Clinical Child and Family Psychology Review (2022) 25:376–394

https://doi.org/10.1007/s10567-021-00374-0

A Systematic Review of the Validity, Reliability, and Clinical Utility

of Developmental Trauma Disorder (DTD) Symptom Criteria
Nicholas M. Morelli1 · Miguel T. Villodas1,2

Accepted: 11 November 2021 / Published online: 29 November 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Exposure to complex trauma is a prevalent and costly public health concern. Though not yet included in the formal diagnostic
systems, developmental trauma disorder (DTD) was proposed to capture the consistent and predictable emotional, behavio-
ral, and neurobiological sequelae observed in children exposed to complex trauma. This systematic review synthesizes and
evaluates the existing empirical evidence for DTD as a reliable, valid, distinctive, and clinically useful construct. We identi-
fied 21 articles reporting on 17 non-overlapping samples that evaluated DTD symptom criteria using objective, empirical
methods (e.g., factor analysis, associations with other diagnostic constructs, associations with trauma exposure type, clinician
ratings of utility). Studies were largely supportive of the DTD construct and its clinical utility; however, it will be crucial
for this work to be replicated in larger samples, by independent research groups, and with more rigorous methodological
and analytic approaches before definitive conclusions can be drawn. Findings from this review, while preliminary, provide
a promising empirical foundation for DTD and bring the field closer to improving diagnostic parsimony for children and
adolescents affected by complex trauma.

Keywords Developmental trauma disorder · Systematic review · Validity · Clinical utility

Introduction (DTD) diagnosis, with the goal of capturing the consistent

Exposure to traumatic experiences that are chronic, repeated,
prolonged, and interpersonal in nature (herein referred to
as complex trauma) is a prevalent and costly public health
concern. Child maltreatment, an experience that typically
falls under the umbrella of complex trauma, has an estimated
per victim lifetime cost of more than $800,000 (Peterson
et al., 2018). The diagnosis of posttraumatic stress disor-
der (PTSD) in the Diagnostic and Statistical Manual of
Mental Disorders (­ 5th ed; DSM-5) has garnered criticism
for its narrowly defined exposure criteria and its supposed
failure to adequately characterize complex trauma symp-
toms in children. In response to these concerns, Van der
Kolk (2005) proposed the Developmental Trauma Disorder
and predictable emotional, behavioral, and neurobiological
sequelae observed in children exposed to complex trauma.
Arguments in support of DTD have drawn primarily from
theory and research on complex trauma and its broad impact
on development. Only recently have attempts been made to
empirically evaluate the validity and reliability of the DTD
construct and its assessment measures, with a focus on spe-
cific DTD symptom criteria. The goal of this systematic
review is to synthesize and evaluate the existing empirical
evidence for DTD as a reliable, valid, distinctive, and clini-
cally useful construct with reliable assessments and discuss
implications for its suitability for inclusion in future editions
of the DSM.

Developmental Considerations in Defining

* Nicholas M. Morelli
nmorelli2662@sdsu.edu Trauma
1
San Diego State University/University of California, San The current DSM-5 PTSD criterion A defines a traumatic
Diego Joint Doctoral Program in Clinical Psychology, 6363 event as “exposure to actual or threatened death, serious
Alvarado Ct., Suite 250, San Diego, CA 92120, USA
injury, or sexual violence,” including directly experiencing
2
Department of Psychology, San Diego State University, the event, witnessing the event, learning the event happened
San Diego, CA, USA

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Clinical Child and Family Psychology Review (2022) 25:376–394
to a close family member or friend, or experiencing repeated
or extreme exposure to aversive details of the event (Ameri-
can Psychiatric Association, 2013, p. 271). Many have sug-
gested that this definition of trauma is too narrow for chil-
dren and adolescents (Van der Kolk, 2005). Some experts
contend that less acute events, such as attachment disrup-
tions, chronic interpersonal conflict or aggression, psycho-
logical/emotional abuse, and experiences characterized by
deprivation (e.g., physical or emotional neglect), may be
equally if not more consequential for youth than the events
described in criterion A. A PTSD subtype for children aged
six years and under included in the DSM-5 has been success-
ful in its goal of increasing detection of PTSD in young chil-
dren (Scheeringa et al., 2012); however, its exposure criteria
are more – not less – restrictive, excluding the “repeated
or extreme exposure” element of criterion A. Perhaps the
most notable omission in the current DSM-5’s trauma- and
stressor-related disorders is the lack of explicit reference to
childhood experiences characterized by complex trauma,
i.e., interpersonal traumatic or stressful experiences that are
chronic, repeated, prolonged, and developmentally adverse.
Such experiences are particularly common among children,
who are dependent on adults for survival and unable to
remove themselves from traumatic environments (Becker-
Blease & Kerig, 2016). Growing evidence indicates that,
among youth, experiences characteristic of complex trauma
may be more prevalent than many of the acute traumatic
stressors described in PTSD criterion A (Chan, Chen, &
Chen, 2021; Finkelhor et al., 2015), highlighting the impor-
tance of defining and understanding trauma in a develop-
mentally appropriate manner.
Impact of Complex Trauma Versus Acute
Trauma
Isolated traumatic incidents tend to produce discrete con-
ditioned behavioral and biological responses to reminders
of the trauma, as observed in PTSD. Complex trauma, on
the other hand, has a more pervasive impact on the body
and brain, disrupting core transdiagnostic, biopsychosocial
developmental processes, including stress response systems,
threat and reward processing, emotion processing and regu-
lation, and neurocognitive functioning (Hein & Monk, 2017;
Kavanaugh et al., 2017; Lupien et al., 2009; Novick et al.,
2018; Tarullo & Gunnar, 2006). As a result, the mental and
behavioral health consequences are wide-ranging. Meta-ana-
lytic evidence documents robust associations between com-
plex trauma and internalizing psychopathology (e.g., depres-
sion, anxiety), externalizing psychopathology (aggression,
rule-breaking behavior, problems with attention and hyper-
activity), severe mental illness (e.g., psychosis), personal-
ity disorders, substance use problems, and suicide (Gardner
377
et al., 2019; Halpern et al., 2018; Miller et al., 2013; Young-
Southward et al., 2019). Complex trauma also increases risk
for poor functional and occupational outcomes, including
impaired academic achievement, involvement in the juvenile
justice system, and poverty later in life (Bunting et al., 2018;
Stone, 2007; van der Put & de Ruiter, 2016).
Another important distinction between complex and acute
trauma involves when and how symptoms are expressed.
Whereas acute, single-event traumas tend to produce a simi-
lar cluster of post-traumatic symptoms in vulnerable youth
and adults, complex trauma often manifests as a pattern of
diverse symptom presentations across development, begin-
ning with regulatory and attachment problems in infancy,
followed by disruptive, impulse control, and conduct disor-
ders at school age, combined conduct and emotional disor-
ders during adolescence, and personality disorders – often
accompanied by substance abuse, self-harm, and affective
disorders – during adulthood (Schmid et al., 2013). Dis-
orders unfold in this manner because the transdiagnostic
domains impacted by complex trauma (e.g., emotion regu-
lation, stress response) are thought to have varying conse-
quences at different stages of development (De Bellis, 2001).
Not surprisingly, children who experience complex trauma
are more likely to receive mood, disruptive behavior, and
anxiety disorder diagnoses than they are PTSD (D'Andrea
et al., 2012; Spinazzola et al., 2017).
Developmental Trauma Disorder
Recognizing the wide-ranging but predictable psychological
sequalae of complex trauma in children and its poor char-
acterization in the DSM, Van der Kolk (2005), building on
foundational work by Herman (1992), proposed the Devel-
opmental Trauma Disorder (DTD) diagnosis. DTD requires
exposure to multiple or prolonged adverse events beginning
in childhood (criterion A), with impairments in affective and
physiological dysregulation (criterion B), attentional and
behavioral dysregulation (criterion C), self and relational
dysregulation (criterion D), posttraumatic spectrum symp-
toms (criterion E), and functional impairment (criterion G),
for a minimum of 6 months (criterion F) (Van der Kolk et al.,
2009; see Table 1 for the full list of criteria and sub-criteria).
Despite efforts by its developers, DTD was not included
in the DSM-5 and remains a preliminary diagnosis. Propo-
nents of DTD’s inclusion in future DSM editions maintain
that (1) the current trauma- and stressor-related disorders in
the DSM-5 do not sufficiently account for the multi-domain
dysregulation observed in many child survivors of complex
trauma; (2) DTD would allow for a single, parsimonious
diagnosis for such symptoms, eliminating unnecessary
comorbidities; (3) a more developmentally appropriate
trauma-related diagnosis is needed to address the differential
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378 Clinical Child and Family Psychology Review (2022) 25:376–394

