Received: 5 November 2021

| Accepted: 3 March 2022

DOI: 10.1111/acps.13424

ORIGINAL ARTICLE

Toward an empirically based Developmental Trauma

Disorder diagnosis and semi-­structured interview for
children: The DTD field trial replication

Julian D. Ford1 | Joseph Spinazzola2 | Bessel van der Kolk3 | Grace Chan1

1
University of Connecticut Medical
School Psychiatry Department, Abstract
Farmington, Connecticut, USA Objective: Developmental trauma disorder (DTD) is a childhood psychiatric
2
Foundation Trust, Melrose, syndrome designed to include sequelae of trauma exposure not fully captured by
Massachusetts, USA
3
PTSD. This study aimed to determine whether the assessment of DTD with an
the Trauma Research Foundation,
Boston, Massachusetts, USA independent sample of children in mental health treatment will replicate results
from an initial validation study.
Correspondence
Methods: The DTD semi-­structured interview (DTD-­SI) was administered to a
Julian D. Ford, UCHC Department of
Psychiatry MC1410, 263 Farmington convenience sample in six sites in the United States (N = 271 children in mental
Ave., Farmington, CT 06030, USA. health care, 8–­18 years old, 47% female, 41% Black or Latinx) with measures of
E-­mail: [email protected]
trauma history, DSM-­IV PTSD, probable DSM-­IV psychiatric diagnoses, emotion
Funding information regulation/dysregulation, internalizing/externalizing problems, and quality of
Lookout Foundation life. Confirmatory factor (CFA) and item response theory (IRT) analyses tested
DTD’s structure and DTD-­SI’s information value. Bivariate and multivariate
analyses tested DTD’s criterion and convergent validity.
Results: A three-­factor solution (i.e., emotion/somatic, attentional/behavio-
ral, and self/relational dysregulation) best fit the data (CFI = 0.91; TLI = 0.89;
BIC = 357.17; RMSEA = 0.06; SRMR = 0.05). DTD-­SI items were informative
across race/ethnicity, gender, and age with three exceptions. Emotion dysregula-
tion was the most informative item at low levels of DTD severity. Non-­suicidal
self-­injury was rare but discriminative in identifying children with high levels of
DTD severity. Results supported the criterion and convergent validity of the DTD
construct.
Conclusion: This replication provides empirical support for DTD as a construct
and potential psychiatric syndrome, and the DTD-­SI’s validity as a clinical re-
search tool.

KEYWORDS
traumatic stress, children, assessment, diagnosis, psychometrics

© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

628 | wileyonlinelibrary.com/journal/acps
 Acta Psychiatr Scand. 2022;145:628–639.
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FORD et al.    | 629

1 | I N T RO DU CT ION
Significant Outcomes
Children who experience severe threat and deprivation
• Developmental trauma disorder’s validity and
are at risk for internalizing (e.g., anxiety and depression),
potential utility as a unifying diagnosis for trau-
externalizing (e.g., aggression and delinquency), somatic
matized children distinct from PTSD was sup-
(e.g., unexplained pain and illness), neurodevelopmen-
ported in this replication study.
tal (e.g., attentional and learning), and dyscontrol (e.g.,
• The structured interview for developmental
mania and psychosis) disorders as well as post-­traumatic
trauma disorder was shown to provide a psy-
stress disorder (PTSD).1,2 Existing categorical psychiatric
chometrically robust assessment for psychiatric
diagnoses offer only partial accounts of complex posttrau-
research and clinical practice.
matic sequelae in children and adolescents.3,4 To address
• Emotion dysregulation was the most informa-
this dilemma, developmental trauma disorder (DTD) was
tive structured interview item at low levels of
developed, to “see anew something that has been there be-
DTD severity. Non-­suicidal self-­injury was rare
fore them all along”5 (p. 295).
but strongly discriminative in identifying chil-
DTD was formulated to assess trauma-­related symp-
dren with high levels of DTD severity.
toms traditionally are assigned to psychiatric diagnoses
other than PTSD. Both ICD-­11 CPTSD (by adding symp-
Significant Limitations
toms in the three Disturbances of Self Organization [DSO]
domains) and DSM-­5 PTSD increased the heterogeneity • Study participants were a convenience sample
of PTSD diagnosis from prior versions (e.g., DSM-­IV), and of children in mental health treatment.
DTD represents a logical extension consistent with research • Participants were solely from the United States,
showing that post-­traumatic sequelae include symptoms although from several regions and both rural
that span several transdiagnostic spectra.1,6,7 DTD involves and urban communities with diverse ethnocul-
a complex combination of both symptoms (e.g., alexithy- tural backgrounds.
mia, somatization, reactive aggression, and self-­harm) and • Validation data were obtained only from a sub-
traits (e.g., intolerance of negative affect; preoccupation set of participants.
with or avoidance of threat; deficit-­based self-­perception;
callousness or empathic over-­involvement), consistent
with transdiagnostic psychopathology models.8 Although
conceptualized as a categorical psychiatric syndrome, In the relational dysregulation domain, both DSM-­5
DTD adopts a hybrid approach aligned with a transdiag- PTSD and ICD-­11 CPTSD assess only detachment and
nostic framework. Based on evidence that trauma-­related withdrawal. DTD incorporates a broader range of rela-
symptoms span the fear, thought disorder, and internaliz- tional problems consistent with transdiagnostic formu-
ing/distress transdiagnostic spectra,6 DTD’s three dysreg- lations8: separation anxiety (i.e., attachment insecurity/
ulation domains include symptoms from each of those disorganization13—­DTD symptom D2) and intimacy
spectra. Additionally, DTD includes externalizing (antago- avoidance (i.e., expectancy of betrayal14—­DTD symp-
nistic, disinhibited) spectra symptoms related to childhood tom D3). In the behavioral dysregulation domain, re-
victimization,1 which PTSD omits.6 active aggression (symptom D4)15 and maladaptive
DTD extends current PTSD conceptualizations by in- self-­soothing (symptom C3) and self-­injury (symptom
cluding symptoms that are not assessed in DSM-­5 PTSD C4)16 are included in DTD (unlike ICD-­11 CPTSD)
(i.e., somatic dysregulation and impaired self-­protection) based on an association with childhood victimiza-
or ICD-­11 CPTSD (i.e., betrayal schemas, self-­soothing, tion9 and because they represent antagonistic and dis-
impaired empathy, and alexithymia). Emotion dysregula- inhibited externalizing problems, respectively, in the
tion is integral to DTD because it is a core sequelae child- transdiagnostic HiTOP (the Hierarchical Taxonomy of
hood exposure to threat and deprivation1,9 and a central Psychopathology) paradigm that has been proposed as
feature in transdiagnostic networks of psychopathology.10 a dimensional alternative to categorical conceptualiza-
Emotion dysregulation is not explicitly included in DSM-­5 tions of psychopathology.8 In the attentional domain,
PTSD, but is prominent in ICD-­11 CPTSD. DTD includes DTD extends the DSM-­5 and ICD-­11 PTSD constructs
somatic forms of emotion dysregulation that are ab- of hypervigilance by explicitly assessing inattention to
sent from CPTSD owing to their network centrality with danger as well as preoccupation with threat (DTD symp-
traumatized children.11 Also, DSM-­5 PTSD and ICD-­11 tom C1), based on transdiagnostic research demonstrat-
CPTSD omit an important form of emotion dysregulation, ing that anxious children exhibit attention bias away
alexithymia.12 from as well as toward threat.17
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
630 |    FORD et al.

