CM E

Developmental
Trauma Disorder
Toward a rational diagnosis for children with complex trauma histories.

C
hildhood trauma, including abuse and neglect, is probably the
Dr. van der Kolk is profes- single most important public health challenge in
sor of psychiatry, Boston the United States, a challenge that
University Medical School, has the potential to be largely
Boston, MA; clinical director, resolved by ap-
The Trauma Center at Justice
Resource Institute, Brookline,
MA; and co-director, the Na-
tional Child Traumatic Stress
Network Community Pro-
gram, Boston.
Address reprint requests
to: Bessel A. van der Kolk, MD,
16 Braddock Park, Boston,
MA 02116.
Dr. van der Kolk has no in-
dustry relationships to disclose.
The following members of
the National Child Traumatic
Stress Network DSM-V task
force contributed to the de-
velopment of the proposed
diagnosis of developmental
trauma disorder: Marylene
Cloitre, PhD; Julian Ford,
PhD; Alicia Lieberman, PhD;
Frank Putnam, MD; Robert
Pynoos, MD; Glenn Saxe, MD;
Michael Scheeringa, PhD; Jo-
seph Spinazzola, PhD; Allan propriate
Steinberg, MD; and Martin prevention and in-
Teicher, MD, PhD. tervention. Each year, more
than 3 million children are reported
to authorities for abuse or neglect in the US;
about 1 million of those cases are substantiated.1 Many

Bessel A. van der Kolk, MD

PSYCHIATRIC ANNALS 35:5 | MAY 2005 401

 EDUCATIONAL OBJECTIVES
matic events, most often of an interper- exposed to repeated medical or surgical
sonal nature (eg, sexual or physical abuse, procedures, have a pervasive effects on
1. Identify emotional triggers
war, community violence) and early-life the development of mind and brain.
and patterns of re-enactment
onset. These exposures often occur within Chronic trauma interferes with neuro-
in traumatized children.
the child’s caregiving system and include biological development (Ford, see page
2. Discuss the spectrum of de- physical, emotional, and educational ne- 410) and the capacity to integrate sensory,
velopmental derailments sec- glect and child maltreatment beginning emotional and cognitive information into
ondary to complex trauma in early childhood (Cook et al., page 390, a cohesive whole. Developmental trauma
exposure. and Spinazzola et al., page 433). sets the stage for unfocused responses to
3. Describe patterns of accom- In the Adverse Childhood Experi- subsequent stress,3 leading to dramatic
modation in traumatized ences (ACE) study by Kaiser Permanente increases in the use of medical, correc-
children. and the Centers for Disease Control and tional, social and mental health services.4
Prevention,2 17,337 adult health mainte- People with childhood histories of trau-
nance organization (HMO) members re- ma, abuse and neglect make up almost
thousands more undergo traumatic medi- sponded to a questionnaire about adverse the entire criminal justice population in
cal and surgical procedures and are vic- childhood experiences, including child- the US.5 Physical abuse and neglect are
tims of accidents and of community vio- hood abuse, neglect, and family dysfunc- associated with very high rates of arrest
lence (see Spinazzola et al., page 433). tion. Eleven percent reported having been for violent offenses. In one prospective
However, most trauma begins at home; emotionally abused as a child, 30.1% re- study of victims of abuse and neglect,
the vast majority of people (about 80%) ported physical abuse, and 19.9% sexual almost half were arrested for nontraffic-
responsible for child maltreatment are abuse. In addition, 23.5% reported being related offenses by age 32.6 Seventy-five
children’s own parents. exposed to family alcohol abuse, 18.8% percent of perpetrators of child sexual
Inquiry into developmental milestones were exposed to mental illness, 12.5% abuse report to have themselves been
and family medical history is routine in witnessed their mothers being battered, sexually abused during childhood.7
medical and psychiatric examinations. In and 4.9% reported family drug abuse. These data suggest that most inter-
contrast, social taboos prevent obtaining in- The ACE study showed that adverse personal trauma on children is perpetu-
formation about childhood trauma, abuse, childhood experiences are vastly more ated by victims who grow up to become
neglect, and other exposures to violence. common than recognized or acknowledged perpetrators or repeat victims of violence.
Research has shown that traumatic child- and that they have a powerful relationship This tendency to repeat represents an in-
hood experiences not only are extremely to adult health a half-century later. The tegral aspect of the cycle of violence in
common but also have a profound impact study confirmed earlier investigations that our society.
on many different areas of functioning. found a highly significant relationship be-
For example, children exposed to alco- tween adverse childhood experiences and TRAUMA, CAREGIVERS, AND AFFECT
holic parents or domestic violence rarely depression, suicide attempts, alcoholism, TOLERANCE
have secure childhoods; their symptom- drug abuse, sexual promiscuity, domes- Children learn to regulate their behav-
atology tends to be pervasive and multi- tic violence, cigarette smoking, obesity, ior by anticipating their caregivers’ re-
faceted and is likely to include depression, physical inactivity, and sexually transmit- sponses to them.8 This interaction allows
various medical illnesses, and a variety ted diseases. In addition, the more adverse them to construct what Bowlby called
of impulsive and self-destructive behav- childhood experiences reported, the more “internal working models.”9 A child’s in-
iors. Approaching each of these problems likely a person was to develop heart dis- ternal working models are defined by the
piecemeal, rather than as expressions of ease, cancer, stroke, diabetes, skeletal frac- internalization of the affective and cogni-
a vast system of internal disorganization, tures, and liver disease. tive characteristics of their primary rela-
runs the risk of losing sight of the forest in Isolated traumatic incidents tend to tionships. Because early experiences oc-
favor of one tree. produce discrete conditioned behavioral cur in the context of a developing brain,
and biological responses to reminders neural development and social interac-
COMPLEX TRAUMA of the trauma, such as those captured in tion are inextricably intertwined. As Don
The traumatic stress field has adopted the posttraumatic stress disorder (PTSD) Tucker has said: “For the human brain,
the term “complex trauma” to describe diagnosis. In contrast, chronic maltreat- the most important information for suc-
the experience of multiple, chronic and ment or inevitable repeated traumatiza- cessful development is conveyed by the
prolonged, developmentally adverse trau- tion, such as occurs in children who are social rather than the physical environ-

