Complex Trauma FAQs SAMHSA

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Complex Trauma and Health Homes – Draft FAQs

SAMHSA, 10.20.15

1. Does complex trauma require involvement in or exposure to "multiple or recurring traumatic events" as stated in the CMS guidance? Could exposure to a single severely distressing event be considered under the concept of complex trauma?

A distinguishing feature of complex trauma is the exposure to multiple or recurring events over a period of time and usually in the context of a specific interpersonal relationship. It is often associated with severe and complex reactions and multiple diagnoses. There is currently no specific DSM diagnostic code for complex trauma; a child experiencing complex trauma may have multiple DSM diagnoses. For a child presenting with multiple diagnostic conditions, it would be important to determine if there is an underlying complex trauma that requires treatment, rather than treating each separate diagnostic condition. Complex trauma may have serious and disabling impact on many dimensions of a child´s functioning, including: attachments and relationships, emotional responses, dissociation, behavioral and cognitive responses, impairments in self-concept and future orientation, and long-term physical health consequences.

Exposure to a single traumatic event may more frequently lead to a diagnosis of post- traumatic stress disorder but generally does not have the global impacts of complex trauma. This diagnosis may be covered under the concept of "serious emotional disturbance" and is differentiated from complex trauma.

The SAMHSA-funded National Child Traumatic Stress Network (NCTSN) provides more information, in its description of Effects of Complex Trauma.

2. Can you provide some guidance regarding appropriate screening and assessment for 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. See: "How to Conduct a Comprehensive Assessment of Complex Trauma.". The NCTSN Learning Center hosts several on-demand webinars on complex trauma. There is one specifically on assessment.

3. Is there an inventory of screening and assessment tools for complex trauma?

The National Child Traumatic Stress Network maintains a table of Standardized Measures to Assess Complex Trauma. This table provides a list of measures, developers of the measure, domains assessed (e.g. affect dysregulation, self-perception, somatization, relations with others, etc.), targeted age, format (e.g. self-, clinician-, caregiver- or observer-report), completion time, cost of measure, and the actual measure or the publisher´s website. There is some differentiation between screening and assessment measures and clinical and research measures.

4. If the definition of complex trauma includes "long-term impact of this exposure," does this preclude infants from being covered by this concept? Is there a consensus among trauma experts that the current definition of complex trauma is intended to allow inclusion of infants and the youngest children? If so, are there ways to ensure that the components of the definition and the essential domains associated with complex trauma do not exclude infants and the youngest children?

We do intend to allow for the inclusion of infants and very young children in this definition of complex trauma. As written, the definition may appear to exclude infants as some of the domains of impairment (e.g., self-perception) are not as relevant for this age group. However, complex trauma does impact other domains of impairment that are quite relevant to young children, such as inability to form attachments and relationships, and difficulty calming down, and they are common problems associated with emotional dysregulation among complexly traumatized children. The formation of self and identity is also affected; however, the symptom presentation in infants and very young children would be different than what is seen in older children or adolescents.

We will not be changing the definition, but will include a qualifying statement to ensure that infants and very young children can be considered for this condition.

5. Are there screening and assessment tools or approaches that are specifically developed for infants and young children?

Screening and assessing for complex trauma in infants and very young children needs to consider: (1) child functioning; (2) caregiver functioning; (3) child-caregiver relationship; and (4) context of the child-caregiver relationships (e.g. social and community supports).

In assessing infant-specific symptoms, it would be essential to examine social, emotional, and developmental functioning with an emphasis on the attachment relationship with the caregiver. This usually involves: (1) a thorough history consisting of interviews with significant adults in the child´s life and a comprehensive review of medical/legal records, in conjunction with (2) a direct behavioral observation of the child and caregiver.

There are specific observational approaches for assessing infants and very young children, such as Parent-Child Structured Play Interaction (the Crowell Procedure), and other infant assessment tools and approaches that may not be trauma-specific for infants but can begin to identify problems early (e.g. Bayley Scales of Infant Development, Ages and Stages Questionnaire, and Pediatric Emotional Distress Scale).

While we have included some guidelines to consider in choosing screening/assessment approaches for this age group and a few selected tools, we are not specifically endorsing these tools as there are a range of options that should be considered. Consultation with experts may be indicated to assist states in identifying the best tools to identify the population to be covered and to accommodate the capacity of their providers.

File: Chronic Conditions 10.20.15