TABLE 1 Developmental trauma disorder (DTD) symptom

A final consideration in defining DTD was the role
criteria.
of dissociation, which is an optional sub-­type (but not
a core symptom) in DSM-­5 PTSD18 and is excluded Criterion B (current emotion or somatic dysregulation, 4 items;
3 required for DTD)
from both ICD-­11 CPTSD19 and transdiagnostic formu-
lations (except somatoform conversion in ICD-­11).8 In B1: Emotion dysregulation
DTD, dissociation is an emotion dysregulation symptom B2: Somatic dysregulation
based on evidence that dissociation mediates relation- B3: Impaired access to emotion or somatic feelings
ships between cumulative trauma and internalizing and B4: Impaired verbal mediation of emotion or somatic feelings
externalizing disorders among sexually abused chil- Criterion C (current attentional or behavioral dysregulation, 5
dren20 and is a risk for suicide attempts in traumatized items; 2 required for DTD)
children.21 C1: Attention bias toward or away from threat
DTD symptoms were identified in an international C2: Impaired self-­protection
survey of clinicians22-­26 as relevant for children with
C3: Maladaptive self-­soothing
multiple psychiatric disorders27,28 in order to facilitate
C4: Non-­suicidal self-­injury
targeted trauma-­focused treatment. DTD was designed
C5: Impaired ability to initiate or sustain goal-­directed
to identify specific symptoms of trauma-­related dysreg-
behavior
ulation that otherwise would lead to psychiatric treat-
Criterion D (current relational-­ or self-­dysregulation, 6 items; 2
ments but, unless PTSD also was diagnosed, would not
required for DTD)
lead clinicians to provide trauma-­focused treatment.
D1: Self-­loathing or self-­viewed as irreparably damaged and
Based on a literature review7 and results of the survey
defective
study, a semi-­structured interview (DTD-­SI) was de-
D2: Attachment insecurity and disorganization
veloped to assess the three biopsychosocial domains of
dysregulation (i.e., affective/physiological [Criterion B], D3: Betrayal-­based relational schemas
cognitive/behavioral [Criterion C], and relational/self D4: Reactive verbal or physical aggression
[Criterion D]; see Table 1) that have been shown across D5: Impaired psychological boundaries
multiple research studies to be sequelae of childhood D6: Impaired interpersonal empathy
traumatization.7
An initial field trial study was conducted and provided
support for the DTD-­SI’s psychometric integrity29 and
DTD’s syndromal validity. Specifically, the initial field tri- hierarchical structure will be replicated, (2) DTD-­SI items
al's results confirmed the DTD-­SI’s item-­level temporal will be informative across race/ ethnicity, gender, and
and inter-­rater reliability, informativeness, and absence age, and (3) DTD criterion and convergent validity will be
(with one exception) of demographic bias, and (b) DTD supported.
construct factor structure, unidimensionality, and con-
vergent and discriminant validity. The hypothesized three
domains of dysregulation (affective/physiological, cog- 2 | MATERIALS AND METHO D S
nitive/behavioral, and relational/self) provided the best
fitted structural model in a confirmatory factor analysis. The authors assert that all procedures contributing to
Additionally, as hypothesized, independent of the effects of this work comply with the ethical standards of the rel-
PTSD, DTD was shown to be associated with past victim- evant national and institutional committees on human
ization (i.e., community or family violence) and attach- experimentation and with the Helsinki Declaration of
ment disruption (i.e., impaired caregivers),30 as well as 1975, as revised in 2008. All procedures involving human
with probable diagnoses of internalizing (i.e., separation subjects/patients were approved by the University of
anxiety and panic) and externalizing (i.e., oppositional de- Connecticut Health Center Institutional Review Board.
fiant and conduct) disorders.31 Written consent was obtained by a parent or guardian
for each child, and assent was obtained from all child
participants.
1.1 | Aims of the current study

Given the importance of replication in science and psy- 2.1 | Sample and procedure
chiatric research, the current study was designed as an
independent replication of the initial DTD field trial re- A convenience sample of 271 children in mental health
sults. It was hypothesized that (1) the three-­factor DTD treatment (ages 8–­18 years old, M = 12.1, SD = 2.9; 47%
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
FORD et al.    | 631