Table 1  Proposed Developmental Trauma Disorder Criteria

A. Exposure
B. Affective and Physiological Dysregulation Impaired developmental competencies related to arousal regulation, including at least two of the
C. Attentional and Behavior Dysregulation
D. Self and Relational Dysregulation
E. PTSD Spectrum Symptoms
F. Duration
G. Functional Impairment
Youth has experienced/witnessed multiple/prolonged adverse events over at least one year begin-
ning in childhood/early adolescence including:
1.Direct experience/witnessing of repeated and severe interpersonal violence
2.Significant disruptions in caregiving due to repeated separation from primary caregiver or
severe/persistent emotional abuse
following:
1.Inability to modulate/tolerate/recover from extreme affect states
2.Dysregulation of bodily functions (e.g., sleeping, eating, elimination)
3.Diminished awareness of sensations, emotions and bodily states
4.Impaired capacity to describe emotions or bodily states
Impaired developmental competencies related to sustained attention/learning/ coping with stress,
including at least three of the following:
1.Preoccupation with/impaired capacity to perceive threat
2.Impaired capacity for self-protection (e.g., risk taking/thrill seeking)
3.Maladaptive attempts at self-soothing (e.g., rocking)
4.Habitual (intentional or automatic) or reactive self-harm
5.Inability to initiate or sustain goal-directed behavior
Impaired developmental competencies in sense of personal identity and involvement in relation-
ships, including at least three of the following:
1.Intense preoccupation with safety of the caregiver/loved ones or difficulty tolerating reunion
with them after separation
2.Persistent negative sense of self (e.g., self-loathing, helplessness, worthlessness)
3.Extreme and persistent distrust/defiance/lack of reciprocity in close relationships
4.Reactive physical or verbal aggression toward peers, caregivers, or other adults
5.Inappropriate attempts to get intimate contact (e.g., sexual or physical intimacy) or excessive
reliance on peers or adults for safety and reassurance
6.Impaired capacity to regulate empathic arousal, including intolerance of/ excessive responsive-
ness to the distress of others
Presence of at least one symptom in at least two of the three PTSD symptom clusters B, C, & D
Symptoms in DTD Criteria B, C, D, and E at least 6 months
Clinically significant distress/impairment in at least two of the following areas:
1.Scholastic (e.g., underperformance, non-attendance, disciplinary problems)
2.Familial (e.g., conflict, avoidance, running away, detachment)
3.Peer group (e.g., isolation, deviant affiliations, persistent conflict)
4.Legal (e.g., arrests/recidivism, detention, convictions, incarceration)
5.Health (e.g., digestive, neurological, sexual, immune; severe headaches)
6.Vocational (e.g., disinterest in work/vocation, inability to get/keep jobs)

impact of trauma in childhood versus adulthood; (4) estab-
lishment of formal DTD diagnostic criteria would stimulate
necessary research on developmental trauma; and (5) DTD
would facilitate more targeted interventions for complex
trauma survivors, whose various comorbidities are often
treated separately and therefore inefficiently (Schmid et al.,
2013). Inclusion of DTD in formal diagnostic systems also
has implications for public perception and policy related to
developmental trauma. This was exemplified by a different
childhood trauma-related construct, adverse childhood expe-
riences (ACEs), which became a widely recognized public
health framework just two decades after its introduction
in Felitti et al.’s (1998) landmark study (Portwood et al.,
2021). Inclusion of DTD in formal diagnostic systems could
enhance public awareness of developmental trauma and its
impacts, increasing demand for additional policy efforts that
would improve early identification, prevention, and inter-
vention of developmental trauma; similar to the State of
California’s recent statewide funding for ACEs screening in
primary care settings.
Arguments against DTD include (1) the potential weak-
ening of current diagnostic systems due to DTD’s overlap
with existing disorders; (2) its reliance on the presumption
that DTD’s symptoms are singularly caused by complex
trauma, and related, the fact that many DTD symptoms can
occur in the absence of exposure to complex trauma; (3)
the fact that many DTD symptoms increase risk for sub-
sequent revictimization, challenging DTD’s assumption of
unidirectionality; (4) the lack of any age differentiation (e.g.,
child vs. adolescent symptom presentations) despite DTD’s
claimed developmental emphasis; and (5) the potential for
interventions to become overly focused on trauma-related
aspects when in fact they may play little or no role in symp-
tom presentation (Schmid et al., 2013). Ultimately, DTD
was not included in the DSM-5 due to the lack of empirical,
prospective testing of the proposed diagnostic criteria (Renz,

