Assessment of Complex Trauma
The section below provides an overview of the importance of a comprehensive assessment of complex trauma and includes a case illustration.
The tabs above provide detailed information for mental health professionals, non-mental health professionals (e.g., educators, child welfare workers), and parents and caregivers.
- Why a Framework for Assessment of Complex Trauma Is Important
- Clinical Illustration
- Developing a Common Framework Across Systems of Providers
- Outcome of Trauma-Informed Assessment for Celia
- How to Conduct a Comprehensive Assessment of Complex Trauma
- Gathering and Using Information Effectively
Developing a comprehensive framework for assessing both the exposure to, and impact of, complex trauma is vital. Complex trauma can have such pervasive impact on developmental trajectories that children often end up with problems across many domains of functioning. A child’s self-image is also profoundly affected. Many of these children end up feeling like they are “bad kids” who just can’t change no matter what they try. These children may be diagnosed with a range of disorders, and consequently treated with multiple medications and therapies that are ultimately ineffective because they fail to address the underlying problem and do not reflect a trauma-informed approach to assessment and treatment.
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.
Children with complex trauma often end up in multiple child-serving systems (e.g., mental health, child welfare, education, juvenile justice) with needs that are both complex and severe. These children may carry multiple diagnoses (e.g., bipolar disorder, attention deficit hyperactivity disorder, etc.) and may be taking various types of medications to address their symptoms, especially when the professional making the diagnoses is unaware of their trauma histories. Furthermore, professionals in each system may use different frameworks to understand children and have varying degrees of understanding of complex trauma. This situation leaves children with complex trauma at risk of being misunderstood, misdiagnosed, and thus “mis-treated.” Child-serving systems must work together to develop a common framework for assessment of complex trauma that can still work within the context of each particular system. Such a comprehensive framework can improve communication across providers and caregivers, and ultimately improve the care of the children and families entrusted to these systems.
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.
Mental Health Professionals
There is no single established standard for the assessment of complex trauma in children. The suggestions offered here address both global assessment approaches and the most likely target areas for the assessment process. In some cases, a distinction is made between areas and components that are “essential” and those that are optimum (for the more complicated cases and professionals or agencies with the resources to use them). Recommendations are derived from collective clinical expertise as well as from important articles published in this area (e.g., Briere & Spinazzola, 2005; Courtois, 2004; Kerig, Fedorowicz, Brown, & Warren, 2000; Ford, 2011).
- General Guidelines for the Assessment of Complex Trauma
- Assessment Tools and Techniques
- Standardized Measures
- Putting It All Together: Making Sense of Assessment Information
1. Create a Safe Environment
- When conducting a trauma assessment with a child and family members choose a setting with adequate privacy. Clients and other professionals should not be able to overhear any part of the assessment. Also, it is very important that the child not be asked about traumatic events in the presence of the alleged perpetrator(s) or other individuals who may be invested in non-disclosure. Ideally, the clinician should spend some time meeting together with the child and family member to establish safety and outline the parameters of the meeting (including the purpose and format), and, if and when the child is comfortable, meeting individually with the child to inquire about possible exposure to traumatic events privately. It is absolutely essential that all persons participating in the assessment know and understand the limits of confidentiality, especially given the clinician’s duty to report previously unidentified child abuse or neglect. It is equally important that everyone understand the efforts that will be made to protect the child and family’s confidentiality.
- Provide the key participants in the assessment (e.g., the child and caregivers) with a basic overview of the purpose of the assessment and how the results will be used. Be judicious in sharing this assessment rationale with other informants (daycare providers, teachers) who will contribute only limited information to the assessment in order to protect the child and family’s confidentiality to the greatest degree possible. Encourage all participants to ask questions before, during, and following the assessment, especially if there appear to be questions or confusion about its purpose.
2. Gather Information from Multiple Perspectives
- Having multiple reporters is better! If at all possible, collect information from the child, all caregivers (biological and foster), at least one teacher, and other relevant professionals in the child’s life (e.g., case/social worker, direct care staff). At the very least, it is essential to gather information from the child and the child’s primary caregiver(s).
3. Use a Variety of Assessment Approaches and Techniques
- The ideal assessment would include a combination of different types of measures and strategies for collecting information. Since there is no one instrument that can fully capture the varied symptoms and problems that children with complex trauma histories may have, it is important to combine tools to capture the relevant information across domains of functioning. It is best to use a range of approaches and techniques, including a clinical interview, observation of the child and/or child and caregiver together, and various self-report measures completed by the child and the caregiver.
