Screening & Assessment of
Trauma for IEP's
Chris Dunning, Ph.D.
Professor Emerita
University of Wisconsin-Milwaukee
cdunning@uwm.edu
Workshop Objectives
• Increase ability to identify effects of child
traumatic experience presenting at school
• Connect trauma-based barriers to learning
to student performance
• Improve ability to use screening and
assessment tools to inform consultation
with teaching staff
• Develop strategies to include trauma
assessment in the development of IEPs.
Why are we doing this?
Trauma & Academics
• Impact of trauma on school readiness
• Impact of trauma on school performance
• Impact of trauma on cognitive functioning
that may result in behavioral difficulties
• Increased likelihood of dropping out of
school
What affects learning associated
with traumatic experience?
Behaviors
Health
School Attendance
Memory
Cognitions
Academic tasks that are difficult when
experiencing trauma related conditions
Concentrating
Sitting
Still
Talking
(When
experiencing
stress
reaction)
Controlling
Impulses and
Behavior
Organizing
Setting
Priorities
Making
Decisions
Processing Oral
Information
(When experiencing
stress reaction)
Contextualizing
(associating concepts
appropriately)
Memory
Remembering
Reference
• Nickerson, Amanda,
Stephen Brock, et al
(eds.) (2008)
Identifying,
Assessing, and
Treating PTSD at
School
• Springer Pub.
What needs to be Assessed? Not PTSD!
Acute and Chronic Traumatic Stress
• Traumatic Experience
– Objective & subjective features
• Appraisal/Response to Threat
–
–
–
–
Scope of danger
Reaction & regulation
Protective responses
Positive/negative adjustment
• Proximal & Distal Reminders
– Internal & external cues
• Proximal & Distal Secondary Stress
– Family functioning, social support, service system
demands
• Acute Reactions
– Symptoms, developmental failure, learning
impairments
• Intrinsic Factors
– Genetics, anxiety sensitivity, developmental status,
trauma history
• Social Ecology
– Parent/Family functioning & psychopathology,
school, peers
• Proximal & Distal Development & Psychopathology
– Biological maturation, cognitive & emotional
development, impulse control, personality features
• Repeated Exposure & Adversity
– Subsequent trauma, chronic life adversity
•
Psychopathology
– Premorbid & comorbid disorders, emergent
vulnerability, treatment response
What We’re Looking For
LONG-TERM STRESS REACTIONS
HEALTHY (Common)
• LEVEL 1: Initial Crisis Reactions
• LEVEL 2: Acute Stress Disorder
• LEVEL 3: Post-Traumatic Stress Reactions
• LEVEL 4: Post-Traumatic Stress Disorder
UNHEALTHY (Uncommon)
Stephen Brock 2008
Utilize comprehensive assessment.
• Trauma-specific standardized assessments can identify
potential risk behaviors (i.e. danger to self, danger to
others) and help determine interventions that will reduce
risk.
• Thorough assessment can identify a student’s reactions
and how his or her behaviors are connected to the
traumatic experience.
• Assessment results provide valuable information for
developing treatment goals with measurable objectives
designed to reduce the negative effects of trauma.
• Assessment results also can be used to determine the
need for referral to trauma-specific mental health care or
more detailed trauma assessment.
Issues which might require referral
Acute Stress Disorder
Post Traumatic Stress Disorder
Dissociative Disorders
Attachment Disorders
Adjustment Disorders
Where do you start?
• Review existing school records for traumarelated markers
– Enrollment pattern
– Attendance
– Health
– Behavior/discipline
– Outside agency connections
– School performance
Let’s Start with Health First
Impact of Trauma over the Life Span
Effects of ACEs*




neurological
biological
psychological
Social
*Adverse Childhood
Experiences
Health Issues Related To Adverse
Experiences In Childhood









Smoking
COPD
Heart disease
Fractures due to reenactment
Diabetes
Severe obesity/bulimia
Compulsive overeating
Alcoholism
Other substance
abuse
 IV drug use
 Early intercourse
 Teen pregnancy –
including paternity
 Promiscuity
 Dysphagiadifficulty
swallowing
 Pseudo-epilepsy
An ACE—adverse childhood experience—is exposure
to any of the following before the age of 18:
1.