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Clinical Child and Family Psychology Review (2022) 25:376–394
2012). Nearly a decade later, the body of empirical literature
on DTD symptom criteria has grown rapidly, but has yet
to be formally synthesized. The consensus on DTD as an
adequate diagnostic addition remains unclear.
Complex Trauma in Existing Diagnostic
Systems
It is worth noting that complex trauma and its impact has
been acknowledged in current and previous diagnostic sys-
tems, albeit not in the form of DTD specifically. Findings
from the DSM-IV field trial supported the existence of a
complex adaptation to chronic interpersonal violence (Roth
et al., 1997), and a resulting category known as disorders
of extreme stress not otherwise specified (DESNOS) was
listed in the DSM-IV under associated and descriptive fea-
tures of PTSD. Although DESNOS was subsequently left
out of the DSM-5, two current diagnoses, reactive attach-
ment disorder and disinhibited social engagement disorder,
do acknowledge the developmental impact of environmental
stressors that fall outside of PTSD exposure criteria events.
Specifically, they recognize the potential impact of neglect
or changes in caregiving on children’s interpersonal func-
tioning, and by doing so, overlap with the proposed rela-
tional dysregulation symptoms of DTD criterion D. It should
also be noted that DSM PTSD criteria in recent editions have
undoubtedly become more inclusive of complex-trauma-like
symptoms, most notably in cluster D (negative cognitions
and mood), with symptoms that include persistent errone-
ous blame of self or others, negative expectations about the
future, and persistent negative mood. Combined with the
externalizing behaviors included in cluster E (hyperarousal
and reactivity) and the inclusion of a dissociative subtype,
the current DSM-5 PTSD criteria arguably offer a suitable
“complex trauma” diagnostic niche (Brewin et al., 2017).
Complex trauma has been recognized more explicitly
outside of the DSM. In the latest edition of the Interna-
tional Classification of Diseases (ICD-11), Complex PTSD
(CPTSD) was added to capture symptoms that result spe-
cifically from complex trauma. CPTSD requires the pres-
ence of all three ICD PTSD criteria (e.g., re-experiencing,
avoidance, perception of heightened current threat) as well
as three additional criteria characterized by (1) problems in
affect regulation; (2) negative distorted beliefs about oneself
and feelings of shame or guilt; and (3) difficulties sustaining
relationships and feeling close to others. CPTSD has gar-
nered substantial empirical support in adult samples (Brewin
et al., 2017). Its support among children and adolescents,
while promising, has been less studied (Haselgruber et al.,
2020; Sachser et al., 2017).
Still, differences between DTD and the traumatic stress
disorders currently available in the DSM-5 and ICD-11
379
remain. DTD, more so than PTSD or CPTSD, is character-
ized by an inability to self-regulate – affectively, physiologi-
cally, attentionally, behaviorally, and relationally. DTD crite-
ria are deliberately less focused on the impact of any single
traumatic event because the neurodevelopmental disruptions
caused by complex trauma result in deficits that span several
transdiagnostic, self-regulatory and neurocognitive domains.
Moreover, DTD was developed fundamentally as a disor-
der originating in childhood and adolescence, informed by
developmental theory and research indicating that trauma
– particularly complex trauma – affects youth and adults
differently (Van der Kolk, 2005). This is in contrast to PTSD
and CPTSD, which were conceptualized and developed pri-
marily based on research in adult samples (Brewin et al.,
2017; Schmid et al., 2013). Finally, although reactive attach-
ment disorder and disinhibited social engagement disorder
recognize the impact of attachment-related trauma, their
symptom profiles are limited to social withdrawal and indis-
criminate social engagement, respectively.
Present Review
DTD represents a promising solution for addressing the
impact of complex trauma and improving diagnostic par-
simony for children and adolescents. However, arguments
in support of DTD have relied primarily on theory and on
broader research involving complex trauma, rather than
empirical evaluations of DTD symptom criteria. The last
10–15 years has seen an increase in studies investigating
DTD and its psychometric properties. To date, there has
been no attempt to formally synthesize this literature. A
consensus about DTD’s inclusion in future DSM editions
remains unclear. Of particular interest is DTD’s clinical util-
ity over and above other trauma- and stressor-related disor-
ders, such as PTSD. Theoretically speaking, DTD symptoms
are expected to overlap with PTSD symptoms given their
shared focus on trauma reactions. On the other hand, too
much overlap would suggest a single underlying construct,
making DTD more redundant than useful. PTSD there-
fore serves as a criterion for both convergent and divergent
validity. The issue of symptom overlap has been examined
extensively in the adult PTSD literature (e.g., Resick et al.,
2012) but has yet to be resolved for DTD. To fill this gap,
the current article systematically reviews, synthesizes, and
evaluates the existing empirical evidence for DTD with the
goal of addressing the following research questions:
• Is DTD a valid construct with reliable assessment meas-
ures?
• Are DTD symptom criteria sufficiently distinct from
those of existing diagnostic constructs, particularly
PTSD?
13
380
• Is DTD clinically useful, and by extension, to what extent
do the authors of the articles included in this review sup-
port its inclusion in formal diagnostic systems?
Method
This systematic review was guided by the PRISMA rec-
ommendations for systematic reviews and meta-analyses
(Moher, Liberati, Tetzlaff, Altman, & Group, 2009).
Search Strategy for Identification of Studies
Computerized searches were conducted by the first author in
the PubMed, APA PsycInfo, and Web of Science databases
for published articles from 2005 (when DTD was initially
proposed) up to July, 2021. The scope of this review focuses
specifically on studies that have evaluated the DTD construct
and symptoms proposed by Van der Kolk (2005, 2009). We
were not interested in reviewing articles on complex PTSD,
nor were we interested in locating articles on developmental
trauma, complex trauma, or any other trauma-related con-
structs broadly if they did not make reference to DTD. Given
this relatively narrow and specific focus, we used the follow-
ing singular search string: ‘developmental trauma disorder’;
as the key phrase for study retrieval in all three databases.
We also reviewed all studies that cited the seminal Van der
Kolk (2005) paper, which formally introduced DTD criteria
into the published literature for the first time. Next, a snow-
ball technique was applied following guidelines from Woh-
lin (2014) whereby reference lists of selected articles were
screened “backward” (i.e., references of included studies are
studied to identify more articles) and “forward” (i.e., articles
citing the selected papers are evaluated). Gray literatures
(e.g., dissertation studies) were also considered.
Inclusion and Exclusion Criteria
Articles were included if they (1) were published in English
from 2005 onward; (2) conducted some form of empirical
analysis of DTD symptom criteria in an attempt to evalu-
ate the validity (e.g., structural, convergent, discriminant,
face), reliability, symptom/item characteristics, prevalence,
or clinical utility of the disorder; (3) recruited samples of
children and/or adolescents (i.e., from 0 to 21 years old) if
formally assessing DTD symptoms; and (4) made specific
and clear reference to DTD symptom criteria, as opposed to
ICD complex posttraumatic stress disorder symptoms, child-
hood posttraumatic stress disorder symptoms, or exposure
to “complex” or “developmental” trauma alone. Theoretical
articles describing the evidence for DTD or arguing for its
inclusion in diagnostic systems based on the broader com-
plex trauma literature were excluded. Only those articles that
13
Clinical Child and Family Psychology Review (2022) 25:376–394
empirically evaluated specific DTD symptom criteria using
objective statistical methods were considered for the current
systematic review.
Selection of Studies
The first author screened the titles, then retrieved abstracts of
all studies that met the inclusion criteria. Articles deemed to
be irrelevant were discarded. Studies that described results
from the same sample were coded as such and treated as
singular studies. The second author then reviewed and con-
firmed the inclusion of all articles retained based on their
abstract and title. Disagreements about the inclusion of
articles were handled through discussion among the first
and second author. Endnote was used as the bibliographic
software. Figure 1 presents the process of studies selection.
Ideally, synthesis of research findings should be done
using effect size procedures such as meta-analysis. How-
ever, research questions were often narrow within each study
and variable across studies. Most studies examined one or
two specific psychometric aspects of DTD’s symptom crite-
ria (e.g., structural validity or face validity or overlap with
PTSD symptom criteria). This resulted in a wide range of
methodologies and analyses. As a result, a narrative review
represented the most appropriate format with which to syn-
thesize this literature.
Results
Twenty-one (21) articles reporting on findings from 17
studies met inclusion criteria for the current review. Details
about the articles and their sample characteristics, study
objectives, assessments of DTD, key findings, and authors’
support for the proposed DTD criteria can be found in
Table 2. The study selection procedure is summarized in
Fig. 1. In brief, we identified 1,023 independent studies that
included the exact term “developmental trauma disorder”
or that cited Van der Kolk (2005). Of these, 975 articles
were screened out for irrelevance based on their title. After
reviewing the remaining 48 abstracts, 24 full-text articles
were assessed, of which the final 21 were determined to meet
inclusion criteria.
Studies varied greatly in the scope of their objectives
and, as a result, in their analytic approaches. Most stud-
ies included comparisons between DTD symptom crite-
ria and theoretically overlapping diagnoses or constructs
(e.g., DSM-IV and/or DSM-5 PTSD criteria) by examining
overlap or discriminability, comparing their clinical utility,
or simply presenting prevalence rates side by side. Stud-
ies that did not make direct comparisons with other psy-
chiatric disorders typically examined the degree to which
complex trauma, versus other forms of trauma (e.g., acute/
Clinical Child and Family Psychology Review (2022) 25:376–394 381

Fig. 1  Flow chart of article

selection process Articles identified through electronic
search in PsycINFO, PubMed, and Web
of Science: k = 188
Articles identified through other sources:
Identified through reference sections of
retrieved studies: k = 9.
Cited the van der Kolk et al. (2005) article:
k = 1,099.

Articles after duplicates removed: k = 1,023

Articles excluded based on title

k = 975

Abstracts reviewed
k = 48
Articles excluded based on abstract:
Conceptual/non-empirical: k = 14
Systematic review: k = 3
Irrelevant: k = 7
Full-text articles assessed
for eligibility
k = 24
Articles excluded based on full-text:
DTD symptom criteria not subjected
to empirical analysis: k = 3

Full-text articles included in

qualitative synthesis with non-
overlapping samples:
k = 21 (17 non-overlapping
samples)

non-interpersonal) or the absence of trauma, were associated
with DTD symptom criteria. A handful of studies examined
psychometric properties of measures designed to assess
DTD symptoms (e.g., DTD Structured Interview).
Sample Characteristics
The articles included in this review reported on a total of
N = 19,998 (non-overlapping) youth ranging in ages from
0–21 years. Sample sizes for each individual study were
generally small to moderate, ranging from 36 to 472, with
the exception of Kisiel et al. (2014), who reviewed records
for 16,212 youth in state child welfare custody. With the
exception of five samples that included greater than 70%
females, participants were generally well-balanced regard-
ing gender. Youth included in the studies were typically
between 7 and 18 years old, with mean ages frequently
between 12–14 years. Only five of the 17 samples included
children under 7 years of age. Samples were also racially/
ethnically and socioeconomically diverse, with ten of the 17
samples comprised of at least 40% non-White youth. These
non-White participants were comprised primarily of Black
youth and were most often recruited from low- and middle-
income communities or school settings. Hispanic youth were
adequately represented (i.e., comprised over 10% of partici-
pants) in three of the 10 U.S. samples, but were underrepre-
sented in the rest. Most participants were either treatment-
seeking (10 of 17 samples) or recruited from communities
or schools (4 of 17 samples). The remaining samples were
comprised of child-welfare-involved youth, incarcerated
females, and university students.
Assessment of DTD Symptom Criteria
Due to the lack of available DTD-specific measures, DTD
symptom criteria were assessed using a wide variety of
methods. Twelve of the 21 included studies assessed DTD by
matching items from related measures onto DTD symptom
criteria. In other studies, authors employed study-developed
and/or unpublished assessments designed specifically to
assess DTD criteria (e.g., Developmental Trauma Disorder
Questionnaire [DTDQ]). One of the included studies (Ford,
Spinazzola, Van der Kolk, & Grasso, 2018) reported on the
development of a DTD structured interview, which was then
used in four subsequent studies (Ford et al., 2021; Spinaz-
zola et al., 2018; Spinazzola, Van der Kolk, & Ford, 2021;
Van der Kolk et al., 2019).

