A PSYCHO-ECONOMIC CASE IN PUBLIC HEALTH: DEVELOPMENTAL TRAUMA DISORDER DIAGNOSIS AND TRAUMA-INFORMED POLICY

Authors: Vittoria Ardino, Elena Acquarini & Rosalba Rombaldoni

ABSTRACT

Negative experiences in human development can settle symptoms of disease or life span disorder. Developmental trauma is a hidden pandemic leading to a multi-layered array of negative outcomes across the lifespan, including critical health conditions and increased healthcare utilization. Such a scenario represents a major socio-economic burden with costs for health and social care and for society as a whole. A trauma-informed public health approach puts childhood adversities at the core of treatment and service provision. It becomes important to outline how a trauma-informed public health approach embedding the recognition of the Developmental Trauma Disorder diagnosis represents a major shift to conceptualizing health and social care provision and to recognizing the pervasiveness of adverse experiences. A projective cost analysis is elaborated to illustrate how the societal, health and social care costs would be reduced if trauma-related policies were implemented. A multidisciplinary view – which includes an economic case aspect – could strengthen ACEs prevention efforts: it could raise awareness of this issue, and adopt useful health and social policies in an integrated perspective.

Keywords: Developmental Trauma Disorder, Child abuse and maltreatment, Trauma-informed approach, Public Health, Economic costs, Health Policy.

REFERENCES

  • American Academy of Pediatrics (AAP), 2018. Screening technical Assistance and Resource (STAR) Center. [online] Available at:https://www.aap.org/en-us/advocacy-and-policy/aap-health- initiatives/Screening/Pages/Screening-Tools.aspx
  • American Academy of Pediatrics (AAP), 2012a. Policy statement: early childhood, toxic stress and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics, 129(1), pp. e232- 46. DOI: 10.1542/peds, 2011-2662.
  • American Academy of Pediatrics (AAP), 2012b. Tecnical report: the lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), pp. e232-46. DOI: 10.1542/peds.2011-2663.
  • American Psychiatric Association (APA), 2013. Diagnostic and statistical manual of mental disorders, 5th ed. DSM-5. Elsevier. DOI: 10.1176/appi.books.9780890425596.
  • Ardino, V. and Rombaldoni, R., 2017. Adverse childhood experiences: Healthcare policy and economics implications. Maltrattamento e Abuso all’Infanzia, pp. 19:7-10. DOI: 10.3280/MAL2017-002001.
  • Bellis, M.A., Hughes, K., Ford, K., Rodriguez, G.R., Sethi, D. and Passmore, J., 2019. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. Lancet Public Health, 10, pp. e517-28. DOI: 10.1016/S2468-2667(19)30145-8.
  • Brown, D.W., Anda, R.F., Felitti, V.J., Edwards, V.J., Malarcher, A.M., Croft,
  • J.B. and Giles, W.H., 2010. Adverse childhood experiences are associated with the risk of lung cancer. A prospective cohort study. BMC Public Health, 10, pp. 311. DOI: 10.1186/1471-2458-10-20.
  • Cahan, E., 2023. A twindemic: Adverse Childhood Experiences jump during the COVID-19 pandemic. American Association of Pediatrics Journals. Available at: https://publications.aap.org/journal-blogs/blog/24377
  • Catalano, R.F., Haggerty, K.P., Oesterle, S., Fleming, C.B. and Hawkins, J.D., 2004. The importance of bonding to school for healthy development: findings from the Social Development Research Group. Journal of School Health, 74(7), pp.252-61. DOI: 10.1111/j.1746- 1561.2004.tb08281.x.
  • Chapman, D.P., Whitfield, C.L., Felitti, V.J., Dube, S.R., Edwards, V.J. and Anda, R.F., 2004. Adverse childhood experiences and the risk of depressive disorders in adulthood. Journal of Affective Disorders, 82(2), pp.217.25.
  • Cloitre, M., Courtois, C.A., Charuvastra, A., Carapezza, R., Stolbach, B.D. and Green, B.L., 2011. Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices. J Trauma Stress, 24(6), pp.615–27. DOI: 10.1002/jts.20697.
  • D’Andrea, W., Ford, J.D., Stolbach, B., Spinazzola, J. and van der Kolk, B.A., 2012. Understanding interpersonal trauma in children: why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry, 82(2), pp.187-200. DOI: 10.1111/j.1939- 0025.2012.01154.x.
