Developmental Trauma Disorder (DTD)
|| Development trauma disorder: the effects of child abuse and neglect
by Maureen V. Kilrain, MS, PA-C
EDITOR'S NOTE: This is an article from a professional. It's chock full of technical info and argument that's extremely detailed. A reader may fine referring to the original web page easier to read, from the May 2017 Issue of Clinical Advisor:
Developmental trauma disorder, not yet officially recognized, results from child maltreatment and has many neurobiologic consequences.
Development trauma disorder: the effects of child abuse and neglect
by Maureen V. Kilrain, MS, PA-C
Child neglect and abuse are perhaps the most significant community health challenge in the United States.1 Mental health experts in trauma continue to investigate and apply a condition known as developmental trauma disorder (DTD), which is characterized by permanent changes in the neurobiologic system of children and adolescents who have been chronically exposed to various types of maltreatment during sensitive periods of childhood development.1 It is believed that a specific criterion is urgently needed to improve recognition of the unique profile DTD victims encompass and to avoid misdiagnosis or confusion with other psychological syndromes, such as posttraumatic stress disorder (PTSD).1
In addition, the effects of DTD continue in adulthood and tend to correlate with multiple health problems.1 Medical providers may consider DTD an underlying cause of several conditions, including depression, anxiety, attention-deficit disorder (ADD), borderline personality disorder (BPD), chronic pain or fatigue, various addictions, and eating disorders.1 During clinical assessment, identifying a history of childhood trauma may broaden therapeutic choices and improve patient outcomes. This article describes some of the neurobiologic consequences of DTD, including cognitive, emotional, social, and somatic manifestations.
Common treatment modalities for DTD are discussed, including reasons to support or oppose DTD as an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Child maltreatment statistics
The National Child Abuse and Neglect Data System (NCANDS) is a federally supported organization that analyzes and records statistical data regarding claims of child maltreatment.2 For calculation purposes, duplicate counts indicate the frequency a child is deemed a victim of abuse, and unique counts represent one incident of abuse, despite the number of times a child was officially reported as maltreated.2
In 2014, the NCANDS revealed that from a population of 6.6 million children, approximately 3.6 million cases of alleged child maltreatment were referred to child protection services (CPS).2 Among 3.9 million reports considered as duplicate counts, a total of 2.1 million cases warranted CPS involvement.2 An additional 3.2 million reports assessed as unique counts also warranted further CPS investigation.2 A final analysis from these reviews concluded 702,000 children were considered victims of maltreatment. The alarming findings revealed millions of potential child maltreatment reports requiring social service's attention.
In the majority of cases, maltreatment consisted of neglect (75.0%) and physical abuse (17.0%), occurring predominantly in children from birth to 1 year.2 Victim gender rates included females (50.6%) and males (48.9%). Racial frequency comprising more than 88% of reported victims involved Caucasians (44.0%), African Americans (21.4%), and Hispanics (22.7%).2 It was further estimated that 98.9% of child maltreatment acts are committed by a main caregiver; 54.1% of the perpetrators are women and 44.8% are men, and the average age of offenders is 18 to 44 years.2 Most complaints of maltreatment were reported by a professional (62.7%), such as a legal associate, or academic and social service employees.2
The national mortality rates occurring from 2010 to 2014 are shown in Table 12 and only involve children who died as a result of maltreatment committed by a parent (79.3%) or other major caregiver.3 Sadly, the latest victim fatality figures equated that more than four children die every day as the result of mainly neglect and/or physical abuse, or in conjunction with another type of maltreatment.3 The most vulnerable groups are children aged 4 years or younger, with 70.7% of deaths occurring in children aged younger than 3 years.3 A breakdown of ethnicity rates reveals that 88.4% of total deaths were Caucasian (43.0%), African American (30.3%), and Hispanic (15.1%).2 In addition, a shocking study regarding childhood mortality suggests that “50% of deaths reported as “unintentional injury deaths” are reclassified after further investigation by medical and forensic experts as deaths due to maltreatment.”3
It is certainly worth noting that only a fraction of child maltreatment cases and related deaths are referred to CPS, indicating formal statistics do not identify the other countless instances of neglect and abuse, or the inappropriate dismissal of child maltreatment by a social worker, healthcare provider, family member, or other bystander. Children are often unable to report mistreatment for many causes, such as insufficient language capability, self-blame, feelings of guilt, and/or fear of retribution from the perpetrator. For these, and many other reasons, child neglect and abuse can be considered a serious and silent epidemic.1
What is developmental trauma disorder?