female; 53% White non-­Hispanic, 31% Black or biracial, 2.2.2 | Traumatic experiences
10% Latinx; 6% Asian American or other) was recruited screening instrument
between October 2014 and November 2016 in six U.S.
urban, suburban, and rural communities. Parent/guard- This semi-­structured interview assesses lifetime his-
ian consent and child assent were obtained following an tory of eight types of non-­interpersonal trauma and 13
Institutional Review Board-­approved protocol. Interviews types of traumatic interpersonal victimization (Table 2).
were conducted with 152 parent–­child dyads, 113 parents Traumatic experiences screening instrument (TESI) items
alone, and alone with six adolescents. One-­third lived have demonstrated retest reliability (Kappa [K] = 0.50–­
with both birth parents, one-­third in step/foster/adop- 0.70) and criterion and predictive validity.32 Inter-­rater
tive families, and one-­third in out-­of-­home placements. agreement for trauma types was M = 97.7% for child and
Foster/adoptive parents were required to be knowledge- 97.4% for parent/guardian-­only interviews.
able of their child's full life history and to be the primary
caregiver for a continuous period of sufficient length to
complete all measures. 2.2.3 | Kiddie schedule for affective
All children met criteria for at least one probable disorders and schizophrenia, present/
psychiatric diagnosis other than PTSD (Median = 4), lifetime version
including major depression (N = 168; 62%); generalized
anxiety disorder (N = 157; 58%); ADHD (N = 144; 53%); This interview assesses DSM-­IV child psychiatric dis-
oppositional defiant disorder, ODD (N = 135; 50%); sepa- orders with child and parent versions.33 The full PTSD
ration anxiety disorder (N = 121; 45%); conduct disorder module was used. Other disorders (Table 2) were identi-
(N = 65; 24%); phobia (N = 64; 24%); bipolar disorder fied as probable using KSADS screening questions. Inter-­
(N = 41; 15%); obsessive compulsive disorder (N = 27; rater agreement for KSADS PTSD items was M = 85.7%
10%), psychotic disorder (N = 26; 10%), and eating disor- for child interviews and 89.4% for parent/guardian-­only
der (N = 15; 6%). interviews. Inter-­rater agreement for probable KSADS di-
Interviewers (N = 25) were trained with simulated agnoses was M = 88.8% with children, and 89.6% with par-
expert interviews. Interviewers independently rated vid- ents. An internally consistent (α = 0.79) impairment index
eotaped interviews until achieving >80% agreement with was calculated based on family, school, and peer function-
expert ratings, and conducted and rated role-­play inter- ing: 95% (N = 258) of participants were impaired in 1+
views until achieving >90% agreement with experts’ re- domain; 84% (N = 228) were impaired in all domains.
views. Interviewers’ first two study interview tapes were
reviewed by an expert with >90% agreement required
for calibration. A randomly selected set of 31 interviews 2.2.4 | Parent ratings
with a parent/guardian only and 15 with a child was inde-
pendently rated for reliability. The Child Behavior Checklist (CBCL) dysregulation
score was calculated as a sum of the anxiety/depression,
attention problems, and aggression CBCL sub-­scale T-­
2.2 | Measures scores.34 Parents also rated their child's emotion-­related
capacities: (1) awareness/expression on the 14-­item re-
2.2.1 | Developmental Trauma Disorder liable (α = 0.94) and validated Children's Alexithymia
Semi-­Structured Interview Measure (CAM)35; and (2) dysregulation (10 items,
α = .82) and (3) adaptive regulation (14 items, α = .91) on
The DTD-­SI assesses 15 items in 30–­45 minutes (13). the reliable and validated Children's Emotion Regulation
In the current sample, inter-­rater agreement of DTD-­SI Checklist (ERC).36 Parent ratings were obtained for
items was M = 93.0% for child interviews and 93.5% for N = 81–­89 cases.
parent interviews (Table 1). DTD cases (N = 74, 27%)
were identified with the algorithm validated in the
first DTD field trial29: criterion B (≥3 of 4 symptoms); 2.2.5 | Child self-­report measures
criteria C and D (≥2 of 5 or 6 symptoms, respectively).
Alternative algorithms were tested with more conserva- Children completed a 5-­item version of the reli-
tive (≥3 symptoms) C or D criteria (i.e., DTD332 or able (α = .73) and cross-­culturally validated Emotion
DTD323), or a more liberal B criterion and conservative Regulation Questionnaire.37 Children also rated the reli-
C and D criteria (i.e., DTD233). able (α = 0.85) and validated 15-­item Pediatric Quality
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
632 |    FORD et al.

TABLE 2 Descriptive statistics.

(N = 68–­70). However, these children did not differ demo-
Child and Parent Report graphically or diagnostically from the remaining sample.
Measures N Range M[SD]
Child Emotion Regulation 70 6–­26 12.76[4.42]
Questionnaire 2.3 | Statistical analyses
Pediatric Quality of Life 68 42–­70 58.12[7.44]
Questionnaire SAS 9.4 was used for all analyses in this project/study.
Child Alexithymia Measure 89 0–­42 12.49[9.61] There were no missing data on any study measure com-
Emotion Regulation Checklist 93 14–­42 24.31[8.01] pleted by participants. Confirmatory factor analysis was
Negative Scale conducted (N = 271) with estimations using the CALIS
Emotion Regulation Checklist 93 16–­40 28.63[5.86] procedure to test the hypothesized 3-­factor DTD symp-
Adaptive Scale tom structure (affect dysregulation: DTD-­SI B1-­B4; at-
Child Behavior Checklist 82 33–­81 56.89 [12.78] tention/behavioral dysregulation: DTD-­SI C1-­C5; self/
Internalizing T-­score relational dysregulation: DTD-­SI D1-­6) versus a 1-­factor
Child Behavior Checklist 82 33–­82 54.48 [12.99] solution or a 4-­factor hybrid solution modeled on the
Externalizing T-­score ICD-­11 Complex PTSD diagnosis.19 The hybrid model
Child Behavior Checklist 82 50–­84 58.79 [9.15] was designed to be the closest approximation to the
Dysregulation T-­score CPTSD domains that was possible using the 15 DTD
DSM-­IV Probable N % symptoms. The hybrid factors were formed by grouping
Psychiatric Diagnoses DTD symptoms consistent with the DSO domains of af-
Posttraumatic Stress Disorder 107 39.5 fect dysregulation (B1-­B4 and C3-­C4), impaired relation-
Depression 168 62 ships (D2-­D6), and altered self-­perceptions (C2, D2), and
a fourth factor composed of DTD symptoms that are not
Bipolar Disorder 41 15
similar to DSO symptoms but are similar to the ITQ’s
Psychotic Disorder 26 9.5
PTSD avoidance and hypervigilance symptoms (C5 and
Panic Disorder 28 10
C1, respectively). A 10-­point lower BIC between non-­
Separation Anxiety Disorder 121 44.5 nested models identified the statistically superior model
Phobia 64 23.5 with 150:1 odds.39
Obsessive Compulsive 27 10 Item response theory (IRT) analyses40 considered
Disorder two models: a 2-­parameter logistic model and an uncon-
Attention Deficit Disorder 144 53 strained single-­slope Rasch model.41 Differential item
Oppositional defiant disorder 136 50 functioning (DIF) was assessed for age, race, and gender
Conduct disorder 65 24 using Lord's chi-­squared test.42 IRT model fitting was car-
Eating Disorder 15 5.5
ried out with the ltm package and DIF model fitting was
done with the difR package43 in the statistical software R.
Trauma History N %
Criterion validity was tested with (1) t-­tests comparing
Non-­Interpersonal Trauma 153 56.5
DTD cases versus non-­cases on number of types of trau-
Traumatic Loss 171 63 matic events and victimization traumas specifically; (2)
Traumatic Separation from 109 40 linear regressions predicting impairment and psychiatric
Caregiver morbidity with the validated algorithm for DTD versus
Traumatic Caregiver 154 57 three alternative algorithms, controlling for PTSD diag-
Impairment nosis, KSADS diagnosis count, poly-­victimization, and
Traumatic Neglect 39 14.5 demographics. Convergent validity was tested with analy-
Traumatic Emotional Abuse 53 19.5 ses of variance comparing DTD sub-­groups on parent and
Interpersonal Violence 132 48.5 child self-­report measures.
Family Violence 88 32.5
Community Violence 49 18
Sexual Trauma 56 20.5
3 | RESULTS