2.
3.
4.
5.
6.
7.
8.
Recurrent physical abuse
Recurrent emotional abuse
Sexual abuse
An alcohol or other drug abuser in the household
An incarcerated family member
A household member who was chronically
depressed, mentally ill, institutionalized or suicidal
Violence between adults in the home
Parental separation or divorce
16
Figure ES2. Prevalence of Individual
ACEs in Wisconsin
• Emotional Abuse
• Substance Abuse In
Household
• Separation/divorce
• Physical Abuse
• Violence Between Adults
• Mental Illness In
Household
• Sexual Abuse
• Incarcerated Household
Member
29%
27%
21%
17%
16%
16%
11%
6%
18
19
ACE Study
Key finding 1: Expanding definition of childhood stress,
trauma and “maltreatment” had real life significance
beyond the event.
Key Finding 2: Adverse childhood experiences can have
an astonishingly broad based, harmful influence on adult
health. (And the beginnings of a health impact are
evident while in childhood.)
Key finding 3: The health effects of adverse childhood
experiences may not appear for decades.
ACE Study
Key Finding 4: The more
kinds of adverse
childhood experiences a
participant reported the
greater the risk for a given
health problem (traumadose relationship).
Key Finding 5: The more
kinds
of
adverse
childhood experiences a
participant reported the
greater the risk for more
health
problems
(comorbidity).
Adverse Childhood Experiences in
Wisconsin: Findings from the 2010
Behavioral Risk Factor Survey.
http://wctf.state.wi.us/index.php?section=adv
erse-childhood
or
http://wichildrenstrustfund.org/index.php?sec
tion=adverse-childhood
The Child’s Brain
Differences due to Trauma
Hippocampal Volume Reduction
in Childhood Abuse-related PTSD
1200
3
Hippocampal Volume (mm )
1100
*
1000
900
PSD (N=17)
Controls (=17)
800
700
600
*p<.05
500
Left Hippocampus
Right
Hippocampus
12% reduction in left hippocampal volume in abuse-related PTSD
Brain Circuits in Trauma Spectrum
Disorders: Brain Volumes
Hippocampus
Amygdala
PTSD
NC
Depression/
Abuse
NC
mPreFront
Cortex/
AC/ Obf
BPD
DID
?
Hippocampal Volume Reduction in PTSD
NORMAL
PTSD
Bremner et al., Am. J. Psychiatry 1995; 152:973-981.
Bremner et al., Biol. Psychiatry 1997; 41:23-32.
Gurvits et al., Biol Psychiatry 1996;40:192-199.
Stein et al., Psychol Med 1997;27:951-959. DeBellis 1999-no
change in children with PTSD
J Douglas Bremner, MD, Emory University
Child’s Brain
Healthy
Neglected/Abused
Lateral Ventricles Measures in an 11 Year
Old Maltreated Male with Chronic PTSD,
Compared with a Healthy, Non-Maltreated
Matched Control
(De Bellis et al., 1999)
Depression from Child Trauma
5-HTTLPR polymorphism
Healthy Child
Depressed Child
Examples of Exclusions/Overlap
So what is it? DSI, NVLD, ADHD, PTSD?
Sensory integration
Dysfunction
Nonverbal Learning
Disorder
•
•
•
•
•
DSI is a neurologically based
disorder, like ADHD and
learning disabilities.
A child with DSI has an inability
to organize sensory input for
use in daily living, which
includes school, play, and
family life.
The child has either a
hyposensitivity or a
hypersensitivity to sensory
input, such as an overreaction
to the feel of clothing or to the
texture of food.
