosocial model to understand the development of mental disorders. DTD is frequently manifested as a mixture of symptoms and syndromes, and a unidirectional relationship between traumatic experiences and the development of a confined syndrome remains is based on a widespread of actual research in the field of psycho traumatology. Moreover, genetic/biological causes of the symptom pattern may be ignored when diagnosing DTD. Critics of a formal DTD diagnosis point out that those similar symptoms may be present in individuals who did not have any traumatic experiences. In line with this, 20% to 30% of patients with borderline personality disorder, whose criteria are similar to those of complex PTSD, had not suffered from any traumatic experience [30]. By explaining complex symptom patterns by a single cause, other disorders that require treatment may remain untreated. Focussing on trauma etiology it might be possible that other comorbid diagnosis like ADHD will not be taken into account and missed to treat with evidenced based interventions. Furthermore, assumption of traumatization as the single cause of the disorder may result in too much importance being attached to identifying the causative traumatic experience, thus ignoring positive life experiences that would facilitate a resource-orientated therapeutic relationship, especially with the parents.
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· Selectivity: Certain children who had been severely traumatized do not develop any mental disorder [113]. Of course this is a weak argument because skeptics can argue in the same way against the classic PTSD diagnosis.According to Malinosky-Rummell and Hansen, 80% of adults who had been physically abused during childhood showed no mental disorder in adulthood [114]. However, Collishaw et al.[115] found considerably weaker psychopathological resilience in a follow-up analysis of adults who had experienced maltreatment during childhood. Furthermore a study of the Dunedin birth cohort (in [15]) suggested that the risk of developing a mental disorder increases with repeated traumatization. Individuals who did not develop any symptoms were found to have good peer relations, success at school and work, and stable relationships. Current research into resilience increasingly focuses on dynamic factors, such as behavior and attitude, which enhance individual or familial resilience [113], and their correlation with genetic factors. Conversely, non-traumatized individuals may develop similar symptoms. The formal DTD criteria do not explain this phenomenon. In addition, there is a relatively high overlap with existing and well-established mental disorders (e.g., borderline disorder, attachment disorder with disinhibition, etc.).
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· Inverse correlation: Diagnosing DTD implies that emotional dysregulation is caused by traumatic experiences but ignores the fact that the reverse relationship also exists. Emotional dysregulation is accompanied by a higher risk of traumatization. It is well established that subjects with impaired emotional control may adversely respond to environmental factors, thus reinforcing the present symptoms [116]. This correlation was described in the transactional model by Fruzzetti et al. [116]. Furthermore, children with externalizing disorders have a four times higher risk of being abused [117].
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· Age sensitivity: Although the proposed diagnostic criteria are meant to take the age and developmental status of the patient into account, symptoms are not sufficiently stipulated age-sensitive. But of course this is a problem of every diagnosis in childhood and adolescence – regarding the actual debate among assessing symptoms of attention deficit and hyperactivity disorder ADHD in childhood, adolescence and adulthood [118]. Furthermore the criteria claim to be development-oriented, however they fail to specify the symptoms for different age groups. Thus, no distinction is being made between young children and adolescents with respect to emotional and physiological regulation. This is due to the limited knowledge about the course of trauma-related symptoms and the methodical problems in longitudinal studies to address the same construct in different age groups with other psychometric methods. Additionally clinical studies are limited by ethical restraints.
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· Treatment: The main purpose of accurately diagnosing psychopathological conditions in children and adolescence is the endeavor to treat them effectively. Critics of the introduction of formal DTD diagnostic criteria argue that comorbidities may remain untreated because too much emphasis is placed on trauma-related aspects of the condition. This can provoke misinterpretations of biological symptoms with the consequence that effective psycho-pharmaceutical treatment options stay unused.
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· Disadvantages of trauma-focused diagnostic explorations: For inexperienced professionals the concentration on trauma-related symptoms in the diagnostic process may result in a pressure to detect traumatic life events. This kind of exploration might have a negative influence on the therapeutic relationship, especially to parents of multi-problem families. It can be difficult to combine a trauma-focused exploration style with solution focused interventions. But without the development of a sustainable therapeutic relationship every treatment will fail. Another negative aspect of trauma-focused diagnostic exploration could be that patients will be pushed in an implicit or explicit way to remember or to talk about traumatic events. It is even possible that some trauma-focused exploration styles provoke false memories of biographical life events with several negative consequences [119].