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ment. The baby brain must begin partici- causes a breakdown in their capacity to either what they feel (their emotions), or
pating effectively in the process of social process, integrate, and categorize what is what they perceive (their cognitions).
information transmission that offers entry happening. At the core of traumatic stress When children are unable to achieve a
into the culture.”10 is a breakdown in the capacity to regu- sense of control and stability, they become
Early patterns of attachment affect the late internal states. If the distress does not helpless. If they are unable to grasp what
quality of information processing through- ease, the relevant sensations, affects, and is going on and unable do anything about
out life.11 Secure infants learn to trust both cognitions cannot be associated — they it to change it, they go immediately from
what they feel and how they understand are dissociated into sensory fragments14 (fearful) stimulus to (fight/flight/freeze) re-
the world. This allows them to rely on both — and, as a result, these children cannot sponse without being able to learn from the
their emotions and their thoughts to react comprehend what is happening or devise experience. Subsequently, when exposed
to any given situation. Their experience of and execute appropriate plans of action. to reminders of a trauma (eg, sensations,
feeling understood provides them with the When caregivers are emotionally ab- physiological states, images,
confidence that they are capable of making sent, inconsistent, frustrating, violent, sounds, situ-
good things happen and that, if they do not intrusive, or neglectful, children are
know how to deal with difficult situations, likely to become intolerably
they can find people who can help them distressed and
find a solution.
Secure children learn a complex vo-
cabulary to describe their emotions, such
as love, hate, pleasure, disgust, and anger.
This allows them to communicate how
they feel and to formulate efficient re-

Secure children learn a complex

vocabulary to describe their
emotions, such as love, hate,
pleasure, disgust, and anger.