  • Danese, A., McLaughlin, K.A., Samara, M. and Stover, C.S., 2020. Psychopathology in children exposed to trauma: detection and intervention needed to reduce downstream burden. BMJ, 37, p. m3073. DOI: 10.1136/bmj.m3073.
  • Dong, M., Giles, W.H., Felitti, V.J., Dube, S.R., Williams, J.E., Chapman, D.P. and Anda, R.F., 2004. Insights into causal pathways for ischemic heart disease. Circulation, 110(3), pp. 1761-1766. DOI: 10.1181/01.CIR.0000143074.54995.7F
  • Dube, S.R., Anda, R.F., Felitti, V.J., Chapman, D.P., Williamson, D.F. and Giles, W.H., 2001. Childhood abuse, household dysfunction and the risk of attempted suicide throughout the life span. Findings from the
  • Adverse Childhood Experiences Study. JAMA, 286(24), pp. 3089-96. DOI: 10.1001/jama.286.24.3089.
  • Dubowitz, H., Feigelman, S., Lane, W. and Kim, J., 2009. Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model. Pediatrics, 123, pp. 858-64. DOI: 10.1542/peds.2008-1376.
  • Ebner-Priemer, U.W., Kuo, J., Schlotz, W., Kleindienst, N., Rosenthal, M.Z., Linean, M.M. and Bohusm, M., 2008. Distress and affective dysregulation in patients with borderline personality disorder: a psychophysiological ambulatory monitoring study. Journal of Nervous and Mental Disorders, 196(4), pp. 314-320. DOI: 10.1097/NMD.ob013e31816a493f.
  • Edwards, V.J., Anda, R.F., Gu, D., Dube, S.R. and Felitti, V.J., 2007. Adverse childhood experiences and smocking persistence in adults with smoking-related symptoms and illness. The Permanente Journal, 11(2), pp. 5-13. DOI: 10.7812/tpp/06-110.
  • El-Khodary, B. and Samara, M., 2020. Effectiveness of a school-based intervention on the student’s mental health after exposure to war- related trauma. Frontiers in Psychiatry, 10, p. 1031. DOI: 10.3389/fpsyt.2019.01031.
  • Fang, X., Brown, D.S., Florence, C.S. and Mercy, J.A., 2012. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect, 36(2), pp. 156-65. DOI: 10.1016/j.chiabu.2011.10.006.
  • Fang, X., Fry, D.A., Brown, D.S., Mercy, J.A., Dunne, M.P., Butchart, A.R., Corso, P.S., Maynzyuk, K., Dzhygyr, Y., Chen, Y., McCoy, A. and Swales, D.M., 2015. The burden of child maltreatment in the East Asia and pacific Region. Child Abuse & Neglect 42, pp.146-62. DOI: 10.1016/j.chiabu.2015.02.012.
  • Felitti, V.J., Anda, R.F., Nordenberg, D., Willamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P. and Marks, J.S., 1998. Relationship of childhood abuse and household dysfunction too many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am Journal of Preventive Medicine, 14(4), pp.245-58. DOI: 10.1016/S0749-3797(98)00017-8.
  • Finkelor, D., Vanderminden, J., Turner, H., Hamby, S. and Shattuck, A., 2014. Upset among youth in response to questions about exposure to violence, sexual assault and family maltreatment. Child Abuse & Neglect, 38, pp.217-23. DOI: 10.1016/j.chiabu.2013.07.021.
  • Finkelstein, N. and Markoff, L.S., 2005. The Women Embracing Life and Living (WELL) Project: using the relational model to develop integrated system of care for women with alcohol/drug use and mental health disorders with histories of violence. Alcoholism Treatment Quarterly, 22(3-4), pp.63-80. DOI: 10.1300/J020v22n03_04.
  • First, M.B., 2005. Clinical utility: a prerequisite for the adoption of a dimensional approach in DSM. J Abnorm Psychol., 114(4), pp. 560–4. DOI: 10.1037/0021-843X.114.4.560
  • Fletcher, J. and Wolfe, B., 2009. Long-term consequences of childhood ADHD on criminal activities. The Journal of Mental Health Policy and Economics, 12(3), pp. 119-38.
  • Ford, J.D., Fraleigh, L.A., Albert, D.B. and Connor, D.F., 2010a. Child abuse and autonomic nervous system hyporesponsivity among psychiatrically impaired children. Child Abuse Negl, 34(7), pp. 507–515. DOI: 10.1016/j.chiabu.2009.11.005.10.
