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Psychiatric Times
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Learn more about how to appropriately diagnose and categorize a spectrum of posttraumatic stress responses in children and adolescents.
Mariya Surmacheva/AdobeStock
SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY
Case Study
Patient History. “Victor,” a 16-year-old adolescent boy born and raised in a southeastern European orphanage, adopted at 30 months old, presented to the clinic with global developmental delays and a complex psychiatric history typical of children exposed to substandard, overcrowded facilities. His previous diagnoses included childhood disorder of social functioning, unspecified; generalized anxiety disorder; encephalopathy (static)/fetal alcohol syndrome (by history at birth); and attention-deficit/hyperactivity disorder (ADHD), combined type.
Academic history. Victor carried an individual education plan throughout his formative educational years. Psychological testing indicated cognitive functioning of low-average to borderline range with notable deficits in higher-order, complex, and abstract verbal reasoning. His academic performance was 2 grade levels behind his chronological age specifically in reading comprehension and mathematics. He ended his primary school years with a combination of modified and general education classes and graduated from high school at 19 years old. He attended community college with plans to be an airplane mechanic or enroll in police academy.
Psychiatric history. ADHD medication management was initiated when Victor was 5 years old by a child developmental neurologist, with moderate tolerability and efficacy until his adolescent years. During adolescence, oppositional and defiant behaviors with poor impulse control presented as constant challenges in the home, social, and academic settings. At 15 years old, Victor became physically violent toward family and property.
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Treatment history. Multiple treatment modalities were investigated and sought after by parents ranging from least restrictive type, in the home and at both private and public schools, including regular outpatient individual and group counseling, speech and language therapies, and academic tutors. Most restrictive type of treatment included a long-term residential treatment center out of state with specific and thoughtful treatment goals to help regulate Victor’s internal emotional conflicts and maladaptive behaviors.
Psychosocial consequences. Throughout our working relationship, Victor’s exaggerated verbal and/or physical response(s), out of proportion to situational stressors, would isolate him further from meaningful relationships, academic pursuits, and lasting employment. He struggled with low self-esteem and worthlessness. He was highly impulsive with maladaptive coping skills to ease his anxiety and anger. Before his suicidal death at 20 years old, Victor became increasingly self-destructive, preferring cannabis to psychotropic medication, stopping all therapies, alienating himself from friends and family, and dropping out of school.
Discussion
How do we appropriately diagnose and categorize a spectrum of posttraumatic stress responses? Which DSM-5 diagnosis accurately reflects the complexity of early childhood adversity on neurodevelopment: Posttraumatic stress disorder (PTSD)? Complex PTSD? Why does it matter? Do treatment outcome responses vary depending on what age the trauma(s) occurred? There is a relatively new diagnostic term used to describe the effects of chronic, interpersonal trauma experienced during development, called development trauma disorder (DTD), which represents the intricacies of treating patients with complex, prolonged childhood trauma(s) as a unique subset. The purpose of this article is to promote for the inclusion of DTD as a specific subcategory, under PTSD, to the DSM.
DSM-5 defines PTSD as continuously reexperiencing 1 traumatic event with frequent and consistent negative ruminations, hyperarousal, and emotional numbing.1 This diagnosis pertains to anyone 6 years of age or older, occurring at any point in one’s lifetime. A high prevalence of psychiatric comorbidities are associated with PTSD, especially in children, and it is rarely the primary diagnosis.2,3 Patients presenting with complex and prolonged childhood adversity are often given PTSD as a diagnosis offering a 1-dimensional narrative, frequently underestimating more robust multifaceted treatment modalities.
Is there a better diagnosis to describe the severity and complexity from chronic and repeated trauma such as childhood abuse or neglect, prolonged domestic violence, or human trafficking? The World Health Organization includes a more descriptive diagnosis, complex PTSD (C-PTSD) to the 11th version of the International Classification of Diseases (ICD).4 C-PTSD criteria include primary symptoms of PTSD (reexperiencing, hyperarousal, and avoidance) along with disturbances of self-regulation, negative self-perception, chronic problems with intimate relationships, and a sense of being permanently damaged or flawed.5,6 C-PTSD (not currently included in the DSM) encompasses more diversity and understanding of a patient’s experiences and suffering.