Descriptive statistics are summarized in Table 2. Most

of Life Enjoyment and Satisfaction Questionnaire (PQ-­ (N = 259; 95.5%) participants endorsed at least one past
LES-­Q38). Owing to logistical limitations, child self-­ traumatic event (median = 4 trauma types [M(SD) = 4.79
ratings were obtained only from a subset of participants (2.26)]. One in six (17%, N = 47) met criteria for
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
FORD et al.    | 633

poly-­victimization (i.e., ≥5 of 8 types of interpersonal for 47% of boys versus 33% of girls, p < 0.05), and age
trauma). One in four (N = 74, 27%) met DTD symptom (with two exceptions, impaired boundaries [D5] was
criteria, and 39% (N = 107) met criteria for PTSD. One in endorsed by 48% of children versus 32% of teenagers,
five children met criteria for PTSD but not DTD (N = 57, and impaired empathy [D6] was endorsed by 41% of
21%), one in 11 for DTD but not PTSD (N = 24, 9%), and teenagers versus 22% of children, p < 0.01). Item char-
18% met criteria for both PTSD and DTD (N = 50). acteristic curves (ICC) and item information curves
A three-­factor solution best fit the CFA, with the high- (IIC) (Figure 1) indicated that DTD-­SI items discrim-
est CFI and TLI and lowest BIC and X2, and RMSEA and inate individual differences at all DTD severity levels.
SRMR at or below optimal levels (Table 3). Item loadings Item B1 (emotion dysregulation) was most informative
supported the proposed DTD structure. Each DTD crite- and most discriminating at low levels of DTD sever-
rion was internally consistent when scored as a count of ity (i.e., maximal IIC height at 0.5 standard deviations
items endorsed (criterion B α = 0.70, criterion C α = 0.60, below average DTD severity). Item C4 (self-­harm) was
criterion D α = 0.73). Inter-­item correlations of crite- least informative but was informative at high levels of
rion scores were significant (criterion B: r = 0.29–­0.46, DTD severity (i.e., maximal IIC height at two standard
p < 0.0001; criterion C: r = 0.20–­0.33, p < 0.001; crite- deviations above average severity). Items C2 (impaired
rion D: r = 0.27–­0.41, p < 0.0001), except for non-­suicidal self-­protection), C3 (maladaptive self-­soothing), D4
self-­injury (C4) with attention dysregulation (C1) and im- (reactive aggression), and D6 (impaired empathy) also
paired self-­protection (C2) (r = 0.09, 0.12, p > 0.05). were most informative at moderately high levels of DTD
IRT item information function (IIF) confirmed: (1) severity (i.e., maximal height at one to 1.5 standard de-
the unidimensionality of the DTD construct with mod- viations above average).
ified parallel analysis44 and scree plot analysis (Figure Compared with children not meeting criteria for DTD,
S1), (2) that DTD-­SI items were informative (maximum children classified as DTD cases experienced more types of
peak information >20% of that of the maximally infor- traumatic events (M[SD] = 7.3[3.2] vs. M[SD] = 5.1[3.4],
mative item, except C4 = 19%), and (3) that items were respectively, t[269] = 4.981, p < .001) and interpersonal
unbiased in relation to race/ethnicity, to gender (with victimization (M[SD] = 3.4[2.5] vs. M[SD = 2.0[2.1], re-
one exception, B2 somatic dysregulation was endorsed spectively, t[269] = 4.694, p < .001). The validated DTD

TABLE 3 Confirmatory factor analyses (CFA) of DTD-­Structured Interview symptom items.

X2 CFI TLI BIC RMSEA [95% CI] SRMR

1-­Factor 198.81 0.88 0.87 366.87 0.07 [0.05–­0.08] 0.06
3-­Factor 172.30 0.91 0.89 357.17 0.06 [0.05–­0.07] 0.05
Hybrid 179.56 0.90 0.87 381.23 0.06 [0.05–­0.07] 0.05

Item N/% Factor 1 Factor 2 Factor 3

B1 (Emotion Dysregulation) 181 (67%) 0.71
B2 (Somatic Dysregulation) 109 (40%) 0.65
B3 (Psychoform/Somatoform Dissociation) 68 (25%) 0.47
B4 (Alexithymia/Somatization) 105 (39%) 0.59
C1 (Attention/Cognitive Dysregulation) 156 (58%) 0.53
C2 (Impaired Self-­Protection) 67 (25%) 0.56
C3 (Maladaptive Self-­Soothing) 70 (26%) 0.46
C4 (Non-­Suicidal Self Injury) 35 (13%) 0.31
C5 (Impaired Goal-­Directed Behavior) 137 (51%) 0.50
D1 (Self/Identity Fundamentally Damaged) 98 (36%) 0.53
D2 (Attachment Disorganization) 110 (41%) 0.48
D3 (Betrayal Relational Schemas) 94 (35%) 0.59
D4 (Reactive Aggression) 80 (30%) 0.67
D5 (Impaired Psychosocial Boundaries) 110 (41%) 0.52
D6 (Impaired Empathy) 83 (31%) 0.55
Abbreviations: BIC, Bayesian information criterion; CFI, comparative fit index; CI, confidence interval; DTD, developmental trauma disorder; RMSEA, root
mean square error of approximation; SRMR, standardized RMR; TLI, Tucker–­Lewis index.
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
634 |    FORD et al.

