Skip to content
A curated collection of Books, Videos, Articles and more to educate consumers, caregivers and professionals about Complex Trauma.

When Nowhere is Safe: New Findings from the Developmental Trauma Disorder National Field Trial on Complex Childhood Trauma

In a recent International Society for Traumatic Stress Studies blog entitled “When Nowhere is Safe: Traumatic Origins of Developmental Trauma Disorder,” Drs. Joseph Spinazzola and Julian Ford highlight findings from the two recently published lead studies of the Developmental Trauma Disorder national field trials.

Their research provides the first data that explicitly substantiates the existence of Developmental Trauma Disorder (DTD), a proposed complex trauma diagnosis for children and youth.

abandoned teddy bear


First Study Supports Diagnosis

The first of these studies provides vital empirical evidence upholding the DTD diagnostic construct. It also validates a clinician-administered interview designed to measure the presence and severity of DTD in children and adolescents. Dr. Margaret Blaustein, Director of the Center for Trauma Treatment and developer of the ARC intervention for children, families and systems impacted by complex trauma, comments on the importance of establishing this new diagnosis.

Explains Dr. Blaustein:

“A substantial proportion of children and adolescents exposed to adversities have experienced multiple, overlapping layers of stress which have the potential to profoundly impact development, across domains of functioning.

In the absence of a diagnosis which adequately captures their experience, reflecting both cause and consequence, these children are at risk for inappropriate or absent supports, and often for further victimization and marginalization. These risks are profound, and further perpetuate the cycle of adversity.

Labels and language influence the lens through which an individual is seen and understood. A diagnosis that more accurately mirrors the impact of developmental trauma has great potential to influence understanding, treatment and services for youth in the mental health, child welfare, juvenile justice, and educational systems.”

Second Study Shows Predictors to DTD

Their second study reveals that disruption in early attachment relationships, even in the absence of other forms of maltreatment, is a significant predictor of DTD. It also shows that while some multiply traumatized youth certainly meet criteria for both DTD and Posttraumatic Disorder (PTSD), these are distinct clinical phenomenon. Children and adolescents can exhibit either of these diagnoses apart from the other. Finally, this study illuminates unique pathways of highest risk for the development of each of these disorders.

Finding the "Bermuda Triangle" of Adversity

Specifically, history of exposure to physical abuse or assault in childhood was found to be the strongest predictor of PTSD. In contrast, DTD was most strongly associated with exposure to three specific types of adversity in childhood:

  1. impaired caregiving due to mental illness, substance abuse or criminal involvement or incarceration of a parent of primary caregiver;
  2. witnessing of family violence; and/or
  3. witnessing of community violence.

The authors refer to the co-occurrence of these three pernicious forms of childhood adversity as the “Bermuda Triangle” of developmental trauma. Notably, all of these are “non-contact” forms of trauma: none of them require the perpetration of physical or sexual violence against youth themselves.

Dr. Sonya Mathies Dinizulu, Assistant Professor in the Department of Psychiatry & Behavioral Neuroscience, and Co-Director of the REACT (Recovery & Empowerment After Community Trauma) Clinic, elaborates on the important implications of this finding for child advocacy and social services.

Notes Dr. Mathies Dinizulu:

“As professionals, we can no longer think narrowly about what constitutes trauma for youth. Many youth in my practice present with non-contact trauma, and report clinical levels of traumatic stress similar to those youth who have been victimized.

The Bermuda Triangle, as noted by Spinazzola and colleagues, validates what we anecdotally observe and measure in the REACT program.  The lack of:

  • a stable and consistent caregiver system,
  • a perceived sense of safety,
  • an emotionally responsive caregiver, and
  • a safe neighborhood

is an assault to a youth’s physical, social-emotional and behavioral development. Too many of our youth become invisible for experiencing these ‘soft traumas.’

This research finding highlights three pertinent risk factors that warrant public health and policy systems to acknowledge and responsibly respond to the needs of these youth as well.”

What We Know Now

The findings from this pair of studies are as important as they are fascinating.

  • They demand societal reconsideration of what constitutes a traumatic experience.
  • They challenge outdated assumptions that maltreatment of a child requires some form of physical or sexual contact.
  • They authenticate a core theoretical and clinical assertion about complex trauma: threats to the emotional security of primary attachment relationships, and perceptions of danger in their immediate world, are experienced as undeniable sources of traumatic stress in young children.
  • If unaddressed, these experiences engender profound survival adaptations that can result in an escalating cascade of psychiatric, behavioral, academic, vocational and relational impairments and difficulties over time.

To access downloadable copies of the published DTD Field Trial studies, visit the Resources section of this website.


Ford, J.D., Spinazzola, J., van der Kolk, B., & Grasso, D.J. (2018). Toward an empirically-based Developmental Trauma Disorder diagnosis for children: Factor structure, item characteristics, reliability, and validity of the developmental trauma disorder semi-structured interview (DTD-SI). Journal of Clinical Psychiatry, 79(5).

Spinazzola, J., & Ford, J. (2018, October 22). When nowhere is safe: The traumatic origins of Developmental Trauma Disorder. [Trauma Blog post]. Retrieved from this article.

Spinazzola, J., Ford, J., & van der Kolk, B. (2018). When nowhere is safe: Interpersonal trauma and attachment adversity as antecedents of posttraumatic stress disorder and developmental trauma disorder. Journal of Traumatic Stress, 31(5), 631-642.