Developmental trauma disorder: pros and cons
of including formal criteria in the psychiatric
Marc Schmid1*, Franz Petermann2and Joerg M Fegert3
Background: This article reviews the current debate on developmental trauma disorder (DTD) with respect to
formalizing its diagnostic criteria. Victims of abuse, neglect, and maltreatment in childhood often develop a wide
range of age-dependent psychopathologies with various mental comorbidities. The supporters of a formal DTD
diagnosis argue that post-traumatic stress disorder (PTSD) does not cover all consequences of severe and complex
traumatization in childhood.
Discussion: Traumatized individuals are difficult to treat, but clinical experience has shown that they tend to
benefit from specific trauma therapy. A main argument against inclusion of formal DTD criteria into existing
diagnostic systems is that emphasis on the etiology of the disorder might force current diagnostic systems to
deviate from their purely descriptive nature. Furthermore, comorbidities and biological aspects of the disorder may
be underdiagnosed using the DTD criteria.
Summary: Here, we discuss arguments for and against the proposal of DTD criteria and address implications and
consequences for the clinical practice.
Keywords: Comorbidity, Developmental psychopathology, Developmental trauma disorder (DTD), Dissociation,
Post-traumatic stress disorder (PTSD)
Inclusion of post-traumatic stress disorder (PTSD) in
psychiatric diagnostic systems represents an important
milestone since a clear connection between traumatic
experiences and mental disorders have not been estab-
lished previously [1-3]. Clinicians in the field of child
and adolescent psychiatry and clinical psychology have
to face acute traumatized children and victims of differ-
ent shades and forms of chronic child abuse, maltreat-
ment and neglect.
In the clinical setting, the effects of neglect, maltreat-
ment, and abuse are noticeable which has prompted the
need for a diagnosis capable of creating the connection
between developmental and psychopathological aspects.
In children and adolescents, the usefulness of diagnostic
criteria of PTSD is limited because the characterization of
the condition is based on symptoms in adults. Because
most symptoms are subjective and require verbal descrip-
tion by the patient, the diagnosis of PTSD in younger
children remains challenging. In the presence of distinct,
well-defined traumata and their effects, the diagnosis of
PTSD can be readily made; childhood traumatization and
neglect tend to be more complex and may entail a multi-
tude of psychosocial risk factors. Therefore, various
proposals for diagnostic criteria have been published
which include developmental psychology factors [4-7].
Most traumatic experiences in children and adole-
scents occur in their immediate social environment
[5,8,9]. Families with neglected, maltreated, or abused
children often carry a number of additional risk factors,
such as mental disorders in parents, poverty, cramped
living conditions, or social isolation [5,10,11]. Moreover,
childhood traumatization leads to a significantly higher
risk of suffering other traumata in adult life [12,13].
Many severely maltreated, sexually abused, or neglec-
ted children who had suffered repeated traumatic events
* Correspondence: marc.Schmid@upkbs.ch
1Department of child and adolescent psychiatry University Basel,
Schanzenstrasse 13, CH-4056, Basel, Switzerland
Full list of author information is available at the end of the article
© 2013 Schmid et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Schmid et al. BMC Psychiatry 2013, 13:3
(i.e., chronic or sequential traumatization) do not fulfill
the diagnostic criteria of PTSD in the strict (adult) sense.
Frequently, affected children experience a multitude of
other psychopathological symptoms [14-16] that often
persist into adulthood, thus making a more systematic
description of the particular symptoms necessary. Terr’s
concept , one of the most influential proposals for the
improvement of diagnostic processes, categorized trau-
mata into single, well-defined, more public traumata
such as accidents, natural disasters, and wartime experi-
ences (type I), and a series of related, sequential trau-
mata such as neglect, maltreatment, and sexual abuse
often committed secretly and over longer time periods by
persons close to the victim (type II). While type I trau-
matization often produces the classic psychopathological
symptoms of PTSD, sequential traumatization may result
in impaired development of personality and heterogene-
ous psychopathological symptoms. Dissociation, low self-
efficacy, impaired regulation of emotion, somatization,
and disturbed perception of self and others are all among
the symptoms caused by chronic traumatization .
Repeatedly traumatized patients tend to exhibit a typical
pattern of successive disorders, i.e., regulatory disorder
during infancy, attachment disorders with or without
disinhibition at preschool age, hyperkinetic conduct dis-
order at school age, or combined conduct and emotional
disorders during adolescence. In later years, personal-
ity disorders are common and often accompanied by
substance abuse, self-harm, and affective disorders. It is
assumed that the same fundamental deficiencies (like
impaired regulation of emotion, low self-efficacy, ten-
dency towards dissociation) have variable consequences
at different developmental stages of the patient, thus
resulting in typical age-related psychopathological symp-
toms  (see Figure 1).
Most literature reviews in this field focus on cross-
sectional studies. Longitudinal studies are rare as they are
difficult to conduct and constrained by ethical limitations.
There are only a few highly important studies supporting
the relevance of interpersonal trauma for developmental
psychopathology from childhood to adulthood [4,14,18].
Empirical evidence of the course of PTSD indicates that
severe sequential traumatization mostly begins in child-
hood showing an inverse correlation between the age of
onset of traumatization and the severity of symptoms.
This gave rise to the need of improved understanding of
developmental aspects in children and adolescents with a
complex trauma history .
In an effort to establish a rational diagnosis in severely
traumatized children, several authors postulated a refined
list of criteria [1,17,19]. To separate these criteria from
those for PTSD, the term ‘developmental trauma disorder’
(DTD) was suggested  (see list of symptoms below).
List of symptoms: consensus of proposed diagnostic
criteria for developmental trauma disorder
In the present paper, the suitability and limitations of the
criteria postulated in the diagnosis of DTD are reviewed,
and implications and consequences for clinical practice
Proposed diagnostic criteria and symptom clusters
To include DTD in the DSM-V algorithm for separated
diagnosis, van der Kolk et al. proposed the following
criteria (organized into three symptom clusters) in
Figure 1 Development heterotopia of trauma.
Schmid et al. BMC Psychiatry 2013, 13:3
Page 2 of 12
addition to the defined symptoms of PTSD (see List of
• Symptoms of emotional and physiological
• Problems with conduct and attention regulation
• Difficulties with self-esteem regulation and in
managing social connections.
In the following, these symptom clusters are addressed
in more detail.
Symptoms of emotional and physiological dysregulation/
Chronic activation of neurobiological systems involved
in the regulation of stress and emotion appears to
potentiate activation of the relevant neurotransmitters
and neuroendocrinological systems. This has also been
implicated in severe emotional dysregulation [21,22].
Several studies reported clear differences in the aptitude
of children with and without traumata in regulation and
recognition of emotion [23-25].
Subjects with difficulties in regulation of emotion react
faster and more fiercely to emotional stimuli and require
more time to calm down after an emotional reaction. This
was particularly evident in studies with adult borderline
patients [26-28]. Moreover, negative emotional reactions
in everyday life seem to be more easily triggered in those
The child or adolescent has experienced or witnessed
multiple or prolonged extremely stressful traumatic
events over a period of at least one year beginning in
childhood or early adolescence, including:
1) Direct experience or witnessing of repeated and
severe episodes of interpersonal violence, and
2) Significant disruptions of protective care giving as a
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:
1) Inability to modulate, tolerate, or recover from
extreme affect states (e.g. fear, anger, shame),
including prolonged and extreme tantrums, or
2) Disturbances in regulation of bodily functions
(e.g. persistent disturbances in sleeping, eating, and
elimination; over-reactivity or under-reactivity to touch
and sounds; disorganization during routine transitions),
3) Diminished awareness/dissociation of sensations,
emotions, and bodily states, and/or
4) Impaired capacity to describe emotions or bodily
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:
1) Preoccupation with threat or impaired capacity to
perceive threat, including misreading of safety and
2) Impaired capacity for self-protection, including
extreme risk-taking or thrill-seeking,
3) Maladaptive attempts at self-soothing (e.g. rocking
and other rhythmical movements, compulsive
4) Habitual (intentional or automatic) or reactive self-
5) Inability to initiate or sustain goal-directed behavior.
