Identification of Childhood Pathology in Complex Cases of Trauma

1. Identification of Childhood Pathology in Complex Cases of Trauma Dr Larry Cashion Specialist Consultant Psychologist Workshop presented at the Communities for Children Connections Conference Launceston, 29 June 2011

2. Workshop Plan • Define key terms • Define the assessment process • Focus on the three main psychological presentations in trauma • Reactive Attachment Disorder • Posttraumatic Stress Disorder • Autistic Disorder (Pervasive Developmental Disorders) – often to be discounted • Demonstrate key issues in assessment and diagnosis in trauma presentations through case examples

3. Definitions • Trauma • A deeply distressing or disturbing experience • Complex Trauma • Either multiple traumatic events OR • Trauma that is exacerbated by additional external factors or events • Diagnosis • Formal conclusions based on consensus or scientific guidelines • Problem Identification • Beyond diagnosis, this is where the presenting issues are identified to inform intervention planning

4. Assessment and Diagnosis Basics • Assessment is a process • Assessment is formal and requires certain guidelines and procedures to be maintained • Ad hoc assessment is guesswork • Diagnosis is the conclusion reached from assessment • Diagnosis is not labelling – it is often a very important part in problem identification and intervention planning

5. Case Study 1 – Assessment and Diagnosis • Cindy is a 3-year-old girl • Her mother has multiple psychopathologies and antisocial behaviour problems • Cindy cannot be cared for my her mother and is placed in family care • Cindy is subsequently removed from family care and placed into foster care • Cindy displays significant behavioural problems in foster care and is provided with speech, OT, and psychological assessment • She is diagnosed with Reactive Attachment Disorder by the psychologist

6. Case Study 1 – Assessment and Diagnosis • Reactive Attachment Disorder of Infancy or Early Childhood • DSM-IV-TR 313.89 • Only recognised from DSM-IV in 1994 • Not universally accepted in psychological and psychiatric communities • A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts • C. Pathogenic care • B. Criterion A is not accounted for solely by developmental delay and does not meet criteria for Pervasive Development Disorder

7. Case Study 1 – Assessment and Diagnosis • Step 1: Is there – • persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses AND/OR • diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments • Responses – Yes to the first, no to the second

8. Case Study 1 – Assessment and Diagnosis • Step 2: Is either one of these present? • Intellectual disability • A Pervasive Developmental Disorder (PDD) • Cindy did not show evidence of an intellectual impairment using appropriate scales • Cindy was not assessed for a PDD • Therefore, it cannot be concluded that RAD is present – nothing else is relevant without this diagnostic criteria being assessed

9. Case Study 1 – Assessment and Diagnosis • Step 3 – Only if the previous criterion is met • Was there ‘grossly pathological’ care in terms of: • persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection • persistent disregard of the child's basic physical needs • repeated changes of primary caregiver that prevent formation of stable attachments • Insufficient evidence existed for these issues, so inappropriate diagnosis in any case • The psychologist relied on hearsay and made no attempt to observe the family dynamics and interaction

10. Case Study 2 – Assessment and Diagnosis • A genuine case of RAD - Betty • 14 year old girl referred after being charged with assault on her mother • Marked impairment in social development and responses with adults and peers • Was prostituting herself for money to buy alcohol and cigarettes • Assessed for PDD, with no evidence of this being underlying cause • Assessed for intellectual ability and within low average range

11. Case Study 2 – Assessment and Diagnosis • Steps 1 and 2 completed. Go to Step 3. • (1) Betty’s mother and father were prostitutes, IV drug users, and drug dealers; There was an absence of communication and interaction with the child • (2) Betty had to spend significant resources on self-help in early childhood due to parental deprivation and neglect • In addition, Betty had no appropriate social role models in childhood ; Undisclosed sexual abuse in childhood; Physical abuse by parents; Inconsistent demands by parents • Comparing Case 2 to Case 1, grossly pathological parenting was present in only Case 2

12. Disordered Versus Reactive Attachment • Is the perceived reactive behaviour directed solely at the parent/s or toward all adults • Has the parent disclosed a history consistent with grossly pathological evidence; or is there evidence of such beyond mere hearsay • When did the perceived reactive behaviour commence – I had a case of disordered attachment where the reactive behaviour started with adolescence – therefore not RAD • Attachment problems can have lifelong effects, but that does not make them RAD