F I G U R E 1 Item characteristic curves (ICC) (upper panels) and item information curves (IIC) (lower panels) for symptoms of
developmental trauma disorder (DTD): ICC: acriterion B symptoms—­left-­hand panel; bcriterion C symptoms—­middle panel; ccriterion D
symptoms—­right-­hand panel. IIC: dcriterion B symptoms—­left-­hand panel; ecriterion C symptoms—­middle panel; fcriterion D symptoms—­
right-­hand panel. Location parameters from the 2-­PL IRM are shown in the ICC as the point at which the curve crosses 0.5, representing the
location where individuals have a 0.5 probability of responding “Yes.” The slope and breadth of the ICC curve for each item represents the
rate at which the probability of “Yes” on that item changes with increasing severity of DTD.

algorithm predicted impairment after controlling for de- heterogeneous and generally informative symptoms pre-
mographics and other algorithms (Table 4). dictive of impairment and distinct from PTSD. DTD-­SI
Children classified as DTD also had worse parent-­rated items were informative across race/ethnicity, age, and
emotion and behavior dysregulation and alexithymia, gender with few exceptions. Interestingly, boys more
lower adaptive regulation, and twice as many probable often experienced somatic dysregulation than girls,
psychiatric disorder diagnoses as children who met only which is the opposite of prior findings45 but is consistent
criterion A or who met no DTD criteria (Table 4). Parent-­ with evidence that severely traumatized boys experience
rated internalizing and externalizing problems and child-­ alexithymia46 and may indirectly express distress via
rated emotion dysregulation were worse for the DTD somatic dysregulation.47 Regarding age invariance, im-
group than the non-­DTD group, although children who paired boundaries were more common among children
met only DTD criterion A did not differ from the DTD or than teens, perhaps because of traumatized children's
non-­DTD groups (Table 5). One finding contrary to study tendency to become enmeshed or conflictual relation-
hypotheses was that there was no difference by DTD sta- ships.48 Adolescents were more likely than younger chil-
tus in children's self-­reported quality of life (Table 4). dren to have impaired empathy, consistent with evidence
that teens with psychiatric problems often have empathy
deficits.49,50 Thus, while DTD symptoms are applicable
4 | DI S C USSION for both boys and girls and from early middle childhood
through adolescence, there are expectable gender and
Study findings replicate results from the prior DTD age differences that should be taken into account when
field trial29: DTD is a hierarchical clinical construct using DTD as a framework for mental health assessment
with three dimensional domains of dysregulation and and treatment planning.
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
FORD et al.    | 635

TABLE 4 Stepwise multiple-­predictor linear regression with the KSADS 3-­item impairment index.

Independent
Step variables Beta SE B t p
1 Age 0.081 0.027 0.184 3.020 0.003
Gender 0.227 0.153 0.091 1.487 0.138
Race/Ethnicity 0.031 0.158 0.012 0.196 0.845
2
Adjusted R = 0.03, F Change = 3.95 p = 0.009
2 Age 0.072 0.025 0.184 3.020 0.003
Gender 0.239 0.142 0.095 1.689 0.092
Race/Ethnicity 0.035 0.147 0.013 0.237 0.813
DTD233 0.572 0.284 0.183 2.017 0.045
DTD323 0.273 0.250 0.091 1.093 0.276
DTD332 0.507 0.317 0.156 1.603 0.110
Adjusted R2 = 0.175, F Change = 40.38 p = 0.000
3 Age 0.063 0.024 0.143 2.584 0.010
Gender 0.280 0.138 0.112 2.024 0.044
Race/Ethnicity 0.038 0.144 0.015 0.266 0.790
DTD233 0.410 0.280 0.131 1.467 0.144
DTD323 0.309 0.287 0.103 1.076 0.283
DTD332 0.332 0.312 0.099 1.032 0.303
Validated DTD 0.934 0.243 0.183 2.017 0.000
Adjusted R2 = 0.215, F Change = 14.73 p = 0.000
Statistically significant (p < 0.05) associations shown in bold font.
Abbreviations: DTD, developmental trauma disorder = three B, two C and two D symptoms; DTD3-­2–­3, three B, two C, and three D symptoms; DTD3-­3–­2 =
three B, three C, and two D symptoms; DTD2-­3–­3, two B, three C, and three D symptoms.

Differences in the degree to which the DTD-­SI items represent attempts to cope with traumatic past (or cur-
are informative at different levels of symptomatic sever- rent) circumstances and developing trauma-­focused ap-
ity also should be considered in clinical and research proaches to treatment that address traumatic stress
applications of DTD. Only one DTD symptom was reactions and behavior problems.51
highly informative for children with low overall lev- Study findings also demonstrate that, although DTD
els of DTD symptoms, but that symptom—­B1, emotion and PTSD often co-­occur, there appears to be a substan-
dysregulation—­was the most informative overall com- tial sub-­group of children in mental health treatment who
pared with all of the other DTD symptoms. Emotion have only one of the two syndromes. Specifically, almost
dysregulation thus may represent a core foundational one in three children in the study sample met criteria only
symptom of DTD, but it is not likely to be sufficient alone for DTD (9%) or for PTSD (21%). As a result, one in eleven
to identify children with DTD because it often occurs in children in this sample of mental health treatment recipi-
the absence of other DTD symptoms. Other symptoms ents, who represented more than one-­third of the children
that are less informative overall but especially informa- who met criteria for DTD, did not qualify for a diagnosis
tive at high levels of total DTD symptomatology—­notably of PTSD and therefore would not be considered in need
self-­harm and maladaptive self-­soothing—­are import- of, or eligible for, trauma-­focused treatment in many
ant to consider in assessment and as targets for safety as healthcare settings and systems. Thus, in the absence of
well as therapeutic intervention with highly traumatized a diagnosis for DTD, one in eleven children in mental
children. Further, symptoms that typically lead to the di- health treatment who have clinically significant trauma-­
agnosis of disruptive behavior disorders and identifying related impairment may be deprived of the opportunity
youths as at risk for delinquency (i.e., reactive aggression to receive potentially essential trauma-­focused treatment.
and impaired empathy) were highly informative overall Including DTD as a diagnostic option also might actually
and especially at relatively high levels of overall DTD reduce the burden of providing intensive services for all
symptomatology. That finding highlights the importance trauma-­affected children, because the more than one in
of identifying youths whose externalizing symptoms five children who met criteria for PTSD but not for DTD
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
636 |    FORD et al.

TABLE 5 Convergent validity analyses.