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 Table 2  Summary of studies examining the prevalence, validity, reliability, or clinical utility of DTD
382

Study Sample size and Objective Assessment of DTD symp- Key findings Overall support for DTD
characteristics toms

13
Teague (2009) Dissertation N = 283; Clinical sample, ages DTD (dichotomous) not
Examine association between Child and Adolescent Needs No definitive comment by
9–16, 55% female DTD and academic associated with academic
and Strengths Assessment– author
achievement Mental Health achievement; sub-threshold
(continuous) DTD scores
negatively associated with
academic achievement
Ford et al. (2013) N = 472 clinicians from six Assess clinician ratings of Clinicians presented with DTD criteria reported as com- Yes
countries, 78% female DTD criteria (face validity, DTD symptoms and parable in clinical utility to
clinical utility, discrimina- vignettes PTSD and other disorders,
bility, amenability to extant discriminable from/not
treatments) fully accounted for by other
disorders, and refractory to
existing treatments
Stolbach et al. (2013) N = 214; Clinical sample all Compare DTD symptom Combination of non-DTD- Youth with DTD Criterion Yes
with PTSD Criterion A trauma criteria in youth with vs. specific measures A trauma exposure were
exposure, ages 3–17, 55% without DTD Criterion A more likely to meet DTD
female trauma exposure symptom criteria than
youth without Criterion A
exposure
Wamser‐Nanney and Vanden- N = 346; Clinical sample, all Compare behavioral and Child Behavior Checklist and Youth exposed to complex Yes
berg (2013) experienced trauma or neglect, trauma-related outcomes in Trauma Symptom Checklist trauma endorsed more
ages 3–18, 61% female youth exposed to complex behavior problems and
trauma vs. other types of trauma symptoms than those
trauma exposed to other traumas
(i.e., non-interpersonal, later
life)
Klasen et al. (2013) N = 330 former child soldiers Examine prevalence of DTD Combination of non-DTD- 78% met criteria for DTD, Yes
interviewed at boarding school in child soldier sample and specific measures whereas 33% met for PTSD;
for war-affected children in retrospective association DTD associated with IPV
Uganda, ages 11–17, 49% with previous traumas and exposure, community
female sociodemographic variables violence, social support,
depression; PTSD associ-
ated with war experiences
Kisiel et al. (2014) N = 16,212 youth in Illinois Compare DTD symptom cri- Child and Adolescent Needs Youth with combined inter- Yes
child welfare, ages 0–16, 49% teria in youth with exposure and Strengths Assessment personal/violent trauma
female to (1) repeated interper- and attachment-based/non-
sonal violence, (2) non- violent trauma met more
violent attachment-based DTD criteria, exhibited
trauma, (3) combination of more functional impairment,
the two, and (4) neither and were more likely to have
placement disruptions and
hospitalizations
Clinical Child and Family Psychology Review (2022) 25:376–394
 Table 2  (continued)
Study Sample size and Objective Assessment of DTD symp- Key findings Overall support for DTD
characteristics toms

Ma and Li (2014)
McDonald et al. (2014)
a
Foster (2013) Dissertation
N = 336 Hong Kong youth
recruited through combination
of school and clinical settings,
ages 9–15, 56% female
N = 186 volunteer university
students, ages 18–19, 73%
female
N = 53; clinical sample present- Examine overlap and dis-
ing for depressive or suicidal
features, mean age 14.9 years,
Compare DTD symptom Combination of non-DTD- Several DTD symptoms (e.g., Yes
criteria in youth with his- specific measures self-blame, emotional dys-
tory of (1) abuse, (2) acute/ regulation, low self-esteem,
non-interpersonal trauma, behavioral difficulties) only
and (2) no trauma observed in youth with
histories of abuse
Examine DTD symptoms Developmental Trauma Participants reported multiple Yes
and their association with Disorder Questionnaire events that would not meet
retrospectively reported (unpublished) PTSD Criterion A; history
exposure to complex child- of multiple/chronic traumas
hood trauma was associated with DTD
symptoms
Structured Interview for Dis- DTD and PTSD symptom Yes
criminability between DTD orders of Extreme Stress- criteria were overlapping
and PTSD, and examine Adolescent (not validated) but distinct; (Lupien et al.,
Clinical Child and Family Psychology Review (2022) 25:376–394

76% female association between DTD 2009); criteria D symptoms

McDonald (2015) Disserta-
tion
Horner (2017) Dissertation
N = 36; clinical sample, ages
8–17, 56% female
N = 229 females, ages 13 to 20, Examine the relationship
in maximum security juvenile
justice facility in Illinois
symptoms and suicidal/self-
injurious behaviors
Assess validity and reliabil- DTDQ and Stressful Events
ity of the Developmental
Trauma Disorder Question-
naire (DTDQ) and the DTD
construct
between complex trauma
and comorbid diagnoses of
incarcerated females using
a developmental trauma
framework
Questionnaire
Clinical Needs Assessment
and overall symptom sever-
ity (continuous) were related
to certain suicidal/NSSI
features
DTDQ demonstrated valid- Yes
ity and reliability. Results
also provided support for a
broadened PTSD criterion A
and support for DTD criteria
more broadly
DTD was associated with Yes
comorbid personality dis-
orders, PTSD, bipolar and
related disorders, and neu-
rodevelopmental disorders;
DTD was not associated
with disruptive, impulse
control, and conduct disor-
ders or depressive disorders