Bessel van der Kolk, MD,1 and colleagues are pioneers in developing DTD philosophy and diagnostic criteria, and they have shared their knowledge globally with the intent to improve the identification, treatment, and prognosis for children who have suffered traumatic experience. Van der Kolk describes DTD as a distinct condition affecting children, adolescents, and adults who have been repeatedly subjected to various forms of childhood maltreatment, including neglect and/or physical, emotional, and sexual abuse, during specific periods of their neurophysiological development.1 Child maltreatment is particularly traumatizing if it was committed by a significant caretaker, such as a parent.4
Other causes of DTD include witnessing acts of violence, permanent loss of an essential caregiver, institutionalization, and experiencing inconsistent custodians, such as multiple and abusive foster parents.1 Among other numerous examples, exposure to poverty, serious illness, multiple surgeries, warfare, or a life-threatening natural disaster or motor vehicle accident can traumatize a child's psyche.1
Van der Kolk has proposed that DTD is manifested in various ways that negatively affects a victim's capacity to relate to oneself and others.1 The following sections address some of the adverse consequences of DTD, including impaired cognitive, emotional, and social functioning, and common somatic symptoms.
Cognitive, emotional, social, and somatic effects
Children are critically dependent on the quality of their relationship with caregivers for normal development, and when they are repetitively traumatized, their psyche becomes damaged.1 They naturally internalize a caregiver's facial expressions, emotions, and actions that serve as a “mirror” reflecting to a child his or her personal worth and identity. If caretakers are deficient or inconsistent in areas of sensitivity and emotion, or if they are violent or negligent, children endure tremendous stress. This stress is often exhibited in victims as persistent psychological states of hyper-arousal, nervousness, and agitation, and/or hypo-arousal or feeling emotionally numb.1,4
Dissociation or tainted consciousness is a characteristic defense mechanism and survival skill that DTD victims use to escape overwhelming emotion and the impact of abuse.1,4 Dissociation includes “thought suppression, minimization, and outright denial.”5 Depersonalization or feeling disengaged from oneself and the world are other described symptoms of dissociation.4,5 As a result, children learn to ignore their authentic emotions, while missing important opportunities to develop the capacity for introspection and self-managing abilities.1,6 They also learn not to trust their thoughts and feelings, causing self-perception and discernment of others to be confusing or distorted.1,6
Due to a lack of self-protection and unable to escape their plight, traumatized children develop other defenses, or maladaptive personalities, described as fight, flight, freeze, and fawn types (4-Fs).6 Fight responders possess a considerable need to control their environment, are typically disruptive or argumentative, and may display violent or aggressive behavior toward others, such as bullying.1,6 Flight personalities will flee or avoid their chaotic life, as seen in children who run away from home, become overactive, develop a compulsive or obsessive nature, or strive for perfectionism.1,6 Freeze types isolate themselves, engaging in dissociative activities such as excessive sleeping or constant use of the television or computer.1,6 Fawn responders are considered submissively co-dependent, sacrificing self-identity and healthy personal boundaries to sustain relationships or avoid rejection.6 Behaviors resulting from the 4-Fs often unjustifiably cause a child to be characterized as difficult, disobedient, rebellious, withdrawn, lazy, shy, or hyperactive.1,6 Within a traumatized and defenseless environment, the 4-Fs may be used interchangeably and serve as a child's primary coping skills, while causing intellectual, social, sensory, and/or motor developmental delay or arrest.1,6
In an attempt to avoid abuse, children become hypervigilant of their surroundings, which further creates anxiety and tension.1,6 When caregivers are unable to provide a predictable and safe environment for their children, or offer relief to their stress, victims develop a limited capacity for emotional self-regulation and impulse control, their ability to experience healthy interpersonal bonds is restricted, and the process of learning from experience becomes fragmented and indistinct.1 These consequences are the primary origins of DTD.1 Other reactions to interpersonal trauma include high-risk and self-destructive behaviors, emotional instability, attention deficit, depression, and eating disorders.1 Deficient school or work performance, a proneness to accidents, and decreased sensitivity to pain are other signs of childhood trauma.1,7 Unexplained and persistent backache, abdominal or pelvic pain, headache, and insomnia are frequent somatic-related symptoms,4,6-7 and these may alert a health provider to identify a psycho-traumatic cause.
