ABSTRACT

1. Introduction

A recent meta-analysis of data from 96 countries concluded that at least 50% of all children in Asia, Africa, and North America had experienced violence in the past year, which translates to more than 1 billion children globally who are victimized by violence (Hillis et al., 2017). Approximately two in every three children and adolescents in the USA have experienced violence or other forms of victimization (Finkelhor, Turner, Shattuck, & Hamby, 2015). Those samples were assessed for multiple types of violence or victimization ranging in severity from relatively mild (e.g. a fight with a same-age peer resulting in no physical injury) to severe (e.g. poly-victimization involving family and community violence and sexual abuse or exploitation). Although children may be adversely impacted by any form of victimization, subgroups who have the most severe cumulative exposure are at highest risk of significant negative biopsychosocial outcomes (Dierkhising, Branson, Ford, Grasso, & Lee, 2018).

Research consistently documents a strong association between exposure to childhood victimization and psychopathology (D’Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012; Norman et al., 2012; Teicher & Samson, 2013), accounting for an estimated 45% of the population attributable risk for childhood-onset psychiatric disorders including depression, anxiety, suicide attempts, psychosis, substance use disorders (SUDs), dysregulation disorders, and personality disorders (Green et al., 2010), as well as poorer treatment response (Nanni, Uher, & Danese, 2012; Ruf et al., 2010; Shenk, Dorn, Kolko, Rausch, & Insana, 2014). The economic toll of childhood fatal and non-fatal maltreatment in the USA in 2008 was estimated by the Centers for Disease Control to be $124 billion (Fang, Brown, Florence, & Mercy, 2012).

Traumatically victimized children are at risk not only for post-traumatic stress disorder (PTSD), but also for multiple internalizing and externalizing psychiatric disorders (Briggs-Gowan et al., 2010; Copeland, Keeler, Angold, & Costello, 2007). A substantial subgroup (approximately 25%) of children receiving outpatient mental healthcare report multiple types of potentially traumatic victimization and receive multiple psychiatric diagnoses (Ford, Wasser, & Connor, 2011; Kretschmar, Tossone, Butcher, & Flannery, 2017). Exposure to interpersonal violence is uniquely associated with externalizing behaviour problems in both community and clinical populations, and may also account for the relationship between non-interpersonal trauma and psychiatric morbidity with internalizing psychopathology (Briggs-Gowan et al., 2010; Ford, Gagnon, Connor, & Pearson, 2011b). Youths with psychiatric diagnoses also are at subsequent risk for multiple forms of trauma exposure and victimization (Cuevas, Finkelhor, Ormrod, & Turner, 2009; McLaughlin et al., 2013). Moreover, the number and complexity of symptoms and diagnoses in childhood increase significantly if multiple forms of traumatic victimization have occurred, i.e. chronically poly-victimized (Terr’s type II) versus single type/incident trauma exposure (Terr’s type I) (Terr, 1991; Finkelhor, Ormrod, & Turner, 2007; Ford, Elhai, Connor, & Frueh, 2010; Gustafsson, Nilsson, & Svedin, 2009; Holt, Finkelhor, & Kantor, 2007). Further, when primary caregiving relationships are disrupted as a result of caregiver impairment or multiple out-of-home placements (Fischer, Dolitzsch, Schmeck, Fegert, & Schmid, 2016; Ford, Connor, & Hawke, 2009), as many as 30–50% of these children are poly-victims and receive multiple psychiatric diagnoses, yet few (< 5%) are identified with PTSD by clinical or research diagnostic criteria. Thus, the combination of interpersonal victimization and disrupted primary caregiving is associated with complex paediatric psychiatric morbidity (D’Andrea et al., 2012).

