APPENDIX
CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER
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.
The Consensus Proposed Criteria for Developmental Trauma Disorder were devised and put forward in February 2009 by a National Child Traumatic Stress Network (NCTSN)-affiliated Task Force led by Bessel A. van der Kolk, MD and Robert S. Pynoos, MD, with the participation of Dante Cicchetti, PhD, Marylene Cloitre, PhD, Wendy D’Andrea, PhD, Julian D. Ford, PhD, Alicia F. Lieberman, PhD, Frank W. Putnam, MD, Glenn Saxe, MD, Joseph Spinazzola, PhD, Bradley C. Stolbach, PhD, and Martin Teicher, MD, PhD. The consensus proposed criteria are based on extensive review of empirical literature, expert clinical wisdom, surveys of NCTSN clinicians, and preliminary analysis of data from thousands of children in numerous clinical and child service system settings, including NCTSN treatment centers, state child welfare systems, inpatient psychiatric settings, and juvenile detention centers. Because their validity, prevalence, symptom thresholds, or clinical utility have yet to be examined through prospective data collection or analysis, these proposed criteria should not be viewed as a formal diagnostic category to be incorporated into the DSM as written here. Rather, they are intended to describe the most clinically significant symptoms exhibited by many children and adolescents following complex trauma. These proposed criteria have guided the Developmental Trauma Disorder field trials that began in 2009 and continue to this day.
CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER
A.Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
A. 1.Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
A. 2.Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse
B.Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following:
B. 1.Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization
B. 2.Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions)
B. 3.Diminished awareness/dissociation of sensations, emotions and bodily states
B. 4.Impaired capacity to describe emotions or bodily states
C.Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following:
C. 1.Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues
C. 2.Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking
C. 3.Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation)
C. 4.Habitual (intentional or automatic) or reactive self-harm
C. 5.Inability to initiate or sustain goal-directed behavior
D.Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following:
D. 1.Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation
D. 2.Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness
D. 3.Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers
D. 4.Reactive physical or verbal aggression toward peers, caregivers, or other adults
D. 5.Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance
D. 6.Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others
E.Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D.
F.Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months.
G.Functional Impairment. The disturbance causes clinically significant distress or impairment in at least two of the following areas of functioning:
Scholastic
Familial
Peer Group
Legal
Health
Vocational (for youth involved in, seeking or referred for employment, volunteer work or job training)
B. A. van der Kolk, “Developmental Trauma Disorder: Toward A Rational Diagnosis For ChildrenWith Complex Trauma Histories,” Psychiatric Annals, 35, no. 5 (2005): 401-408.
RESOURCES
GENERAL INFORMATION ABOUT TRAUMA AND ITS TREATMENT
The Trauma Center at JRI. This is the website of the Trauma Center of which I am the medical director, which has numerous resources for special populations, various treatment approaches, lectures and courses: www.traumacenter.org.
David Baldwin’s Trauma Information Pages provide information for clinicians and researchers in the traumatic-stress field: http://www.trauma -pages.com/.
National Child Traumatic Stress Network (NCTSN). Effective treatments for youth, trauma training, and education measures; reviews of measures examining trauma for parents, educators, judges, child welfare agencies, military personnel, and therapists: http://www.nctsnet.org/.
American Psychological Association. Resource guide for traumatized people and their loved ones: http://www.apa.org/topics/trauma/.
Averse Childhood Experiences. Several websites are devoted to the ACE study and its consequences: http://acestoohigh.com/got-your-ace-score/; http://www.cdc.gov/violenceprevention/acesstudy/; http://aces tudy.org/.
Gift from Within PTSD Resources for Survivors and Caregivers: giftfromwithin.org.
There & Back Again is a nonprofit organization that supports the well-being of service-members. Its mission is to provide reintegration support services to combat veterans of all conflicts: http://thereandbackagain.org/.
HelpPRO Therapist Finder. Comprehensive listings of local therapists specializing in trauma and other concerns, serving specific age groups, accepting payment options and more: http://www.helppro.com/.
Sidran Foundation includes traumatic memories and general information about dealing with trauma: www.sidran.org.
Traumatology. Green Cross Academy of Traumatology electron
ic journal, edited by Charles Figley: www.greencross.org/.
PILOTS database at Dartmouth is a searchable database of the world’s literature on post-traumatic stress disorder, produced by the National Center for PTSD: http://search.proquest.com/pilots/?accountid=28179.
