The Complexities of
Developmental Trauma:
A Clinician’s View
Larry M. Rosenberg, Ph.D.
Our Agenda
 My clinical experience with Developmental
Trauma
 Some preliminary research on the subject
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ADD, ODD, CDD, and Adjudicated Teens
 The early interpersonal nature of Developmental
Trauma: A synthesis of theory
 Discussion of Developmental Trauma as a
diagnostic category?
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Benefits
Problems
Implications for treatment
My Clinical Experience
 Rape victims
 The kids that I was seeing
 The problem with diagnosis based on
observable behaviors alone
 What do you see when you include intrapsychic factors into the diagnostic
discussion?
 Pilot studies
Findings 1987
 1987: A subgroup of these children
emerges…”These are…children who have
been chronically traumatized; children from
backgrounds that are chaotic, destructive,
overwhelming and may involve exposure to
violence, abuse and/or neglect; children
whose development reveals little protection
from intrusive and disruptive impingement on
a state of going on being…that is the basis of
the development of ego strength…and the
unfolding of a sense of self and other.
2 More Pilot Studies
 Children with ODD
 Children who have experienced abuse and
neglect
 2 distinct subgroups of kids with ODD
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1 higher functioning group of oppositional children
looking liked you would expect ‘spoiled’, ‘neurotic’
children having difficulty with authority figures
1 much more impulsive, angry, primitive in the
functioning and appearing to have an Axis II,
rather than an Axis I appearance
 Over and Under Stimulation
Comparing Borderline Traits with
Developmental Trauma
BPD
 From a neurobiological
perspective
 Key dimensions of BPD
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Affect modulation/self
regulation
Impaired interpersonal
relationships
Identity diffusion
Impulsivity
Self injurious behaviors
and suicidality
Developmental Trauma
 From Criteria Proposed
for DSM V
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Affective and Physiological
Dysregulation
Attentional and Behavioral
Dysregulation including
habitual or reactive self
harm
Self and Relational
Dysregulation
What About the Comparison?
 Developmental Trauma is not the equivalent
of Borderline Personality Disorder, ADHD, or
ODD
 But there is considerable overlap between the
diagnostic categories and
 To the degree that there is overlap is not just
in the area of behavior, but in the root causes
and the resulting neuro-biological and intrapsychic affects
At the Outset: Mirroring
 What is the mirroring function of the “mother”
figure?
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A paradigm for the way manner in which the
child comes to understand who he/she is
The only way for the infant child has to see
himself at the outset is through his mother’s
eyes
“In human development the precursor of the
mirror is the mother’s face”
Consequences of the Mother’s Gaze
 If she is unattuned to the child and blank by way
of her own depression or emptiness:
 The child may come to feel that he himself is
empty or that the world is devoid of supplies
If she projects her own self onto him
 He winds up seeing her face and not his own
 He is left unable to differentiate himself from
the other
 He comes to believe that he has to be her in
order to engage her
What are we Saying About the
Mirroring Function
 Critical to the development of the sense of
self
 Critical to the ability to differentiate oneself
from another
 A forerunner of empathy and mindfulness
 Involved in the formation of identity
 Critical beginning to the experience of how
one views others
Protecting the Young Child
 The primary caregiver initially has to protect
the child from becoming overly distressed
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The notion of a stimulus barrier
 Stress can come from within or outside of the
infant
 The infant has no ability to protect herself,
except by way of withdrawal
 Clearly relates to the issue of attachment,
establishment of basic trust, and the capacity
to postpone gratification
Empathic Attunement
 This refers to the ability of the mothering
figure to understand, empathize with, and
respond in keeping with the affective state of
the child
 Being in rhythm or in tune with the child
 Stern, Beebe, Brazelton, Kestenberg
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Feeding
Rhythm
What Results from Empathic Attunement?
 Helps the child to regulate themselves
 Helps restore a child’s emotional equilibrium
once the child has become dysregulated
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Kestenberg’s work with rhythm and
choreographic notation
Beebe and Stern
What Results When the Mothering Figure
is not Attuned to the Child?