Children who receive multiple diagnoses as a result of complex emotional and behavioural problems often are refractory to focal treatment regimens and receive costly and fragmented multiple-component treatment regimens (Comer, Olfson, & Mojtabai, 2010; Grella & Joshi, 2003; Lau & Weisz, 2003; Mojtabai & Olfson, 2010; Mueser & Taub, 2008; Saldana et al., 2014). Poly-pharmacological and/or poly-psychotherapeutic treatment is at best only partially and temporarily effective with chronic and severe psychiatric disorders (Grella & Joshi, 2003; Holtmann et al., 2011; Jacobs et al., 2008; Jucksch et al., 2011) and may lead to severe adverse reactions (Barbui et al., 2007; Luo, Cappelleri, & Frush, 2007; Schorr, Loonen, Brouwers, & Taxis, 2008). Treatment targeted to address trauma-related symptoms could provide a complementary or alternative approach for poly-victimized and poly-diagnosed children and adolescents (D’Andrea et al., 2012). Targeted therapies are emerging for these children and adolescents (Ford & Courtois, 2013) and show promise in observational studies (Dorsey et al., 2017; Harvey & Taylor, 2010) and preliminary efficacy trials (Ford, Grasso, Levine, & Tennen, 2018; Ford, Steinberg, Hawke, Levine, & Zhang, 2012; Lowell, Carter, Godoy, Paulicin, & Briggs-Gowan, 2011; Murray et al., 2015; Pfeiffer, Sachser, Rohlmann, & Goldbeck, 2018; Ruf et al., 2010; Spinhoven, Slee, Garnefski, & Arensman, 2009). However, these studies use a wide variety of clinical criteria and assessment measures to identify participants and monitor outcome, making it difficult to compare the findings and make progress towards evidence-based treatments. Establishing a single integrative set of clinical criteria that can be operationalized by a validated assessment protocol could greatly enhance this research, and that is the goal of the present study.

The empirically guided refinements and elaboration of the criteria for PTSD in adults (Weathers, 2017) and young children (Scheeringa, Myers, Putnam, & Zeanah, 2012) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provide a potential framework for addressing complex biopsychosocial sequelae that were not previously included in the PTSD diagnosis. However, evidence supporting the establishment of a complex subtype of PTSD in adults (Brewin et al., 2017) and children (Sachser, Keller, & Goldbeck, 2017) suggests that a parallel complex subtype may be warranted to fully assess the complex sequelae of poly-victimization in childhood and adolescence. Many poly-victimized children do not meet criteria for PTSD despite having severe internalizing and externalizing problems (D’Andrea et al., 2012). The absence of a focal clinical/conceptual framework and comprehensive yet efficient assessment measures to characterize the complex sequelae of traumatic victimization in children has limited the development and testing of targeted therapies for poly-victimized children and adolescents (Ford, 2015).

Therefore, based on a review of the research on the childhood sequelae of severe and chronic exposure to interpersonal violence and impaired primary caregivers (D’Andrea et al., 2012), developmental trauma disorder (DTD) was formulated (van der Kolk, 2005). Consistent with the results of an international survey of clinicians (Ford et al., 2013), DTD was operationalized as 15 symptoms in three biopsychosocial domains: (1) emotion and somatic; (2) cognition and behaviour; and (2) self and relationships. This structure parallels that proposed for adults in the complex post-traumatic stress disorder (CPTSD) symptom domains of ‘disturbances of self-organization’, which identify problems of emotion regulation, cognitive distortions, and behavioural and interpersonal problems that are distinct from the symptoms of traditional [Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)] PTSD (Karatzias et al., 2017; Murphy, Elklit, Dokkedahl, & Shevlin, 2016; Shevlin et al., 2017, 2018).

The present study extends initial findings from a field trial with children in mental health or paediatric treatment that evaluated the psychometrics of a structured interview for DTD (Ford, Spinazzola, van der Kolk, & Grasso, 2018) and demonstrated that DTD and PTSD share many trauma antecedents but also each have distinct unique trauma history profiles (Spinazzola, van der Kolk, & Ford, 2018). The key question addressed here is whether DTD and PTSD have distinct patterns of psychiatric comorbidity. If DTD can be shown to have psychiatric comorbidities different from or independent of PTSD’s comorbidities, DTD may have incremental clinical utility by identifying psychiatrically impaired children who do not meet criteria for PTSD but could benefit from trauma-focused treatment. On the other hand, if DTD has no unique psychiatric comorbidities independent from those associated with PTSD, this would suggest that PTSD is sufficient as a means of identifying psychiatrically impaired children who are traumatized, including poly-victims. That also would be consistent with a view that DTD is reducible to PTSD plus psychiatric comorbidities, as has been proposed for adult complex trauma survivors (De Jongh et al., 2016; Resick et al., 2012).

