Developmental Trauma Disorder -- Worthy of formal diagnosis?
Jan 4, 2013
Schmid et al (2013) [LINK] have called into question whether or not it is desirable for Developmental Trauma Disorder -- a "childhood" disorder I've spoken about often on my website, as my weinsite is primarily about the nature of, and recovery from, childhood trauma -- to be afforded formal diagnostic in current, and proposed, diagnostic systems. On the one hand, they state, the supporters of a formal DTD diagnosis argue that post-traumatic stress disorder (PTSD) does not cover all consequences of severeand complex traumatization in childhood. On the other, a main argument against inclusion of formal DTD criteria into existing diagnostic systems is that emphasis on the etiology of the disorder might force current diagnostic systems to deviate from their purely descriptive nature. Furthermore, they believe, comorbidities and biological aspects of the disorder may be underdiagnosed using the heretofore proposed DTD criteria -- see my previous discussions on my website for links to relevant articles, for example this page here [LINK]. The signs and symptoms of the disorder are also reviewed in the article by Schmid et al.
What is not discussed in the article by Schmid et al is "Complex Trauma" -- children's histories of "complex traumatization" are discussed, but whether or not this is the same disorder as adult Complex Trauma is not discussed. Complex Trauma "perhaps" is an adult form of DTD -- I say "perhaps" as it too lacks a formal diagnosis, has many of the same diagnostic issues as DTD, including a controversial status, and has perhaps equally significant clinical and social consequences for individuals and society generally. Therapy for those adults with Complex Trauma is discussed in many places on my site, but perhaps you could start by reviewing this page [LINK], and go into more depth concerning the very lengthy, if not lifelong, consequences of childhood trauma discussed in the literature review linked to through my Home Page [LINK]
Schmid et al opine that it is trauma experts working in specialized institutions that deal exclusively with traumatized individuals who tend to be the main supporters of a formal definition of DTD diagnostic criteria, while professionals working in the general clinical and psychiatric setting remain critical. Regardless of the outcome of the ongoing debate, treatment of severely traumatized children and adolescents should be improved substantially. Although trauma outpatient clinics offering symptom-specific treatment will be of help, general psychotherapeutic professionals also need to be trained in this area since many traumatized children are encountered in the clinical setting. Therapeutic concepts currently available for hospitalized patients are grossly inadequate to address the, at times dramatic, problems suffered by severely traumatized children. Trauma-specific concepts of outpatient treatment with possible inpatient-interval treatment should be developed and implemented, taking the specific needs of children and adolescents into account as well as the need of their parents, foster parents or residential care staff. It is important to be able to combine both treatment needs: to maintain a “safe place” and to have the possibility to do effective (if necessary, prolonged) exposure therapy. For severely traumatized patients a combination of a skill training and trauma therapeutic exposure treatment is currently regarded to be the best approach with the least drop-out rates. The trauma system therapy as a model of combined milieu therapeutic, systemic / family centered, and psychotherapeutic intervention is a very promising and, as the first results show, successful treatment approach for children and adolescents suffering from complex trauma or developmental trauma disorder. The psychotherapeutic skill training focuses on the capacities to cope with dissociation, emotion regulation problems, situations of extreme stress and tension as well as intrusions, disgust and social problems. The additive skill training will help to overcome tension and dissociation during the exposure therapy and is a kind of precondition for exposure therapy with complex traumatized patients with fewer capacities to cope with stress, tension and dissociation. Dialectical Behavior Therapy and its adaptions for adolescents are the best evaluated treatment concepts to improve these skills. For such treatment concepts to be effective, specialized wards are needed, which will probably require inpatient treatment for a greater catchment area and build a network of outpatient therapists cooperating with this specialized ward. This is much the same as recommended for adults with Complex Trauma -- see my site.
As many severely traumatized children and adolescents cannot stay in their families of origin, psychiatric liaison services for adolescents in residential care institutions and youth welfare services should be implemented. These liaison services can help to reach more burdened children, reduce inpatient- child and adolescent psychiatric treatment days, and improve continuity in residential and foster care placements. Youth welfare concepts should be sensitized to trauma symptoms and try to promote and enhance resilience factors, self-efficacy and social and emotion-regulation skills . Schmid, after their review of disorder and treatment outcome studies conclude that the available arguments for and against the implementation formal diagnostic criteria for DTD cannot be appraised conclusively based on current research. The main advantage, these authors believe, appears to be therapists' improved sensitization to trauma outcomes and more tailor-made treatment options, but this may also be achieved by a descriptive approach. A dimensional diagnostic system comprising the relevant domains, such as relationship / attachment representation, assessing interpersonal trust, emotion regulation, affinity to dissociation / sensual perception, and lacking expectation of self-efficacy, could also be envisaged. Specific symptom scales for emotion regulation, attachment/ interpersonal trust, self-efficacy and dissociation may be effective in predicting the outcome of psychotherapeutic treatment. These symptom scales may show relevant aspects of developmental psychopathology, can support the diagnostic process, and help to develop individualized treatment concepts with specific guidelines for the arrangement of the therapeutic alliance. Probably the sensitization to trauma symptoms and the interpersonal learning history of a patient can prevent drop-out and improve therapeutic outcomes. On my site I provide guidelines for how drop-out can be reduced through following recommendations for "essentials" in trauma treatment [LINK].