Practice Briefs

Working Clinically with Developmental Trauma in Children and Adolescents

Introduction

According to 2017–18 National Survey of Children’s Health data, approximately 30% of children experience at least one adverse childhood experience (ACE), excluding economic hardship, and roughly 14% experience two or more (National Conference of State Legislatures, 2022). Despite this prevalence of childhood adversity, there is currently no diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; text rev.; DSM-5-TR; American Psychological Association, 2022) that fully accounts for the developmental impact of repeated and relational trauma exposure. As a result, clinicians frequently rely on multiple comorbid diagnoses to capture symptoms that stem from chronic trauma, which can lead to fragmented conceptualization and inconsistent treatment planning (Ford, 2021; Ford et al., 2022).

Although posttraumatic stress disorder (PTSD) is the most common trauma-related diagnosis, research demonstrates that many children who experience chronic adversity do not meet PTSD criteria, in part because Criterion A focuses on acute, life-threatening events rather than relational and developmental trauma (APA, 2022; Ford, 2021). Whereas PTSD emphasizes responses to discrete traumatic events, developmental trauma reflects the cumulative impact of chronic, relational trauma occurring during critical periods of development (Ford, 2021; Spinazzola et al., 2021). Research consistently demonstrates that chronic trauma during childhood can significantly disrupt emotional regulation, identity development, attachment patterns, and cognitive functioning, often resulting in impairment across multiple developmental domains and extending into adulthood (Bremness & Polzin, 2014; Spinazzola et al., 2021).

Developmental trauma disorder (DTD) has been proposed to capture the complex emotional, relational, and physiological challenges experienced by children who are exposed to chronic interpersonal trauma and ongoing adversity (van der Kolk, 2005). DTD was introduced in 2005 to account for these developmental effects, and a formal proposal was submitted in 2009; however, concerns regarding emerging evidence prevented its inclusion in the DSM at that time (van der Kolk et al., 2009; Frogley, 2018). Since then, a growing body of research has provided empirical support for DTD as a distinct and developmentally appropriate trauma presentation, with findings suggesting symptom patterns and functional impairment that differ meaningfully from PTSD in children (Morelli & Villodas, 2022; Corwin & MacMillan, 2022; Ford, 2021).

Counselors are often on the front lines of identifying developmental trauma and supporting children and their families. Without an established diagnostic category, clinicians must conceptualize symptoms through a developmental trauma lens, implement trauma-informed interventions, and advocate for recognition of trauma-related developmental impairment within clinical and educational systems. Without this lens, trauma responses may be misinterpreted as behavioral or oppositional disorders, increasing the risk of misdiagnosis and inequitable treatment (van der Kolk, 2005; Ford, 2021). A clearer understanding of developmental trauma can support more accurate assessment, culturally responsive treatment planning, and coordinated care for trauma-impacted youth.

Assessment Strategies

The diagnostic criteria for developmental trauma disorder was proposed in February 2009 by van der Kolk et al. to effectively illustrate the clinical presentations of children exposed to chronic trauma (van der Kolk et al., 2009). The criteria listed seven overarching criteria with 23 sub-criteria, including chronic trauma exposure; persistent dysregulation across emotional, behavioral, relational, and identity domains; symptoms lasting at least six months; and functional impairment. Although the early critiques of the DTD framework centered on the reliance on unpublished field trial data, more recent studies provide empirical support for the construct and clarify its clinical utility (Corwin & MacMillan, 2022; Ford, 2022). Research has shown that symptoms cluster differently than PTSD in children and may require distinct clinical conceptualization (Ford, 2022). These findings suggest that assessment should attend not only to trauma exposure, but also to the child’s developmental functioning across multiple domains.

When assessing children with suspected developmental trauma, counselors may utilize trauma-informed strategies consistent with the DTD framework. Trauma-informed interviews with children and caregivers can be used to gather contextual information about chronic adversity, relational disruptions, and developmental history that may not be fully captured through symptom-based assessments alone (van der Kolk et al., 2009). Counselors may also use adverse childhood experiences (ACEs) screening tools and other trauma-informed measures to document cumulative exposure to adversity and to support clinical conceptualization, while recognizing that these tools are not diagnostic of DTD (Felitti et al., 1998; National Conference of State Legislatures, 2022).