Ultimately, many perpetrators consistently induce intense emotions within their victims, including fear, humiliation, and unnecessary remorse resulting in poor self-esteem, or self-hatred. Above all, these children learn not to rely on themselves and others and lack a broader interpretation of life apart from their trauma-induced version. As a result, victims may develop a host of physical and psychological impairments affecting their health and ability to interact successfully with themselves and others.1,6,8
Neurobiologic system effects
Scientific research has provided considerable evidence involving the destructive effects of chronic child maltreatment that permanently alter brain maturation and interfere with its normal structural formation and function.9,11 These damaging consequences influence the capacity to regulate cognition, emotion, and behavior.10 There are four essential and vulnerable stages in brain development: early childhood (15 months-4 years), late childhood (6-10 years), puberty, and adolescence.10 Any significant or prolonged environmental disruption that occurs during these stages will ultimately produce harmful neurobiologic results.
A brief summary regarding some of the features of cerebral development includes neurogenesis, which involves the proliferation of several neural networks that provide pathways for processing information and occurs mainly in utero, with not much further development after birth.11 Neurons initially migrate to the brainstem, or lower brain, then to the cortex, or higher brain.11 This migration occurs in utero, during the perinatal period, throughout childhood, and possibly into adulthood.11 Arborization is the process of dendrite formation that assists neural activity.11 The degree of dendrite density is related to the amount and type of external input children receive while their brains are programmed to incorporate or assimilate complex stimuli.11 During synaptogenesis, the evolving neurons form axons and synapses, which enhance brain function and determine how vast the brain organizes and utilizes information.11
Differentiation involves the production of several neurotransmitters, such as dopamine, norepinephrine, serotonin, corticotropin-releasing factor, and substance P, which are released in response to stress and other emotions.10,11 The levels of these neurochemicals fluctuate widely in children reacting to a traumatic environment, affecting the neurobiologic system. In addition, response to stress affects the levels of many hormones, such as adrenalin and glucocorticoids—specifically cortisol, which is typically elevated in trauma victims.10 Consequently, the erratic production of neurochemicals and hormones may increase heart rate and gastrointestinal activity, induce chronic depression and/or anxiety, or cause immunodeficiency disease, to name only a few effects, while impairing or damaging the neuroendocrine system and various anatomical structures.10,11
A newborn's external experience promotes “neural differentiation, arborization, and synaptogenesis,” helping to “create functional neural networks.”11 Within the first 8 months of life, synaptic density increases eightfold as neurons form proper connections, indicating that a neurobiologic susceptibility to trauma is enhanced during the first year of life.11 Stimulation of the developing brain induces neural activity and the formation of synaptic connections. When external stimuli is overly stressful, negative, or sparse, as with neglected or abused children, neurons die, and their correct placement fails and/or are displayed in a disorderly fashion (Figure 1),12 while hyper-synaptic activity occurs.10,11
Among several essential parts of the brain, the prefrontal cortex is responsible for developing memory, controlling impulses, and allows one to learn from negative experience.10 These specific cortical functions are compromised in traumatized children who experienced elevated norepinephrine levels, due to chronic hyper-arousal states.10 In addition to decreased brain volume, a history of childhood trauma may cause deficient growth within areas of the limbic system involving the hippocampus and amygdala, also known as the “emotional brain” [within the link, see p. 111, Fig. 2].10-11 The hippocampus is susceptible to atrophy or lesser development when glucocorticoid levels are elevated in response to traumatic experience. Injury to this subcortical structure compromises the ability to control emotion and the capacity for cognitive or verbal memory.10,11 The amygdala begins to function at birth and permits an infant to sense danger, inducing the release of cortisol and adrenalin, and the ensuing fight-or-flight response.10 As a result of a traumatized upbringing, increased or persistent activation of the amygdala occurs, causing victims to miscalculate the severity of a dangerous situation or person.10 This eventually produces a general unrealistic interpretation of a victim's environment and perceptions of oneself and others.6,10
Further explanation regarding a victim's altered self-misconception and of his or her surroundings, is the occurrence of flashbacks, which are conscious or unconscious recollections of abuse triggered by internal or external stimuli involving “affect, vision, tactile, taste, smell, auditory, and motor systems.”9 During a flashback, victims inaccurately respond to emotions, situations, and others due to their distorted insights that confuse past trauma with present experience.1,6,9 Other compromised states of cognizance include an inability to read social cues, memory loss, hypermnesia (atypical vivid memory), and trauma-related nightmares.1