D. Self and relational deregulation
The child exhibits impaired normative developmental
competencies in his/her sense of personal identity and
involvement in relationships, including at least three of
1) Intense preoccupation with safety of the caregiver or
other loved ones (including precocious care giving)
or difficulty tolerating reunion with them after
2) Persistent negative sense of self, including self-
loathing, helplessness, worthlessness, ineffectiveness,
3) Extreme and persistent distrust, defiance or lack of
reciprocal behavior in close relationships with adults
4) Reactive physical or verbal aggression toward peers,
caregivers, or other adults,
5) Inappropriate (excessive or promiscuous) attempts to
achieve intimate contact (including but not limited
to sexual or physical intimacy), or excessive reliance
on peers or adults for safety and reassurance, and/or
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. Post-traumatic spectrum symptoms
The child exhibits at least one symptom in at least two
of the three PTSD symptom clusters B, C, and D.
Schmid et al. BMC Psychiatry 2013, 13:3
Page 3 of 12
F. Duration of disturbance
Persistence of symptoms in criteria B, C, D, and E for at
least 6 months.
G. Functional impairment
The disturbance causes clinically significant distress or
impairment in at least two of the following areas of
1) Scholastic: under-performance, non-attendance,
disciplinary problems, drop-out, failure to complete
degree/credential(s), conflict with school personnel,
learning disabilities, or intellectual impairment that
cannot be accounted for by neurological or other
2) Familial: conflict, avoidance/passivity, running away,
detachment and surrogate replacements, attempts to
physically or emotionally hurt family members, non-
fulfillment of responsibilities within the family,
3) Peer group: isolation, deviant affiliations, persistent
physical or emotional conflict, avoidance/passivity,
involvement in violence or unsafe acts, age-
inappropriate affiliations or style of interaction,
4) Legal: arrests/recidivism, detention, convictions,
incarceration, violation of probation or other court
orders, increasingly severe offenses, crimes against
other persons, disregard or contempt for the law or
for conventional moral standards, and/or
5) Health: physical illness or problems that cannot be
fully accounted for, physical injury or degeneration,
involving the digestive, neurological (including
conversion symptoms and analgesia), sexual,
immune, cardiopulmonary, proprioceptive, or
sensory systems, severe headache (including
migraine), or chronic pain or fatigue.
Dissociation may be described as a loss of outward
perception and trance-like state of mind, which is
accompanied by a loss of coenesthesia and sense of time,
spatial orientation, facial expression, perception of pain,
and often a feeling of derealization. Dissociative disrup-
tions may also involve the loss of memory of own and
observed external actions. As shown in recent experi-
ments , both learning and assimilation of new infor-
mation are strongly inhibited in dissociated states. Lynch
et al.  demonstrated that reducing dissociation ten-
dency improves the success of outpatient psychotherapy.
While approximately 10% of the general population
reacts with a stronger tendency to dissociation in response
to trauma, 50% of affected individuals may suffer from
chronic dissociation when faced with repeated trau-
matization [33,34]. Apart from the genetic disposition,
susceptibility of reacting to traumatic experiences with
dissociation is markedly influenced by the frequency and
nature of traumatic experiences. Furthermore, dissociation
tendency is a predictor for the development of PTSD in
response to traumatic experiences [35,36].
Maltreated or sexually abused schoolchildren have a
much stronger tendency towards dissociation than non-
maltreated children . Extreme familial psychosocial
stress and a tense family atmosphere are both factors
that appear to potentiate this tendency [38,39].
Somatization, body and sensory perception
Among chronically traumatized individuals, body percep-
tion is frequently impaired . Good body perception is
necessary for recognizing, processing, and expressing
emotions . In traumatized individuals, perception of
pain during tense conditions is diminished [42,43], and
auditory perception is impaired . Overall, body per-
ception, sensory perception, experience of pleasure, and
ability to focus on positive sensory perceptions such as
taste and music are clearly underdeveloped in affected
Studies show a clear relationship between early expe-
riences of neglect/malnutrition and somatic diseases
(e.g. high blood pressure, coronary heart disease, diabetes)
in adulthood . Furthermore, there is increasing evi-
dence that PTSD is not only associated with a higher
vulnerability for comorbid mental disorders but also with
an increased incidence of (psycho-) somatic disorders
[46,47]. Many traumatized children suffer from severe
sleep disorders [48,49].
Self-injury, high risk behavior, and sexual abnormalities
Non-suicidal self-injury  and suicidal behavior [51,52]
constitute the symptoms most strongly linked with
traumatization, particularly sexual abuse. More than 80%
of patients with a history of self-injury report traumatic
events in their earlier lives . Given the high prevalence
of self-injuries among adolescents, periodical and repeti-
tive self-injuring behavior should be regarded separately
since it is unlikely that the majority of adolescent self-
injurers share a history of traumatic events. Interestingly,
repetitive self-injury has been reported more often in
adults with a childhood history of sexual abuse, whereas
intermittent self-injury appears to be more frequently
associated with physical abuse in childhood . None-
theless, a meta-analysis of 45 studies on the association of
sexual abuse and self-injury only found a relatively weak
relationship between self-injury and sexual abuse indicat-
ing that sexual abuse ceased to explain the variance in
self-injurious behavior if the studies were controlled for
other psychiatric risk factors . Other studies described
a relationship between self-injury and traumatization
[55,56]. A recent review suggests that the association of
child maltreatment and self-injury varies according to the
type of maltreatment . Weierich and Nock showed
Schmid et al. BMC Psychiatry 2013, 13:3
Page 4 of 12
that PTSD symptoms mediate the relation between sexual
abuse and self-injury . Self-injury probably functions
as a support of emotion regulation and disrupts dissocia-
tive states and the emotional tension related to regulation
of emotion . Neurobiologically, self-injury can be seen
as an attempt to alter the state of the autonomic nervous
system that has been pushed to an extreme state by
reminders of traumatic events .
Glassman et al.  found that traumatization leads to
self-injury, particularly when shame and self-criticism
transform into self-hate. Among all psychological disor-
ders, post-traumatic syndromes are most closely related to
suicidal ideation and are associated with the highest
suicide rates. PTSD symptoms like flashbacks, nightmares
and intrusions were reported to be significantly associated
with tension, dissociation and self-injury [53,58]. The
literature concerning the association between a history of
traumatic events and suicidal behavior is particularly
consistent. Recent data from the World Mental Health
survey (21 countries, n=55’299) showed a strong relation-
ship between childhood adversities (odds ratio [OR] for
suicide attempt after sexual abuse: 5.7) and suicidal behav-
ior, such as suicidal ideation or attempts .
Children who have experienced sexual abuse seem to be
more preoccupied with their sexuality, show more sexua-
lized behavior, and may exhibit compulsive masturbating
behavior [61,62]. Several reviews suggest that impulsive
high-risk-behavior in adolescents (e.g. unprotected sexual
intercourse, risky behavior in traffic, carrying arms) often
occurs in young individuals who have been traumatized
. In particular, early substance abuse is likely alongside
impulsivity and psychosocial risk factors .
Difficulties with executive functions and the regulation
Studies in heavily deprived Romanian orphans showed
that without a minimum of stimulation during the sensi-
tive phase of development, cognitive development is
sustainably impaired [65-67]. Executive functions, such
as attention span, distractibility, and the ability for serial
structuring and making plans are particularly affected.
However, there is a clear distinction between these traits
and the symptoms of attention deficit hyperactivity
disorder (ADHD) [67,68]. The work group around
Michael Rutter analyzed the intelligence profiles of trau-
matized and neglected Romanian residential care children
after adoption by families in the United Kingdom and
noticed that these children show deficits in their executive
functions [65,68]. On the neuropsychological level, self-
regulation of more complex behaviors and future orien-
tated planning in daily life appear to be limited or
impaired, because complex traumatized children have
learned to focus on the next moment to survive and not
to overlook broader timeframes [17,19]. Some studies
showed different significant problems in working memory
in students following sexual abuse and childhood trauma
[69,70]. Endo and colleagues  found that dissociative
children meet criteria of ADHD whereas non maltreated
children with ADHD do not show dissociative symptoms.
