Beyond PTSD: The Complexity of Diagnosis and Treatment for Teens in Child Welfare Custody

Cases like Sara’s underscore the limitations of our current diagnoses. Adolescents in the child welfare system, like Sara, have high rates of psychiatric diagnoses. Their medical charts often list multiple hospitalizations and medication trials. But their charts rarely capture the terrible pain of ongoing trauma: of separation from family, of court dates where youth face the perpetrators of their abuse or those who failed to protect them, of constant fear of being sent back or of being sent away, of ongoing abuse or neglect in foster homes or within the family, of nightmares and flashbacks that have never been effectively treated, of not being heard or believed.

Complex PTSD, which will soon be added to the International Classification of Diseases in the ICD-11, attempts to better represent the severe impact of childhood trauma and the complexity of symptoms that follow, including mood and anxiety symptoms, behavioral dysregulation, and attention and memory problems. It is hoped that this new diagnosis will lend diagnostic clarity for youth who have experienced trauma and focus their treatment on achieving safety (both physical and psychological) and processing what they have lived through.

Even with clarity on diagnosis and treatment, identifying trauma-exposed youth and engaging them in trauma-focused treatment can be difficult. Many teens exposed to trauma develop a guarded, dismissive attitude to evade those they fear may attempt to discuss the trauma or the painful/shameful emotions that surround it. The concept of “universal trauma precautions” suggests that we should assume all youth (especially those in child welfare) have experienced trauma, but asking them directly about it must be done with skill and nuance to overcome the youth’s trauma-related avoidance. Normalization, generalization, validation, empathy, and transparency can help put the teen at ease and demonstrate that you want to hear and to help. A curious and nonjudgmental stance with respect for the teen’s pace and limits will avoid pushing too hard and triggering the youth’s protective defenses. Here are some additional techniques:

A respectful, validating, and curious stance can help get to what is often called the “second story.” Instead of getting stuck in simplistic explanations that too often lead to superficial or unhelpful solutions, with the “second story” you can begin to connect past traumas to current behaviors and foster motivation for treatment. Understanding the connection between trauma and behavior also forms the foundation for choosing an appropriate evidence-based trauma therapy (to familiarize yourself with evidence-based practices for child welfare, visit www.cebc4cw.org/search/topic-areas/). Even with the “right” treatment, it may take some heavy “doses” of the techniques described above to shift the teen’s view of, and openness to, mental health treatment. And even more importantly, a trauma-informed, developmentally appropriate approach can change the way the teen views himself or herself and the capacity to connect with others, change patterns of behavior, and take control of the future. ■