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