Screening and Assessment

Clinical Illustration

 
Celia is a 12-year-old girl with a long history of trauma. Child Protective Services first removed her from her mother’s home at the age of three for neglect and parental substance abuse. After 10 months, she was reunited with her mother who married her live-in boyfriend soon afterwards. Celia remained in their care from ages four through seven and then was removed again when she disclosed that she been sexually abused by her stepfather and had witnessed domestic violence between her mother and stepfather.
 
Following this second placement in foster care, Celia was referred for an assessment due to academic problems, severe inattention, hyperactivity, and oppositional behavior, as well as physically violent tantrums. She was diagnosed with oppositional defiant disorder and bipolar disorder. Treatments addressing her behavior, including medication and therapy, have been minimally successful. Following her adoption, at age 9, her unpredictable mood swings, noncompliance, and a more persistent preoccupation with sexual ideas continued to be a concern.
 

Celia’s presentation is not uncommon for children who have experienced multiple traumas from an early age and in caregiving relationships in which they are supposed to feel safe. Along with typical post-traumatic stress reactions, these children often display a wide range of developmental impairments including difficulty developing and sustaining relationships, behavioral issues, emotional problems, dissociation, learning disabilities, and even chronic health problems. Their complicated symptom presentation often leads to multiple diagnoses and potential misdiagnoses, particularly when the impact of their complex trauma histories goes unrecognized.

Therefore, it is essential that clinicians perform a comprehensive assessment that captures this broad range of reactions. A thorough assessment must also carefully date and track the various traumatic events so they can be linked with developmental derailments.

How to Conduct a Comprehensive Assessment of Complex Trauma

The assessment of complex trauma is by definition “complex” as it involves both assessing children’s exposure to multiple traumatic events, as well as the wide-ranging and severe impact of this trauma exposure across domains of development. It is important that mental health providers, family members, and other caregivers become aware of specific questions to ask when seeking the most effective services for these children.

The following are some key steps for conducting a comprehensive assessment of complex trauma:

  • Assess for a wide range of traumatic events. Determine when they occurred so that they can be linked to developmental stages.
  • Assess for a wide range of symptoms (beyond PTSD), risk behaviors, functional impairments, and developmental derailments.
  • Gather information using a variety of techniques (clinical interviews, standardized measures, and behavioral observations.
  • Gather information from a variety of perspectives (child, caregivers, teachers, other providers, etc).
  • Try to make sense of how each traumatic event might have impacted developmental tasks and derailed future development. Note: this may be challenging given the number of pervasive and chronic traumatic events a child may have experienced throughout his or her young life.
  • Try to link traumatic events to trauma reminders that may trigger symptoms or avoidant behavior. Remember that trauma reminders can be remembered both in explicit memory and out of awareness in the child’s body and emotions.

The assessment should be conducted by a clinically trained provider who understands child development and complex trauma. Ideally, the assessment should involve a multi-disciplinary team. An ideal team would include a pediatrician, mental health professional, educational specialist, and, where appropriate, an occupational therapist. In residential, day treatment, and juvenile justice settings, a multi-disciplinary team might also include direct care staff familiar with the child.

After conducting an assessment, it may be difficult to determine if the child’s various symptoms are related to outcomes of trauma or if they also reflect other diagnoses such as ADHD, oppositional defiant disorder, or bipolar disorder. However, when using a complex trauma framework, it may be more meaningful to suspend judgment and labeling at first. Engage instead in an open, flexible, and ongoing process that addresses the traumatic stress reactions initially and over the course of a child’s treatment. It is crucial to monitor how symptoms and behaviors change over the course of time and in response to trauma-focused treatment. Make sure to engage the child, family, and all providers in a continuing dialogue about what makes sense, what is working, and the most useful next steps for intervention.

Resources on Assessment of Complex Trauma

The resources linked below provide targeted information and guidelines for mental health professionals, other child-serving professionals (e.g., educators and pediatricians), and parents and caregivers related to the assessment of complex trauma. Also available is a list of standardized measures to assess the broad range of complex trauma domains, as well as measures that focus on a specific domain in greater detail. For some of these measures, additional information regarding reliability and validity is available in the Measure Reviews Database.

Outcomes of Trauma-Informed Assessment for Celia

Fortunately, Celia was eventually assessed by a trauma-informed clinician. Her history of traumas was clearly chronicled and linked to her symptom presentation. The clinician understood that complex trauma leaves a child mistrustful of others, in need of controlling her environment, emotionally reactive or shut down, hyper-aroused, unfocused, and distracted by fear. Following the assessment, the clinician set up a meeting and shared her findings with Celia, her adoptive parents, and her case manager. The findings were discussed in language that Celia could understand. The clinician was careful to convey the message that Celia was not to blame for her “bad behaviors.” Instead the clinician framed her behaviors as typical responses of children who experienced what Celia went through. Celia felt a great relief that someone understood.