The Need for a Developmental Trauma Diagnosis

‘Developmental Trauma’ is often used to describe childhood traumas or adverse childhood experiences (ACEs). ACEs include events commonly recognized as traumatic like the death of a parent, physical or sexual abuse, and neglect. However, they also include other major stressors like witnessing parental substance use, having a parent who was incarcerated, or parents getting a divorce.

“Children who experience a higher number of ACEs are at a greater risk of experiencing mental and physical health challenges throughout their lifespan.” 

Interestingly, not all of these children meet the diagnostic criteria for post traumatic stress disorder (PTSD). This is largely because this diagnosis was meant to describe symptoms in adults. While some children can be diagnosed with PTSD many who are suffering as a result of past trauma do not. This forces clinicians to force a square peg into a round hole, so to speak, by giving a child another diagnosis that may not accurately explain what is going on.

We are forced to diagnose children who are clearly displaying certain behaviors and symptoms as a direct result of chronic and complex trauma with things like oppositional defiant disorder (ODD), attention-deficit/hyperactivity disorder (ADHD), and conduct disorder. A past professor of mine called these “trashcan diagnoses.” “We have to bill under something so we just chuck these kids into the can,” she said.

A diagnosis like ODD or conduct disorder flags a child as ‘behavioral.’ The implication is that they are simply violent and aggressive due to a lack of empathy and poor upbringing.

In reality, most children with this diagnosis are trying to protect themselves from being hurt again by, in their minds, defending themselves physically or cutting themselves off from others emotionally.

A diagnosis like ADHD is almost always addressed through medication. Giving a child a stimulant probably won’t help very much if they are already constantly stressed and on the lookout for an incoming attack.

Enter Dr. Bessel van der Kolk and the National Child Traumatic Stress Network. They proposed that Developmental Trauma Disorder be included in the DSM-5.

The proposed criteria included exposure to trauma and other criteria of the exiting PTSD diagnosis as well as the following:

• “Symptoms of emotional and physiological dysregulation/dissociation.

• Problems with conduct and attention regulation.

• Difficulties with self-esteem regulation and in managing social connections.”

Of course, it wasn’t accepted – so oh, well I guess. This diagnosis would be helpful in that it describes both the cause and result of the behaviors and symptoms presented. Instead of telling parents that their kid lacks concentration, makes their teachers mad, and punches other kids because we don’t know why we can demonstrate the connection to trauma through actual diagnostic criteria. Most clinicians understand this connection but it is important to be able to back it up with something nationally recognized, and recognized by insurance companies, like the DSM-5 

As always, there is a danger in pathologizing behaviors – especially when it comes to children. While I recognize this I still believe it would be more helpful for this diagnosis to be realized than ignored. Without it, we are still forced to pathologized completely normal (I repeat normal) reactions to completely abnormal and horrific experiences that many children are forced to endure. The difference is that we are currently forced to tag these children with even more alienating labels like ODD and conduct disorder. The other concern is that clinicians and prescribers may treat a child for an inaccurate diagnosis. As mentioned earlier, the proper treatment for ADHD is not the proper treatment for a child who has been traumatized. 

 For the time being, there isn’t much to be done to address this misstep by the APA and the DSM-5 Task Force. For clinicians and other providers, we can continue to collect information about the source and impact of developmental trauma. We also have a duty to educate patients and their families about developmental trauma. The following quick video from Angela Gonzalez is a great primer.

I don’t think I have ever written a treatment plan or worked with a family without addressing trauma, even when the diagnosis is trash (see above). So here’s to staying positive and hopeful that the DSM-6, whenever it may be, will help us address developmental trauma appropriately.