Transcript Identification of Childhood Pathology in Complex Cases of

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
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
DEFINITIONS

Trauma
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
A deeply distressing or disturbing experience
Complex Trauma
Either multiple traumatic events OR
 Trauma that is exacerbated by additional external
factors or events

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Diagnosis

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Formal conclusions based on consensus or scientific
guidelines
Problem Identification

Beyond diagnosis, this is where the presenting issues
are identified to inform intervention planning
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

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

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

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
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

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

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

CASE STUDY 2 – ASSESSMENT AND
DIAGNOSIS

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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
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

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
POSTTRAUMATIC STRESS DISORDER
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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

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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
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?

A THEORETICAL MODEL OF SYMPTOMS
PTSD
RAD
PDD
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

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

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

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 DSMIV-TR criteria?
 Refused to engage in further assessment

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

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

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

CASE STUDY 3 – COMPLEX TRAUMA

What does Katie present with?
Reactive Attachment Disorder
 Posttraumatic Stress Disorder
 Inhalant Abuse
 Conduct Disorder
 Executive dysfunction
 Emerging psychosis
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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