13
383
 Table 2  (continued)
Study Sample size and
characteristics
13
b
Ford et al. (2018) N = 236; community sample
of youth ages 7–18 years, 50%
female
b
Spinazzola et al. (2018) N = 236; community sample
of youth ages 7–18 years, 50%
female
b
Van der Kolk et al. (2019) N = 236; community sample
of youth ages 7–18 years, 50%
female
DePierro et al. (2019) N = 210 psychotherapists report- Examine how PTSD and
ing on 563 clients; client ages
2–21, 60% female
Objective
Examine the factor struc-
ture, item characteristics,
reliability, and validity of
the developmental trauma
disorder semi-structured
interview (DTD-SI)
Determine whether DTD is
associated with different
traumatic antecedents than
PTSD
Characterize the psycho-
pathology comorbid with
DTD and to determine
whether this comorbidity is
distinct from, and extends
beyond, comorbidities of
PTSD
DTD diagnoses relate to
functional impairment and
trauma exposure using
clinician report surveys
384
Assessment of DTD symp- Key findings Overall support for DTD
toms
DTD-SI DTD-SI showed evidence of Yes
reliability, construct validity,
informativeness on an item-
level basis, and convergent
and discriminant validity.
DTD was associated with
psychosocial impairment
independent of PTSD,
polyvictimization, and
demographics. DTD was
discriminable from alterna-
tive DSM-5 diagnoses that
include some symptoms that
closely parallel some DTD
symptoms
DTD-SI DTD was associated with his- Yes
tory of interpersonal trauma
and attachment adversity,
independent of PTSD. DTD
exposure criterion was
associated with total DTD
and self/relational dysregu-
lation symptoms (Criterion
D), independent of PTSD,
polyvictimization, and
demographic variables
DTD-SI DTD's comorbidities over- Yes
lapped with but extended
beyond those of PTSD to
include panic, separation
anxiety, and disruptive
behavior disorders
Child Complex Trauma Comorbidity between DTD Yes
Symptom Checklist and PTSD was high.
Comorbid DTD/PTSD and
DTD-alone groups had
more functional domains
impacted and greater expo-
sure to some types of trauma
relative to the other groups
Clinical Child and Family Psychology Review (2022) 25:376–394
 Table 2  (continued)
Study
Zhang et al. (2019)
Metzner et al. (2018)
a
Foster et al. (2019)
Basu and Isaacs (2019)
c
Ford et al. (2021)
c
Spinazzola et al. (2021)
Superscript letters indicate articles that report on the same sample
DTD: developmental trauma disorder; PTSD: posttraumatic stress disorder; IPV: intimate partner violence; DTDQ: Developmental Trauma Disorder Questionnaire; DTD-SI: Developmental
Trauma Disorder Semi-Structured Interview; DMDD: disruptive mood dysregulation disorder; ADHD: attention-deficit/hyperactivity disorder
13
Sample size and Objective
characteristics
N = 322; community sample Examine the association
of 13-year-olds (at baseline) between parental absence
recruited from local schools in and change in DTD symp-
the Shanxi province in China, toms across a five-year
62% female period in Chinese youth
N = 161; clinical sample of Compare DTD symptom cri-
youth with trauma exposure, teria among youth exposed
ages 1–18, 61% female to Type II (complex) vs.
Type I (acute) trauma
N = 53; clinical sample present- Examine the prevalence and
ing for depressive or suicidal discriminability of DTD
features, mean age 14.9 years, relative to DSM-IV and
76% female DSM-5 PTSD
N = 101; clinical sample of Identify most psychiatric
youth in regional Victoria, common disorders and
Australia, mean age 13.3, 46% stressors among transcul-
Aboriginal, 42% female tural youth in Australia
N = 271; clinical sample ages Replication of Van der Kolk
8–18, 47% female et al. (2019); characterize
comorbidities of DTD and
evaluate its distinctiveness
from PTSD
N = 271; clinical sample ages Replication of DePierro
8–18, 47% female et al. (2019); character-
ize traumatic antecedents
and functional impairment
associated with DTD
Assessment of DTD symp-
toms
25-item author-developed
instrument
Physician notes were coded
for DTD using an adapted
DTD algorithm
Structured Interview for Dis-
orders of Extreme Stress-
Adolescent (not validated)
Not addressed
DTD-SI
DTD-SI
Key findings Overall support for DTD
Parental absence was not Yes
associated with DTD
symptoms at age 13, but was
associated with worsening
symptoms over time and
with age 18 DTD symptoms
77% of youth experienced No
Type II trauma and 6% met
criteria for DTD. Total DTD
symptoms did not differ by
trauma exposure type
DTD symptomatology was as Yes
prevalent as DSM-IV and
DSM-5 PTSD; DTD over-
lapped with but was distinct
Clinical Child and Family Psychology Review (2022) 25:376–394
from PTSD
27% met criteria for DTD No definitive comment by
(third most common after author
DMDD and ADHD); fewer
(15%) met for PTSD
DTD and PTSD often co- Yes
occurred and shared several
psychiatric comorbidities;
DTD also occurred sepa-
rately from PTSD and had
comorbidities that were
distinct from PTSD
Although PTSD and Yes
DTD share traumatic ante-
cedents, DTD is uniquely
associated with traumatic
emotional abuse and car-
egiver separation
385
386
Key Findings
The studies included in the present review differed in their
specific objectives, but generally took one or more of the fol-
lowing analytic approaches: (1) Examined divergent valid-
ity or discriminability of DTD by making direct empirical
comparisons with other theoretically similar diagnoses; (2)
examined convergent validity of DTD by reporting associa-
tions with related measures, behaviors, or constructs; (3)
examined the association between trauma exposure type and
presence/severity of DTD symptom criteria; (4) examined
the psychometric properties of a measure developed spe-
cifically to assess DTD symptom criteria; and (5) examined
clinician reports of DTD’s clinical utility. One study (Basu
& Isaacs, 2019) merely reported prevalence rates of DTD
in their sample.
Divergent Validity or Discriminability
An important prerequisite for a disorder’s clinical utility is
that it does not overlap excessively with existing disorders.
This issue is particularly relevant for DTD, given the exist-
ence of several theoretically similar diagnostic constructs
already available in the DSM-5 and ICD-11. Eight studies
included in the current review assessed divergent validity
or discriminability of DTD from other related diagnoses
in some form, with a particular focus on PTSD. In brief,
all eight studies found support for DTD’s distinctiveness.
Three studies reporting on the same community sample of
7–18-year-olds (Ford et al., 2018; Spinazzola et al., 2018;
Van der Kolk et al., 2019) showed that PTSD and DTD were
comorbid in only 16.5% of youth and that PTSD, more so
than DTD, was associated with related psychiatric condi-
tions (e.g., reactive attachment disorder [RAD], disinhibited
social engagement disorder [DSED], disruptive mood dys-
regulation disorder [DMDD], and nonsuicidal self-injury).
The authors identified a number of psychiatric comorbidities
associated with DTD but not with PTSD (i.e., attention-def-
icit/hyperactivity disorder [ADHD] and separation anxiety
disorder in multivariate analyses; oppositional defiant dis-
order [ODD], conduct disorder [CD], and panic disorder in
bivariate analyses), supporting DTD’s discriminability. Sim-
ilar results were found by the same author group replicating
their work in a sample of treatment-seeking 8–18-year-olds,
showing that DTD was uniquely associated with several
comorbidities after controlling for PTSD (i.e., separation
anxiety disorder, depression, and oppositional defiant disor-
der), while PTSD was associated only with separation anxi-
ety disorder after controlling for DTD (Ford et al., 2021).
Two studies reporting on the same small (N = 53) sample
of treatment-seeking adolescents (Foster, 2013; Foster et al.,
2019) found that DTD was associated with the presence of
DSM-IV PTSD, χ 2(1) = 6.01, p = 0.009, but not DSM-5
13
Clinical Child and Family Psychology Review (2022) 25:376–394
PTSD χ2(1) = 0.81, p = 0.368. The proportion of youth with
DTD who also met criteria for DSM-5 PTSD (27%) was
smaller than the proportion of youth with DSM-5 PTSD who
also met criteria for DTD (66%), though the small sample
size makes these proportions difficult to interpret, as DTD
and DSM-5 PTSD were identified in 26 and nine youth,
respectively. The authors ultimately concluded that DTD and
PTSD symptoms were overlapping but sufficiently independ-
ent from one another, and that this overlap was similar to
that observed in other mood, anxiety, and trauma-related dis-
orders. One study of former Ugandan child soldiers (Klasen
et al., 2013) found that DTD was more prevalent than PTSD
in their sample (78% versus 33%, respectively). Ford et al.
(2013) had clinicians rate the discriminability of each DTD
symptom criterion on a 9-point Likert-type scale with higher
values indicating more discriminability. Approximately half
of all DTD symptom criteria were perceived to be discrimi-
nable from PTSD (defined by lower bound of 95% CI ≥ 4)
and from other affective and externalizing disorders (defined
by lower bound of 95% CI ≥ 5), with criteria D symptoms
(i.e., self and relational dysregulation) demonstrating the
most consistent perceived discriminability. In another clini-
cian report study, in which clinicians were asked to report
on their clients’ trauma-related symptoms, DTD was associ-
ated with more functional impairment than PTSD (DePierro
et al., 2019). In one final example of divergent validity, a
dissertation study of treatment-seeking older children and
adolescents found that the DTDQ was only weakly associ-
ated with the prosocial scale of the Strengths and Difficul-
ties Questionnaire, a scale the author hypothesized would be
irrelevant to the DTD construct (McDonald, 2015). All eight
aforementioned studies concluded that DTD demonstrated
sufficient discriminability from PTSD and other psychiatric
diagnoses and constructs. However, it is worth highlight-
ing findings from Van der Kolk et al. (2019) indicating that
DTD was associated with an extremely wide range – wider
than PTSD – of mood, anxiety, psychotic, and externalizing
disorders.
Convergent Validity
Eleven studies examined DTD’s association with theoreti-