Difficulties in self-regulation and establishment of
Eighty percent of all traumatized (physically abused) chil-
dren show a disorganized style of attachment [72-74].
Abused and neglected children often develop highly inse-
cure representations of attachment [75,76] and show pro-
miscuous and non-selective behavior in their attachment
to adults [67,77]. Other studies found that exposure to
interpersonal trauma leeds to social isolation . Attach-
ment is an important resilience factor for preventing the
development of a mental disorder after traumatization.
Emotional support provided directly following a trauma-
tizing experience reduces the risk of developing PTSD
[35,36]. Moreover, positive relationships enhance the suc-
cess of psychosocial interventions .
Perception of social situations is altered in traumatized
children because they are highly sensitized to potentially
threatening stimuli. Dodge and Schwartz  showed that
traumatized children tend to interpret neutral behavior of
other people as hostile and react to more aggressive
behavior with fear or even dissociation. Furthermore,
abused children react stronger and more impulsive to
negative facial expressions, especially to those of anger
[23,81-83]. This hypersensitivity to potentially threatening
stimuli often leads to aggressive reactions in affected indi-
viduals [80,84,85]. Probably reduced grey matter in the
visual cortex represents a neurobiological correlate of
difficulties in the recognition and interpretation of emo-
tions and social skills .
Traumatized individuals often develop feelings of self-
reproach, guilt, and shame . Development of a
healthy self-image is substantially impaired in trauma-
tized subjects. The impact of abuse and neglect on the
development of self-esteem (self-insufficiency, defective-
ness) has been addressed in longitudinal studies [85,88].
Kim and Cicchetti reported that feelings of shame
caused by traumatization were responsible for interper-
sonal problems in adulthood .
Several studies have addressed empathy, theory of
mind, and the ability for mentalization in traumatized
and heavily neglected children [89,90]. The ability of tak-
ing the perspectives of others was diminished, increasing
with the length of the children being in conditions of
deprivation . When studying mentalization , the
ability to take the perspective of others in emotional
situations involving pressure was of main interest. Under
such circumstances, deficient regulation of emotion and
lacking ability to take others perspectives are additive.
Schmid et al. BMC Psychiatry 2013, 13:3
Page 5 of 12
Because of scientific discussion among the long term
consequences of childhood trauma and the criteria of
development trauma disorders a discussion among pros
and cons of the introduction of such a diagnosis in the
revision of DSM-V and ICD-11 started (see Table 1).
Arguments for and against a systematic diagnosis of DTD
Arguments in favor of formalized DTD diagnostic criteria
The following arguments support the initiative to in-
clude DTD as a distinct mental disorder in diagnostic
• More specific diagnosis: The diagnosis of PTSD does
not sufficiently take into account the symptoms of
traumatized patients. The postulated DTD diagnostic
criteria comprise a range of symptoms seen to occur
after complex and repeated traumatization. For the
diagnosis of DTD, traumatic experience is essential but
not exclusive, and genetic and biopsychosocial origins
of the disorder must be ruled out to specify the
interaction between neurobiology, epigenetics and
transgenerational traumatic life events and their
consequenses for the development of mental disorders.
The existence of specific and validated DTD diagnostic
criteria may sensitize professionals and the general
public to the drastic consequences of child abuse,
neglect, and traumatization. Moreover, the
establishment of measures for e.g. child protection,
policy making would be expedited.
• Course of mental disorders: The supporters of this
initiative argue that more emphasis should be placed
on developmental aspects of disorders caused by
traumatization. The few longitudinal studies available
indicate that more than 60% of adults with psychiatric
disorders suffered from psychopathological symptoms
during adolescence, and 77% exhibited symptoms
before the age of 18 years [87,92]. Furthermore, PTSD
frequently becomes chronic. In a longitudinal study in
adolescents with PTSD, 48% of patients still met the
criteria for PTSD three to four years later .
• Enhance research: Establishment of formal diagnostic
criteria for DTD is expected to stimulate research
efforts in this area (e.g., epidemiological studies,
developmental-psychopathological research). Cross-
sectional and longitudinal studies on psychosocial risks
and comorbidities during childhood and adolescence
should be encouraged.
• Explain comorbidities: From a clinical point of view,
the diagnosis of DTD focuses on traumatization as the
psychopathological trigger of mental disorders .
Several well-designed studies clearly demonstrated such
correlations. Post-traumatic symptoms may occur
together with other mental disorders. As many as 80%
of PTSD patients meet the criteria for another disorder
[95-98]. In an evaluation of the ‘Dunedin longitudinal
study’, Koenen et al.  showed that all subjects
meeting the criteria for PTSD in young adulthood had
suffered from mental disorders at a young age.
Conversely, other mental disorders may be present
before PTSD or may develop after its occurrence
[15,87,92]. In particular, victims of sequential
traumatization have an inherently high risk of
developing a complex syndrome of disorders that often
go hand-in-hand with single symptoms of PTSD
without fulfilling the complete clinical picture of PTSD
. In children and adolescents, comorbidities with
ADHD, anxiety disorder, suicidal thoughts, and a trend
towards affective disorders is highly prevalent [1,98].
• Enable effective treatment: By selectively treating
trauma symptoms, patients can be stabilized, and
concomitant illnesses (like anxiety disorder or
depression) can be addressed. The effectiveness of
therapeutic interventions in traumatized children and
adolescents has been well documented in recent years
[99-103]. Spinazzola et al.  pointed out that more
Table 1 Arguments for and against the introduction of development trauma disorder in the psychiatric diagnostic systems
Arguments: pro development trauma disorderArguments against development trauma disorder
Specific diagnosis for observed symptoms from severely
Conflicts the traditional diagnostic systems on constraining on the
description of symptoms
Regards developmental psychopathology and the course
of mental disorders
Assumed mono-causality is conflicting bio-psycho-social model of the
etiology of mental disorders
Explains co-morbidityUnderestimates the aspects of inverse correlations of psychopathology
Enables effective treatment for co-morbid disordersSelectivity underestimates the role of resilience
Enhances research in the field of developmental psychopathology
and trauma related disorders
Higher risk to miss co-morbid disorders and effective (psycho-)
Show scientific based arguments for a improvement of child
protection, prevention and resources of youth welfare services
Failed to define age-related symptoms
Explains severe problem behavior, for example reactive aggression,
chronic dissociation and self-injury
Trauma focused explorations might lead to a problem focused
Schmid et al. BMC Psychiatry 2013, 13:3
Page 6 of 12
attention should be given to naturalistic studies in
inpatients suffering from psychosocial stress being at
risk of suicide.
Patients with severe interpersonal traumatization in
childhood are the hardest to treat and have the poorest
prognosis. Treatment may be constrained by
insufficient understanding of the underlying illness, and
patients often cannot be reached by the psychosocial
care system. Moreover, the degree of traumatization
affects treatment success. Therefore, it is important to
take the nature and severity of traumatic experiences
into account when developing a treatment plan. With a
more specific diagnosis, treatment options can be
• Social and legal aspects: Many victims of neglect,
child abuse, and maltreatment live on the edge of
society and depend on social services for most of their
lives. Failures at school and in youth welfare
institutions are common . Clear definition of
trauma-related symptoms could help to change
attitudes towards delinquent or aggressive adolescents
and facilitate the initiation of treatment .
Several studies have addressed the enormous
healthcare costs arising from traumatization, such as
medical treatment costs, early retirement, inability to
work, need for social benefits, and even imprisonment
[107,108]. If the consequences of childhood
traumatization were officially recognized, patients
would benefit from improved social acceptance of their
difficulties. Moreover, inclusion of mental disorders
arising from complex traumatization in the official
diagnostic systems would assist patients in obtaining
compensation and legal support (court, victim aid).
Many traumatized patients develop chronic mental
disorders with serious impairment of their working
ability and social interactions. Early and effective
intervention is necessary to help patients to maintain a
normal life style.