2. Method

3. Results

4. Discussion

The study findings provide support for the study hypothesis that the proposed DTD syndrome is associated with pervasive psychiatric comorbidities that are distinct from those for PTSD. This finding suggests that, contrary to the position of sceptics who question the complex PTSD framework for adult trauma survivors (De Jongh et al., 2016; Resick et al., 2012), DTD does not seem to be reducible to a combination of PTSD plus psychiatric comorbidities. Instead, the study results suggest that DTD may co-occur with other psychiatric disorders in a subset of cases in which PTSD is not present. DTD thus cannot be explained simply as a variant of PTSD or any other disorder, and may complicate the symptoms and impairment of some children who are diagnosed with psychiatric disorders but not recognized as trauma survivors owing to not meeting criteria for PTSD. Implications of these findings for research and practice will be discussed. The findings converge with those of an international survey of child-serving clinicians (Ford et al., 2013) to indicate that DTD may have clinical utility as a parsimonious integrative diagnostic framework that, in addition to PTSD, can inform clinical formulation and treatment planning for traumatically poly-victimized (Spinazzola et al., 2018) children and adolescents. Although comorbidity is common for most psychiatric disorders, what is unique about the current study’s findings is that they show that DTD has comorbidities that cannot be accounted for by the comorbidities of PTSD. DTD thus potentially could enable clinicians to identify children and adolescents who could benefit from trauma-focused treatment who would be overlooked if only PTSD was considered as a basis for recommending that treatment. If those youths do not respond positively to evidence-based treatment for the comorbid diagnoses owing, at least in part, to untreated traumatic stress symptoms, this could add to the economic and social costs of their disorders as well as adversely impacting their health and quality of life. Research therefore is warranted to test whether identifying and treating DTD can enhance the psychosocial outcomes and reduce the costs of treatment for DTD’s comorbid psychiatric disorders.

The psychiatric comorbidities associated with DTD but not PTSD – ADHD and separation anxiety disorder in multivariate analyses; ODD, CD, and panic disorder in bivariate analyses – suggest that DTD may play a role in the symptoms of a subgroup of children and adolescents who present with either externalizing or internalizing psychopathology. By contrast, PTSD was comorbid with two internalizing disorders independent of the effects of DTD: generalized anxiety disorder and major depressive disorder. Thus, although DTD and PTSD have comorbidities in common, their association with other psychiatric disorders is sufficiently distinct to indicate that DTD may offer an added approach to identifying poly-traumatized psychiatrically impaired children who might be missed if only PTSD is used as the basis for assessing the sequelae of trauma exposure. Whether DTD is better conceptualized and operationalized as a complex subtype of PTSD [as is proposed for the International Classification of Diseases, 11th revision (ICD-11) adult CPTSD subtype] (Brewin et al., 2017) or as a separate traumatic stress disorder apart from PTSD (as originally proposed for adult CPTSD) (Ford, 2017) was not addressed in this study and remains to be determined by future research.

The study findings may, however, shed light on the fundamental question of whether DTD can be justified as a distinct psychiatric syndrome. One argument against DTD is that its symptoms overlap with, and therefore may be explained by the presence of, other psychiatric disorders (Schmid, Petermann, & Fegert, 2013). Despite the evidence of comorbidity in the current study, DTD occurred with no psychiatric comorbidity for a subset of children and adolescents. DTD was particularly likely to co-occur only with a subset of the childhood psychiatric disorders studied (i.e. separation anxiety disorder, bipolar disorder, ADHD, ODD, CD, panic disorder), and contained symptoms not included in any of those disorders. Thus, although DTD had several psychiatric comorbidities, the study results indicate that DTD was not entirely reducible to any other disorder or combination of disorders. Instead, DTD identified subgroups in each of these psychiatric diagnostic cohorts who may warrant trauma-focused treatment in addition to treatment for their identified psychiatric disorder(s).

However, it is important to note that trauma-focused treatment may be beneficial with clients who have a history of exposure to traumatic stressors and do not meet criteria for PTSD but are experiencing emotional or behavioural symptoms that may be related to or exacerbated by their trauma history (Ford, 2018). Trauma exposure is a well-documented antecedent of many childhood psychiatric disorders (D’Andrea et al., 2012), so it is important not to overlook the potential impact of trauma history in conducting assessment and providing treatment with children and adolescents who are identified with disorders other than PTSD or DTD. Although the current study focused on comparing the likelihood of different forms of psychiatric comorbidity among youths who did versus those did not meet full criteria for DTD, youths who do not meet those full diagnostic criteria may have symptoms of DTD that could warrant trauma-focused treatment. The study findings therefore should not be assumed to imply that trauma-focused assessment and treatment are indicated only if full DTD co-occurs with other psychiatric disorders. Indeed, a potential clinical implication of the study findings, which warrants empirical testing in future research, is that the provision of evidence-based trauma-focused treatment designed to address clinically identified DTD symptoms (Ford, Blaustein, Habib, & Kagan, 2013) may enhance the outcome of other evidence-based treatments for children and adolescents who have developmental trauma histories and other psychiatric disorders.