DSI is similar to ADHD in that it
impacts learning, but is not a
learning disability. DSI overlaps
with ADHD in symptoms of
inattention and restlessness
•
(NVLD) is a type of learning
disability where the child has
deficiencies in nonverbal
reasoning.
NVLD overlaps with both ADHD
and DSI: the child with NVLD
can have the sensory sensitivity
of a child with DSI and the
impulsiveness, disorganization,
and hyperactivity of a child with
ADHD or with DSI.
Auditory Distortions
 Auditory Perceptual Problem: Trouble taking
information in through the sense of hearing
and/or processing that information.
 Auditory discrimination problem - hearing an
angry rather than a joking tone of voice.
 Auditory figure-ground problem - Trouble
hearing a sound over background noise: for
example, being unable to hear the telephone
ring when one is listening to the radio.
Stimuli Distortions
 Catastrophic response - An involuntary
reaction to too may sights, sounds, extreme
emotions or other strong stimuli.This may
result in losing one's temper, becoming
dazed or unaware of one's surroundings, or
"freezing" for a short time.
 Cognitive Disorganization: Difficulty thinking
in an orderly, logical way, People with this
problem often jump to conclusions and have
difficulty planning tasks.
Body Distortions
 Crossing the Midline : Trouble with moving
one's limbs across the center of the body.
This could include: Difficulty writing across
a page, sweeping a floor or controlling a
steering wheel.
 Unaware of body parts, such as not being
aware of self below waist.
Sense Of Touch
Tactile Perceptual Problem: Trouble taking
information in through the sense of touch.
Some tactile handicaps are:
 Immature Tactile System- People with this problem
dislike being touched lightly, but crave pressure touch,
such as being hugged hard or huddling with knees to
their chest. Until the immaturity is overcome, tactical
discrimination cannot develop.
 Tactile Defensiveness- Tendency to avoid being touched
because of an immature tactile system.
Sensory integration dysfunction
(DSI or SI)
• …can look like a learning disability, but it isn’t.
• DSI is a neurologically based disorder, like ADHD and
learning disabilities.
• A child with DSI has an inability to organize sensory
input for use in daily living, which includes school, play,
and family life.
• The child has either a hyposensitivity or a
hypersensitivity to sensory input, such as an
overreaction to the feel of clothing or to the texture of
food.
• DSI is similar to ADHD in that it impacts learning, but is
not a learning disability. DSI overlaps with ADHD in
symptoms of inattention and restlessness.
Memory Problems
Memory Problem - Short term,, Trouble
remembering; names, numbers, specific
facts, what happened a few minutes ago.
A poor memory makes academic success
difficult.
Perceptual Problems: Trouble taking
information in through one's senses and/or
processing that information.
Neurological Signs
Soft Neurological Signs: Signs of central
nervous system dysfunction that can be
observed;





staring,
turning the head instead of moving the eyes,
inability to look people in the eye,
not holding the head straight,
being easily startled.
Impact of Recurrent ACE on
Development
• Chronic exposure to trauma may result in
– deficits in the ability to identify internal
emotional experience
– difficulties with safe expression of emotions
– impaired capacity to modulate emotional
experience
– regression in behavior and physical control
needs
Behavioral Presentations
• Where do you start?
– With school performance?
– With Behavior?