Arguments against formalized DTD diagnostic criteria
The following arguments question the usefulness of in-
cluding DTD as a distinct mental disorder in diagnostic
• Conflicting DSM and ICD diagnostic systems: Formal
DTD diagnostic criteria are thought to weaken the
power of existing diagnostic systems, such as DSM-IV-
TR and ICD-10. Both diagnostic systems were strictly
designed to exclude any theory about the etiology of
the mental disorders and confine themselves to a clear
and operationalizable description of the symptoms and
disorders. Since Axis V of the multiaxial diagnostic
system covers psychosocial risk factors, aspects
associated with chronic exposures to traumatic events
are included in existing systems. In addition, critics
claim that there is no clear distinction between
symptoms and syndromes, and that DTD criteria
overlap with those of some established and some
discussed diagnoses. Many symptoms of borderline
personality disorder or attachment disorder are
included in the list of DTD symptoms, thus impeding
the distinction between these disorders. Similarly, DTD
criteria overlap with those of attachment disorders,
conduct disorder, multiple complex development
disorders (MCDD)  or the criteria for borderline
disorder in childhood and adolescence . Although,
all of these diagnosis have a high prevalence among
people with traumatic life events, problems with
validity and reliability [110,111] and high comorbidities
with other mental disorders. Some diagnosis like
multiple complex trauma disorder and borderline
personality disorder in childhood are not part of the
• Monocausality: concerning the diagnosis of DTD,
monocausality is assumed, but this has not been proven
. DTD diagnosis favors a psychosocial explanation
for the etiology of the disorders and neglects the
biological explanations of the biopsychosocial model to
understand the development of mental disorders. DTD
is frequently manifested as a mixture of symptoms and
syndromes, and a unidirectional relationship between
traumatic experiences and the development of a
confined syndrome remains is based on a widespread of
actual research in the field of psycho traumatology.
Moreover, genetic/biological causes of the symptom
pattern may be ignored when diagnosing DTD. Critics
of a formal DTD diagnosis point out that those similar
symptoms may be present in individuals who did not
have any traumatic experiences. In line with this, 20%
to 30% of patients with borderline personality disorder,
whose criteria are similar to those of complex PTSD,
had not suffered from any traumatic experience .
By explaining complex symptom patterns by a single
cause, other disorders that require treatment may
remain untreated. Focussing on trauma etiology it
might be possible that other comorbid diagnosis like
ADHD will not be taken into account and missed to
treat with evidenced based interventions. Furthermore,
assumption of traumatization as the single cause of the
disorder may result in too much importance being
attached to identifying the causative traumatic
experience, thus ignoring positive life experiences that
would facilitate a resource-orientated therapeutic
relationship, especially with the parents.
• Selectivity: Certain children who had been severely
traumatized do not develop any mental disorder .
Of course this is a weak argument because skeptics can
argue in the same way against the classic PTSD diagnosis.
Schmid et al. BMC Psychiatry 2013, 13:3
Page 7 of 12
According to Malinosky-Rummell and Hansen, 80% of
adults who had been physically abused during childhood
showed no mental disorder in adulthood . However,
Collishaw et al.  found considerably weaker
psychopathological resilience in a follow-up analysis of
adults who had experienced maltreatment during
childhood. Furthermore a study of the Dunedin birth
cohort (in ) suggested that the risk of developing a
mental disorder increases with repeated traumatization.
Individuals who did not develop any symptoms were
found to have good peer relations, success at school and
work, and stable relationships. Current research into
resilience increasingly focuses on dynamic factors, such as
behavior and attitude, which enhance individual or
familial resilience , and their correlation with genetic
factors. Conversely, non-traumatized individuals may
develop similar symptoms. The formal DTD criteria do
not explain this phenomenon. In addition, there is a
relatively high overlap with existing and well-established
mental disorders (e.g., borderline disorder, attachment
disorder with disinhibition, etc.).
• Inverse correlation: Diagnosing DTD implies that
emotional dysregulation is caused by traumatic
experiences but ignores the fact that the reverse
relationship also exists. Emotional dysregulation is
accompanied by a higher risk of traumatization. It is
well established that subjects with impaired emotional
control may adversely respond to environmental
factors, thus reinforcing the present symptoms .
This correlation was described in the transactional
model by Fruzzetti et al. . Furthermore, children
with externalizing disorders have a four times higher
risk of being abused .
• Age sensitivity: Although the proposed diagnostic
criteria are meant to take the age and developmental
status of the patient into account, symptoms are not
sufficiently stipulated age-sensitive. But of course this is
a problem of every diagnosis in childhood and
adolescence – regarding the actual debate among
assessing symptoms of attention deficit and
hyperactivity disorder ADHD in childhood, adolescence
and adulthood . Furthermore the criteria claim to
be development-oriented, however they fail to specify
the symptoms for different age groups. Thus, no
distinction is being made between young children and
adolescents with respect to emotional and physiological
regulation. This is due to the limited knowledge about
the course of trauma-related symptoms and the
methodical problems in longitudinal studies to address
the same construct in different age groups with other
psychometric methods. Additionally clinical studies are
limited by ethical restraints.
• Treatment: The main purpose of accurately
diagnosing psychopathological conditions in children
and adolescence is the endeavor to treat them
effectively. Critics of the introduction of formal DTD
diagnostic criteria argue that comorbidities may remain
untreated because too much emphasis is placed on
trauma-related aspects of the condition. This can
provoke misinterpretations of biological symptoms with
the consequence that effective psycho-pharmaceutical
treatment options stay unused.
• Disadvantages of trauma-focused diagnostic
explorations: For inexperienced professionals the
concentration on trauma-related symptoms in the
diagnostic process may result in a pressure to detect
traumatic life events. This kind of exploration might
have a negative influence on the therapeutic
relationship, especially to parents of multi-problem
families. It can be difficult to combine a trauma-
focused exploration style with solution focused
interventions. But without the development of a
sustainable therapeutic relationship every treatment
will fail. Another negative aspect of trauma-focused
diagnostic exploration could be that patients will be
pushed in an implicit or explicit way to remember or to
talk about traumatic events. It is even possible that
some trauma-focused exploration styles provoke false
memories of biographical life events with several
negative consequences .
There is considerable controversy with respect to imple-
menting formal DTD diagnostic criteria; based on exist-
ing empirical studies the correlation between traumatic
experiences and related symptoms is not in question
among experts. Studies focusing on the neurobiology of
mental disorder in childhood have clearly identified
traumatization as an important cause .
The current debate on the need for a formal definition
of DTD criteria highlights the important role of trau-
matization and neglect in the development of complex
psychopathological disorders that are difficult to treat.
Awareness of long-term outcomes of child abuse and
neglect may strengthen the acceptance of initiatives to
protect children from maltreatment and improve atti-
tudes towards ‘difficult’ adolescents who live at the edge
of society. A better understanding of the effects of
traumatization might lead to improved psychosocial
treatment options for these children and adolescents
and may help to prevent from participation restrictions
in the society.
The arguments for and against implementing formal
DTD diagnostic criteria are convincing, and the debate
can only be resolved conclusively based on the emergence
of new information. Sophisticated neurobiological and
genetic studies are needed because traumatization is
known to affect prenatal factors, such as endocrinological
Schmid et al. BMC Psychiatry 2013, 13:3
Page 8 of 12
processes during and after pregnancy, or even genotype
[121-124]. Moreover, longitudinal studies are necessary
because DTD is not a static but a rather dynamic condi-
tion, undergoing changes in its manifestation over time.
An innovative method using a developmental-heterotopic
approach has been described by Fegert et al. and Schmid
et al. [4,125,126].
In addition, clusters of mental disorders should be
identified, and interaction of psychosocial and biological
aspects in the development of these clusters should be
addressed. Such an approach would help to explain the
pervasive nature of trauma-related psychopathological
Trauma experts working in specialized institutions that
deal exclusively with traumatized individuals tend to be
the main supporters of a formal definition of DTD diag-
nostic criteria, while professionals working in the general
clinical and psychiatric setting remain critical for the
reasons stipulated above. Regardless of the outcome of the
ongoing debate, treatment of severely traumatized chil-
dren and adolescents should be improved substantially.