Affect attunement is the bond between a child and his or her primary caregiver and is crucial for healthy neurobiologic development.10 It plays a critical role in helping a child learn to regulate emotion, behavior, and affect, and it determines the ability to control reactions to stress.9,10 Parental attachments are considered a gateway into a child's inner self and character formation—the “more disorganized the parent, the more disorganized the child.”10 When these bonds are deficient, dangerous, or overwhelming, a child enters a world of irrational and inflexible responses to nominal tension and circumstances.9 In addition, fragmented relations with caregivers compromise a child's abstract reasoning, visual-spatial skills, attention or concentration abilities, and capacity for verbal learning.1
Any considerable disturbance that occurs during neurologic development, such as abuse, neglect, or high levels of stress or violence, will have a profound effect in the brain and lead to various types of psychopathology.11 Primarily, a child's stage of development at the time of victimization, the degree and nature of the maltreatment, and whether the abuser is an essential caretaker are significantly correlated with the extent of cerebral injury or compromise.4,10,11 Overall, the neurobiologic impact of DTD appears to extensively interfere with a child's cognitive, emotional, and sensory development and performance that generally continues into adulthood.
Developmental trauma disorder in adults
Adult victims who were subjected to years of abuse and betrayal as children, and who believed important caretakers could not be trusted, often remain guarded as adults. Some of the most significant consequences of DTD in adults are inner conflict regarding emotional self-regulation and an inability to develop and maintain healthy interpersonal relationships.9 The aftereffects of childhood maltreatment are thought to be the result of an unconscious compulsion to preserve or resolve past trauma.6,9,13 The 4-F survival skills are expressed inappropriately as a consequence of imprinted trauma experiences and habitual reactions within the brain, or from vague or repressed memories of trauma.1,6,13 A psychologically ingrained cycle of abuse continues long after a victim is free from his or her original abuser(s). According to van der Kolk, “In behavioral re-enactment of the trauma, the self may play the role of either victim or victimizer.”13
Examples of trauma re-enactment include enduring domestic violence or dysfunctional relationships, consistent feelings of helplessness or possessing a dependent personality, drug or alcohol addiction, suicide, chronic pain and fatigue, depression, anxiety, and panic or phobic disorders.1,7,9,13 Among sex offenders, 75% report a history of childhood incest or sexual assault.1 This particular type of trauma is a major reason why victims engage in prostitution or pornography, both of which serve to perpetuate past abuse.12 Unfortunately, many mimic the offender's destructive conduct, engaging in illegal activity or violent behavior and crimes, encompassing the majority of inmates residing in our prison and juvenile detention systems today.1,7,10,13 In addition to victims reenacting their abuse, they have an urgent need to avoid it; this coupled with their societal mistrust, causes the emotional and physical isolation that many DTD victims endure.1
One of the largest research analyses regarding the frequency of childhood trauma and its effects in adults is the Adverse Childhood Experiences (ACE).14 The ACE study was led by Kaiser Permanente (KP) and the Centers for Disease Control and Prevention (CDC) and included 17,337 KP members aged older than 50 years. A questionnaire regarding childhood neglect and abuse and other family dysfunction was offered to each participant. Omitting a third of the subjects who denied a history of childhood maltreatment, survey respondents reported physical abuse (26%), sexual abuse (21%), emotional and physical neglect (20%), and emotional abuse (10%).14 In addition, 28% were subjected to a caretaker who abused a substance, 20% were exposed to a caregiver with mental illness, and 13% witnessed violence against a maternal figure.13 It was also discovered common for more than one of these types of maltreatment to co-exist in the same person.14
In summary, ACE researchers concluded that a history of childhood neglect and abuse is often under-recognized in adult victims, and the consequences are substantial.1 Many of the subjects reported depression, suicide attempts, drug use, alcoholism, sexual promiscuity, domestic violence, cigarette smoking, obesity, and sexually transmitted diseases.13 Furthermore, a history of childhood trauma carries a 10% to 15% increased risk for developing heart and lung disease, cancer, and diabetes.10,14 It is also linked to liver disorders, stroke, and bone fractures.1 Victims' frequent use of medical and psychological services are typical.9 Also noted, because of societal taboos regarding the topic of child maltreatment, healthcare providers are often reluctant to discuss histories or issues of neglect and abuse with patients or their families.1,14 In essence, this averseness only serves to exacerbate a victim's solitude and self-justify his or her mistrust of others.