  • Ford, J.D., Fraleigh, L.A. and Connor, D.F., 2010b. Child abuse and aggression among seriously emotionally disturbed children. J Clin Child Adolesc Psychol, 39(1), pp. 25-34. DOI: 10.1080/15374410903401104.
  • Ford, J.D., Grasso, D., Greene, C., Levine, J., Spinazzola, J. and van der Kolk, B.A., 2013. Clinical significance of a proposed developmental trauma disorder diagnosis: Results of an international survey of clinicians. J Clin Psychiatry, 74(8), pp. 841-9. DOI: 10.4088/JCP.12m08030.
  • Ford, J.D., Spinazzola, J., van der Kolk, B.A. and Chan, G., 2022. Toward an empirically based Developmental Trauma Disorder diagnosis and semi- structured interview for children: the DTD field trial replication. Acta Psychiatrica Scandinavica, 145(6), pp. 628-39. DOI: 10.1111/acps.13424.
  • Ford, J.D., Spinazzola, J., van der Kolk, B.A. and Grasso, D., 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). J Clinical Psychiatry, 79(5), pp. 1-9. DOI: 10.4088/JCP.17m11675.
  • Greene, C.A., Haisley, L., Wallace, C. and Ford, J.D., 2020. Intergenerational effects of childhood maltreatment: a systematic review of the parenting practices of adult survivors of childhood abuse, neglect and violence. Clinical Psychology Review, 80, pp. 101891. DOI: 10- 1016/j.cpr.2020.101891.
  • Habetha, S., Bleich, S., Weidenhammer, J. and Fegert, J.M., 2020. A prevalence-based approach to societal costs occurring in consequence of child abuse and neglect. Child and Adolescent Psychiatry and Mental Health, 6, p.5. DOI: 10.1186/1753-2000-6-35.
  • Harris, M. and Fallot, R.D., 2001 (Eds). Using trauma theory to design service systems. Jossey-Bass/Wiley,
  • Haselgruber, S., Solva, K. and Lueger-Schuster, B., 2020. Symptom structure of ICD-11 Complex Posttraumatic Stress Disorder (CPTSD) in trauma- exposed foster children: examining the International Trauma Questionnaire – Child and Adolescent Version (ITQ-CA). EJPT, 11(1), p. 1818974. DOI: 10.1080/20008198.2020.1818974.
  • Heckman, J.J. and Krueger, A.B., 2003 (Eds). Inequality in America: what role for human capital policy?. MIT Press. DOI: 10.3386/w9495.
  • Hertz, M., Viox, M.H., Massetti, G.M., Anderson, K.N., Bacon, S., Fordyce, E., Mercado, M.C. and Verlenden, J.V., 2023. Adverse Childhood Experiences among US adolescents over the course of the COVID-19 pandemic. Pediatrics, 151(6):e2022060799.DOI: 10.1542/peds2022- 060799.
  • Holman, D.M., Ports, K.A., Buchanan, N.D., Hawkins, N.A., Merrick, M.T., Metzier, M. and Trivers, K.F., 2016. The association between Adverse Childhood Experiences and risk of cancer in adulthood: a systematic review of the literature. Pediatrics, 138(suppl 1), pp. 581-91. DOI: 10.1542/peds.2015-4268L.
  • Hughes, K., Bellis, M.A., Hardcastle, K.A., Sethi, D., Butchart, A., Mikton, C., Lones, l. and Dunne, M.P., 2017. The effect of multiple adverse childhood experiences on health: a systematic review and meta- analysis. Lancet Public Health, 2(8), p. e356-66. DOI: 10.1016/S2468- 2667(17)30118-4.
  • Hughes, K., Ford, K., Bellis, M.A., Glendinning, F., Harrison, E. and Passmore, J., 2021. Health and financial costs of adverse childhood experiences in 28 European countries. A systematic review and meta- analysis. Lancet Public Health, 6(11), p. e848-57. DOI: 10.1016/S2468- 2667(21)00232-2.
  • Hughes, K.E., Bellis, M., Sethi, D., Andrew, R., Yon, Y., Wood, S., Ford, K., Baban, A., Boderscova, L., Kachaeva, M., Makaruk, K., Markovic, M., Povilaitis, R., Raleva, M., Terzic, N., Veleminsky, M., Wlodarczyk, J. and Zakhozha, V., 2019. Adverse childhood experiences, childhood relationships and associated substance use and mental health in young Europeans. The European Journal of Public Health, 29, pp.741–47. DOI: 10.1093eurpub/ckz037.