Although trauma outpatient clinics offering symptom-
specific treatment will be of help, general psychothera-
peutic professionals also need to be trained in this area
since many traumatized children are encountered in the
clinical setting. Therapeutic concepts currently available
for hospitalized patients are grossly inadequate to address
the dramatic squeal in severely traumatized children.
Trauma-specific concepts of outpatient treatment with
possible inpatient interval treatment should be developed
and implemented [101,127-129], taking the specific needs
of children and adolescents into account as well as the
need of their parents, foster parents or residential care
staff. It is important to be able to combine both treatment
needs: to maintain a “save place” and to have the possibil-
ity to do effective (prolonged) exposure therapy. For se-
verely traumatized patients a combination of a skill
training and trauma therapeutic exposure treatment is
currently regarded to be the best approach [101,103] with
the least drop-out rates. The trauma system therapy as a
model of combined milieu therapeutic, systemic / family
centered and psychotherapeutic intervention is a very
promising and, as the first results show, successful treat-
ment approach for children and adolescents suffering
from complex trauma or developmental trauma disorder
. The psychotherapeutic skill training focuses on the
capacities to cope with dissociation, emotion regulation
problems, situations of extreme stress and tension as well
as intrusions, disgust and social problems [101,103,127].
The additive skill training will help to overcome tension
and dissociation during the exposure therapy and is a kind
of precondition for exposure therapy with complex trau-
matized patients with fewer capacities to cope with stress,
tension and dissociation . The dialectical behavior
therapy and their adaptions for adolescents [132,133] are
the best evaluated treatment concepts to improve these
skills. For such treatment concepts to be effective, specia-
lized wards are needed, which will probably require in-
patient treatment for a greater catchment area and build a
network of outpatient therapists cooperating with this
As many severely traumatized children and adoles-
cents cannot stay in their families of origin, psychiatric
liaison services for adolescents in residential care institu-
tions and youth welfare services should be implemented.
These liaison services can help to reach more burdened
children, reduce inpatient child- and adolescent psychi-
atric treatment days and improve continuity in residen-
tial and foster care placements . Youth welfare
concepts should be sensitized to trauma symptoms and
try to promote and enhance resilience factors, self-
efficacy and social and emotion-regulation skills 106]. In
conclusion, the available arguments for and against the
implementation formal diagnostic criteria for DTD
cannot be appraised conclusively based on current
research. The main advantage appears to be improved
sensitization to trauma outcomes and more tailor-made
treatment options, but this may also be achieved by a
descriptive approach. A dimensional diagnostic system
comprising the relevant domains, such as relationship /
attachment representation, assessing interpersonal trust,
emotion regulation, affinity to dissociation / sensual per-
ception, and lacking expectation of self-efficacy, could
also be envisaged. Specific symptom scales for emotion
regulation, attachment/ interpersonal trust, self-efficacy
and dissociation may be effective in predicting the out-
come of psychotherapeutic treatment. These symptom
scales may show relevant aspects of developmental psy-
chopathology, can support the diagnostic process, and
help to develop individualized treatment concepts with
specific guidelines for the arrangement of the thera-
peutic alliance. Probably the sensitization to trauma
symptoms and the interpersonal learning history of a
patient can prevent drop-out and improve the thera-
The authors declare that they have no competing interests.
JMF and FP contributed equally to this work. This paper is based on a former
German publication by MS, JMF, FP. (2010) Traumaentwicklungsstörung: Pro
und Contra. Kindheit & Entwicklung, 19 (1), 47–63. All authors read and
approved the final manuscript.
Dr. Marc Schmid is chief psychologist at the department of child and
adolescent psychiatry at the University Basel (Switzerland). Head of the
center for the psychiatric and psychotherapeutic liaison services with youth
welfare institutions and the EQUALS project.
Schmid et al. BMC Psychiatry 2013, 13:3
Page 9 of 12
Prof. Dr. Franz Petermann is Director of the center of rehabilitation and
clinical psychology and professor for psychological diagnostics and
intervention at the University Bremen (Germany).
Prof. Dr. Jörg M. Fegert is Medical Director of the department for child and
adolescent psychiatry at the University of Ulm (Germany). Professor Fegert is
member of diverse academic advisory boards of the German government
among family affairs, research, child abuse and neglect.
1Department of child and adolescent psychiatry University Basel,
Schanzenstrasse 13, CH-4056, Basel, Switzerland.2Center of clinical
psychology and rehabilitation University Bremen, Grazer Strasse 6, DE-28329,
Bremen, Germany.3Department of Child and Adolescent Psychiatry and
Psychotherapy, University of Ulm, Steinhövelstrasse 5, DE-89075, Ulm,
Received: 4 January 2012 Accepted: 29 November 2012
Published: 3 January 2013
1.Cloitre M, Stolbach BC, Herman JL, Kolk BV, Pynoos R, Wang J, Petkova E:
A developmental approach to complex PTSD: Childhood and adult
cumulative trauma as predictors of symptom complexity. J Trauma Stress
2.Terr LC: Childhood traumas: an outline and overview. Am J Psychiatry
3.van der Kolk BA, Roth S, Pelcovitz D, Sunday S, Spinazzola J: Disorders of
extreme stress: The empirical foundation of a complex adaptation to
trauma. J Trauma Stress 2005, 18(5):389–399.
4.D'Andrea W, Ford J, Stolbach B, Spinazzola J, van der Kolk BA:
Understanding interpersonal trauma in children: why we need a
developmentally appropriate trauma diagnosis. Am J Orthopsychiatry
5.Euser EM, van Ijzendoorn M, Prinzie P, Bakermans-Kranenburg MJ:
The Prevalence of Child Maltreatment in the Netherlands. Child Maltreat
6.Scheeringa MS, Zeanah CH, Myers L, Putnam FW: New findings on
alternative criteria for PTSD in preschool children. J Am Acad Child
Adolesc Psychiatry 2003, 42(5):561–570.
7. Simons M, Herpertz-Dahlmann B: Traumata und Traumafolgestörungen
bei Kindern und Jugendlichen - eine kritische Übersicht zu Klassifkation
und diagnostischen Kriterien. Z Kinder Jugendpsychiatr Psychother 2008,
8. Finkelhor D, Ormrod RK, Turner HA: Poly-victimization: a neglected
component in child victimization. Child Abuse Negl 2007, 31(1):7–26.
9. Finkelhor D, Ormrod RK, Turner HA: Lifetime assessment of poly-
victimization in a national sample of children and youth. Child Abuse Negl
10.Kienberger Jaudes P, Mackey-Bilaver L: Do chronic conditions increase
young children's risk of being maltreated? Child Abuse Negl 2008,
11. Larson K, Russ SA, Crall JJ, Halfon N: Influence of multiple social risks on
children's health. Pediatrics 2008, 121(2):337–344.
12.Classen CC, Palesh OG, Aggarwal R: Sexual revictimization: a review of the
empirical literature. Trauma Violence Abuse 2005, 6(2):103–129.
13. Widom CS, Czaja SJ, Dutton MA: Childhood victimization and lifetime
revictimization. Child Abuse Negl 2008, 32(8):785–796.
14.Copeland WE, Keeler G, Angold A, Costello EJ: Traumatic events and
posttraumatic stress in childhood. Arch Gen Psychiatry 2007, 64(5):577–584.
15.Koenen KC, Moffitt TE, Caspi A, Gregory A, Harrington H, Poulton R:
The developmental mental-disorder histories of adults with
posttraumatic stress disorder: a prospective longitudinal birth cohort
study. J Abnorm Psychol 2008, 117(2):460–466.
16.Pelcovitz D, Kaplan SJ, DeRosa RR, Mandel FS, Salzinger S: Psychiatric
disorders in adolescents exposed to domestic violence and physical
abuse. Am J Orthopsychiatry 2000, 70(3):360–369.
17.De Bellis MD: Developmental traumatology: the psychobiological
development of maltreated children and its implications for research,
treatment, and policy. Dev Psychopathol 2001, 13(3):539–564.
18.Widom CS: Posttraumatic stress disorder in abused and neglected
children grown up. Am J Psychiatry 1999, 156(8):1223–1229.
