This week’s blog was contributed by Jeremy Sharp, PhD, licensed psychologist and clinical director at the Colorado Center for Assessment & Counseling and the host of the Testing Psychologist Podcast. Dr. Sharp earned his undergraduate degree in experimental psychology from the University of South Carolina and earned his master’s degree and doctorate in counseling psychology from Colorado State University. He specializes in psychological and neuropsychological evaluation of children and adolescents and provides private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. He lives in Fort Collins, Colorado with his wife (also a therapist) and two kids.
First, what IS trauma? The DSM-5 definition is easy to find, but the very first requirement for a PTSD diagnosis (“Exposure to actual or threatened death, serious injury, or sexual violence…”) does not capture the broad range of experiences that may lead to a trauma response. Right away, we find the categorical nature of the DSM-5 may not adequately conceptualize or capture the huge continuum of traumatic experiences. I think we can all agree that not all “traumatic” experiences involve exposure to death, serious injury, or sexual violence. What about neglect? What about emotional or psychological abuse? It is necessary to further define trauma and the many ways it can occur. One way to break it down a little further is to distinguish between acute (“Big T”) trauma and developmental or complex (“little T”) trauma.
Acute trauma refers to a discrete event that occurs at a single point in time. With acute trauma, one can generally identify a clear change in functioning from before the event to after the event. An acute trauma may be something like a sexual assault, a car accident, or being held up at gunpoint. Complex trauma is more complicated and refers to ongoing, recurrent traumatic experiences. When these recurrent traumatic experiences happen during childhood, the collective experience is called developmental trauma.
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Why is this distinction relevant for us as clinicians? Because it affects how we assess and treat individuals. We know that individuals with acute trauma typically may have a quicker path to recovery, while individuals with complex trauma tend to show more chronic symptoms. Acute trauma is also easier to assess in the sense that we are only gathering information about one event, with a relatively clear before and after, while complex trauma tends to be multilayered.
Regarding the assessment process specifically, detailed questions about trauma should be included in nearly all diagnostic interviews. As mentioned earlier, many parents and individuals can overlook or downplay potentially traumatic experiences. Kids also may not share their traumatic experiences with their parents or others unless asked directly. There are a couple of ways to get at these concerns without coming across as too heavy-handed. One is to say something like, “Tell me about some of the most important events in your life” or “What are the top three hardest/worst things that you can remember?” or “Have you held any secrets for a long time that you’d like to share?” Note that forensic interviewing is a clear subspecialty in our field. Do NOT practice outside the scope of your expertise! Another way to explore these questions is to use a broadband questionnaire as a guide for topics/events to inquire about. If your client shares anything that warrants further exploration, you can integrate a narrower questionnaire to drill down on specific trauma symptoms.
Moving further down the path of the assessment process, it is important to think through the relationship between trauma and other mental health diagnoses. A question that comes up often is, how to separate trauma from ADHD/autism/anxiety, etc. As Dr. Maggie Sibley and Dr. Julia Strait noted on past Testing Psychologist podcast episodes, maybe we don’t. Maybe we need to stop thinking about how to separate these diagnoses, because it is nearly impossible to do so, particularly in the case of developmental trauma. Even going by the DSM-5 definition of PTSD or acute stress disorder, there are many PTSD symptoms that occur in other diagnoses. These symptoms include repetitive play (autism), intrusive memories/thoughts (OCD), distress when exposed to certain cues (specific phobia), poor memory (ADHD), and alterations in cognition (depression, anxiety, ADHD), just to name a few. Unless we have a clear picture of functioning before the trauma started, it is extremely challenging to know if these symptoms “belong” to the trauma or something else. In these (and all) cases, gathering an accurate history is crucial to establishing context to interpret an individual’s symptoms and assessment results.
In cases when an accurate history is not available from the primary caregiver, clinicians may need to expand the scope of the evaluation and incorporate a broader record review or interviews with additional people in the client’s life. Even then, we sometimes must simply do our best with what we’ve got to come up with meaningful conceptualization and recommendations.
Ultimately, we want our assessment to guide treatment and provide helpful recommendations for our clients. By conducting a thorough clinical interview; utilizing well-standardized assessment instruments; and providing realistic, evidence-based recommendations, testing psychologists play a vital role in helping individuals identify and heal from their adverse experiences.
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