GOVERNMENT RESOURCES
National Center for PTSD includes links to the PTSD Research Quarterly and National Center divisions, including behavioral science division, clinical neuroscience division, and women’s health sciences division: http://www.ptsd.va.gov/.
Office for Victims of Crime in the Department of Justice. Provides a variety of resources for victims of crime in the United States and internationally, including the National Directory of Victim Assistance Funding Opportunities which lists, by state and territory, the contact names, mailing addresses, telephone numbers, and e-mail addresses for the federal grant programs that provide assistance to crime victims: http://ojp.gov/ovc/.
National Institutes of Mental Health: http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml.
WEBSITES SPECIFICALLY DEALING WITH TRAUMA AND MEMORY
Jim Hopper.com. Info on the stages of recovery, recovered memories, and comprehensive literature review on remembering trauma.
The Recovered Memory Project. Archive compiled by Ross Cheit at Brown University: http://www.brown.edu/academics/taubman-center/.
MEDICATIONS
About Medications for Combat PTSD. Jonathan Shay, MD, PhD, staff psychiatrist, Boston VA Outpatient Clinic: http://www.dr-bob.org/tips/ptsd.html. webMD http://www.webmd.com/drugs/condition=1020-post+traumatic+stress+disorderaspx?diseaseid=10200diseasename=post+traumatic+stress+disorder
PROFESSIONAL ORGANIZATIONS FOCUSED ON GENERAL TRAUMA RESEARCH AND DISSEMINATION
International Society for Traumatic Stress Studies: www.istss.com.
European Society for Traumatic Stress Studies: www.estss.org.
International Society for the Study of Trauma and Dissociation (ISSTD): http://www.isst-d.org/.
PROFESSIONAL ORGANIZATIONS DEALING WITH PARTICULAR TREATMENT METHODS
The EMDR International Association (EMDRIA): http://www.emdria.org/.
Sensorimotor Institute (founded by Pat Ogden): http://www.sensorimotorpsychotherapy.org/home/index.html.
Somatic experiencing (founded by Peter Levine): http://www.traumahealing.com/somatic-experiencing/index.html.
Internal family systems therapy: http://www.selfleadership.org/.
Pesso Boyden system psychomotor therapy: PBSP.com.
THEATER PROGRAMS (A SAMPLE OF PROGRAMS FOR TRAUMATIZED YOUTH)
Urban Improv uses improvisational theater workshops to teach violence prevention, conflict resolution, and decision making: http://www.urbanimprov.org/.
The Possibility Project. Based in NYC: http://the-possibility-project.org/.
Shakespeare in the Courts: http://www.shakespeare.org/education/for-youth/shakespeare-courts/.
YOGA AND MINDFULNESS
http://givebackyoga.org/.
http://www.kripalu.org/.
http://www.mindandlife.org/.
FURTHER READING
DEALING WITH TRAUMATIZED CHILDREN
Blaustein, Margaret, and Kristine Kinniburgh. Treating Traumatic Stress in Children and Adolescents: How to Foster Resilience through Attachment, Self-Regulation, and Competency. New York: Guilford, 2012..
Hughes, Daniel. Building the Bonds of Attachment. New York: Jason Aronson, 2006.
Perry, Bruce, and Maia Szalavitz. The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook. New York: Basic Books, 2006.
Terr, Lenore. Too Scared to Cry: Psychic Trauma in Childhood. Basic Books, 2008.
Terr, Lenore C. Working with Children to Heal Interpersonal Trauma: The Power of Play. Ed., Eliana Gil. New York: Guilford Press, 2011.
Saxe, Glenn, Heidi Ellis, and Julie Kaplow. Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach. New York: Guilford Press, 2006.
Lieberman, Alicia, and Patricia van Horn. Psychotherapy with Infants and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment. New York: Guilford Press, 2011.
PSYCHOTHERAPY
Siegel, Daniel J. Mindsight: The New Science of Personal Transformation. New York: Norton, 2010.
Fosha D., M. Solomon, and D. J. Siegel. The Healing Power of Emotion: Affective Neuroscience, Development and Clinical Practice (Norton Series on Interpersonal Neurobiology). New York: Norton, 2009.
Siegel, D., and M. Solomon: Healing Trauma: Attachment, Mind, Body and Brain (Norton Series on Interpersonal Neurobiology). New York: Norton, 2003.
Courtois, Christine, and Julian Ford. Treating Complex Traumatic Stress Disorders (Adults): Scientific Foundations and Therapeutic Models. New York: Guilford, 2013.