- The specific tools and techniques used will depend on your setting, target population, specific referral question(s) and areas of need (e.g., dissociation, attachment), and available resources. There is no clear consensus as to which approach is best, as each has its pros and cons (e.g., cost, ease of administration, etc.). It is important to use at least some established measures with good psychometric properties (e.g., validity and reliability). In addition, there is some evidence that clinician-administered interviews elicit more detailed information than do other techniques. Open-ended inquiry also may be more effective at linking trauma experiences with developmental functioning. For a more detailed overview regarding specific approaches and recommendations for measures, please see Briere & Spinazzola (2005), Habib & Labruna (2012), Mash & Barkley (2007), and Nader (2008).
- In the case of limited resources, include at least one comprehensive measure that addresses most or all of the domains listed in the following section, as well as supplemental interview questions and assessment techniques as needed. Examples of tools that tap into multiple domains include the Structured Interview for Disorders of Extreme Stress-Adolescent Version (SIDES-A), a measure designed specifically to assess all the core domains of complex trauma in adolescents and young adults, and the Child and Adolescent Needs and Strengths, CANS -Trauma Comprehensive (a comprehensive measure that assesses trauma experiences, traumatic stress, broader mental health symptoms, risk behaviors, day-to-day functioning, caregiver problem areas or needs, and child and caregiver strengths.
4. Work With the Child's Team and Family to Make Sense of Results and Develop Treatment/Service Plans
- Review the results of the evaluation with a multidisciplinary team for the purpose of integrating the findings, reaching conclusions, and making appropriate recommendations (e.g., for follow-up services).
- At the very least, the results of the assessment should be reviewed and discussed by at least two professionals (e.g., the assessor and his/her supervisor or colleague) and should be used to inform treatment planning.
- At the completion of the assessment process, review the key findings with the child’s caregiver(s) and, as developmentally appropriate, with the child him- or herself. Draw the connections between the referral question, the results of the assessment, and recommendations for services. Invite the family members to provide their own thoughts on the findings and to ask any questions.
5. Assess Children Over Time
- Ongoing assessment is important for several reasons. First, symptom expression often changes as children develop and have new experiences and exposure to new stressors. Second, monitoring change over time will reveal whether the current interventions are adequately addressing the child’s needs. Third, children and families do not always disclose all relevant information during the first assessment; this may be especially true regarding traumatic events which children commonly disclose over time, as they develop increased rapport with the clinician.
Key Developmental Domains Affected by Complex Trauma
Children at different stages of development experience and express trauma differently. Repeated trauma may interfere with a child’s achievement of developmental competencies. A multi-disciplinary approach will aid in clarifying the relationship between specific developmental domains (e.g., language and sensory dysfunction) and the impact of trauma. The table below provides some examples of how complex trauma may derail a child’s developmental functioning in each of seven domains. Appropriate developmental functioning and tasks always need to be considered when conducting a trauma assessment. The table can guide the clinical interview process and selection of appropriate assessment tools and techniques. (See “Effects of Complex Trauma” for a more detailed description of each of these domains).
Other Areas Essential to a Comprehensive Assessment
In addition to gathering information on the primary domains of complex trauma, it is also important to assess trauma history, classic post-traumatic stress symptoms, and family environment. While assessing a child’s problems and difficulties, it is also important to consider the child’s strengths, talents, abilities, sources of emotional support, and capacity for resilience.
Click here to view a list of standardized measures to assess the broad range of complex trauma domains noted above, as well as measures that focus on a specific domain in greater detail. Please note that this is not an exhaustive list. Where more information is available, links are provided to the NCTSN Measures Review Database, the publisher's website, or the measure itself.
In conducting a comprehensive assessment for complex trauma, a critical step is connecting the dots to elucidate the link between the various domains of complex trauma and trauma exposure. Establishing the specific timeframe for traumatic events and their duration is critical to drawing these connections. Clinical interviews and the open-ended information they provide often clarify these links best. Understanding the role of trauma triggers is also critical in determining how specific internal or external stimuli precipitate reactions in the child. By identifying these reminders, you can help the child develop approaches for coping with them, and also may be able to buffer the child from unnecessary exposure. Making connections between different areas of difficulty (e.g., how affect dysregulation or dissociation may lead to behavioral issues or outbursts) is also important to consider when determining where to intervene, how to prioritize treatment targets, and how to plan for additional resources and services.