Emotional and behavioral consequences
occurring across age groups:
1. Regression to childish/dependent
behavior
2. Fears/anxieties
3. Changes in eating patterns
4. Changes in sleeping patterns
5. Gender differences
6. School problems
7. Disciplinary Referrals
8. Freezing
9. Dissociation
Conditions Co-morbid with Child
PTSD
•
•
•
•
•
•
•
•
AD/HD
Depression
Obsessive/Compulsive Disorder
Oppositional/Defiant Disorder
Anxiety Disorder
Conduct Disorder
Intermittent Explosive Disorder
Impulse Control Disorders
Consequences of PTSD/Developmental
Trauma Disorder
Academic
1. Cognitive
2. Academic achievement
3. Academic performance
4. Grade retention
5. Adult outcome
6. School behavior
Impact on Learning
•
•
•
•
•
•
•
Organizing narrative material
Cause & effect
Taking another's perspective
Attentiveness
Regulating emotions
Executive functioning
Engaging in curriculum
Impact on Learning (continued)
• Single exposure may cause
– Jumpiness, intrusive thoughts, interrupted
sleep and nightmares
– Anger and moodiness, and/or, social withdraw
any of which can interfere with concentration
and memory
Impact on Learning (continued)
• Chronic exposure, especially during child’s early
years (complex/developmental trauma) can
adversely affect:
– Attention, Memory, and Cognition
– Reduce a child’s ability to focus, organize and
process information
– Interfere with effective problem solving and/or
planning
– Result in overwhelming of feelings of frustration
and anxiety
Impact on Classroom Behavior
•
•
•
•
•
Reactivity & impulsivity
Aggression
Defiance
Withdrawal
Perfectionism
Academic
Childhood trauma creates difficulty with:
•Focus
•Social functioning
•Decline in academic performance
•Outbursts of anger, hyperactivity,
impulsivity
All are symptoms often associated with LD
Consequences of PTSD effects on
cognitive functioning
1. Motivation and persistence in academic
tasks
2. Development of short-and long-term
goals
3. Sequential memory
4. Ordinal positioning
5. Procedural memory
6. Attention/Working memory
Consequences of PTSD executive
functioning
All cognitions have an emotional context.
•Educators must emotionally engage students
•Learning does not occur without positive emotional
engagement.
•When in an acute emotional state, frontal lobes are
“off-line.”
•You have input and output.
•Between input and output, organization needs to
take place.
•Have to have organization of input to get output.
•Executive functioning is the conductor
Differences Between Traumatized Student
And Those Who Were Resilient Or With LD
Sense of fatalism,
Corrupt or evil self-esteem,
Inconsistent cognitive abilities,
 Self-destructiveness,
Impaired hope and fantasy,
Hyperaroused behavior patterns
Inability to use external support.
Difficulties in Assessment of TraumaRelatedness
• Internal experiences are difficult to articulate
• Difficulty often in trusting adult during
assessment since often a “trusted adult”
perpetrated abuse
• Resist disclosure—fearing further fragmentation
of self or family
• Concern about disclosure of unusual symptoms
since they may be viewed as “crazy”
• Symptoms may be confused with schizophrenialike symptoms (eg. Hearing voices)
• Symptom pattern may change over time and
age/development
• Other symptoms may draw more attention
Approaches to Assessment of Trauma
3 Basic approaches to assessment of trauma
and post-traumatic sequelae through tools
and instruments:
– Instruments that directly measure traumatic
experiences or reactions
– Broadly based diagnostic instruments that include
traumatic symptoms (PTSD subscales-not
looking to diagnose PTSD)
– Instruments that assess symptoms not trauma
specific but commonly associated symptoms of
trauma
What students say when they present
I can’t sleep
• I have nightmares
• I don’t want to be around people- Social
withdrawal
• I have
 …family problems
 …legal issues with the court
 …school problems
 ...aggression/anger
 …health symptoms
 …substance abuse
 …depression
•
Exposure Instruments-Child
• Life Incidence of Traumatic Event
(Child/Parent)
• Dimensions of Stressful Events Rating
Scale (DOSE)
• Traumatic Events Screening Inventory
(TESI)
• My Worst Experiences Survey
• When Bad Things Happen Scale
Example: TESI Items
•
Has your child ever experienced
the severe illness or injury of
someone close to him/her?
Yes  No  Unsure
– IF YES, What was this
person’s relationship to
your child?
– How old was your child?
The first time:________
The last time:________
The most
stressful:________
– Was your child strongly
affected by one or more of
these experiences?  yes
 no  unsure
•
Has someone ever physically
assaulted your child, like hitting,
pushing, choking, shaking, biting, or
burning? Or punished your child
and caused physical injury or
bruises. Or attacked your child with
a gun, knife, or other weapon? (This
could be done by someone in the
family or by someone not in your
child’s family). Yes  No  Unsure
– IF YES, What was this person’s
relationship to your child?