Assessments should further account for cultural considerations in symptom expression, acknowledging that trauma responses and coping strategies are shaped by cultural, relational, and systemic factors (Spinazzola et al., 2021). Finally, collaboration with interdisciplinary providers, when appropriate, can support a more comprehensive understanding of the child’s functioning across systems of care and contribute to coordinated, developmentally appropriate assessment and planning. In the absence of a formal DTD diagnosis, clinicians commonly conceptualize these presentations using diagnoses such as PTSD, other specified trauma- and stressor-related disorder, reactive attachment disorder, or comorbid mood and behavioral disorders, while maintaining a developmental trauma-informed case formulation to guide treatment planning (Ford, 2021).

Treatment Approaches

At this time, there is limited research on effective intervention strategies specifically for DTD. Research has been focused thus far on proving the justification for the diagnosis rather than on effective interventions to remedy symptoms of said diagnosis. As a result, clinicians must rely on evidence-based treatments for complex trauma and chronic adversity when addressing the symptom presentations associated with developmental trauma. The interventions listed below are based on empirical research into complex trauma and trauma-related symptom presentations in children and adolescents.

Play therapy is a developmentally appropriate intervention that allows children to build coping skills, increase self-regulation, and expand their definition of self (Humble et al., 2019). Play therapy is an empirically researched and reviewed intervention that has historically shown positive results with children who have experienced ACEs (Vicario et al., 2013). More recent research further supports the effectiveness of child-centered play therapy (CCPT) for children with exposure to multiple ACEs. In a randomized controlled trial, Ray et al. (2021) found that children who participated in CCPT demonstrated statistically significant improvements in social-emotional competencies, including empathy, social competence, and self-regulation, as well as significant reductions in total behavior problems compared to a waitlist control group. The experience of trauma is mainly stored in the sensory areas of the brain and are not usually saved as verbal memory, particularly in younger children whose neurodevelopmental systems are still maturing (van der Kolk, 2005). Consistent with this understanding, play therapy may provide children with opportunities to process traumatic experiences through symbolic, relational, and embodied forms of expression rather than relying solely on verbal narration. Play therapy is an embodied intervention that employs aesthetic distance to allow for effective cognitive and sensory processing of trauma using directive and nondirective methods (Boyd Webb, 2015). In a 2012 study conducted by Schottelkorb et al., play therapy was proven to be as effective as trauma-focused cognitive behavioral therapy (TF-CBT). Play therapy integrates research on developmental neuroscience and complex trauma in the execution of interventions, making it an appropriate approach for children who have experienced ACEs (Agarwal & Ray, 2019; Woollett & Hatcher, 2020).

TF-CBT is an evidence-based treatment intervention for children and adolescents who have experienced ACEs (Cohen et al., 2018). TF-CBT is a “phase-based therapy” that has proven to be adaptable across multiple settings and populations (Peters et al., 2021; Cohen et al., 2017). The TF-CBT treatment structure typically lasts for 8–25 sessions and includes nine specific components of psychoeducation, parenting skills, relaxation skills, affective skills, cognitive processing skills, trauma narration and processing, “in vivo mastery,” parent-child sessions, and a focus on increasing safety in order to effectively address the issues and symptoms (Cohen et al., 2018). The therapeutic rapport and relationship are considered key in utilizing TF-CBT in the treatment of children and adolescents; this allows for effective modeling of a securely attached adult-child relationship.

When working with children impacted by chronic interpersonal trauma, TF-CBT and play therapy can be used in a complementary or sequential manner rather than as isolated interventions. Play therapy may be used to support emotional regulation, engagement, and relationship safety, particularly in the early phases of treatment, and TF-CBT components may be introduced to support cognitive processing and caregiver involvement once sufficient stabilization has been established (Cohen et al., 2018; Peters et al., 2021). In addition, the Attachment, Regulation, and Competency (ARC) framework offers a developmentally informed, trauma-responsive approach that aligns closely with the core domains affected by developmental trauma. ARC emphasizes strengthening caregiver-child attachment, building regulation skills, and supporting developmental competencies disrupted by chronic trauma exposure (Fehrenbach et al., 2022). ARC has been described as a flexible, community-based framework that can be implemented independently or integrated alongside other evidence-based trauma treatments, making it particularly well-suited for children with complex trauma histories.