cally similar constructs, behaviors, or measures. The most
common comparison was between DTD and PTSD, con-
sistent with the notion that DTD and PTSD should dem-
onstrate some degree of overlap based on the similarity of
their constructs. Estimates of their comorbidity were 8.7%
(Horner, 2017), 13.6% (Klasen et al., 2013), 16.5% (Van
der Kolk et al., 2019), 18% (Ford et al., 2021), 19–30%
depending on the specific PTSD criteria (e.g., DSM-IV vs.
DSM-5, adult vs. child subtype; Foster, 2013; Foster et al.,
2019), and 52.4–59.9% for adult and child subtype, respec-
tively (DePierro et al., 2019). McDonald (2015) reported
Clinical Child and Family Psychology Review (2022) 25:376–394
significant associations between the DTDQ and UCLA
PTSD Reaction Index (r = 0.83 for child-reported DTDQ,
r = 0.43 when adult reported), and two studies reporting on
the same sample indicated that the odds of meeting crite-
ria for DTD was significantly greater given the presence
of a PTSD diagnosis, and vice versa, after controlling for a
variety of sociodemographic factors, trauma exposure types,
and other psychiatric disorders (ORs = 2.04–3.01; Spinaz-
zola et al., 2018; Van der Kolk et al., 2019).
DTD was also associated with psychopathologies beyond
PTSD. In one community sample, DTD was associated with
internalizing and externalizing symptoms, major depressive
disorder, bipolar disorder, psychosis, panic disorder, separa-
tion anxiety disorder, phobias, generalized anxiety disorder
(GAD), ADHD, ODD, CD, and DMDD (Ford et al., 2018;
Van der Kolk et al., 2019); after controlling for covariates
and the effects of all probabilistic DSM-5 diagnoses, the
odds of meeting criteria for DTD remained significantly
higher given the presence of separation anxiety disorder
(OR = 2.13) and ADHD (OR = 2.12; Van der Kolk et al.,
2019). A replication of this work by the same research
group confirmed these findings in a treatment-seeking sam-
ple, showing that DTD was associated in bivariate analyses
with nearly all other psychiatric disorders. After controlling
for covariates and all probable DSM-IV psychiatric disor-
ders, children with DTD were 3.5, 2.9, and 2.3 times more
likely than others to meet criteria for ODD, depression, and
separation anxiety disorder, respectively, X ­ 2(16) = 128.58,
2
Log Likelihood = 201.62, Nagelkerke ­R = 0.54 (Ford et al.,
2021). In a sample of incarcerated female adolescents, DTD
was associated with comorbid personality disorders, bipo-
lar and related disorders, and neurodevelopmental disor-
ders (non-specific), but not disruptive, impulse control, and
conduct disorders or depressive disorders (Horner, 2017).
Finally, (Klasen et al., 2013) found that DTD and PTSD
were associated with different types of traumatic experiences
(i.e., DTD with intimate partner violence and community
violence, PTSD with war experiences).
A handful of included studies reported associations
between DTD and non-psychiatric constructs. For example,
Ford et al. (2018) found significant negative associations
with levels of hope, quality of life, and emotion regula-
tion, and positive associations with dysregulation and alex-
ithymia. In two dissertations, contrary to hypotheses, the
presence of DTD was not associated with poor academic
achievement, nor was it consistently associated with suicidal
and self-injurious behaviors (Foster, 2013; Teague, 2009)
though sub-threshold DTD symptom scores for specific cri-
terion domains (e.g., criterion D) were associated with these
constructs. In sum, most of the included studies documented
hypothesized associations between DTD and existing diag-
noses or related constructs. However, the extent of these
associations ranged from study to study, and in some cases
387
DTD’s overlap with other diagnostic constructs was larger
than would typically be expected from a unique and clini-
cally useful diagnosis (e.g., correlation of r = 0.83 between
DTDQ and UCLA PTSD Reaction Index; McDonald, 2015).
Associations Between Trauma Exposure and DTD
Symptoms
If DTD represents an outcome of complex trauma exposure,
then youth who meet symptom criteria (i.e., B through G)
should be more likely to have experienced complex trauma
relative to other forms of trauma exposure (or no trauma).
More broadly, complex trauma exposure as defined by DTD
exposure criterion A should be associated with a wider
range of dysfunction than other forms of trauma exposure.
Thirteen studies investigated these questions in some form,
generally finding associations between DTD symptoms and
retrospectively reported complex trauma exposure.
Stolbach et al. (2013) found that youth who met DTD
exposure criterion A were more likely to endorse symptom
criteria B through G. Wamser‐Nanney and Vandenberg
(2013) found that youth exposed to complex trauma early in
life endorsed more behavioral and trauma symptoms char-
acteristic of DTD than those exposed to complex trauma
later in life and those exposed to non-interpersonal/acute
trauma. Ma and Li (2014) compared groups of students in
Hong Kong exposed to (1) repeated physical or sexual abuse
by family members, (2) acute/non-interpersonal trauma, or
(3) neither, finding that several DTD symptoms (e.g., self-
blame, emotional dysregulation, low self-esteem, behavioral
difficulties) were only observed in youth with histories of
abuse. Two studies reporting on the same community sample
found that youth who did versus did not meet criteria for
DTD experienced 50% more types of potentially traumatic
experiences and twice as many types of interpersonal vic-
timization (Ford et al., 2018), and that DTD was associated
with a history of interpersonal trauma and attachment adver-
sity independent of PTSD (Spinazzola et al., 2018). Findings
also revealed that DTD exposure criterion A was associated
with total DTD and self/relational dysregulation symptoms
(criterion D), independent of PTSD, polyvictimization, and
demographic variables (Spinazzola et al., 2018). A replica-
tion of these findings by the same research group confirmed
that DTD was uniquely associated with traumatic victimiza-
tion and attachment disruption independent of the effects of
PTSD. This replication study examined DTD exposure crite-
rion A in greater detail, revealing that children who met both
criterion A1 (traumatic victimization) and A2 (attachment
disruption) were more likely than those who met only crite-
rion A1, or neither exposure criteria, to meet DTD symptom
criteria B through G (Spinazzola et al., 2021). A history of
multiple, chronic traumas was associated with DTD symp-
toms among university students (McDonald et al., 2014) and
13
388
among treatment-seeking adolescents (McDonald, 2015).
Treatment-seeking youth with DTD reported more cumula-
tive trauma, physical/emotional neglect, and IPV exposure
than youth without DTD (DePierro et al., 2019). The pres-
ence of DTD among former child soldiers was associated
with exposure to IPV and community violence but not war
experiences (Klasen et al., 2013). Finally, youth with com-
bined exposure to interpersonal/violent trauma and attach-
ment-based/non-violent trauma, compared to either type
alone, met more DTD criteria, exhibited more functional
impairment, and were more likely to have placement disrup-
tions and hospitalizations (Kisiel et al., 2014).
A minority of studies reported mixed findings. For exam-
ple, Zhang et al. (2019) compared Chinese students with and
without exposure to parental absence, finding that paren-
tal absence was not associated with DTD symptoms at age
13, but was associated with worsening symptoms over time
and with age 18 DTD symptoms. In a sample of treatment-
seeking children and adolescents ages 1–18 years, Metzner
et al. (2018) found that of the 77% who experienced complex
trauma, only 6% met criteria for DTD, and total DTD symp-
toms did not differ by trauma exposure type.
Measure Development Studies
DTD’s absence from formal diagnostic systems has con-
tributed to a dearth of DTD measure development work.
The current review identified three studies reporting on the
psychometric properties of measures designed specifically
to assess DTD symptom criteria (for a review of complex
trauma exposure assessments, see Denton et al., 2017). The
first study, a dissertation by McDonald (2015), examined the
validity and reliability of the Developmental Trauma Disor-
der Questionnaire (DTDQ) in a very small (N = 36) clinical
sample of 8–17-year-olds. The DTDQ, a 15-item child- and
caregiver-report questionnaire, assesses non-exposure DTD
symptom criteria. McDonald (2015) found mixed support
for internal consistency (αs > 0.70 except for child functional
impairment scale, α = 0.41), but good test–retest reliability
(1–2 weeks) of both the child- and caregiver-report ver-
sions of the DTDQ. Convergent validity was generally sup-
ported, as evidenced by strong associations with the UCLA
PTSD Reaction Index (UPRI) and with the emotional and
conduct symptoms scale of the Strengths and Difficulties
Questionnaire (SDQ). As hypothesized, neither the child nor
caregiver DTDQ was associated with the SDQ’s prosocial
behavior subscale, providing some evidence for divergent
validity. In regression analyses controlling for sociodemo-
graphic variables, frequency of trauma exposure was related
to child but not caregiver DTDQ total scores. Support was
also found for item-level characteristics and readability. The
DTDQ’s factor structure was not investigated.
13
Clinical Child and Family Psychology Review (2022) 25:376–394
The second measure development study evaluated the
factor structure and psychometric properties of the Devel-
opmental Trauma Disorder Structured Interview (DTD-SI)
in a diverse, moderately sized (N = 236) community sam-
ple of 7–18-year-olds (Ford et al., 2018). The DTD-SI is a
clinician-administered interview assessing DTD criteria B,
C, and D. Confirmatory factor analysis (CFA) supported the
hypothesized three-factor solution compared to a 1-factor
or hybrid 4-factor solution modeled on the DSM-5 PTSD
conceptualization, as evidenced by lower BIC and χ2 values.
Interrater reliability was generally strong, ks > 0.70, with
the exception of the nonsuicidal self-injury item (k = 0.64).
