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.
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:
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.
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 [1].
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.
Links
[1] https://www.nctsn.org/treatments-and-practices/screening-and-assessments/measure-reviews
[2] https://www.nctsn.org/resources/assessment-complex-trauma-mental-health-professionals
[3] https://www.nctsn.org/resources/assessment-complex-trauma-information-non-mental-health-professionals
[4] https://www.nctsn.org/resources/assessment-complex-trauma-parents-and-caregivers
[5] https://www.nctsn.org/resources/complex-trauma-standardized-measures