We would like to periodically offer some case examples to illustrate the challenges that children who have experienced complex trauma might present with. CTR is actively providing consultation and case support to with children and youth ranging from age 4 to age 17. All of these children/youth are referred to CTR because of serious emotional and behavioural problems. Most of these children/youth are involved in the foster care system, although we also have worked with an increasing number of adoptive children – both from international adoptions and adoptions from foster care. We’ve worked with children living in family-style homes and those in staffed homes. What we see over and over again is that typical caregiving approaches are unlikely to work and, on the positive side, that intervention plans and strategies based on an understanding of the neurobiological effects of trauma are often extremely effective. Many more examples are available to CTR members.
**All case examples posted on this site are fictitious; however, these are based on actual situations that we have encountered.
The Case of Sophie
Background: Sophie is an 8 year old Caucasian girl who has lived with her aunt, Helen, for the past 5 months. Helen is committed to caring for Sophie and is seeking custody. Sophie’s behaviours are escalating and Helen is finding it more difficult to care for her and would like support. Sophie constantly asks Helen if she will be staying with her forever.
Sophie has moved around to many different relatives and family friends since she was 2. She was removed from her parents at age 2 and returned when she was 3 and recently removed again 1 year ago. In her early years she was exposed to chaotic and violent environments. She was born while her mother was in a transition home and shortly afterwards her parents reunited for a period of time but her father then disappeared as there were warrants for his arrest. She has not seen her mom for the past year. While in the care of her mom she moved around a lot and mom had many different men in the homes.
Query of FASD and has many ADHD symptoms but no diagnosis.
Strengths: Sophie can be engaging and smiles shyly upon first meeting someone new. She is engaging when she is comfortable with people and can be quite chatty and funny. She does well with colouring and painting. Sophie has lots of energy and loves to climb on the playground equipment. She likes to help younger children and often plays well with her younger cousins.
Challenges: She tends to be clingy with Helen and does not want to leave her side. Sophie seems to question non-stop how long she will be allowed to live with Helen. She can be explosive when her needs are not met and when things do not go as she thought they were planned. It can take her a couple minutes to explode but hours to calm down. These meltdowns can happen frequently. When she is exploding she yells, swears, throw things and can destroy things around her. She does this both in home and in school. She has locked herself in the bathroom when she was triggered by something and cousin had to be called to get her out. She gets extremely angry and can be aggressive.
Sophie gets overwhelmed by busyness and noises – like the school bell. She comes to school appearing tired and on high alert. She knows what is happening around her even if she is not directly involved. Helen says that she has a difficult time sleeping and has night terrors. She can often be found either twisting her hair and rocking. At times she hides in her closet at home. When she’s stressed she will also suck her thumb. She is hungry all the time and takes others’ lunches at school.
While Sophie can be engaging with adults she has difficulty making friends with peers as she can be quite bossy and intimidating. She gravitates to younger children or children who have gone through similar situations. She pushes others around physically and emotionally, making sure she is first in line. The students in her class don’t seem to like her.
At school she is often disruptive and gets easily frustrated. She is often defiant and refuses to do the tasks asked of her. Things are especially hard when there is substitute teacher. She is easily distracted. While she appears to have good expressive language she does not seem to fully understand what she is being told and is often a couple steps behind the class in tasks. She loses her school supplies and often things are spilling out of her desk. She often calls herself dumb and compares herself to others.
Sophie has been diagnosed with ADHD and Oppositional Defiant Disorder. There is some concern by the social worker that Sophie has FASD. She has recently been given a prescription for Ritalin but this doesn’t seem to have changed anything. Helen tried a consequence-based behavioural chart system but Sophie tore it up.
Assessment and Intervention Plan: Our Functional Developmental Assessment led to a priority focus on reducing Sophie’s over-reactive stress response system and deepening her attachment experiences with Helen. The team began by:
- Reducing the stressful demands on Sophie for situations where she was unsuccessful
- Decreasing her time at school to mornings only
- Building in regular periods of calming activities during the day
- Emphasizing the need for predictable routines
- Coaching Helen in emotional attunement
- Asking Helen to avoid time-outs and other possible attachment rejection consequences
- Asking Helen to create fun rituals around key times such as bedtime, bathtime, reading out loud, meals, and leaving-returning
Outcomes: Sophie responded very quickly to the changes. At school she became more settled and less aggressive. Within two months she was having mostly positive days at school with minimal outbursts. At home she became less clingy and demanding and began to be able to play quietly on her own for periods of time. She loved the fun rituals that Helen put in place and made up some of her own. Most of the stress response behaviour such as twisting her hair and rocking began to disappear. She continued to have a strong response when she was frustrated but these incidents were resolved within minutes rather than hours.
- Current and Previous Diagnoses:
Query of FASD and has many ADHD symptoms but no diagnosis.
The case examples presented here are organized according to the 7 Developmental Domains. The first cases are shorter and emphasize one of the domains each. The last case is a longer example where we pull it all together.