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1. Trauma informed
Child development,
attachment and
assessment
CLINICAL ASSESSMENT OF
PSYCHOLOGICAL TRAUMA AND PTSD WITH
CHILDREN AND ADOLESCENTS

2. Trauma Exposed Children and Adolescents:
Overview
PTSD is a rare condition in the general population
of children and adolescents. Prevalence of PTSD
and the presenting symptoms of PTSD generally
change with development.
Recovery from trauma influenced by:
Development period of trauma exposure
Type of trauma
Repeated exposure and exposure to multiple
traumas

3. Trauma Exposed Children and
Adolescents: Pre-Trauma Risk Factors
Pre-trauma risk factors for poor psychological outcomes after
trauma exposure include:
History of parental mental illness
Insecure child- parent attachment patterns
Family conflict, lack of family cohesion, coercive child rearing
practices, large families and divorce
Economic hardship
Social isolation, living in dangerous neighbourhoods,
Caregiver alcohol or drug dependence
Child has a disability (see references below)

4. Trauma Exposed Children and
Adolescents: Pre-Trauma Protective
Factors
Factors that contribute to a child's resilience
include:
Child attributes
Features of the family environment
Extra-familial and community resources

5. Trauma Exposed Children and Adolescents:
Developmental Considerations
In infants and young children they and their caregivers still are
developing what Bowlby (1969) described as their ‘working models’ of
attachment- developmentally significant milestones.
Bowlby (1951) proposed that, in order to promote good mental health
outcomes in children, “the infant and young child should experience a
warm, intimate and continuous relationship with his mother (or
permanent mother substitute) in which both find satisfaction and
enjoyment” (p. 13)

6. Trauma Exposed Children and Adolescents:
Four Phases of Attachment
The developmental outline for attachments includes
four phases:
0-3 months, indiscriminate social responses
3-6 months, preferential social responsiveness
6-24 months, secure base behaviour, is observed
24-30 months, goal-corrected partnership between
the child and the attachment figure

7. Trauma Exposed Children and Adolescents:
Four Phases of Attachment(con)
Bowlby (1969, 1988) provided an ethological
perspective to explain the development and
mechanisms of attachment as intrinsic to
evolutionary adaptation.
Homeostatic system of regulation
Felt security
System wherein the individual continuously
monitors internal and external cues and adjusts
his/her behaviour accordingly.

8. Trauma Exposed Children and Adolescents:
The Working Model
The term “working model” refers to a set of
knowledge structures that include “expectations,
beliefs, emotional appraisals, and rules for
processing, and excluding information. They can
be partly conscious or unconscious and need not be
completely consistent or coherent” (Bowlby, 1980,
p. 407).

9. Trauma Exposed Children and Adolescents:
The Working Model (con)
In line with information processing theory, Bowlby (1973)
conceptualised all information, including conflicting or new information,
as passing through many processing stages, terminating in
accommodation and awareness of the new information (integration into
existing autobiographical memory).
Revision of one’s working model may require a conscious process of
revising, extending and checking the consistency of the model content
for healthy development.
Defensive strategies are believed to seriously compromise the capability
of the internal working model.

10. Trauma Exposed Children and Adolescents:
Attachment Development and the Working
Model
Immature internal working models in childhood primarily focus on
expectations about the (emotional) availability and approachability of the
caregiver in threatening or anxiety-provoking situations. Congruent with
the child’s cognitive development is the simultaneous development of an
internal working model that permits cognitive conceptualisation. This
lays the foundation of the child’s assumptions about how close
relationships function, the child’s perception of self (as worthy or
unworthy of love and support), as well as the child’s perception of others
(as dependable or undependable). An individual’s working model and
attachment style are intricately entwined. In situations where the
attachment figure is unavailable as a secure base, insecure attachment
orientations develop.

11. Trauma Exposed Children and Adolescents:
Attachment Development and the Working
Model (con)
As the child enters adolescence, cognitive
development permits important changes in
attachment functioning; for example: the individual
may engage symbolic/mental representations in
attachment seeking and proximity to attachment
figures; a hierarchy of attachment figures may
develop, with attachments being formed/transferred
to those other than primary caregivers (e.g., peers,
romantic partners) this increases the availability of
possible attachment resources.

12. Trauma Exposed Children and Adolescents:
Attachment Development and the Working
Model (con)
Once the individual’s working model and attachment system is matured,
it is considered resistant to dramatic fluctuations.
Unique psychological and neurobiological differences that reflect the
individual’s experiences and attachment system organisation over the
lifespan are able to be explained.
Bowlby (1973) that is very pertinent to our discussion, “the inheritance
of mental health and of ill health through family micro-culture is no less
important, and may well be far more important, than is genetic
inheritance” (p. 323).

13. Trauma Exposed Children and Adolescents:
Neurodevelopmental Considerations
Perry (2009) suggested that early attachment experiences are
intrinsically involved in neural development.
Each region of the brain is subject to developmentally
sensitive periods
Sensitive periods occur when the brain has the ability: “to
rapidly and efficiently organize in response to the unique
demands of a given environment to express from its broad
genetic potential those characteristics that best fit the child’s
world; different genes can be expressed, and different neural
networks can be organized from the child’s potential to best
fit that family, culture, and environment” (p. 245).