– Was a weapon used?  unsure 
no  yes Type?
– How old was your child? The first
time? The last time? The most
stressful?
– Was your child strongly affected
by one or more of these
experiences?  yes  no 
unsure
NCTSN Child Welfare Toolkit:
Trauma/Loss Exposure History
But can you ask these questions??
Trauma Type Yes/Suspected/No/Unknown
Age(s) Experienced (Check
each box as appropriate –
example sexual
abuse from ages 6–9 would
check 6, 7, 8, and 9)
1. Sexual Abuse or Assault/Rape
2. Physical Abuse or Assault
3. Emotional Abuse/Psychological Maltreatment
4. Neglect
5. Serious Accident or Illness/Medical Procedure
6. Witness to Domestic Violence
7. Victim/Witness to Community Violence
8. Victim/Witness to School Violence
9. Natural or Manmade Disasters
10. Forced Displacement
11 . War/Terrorism/Political Violence
12. Victim/Witness to Extreme Personal/Interpersonal Violence
13 . Traumatic Grief/Separation (does not include placement in foster care)
14 . Systems-Induced Trauma
Repository of Information on
Trauma Assessment Tools
• http://www.ptsd.va.gov/professional/pa
ges/assessments/list-trauma-exposuremeasures.asp
• http://www.nctsn.org/sites/default/files/
assets/pdfs/cwt3_sho_referral.pdf
Assessing Trauma’s Impact
• Rather than
documenting that the
child has experienced
a traumatic event
– Child Stress Disorder
Checklist-Saxe
– Acute Stress Checklist
for Children (ASCKIDS)
Kassam-Adams
Acute Stress Checklist for Children (ASCKIDS)
Child self report Ages 817
• Assesses
– Objective (A1) &
subjective (A2)
experience of trauma
– Dissociation
– Re-experiencing
– Avoidance
– Arousal
– Impairment & Duration
– Additional items related
to fear of death, parental
response & coping
ASC-KIDS Items
• I can’t remember some
important parts of what
happened
• I felt in a daze-like I didn’t
know what was going on
• Pictures or sounds from
what happened keep
popping into my mind
• I can’t stop thinking about
it
• I try not to think about
what happened
• I want to stay away from
things that remind me of
what happened
• Since this happened, I
get angry or bothered
more easily
• A sudden noise really
makes me jump
Traumatic Coping
Kidcope Items
1. Distraction
2. Social withdrawal
3. Cognitive restructuring
4. Self-criticism
5. Blaming others
6. Problem solving
7. Emotional regulation
8. Wishful thinking
9. Social support
10. Resignation
Kidcope
Distraction
• I Tried to Forget
• I Watched TV/Played a Game
Social Withdrawal
• I Stayed by Myself
• I Kept Quiet About the Problem
Cognitive Restructuring
• I Tried to See the Good Side of
Things
Self Criticism
• I Blamed Myself for Causing
the Problem
Blaming Others
• I Blamed Someone
Else/Causing/Problem
Problem Solving
• I Tried/Fix the Problem/Thinking of
Answers
• I Tried/Fix the Problem/Doing
Something or
Talking with Someone
Emotional Regulation
• I Yelled, Screamed, got Mad
• I Tried to Calm Myself Down
Wishful Thinking
• I Wished the Problem had Never
Happened
• I Wished I Could Make Things
Different
Social Support
• I Tried to Feel Better Spending
Time with Others like Family,
Grownups, or Friends
Resignation
• I Didn’t do Anything Because the
Problem Couldn’t be Fixed
Child PTSD and General Symptom
Screening Measures
• Child Posttraumatic Stress Reaction Index
(CPTS-RI)
• The Child PTSD Symptom Scale (CPSS)
• Children’s Impact of Traumatic Events ScaleRevised (CITES-2)
• Parent Report of Child’s Reaction to Stress
• Trauma Symptom Checklist for Children (TSCC)
• Trauma Symptom Checklist for Young Children
(TSCYC)
CBCL Clinical Scales
Scales
• Total problems
• Internalizing symptoms
• Externalizing symptoms
Syndrome subscales
• Anxious-depressed
• Withdrawn-depressed
• Somatic complaints
• Social problems
• Thought problems
• Attention problems
• Aggressive behavior
• Rule breaking behavior
UCLA PTSD Index for DSM-IV–(Revision 2)
(Rodriguez, Steinberg, & Pynoos, 2002)
• 34-item parent-report
(and 33-item youthreport instrument that
screens school-age
children and
adolescents for all
DSM-IV PTSD
symptoms)
• Allows for computation
of severity scores for
Criterion A1 and A2,
Criterion B, C, and D.