19.van der Kolk BA: Developmental Trauma Disorder: Toward a rational
diagnosis for children with complex trauma histories. Psychiatr Ann 2005,
VanderKolk BA, Pynoos RS, Cicchetti D, Cloitre M, D’Andrea W, Ford JD,
Lieberman AF, Putnam FW, Saxe G, Spinazzola J, Stolbach BC, Teicher M:
Proposal to include a developmental trauma disorder diagnosis for children
and adolescents in DSM-V; http://www.traumacenter.org/announcements/
De Bellis MD: The psychobiology of neglect. Child Maltreat 2005, 10(2):150–172.
Cicchetti D, Toth SL: Development psychopathology and disorders of
affect. In Developmental Psychopathology. Edited by Cicchetti D, Cohen DJ.
New York: Wiley; 1995:369–420.
Pollak SD, Sinha P: Effects of early experience on children's recognition of
facial displays of emotion. Dev Psychol 2002, 38(5):784–791.
Walden TA, Smith MC: Emotion regulation. Motiv Emot 1997, 21(1):7–25.
Shields A, Cicchetti D: Reactive aggression among maltreated children:
the contributions of attention and emotion dysregulation. J Clin Child
Psychol 1998, 27(4):381–395.
Domes G, Lischke A, Berger C, Grossmann A, Hauenstein K, Heinrichs M,
Herpertz SC: Effects of intranasal oxytocin on emotional face processing
in women. Psychoneuroendocrinology 2010, 35(1):83–93.
Schore AN: Effect of early relational trauma on affect regulation:
The development od borderline and antisocial personality disorders and
a predisposition to violence. In Affect dysregulation and disorders of the self.
Edited by Schore AN. New York: W.W. Norton; 2003:266–306.
Schmid M, Schmeck K, Petermann F: Persönlichkeitsstörungen im
Kindes- und Jugendalter? Kindheit und Entwicklung 2008, 17(3):190–202.
Ebner-Priemer UW, Kuo J, Schlotz W, Kleindienst N, Rosenthal MZ,
Detterer L, Linehan MM, Bohus M: Distress and affective dysregulation in
patients with borderline personality disorder: a psychophysiological
ambulatory monitoring study. J Nerv Ment Dis 2008, 196(4):314–320.
Ebner-Priemer UW, Welch SS, Grossman P, Reisch T, Linehan MM, Bohus M:
Psychophysiological ambulatory assessment of affective dysregulation in
borderline personality disorder. Psychiatry Res 2007, 150(3):265–275.
Stiglmayr CE, Ebner-Priemer UW, Bretz J, Behm R, Mohse M, Lammers CH,
Anghelescu IG, Schmahl C, Schlotz W, Kleindienst N, et al: Dissociative
symptoms are positively related to stress in borderline personality
disorder. Acta Psychiatr Scand 2008, 117(2):139–147.
Lynch SM, Forman E, Mendelsohn M, Herman J: Attending to dissociation:
assessing change in dissociation and predicting treatment outcome.
J Trauma Dissociation 2008, 9(3):301–319.
Merckelbach H, Muris P: The causal link between self-reported trauma
and dissociation: a critical review. Behav Res Ther 2001, 39(3):245–254.
Zucker M, Spinazzola J, Blaustein M, van der Kolk BA: Dissociative
symptomatology in posttraumatic stress disorder and disorders of
extreme stress. J Trauma Dissociation 2006, 7(1):19–31.
Brewin CR, Andrews B, Valentine JD: Meta-analysis of risk factors for
posttraumatic stress disorder in trauma-exposed adults. J Consult Clin
Psychol 2000, 68(5):748–766.
Tuulikki Kultalahti T, Rosner R: Risikofaktoren der Posttraumatischen
Belastungsstörung nach Trauma-Typ-I. Kindheit und Entwicklung 2008,
Macfie J, Cicchetti D, Toth SL: Dissociation in maltreated versus
nonmaltreated preschool-aged children. Child Abuse Negl 2001,
DiTomasso MJ, Routh DK: Recall of abuse in childhood and three
measures of dissociation. Child Abuse Negl 1993, 17(4):477–485.
Merckelbach H, Muris P, Rassin E: Fantasy proneness and cognitive failures
as correlates of dissociative experiences. Personal Individ Differ 1999,
Sack M, Boroske-Leiner K, Lahmann C: Association of nonsexual and sexual
traumatizations with body image and psychosomatic symptoms in
psychosomatic outpatients. Gen Hosp Psychiatry 2010, 32(3):315–320.
Schmid M: Komplexe Traumatisierung und deren Auswirkungen auf die
implizite und explizite Emotionsregulation. In Emotions regulation bei
psychischen Erkrankungen im Kindes- und Jugendalter. Edited by In-Albon T.
Stuttgart: Kohlhammer; in press.
Ludäscher P, Bohus M, Lieb K, Philipsen A, Jochims A, Schmahl C:
Elevated pain thresholds correlate with dissociation and aversive arousal
in patients with borderline personality disorder. Psychiatry Res 2007,
Schmid et al. BMC Psychiatry 2013, 13:3
Page 10 of 12
43.Klossika I, Flor H, Kamping S, Bleichhardt G, Trautmann N, Treede RD,
Bohus M, Schmahl C: Emotional modulation of pain: a clinical
perspective. Pain 2006, 124(3):264–268.
Maercker A, Karl A: Lifespan-developmental differences in physiologic
reactivity to loud tones in trauma victims: a pilot study. Psychol Rep 2003,
93(3 Pt 1):941–948.
Barker DJ: Fetal nutrition and cardiovascular disease in later life. Br Med Bull
Dobie DJ, Kivlahan DR, Maynard C, Bush KR, Davis TM, Bradley KA:
Posttraumatic stress disorder in female veterans: association with
self-reported health problems and functional impairment. Arch Intern Med
Seng JS, Graham-Bermann SA, Clark MK, McCarthy AM, Ronis DL:
Posttraumatic stress disorder and physical comorbidity among female
children and adolescents: results from service-use data. Pediatrics 2005,
Martin J, Hiscock H, Hardy P, Davey B, Wake M: Adverse associations of infant
and child sleep problems and parent health: an Australian population
study. Pediatrics 2007, 119(5):947–955.
Noll JG, Trickett PK, Susman EJ, Putnam FW: Sleep disturbances and
childhood sexual abuse. J Pediatr Psychol 2006, 31(5):469–480.
Yates TM, Carlson EA, Egeland B: A prospective study of child maltreatment
and self-injurious behavior in a community sample. Dev Psychopathol 2008,
Bruffaerts R, Demyttenaere K, Borges G, Haro JM, Chiu WT, Hwang I, Karam EG,
Kessler RC, Sampson N, Alonso J, et al: Childhood adversities as risk factors
for onset and persistence of suicidal behaviour. Br J Psychiatry 2010,
Plener PL, Singer H, Goldbeck L: Traumatic events and suicidally in a German
adolescent community sample. J Trauma Stress 2011, 24(1):121–124.
van der Kolk BA, Perry JC, Herman JL: Childhood origins of self-destructive
behavior. Am J Psychiatry 1991, 148(12):1665–1671.
Klonsky ED, Moyer A: Childhood sexual abuse and non-suicidal self-injury:
meta-analysis. Br J Psychiatry 2008, 192(3):166–170.
Weierich MR, Nock MK: Posttraumatic stress symptoms mediate the
relation between childhood sexual abuse and nonsuicidal self-injury.
J Consult Clin Psychol 2008, 76(1):39–44.
Lang CM, Sharma-Patel K: The relation between childhood maltreatment
and self-injury: a review of the literature on conceptualization and
intervention. Trauma Violence Abuse 2011, 12(1):23–37.
Afifi TO, Boman J, Fleisher W, Sareen J: The relationship between child
abuse, parental divorce, and lifetime mental disorders and suicidality in
a nationally representative adult sample. Child Abuse Negl 2009,
Klonsky ED: The functions of deliberate self-injury: a review of the
evidence. Clin Psychol Rev 2007, 27(2):226–239.
Corrigan FM, Fisher JJ, Nutt DJ: Autonomic dysregulation and the Window
of Tolerance model of the effects of complex emotional trauma.
J Psychopharmacol 2011, 25(1):17–25.
