Complex Trauma and Assessment
by Dr. Chuck Geddes
We received a referral last month for a young 10 yr old boy. (We’ll call him David although that isn’t his real name.) David was referred for help because none of the existing services were making a difference with his extreme behaviour. David had recently been suspended from school for the 4th time in the first 4 weeks of school. He was seen to be having regular “meltdowns” in which he would scream and yell, throw books, and threaten classmates. When escorted outside the building he would pick up rocks and throw them at teachers and cars. His foster parents reported that this was all pretty typical behaviour for David and they were at their wits end. Even though this was his third foster home in two years they might have to give up on him too as they worried about their safety. David was viewed as a bright and engaging boy in his good moments but an “explosion waiting to happen” the rest of the time.It turns out that David had been kicked out of most of the support services which were offered — for things like threatening and verbal abuse of kids in his social skills group, and for punching his counsellor from Child and Youth Mental Health. He was currently on multiple medications to try to control his outbursts
David had recently completed a 30-day inpatient assessment at a regional children’s psychiatric centre. His emotional outbursts and difficulties led to this list of DSM-V diagnoses:
- Reactive Attachment Disorder
- Mood disorder, Unspecified
- Disruptive Behaviour Disorder (ADHD)
- Social Communication Disorder
- Post Traumatic Stress Disorder (chronic)Learning Disorders
- Tourette’s Disorder
- Alcohol-Related Neurodevelopmental Disorder
As you can probably imagine this felt quite overwhelming to the social worker, school and foster parents. One said privately “I knew that he was kind of messed up but I just didn’t know he had all these problems.” The report included a list of evidence-based interventions for each of the disorders, many of which were not available in their community. Instead of providing answers, the assessment had actually left the team more discouraged.
The traditional diagnostic approach often leads to a series of disconnected therapy recommendations and encourages the use of multiple medications to control the various “disorders”. We see case after case in the child welfare system where this isn’t helpful and the child’s difficulties continue. From our perspective, David’s extensive trauma history is the underlying cause of each of the problems noted in the assessment. Instead of a long list of separate disorders, David is suffering the effects of complex trauma and the various “symptoms” are linked. See About/Our Approach http://www.complextrauma.ca/about/our-approach/ for more detail on this.
Our non-diagnostic approach allows us to focus on the trauma-specific goals instead of on the formal diagnostic terminology. In doing so, we would work with the caregivers, the care team and the child/youth on some of the following focal points:
1. Decreasing Stress and Hyperarousal
2. Deepening Healthy Attachment
3. Developing Emotional Literacy
4. Focusing on the Child’s Successes
The complex trauma understanding gives the caregivers, social workers, and other professionals a foundation upon which to understand a boy like David and respond to his needs. We see children and youth calming and slowing down, losing their hair trigger responses, and connecting with their caregivers and other caring adults in a healthier way.
Let’s return to the challenge facing those who were asked to provide a mental health assessment for David. The psychiatrists and psychologists at the inpatient unit have used the tool available to them, namely the DSM-V. They have no choice but to list all of the different diagnoses which might apply to David. Unfortunately, a well-researched proposal to include a Developmental Trauma Disorder (Complex Trauma) as a separate diagnosis in the DSM-V was unsuccessful, even though it had the backing of internationally renowned trauma researchers such as Bessel van der Kolk. Apparently, one of the reasons that the proposal was unsuccessful was that the symptoms of complex trauma or Developmental Trauma Disorder ranged across many existing diagnostic categories, and thus didn’t fit well within the current system.
Diagnosis can be useful in certain circumstances; however, I have seen hundreds of cases in which the existing assessment system is not helpful to kids or the adults that care for them. One of our favourite quotes is from psychologist Ross Greene who notes that “Understanding leads to intervention.” What we seem to be offering our hurting kids is a system of Understanding that regularly misses the point, and thus leads to Interventions that miss the point as well. Surely we can do better than that. David deserves an approach that would be fully understanding of his losses and grief and abuse – an approach that would be grounded in the science of brain and nervous system development. David has a right to the best help and treatment possible, and that begins with an appropriate and accurate assessment.
For more on David’s case, watch his unfolding story in our next Clinical Director’s view as we look at Complex Trauma and Medication.
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