The Important Role of Other Professionals in Assessing Complex Trauma
Professionals involved in a child’s life, such as teachers, pediatricians, and those in the juvenile justice system, can play an important role in helping children receive trauma-focused assessment or services. There are a variety of resources, including brief screening tools, available to assist in this process of determining the need for more in-depth assessment or trauma-focused treatment. Some of these resources address child traumatic stress more generally, while others have been developed specifically to highlight the effects of complex trauma. Some examples include:
- Trauma Screening Checklist: Identifying Children at Risk. This one-page screening tool, with versions for school-aged children and children aged 0-5, assesses exposure to a range of types of trauma as well as the impact of trauma in multiple domains (behavior, feelings, and relationships). This tool was developed by an NCTSN center and is designed for use primarily in Child Welfare settings.
- NCTSN Child Trauma Toolkit for Educators. This resource, available in English or Spanish, provides suggestions for educators, including guidance on when to make a referral for additional help for a child. Fact sheets describe the potentially wide-ranging psychological and behavioral impact of trauma for children of different ages and include case examples of children with complex trauma.
- NCTSN Bench Card for the Trauma-informed Judge. This quick reference is designed to provide judges with guidelines to help them make decisions based on the emerging scientific findings in the traumatic stress field. The card includes a list of questions to assess whether trauma-informed services are warranted, including a reminder to assess for multiple or prolonged trauma exposure.
Not all children who’ve gone through traumatic experiences demonstrate the multiple functional impairments associated with complex trauma. The following questions can help determine whether to refer a child/family for more comprehensive assessment.
Has the child experienced early and repeated exposure to overwhelming events in the context of a caregiver/family setting or in the community?
Is the child having difficulty regulating or controlling behavior, sometimes appearing hyperactive, engaging in risk behaviors, or having difficulties with complying with rules? (There may be a diagnosis of ADHD treated with limited success).
Is the child having difficulty with sustaining attention, concentration or learning?
Is the child showing persistent difficulties in his/her relationships with others?
Does the child have difficulty regulating bodily states and emotions, including problems with sleep, eating, sensory processing, and/or difficulties with regulating or identifying/expressing feelings?
Does the child have multiple mental health diagnoses without any one sufficient diagnosis explaining his/her problems?
Families and Caregivers
Information for Families and Caregivers
Accurate assessment is important because it helps clinicians to choose the best treatment possible. Children and adolescents with complex trauma may have a wide range of symptoms. Different children can have different combinations of symptoms, and these symptoms may change over time. How a child reacts depends on age, experiences, personality, strengths, and individual vulnerabilities. To learn more about complex trauma, please click here.
There currently is no official diagnosis that captures the full range of complex trauma symptoms. However, through a comprehensive assessment, informed and experienced mental health professionals can help determine if your child's problems are related to complex trauma. Children with complex trauma sometimes carry multiple diagnoses (for example, bipolar disorder, attention deficit hyperactivity disorder, posttraumatic stress disorder, and so on) for which they may be prescribed several different medications. This may happen when the professionals making the diagnoses have not fully taken into account the impact of the child’s trauma history. This can lead to a child’s receiving improper diagnoses or treatment.
Please read the statements below. If you answer yes to two or more, you may want to consider referring your child for a complete assessment for complex trauma. The survey below is a tool to help you decide when you need to seek professional help.
My child has been exposed to many potentially traumatic experiences.
My child has difficulty controlling emotions and easily can become sad, angry, or scared.
My child has trouble controlling behaviors.
My child often exhibits significant changes in activity level, appearing overactive or agitated sometimes and then calmer, or even quite slowed down at other times.
My child has trouble remembering, concentrating, and/or focusing. He/she sometimes appears “spacey.”
My child has problems with eating, sleeping, and/or complains about physical symptoms even though doctors find nothing physically wrong to explain these symptoms.
My child has difficulties in forming and sustaining relationships with other children and adults.
My child seems to need and seek out more stimulation than other children and/or can be easily distracted by noises, sounds, movements, and other changes in the environment.
My child has many mental health diagnoses but none of them quite seem to explain his/her problems.
My child is taking medication (or many medications) for these diagnoses but the medicines are not helping.