Internal consistency was not particularly strong (criterion
B α = 0.67, criterion C α = 0.61, criterion D α = 0.72). Item
response theory analyses demonstrated that DTD-SI items
were psychometrically informative in relation to overall
DTD symptomatology and unbiased in relation to demo-
graphics. Convergent and divergent validity were also sup-
ported, as evidenced by associations with a variety of theo-
retically related constructs (e.g., low hope and quality of
life, poor emotion regulation, internalizing and externalizing
symptoms, number of psychiatric comorbidities) and by the
absence of significant associations with other disorders (e.g.,
RAD, DSED, and DMDD). All participants who met symp-
tom criteria had histories of interpersonal victimization and
attachment disruption.
A third study examined the association between parental
absence and longitudinal changes in DTD symptoms in a
community sample of N = 322 Chinese youth (Zhang et al.,
2019). Although measure development was not the focus
of their investigation, the authors reported internal consist-
ency and results from a CFA of a study-developed, 25-item,
self-report questionnaire of DTD symptoms assessing cri-
teria B, C, and D. Internal consistency was supported for all
three scales (ωs > 0.80). The hypothesized three-factor solu-
tion demonstrated acceptable model fit, χ2(272) = 502.76,
p < 0.001, CFI = 0.91, TLI = 0.90, RMSEA = 0.051,
SRMR = 0.062. No other psychometric properties were
reported or interpreted.
Clinician Ratings of DTD Symptom Criteria
One study evaluated clinician ratings of DTD’s clinical util-
ity by surveying N = 472 medical, mental health, counseling,
child welfare, and education professionals across six coun-
tries (Ford et al., 2013). Clinicians were asked to rate DTD
symptom criteria on a 9-point Likert-type scale with regard
to clinical utility, discriminability, ability of other disorders
to account for DTD symptoms, and refractoriness to existing
treatments. In general, respondents viewed DTD criteria as
(1) clinically useful, as evidenced by moderate (lower bound
of 95% CI = 3.5–6.5) to high (lower bound of 95% CI ≥ 6.5)
mean ratings on nearly all DTD exposure and symptom
Clinical Child and Family Psychology Review (2022) 25:376–394
criteria; (2) discriminable from PTSD and other affective
and externalizing disorders (see Divergent Validity or Dis-
criminability above for detail); (3) “potentially” or “prob-
ably” not better accounted for by other psychiatric disorders,
as evidenced by 19 of 23 DTD symptom ratings having a
lower bound 95% CI of ≥ 4.5; and (4) at most, only “partially
remediable” by the array of existing evidence-based treat-
ments for PTSD and other internalizing and externalizing
disorders, as evidenced by nearly all DTD symptom ratings
having an upper bound 95% CI of ≤ 6.
We mention one final study, which reported the preva-
lence of DTD in a multi-cultural (e.g., 46% Aboriginal)
treatment-seeking sample of N = 101 adolescents in Victoria,
Australia. DTD criteria were met by 27% of youth, repre-
senting the third most prevalent psychiatric disorder after
DMDD and ADHD. By comparison, PTSD was endorsed
by 15% of youth.
Discussion
Since its introduction into the published literature in 2005,
developmental trauma disorder has received substantial
attention from clinicians and researchers alike. Proponents
for its inclusion in formal diagnostic systems argue that DTD
represents a parsimonious and developmentally appropri-
ate diagnosis for the consistent and predictable emotional,
behavioral, and neurobiological sequelae observed in chil-
dren exposed to complex trauma. However, these claims
have often lacked sufficient empirical backing, and although
substantial effort has gone toward evaluating DTD symptom
criteria within the last decade, this body of work has not yet
been synthesized. The current paper sought to systemati-
cally review the literature to date that has empirically evalu-
ated DTD symptom criteria in order to determine whether
DTD represents (1) a valid diagnostic construct with reli-
able assessment measures that is (2) sufficiently distinct
from existing diagnostic constructs, particularly PTSD, and
is (3) clinically useful.
Considering the expansive inclusion criteria of this
review (i.e., no restrictions on sample size, assessment of
DTD, analytic strategy) only a relatively small number of eli-
gible studies were identified, ranging widely in their objec-
tives, methodologies, and scope of their analytic approaches.
That being said, studies were largely supportive of DTD as a
valid and reliable, sufficiently distinct, and clinically useful
diagnostic construct. Every study in which discriminability
was evaluated found support for DTD’s distinctiveness from
other disorders, including PTSD. At the same time, stud-
ies reported associations (sometimes quite strong) between
DTD and related disorders or constructs. Strong associations
with other diagnoses may be inherent to a new diagnostic
construct without a “not otherwise specified” subtype or
389
differential diagnosis exclusions. Nevertheless, such find-
ings raise important questions about DTD’s distinctiveness.
As expected, DTD symptoms tended to be associated
with complex trauma experiences, and a handful of studies
found that PTSD and DTD were related to different types of
traumatic experiences. CFAs in two studies supported the
proposed three-factor solution for DTD criteria B, C, and D,
and a survey of clinicians indicated, on average, that DTD
is perceived to be clinically useful, discriminable from and
not better accounted for by other disorders, and refractory
to existing treatments. Overall, these findings align with a
sizeable body of conceptual literature arguing for a devel-
opmentally appropriate trauma diagnosis (Cook et al., 2005;
D'Andrea et al., 2012; Ford, 2017). Findings also converge
with literature in support of other complex trauma diagno-
ses, and in particular, CPTSD – the only existing diagnosis
to explicitly recognize the impact of complex trauma. The
inclusion of CPTSD in ICD-10 and 11 constituted a crucial
step forward for clinicians and researchers hoping to achieve
diagnostic parsimony for individuals exposed to complex
trauma, and a sizable literature now supports CPTSD’s con-
struct validity and clinical utility (Brewin et al., 2017). Still,
CPTSD was conceptualized and evaluated primarily in adult
samples, and at present, full ICD-11 PTSD criteria must be
met in order for CPTSD to be diagnosed. DTD, in contrast,
was developed fundamentally as a disorder originating in
childhood and adolescence and is not diagnostically tied to
PTSD in any way. The need for DTD within formal diagnos-
tic systems, particularly the DSM, remains plausible.
Limitations of the Empirical DTD Literature
The support for DTD identified in this review is promising
but should nevertheless be considered in the context of a sev-
eral key limitations. With one exception (Kisiel et al., 2014),
samples were generally modest in size. Eleven of the 17 sam-
ples included fewer than 300 participants, limiting the com-
plexity of analytic approaches available in some cases (e.g.,
factor analysis). Studies consistently framed their findings
as “preliminary,” often highlighting the need for additional
research with larger samples to confirm and extend their
findings. Most employed simple analytic approaches (e.g.,
examining bivariate associations/overlap between DTD and
other psychiatric diagnoses or associations between trauma
type and DTD symptoms). These approaches are important
for establishing initial support for a new diagnostic con-
struct, but lack the sophistication to draw more nuanced
conclusions. The preliminary nature of many studies may
be in part due to funding issues. Although funding agencies
have increasingly supported work that does not rely on disor-
der-based categories (e.g., NIH’s Research Domain Criteria
initiative; Insel et al., 2010), in past years it may have been
challenging to conduct rigorous diagnostic research without
13
390
DSM or ICD recognition. This problem was exemplified
when a field trial lost funding after it became clear that DTD
would not be included in the DSM-5 (Renz, 2012). In spite
of these challenges, a few of the included studies demon-
strated notable rigor. One example was a measure develop-
ment study by Ford et al. (2018). One of only two studies to
employ factor analysis, this article examined DTD’s factor
structure, item characteristics (using item response theory),
interrater reliability, convergent, and discriminant validity,
and evaluated alternative algorithms for classifying DTD
cases.
Also important for contextualizing findings was the inclu-
sion of several unpublished studies that were not subject
to peer-review outside of a dissertation committee. Many
of these studies’ methodological and analytic approaches
lacked sophistication, often correlating or comparing many
variables without correcting for multiple tests or adequately
controlling for sociodemographic variables. Two of the four
dissertations reported on samples of N = 53 or fewer (Foster,
2013; McDonald, 2015). McDonald (2015) reported that the
DTDQ showed promising psychometric properties, a con-
clusion that was reached primarily by interpreting statistical
significance in a sample of N = 36, making Type II errors
highly likely. No a priori cutoffs were stated for evaluating
the presence or lack of convergent and divergent validity.
Methodological limitations were not unique to the disser-
tations. Nineteen of the 21 included studies were cross-sec-
tional in nature. This proportion is surprising given DTD’s
strong developmental emphasis and underscores the need
for more longitudinal research to understand the course of
the disorder. Only Zhang et al. (2019) included a follow-
up component, which proved crucial for demonstrating
that parental absence was associated with worsening DTD
symptoms over time. Furthermore, all of the included stud-
ies used retrospective, single-informant reports of trauma.
This is problematic and limits the studies’ interpretability in
light of meta-analytic investigations confirming that retro-