N Mean SD SE 95% CI F p
a
Parent Rated Child No DTD 50 22.5800 7.54332 1.06679 20.4362–­24.7238
Dysregulation Criterion A a
24 22.9583 6.18890 1.26330 20.3450–­25.5717
b
DTD 15 31.6667 8.45718 2.18363 26.9832–­36.3501
Total 89 24.2135 8.03044 .85123 22.5219–­25.9051 9.25 0.000
a
Parent Rated Child No DTD 48 30.0208 6.12803 .88450 28.2414–­31.8002
Adaptive Regulation Criterion Ab 24 28.9167 4.86261 .99258 26.8634–­30.9700
b
DTD 14 24.3571 4.21731 1.12712 21.9221–­26.7921
Total 86 28.7907 5.82917 .62858 27.5409–­30.0405 5.69 0.005
Child Self Report Emotion No DTDa 36 8.0833 2.96045 .49341 7.0817–­9.0850
Dysregulation Criterion A 17 10.0588 3.89664 .94507 8.0554–­12.0623
DTDb 17 11.5294 5.11270 1.24001 8.9007–­14.1581
Total 70 9.4000 4.01952 .48042 8.4416–­10.3584 5.08 0.009
a
Parent Rated Child No DTD 47 11.0213 9.53139 1.39030 8.2228–­13.8198
Alexithymia Criterion Aa 20 10.0000 8.62676 1.92900 5.9626–­14.0374
b
DTD 14 18.6429 10.1875 2.72273 12.7608–­24.5250
Total 81 12.0864 9.80076 1.08897 9.9193–­14.2535 4.17 0.019
Child Self Report Pediatric No DTD 33 63.2424 7.34860 1.27923 60.6367–­65.8481
Quality of Life Criterion A 15 62.9333 7.17602 1.85284 58.9594–­66.9073
DTD 16 61.0000 7.89937 1.97484 56.7907–­65.2093
Total 64 62.6094 7.39072 .92384 60.7632–­64.4555 0.51 0.605
a
N Psychiatric Diagnoses No DTD 122 2.8115 2.32248 .21027 2.3952–­3.2278
(except PTSD) Criterion Aa 85 3.2000 2.21359 .24010 2.7225–­3.6775
b
DTD 64 5.8906 1.94461 .24308 5.4049–­6.3764
Total 271 3.6605 2.52892 .15362 3.3581–­3.9630 43.65 0.000
CBCL No DTDa 44 53.4091 14.0307 2.11616 49.1414–­57.6767
Internalizing T Criterion A 23 56.6957 9.63627 2.00930 52.5285–­60.8627
DTDb 15 65.2000 9.12767 2.3.5675 60.1453–­70.2547
Total 82 56.4878 12.7483 1.41179 53.6788–­59.2968 5.26 0.007
a
CBCL No DTD 44 50.7273 13.3266 2.00906 46.6756–­54.7789
Externalizing T Criterion A 23 55.1304 10.5714 2.20429 50.5590–­59.7019
b
DTD 15 63.4000 11.1791 2.88642 57.2092–­69.5908
Total 82 54.2805 12.9884 1.43433 51.4266–­57.1343 6.07 0.004
a
CBCL No DTD 44 57.5909 9.19298 1.38589 54.7960–­60.3858
a
Dysregulation T Criterion A 23 56.6182 5.64029 1.17608 54.2421–­59.1202
DTDb 15 65.5333 10.7000 2.76271 59.6079–­71.4589
Total 82 58.7896 9.15190 1.01066 56.7777–­60.7995 5.64 0.005
a, b
Note: Superscripts ( ) denote groups with significantly different scores.
Abbreviations: CBCL, child behavior checklist; SD, standard deviation; SE, standard error; T, T-­score.

could be safely and ethically provided with relatively brief Study limitations include the convenience sample with
evidence-­based approaches to trauma-­focused therapy most data provided by parents. Foster/adoptive parents
based on the careful rule out of more complex DTD symp- also may not have known their child's trauma history as
toms and impairments. These potential implications of in- fully as biological parents, but all adult caregivers had
cluding DTD as a childhood psychiatric diagnosis warrant resided with the child for several months (and typically
both clinical research and testing in clinical practice and many years). Questionnaire data were obtained from a
health services research. sub-­sample, and convergent validity data may have been
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
FORD et al.    | 637