Glassman LH, Weierich MR, Hooley JM, Deliberto TL, Nock MK:
Child maltreatment, non-suicidal self-injury, and the mediating role of
self-criticism. Behavior Research and Therapy 2007, 45(10):2483–2490.
Elkovitch N, Latzman RD, Hansen DJ, Flood MF: Understanding child sexual
behavior problems: a developmental psychopathology framework.
Clin Psychol Rev 2009, 29(7):586–598.
Wells RD, McCann J, Adams J, Voris J, Ensign J: Emotional, behavioral,
and physical symptoms reported by parents of sexually abused,
nonabused, and allegedly abused prepubescent females. Child Abuse
Negl 1995, 19(2):155–163.
Shafii T, Rivara FP, Wang J, Jurkovich GJ: Screening Adolescent Patients
Admitted to the Trauma Service for High-Risk Behaviors: Who Is
Responsible? J Trauma 2009, 67(6):1288–1292.
Blomeyer D, Treutlein J, Esser G, Schmidt MH, Schumann G, Laucht M:
Interaction between CRHR1 gene and stressful life events predicts
adolescent heavy alcohol use. Biol Psychiatry 2008, 63(2):146–151.
Beckett C, Maughan B, Rutter M, Castle J, Colvert E, Groothues C, Hawkins A,
Kreppner J, O'Connor TG, Stevens S, et al: Scholastic attainment following
severe early institutional deprivation: a study of children adopted from
Romania. J Abnorm Child Psychol 2007, 35(6):1063–1073.
Colvert E, Rutter M, Beckett C, Castle J, Groothues C, Hawkins A,
Kreppner J, O'Connor TG, Stevens S, Sonuga-Barke EJ: Emotional difficulties
in early adolescence following severe early deprivation: Findings from
the English and Romanian adoptees study. Dev Psychopathol 2008,
Rutter M, Colvert E, Kreppner J, Beckett C, Castle J, Groothues C,
Hawkins A, O'Connor TG, Stevens SE, Sonuga-Barke EJ: Early adolescent
outcomes for institutionally-deprived and non-deprived adoptees. I:
disinhibited attachment. J Child Psychol Psychiatry 2007, 48(1):17–30.
Beers SR, De Bellis MD: Neuropsychological function in children with
maltreatment-related posttraumatic stress disorder. Am J Psychiatry
Navalta CP, Polcari A, Webster DM, Boghossian A, Teicher MH: Effects
of childhood sexual abuse on neuropsychological and cognitive
function in college women. J Neuropsychiatry Clin Neurosci 2006,
Savitz J, Jansen P: The Stroop Color-Word Interference Test as an
indicator of ADHD in poor readers. The Journal of Genetic Psychology:
Research and Theory on Human Development 2003, 164(3):319–333.
Endo T, Sugiyama T, Someya T: Attention-deficit/hyperactivity disorder
and dissociative disorder among abused children. Psychiatry Clin Neurosci
Hipwell AE, Goossens FA, Melhuish EC, Kumar R: Severe maternal
psychopathology and infant-mother attachment. Dev Psychopathol 2000,
Muller RT, Sicoli LA, Lemieux KE: Relationship between attachment style
and posttraumatic stress symptomatology among adults who report the
experience of childhood abuse. J Trauma Stress 2000, 13(2):321–332.
Van Ijzendoorn MH, Schuengel C, Bakermans-Kranenburg MJ:
Disorganized attachment in early childhood: Meta-analysis of
precursors, concomitants, and sequelae. Dev Psychopathol 1999,
Kim J, Cicchetti D: A longitudinal study of child maltreatment,
mother-child relationship quality and maladjustment: the role of
self-esteem and social competence. J Abnorm Child Psychol 2004,
Weinfield NS, Sroufe LA, Egeland B: Attachment from infancy to early
adulthood in a high-risk sample: Continuity, discontinuity, and their
correlates. Child Dev 2000, 71(3):695–702.
O'Connor TG, Rutter M: Attachment disorder behavior following early
severe deprivation: extension and longitudinal follow-up. English and
Romanian Adoptees Study Team. J Am Acad Child Adolesc Psychiatry 2000,
Elliott GC, Cunningham SM, Linder M, Colangelo M, Gross M: Child Physical
Abuse and Self-Perceived Social Isolation Among Adolescents. J Interpers
Violence 2005, 20(12):1663–1684.
Skodol AE, Bender DS, Pagano ME, Shea MT, Yen S, Sanislow CA, Grilo CM,
Daversa MT, Stout RL, Zanarini MC, et al: Positive childhood experiences:
resilience and recovery from personality disorder in early adulthood.
J Clin Psychiatry 2007, 68(7):1102–1108.
Dodge KA, Schwartz D: Social information-processing mechanisms in
aggressive behaviour. In Handbook of antisocial behavior. Edited by Stoff
DM, Breiling J, Maser JD. New York: Wiley; 1997:171–180.
Pollak SD, Tolley-Schell S: Selective attention to facial emotion in
physically abused children. J Abnorm Psychol 2003, 112(3):323–338.
Cullerton-Sen C, Cassidy AR, Murray-Close D, Cicchetti D, Crick NR,
Rogosch FA: Childhood maltreatment and the development of
relational and physical aggression: the importance of a gender-
informed approach. Child Dev 2008, 79(6):1736–1751.
Ford JD, Fraleigh LA, Connor DF: Child abuse and aggression among
seriously emotionally disturbed children. J Clin Child Adolesc Psychol 2010,
Maughan A, Cicchetti D: Impact of child maltreatment and interadult
violence on children's emotion regulation abilities and
socioemotional adjustment. Child Dev 2002, 73(5):1525–1542.
Wyatt GE, Newcomb M: Internal and external mediators of women's
sexual abuse in childhood. J Consult Clin Psychol 1990, 58(6):758–767.
Tomoda A, Navalta CP, Polcari A, Sadato N, Teicher MH: Childhood sexual
abuse is associated with reduced gray matter volume in visual cortex of
young women. Biol Psychiatry 2009, 66(7):642–648.
Copeland WE, Shanahan L, Costello EJ, Angold A: Childhood and
adolescent psychiatric disorders as predictors of young adult
disorders. Arch Gen Psychiatry 2009, 66(7):764–772.
Schmid et al. BMC Psychiatry 2013, 13:3
Page 11 of 12
88.Kim J, Cicchetti D: Social self-efficacy and behavior problems in
maltreated and nonmaltreated children. J Clin Child Adolesc Psychol 2003,
Pears KC, Fisher PA: Emotion understanding and theory of mind among
maltreated children in foster care: evidence of deficits. Dev Psychopathol
Pears KC, Moses LJ: Demographics, parenting, and theory of mind in
preschool children. Soc Dev 2003, 12(1):1–20.
Fonagy P, Gergely G, Jurist EL, Target M: Affect regulation, mentalization,
and the development of the self. New York: Other Press; 2002.
Kim-Cohen J, Caspi A, Moffitt TE, Harrington H, Milne BJ, Poulton R:
Prior juvenile diagnoses in adults with mental disorder: developmental
follow-back of a prospective-longitudinal cohort. Arch Gen Psychiatry
Perkonigg A, Pfister H, Stein MB, Hofler M, Lieb R, Maercker A, Wittchen HU:
Longitudinal course of posttraumatic stress disorder and posttraumatic
stress disorder symptoms in a community sample of adolescents and
young adults. Am J Psychiatry 2005, 162(7):1320–1327.
Brady KT, Killeen TK, Brewerton T, Lucerini S: Comorbidity of psychiatric
disorders and posttraumatic stress disorder. J Clin Psychiatry 2000,
Essau CA, Conradt J, Petermann F: Häufigkeit der Posttraumatischen
Belastungsstörung bei Jugendlichen: Ergebnisse der Bremer
Jugendstudie. Z Kinder Jugendpsychiatr Psychother 1999, 27(1):37–45.
McFarlane AC: Posttraumatic stress disorder: a model of the longitudinal
course and the role of risk factors. J Clin Psychiatry 2000, 61(5):15–20.
Ross CA: The trauma model: a solution to the problem of comorbidity in
psychiatry. Richardson: Manitou Communications; 2000.