Cultural and Ethical Considerations 

Ethical practice includes trauma training, consultation, and collaboration across systems (APA, 2013; Ford et al., 2022). Children from marginalized racial, ethnic, and socioeconomic backgrounds face disproportionate exposure to ACEs and systemic adversity (National Conference of State Legislatures, 2022). Additionally, trauma responses may vary across cultural contexts, requiring clinicians to avoid pathologizing adaptive survival strategies or culturally rooted emotional expression (Spinazzola et al., 2021). Ethical trauma-informed care demands cultural humility, contextual understanding of trauma sources, and awareness of historical trauma and structural oppression that shape children’s experiences and symptom presentations (Bremness & Polzin, 2014). The ACA Code of Ethics (2014) requires counselors to maintain competence, respect cultural diversity, avoid diagnostic bias, and collaborate with caregivers and community supports. Inadequate recognition of developmental trauma can perpetuate misdiagnosis, treatment inequity, and systemic harm (Ford, 2021; van der Kolk, 2005).

Advocacy

Counselors play a critical role in advocating for trauma-responsive and developmentally informed systems of care across schools, child welfare settings, and behavioral health systems. The absence of a formal DTD diagnosis often leads to multiple fragmented diagnoses and piecemeal treatment approaches that fail to capture the developmental impact of chronic trauma (Ford et al., 2022; Spinazzola et al., 2021). Within the current diagnostic frameworks, counselors can advocate for trauma-informed conceptualization that prioritizes developmental history, attachment disruption, and chronic adversity when determining appropriate diagnoses and treatment planning. Counselors can promote trauma-informed training for educators and health-care providers, support early-identification models, and educate caregivers on the effects of relational trauma (National Conference of State Legislatures, 2022). Advocacy also includes engaging in research, supporting policy initiatives, and collaborating with interdisciplinary professionals to increase access to trauma-focused interventions and reduce stigma associated with trauma-related dysregulation (Morelli & Villodas, 2022; van der Kolk, 2005). Ultimately, counselor advocacy contributes to systemic change that validates trauma-impacted children’s needs and improves long-term developmental outcomes.

Conclusion

Developmental trauma disorder offers a framework that more accurately reflects the wide-ranging and long-term effects of chronic interpersonal trauma in childhood (van der Kolk, 2005). Although it is not formally included in the DSM-5-TR, research continues to demonstrate that children exposed to ongoing adversity often present with complex emotional, behavioral, cognitive, and relational symptoms that are not fully captured by existing trauma-related diagnoses (Ford, 2021; Spinazzola et al., 2021). As a result, many children receive multiple comorbid diagnoses that are not fully captured by existing trauma-related diagnoses (Ford et al., 2022).

Multiple comorbid diagnoses that attempt to account for trauma-related dysregulation can lead to fragmented conceptualization and inconsistent treatment planning (Ford et al., 2022). Until formal recognition occurs, counselors can work within existing clinical parameters by applying trauma-informed assessment practices, utilizing evidence-based interventions for complex trauma, collaborating across care systems, and maintaining cultural and developmental sensitivity in treatment planning (Cohen et al., 2018; van der Kolk, 2005). Continued research, training, and advocacy are necessary to support diagnostic reform efforts and ensure that young people impacted by chronic adversity receive comprehensive, responsive, and effective care.

Resources

• Attachment & Trauma Network: Developmental trauma disorder (https://www.attachmenttraumanetwork.org/developmental-trauma-disorder/)

Further Reading

• Abrams, Z. (2021, July 1). Improved treatment for developmental trauma. Monitor on Psychology, 52(5). https://www.apa.org/monitor/2021/07/ce-corner-developmental-trauma

To Cite This Practice Brief:

Cornell-Mullane, K. (2026). Working clinically with developmental trauma in children and adolescents [Practice Brief]. Counseling Nexus. https://doi.org/10.63134/ZGOZ4628

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