Trauma comes in a lot of shapes and sizes. Before a few years ago, people tended to only think of trauma in terms of PTSD (post-traumatic stress disorder) in combat veterans. In recent years, people have begun to use the term trauma for many experiences (although it has also begun to be used out of context which unfortunately starts to water down the meaning. Think, “Omg I was traumatized by that physics test”, similar to how people say “Oh, I am so OCD” when they mean they like things organized).
The goal of this blog is to talk about the type of trauma that occurs throughout a child/young person’s life that happens on an ongoing basis, rather than one acute traumatic event. While one is not "easier or harder" than the other, the implications for how trauma impacts a person and the way that mental health providers treat each type of trauma should be changed based on the type of trauma that occurs. It is important to shed light on the nuances of developmental trauma, its current status in diagnostic manuals, and the importance of a comprehensive understanding for effective treatment.
Understanding Developmental Trauma
Developmental trauma refers to the complex and pervasive impact of early, chronic trauma on a child’s development. Interpersonally, this may look like seeing one parent abuse another throughout your childhood, seeing a parent have chronic drug use, or seeing a sibling being mistreated or abused. Chronic trauma could also look like having a medical condition and needing frequent painful procedures throughout childhood, having a parent go through medical procedures and have medical scares, or something else. Despite its profound effects, developmental trauma is often not addressed in mainstream diagnostic frameworks (Think, the DSM-5-TR, more on that below). Unfortunately, the DSM is what providers need to use to provide diagnostic codes to insurance companies, otherwise insurance companies will not approve mental health coverage.
Limitations of the DSM-5-TR in Addressing Developmental Trauma
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), is the cornerstone for diagnosing mental health disorders, and a diagnosis from the DSM 5-TR is required for coverage by insurance companies. However, it falls short of adequately capturing developmental trauma. The DSM-5-TR lists several Trauma and Stressor-Related Disorders, including Reactive Attachment Disorder, Disinhibited Social Engagement Disorder, Posttraumatic Stress Disorder (PTSD), Acute Stress Disorder, Adjustment Disorders, Prolonged Grief Disorder, and Other Specified and Unspecified Trauma and Stressor-Related Disorders. These categories often fail to encompass the multifaceted nature of developmental trauma experienced by children. Oftentimes, as providers, we will have a difficult time diagnosing someone with developmental trauma by using DSM codes because we get stuck having to use multiple diagnoses that touch more of the surface-level symptoms rather than looking at the root of the issues, which is developmental trauma.
A More Comprehensive Approach: The Psychodynamic Diagnostic Manual (PDM-2)
Alternatively to the DSM-5-TR, the Psychodynamic Diagnostic Manual, Second Edition (PDM-2), offers a more detailed perspective on developmental trauma. However, the PDM-2 is rarely discussed or used in medical settings, in part because insurance companies do not recognize it as a source.
It introduces diagnoses such as Complex Posttraumatic Disorder and recognizes the use of the term Developmental Trauma Disorder. The PDM-2 acknowledges sustained exposure to overwhelming events and uses terms like strain trauma, cumulative trauma, relational trauma, and complex trauma. This nuanced approach is crucial for recognizing the extensive and varied impacts of chronic childhood trauma because developmental/complex trauma will not perfectly fit the DSM criteria for any of the trauma or stressor-related disorders.
Recognizing Complex Posttraumatic Stress Disorder (CPTSD)
If Complex Posttraumatic Stress Disorder (CPTSD) or Developmental Trauma Disorder were more widely recognized, it would significantly reduce the use of numerous diagnoses that show part of the picture, but not in a precise or helpful way. This recognition is vital as CPTSD encompasses a broader spectrum of symptoms.
As stated above, when I have a client who has experienced developmental trauma I am limited in my ability to give a diagnosis that accurately describes what they are experiencing. Instead, clients may potentially have symptoms from all DSM diagnostic categories, excluding only schizophrenia, bipolar disorder, and organic brain syndromes.
Bessel A. Van der Kolk, MD, addresses the need for sufficient distinction between developmental trauma disorder and other disorders. He contrasts it with classical PTSD, depression, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), reactive attachment disorder (RAD), separation anxiety disorder, bipolar disorder, dissociative disorders, and personality disorders. He concludes that developmental trauma disorder is distinct yet often co-exists with many of these disorders.
Almost no one will exhibit symptoms from all categories but they will often exhibit symptoms from two to three categories. So for the sake of insurance companies or even understanding from other medical providers, psychologists are stuck diagnosing an anxiety disorder, mood disorder, and/or something else. Almost no one will exhibit symptoms from all categories but they will often exhibit symptoms from two to three categories. Having to diagnose in this way obviously does not serve the clients in the best way or the psychological community as a whole.
More Insights from Bessel A. van der Kolk, MD, author of The Body Keeps the Score
Renowned trauma expert Bessel A. van der Kolk, MD, highlights the inadequacies of the DSM’s PTSD diagnosis in capturing the developmental effects of childhood trauma. PTSD often fails to account for the complex disruptions in emotional regulation, changes to attachment styles and interpersonal relationships, and rapid backslides into past behaviors that characterize developmental trauma. He also discusses other overlooked impacts including the loss of personal goals and life direction, aggressive behavior, falling behind developmental expectations, and disrupted bodily regulation (sleep, food, self-care).
Van der Kolk also points out that many forms of interpersonal trauma, such as psychological maltreatment, neglect, separation from caregivers, traumatic loss, and inappropriate sexual behavior, do not meet the DSM-IV “Criterion A” for a traumatic event.
Criterion A for PTSD is:
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work-related.
Consequently, children exposed to these adversities may not qualify for a PTSD diagnosis despite exhibiting significant trauma symptoms. Developmental trauma is trauma and the lack of meeting criteria for PTSD can often feel invalidating. Providers must validate the experiences of trauma and validate the very real impacts it has had, even if someone does not meet the specific and exclusive criteria for PTSD.
Provisional Diagnosis: Developmental Trauma Disorder
A provisional diagnosis based on the concept of multiple exposures to interpersonal trauma—such as abandonment, betrayal, physical or sexual assaults, or witnessing domestic violence—reveals consistent and predictable consequences affecting numerous areas of functioning. This diagnosis underscores the need for a more inclusive and detailed diagnostic framework.
Conclusion
Recognizing and addressing developmental trauma is paramount for effective psychological treatment. The current diagnostic frameworks fall short, necessitating a more comprehensive and nuanced approach. Psychologists must advocate for broader recognition of Complex Posttraumatic Stress Disorder and embrace family-centered approaches to provide the best care for those affected by early, chronic trauma. By including a new diagnosis of Developmental Trauma Disorder, researchers will dive head first into learning more about potential treatments and there will be more funding for researchers to focus more heavily on the effects of developmental trauma. Therefore making this diagnosis official will help more people live better quality lives. Understanding developmental trauma is the first step toward healing.
If you or a loved one is struggling with the effects of early trauma, you don't have to navigate it alone. Reach out today to schedule a free consultation and explore how therapy can support your journey to recovery. Let’s work together to find the path forward.
References:
The Body Keeps The Score by Bessel A. van der Kolk, MD
Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. Bessel A. van der Kolk, MD in Psychiatric Annals May 2005
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)
Psychodynamic Diagnostic Manual (PDM-2)
Attachment and Trauma Network Inc.
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