spective reporting of trauma does not accurately capture the
experiences of children as measured in longitudinal studies
(Baldwin et al., 2019).
It is also worth noting that nearly half of the included
articles (k = 10), all of which were strongly supportive of
the DTD construct and clinical utility, were conducted by
co-authors of the original DTD symptom criteria proposal
(Van der Kolk et al., 2009). All of these investigators have
published previously about the advantages of DTD or similar
developmentally appropriate trauma diagnoses (e.g., Cook
et al., 2005; D'Andrea et al., 2012; Ford, 2017; Van der Kolk,
2017). The other 11 articles were written mostly by sepa-
rate research groups that were not involved in drafting DTD
symptom criteria. Ultimately, more research conducted by
additional independent groups will be necessary to confirm
the largely favorable DTD findings reported in this review.
13
Clinical Child and Family Psychology Review (2022) 25:376–394
All research is susceptible to the influence of authors’ prior
beliefs (Abou-Setta et al., 2019; Bastian, 2006), but research
that has direct implications for the formation of new diag-
nostic constructs may be particularly susceptible.
Assessment of DTD
Currently, no gold standard DTD assessment exists, and few
have been published or validated. As a result, the studies
included in this review varied widely in their assessment of
DTD, ranging from child- or caregiver-reported question-
naires, to structured interviews, to coded electronic health
records, to clinicians’ subjective ratings of DTD. The most
common method of DTD assessment involved retrospec-
tively fitting items from non-DTD measures onto DTD
symptom criteria. These “substitute” measures included
the Trauma Symptom Checklist for Children (Briere, 1996),
various versions of the Child and Adolescent Needs and
Strengths assessment, the Child Complex Trauma Symp-
tom Checklist (Ford et al., 2007), and the Child Behavior
Checklist (Achenbach & Rescorla, 2001). Although these
measures assess many of DTD’s core symptoms, their items
do not always map on precisely to DTD criteria, a limitation
noted by several of the included studies (e.g., Kisiel et al.,
2014; Stolbach et al., 2013; Zhang et al., 2019).
A handful of studies did employ assessments designed
specifically for DTD, including child- or caregiver-reported
questionnaires (McDonald, 2015; McDonald et al., 2014;
Zhang et al., 2019) and structured interviews (Ford et al.,
2018, 2021; Spinazzola et al., 2018, 2021; Van der Kolk
et al., 2019). The DTD-SI (Ford et al., 2018), a particularly
rigorous, clinician-administered, structured interview for
DTD, was administered in only two of the 17 independent
samples. Overall, substantial variability in the assessment of
DTD, as well as the use of “substitute” DTD assessments,
makes it difficult to compare individual studies and draw
broader conclusions. Measurement of the DTD construct
undoubtedly needs to be further refined and validated. DTD-
specific measures that have demonstrated strong preliminary
psychometric properties should continue to be evaluated in
other, larger samples.
Strengths of the Empirical DTD Literature
Despite the limitations noted above, a few key strengths of
the reviewed articles should be highlighted. First and fore-
most was the racial/ethnic and socioeconomic diversity of
participants. Complex trauma disproportionately impacts
youth of color and youth from families of lower socioeco-
nomic status (SES) (Andrews et al., 2015; Hatch & Dohren-
wend, 2007), populations that are also typically underrep-
resented in diagnostic development research (Liang et al.,
2016). Poverty, a significant stressor on its own, represents
Clinical Child and Family Psychology Review (2022) 25:376–394
a particularly perilous context that increases risk for poten-
tially traumatic experiences (McLaughlin et al., 2019). Of
the 10 independent youth samples recruited within the U.S.
for which racial/ethnic information was available, seven
were comprised of majority non-White youth. Black youth
were particularly well represented. Hispanic youth consti-
tuted over 10% of the sample in seven of the 21 articles
(three unique samples; Ford et al., 2018; Foster, 2013; Foster
et al., 2019; Spinazzola et al., 2018; Van der Kolk et al.,
2019). Native American youth, despite their disproportion-
ate risk of childhood victimization (U.S. Department of Jus-
tice, 2004), were not well represented.
Studies also demonstrated an impressive range of recruit-
ment sources. Participants were recruited from local mental
health clinics, communities, public schools, the child wel-
fare system, and a juvenile justice center. These contexts
are likely to reflect the sociodemographic characteristics
of populations for whom complex trauma is most relevant.
Only one study reported on a majority White undergradu-
ate university sample (McDonald et al., 2014). Finally, it is
worth acknowledging that six of the 17 independent samples
consisted of participants outside of the U.S. (e.g., Germany,
China, Uganda, Australia), providing preliminary support
for the DTD construct on an international level. In sum, it
appears that most studies made efforts in their sampling
strategies to maximize sample inclusivity, increasing confi-
dence in the external validity of these findings.
Future Directions
Findings from this review support DTD as a promising
diagnostic construct, one that may ultimately be useful for
improving the assessment and treatment of youth exposed
to complex trauma. However, due to the preliminary nature
of many of the included studies, we strongly recommend
further investigation to confirm and extend these findings
before any definitive conclusions are made. First, additional
studies from independent research groups (i.e., those not
involved with the formation of DTD symptom criteria)
would be helpful for increasing confidence that the prelimi-
nary support for DTD found here was not driven by author
bias. Second, standardized assessment of DTD should be
further tested and refined. Third, more rigorous examination
of convergent, divergent, and criterion validity using a vari-
ety of comparison measures, larger samples, and strict a pri-
ori cutoff decisions will be crucial for confirming the current
findings. Fourth, while several studies showed that DTD was
related to previous complex trauma exposure, only a hand-
ful of studies controlled for the effects of similar trauma-
and stressor-related disorders (e.g., PTSD). Evidence that
complex trauma is uniquely associated with DTD symptom
criteria is essential for demonstrating the incremental clini-
cal utility of DTD over and above PTSD and other existing
391
diagnostic constructs (Regier et al., 2009). Fifth, given
evidence that retrospective reporting of childhood trauma
captures different experiences than prospective reporting
(Baldwin et al., 2019), it is crucial that findings from this
review are replicated with larger samples and in longitudinal
studies. Longitudinal work would be helpful for estimating
the proportion of complex trauma survivors that go on to
develop DTD – a question that was unaddressed by studies in
this review. Longitudinal research will also be necessary to
explore how children’s manifestation of DTD symptoms may
change across different developmental periods, an issue that
has been raised for posttraumatic stress symptoms in child-
hood (Weems et al., 2021). Sixth, research exploring neural
correlates and other biomarkers of DTD – perhaps inde-
pendent of PTSD – would strengthen the case for DTD as a
unique diagnostic construct. Seventh, more work is needed
to confirm the three-factor structure of DTD symptom cri-
teria B, C, and D, which was examined by only two studies.
Eighth, and finally, it remains entirely unknown whether the
availability of a DTD diagnosis would lead to better treat-
ment outcomes for complex-trauma-exposed youth. This is
a key component of clinical utility and represents one of the
core criteria for the addition of a new diagnosis in the DSM
(Regier et al., 2009).
Limitations of the Present Review
This review is not without limitations. The process of search-
ing for, narrowing down, and coding articles was completed
solely by the first author; the second author reviewed and
confirmed the final 21 articles included in the review. As
such, interrater reliability (i.e., kappa) is not available for the
coding of articles. Additionally, though it was considered,
the decision was made not to include a standardized assess-
ment of bias or quality. The articles included in this review
varied substantially in their methodologies, scope of objec-
tives, analytic approaches, and assessment methods. Articles
often examined narrow aspects of the DTD construct which
did not overlap with other articles, making direct compari-
sons difficult. For this reason, the authors felt that a narrative
summary of the limitations of the DTD literature, rather than
a standardized bias or quality assessment, would allow for
an appropriately nuanced discussion of each article’s limita-
tions, within the context of inter-article variability.
Conclusion
At present, the extant empirical literature suggests that DTD
may be (1) valid and reliable, (2) sufficiently distinct from
existing diagnostic constructs, and (3) has clinical utility.
Articles included in this review were largely supportive of
the DTD construct and its inclusion in future editions of the
13
392
DSM. Ultimately, we consider these findings preliminary. It
will be important for this work to be replicated in larger sam-
ples, by independent research groups and with more rigorous
methodological and analytic approaches. That being said,
these findings provide a promising empirical foundation for
the DTD construct and bring the field closer to improving
diagnostic parsimony for children and adolescents affected
by complex trauma.
Declarations
Conflict of interest The authors declare that they have no confict of
interest.
Ethical Approval This article does not contain any studies with human
participants or animals performed by any of the authors.
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