14. Trauma Exposed Children and Adolescents:
Neurodevelopmental Considerations (con)
Brain organises in use dependent manner.
Environmental and micro-environmental cues (e.g., neurotransmitters,
cellular adhesion molecules, neurohormones, amino acids, ions) are
crucial for the neural systems to develop from the undifferentiated
immature forms of an infant. The brain organises in a use-dependent
manner, and relies on molecular cues to influence this process.
In immature and mature brains, use-dependent changes in the stress
response system occur when the individual experiences prolonged or
repeated exposure to threat, fear, chaos, stress and trauma. In turn, this
alters the molecular characteristics of individual neurons, synaptic
distributions, dendritic trees, and the microstructure and microchemicals
of the stress response neural networks.

15. Trauma Exposed Children and Adolescents:
Neurodevelopmental Considerations (con)
Protective factors of healthy relationships that mitigate the impact and
outcome of adversity in the developing brain as the relational modulation
of stress.
Perry stated that the relational modulation of stress is mediated by two
interconnected and widely distributed systems in the brain, namely, the
stress response system and the neural networks associated with bonding,
attachment, social communication and affiliation
Primary caregivers also provide the developing brain with initial
templates of relational interactions. When these templates are comprised
of safety and comfort, a foundation for building future positive relational
interactions exists. Moreover, those protective relational interactions,
although initiated by the primary caregiver throughout development,
extend to include other familiar and safe individuals

16. Trauma Exposed Children and
Adolescents: Attachment Outcomes
Secure attachment
Anxious-Avoidant Attachment
Anxious-Resistant Attachment
Disorganised Attachment

17. Trauma Exposed Children and Adolescents:
Considerations of Symptoms of Complex
Trauma
Insecure attachment
Biological issues
Regulation of affect (emotions)
Dissociation
Behavioural control
Cognitive deficits
Self-concept
These symptoms are likely to interfere with developmental
tasks which create a more complex clinical picture as the
child matures

18. Trauma Exposed Children and
Adolescents: Attachment Outcomes
Across the Lifespan
Secure Attachment
Dismissive Avoidant (or Anxious-Avoidant)
Attachment
Anxious-Preoccupied (or Anxious-Resistant)
Attachment
Fearful Avoidant (or Disorganized) Attachment

19. Trauma Exposed Children and Adolescents:
Assessing Trauma and Personal History
The empirical evidence provides a strong argument for the necessity of
conducting a thorough and comprehensive assessment of the child’s
trauma history, personal and family history and background in general.
Depending on the age of the child and the family make-up this can be
somewhat challenging. In part this is why a multidimensional approach
to gathering information is undertaken.
When conducting an assessment with children and adolescents numerous
sources of information must be gathered. In this setting collateral
ratings/reports will be essential (typically via ratings by parents or other
adult caregivers, teachers).
In addition, appropriate structured interviews and questionnaire
measures may be completed with the child. Where possible and
appropriate direct observation in the home or in clinical settings along
with collateral reports/ratings can provide valuable information for
corroboration or revision of the information gathered.

20. Trauma Exposed Children and Adolescents:
Assessment DSM-5 pre-school subtype of
PTSD
In the DSM-5 is a pre-school subtype of PTSD which applies to children
under the age of six years old
This diagnostic criteria reflects developmental considerations in PTSD.
For example depending on the developmental stage of the child abstract
cognitive and verbal expression abilities may not yet have developed or
are only emerging
The algorithm required to meet the diagnostic criteria is different than
that for adults, adolescents, and children older than six years.
The pre-school subtype requires the child experience at least one
symptom from Criterion B, two symptoms from Criterion E and one
symptom from Criterion C or D. Perritraumatic reaction is not assessed
in these young clients

21. Trauma Exposed Children and Adolescents:
Assessment DSM-5 pre-school subtype of
PTSD
Should the child meet the full diagnostic requirement of PTSD the
specification of delayed onset is also considered. Meaning delayed
expression: Full diagnosis is not met until at least six months after the
trauma(s), although onset of symptoms may occur immediately. This
new diagnosis is mindful of the unique trauma experiences and responses
of children.
Symptoms are behaviourally based, rather than being reliant upon the
cognitive or linguistic complexity absent in young survivors. For
example, symptoms include restless sleep, temper tantrums or decreased
participation in play. Children may express symptoms through behaviour
or play re-enactment, which may or may not appear related to the
traumatic event.

22. Trauma Exposed Children and Adolescents:
Assessment -Trauma Associated Dysfunction
and Disorder
It is important to determine what specific PTSD or associated traumatic
stress reactions or trauma-exacerbated symptoms are interfering with a
child’s ability to function healthily
For school-age children and adolescents, self-report questionnaires
assessing externalising problems such as, aggression, attention problems,
conduct problems, hyperactivity, learning problems and internalising
problems such as- anxiety, atypicality (psychosis), depression,
somatisation, withdrawal as well as several domains of self-regulation
and social competence which refers to, daily activities, adaptability,
functional communication, leadership, social skills, study skills is
important information that is gathered
It is important to note that while parents and teachers tend to provide the
most accurate reports of the child’s daily functioning, the child is most
accurate when it comes to reporting internal distress being experienced

23. Trauma Exposed Children and Adolescents:
Assessment -Trauma Associated Dysfunction
and Disorder (con)
For pre-adolescents and adolescents, it is important to assess key risks
(e.g. self-harm, substance use problems) and competences (e.g. impulse
control, consideration for others and responsibility, emotion regulation,
self-efficacy and optimism) as well as PTSD and related symptoms
The child’s / adolescents history of coping style, adjustment, and
functioning prior to the traumatic experience(s)
Several measures have been established for assessment of behavioural
and emotional functioning, as well as general and specific measures of
disorders commonly associated with trauma with or without PTSD
It is important to question children directly and/or utilise self-report
standardised measures to assess for the possible presence of depression,
anxiety, and/or other internal trauma symptoms in children and
adolescents