What about our patients with complex and prolonged childhood trauma histories and neurodevelopmental delays or issues? An isolated finding or integrated? Young patients who chronically display difficulties with managing emotional regulation, who dissociate in social settings, cannot sustain relationships with peers or adults, or present with multiple somatic complaints, and struggle with self-identity? The complexity of sustained childhood adverse events (neglect, deprivation, abuse) experienced during critical neurodevelopment periods are directly related to successful transition into stable, meaningful adulthood.6
DTD7—not currently represented in DSM-5 or in the ICD classifications—accentuates a more specific and accurate depiction of the complexities, specific to early sustained childhood adversity, on delayed or inhibited neurocognitive development. DTD further expands the C-PTSD diagnosis by introducing neurocognitive delays and disruptions as integral aspects to appropriate, best-practice treatment options. Individuals with DTD often require extensive early interventions incorporating psychological, medical, community/social, and educational supports.8
Adverse childhood events (ACEs) can result in delays of social/emotional maturity and self-regulation, cumulative cognitive/academic deficits, and emotional fragility with attachment deficits.9,10 Children with developmental trauma demonstrate a broad range of symptoms: inconsolable anxiety, defiance, inattentiveness, impulsivity, depression, irritability, sleep disturbance, suicidality, and violent outbursts.7,8,11 They are also more likely to enter the child welfare system and the juvenile system, experience multiple out-of-home placements, and be eligible for special education services including higher use of both in- and outpatient psychiatric, substance use, and medical services.2,3
Treatment goals specific for DTD, differing from traditional PTSD treatments, are generalized based on the data and research of C-PTSD treatments. Treatment focus and goals include promoting the ability to regulate information processing without emotional instability or exaggerated, maladaptive response (self-harm, suicidal intent, or homicidal intent), integrate their traumatic experience(s), and improve relational engagement or attachment. An important treatment goal is to assist patients to appropriately self-regulate and incorporate the consequences of childhood ACEs into everyday life challenges.2,3
Multiple works have been published supporting need for DTD as a DSM classification.11-13 Support for separate classification presumably will increase access to appropriate treatment modalities including but not limited to psychopharmacology, educational accommodations, and social support systems for families and caregivers.14
Concluding Thoughts
Children with prolonged and repetitive childhood adversities during critical neurodevelopmental periods consistently demonstrate psychological disturbances not well-defined by PTSD diagnosis alone. DTD reflects how pervasive psychological effects of childhood adversity as related to self-dysregulation extend into inadequate, underdeveloped adult relationships and deficits in lifelong functionality. ACEs are strong predictors of future psychiatric disorders such as substance use disorders; borderline and antisocial personality; eating disorders; dissociative, affective, somatoform, cardiovascular, metabolic, immunological, and sexual disorders.11 According to Child Maltreatment Report in 2019, 4,378,000 referrals alleging child maltreatment were reported to child protective services involving 7,880,400 children.15 The importance of appropriate diagnosis and treatment is statistically relevant and urgently needed in our communities.
Dr Hughes is a psychiatric physician associate.
References
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4. International Classification of Diseases, 11th Revision. World Health Organization; 2018.
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9. Adverse childhood experiences (ACEs). CDC. October 8, 2024. Accessed December 19, 2024. https://www.cdc.gov/violenceprevention/aces/index.html
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12. Cloitre M, Garvert DW, Brewin CR, et al. Evidence for proposed ICD-11 PTSD and complex PTSD: a latent profile analysis. Eur J Psychotraumatol. 2013;4.
13. van der Kolk BA, Pynoos RS, Cicchetti D, et al. Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. February 1, 2009. Accessed December 20, 2024. https://www.complextrauma.org/wp-content/uploads/2019/03/Complex-Trauma-Resource-3-Joseph-Spinazzola.pdf
14. Early years. Nuffield Foundation. Accessed December 20, 2024. https://www.nuffieldfoundation.org/research/education/early-years
15. Children’s Bureau. Child Maltreatment 2019. January 14, 2021. Accessed December 20, 2024. https://www.acf.hhs.gov/cb/report/