inflated when the same individual completed both the in- PEER REVIEW
terviews and questionnaires. Although the findings pro- The peer review history for this article is available at
vide an independent replication of the initial DTD field https://publo​ns.com/publo​n/10.1111/acps.13424.
trial's structure and item content, additional adaptation
and testing of the DTD-­SI items and structure is warranted DATA AVAILABILITY STATEMENT
because of the modest levels of internal consistency for The data that support the findings of this study are availa-
the DTD symptom criterion scores (especially for criterion ble from the corresponding author, [author initials], upon
C, i.e., alpha = .60) and the finding that several items had reasonable request.
factor loadings less than .55 (especially items C3 and C4,
with loadings of .46 and .31, respectively). The assessment ORCID
of PTSD using the DSM-­IV criteria rather than more re- Julian D. Ford https://orcid.org/0000-0001-7923-0658
cent DSM-­5 or ICD-­11 criteria also is a limitation.
In conclusion, this independent replication supported REFERENCES
DTD’s validity and potential utility as a unifying diagnosis 1. Miller AB, Machlin L, McLaughlin KA, Sheridan MA.
for traumatized children with heterogeneous symptoms Deprivation and psychopathology in the Fragile Families
that span multiple transdiagnostic spectra. Overall, study Study: A 15-­year longitudinal investigation. J Child Psychol
Psychiatry. 2021;62(4):382-­391.
findings point to the value of DTD as a trauma-­related
2. van der Kolk B. Commentary: The devastating effects of ig-
diagnosis that brings together heterogeneous symptoms
noring child maltreatment in psychiatry –­ a commentary
based on the overarching theme of posttraumatic dysreg- on Teicher and Samson 2016. J Child Psychol Psychiatry.
ulation. DTD therefore could expand the scope trauma-­ 2016;57(3):267-­270.
focused assessment and treatment for children diagnosed 3. Greger HK, Myhre AK, Lydersen S, Jozefiak T. Previous mal-
with multiple comorbidity52—­including many who other- treatment and present mental health in a high-­risk adolescent
wise may not receive trauma-­focused treatment because population. Child Abuse Negl. 2015;45:122-­134.
of not meeting criteria for PTSD. 4. Warmingham JM, Handley ED, Rogosch FA, Manly JT,
Cicchetti D. Identifying maltreatment subgroups with patterns
of maltreatment subtype and chronicity: a latent class analysis
ACKNOWLEDGMENTS
approach. Child Abuse Negl. 2019;87:28-­39.
The study was funded by the Lookout Foundation (2015-­ 5. Zachar P. Quantitative classification as (re-­)descriptive psycho-
001), Joseph Spinazzola and Julian Ford, Principal pathology. World Psychiatry. 2018;17(3):294-­295.
Investigators. No organizational or individual funder had 6. Forbes MK, Sunderland M, Rapee RM, et al. A detailed hier-
any role in the conduct or publication of this study. The archical model of psychopathology: from individual symptoms
authors gratefully acknowledge the contributions of the up to the general factor of psychopathology. Clin Psychol Sci.
National Child Traumatic Stress Network Developmental 2021;9(2):139-­168.
7. D'Andrea W, Ford JD, Stolbach B, Spinazzola J, van der Kolk
Trauma Disorder Work Group, co-­led by Robert Pynoos,
BA. Understanding interpersonal trauma in children: why we
M.D. (UCLA Department of Psychiatry) and Bessel van need a developmentally appropriate trauma diagnosis. Am J
der Kolk, M.D., to the conceptual framework and initial Orthopsychiatry. 2012;82(2):187-­200.
item development of the Developmental Trauma Disorder 8. DeYoung CG, Chmielewski M, Clark LA, et al. The distinction
Semi-­structured Interview (DTD-­SI), and the field site co- between symptoms and traits in the Hierarchical Taxonomy of
ordinators and interviewers who accomplished the data Psychopathology (HiTOP). J Pers. 2020;90:20–­33.
collection for this study. 9. Villalta L, Smith P, Hickin N, Stringaris A. Emotion regula-
tion difficulties in traumatized youth: a meta-­analysis and
conceptual review. Eur Child Adolesc Psychiatry. 2018;27(4):​
CONFLICT OF INTEREST
527-­544.
Bessel van der Kolk and Joseph Spinazzola report no con- 10. Vine V, Byrd AL, Mohr H, Scott LN, Beeney JE, Stepp SD. The
flicts of interest. Julian Ford is a consultant to Advanced structure of psychopathology in a sample of clinically referred,
Trauma Solutions Professionals, Inc., the sole licensed emotionally dysregulated early adolescents. J Abnorm Child
distributor of the TARGET model copyrighted by the Psychol. 2020;48(11):1379-­1393.
University of Connecticut. 11. Saxe GN. Network psychiatry: computational methods to un-
derstand the complexity of psychiatric disorders. J Am Acad
Child Adolesc Psychiatry. 2017;56(8):639-­641.
AUTHOR CONTRIBUTIONS
12. Putica A, Van Dam NT, Steward T, Agathos J, Felmingham K,
Julian Ford, Joseph Spinazzola, and Bessel van der Kolk
O'Donnell M. Alexithymia in post-­traumatic stress disorder is
formulated the research questions and designed the study, not just emotion numbing: systematic review of neural evidence
Julian Ford and Joseph Spinazzola carried out the study, and clinical implications. J Affect Disord. 2020;278:519-­527.
Grace Chan analyzed the data, Julian Ford wrote the ar- 13. Obsuth I, Hennighausen K, Brumariu LE, Lyons-­Ruth K.
ticle with contributions from the other three co-­authors. Disorganized behavior in adolescent-­parent interaction:
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
638 |    FORD et al.