sponse strategies. They spend more time

describing physiological states such as
hunger and thirst, as well as emotional
states, than do maltreated children.12
Under most conditions, parents are unlikely
able to help their distressed children re- to develop a
store a sense of safety and control. The sense that the external en-
security of the attachment bond mitigates vironment is able to provide relief.
against trauma-induced terror. When trau- Thus, children with insecure attachment
ma occurs in the presence of a supportive, patterns have trouble relying on others
if helpless, caregiver, the child’s response to help them and are unable to regulate ations), they
is likely to mimic that of the parent — the their emotional states by themselves. As a tend to behave as if they
more disorganized the parent, the more result, they experience excessive anxiety, were traumatized all over again
disorganized the child.13 anger, and longings to be taken care of. — as a catastrophe.15 Many problems of
However, if the distress is overwhelm- These feelings may become so extreme traumatized children can be understood as
ing, or when the caregivers themselves as to precipitate dissociative states or efforts to minimize objective threat and to
are the source of the distress, children self-defeating aggression. “Spaced out” regulate their emotional distress.16 Unless
are unable to modulate their arousal. This and hyperaroused children learn to ignore caregivers understand the nature of such

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 able stress and if the caregiver does not
SIDEBAR.
take over the function of modulating the
Developmental Trauma Disorder child’s arousal, as occurs when children
A. Exposure
are exposed to family dysfunction or vio-
lence, the child will be unable to organize
• Multiple or chronic exposure to one or more forms of developmentally ad-
verse interpersonal trauma (eg, abandonment, betrayal, physical assaults, and categorize experiences in a coherent
sexual assaults, threats to bodily integrity, coercive practices, emotional fashion. Unlike adults, children do not
abuse, witnessing violence and death). have the option to report, move away or
• Subjective experience (eg, rage, betrayal, fear, resignation, defeat, shame). otherwise protect themselves; they depend
B. Triggered pattern of repeated dysregulation in response to trauma cues on their caregivers for their very survival.
Dysregulation (high or low) in presence of cues. Changes persist and do not When trauma emanates from within
return to baseline; not reduced in intensity by conscious awareness.
the family, children experience a crisis of
• Affective.
loyalty and organize their behavior to sur-
• Somatic (eg, physiological, motoric, medical). vive within their families. Being prevent-
• Behavioral (eg, re-enactment, cutting). ed from articulating what they observe
• Cognitive (eg, thinking that it is happening again, confusion, dissociation, and experience, traumatized children will
depersonalization).
organize their behavior around keeping
• Relational (eg, clinging, oppositional, distrustful, compliant).
the secret, deal with their helplessness
• Self-attribution (eg, self-hate, blame).
with compliance or defiance, and accli-
C. Persistently Altered Attributions and Expectancies
mate in any way they can to entrapment
• Negative self-attribution. in abusive or neglectful situations.19
• Distrust of protective caretaker. When professionals are unaware of
• Loss of expectancy of protection by others. children’s need to adjust to traumatizing
• Loss of trust in social agencies to protect. environments and expect that children
• Lack of recourse to social justice/retribution. should behave in accordance with adult
• Inevitability of future victimization. standards of self-determination and au-
D. Functional Impairment tonomous, rational choices, these mal-
• Educational. adaptive behaviors tend to inspire revul-
• Familial. sion and rejection. Ignorance of this fact
• Peer. is likely to lead to labeling and stigmatiz-
• Legal. ing children for behaviors that are meant
• Vocational. to ensure survival.
Being left to their own devices leaves
chronically traumatized children with
re-enactments, they are likely to label the one’s personal experience over time.17 deficits in emotional self-regulation.
child as “oppositional,” “rebellious,” “un- Piaget18 called this “decentration”: mov- This results in problems with self-defi-
motivated,” or “antisocial.” ing from being one’s reflexes, move- nition as reflected by a lack of a con-
ments, and sensations to having them. tinuous sense of self, poorly modulated
THE DYNAMICS OF CHILDHOOD Predictability and continuity are critical affect and impulse control, including
TRAUMA for a child to develop a good sense of cau- aggression against self and others, and
Young children, still embedded in the sality and learn to categorize experience. uncertainty about the reliability and pre-
here-and-now and lacking the capacity to A child needs to develop categories to be dictability of others, expressed as dis-
see themselves in the perspective of the able to place any particular experience in a trust, suspiciousness, and problems with
larger context, have no choice but to see larger context. Only then will he or she be intimacy, resulting in social isolation.20
themselves as the center of the universe. able to evaluate what is happening and en- Chronically traumatized children tend to
In their eyes, everything that happens is tertain a range of options with which they suffer from distinct alterations in states
related directly to their own sensations. can affect the outcome of events. Imagin- of consciousness, including amnesia,
Development consists of learning to mas- ing being able to play an active role leads hypermnesia, dissociation, depersonal-
ter and “own” one’s experiences and to to problem-focused coping.15 ization and derealization, flashbacks and
learn to experience the present as part of If children are exposed to unmanage- nightmares of specific events, school

