DTD — Something New and Big in the World of Challenging Children

DTD is not a condition suffered by alcoholics. It is a new diagnostic description of the emotional disturbances of many challenging children. For years we have been left with the limitations of Reactive Attachment Disorder (RAD). Led by Bessel van der Kolk, M.D., clinicians have developed a new diagnosis, Developmental Trauma Disorder (DTD), to describe the sufferings of many challenging children. Let’s take a look at DTD and see what it is all about using plain English (as much as possible) rather than the technical language of the formal DTD description.

A child who for at least one year experiences or witnesses repeated and severe episodes of any of the following is at risk for DTD:

1. Interpersonal violence
2. Significant disruptions of protective caregiving
3. Exposure to severe and persistent emotional abuse

When a child’s life history includes any of those events, the next step is to determine whether at least two of the following physical effects plague the child.

1. An inability to handle extreme feelings (such as fear, anger, or shame) which may result  severe tantrums or immobilization
2. Serious problems with normal bodily functions, such as chronic sleeping difficulties, eating, and elimination; inappropriate reactions to touch or sounds; difficulty with transitions)
3. Lack of awareness of sensations, emotions and bodily states
4. Difficulty describing emotions or bodily states

The next step is to determine whether the child fails to have age appropriate abilities to handle sustained attention, learning, or coping with stress. At least three of the following criteria must be met for a diagnosis of DTD:

1. Either a preoccupation with threat or the inability to perceive actual threat,
2. Failure to be self-protective, including extreme risk-taking or thrill-seeking
3. Inappropriate self-soothing (for example, rocking and other rhythmical movements or compulsive masturbation)
4. Self-harm
5. Complete absence of goals

The next set of criteria has to do with the child’s sense of self and relationships with others. A child who exhibits three may have DTD:

1. Exaggerated concern with the safety of the caregiver or other loved ones or difficulty reuniting with them after separation
2. Negative self-image, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness
3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships
4. Reactive physical or verbal aggression toward peers, caregivers, or other adults
5. Inappropriate attempts to get intimate contact or excessive reliance on peers or adults for safety and reassurance
6. Lack of empathy for others or excessive reactions to the distress of others

Finally, we want to see if the child shows at least two symptoms of Post Traumatic Stress Disorder (PTSD) within the following broad categories of PTSD. Specific symptoms, not listed here, are found in the description of PTSD.

1. The traumatic event is reexperienced with frequency
2. Avoidance of events and situations associated with the trauma and a numbing of responsiveness
3. Increased arousal (such as hypervigilance and outbursts of anger all too familiar with parents of challenging children)

The DTD symptoms must last for a minimum of 6 months and cause distress or impairment in two or more of the following areas:

1. Difficulties with school, which may involve any number of difficulties, including, for example, under-performance, disciplinary problems, conflict with school personnel, and learning disabilities.
2. Problems functioning in family, including, for example, conflict with family members, attempts to physically or emotionally hurt family members and non-fulfillment of responsibilities within the family.
3. Issues with peers, which may include isolation, persistent physical or emotional conflict, and involvement in violence or unsafe acts.
4. Legal problems of any kind as well as disregard for conventional moral standards.
5. Health problems not explainable by physical examination or tests.
6. Vocational problems for youth or young adults.

There you have the gist of Developmental Trauma Disorder. I will write more about DTD, including hypothetical DTD diagnoses and a discussion of DTD in the context of RAD and other conditions in upcoming blog postings. If you have any questions about DTD which you would like me to address, please let me know.

If you are interested in the complete description of DTD or technical papers about DTD, please send me an email and I will send them to you. In the meantime, what do you think about DTD? Do you believe it more accurately describes the difficulties you see in your child? Please post your thoughts in the comments section below.

Tagged as: Developmental Trauma Disorder, DTD, RAD, Reactive Attachment Disorder