relations to attachment state of mind, partner abuse, and psy- children: factor structure, item characteristics, reliability, and
chopathology. Child Dev. 2014;85(1):370-­387. validity of the Developmental Trauma Disorder Semi-­Structured
14. Gagnon KL, DePrince AP, Chu AT, Gorman M, Saylor MM. Interview (DTD-­SI). J Clin Psychiatry. 2018;79(5):e1-­e9.
Betrayal trauma and child symptoms: the role of emotion. J 30. Spinazzola J, van der Kolk B, Ford JD. When nowhere is safe:
Trauma & Dissociat. 2016;17(2):207-­222. trauma history antecedents of posttraumatic stress disorder
15. Ford JD, Fraleigh LA, Connor DF. Child abuse and aggression and developmental trauma disorder in childhood. J Trauma
among seriously emotionally disturbed children. J Clin Child Stress. 2018;31(5):631-­642.
Adolescent Psychol 53. 2010;39(1):25-­34. 31. van der Kolk B, Ford JD, Spinazzola J. Comorbidity of develop-
16. Ford JD, Gomez JM. The relationship of psychological trauma mental trauma disorder (DTD) and post-­traumatic stress disor-
and dissociative and posttraumatic stress disorders to nonsui- der: findings from the DTD field trial. Europ J Psychotraumatol.
cidal self-­injury and suicidality: a review. J Trauma Dissociat. 2019;10(1):1562841.
2015;16(3):232-­271. 32. Choi KR, McCreary M, Ford JD, Rahmanian Koushkaki S,
17. Pine DS, Mogg K, Bradley BP, et al. Attention bias to threat in Kenan KN, Zima BT. Validation of the traumatic events screen-
maltreated children: implications for vulnerability to stress-­ ing inventory for ACEs. Pediatrics. 2019;143(4).
related psychopathology. Am J Psychiatry. 2005;162(2):291-­296. 33. Kaufman J, Birmaher B, Brent D, Rao U, Ryan N. Schedule for
18. Frewen PA, Brown MF, Steuwe C, Lanius RA. Latent profile affective disorders and schizophrenia for school-­age children-­
analysis and principal axis factoring of the DSM-­5 dissociative present and lifetime version (K-­SADS-­PL): initial reliability and
subtype. Europ J Psychotraumatol. 2015;6:26406. validity data. J Clin Child Adolesc Psychol. 1996;36:980-­988.
19. Brewin CR, Cloitre M, Hyland P, et al. A review of current evi- 34. Masi G, Pisano S, Milone A, Muratori P. Child behavior checklist
dence regarding the ICD-­11 proposals for diagnosing PTSD and dysregulation profile in children with disruptive behavior dis-
complex PTSD. Clin Psychol Rev. 2017;58:1-­15. orders: a longitudinal study. J Affect Disord. 2015;186:249-­253.
20. Hebert M, Langevin R, Oussaid E. Cumulative childhood 35. Way I, Black-­Pond C, Applegate B, Yelsma P, Cai X, Roberts
trauma, emotion regulation, dissociation, and behavior prob- E. Children’s Alexithymia Measure (CAM): a new instrument
lems in school-­aged sexual abuse victims. J Affectiver Disord. for screening difficulties with emotional expression. J Child
2018;225:306-­312. Adolescent Trauma. 2010;3:303-­318.
21. Bodzy ME, Barreto SJ, Swenson LP, Liguori G, Costea G. 36. Suveg C, Zeman J. Emotion regulation in children with anxiety
Self-­reported psychopathology, trauma symptoms, and emo- disorders. J Clin Child Adolesc Psychol. 2004;33(4):750-­759.
tion coping among child suicide attempters and ideators: an 37. Spaapen DL, Waters F, Brummer L, Stopa L, Bucks RS. The emo-
exploratory study of young children. Archives Suicide Res. tion regulation questionnaire: validation of the ERQ-­9 in two
2016;20(2):160-­175. community samples. Psychol Assessessment. 2014;26(1):46-­54.
22. Ford JD, Grasso D, Greene C, Levine J, Spinazzola J, van der 38. Endicott J, Nee J, Yang R, Wohlberg C. Pediatric Quality of
Kolk B. Clinical significance of a proposed developmental Life Enjoyment and Satisfaction Questionnaire (PQ-­LES-­Q):
trauma disorder diagnosis: results of an international survey of reliability and validity. J Am Acad Child Adolesc Psychiatry.
clinicians. J Clin Psychiatry. 2013;74(8):841-­849. 2006;45(4):401-­407.
23. DePierro J, D'Andrea W, Spinazzola J, et al. Beyond PTSD: 39. Volinsky CT, Raftery AE. Bayesian information criterion for
Client presentations of developmental trauma disorder from a censored survival models. Biometrics. 2000;56(1):256-­262.
national survey of clinicians. Psychol Trauma Theory Res Pract 40. Cappelleri JC, Jason Lundy J, Hays RD. Overview of classical
Policy. 2019. test theory and item response theory for the quantitative assess-
24. Metzner F, Dahm K, Richter-­Appelt H, Pawils S, Moulaa-­ ment of items in developing patient-­reported outcomes mea-
Edmondson MJ, Stellermann-­Strehlow K. Developmental sures. Clin Ther. 2014;36(5):648-­662.
trauma disorder (DTD) in children and adolescents –­ re- 41. Petrillo J, Cano SJ, McLeod LD, Coon CD. Using classical test
sults from a patient population at the special consultation theory, item response theory, and Rasch measurement theory
hour for traumatized children and adolescents. Z Kinder to evaluate patient-­reported outcome measures: a comparison
Jugendpsychiatry & Psychotherapy. 2019;47(4):300-­312. of worked examples. Value Health. 2015;18(1):25-­34.
25. Rahim M. Developmental trauma disorder: an attachment-­based 42. Lord F. Applications of item response theory to practical testing
perspective. Clinical Child Psychol Psych. 2014;19(4):548-­560. problems. Lawrence Erlbaum Associates; 1980.
26. Schmid M, Petermann F, Fegert JM. Developmental trauma 43. Magis D, Beland S, Tuerlinckx F, De Boeck P. A general frame-
disorder: pros and cons of including formal criteria in the psy- work and an R package for the detection of dichotomous
chiatric diagnostic systems. BMC Psychiatry. 2013;13:3. differential item functioning. Behav Res Methods. 2010;42:​
27. Feenstra DJ, Busschbach JJ, Verheul R, Hutsebaut J. Prevalence 847-­862.
and comorbidity of axis I and axis II disorders among treatment 44. Medina-­Mirapeix F, Navarro-­Pujalte E, Escolar-­Reina P,
refractory adolescents admitted for specialized psychotherapy. Montilla-­Herrador J, Valera-­Garrido JF, Collins SM. Mobility
J Pers Disord. 2011;25(6):842-­850. activities measurement for outpatient rehabilitation settings.
28. McGuire JF, Orr SP, Essoe JK, McCracken JT, Storch EA, Arch Phys Med Rehabil. 2011;92(4):632-­639.
Piacentini J. Extinction learning in childhood anxiety disor- 45. Romero-­Acosta K, Canals J, Hernandez-­Martinez C, Penelo E,
ders, obsessive compulsive disorder and post-­traumatic stress Zolog TC, Domenech-­Llaberia E. Age and gender differences
disorder: implications for treatment. Expert Rev Neurother. of somatic symptoms in children and adolescents. J Mental
2016;16(10):1155-­1174. Health. 2013;22(1):33-­41.
29. Ford JD, Spinazzola J, van der Kolk B, Grasso D. Toward an 46. Chung MC, Chen ZS. Gender differences in child abuse,
empirically-­based developmental trauma disorder diagnosis for emotional processing difficulties, alexithymia, psychological
 16000447, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13424 by Liberty University, Wiley Online Library on [20/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
FORD et al.    | 639

symptoms and behavioural problems among Chinese adoles- 52. Mavranezouli I, Megnin-­Viggars O, Trickey D, et al. Cost-­
cents. Psychiatr Q. 2020;91(2):321-­332. effectiveness of psychological interventions for children and
47. Garralda ME. Unexplained physical complaints. Pediatr Clin young people with post-­traumatic stress disorder. J Child
North Am. 2011;58(4):pp. 803–­813, ix. Psychol Psychiatry. 2020;61(6):699-­710.
48. Hershkowitz I. The effects of abuse history on sexually intru-
sive behavior by children: An analysis of child justice records.
Child Abuse Negl. 2011;35(1):40-­49. SUPPORTING INFORMATION
49. Morosan L, Ghisletta P, Badoud D, Toffel E, Eliez S, Debbane Additional supporting information may be found in the
M. Longitudinal relationships between reflective functioning,
online version of the article at the publisher’s website.
empathy, and externalizing behaviors during adolescence
and young adulthood. Child Psychiatry Hum Dev. 2020;​
51(1):59-­70.
50. Espejo-­Siles R, Zych I, Llorent VJ. Empathy, social and emo-
How to cite this article: Ford JD, Spinazzola J,
tional competencies, bullying perpetration and victimization as van der Kolk B, Chan G. Toward an empirically
longitudinal predictors of somatic symptoms in adolescence. J based Developmental Trauma Disorder diagnosis
Affect Disord. 2020;271:145-­151. and semi-­structured interview for children: The
51. Ford JD, Kerig PK, Desai N, Feierman J. Psychosocial DTD field trial replication. Acta Psychiatr Scand.
Interventions for traumatized youth in the juvenile justice 2022;145:628–­639. doi:10.1111/acps.13424
system: Clinical, research, and legal perspectives. J Juvenile
Justice. 2016;5(1):31-­49.