Arthur Becker-Weidman, Ph.D., director of the Center for Family Development in Buffalo, New York, presented “Developmental Trauma Disorder:  Effects on Child Development and Treatment” this week at the Doylestown Health and Wellness Center.

Dr. Becker-Weidman’s presentation style, was quiet and low-key, however, the information was very important, and the audience very attentive throughout the 3-hour workshop. There were many questions during his presentation, but Dr. Becker-Weidman was able to meet the Workshop goals. These included:

• Define Developmental Trauma Disorder and identify the seven domains that may be affected
• Describe one new tool for assessing children who have experienced Complex Trauma
• Explain the difference between PTSD and Developmental Trauma Disorder
• Name the essential principles of attachment-focused treatment

Dr. Becker-Weidman explained that “Developmental Trauma Disorder,” also known as “Complex Trauma,” refers to the effects of early (first 3-5 years), chronic maltreatment in a care-giving relationship. He said that Complex Trauma is not a DSM diagnosis: It is a clinical formulation that is broader and more useful than the psychiatric diagnosis of Reactive Attachment Disorder, but RAD may be included in the formulation. He noted that this concept captures a larger-range of impairments caused by chronic, early maltreatment. Dr. Becker-Weidman pointed out that Complex Trauma is different than PTSD. PTSD typically includes brief “Flashbacks” of a Traumatic event, or “Short Attribution Error.” Complex Trauma is more involved and requires a broader treatment regimen.

The concept of Complex Trauma includes seven domains of system impairment. Dr. Becker-Weidman said that these include

1. Attachment, which includes
   1. Relational boundaries,
   2. Trust,
   3. Social isolation,
   4. Difficulty attuning emotional states,
   5. Lack of empathy, and
   6. Lack of a secure base.
2. Biology, referring to
   1. Sensory-motor developmental problems
   2. Analgesia
   3. Sensory-motor dysfunction
   4. Somatization
   5. Increased medical problems.
3. Emotional Regulation including
   1. Poor affect regulation
   2. Difficulty identifying and expressing emotions
   3. Difficulty identifying and describing internal states,  and
   4. Difficulty communicating needs and wishes.
4. Dissociation — Defensive Functions such as
   1. Distinct alterations in states of consciousness, Amnesia
   2. Depersonalization and derealization
   3. Discrete states of consciousness, with discrete memories, affect and functioning
   4. Impaired memories for state-based events and Really, a defense against overwhelming threat and distress.
5. Behavioral Regulation includes
   1. Disturbance of eating
   2. Substance abuse
   3. Excessive compliance
   4. Excessive defiance
   5. Problems complying with rules, and
   6. Reenactment of trauma in behavior or play.
6. Cognition, including problems with
   1. Attention
   2. Executive functions
   3. Processing new information
   4. Focusing on tasks, and
   5. Difficulty with object constancy.
7. Self Concept, as characterized by
   1. Fragmented and disconnected autobiographical narrative
   2. Poorly developed sense of separateness (always bumping into things)
   3. Disturbed body image, low self-esteem and excessive shame.

Dr. Becker-Weidman discussed the role of brain systems and functions as related to Complex Trauma. He also stressed that symptoms of this disorder may mimic symptoms of other behavioral health disorders, or may be co-occurring with them. A comprehensive assessment, including history, interviews with parents and the child and multiple formal assessment instruments is required, prior to the onset of treatment. Several times, Dr. Becker-Weidman mentioned that the developmental age of the child must be considered in the assessment and treatment.

Dr. Becker-Weidman described a three-session model of assessment: All records are reviewed then a first session with the parents to evaluate the parents’ description and understanding of the child’s presenting problem, relationships, health,  school , pattern of attachment, reflective function and commitment. A broad series of psychological assessments and surveys are completed by the parents relating to the child, and relating to the parents themselves.

Assessment Session two includes a clinical Interview with the child. Dr. Becker-Weidman said that this session includes a mental status exam, and several different forma assessment methods including the House-Tree-Person, once with a single color, and later with multiple colors.

Dr. Becker-Weidman also described a new projective technique, in development, in which the child is asked to choose a crayon with a color that represents an emotion, then draw a heart, with the area filled in using the different colored crayons, with the amount of the area using each color to represent the child’s perception of how they feel. Dr. Becker-Weidman stated, and I think the audience agreed, that most young children are much more comfortable talking when they are drawing or coloring.

The third, and final session of the assessment includes a discussion with the parents of the assessment and diagnosis, what is causing the problem and driving the behavior, suggestions for more evaluation if needed, and the treatment recommendations.

Dr. Becker-Weidman emphasized that “DYADIC Developmental Psychotherapy” (DDP) is an empirically based treatment method. He provided a brief description of several research studies to make this point. He described the General Principles of this approach to include

1. Causes, not symptoms
2. Kind attributions (e.g. non-pejorative, Relationships and underlying affect, all behavior is adaptive)
3. Connections, not compliance
4. Developmental, not chronological age
5. Create a “Healing Place” with time together, and
6. Assume “Can’t versus won’t” from the child, with refusals.

Forming an alliance with the child and parents is essential for effective treatment.

Overall, this was a very satisfying workshop. Dr. Becker-Weidman was very clear with his concepts, and provided good examples, with a good sense of humor. I heard no complaints during the break, and the audience was quick to return to their seats for the second half. I did hear one comment during the presentation, that someone in the back couldn’t hear all the questions asked. It’s always a good idea for the presenter to repeat the questions asked. Also, as typical when there are a lot of questions in a workshop, there were several pages of slides with 10 minutes left in the workshop, so things were a little rushed at the end.

My final comment is a question. While I understand, and agree with the value of the extensive, comprehensive assessment that Dr. Becker-Weidman described, using  3+ sessions and multiple assessment instruments, how many of the practitioners in the audience have the resources, or, are reimbursed for this level of evaluation. Who pays for it?