Unfortunately, DTD is a permanent condition, and without treatment, adult victims exhibit a multitude of emotional, social, and health-related complications, and are highly prone to replicating generations of traumatized families.
Developmental trauma disorder and the Diagnostic and Statistical Manual
Van der Kolk and colleagues submitted an in-depth proposal to the board of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) advocating for the inclusion of DTD as a diagnosis, specifying the following in their statement of purpose:7
“The goal of introducing the diagnosis of Developmental Trauma Disorder is to capture the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma and thereby guide clinicians to develop and utilize effective interventions and for researchers to study the neurobiology and transmission of chronic interpersonal violence. Whether or not they exhibit symptoms of PTSD, children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems are ill-served by the current diagnostic system, as it frequently leads to no diagnosis, multiple unrelated diagnoses, an emphasis on behavioral control without recognition of interpersonal trauma and lack of safety in the etiology of symptoms, and a lack of attention to ameliorating the developmental disruptions that underlie the symptoms.”
In May 2013, despite vast support from experts in the psychiatric community for the recognition of DTD as a diagnosis and more than 20 years of relevant clinical research and practice indications, the DSM-V committee elected not to include DTD as a formal diagnosis. Consequently, there is no current diagnostic criteria that entirely describe the unique effects of chronic maltreatment occurring in children and adolescents and in whom other numerous primary disorders are often misdiagnosed.1,7,9
Examples of such disorders include depression, BPD, ADD, attention-deficit/hyperactivity disorder (ADHD), bipolar and attachment disorders, separation anxiety disorder (SAD), and oppositional defiant disorder (ODD).7,9,15 Symptoms of these conditions often reflect the dysfunctional coping skills of DTD victims, such as hyperactivity and poor attention span in ADHD and self-mutilation in BPD.1,7 For instance, patients in whom BPD is diagnosed have mainly a history of childhood trauma, especially sexual and/or physical abuse.1,5,7,15 It is believed that chronic child maltreatment causes a risk for most of the personality disorders listed in the DSM, including psychosis, BPD, ADD, ADHD, depression, and addictive personality.1,6,9,11 An unclear or inadequate analysis may lead to treatment that is insufficient or unnecessary, such as psychotropic drugs, because treatment is often focused on a patient's symptoms or behavior rather than a patient's trauma experiences.1,7,9
In contrast, among various possible reasons why DTD was not accepted as a diagnosis in the DSM-V is that clinicians may focus too much on trauma history causing a misdiagnosis, particularly in patients without a history of child maltreatment or in those who possess a biologic or congenital basis for mental illness.15 In addition, opposing views speculate that DTD comprises an array of symptoms related to other DSM-specified disorders, such as BPD, attachment disorder, and ODD.14 However, as mentioned, many patients diagnosed with these, and other psychological disorders, often have histories of child maltreatment.1,6-7,9,15
Deliberated further, DTD develops during specific phases in a child's life, but the diagnosis fails to address distinct symptoms for each stage.14 However, a precise list of signs may lack in other disorders, due to limited capacity for subjective reporting and the capacity of self-analysis in children.7,15 Regardless of a professional vindication for DTD as a sole diagnosis, at the present time, debate and resolution for DSM acknowledgment continues.