Herman, Judith. Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. New York: Basic Books, 1992.
NEUROSCIENCE OF TRAUMA
Panksepp, Jaak, and Lucy Biven. The Archaeology of Mind: Neuroevolutionary Origins of Human Emotions (Norton Series on Interpersonal Neurobiology). New York: Norton, 2012.
Davidson, Richard, and Sharon Begley. The Emotional Life of Your Brain: How Its Unique Patterns Affect the Way You Think, Feel, and Live—and How You Can Change Them. New York: Hachette, 2012.
Porges, Stephen. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation (Norton Series on Interpersonal Neurobiology). New York: Norton, 2011.
Fogel, Alan. Body Sense: The Science and Practice of Embodied Self-Awareness (Norton Series on Interpersonal Neurobiology). New York: Norton, 2009.
Shore, Allan N. Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. New York: Psychology Press, 1994.
Damasio, Antonio R. The Feeling of What Happens: Body and Emotion in the Making of Consciousness. Houghton Mifflin Harcourt, 2000.
BODY-ORIENTED APPROACHES
Cozzolino, Louis. The Neuroscience of Psychotherapy: Healing the Social Brain, second edition (Norton Series on Interpersonal Neurobiology). New York: Norton, 2010.
Ogden, Pat, and Kekuni Minton. Trauma and the Body: A Sensorimotor Approach to Psychotherapy (Norton Series on Interpersonal Neurobiology). New York: Norton, 2008.
Levine, Peter A. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley: North Atlantic, 2010.
Levine, Peter A., and Ann Frederic. Waking the Tiger: Healing Trauma. Berkeley: North Atlantic, 2012
Curran, Linda. 101 Trauma-Informed Interventions: Activities, Exercises and Assignments to Move the Client and Therapy Forward. PESI, 2013.
EMDR
Parnell, Laura. Attachment-Focused EMDR: Healing Relational Trauma. New York: Norton, 2013.
Shapiro, Francine. Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy. Emmaus, PA: Rodale, 2012.
Shapiro, Francine, and Margot Silk Forrest. EMDR: The Breakthrough “Eye Movement” Therapy for Overcoming Anxiety, Stress, and Trauma. New York: Basic Books, 2004.
WORKING WITH DISSOCIATION
Schwartz, Richard C. Internal Family Systems Therapy (The Guilford Family Therapy Series). New York: Guilford, 1997.
O. van der Hart, E. R. Nijenhuis, and F. Steele. The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. New York: Norton, 2006.
COUPLES
Gottman, John. The Science of Trust: Emotional Attunement for Couples. New York: Norton, 2011.
YOGA
Emerson, David, and Elizabeth Hopper. Overcoming Trauma through Yoga: Reclaiming Your Body. Berkeley: North Atlantic, 2012.
&
nbsp; Cope, Stephen. Yoga and the Quest for the True Self. New York: Bantam Books, 1999.
NEUROFEEDBACK
Fisher, Sebern. Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain. New York: Norton, 2014.
Demos, John N. Getting Started with Neurofeedback. New York: Norton, 2005.
Evans, James R. Handbook of Neurofeedback: Dynamics and Clinical Applications. CRC Press, 2013.
PHYSICAL EFFECTS OF TRAUMA
Mate, Gabor When the Body Says No: Understanding the Stress-Disease Connection. New York: Random House, 2011.
Sapolsky, Robert. Why Zebras Don’t Get Ulcers: The Acclaimed Guide to Stress, Stress-Related Diseases, and Coping. New York: Macmillan 2004.
MEDITATION AND MINDFULNESS
Zinn, Jon Kabat and Thich Nat Hanh. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness, revised edition. New York: Random House, 2009.
Kornfield, Jack. A Path with Heart: A Guide Through The Perils and Promises of Spiritual Life. New York: Random House, 2009.
Goldstein, Joseph, and Jack Kornfield. Seeking the Heart of Wisdom: The Path of Insight Meditation. Shambhala Publications, 2001.
PSYCHOMOTOR THERAPY
Pesso, Albert, and John S. Crandell. Moving Psychotherapy: Theory and Application of Pesso System-Psychomotor Therapy. Brookline Books, 1991.
Pesso, Albert. Experience In Action: A Psychomotor Psychology, New York: New York University Press, 1969.
NOTES
PROLOGUE
1.V. Felitti, et al. “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study.” American Journal of Preventive Medicine 14, no. 4 (1998): 245–58.
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