  • Karoly, L.A., Kilburb, M.R. and Cannon, J.S., 2005. Early Childhood Interventions. Proven results, future promise. Santa Monica CA: RAND Corporation. DOI: 10.7249/MG341.
  • Kendall-Tackett, K., 2002. The health effects of childhood abuse: four pathways by which abuse can influence health. Child Abuse & Neglect, 26(6-7), pp. 715-29. DOI: 10.1016/S0145-2134(02)00343-5.
  • Larkin, H., Felitti, V.J. and Anda, R.F., 2011. Social work and adverse childhood experiences research: implications for practice and health policy. Social Work in Public Health, 29(1), pp.1-16. DOI: 10.1080/19371918.2011.619433.
  • Larkin, H. and Records, J., 2007. Adverse childhood experiences: overview, response strategy and integral theory. Journal of Integral Theory and Practice, 2(3), pp.1-25.
  • Lazarus, R.S. and Folkman, S., 1984. Stress, appraisal and coping. Springer Publishing Company.
  • Lloyd-Williams, H., Spencer, L.H. and Edwards, R.T., 2022. Systematic review of the costs of adverse childhood experiences presenting the evidence on odds ratios and costs. Research Square. DOI: 10.21203/rs.3.rs- 1532626/v1.
  • Mavranezouli, I., Megnin-Viggars, O., Trickey, D., Meiser-Stedman, R., Daly, C., Dias, S., Stockton, S. and Pilling, S., 2020. Cost-effectiveness of psychological interventions for children and young people with post- traumatic stress disorder. Journal of Child Psychology and Psychiatry, 61, pp. 699-710. DOI: 10.1111/jcpp.13142.
  • McCarthy, M.M., Taylor, P., Norman, R.E., Pezzullo, L., Tucci, J. and Goddard, C., 2016. The lifetime economic and social costs of child maltreatment in Australia. Children and Youth Services Review, 71, pp. 217-26. DOI: 10.1016/j.childyouth.2016.11.014.
  • McEwen, B.S., 2018. Redefining neuroendocrinology. Epigenetics of brain- body communication over the life course Frontiers in Neuroendocrinology, 49, pp. 8-30. DOI: 10.1016/j.yfrne.2017.11.001.
  • McLaughlin, K.A., Colich, N.L., Rodman, A.M. and Wiessman, D.G., 2020. Mechanisms linking childhood trauma exposure and psychopathology: a transdiagnostic model of risk and resilience. BMC Medicine, 18, p.96. DOI: 10.1186/s12916.020.01561.6.
  • Meehan, A.J., Latham, R.M., Arseneault, L., Stahl, D., Fisher, H.L. and Danese, A., 2020. Developing an individualized risk calculator for psychopathology among young people victimized during childhood: A population-representative cohort study. Journal of Affective Disorders, 262, pp.90-8. DOI: 10.1016/j.ad.2019.10.034.
  • Morelli, N.M. and Villodas, M.T., 2021. A Systematic Review of the Validity, Reliability and Clinical utility of Developmental Trauma Disorder (DTD) Symptom Criteria. Clin Child Fam Psychol Review (no pag spec). DOI: 10.1007/s10567-021-00374-0.
  • Narayan, A.J., Lieberman, A.F. and Masten, A.S., 2021. Intergenerational transmission and prevention of adverse childhood experiences (ACEs). Journal of Clinical and Psychological Reviews, 85, p. e101997. DOI: 10.1016/j.cpr.2021.101997.
  • Norman, R.E., Byambaa, M., De, R., Butchart, A., Scott, J. and Vos, T., 2012. The long-term health consequences of child physical abuse, emotional abuse and neglect: a systematic review and meta-analysis. PLoS Medicine, 9(11), p. e1001349. DOI: 10.1371/journal.pmed.1001349.
  • Peterson, C., Kearns, M.C., McIntosh, W.L., Estefan, L.F., Nicolaidis, C., McCollister, K.E., Gordon, A. and Florence, C., 2018. Lifetime economic burden of intimate partner violence among US adults. Am J Preventive      Medicine,        55(4),   pp.433-44. DOI: 10.1016/j.amepre.2018.04.049.