Developmental trauma disorder versus posttraumatic stress disorder
Theories regarding human psychological trauma became increasingly recognized in the mid-1970s, due to emotionally distressed Vietnam veterans, and eventually led to the concept of PTSD.9 However, interpersonal childhood trauma did not become the focus of attention within the mental health community until the late 1980s or early 1990s.4,5 PTSD is defined as being caused by a single event or specific type of trauma, such as experiencing the effects from war or rape.16 However, DTD, also paralleled with complex PTSD (CPTSD),5-6,9 is caused by chronic and multifaceted traumatic events that occur during childhood that permanently influence a developing brain, affecting emotional and cognitive function and behavior. Traumatized children meet the DSM diagnostic criteria for many disorders, such as PTSD, but the various symptoms of DTD or CPTSD are not completely listed in the PTSD criteria and are often labeled as comorbidities.1,9,15 Common symptoms that distinguish PTSD and CPTSD are listed in Table 2.17
Most recently, DSM modifications for PTSD included a subtype group for children aged younger than 6 years.18 Research has shown when diagnostic criteria that are sensitive to child developmental stages were used, together with an appropriate behavioral assessment, more children qualified for a diagnosis of the child PTSD subtype than any other PTSD groups.18 Child PTSD evaluation include a lack of verbal skills in reporting abuse and the manner in which trauma-related symptoms and memory are expressed.18 For example, decreased interest in routine activities and play or “restricted play” are considered, and severe temper tantrums are noted to represent increased arousal behavior.18 Other childhood signs of PTSD include “loss of interests, restricted range of affect, detachment from loved ones, and avoidance of thoughts or feelings related to the trauma.”18 These symptoms are tyical for children but are less distinct in adults with PTSD.18
In short, victims of childhood trauma exhibit many symptoms of PTSD, including dissociation, guilt, and hopelessness, but the diagnostic criteria for PTSD does not accurately include all the important indicators of DTD.1,5,6
Support and treatment
In 2000, Congress developed the National Child Traumatic Stress Network (NCTSN) to offer education and resources to victims and families and to increase public and professional awareness regarding childhood trauma.19 In addition, NCTSN provides patient assessment tools for non-mental health professionals to help them identify specific types of trauma and initiate appropriate remedies.
Treatment options for victims provide new and safe ways for them to experience the world and increase their self-awareness and self-esteem. Play or art therapy encourages young children to emote safely, while allowing victims to express trauma experience according to their language capacity and maturity level.1,10 Educating victims in alternative ways of relating to themselves and others, rather than inaptly engaging in the 4-F personalities, is crucial1,6,10 and helps to break destructive habits regarding personal and social interaction, restructure disorganized brain patterns, and offer a sense of self-empowerment.1,6
Psychotherapy with a certified trauma specialist is essential for evaluating and grieving past damaging events. It is also beneficial for identifying self-defeating and trauma-related thoughts and behaviors, reducing dissociative tendencies, and improving the ability to manage emotions.1,5,6 Common psychotherapeutic methods include cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and eye movement desensitization and reprocessing (EMDR).4,18
In addition, medications may be used appropriately to regulate mood without causing further dissociation or dulling the emotions required for personal growth and recovery. Yoga can be included to enhance integration of the mind, body, and spirit, and to improve a patient's overall affect.20 Meditation or mindfulness techniques are used to increase self-connection with feelings and sensory and physical sensations, improve ability to control emotions, and reduce anxiety and dissociative or reactive tendencies, thereby greatly improving self-management skills.6,9,21
Most importantly, the human brain is remarkably resilient, particularly the minds of children; therefore, early detection of a trauma history and instituting suitable treatment plans can significantly help avoid or minimize the various emotional, social, and medical issues that victims encounter.
Undoubtedly, a tremendous health and safety crisis exists within the vast population of maltreated children, many of whom suffer as adults. Frequently, the aforementioned effects of DTD will prevail without proper aid and support. Establishing DTD as a distinct syndrome may prevent confusion with other psychiatric illnesses, offer more insightful solutions for victims, and create a compassionate consciousness among professionals and the public regarding the numerous problems childhood trauma produces. Furthermore, awareness of DTD may offer healthcare providers trauma-focused consideration that may enhance treatment or referral options and improve the prognosis of common ailments encountered in their practice.
Although negative aspects regarding DTD have been considered, such as enmeshment of other DSM-defined disorders, there remains the dilemma of formulating an explicit condition for the enormous population of abused and neglected children—many of whom tragically lost their lives due to caretakers who were trauma victims themselves. According to Bremness,22 there is an urgent requirement for a more flexible diagnostic system regarding environmental influences and for DTD philosophy, including serious recognition from the DSM officials. Often, the only voice trauma victims possess is an empathetic and astute professional, and it is vital that appropriate action and interventions are implemented. Maureen Kilrain, MS, PA-C, is a practicing physician assistant in the Cleveland, Ohio, area.
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2. Child maltreatment 2014. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families Children's Bureau website. https://www.acf.hhs.gov/sites/default/files/cb/cm2014.pdf#page=31. Accessed April 10, 2017.