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problems, difficulties in attention regu- CHILDHOOD TRAUMA AND fourth ediction (DSM-IV),28 Field Trial
lation, disorientation in time and space, PSYCHIATRIC ILLNESS suggested that trauma has its most per-
and sensorimotor developmental disor- Posttraumatic stress disorder (PTSD) is vasive impact during the first decade of
ders. The children often are literally are not the most common psychiatric diagnosis life and becomes more circumscribed
“out of touch” with their feelings, and in children with histories of chronic trauma (ie, more like “pure” PTSD) with age.29
often have no language to describe in- (Cook et al., see page 390). For example, The diagnosis of PTSD is not devel-
ternal states.21 in one study of 364 abused children,22 the opmentally sensitive and does not ad-
When a child lacks a sense of predict- most common diagnoses in order of fre- equately describe the effect of exposure
ability, he or she may experience diffi- quency were separation anxiety disorder, to childhood trauma on the developing
culty developing object constancy and oppositional defiant disorder, phobic dis- child. Because infants and children who
inner representations of their own inner orders, PTSD, and ADHD.22 Numerous experience multiple forms of abuse of-
world or their surroundings. As a result, studies of traumatized children find prob- ten experience developmen-
they lack a good sense of cause and ef- lems with unmodulated aggression and tal delays
fect and of their own contributions to impulse control,23,24 attentional and dis-
what happens to them. Without internal sociative problems,25 and diffi-
maps to guide them, they act instead of culty negotiating
plan and show their wishes in their be-
haviors, rather than discussing what they
want.15 Unable to appreciate clearly who
they or others are, they have problems
enlisting other people as allies on their
behalf. Other people are sources of ter-

A history of childhood physical

and sexual assault is associated
with a host of other psychiatric
diagnoses in adolescence
and adulthood.
ror or pleasure but are rarely fellow hu-
man beings with their own sets of needs
and desires.
These children also have difficulty
appreciating novelty. Without a map to relation-
compare and contrast, anything new is ships with care-
potentially threatening. What is familiar givers, peers, and, later in
tends to be experienced as safer, even if it life, intimate partners.26
is a predictable source of terror.15 A history of childhood physical and sex-
Traumatized children rarely discuss ual assault is associated with a host of other across
their fears and traumas spontaneously. psychiatric diagnoses in adolescence and a broad spec
They also have little insight into the re- adulthood. These may include substance trum, including cog
lationship between what they do, what abuse, borderline and antisocial personal- nitive, language, motor, and
they feel, and what has happened to them. ity, or eating, dissociative, affective, so- socialization skills,30 they tend to dis-
They tend to communicate the nature of matoform, cardiovascular, metabolic, im- play very complex disturbances, with
their traumatic past by repeating it in the munologic, and sexual disorders.27 a variety of different, often fluctuating,
form of interpersonal enactments, both in The results of the Diagnostic and presentations.
their play and in their fantasy lives. Statistical Manual of Mental Disorders, However, because there currently is

