2/4/2020 Screening and Assessment

Published on The National Child Traumatic Stress Network (https://www.nctsn.org)

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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:

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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 [1] .

Guidance for Mental Health Professionals [2]

Guidance for Other Professionals [3]
Guidance for Families and Caregivers [4]
Standardized Measures to Assess Complex Trauma [5]

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
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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.

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Source URL: https://www.nctsn.org/what-is-child-trauma/trauma-types/complex-trauma/screening-and-assessment

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
[6] https://www.nctsn.org/print/822

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