Famularo R, Fenton T, Kinscherff R, Augustyn M: Psychiatric comorbidity in
childhood post traumatic stress disorder. Child Abuse Negl 1996,
Rodenburg R, Benjamin A, de Roos C, Meijer AM, Stams GJ: Efficacy of
EMDR in children: a meta-analysis. Clin Psychol Rev 2009, 29(7):599–606.
100. Cohen JA, Deblinger E, Mannarino AP, Steer RA: A multisite, randomized
controlled trial for children with sexual abuse-related PTSD symptoms.
J Am Acad Child Adolesc Psychiatry 2004, 43(4):393–402.
101. Cohen JA, Mannarino AP, Deblinger E: Treating trauma and traumatic grief in
children and adolescents. New York: Guilford Press; 2006.
102. Deblinger E, Mannarino AP, Cohen JA, Steer RA: A Follow-up Study of a
Multisite, Randomized, Controlled Trial for Children With Sexual
Abuse-Related PTSD Symptoms. J Am Acad Child Adolesc Psychiatry 2006,
103. Cloitre M, Stovall-McClough KC, Nooner K, Zorbas P, Cherry S, Jackson CL,
Gan W, Petkova E: Treatment for PTSD Related to Childhood Abuse: A
Randomized Controlled Trial. Am J Psychiatry 2010, 167(8):915–924.
104. Spinazzola J, Blaustein M, van der Kolk BA: Posttraumatic stress disorder
treatment outcome research: The study of unrepresentative samples?
J Trauma Stress 2005, 18(5):425–436.
105. Schmid M, Goldbeck L, Nuetzel J, Fegert JM: Prevalence of mental
disorders among adolescents in German youth welfare institutions.
Child and Adolescent Psychiatry and Mental Health 2008, 2(1):2.
106. Schmid M: Entwicklungspsychopathologische Grundlagen einer
Traumapädagogik. Trauma & Gewalt 2008, 2(4):288–309.
107. Solomon SD, Davidson JR: Trauma: prevalence, impairment, service use,
and cost. J Clin Psychiatry 1997, 58(Suppl 9):5–11.
108. Kessler RC: Posttraumatic stress disorder: the burden to the individual
and to society. J Clin Psychiatry 2000, 61(5):4–12. discussion 13–14.
109. Ad-Dab'bagh Y, Greenfield B: Multiple complex developmental disorder:
the "multiple and complex" evolution of the "childhood borderline
syndrome" construct. J Am Acad Child Adolesc Psychiatry 2001,
110. Moffitt TE, Arseneault L, Jaffee SR, Kim-Cohen J, Koenen KC, Odgers CL,
Slutske WS, Viding E: Research review: DSM-V conduct disorder: research
needs for an evidence base. J Child Psychol Psychiatry 2008, 49(1):3–33.
111. Minnis H, Marwick H, Arthur J, McLaughlin A: Reactive attachment
disorder–a theoretical model beyond attachment. Eur Child Adolesc
Psychiatry 2006, 15(6):336–342.
112. Schweiger U, Sipos V, Hohagen F: Kritische Überlegungen zum Begriff der
"komplexen posttraumatischen Belastungsstörung". Der Nervenarzt 2005,
76(3):344–346. author reply 346–347.
113. Luthar S: Resilience and Vulnerability. Cambridge: Cambridge University Press; 2003.
114. Malinosky-Rummell R, Hansen D: Long-term consequences of childhood
physical abuse. Psychol Bull 1993, 114(1):68–79.
115. Collishaw S, Pickles A, Messer J, Rutter M, Shearer C, Maughan B: Resilience
to adult psychopathology following childhood maltreatment: evidence
from a community sample. Child Abuse Negl 2007, 31(3):211–229.
116. Fruzzetti AE, Shenk C, Hoffman PD: Family interaction and the
development of borderline personality disorder: A transactional model.
Dev Psychopathol 2005, 17(4):1007–1030.
117. Ouyang L, Fang X, Mercy J, Perou R, Grosse SD: Attention-deficit/
hyperactivity disorder symptoms and child maltreatment: a population-
based study. J Pediatr 2008, 153(6):851–856.
118. Matte B, Rohde LA, Grevet EH: ADHD in adults: a concept in evolution.
Atten Defic Hyperact Disord 2012, 4(2):53–62.
119. Jelinek L, Hottenrott B, Randjbar S, Peters MJ, Moritz S: Visual false
memories in post-traumatic stress disorder (PTSD). J Behav Ther Exp
Psychiatry 2009, 40(2):374–383.
120. Murray-Close D, Han G, Cicchetti D, Crick NR, Rogosch FA: Neuroendocrine
regulation and physical and relational aggression: the moderating roles
of child maltreatment and gender. Dev Psychol 2008, 44(4):1160–1176.
121. Caspi A, Moffitt TE: Gene-environment interactions in psychiatry: joining
forces with neuroscience. Nat Rev Neurosci 2006, 7(7):583–590.
122. Radtke KM, Ruf M, Gunter HM, Dohrmann K, Schauer M, Meyer A, Elbert T:
Transgenerational impact of intimate partner violence on methylation
in the promoter of the glucocorticoid receptor. Translational Psychiatry
123. Yehuda R, Bierer LM: The relevance of epigenetics to PTSD: Implications
for the DSM-V. J Trauma Stress 2009, 22(5):427–434.
124. Kim-Cohen J, Caspi A, Taylor A, Williams B, Newcombe R, Craig IW,
Moffitt TE: MAOA, maltreatment, and gene-environment interaction
predicting children's mental health: new evidence and a meta-analysis.
Mol Psychiatry 2006, 11(10):903–913.
125. Fegert JM, Spröber N, Streeck-Fischer A, Freyberger HJ: "Adoleszenzkrisen"
aus entwicklungspsychologischer und psychiatrischer Sicht. Psychodyn
Psychother 2010, 9(1):2–13.
126. Schmid M, Fegert JM, Petermann F: Traumaentwicklungsstörung: Pro und
Contra. Kindheit und Entwicklung 2010, 19(1):47–63.
127. Schmid M, Goldbeck L: Kognitiv verhaltenstherapeutische Ansätze bei
komplex traumatisierten Jugendlichen. Prax Kinderpsychol Kinderpsychiatr
128. Sachsse U, Vogel C, Leichsenring F: Results of psychodynamically oriented
trauma-focused inpatient treatment for women with complex
posttraumatic stress disorder (PTSD) and borderline personality disorder
(BPD). Bull Menninger Clin 2006, 70(2):125–144.
129. Steil R, Dyer A, Priebe K, Kleindienst N, Bohus M: Dialectical behavior
therapy for posttraumatic stress disorder related to childhood sexual
abuse: a pilot study of an intensive residential treatment program.
J Trauma Stress 2011, 24(1):102–106.
130. Ellis B, Fogler J, Hansen S, Forbes P, Navalta CP, Saxe G: Trauma systems
therapy: 15-month outcomes and the importance of effecting
environmental change. Psychological Trauma: Theory, Research, Practice,
and Policy Aug 2011, (Pagination):No Pagination Specified.
131. Priebe K, Steil R, Kleindienst N, Dyer AS, Krueger A, Bohus M:
Psychotherapie der Posttraumatischen Belastungsstörung nach
sexuellem Missbrauch: Ein Überblick über die Datenlage. Psychother
Psychosom Med Psychol 2012, 62(1):5–17.
132. Linehan MM: Cognitive-behavioral treatment of borderline personality disorder.
New York: Guilford Press; 1993.
133. Miller AL, Rathus JH, Linehan MM: Dialectical behavior therapy with suicidal
adolescents. New York: Guilford Press; 2006.
134. Besier T, Fegert JM, Goldbeck L: Evaluation of psychiatric liaison-services
for adolescents in residential group homes. Eur Psychiatry 2009,
Cite this article as: Schmid et al.: Developmental trauma disorder: pros
and cons of including formal criteria in the psychiatric diagnostic
systems. BMC Psychiatry 2013 13:3.
Schmid et al. BMC Psychiatry 2013, 13:3
Page 12 of 12