  • Public Health Leadership Society, 2002. Principles of the ethical practice of public health. Available at:https://www.alpha.org/media/files/pdf/membergroups/ethic_rochure.a shx
  • Purgato, M., Gross, A.L., Betancourt, T., Bolton, P., Bonetto, C., Gastaldon, C., Gordon, J., O’Callaghan, P., Papola, D., Peltonen, K., Punamaki, R.-L., Richards, J., Staples, J.K., Unterhitzenberger, J., van Ommeren, M., de Jong, J., Jordans, M.J.D., Tol, W.A. and Barbui, C., 2018. Focused psychosocial interventions for children in low-resource humanitarian settings: a systematic review and individual participant data meta-analysis. Lancet Global Health, 6, pp, 390-400. DOI: 10.1016/S2214.109X (18)30046-9.
  • Rombaldoni, R., 2017. Economic evaluation of child maltreatment: is there any place for prevention?. Maltrattamento e Abuso all’Infanzia, 19, pp. 11-29. DOI: 10.3280/MAL2017-002002.
  • Schore, A.N., 2003. Effect of early relational trauma on affect regulation: the development of borderline personality disorders and a predisposition to violence. In Schore AN (Ed), Affect dysregulation and disorders of the Self. W.W. Norton NY (pp. 266-306).
  • Sethi, D., Bellis, M., Hughes, K., Gilbert, R., Mitis, F. and Galea, G., 2013. European report on preventing child maltreatment. WHO Regional Office for EU. Available at: https://apps.who.int/iris/handle/10665/326375
  • Spinazzola, J., van der Kolk, B.A. and Ford, J.D., 2021a. Developmental Trauma Disorder: a legacy of attachment trauma in victimized children. Journal of Traumatic Stress, 34(4), pp. 711-20. DOI: 10.1002/jts.22697. Spinazzola, J., van der Kolk, B.A. and Ford, J.D., 2021b. Psychiatric comorbidity of developmental trauma disorder and posttraumatic stress disorder: findings from the DTD field trial replication (DTDFT-R). EJPT, 12(1), p. 1929028. DOI: 10.1080/20008198.2021.1929028.
  • Spinazzola, J., van der Kolk, B.A. and Ford, J.D., 2018. When nowhere is safe: trauma history antecedents of posttraumatic stress disorder and Developmental Trauma Disorder in childhood. Journal of Traumatic Stress, 31(5), pp. 631-42. DOI: 10.1002/jts.22320.
  • Springer, K.W., Sheridan, J., Kuo, D. and Carnes, M., 2003. The long-term health outcomes of childhood abuse. Journal of General Internal Medicine, 18, pp. 864-70. DOI: 10.1046/j.1525-1497.2003.20918.x.
  • Stoltenborgh, M., Bakermans-Kranenburg, M.J., Alink, L.R.A. and van Ijzendoorn, M.H., 2015. The prevalence of child maltreatment across the globe: review of a series of meta-analyses. Child Abuse Review, 24(1), pp. 37-50. DOI: 10.1022/car.2353.
  • Substance Abuse and Mental Health Services Administration (SAMHSA), 2014. Early Childhood Mental Health Programs. Available at: <http://www.samhsa.gov/nctic/trauma-interventions>.
  • Teicher, M.H. and Samson, J.A., 2016. Annual research review: enduring neurobiological effects of childhood abuse and neglect. The Journal of Child Psychology and Psychiatry, 57(3), pp. 241-66. DOI: 10.1111/jcpp.12507.
  • Thoma, V., Weiss-Cohen, L., Filkukova, P. and Ayton, P., 2021. Cognitive predictors of precautionary behavior during the COVID-19 pandemic. Frontiers in Psychology, 12, p. 589800. DOI: 10.3389/fpsyg.2021.6589800.
  • van der Kolk, B.A., Ford, J.D. and Spinazzola, J., 2019. Comorbidity of developmental trauma disorder (DTD) and post-traumatic stress disorder: findings from DTD field trial. EJPT, 10(1), p. 1562841. DOI: 10.1080/200008198.2018.1562841.
  • van der Kolk, B.A., Pynoos, R.S., Cicchetti, D., Cloitre, M., D’Andrea, W., Ford, J.D., Leberman, A.F., Putnam, F.W., Saxe, G., Spinazzola, J., Stolbach BC and Teicher, M., 2009. Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. Available at: <http://www.traumacenter.org/announcements/DTD_papers_Oct_09.p df >.van der Kolk, B.A., 2014. The body keeps the score: mind, brain and body in the transformation of trauma. Viking NY (US).
  • Walden, T.A. and Smith, M.C., 1997. Emotion regulation. Motivation and Emotion, 21(1), pp. 7-25.
  • World Health Organization (WHO), 2019. International Statistical Classification of Diseases and Related health problems. 11th ed. (ICD- 11). Available at: <https://icd.who.int/>.