 The mother does recognize the impact that
the environment is having on the child’s
affective state
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The child becomes over-stimulated; unable to
emotionally contend with the level of
stimulation that the environment is presenting
him with
The child becomes disorganized internally;
unable to organize his experience of the world
Overwhelmed by his own affect; a definition of
traumatic experience
Mother (cont)
 If the mother’s own range of emotions is
limited and she reacts only in this limited way,
the child’s own affective range will be
similarly limited
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0-60 and back again
Blunted constricted affect
A Brief Summary
 Said another way, if the environment surrounding
the child fails to provide a protective function in
the form of empathic attunement the result is
either inadequate or excessive stimulation of the
child
 It is this under or over-stimulation of the baby that
leads to difficulties in the areas of development of
self, self differentiation, and in the child’s capacity
to self regulate
 We now potentially have a child who either
doesn’t know who he is, and/or can’t manage to
keep himself emotionally stable
The Protective Function of the
Child’s Environment (cont)
 Note that all that we have just described as
emanating from a chronically deficient care
giving environment mimics what we see
being proposed as DTD and possesses
similarities to BPD, ADHD and other existing
diagnostic categories
 Aside from genetic and biological factors, the
failure to adequately protect the child from the
environment is the stuff that psychopathology
is made of
Synthesizing Theories that Underlie the
Concept of Developmental Trauma
 What happens when a child experiences events
reflective of poor attachment, lack of empathic
attunement, failures to protect the child from the
environment, failures to experience oneself as
enjoyed by the parenting figures, and excessively
stimulated by the environment on a consistent or
chronic basis?
 We have strung together theories ranging from
Freud, to object relations theory, self psychology, to
attachment theory, to trauma
 An analog: Casson and Siegel
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DTD too produces actual affects on brain development,
cortical mass, neuropeptides and the corpus collosum
Developmental Trauma
 Symptom presentation is more complex than
in PTSD
 Diffuse and tenacious
 It leads to personality changes including
problems with relatedness and identity (Axis
II)
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It leads to further harm; either self or other
inflicted
It involves the loss of the capacity to self
soothe and to tolerate or regulate affect
Developmental Trauma (cont)
 In CT 60-80% of out-pt kids screened positive for
trauma as do 80% of kids in juvenile justice system
 They may be entirely overlapping populations
 Likely the same patient population I saw 25 years
ago
 Though involvement in anti-social activities is only
one of the bi-products of this kind of cumulative
trauma.
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Substance abuse, academic performance, relational
problems, health problems, etc.
Trauma in Its Extreme Form
 Overwhelming affect leading to
immobilization, withdrawal, somaticization,
dissociation, and psychological
disorganization
 At its worst we see breaks with reality,
disturbances in ones ability to experience
emotion, or regulate affect, a loss of ones
sense of self, and cognitive impairment
 It is not an all or none phenomenon, but
occurs on a spectrum of severity
What Trauma is not
 Trauma should not be defined or determined
by an aversive event
 Trauma should be defined by the nature of
ones reaction to an aversive event
Mitigating Factors
 What we don’t know is the portion of the
variance in trauma that relates to
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where the aversive event took place,
who was responsible for the exposure,
or how it was responded to by caregivers
 All of the above may relate to influence
whether a trauma occurs and the severity
with which it does occur
Will DTD Become a Diagnosis?
 Why yes?
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More accurately diagnosis kids and provide more
appropriately focused treatment
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Co-morbid possibilities at present include CD, BPD,
Major affective disorder, ADHD, phobias, dissociative
disorders, OCD, panic disorders’
PTSD is inadequate and fails to capture the essence
of the problem, omitting the attachment, relational, and
early and pervasive level of impairment
Children may be more appropriately medicated or not
medicated as often
DTD Diagnosis?
 Why not?
 It is not viewed as having sufficient specificity as to causality
 The definitions of maltreatment are too broad, as are the
definitions of trauma itself
 Some researchers remain unconvinced by the evidence
 Some say that “the science around it is not serious”
 There might be consequences to the pharmacological
industry and the insurance industry
 It may shift too much focus to parenting to be politically
unviable
 Many of those who will be voting are not people who work
with children, or people who are clinicians
Treatment Implications
 TF CBT, DBT or psychodynamic treatment or group
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seem indicated
Any treatment for DTD should have an interpersonal
component
Where areas to address would be basic trust,
building a clear sense of self, and affect regulation
through the use of empathic attunement, consistency,
and support
The ability of the clinician to tolerate the affect of the
child in association with the mistreatment they have
suffered
Significant caring for the parent figure who must
likewise be able to do all of the above for the child
Implications (cont)
 The need for longer term treatment
 The benefits of having families deal with one clinician
from start to finish
 The benefit of spending time, at the outset of
treatment, in establishing helpful alliances with
primary caregivers
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This, rather than an emphasis on data collection or
quick diagnosis
 An alteration in the way we view the caregivers of our
patients
 The ability to see them as we would any patient so
that empathy becomes more easily attainable and so
that the focus is not solely on the experience of the
child