An additional related criticism of both PTSD and DTD is that these syndromes’ purported trauma-based aetiology oversimplifies the complex biopsychosocial origins of psychopathology (Schmid et al., 2013). Specifically, the putative symptoms of PTSD or DTD may occur in the absence of any trauma history, or, in the case of DTD, as sequelae of traumatic stressors that do not include interpersonal victimization and impaired caregivers. Prior analyses with this data set showed that symptoms qualifying for a diagnosis of DTD were unlikely to occur in the absence of a history of traumatic exposure to family and community violence or impaired caregivers, and most likely to occur when both had occurred, independent of the presence of PTSD (Spinazzola et al., 2018). This does not prove causal aetiology, but instead suggests that a history of the hypothesized pattern of victimization plus disrupted primary caregiver bonding may place children at risk for symptoms constituting DTD.

The comorbidity findings reported here further demonstrate that the traumatic antecedents and symptoms proposed to constitute DTD are associated with a pattern of comorbidity that involves internalizing and externalizing disorders for which exposure to traumatic stressors is not generally considered an aetiological factor (D’Andrea et al., 2012). These findings neither presuppose that, nor test whether, this profile of traumatic antecedents is the cause of DTD and its distinct psychiatric comorbidities. Instead, the comorbidity findings indicate that children with externalizing disorders or internalizing (panic/separation anxiety) disorders may benefit from a thorough assessment of trauma history and of DTD symptoms to identify a potential subgroup who are experiencing clinically significant trauma-related symptoms and who might benefit from trauma-focused treatment yet otherwise may be overlooked. This would in no way rule out other aetiological factors for those disorders, nor would it contraindicate the provision of evidence-based treatment for the ‘primary’ psychiatric disorder. Instead, identifying children who meet criteria for DTD in addition to other psychiatric disorders would open the door to trauma-focused treatment for that subgroup, in the context of a multi-syndrome and multi-disciplinary treatment plan (Schmid et al., 2013).

Study findings regarding the comorbidities of DTD that are either not shared by PTSD or independent of their relationship to PTSD are consistent with extensive prior research. With regard to the externalizing disorder comorbidities of DTD (ADHD, ODD, CD), externalizing behaviour problems have been linked empirically to cumulative exposure to violence (Alvarez-Lister, Pereda, Abad, & Guilera, 2014; Briggs-Gowan et al., 2010; Cudmore, Cuevas, & Sabina, 2015; du Plessis, Kaminer, Hardy, & Benjamin, 2015; Ford et al., 2010, 2011; Greger, Myhre, Lydersen, & Jozefiak, 2015; Horan & Widom, 2015; Shen, 2009; Turner, Shattuck, Finkelhor, & Hamby, 2015), including childhood maltreatment (Boden, Fergusson, & Horwood, 2010; Ford, Gagnon, Connor, & Pearson, 2011a; Ford et al., 1999; Greger et al., 2015; Horan & Widom, 2015; Lewis et al., 2015; Shen, 2009; Simmel, Brooks, Barth, & Hinshaw, 2001), family violence (Briggs-Gowan et al., 2010; Ford et al., 2011a, 1999; Lewis et al., 2015; Shen, 2009), community violence (Borofsky, Kellerman, Baucom, Oliver, & Margolin, 2013; Briggs-Gowan et al., 2010; Cecil, Viding, Barker, Guiney, & McCrory, 2014; Ford et al., 2011a; Ford, Hartman, Hawke, & Chapman, 2008; Ford et al., 1999; Javdani, Abdul-Adil, Suarez, Nichols, & Farmer, 2014; Lambert, Boyd, Cammack, & Ialongo, 2012; Lewis et al., 2015), and maladaptive parenting (Briggs-Gowan et al., 2010; Horan & Widom, 2015; Logan-Greene & Semanchin Jones, 2015; Maguire et al., 2015; Moffitt et al., 2008). With regard to internalizing disorders, victimization is associated with separation anxiety disorder (Battaglia, Ogliari, D’Amato, & Kinkead, 2014; Silove et al., 2015) and panic disorder (Battaglia et al., 2014; Ural, Belli, Akbudak, & Tabo, 2015) (Liu, Sareen, Bolton, & Wang, 2015). Thus, for the subgroup of children with these disorders who have experienced victimization and impaired primary caregivers, but do not meet criteria for PTSD, DTD may provide a framework for targeting trauma-focused treatment.

Funding Statement

The study was funded by contributions to the Justice Resource Institute by organizations and individuals (see www.jri.org), Julian Ford PhD and Bessel van der Kolk MD, principal investigators.

References