PSYCHIATRIC ANNALS 35:5 | MAY 2005 405

no other diagnostic entity that describes resulting self endangering behaviors; the the issue of triggered dysregulation in re-
the pervasive effects of trauma on child self-hatred and self-blame; and the chron- sponse to traumatic reminders, stimulus
development, these children are given a ic feelings of ineffectiveness. generalization, and the anticipatory orga-
range of “comorbid” diagnoses, as if they Interestingly, many forms of interper- nization of behavior to prevent the recur-
occurred independently from the PTSD sonal trauma, in particular psychological rence of the trauma effects.
symptoms. None of these do justice to maltreatment, neglect, separation from This provisional diagnosis is based
the spectrum of problems of traumatized caregivers, traumatic loss, and inappro- on the concept that multiple exposures
children, and none provide guidelines on priate sexual behavior, do not necessar- to interpersonal trauma, such as aban-
what is needed for effective prevention ily meet DSM-IV “Criterion A” defini- donment, betrayal, physical or sexual as-
and intervention. By relegating the full tion for a traumatic event. This criteria saults, or witnessing domestic violence,
spectrum of trauma-related problems to requires, in part, an experience involving have consistent and predictable conse-
seemingly unrelated “comorbid” condi- “actual or threatened death or serious in- quences that affect many areas of func-
tions, fundamental trauma-related dis- jury, or a threat to the physical integrity tioning. These experiences engender in-
turbances may be lost to scientific inves- of self or others.”28 Children exposed to tense affects, such as rage, betrayal, fear,
tigation, and clinicians may run the risk these common types of interpersonal ad- resignation, defeat, and shame, and ef-
of applying treatment approaches that versity thus typically would not qualify forts to ward off the recurrence of those
are not helpful. for a PTSD diagnosis unless they also emotions, including the avoidance of ex-
were exposed to experiences or events periences that precipitate them or engag-
A NEW DIAGNOSIS: that qualify as “traumatic,” even if they ing in behaviors that convey a subjective
DEVELOPMENTAL TRAUMA have symptoms that would otherwise sense of control in the face of potential
DISORDER warrant a PTSD diagnosis. threats. These children tend to reenact
The question of how best to organize This finding has several implica- their traumas behaviorally, either as per-
the very complex emotional, behavioral, tions for the diagnosis and treatment of petrators (eg, aggressive or sexual acting
and neurobiological sequelae of child- traumatized children and adolescents. out against other children) or in frozen
hood trauma has vexed clinicians for sev- Non-Criterion A forms of childhood avoidance reactions. Their physiological
eral decades. Because DSM-IV includes a trauma exposure — such as psychologi- dysregulation may lead to multiple so-
diagnosis for adult onset trauma, PTSD, cal or emotional abuse and traumatic matic problems, such as headaches and
this label often is applied to traumatized loss — have been demonstrated to be as- stomachaches, in response to fearful and
children as well. However, the majority sociated with PTSD symptoms and self- helpless emotions.
of traumatized children do not meet di- regulatory impairments in children32 and Persistent sensitivity to reminders inter-
agnostic criteria for PTSD31 (Cook et al., into adulthood.33 Thus, classification of feres with the development of emotional
see page 390), and PTSD cannot capture traumatic events may need to be defined regulation and causes long-term emotional
the multiplicity of exposures over critical more broadly, and treatment may need to dysregulation and precipitous behavior
developmental periods. address directly the sequelae of these in- changes. Children’s over- and underre-
Moreover, the PTSD diagnosis does terpersonal adversities, given their preva- activity is manifested on multiple levels:
not capture the developmental effects of lence and potentially severe negative emotional, physical, behavioral, cognitive,
childhood trauma: the complex disrup- effects on children’s development and and relational. They have fearful, enraged,
tions of affect regulation; the disturbed emotional health. or avoidant emotional reactions to minor
attachment patterns; the rapid behavioral The Complex Trauma taskforce of the stimuli that would have no significant ef-
regressions and shifts in emotional states; National Child Traumatic Stress Network fect on secure children. After having be-
the loss of autonomous strivings; the ag- has been concerned about the need for a come aroused, these children have a great
gressive behavior against self and others; more precise diagnosis for children with deal of difficulty restoring homeostasis
the failure to achieve developmental com- complex histories. In an attempt to more and returning to baseline. Insight and un-
petencies; the loss of bodily regulation in clearly delineate what these children suf- derstanding about the origins of their reac-
the areas of sleep, food, and self-care; the fer from and to serve as a guide for ratio- tions seems to have little effect.
altered schemas of the world; the anticipa- nal therapeutics this taskforce has started In addition to the conditioned physi-
tory behavior and traumatic expectations; to conceptualize a new diagnosis, pro- ological and emotional responses to re-
the multiple somatic problems, from gas- visionally called developmental trauma minders characteristic of PTSD, children
trointestinal distress to headaches; the disorder (Sidebar, see page 404). This with complex trauma develop a view of
apparent lack of awareness of danger and proposed diagnosis is organized around the world that incorporates their betrayal