3. Child abuse and neglect fatalities 2015: Statistics and interventions. Children's Bureau Child Welfare website. Accessed April 10, 2017.
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5. Herman JL. Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. J Trauma Stress. 1992;5:377-391. http://188.8.131.52/boundary/Childhood_trauma_and_PTSD/complex_PTSD.pdf. Accessed April 10, 2017.
6. Walker P. Complex PTSD: From Surviving to Thriving: A Guide and Map for Recovering From Childhood Trauma. 1st ed. Lafayette, CA: Azure Coyote; 2013.
7. Van der Kolk BA, Pynoos RS. Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. http://www.traumacenter.org/announcements/DTD_papers_Oct_09.pdf. Published February 1, 2009. Accessed April 10, 2017.
8. Gabowitz D, Zucker M, Cook A. Neuropsychological assessment in clinical evaluation of children and adolescents with complex trauma. J Child Adolesc Trauma. 2008;1:163-178. http://dx.doi.org/10.1080/19361520802003822. Accessed April 10, 2017.
9. Van der Kolk BA. The assessment and treatment of complex PTSD. In: Yehuda R, ed. Traumatic Stress. Washington, DC: American Psychiatric Press; 2001;1-29. http://www.traumacenter.org/products/pdf_files/complex_ptsd.pdf. Accessed April 10, 2017.
10. Van der Kolk BA. The neurobiology of childhood trauma and abuse. Child Adolesc Psychiatr Clin N Am. 2003;12:293-317. http://bit.ly/2pe998H. Accessed April 10, 2017.
11. Perry BD. Child maltreatment: A neurodevelopmental perspective on the role of trauma and neglect in psychopathology. In: Beauchaine T, Hinshaw SP, eds. Child and Adolescent Psychopathology. Hoboken, NJ: John Wiley & Sons; 2008:93-129. https://childtrauma.org/wp-content/uploads/2014/01/Perry_Psychopathology_Chapter_08.pdf. Accessed April 10, 2017.
12. The science of early childhood development (InBrief). Harvard University Center on the Developing Child website. http://developingchild.harvard.edu/resources/inbrief-science-of-ecd. Accessed April 10, 2017.
13. Van der Kolk B. The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatr Clin North Am. 1989;12:389-411. http://www.traumacenter.org/products/pdf_files/Compulsion_to_Repeat.pdf. Accessed April 10, 2017.
14. Anda RF, Felitti VJ. Adverse childhood experiences study. Ace Reporter. 2003;1:1-4. http://thecrimereport.s3.amazonaws.com/2/94/9/3076/acestudy.pdf. Accessed April 10, 2017.
15. Schmid M, Petermann F, Fegert JM. Developmental trauma disorder: Pros and cons of including formal criteria in the psychiatric diagnostic systems. BMC Psychiatry. 2013;13:3. http://dx.doi.org/10.1186/1471-244X-13-3. Accessed April 10, 2017.
16. American Psychiatric Association. What is posttraumatic stress disorder? In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Publishing; 2013. https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd. Accessed April 10, 2017.
17. Scheg KE. Complex posttraumatic stress disorder and emotional regulation. Core Transformation Counseling website. http://www.coretransformationcounseling.com/Complex_PTSD.html. Published 2016. Accessed April 10, 2017.
18. Scheeringa M. PTSD for children 6 years and younger. PTSD: National Center for PTSD. U.S. Department of Veterans Affairs website. http://www.ptsd.va.gov/professional/PTSD-overview/ptsd_children_6_and_younger.asp. Accessed April 10, 2017.
19. Assessment of complex trauma. The National Child Traumatic Stress Network. http://www.nctsn.org/trauma-types/complex-trauma/assessment. Accessed April 10, 2017.
20. Emerson D, Sharma R, Chaudhry S, Turner J. Trauma-sensitive yoga: Principles, practice, and research. Int J Yoga Ther. 2009;19:123-128. http://www.traumacenter.org/products/pdf_files/IJYT_article_2009.pdf. Accessed April 10, 2017.
21. Davis M, Hayes J. What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy. 2011;48:198-208. http://www.traumacenter.org/products/pdf_files/Benefits_of_Mindfulness.pdf. Accessed April 10, 2017.
22. Bremness A. Commentary: Developmental trauma disorder: a missed opportunity in DSM V. J Can Acad Child Adolesc Psychiatry. 2014;23:142-145. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032083. Accessed April 10, 2017.