13. Posttraumatic Stress Disorder • Posttraumatic Stress Disorder • DSM-IV-TR 309.81 • The development of characteristic symptoms following exposure to an extreme traumatic experience stressor • Direct personal experience OR • Vicarious experience with close relationship • PTSD is a syndrome – there are other responses to trauma that do not meet the criteria

14. Posttraumatic Stress Disorder • Persistent reexperiencing • Recurrent distressing thoughts – in child play with congruent aspects of trauma • Recurrent distressing dreams – in children, nightmares with little congruence to trauma • Reliving experiences – in children reenactment can occur • Intense psychological distress • Physiological reactivity on exposure to cues • Persistent avoidance • Thoughts, feelings, conversations about traumatic event • Activities, places, people associated with traumatic event • Inability recall important aspects of traumatic event • Diminished interests • Detachment • Restricted range of affect • Sense of foreshortened future

15. Posttraumatic Stress Disorder • Avoidance • Difficulty getting to or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response • Question: Does this sound like something else were have been discussing? • Can RAD be conceptualised as a form of PTSD with disordered attachment? • Is the grossly pathological parenting in RAD just another form of trauma under the PTSD umbrella?

16. A Theoretical Model of Symptoms RAD PTSD PDD

17. The Assessment Process • Formal consideration of presentation • Structured interviews – e.g., Sattler, ADI-R • Parent/carer/teacher reports – e.g., CBCL (Achenbach), ABAS, BRIEF • Clinical observations across multiple contexts – home, school/preschool/day care, office • Caution – be careful not to rely solely on the reports and interpretations of others! • Best practice standards for PDD assessment is to have multiple informants from multiple contexts – this should apply to trauma assessments

18. The Assessment Process • Consider the diagnostic criteria • Liking or disliking the criteria from DSM or ICD is not the relevant issue – for kids to receive assistance funding they need a diagnosis that reflects the standard set by the government • RAD and PTSD can be dual diagnosed • A PDD and PTSD can be dual diagnosed • RAD and a PDD are mutually exclusive

19. Case Study 3 – Complex Trauma • Katie – 12 year old Indigenous female • Came from town camp near Alice Springs • Mother was high volume alcohol and cannabis abuser; was petrol sniffer in youth • Father lived in Darwin and Katie lived with him from time to time; high level cannabis and alcohol abuser • Evidence of neglect by both parents • Taken into state care at for final time at age 10 years • Highly oppositional

20. Case Study 3 – Complex Trauma • Katie was running away from her care placement • Katie showed disinhibited attachments to people that were often of brief duration • She was thought to be intellectually disabled • Subsequent testing showed a variable IQ profile ranging for 56 for working memory to 88 for perceptual reasoning • Was this enough to eliminate RAD under DSM-IV-TR criteria? • Refused to engage in further assessment

21. Case Study 3 – Complex Trauma • Initial assessment by paediatrician suggested ‘autistic-like’ behaviour • Formal assessment ruled this out • So: • Katie was reported to have experienced pathological parenting, where her physical and emotional needs were not met • She was in care at multiple placements throughout her lifetime; these mostly broke down due to her challenging behaviour

22. Case Study 3 – Complex Trauma • Although these circumstances existed , the assessing clinician was not provided with the background information • Katie experienced significant symptoms of ADHD, which was diagnosed as her primary issue • She was treated with stimulant medication – this medication sedated her, but did not seem to otherwise assist • After a few months, Katie refused to take her medication and was subsequently placed into a specialist care placement

23. Case Study 3 – Complex Trauma • Katie’s assessment at age 13 • It was subsequently revealed that Katie had been sexually abused on multiple occasions as a child • Katie was reported to be prostituting herself for alcohol and volatile substances, especially glue – these acts were committed with much older males in some cases – she had multiple STIs • Katie refused to attend school • She had contact with police regarding assaults and shop stealing • Hears people speaking when no one is there

24. Case Study 3 – Complex Trauma • What does Katie present with? • Reactive Attachment Disorder • Posttraumatic Stress Disorder • Inhalant Abuse • Conduct Disorder • Executive dysfunction • Emerging psychosis

25. Case Study 3 – Complex Trauma • What does Katie present with? • Reactive Attachment Disorder • Posttraumatic Stress Disorder • Attention-Deficit/Hyperactivity Disorder • Inhalant Abuse • Conduct Disorder • Executive dysfunction • Emerging psychosis