406 PSYCHIATRIC ANNALS 35:5 | MAY 2005

and hurt. They anticipate and expect the from familiar environments and people pacity to play with other children, engage
trauma to recur and respond with hyper- to whom they are intensely attached but in simple group activities and deal with
activity, aggression, defeat, or freeze re- who are likely to cause further substantial more complex issues.
sponses to minor stresses. Cognition in damage.15 Treatment must focus on three
these children also is affected by remind- primary areas: establishing safety and Dealing With Traumatic
ers of the trauma. They tend to become compentence, dealing with traumatic re- Re-enactments
confused, dissociated, and disoriented enactments, and integration and master of After a child is traumatized multiple
when faced with stressful stimuli. They the body and mind. times, the imprint of the trauma becomes
easily misinterpret events in the direction lodged in many aspects of his or her make-
of a return of trauma and helplessness, Establishing Safety and Competence up. This is manifested in multiple ways:
which causes them to be constantly on Complexly traumatized children need fearful reactions, aggressive and sexual
guard, frightened, and overreactive. to be helped to engage their attention in acting out, avoidance, and un-
In addition, expectations of a return of pursuits that do not remind them of trau- controlled emo-
the trauma permeate their relationships. ma-related triggers and that give them a
This is expressed as negative self-attri- sense of pleasure and mastery.
butions, loss of trust in caretakers, and Safety, predict-
loss of the belief that some somebody
will look after them and make them feel
safe. They tend to lose the expectation
that they will be protected and act ac-
cordingly. As a result, they organize their
relationships around the expectation or

After a child is traumatized

multiple times, the imprint of the
trauma becomes lodged in many
aspects of his or her makeup.

prevention of abandonment or victim-

ization. This is expressed as excessive
clinging, compliance, oppositional defi-
ance, and distrustful behavior. They also
may be preoccupied with retribution ability,
and revenge. All of these problems are and “fun” are
expressed in dysfunction in multiple ar- essential for the establish-
eas of functioning: educational, familial, ment of the capacity to observe
peer-related, legal, and work-related. what is going on, put it into a larger con-
text, and initiate physiological and mo- tional
TREATMENT IMPLICATIONS toric self-regulation. reactions. Un-
In the treatment of traumatized chil- Before addressing anything else, these less this tendency to re-
dren and adolescents, there often is a children need to be helped how to react peat the trauma is recognized, the
painful dilemma of whether to keep them differently from their habitual fight/flight/ response of the environment is likely to
in the care of people or institutions who freeze reactions.15 Only after children de- replay the original traumatizing, abusive,
are sources of hurt and threat, or whether velop the capacity to focus on pleasurable but familiar, relationships. Because these
to play into abandonment and separa- activities without becoming disorganized children are prone to experience anything
tion distress by taking the child away do they have a chance to develop the ca- novel, including rules and other protective

PSYCHIATRIC ANNALS 35:5 | MAY 2005 407

interventions, as punishments, they tend to of death in adults. The Adverse Childhood commodation syndrome. Child Abuse Negl.
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1998;14(4):245-258. 20. Cole PM, Putnam FW. Effect of incest on
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