• Measure is split into the
Youth Trauma Screen
(trauma exposure and
distress) and the PTSD
Index (trauma
symptoms).
.
• Construct validity: Part
I items predict severity
of peritraumatic
dissociation and PTSD
symptoms.
UCLA PTSD Index Items
• When something reminds
my child of what
happened he/she gets
very upset, scared or sad
(B)
• My child has dreams
about what happened or
other bad dreams (B)
• My child feels alone
inside and not close to
other people (C)
• My child tries not to talk
about, think about or
have feelings about what
happened (C)
• My child feels jumpy or
startles easily, for
example, when he/she
hears a loud noise or
when something
surprises him/her (D)
• My child has trouble
concentrating of paying
attention (D)
• My child feels that some
part of what happened is
his/her fault (AF)
• My child is afraid that the
bad things will happen
again (AF)
Tier 2
Trauma assessment
screening
DERS
CPTSRI
CANS
CROPS/PROPS
Sensory Regulation
Experiential
Therapies
Group Trauma
Interventions
TARGET
SPARCS
SSET
TGF-CBT
Tier 3
Evidence-Based Trauma
Interventions for Schools
www.nctsn.org
Individual Trauma
Interventions
TF-CBT
CBITS (Child Behavioral
Intervention for
Trauma
in Schools
Sensory ExperiencingSE
ADBT-SP (Adapted
Dialectical Behavioral
Therapy)
Life Skills/Life Story
SITCAP
http://www.nctsn.org/resources/topics/treatments-that-work/promising-practices
Trauma Knowledge is a work in
Process
This is not the End really-work
continues on Developmental Trauma Disorder
CONSENSUS PROPOSED CRITERIA FOR
DEVELOPMENTAL TRAUMA DISORDER
A. Exposure. The child or adolescent has experienced or
witnessed multiple or prolonged adverse events over a
period of at least one year beginning in childhood or early
adolescence, including:
A. 1. Direct experience or witnessing of repeated and severe
episodes of interpersonal violence; and
A. 2. Significant disruptions of protective caregiving as the
result of repeated changes in primary caregiver;
repeated separation from the primary caregiver; or
exposure to severe and persistent emotional abuse
B. Affective and Physiological Dysregulation. The child
exhibits impaired normative developmental
competencies related to arousal regulation, including at
least two of the following:
B. 1. Inability to modulate, tolerate, or recover from extreme
affect states (e.g., fear, anger, shame), including
prolonged and extreme tantrums, or immobilization
B. 2. Disturbances in regulation in bodily functions (e.g.
persistent disturbances in sleeping, eating, and
elimination; over-reactivity or under-reactivity to touch
and sounds; disorganization during routine transitions)
B. 3. Diminished awareness/dissociation of sensations,
emotions and bodily states
B. 4. Impaired capacity to describe emotions or bodily states
C. Attentional and Behavioral Dysregulation: The child
exhibits impaired normative developmental
competencies related to sustained attention, learning,
or coping with stress, including at least three of the
following:
C. 1. Preoccupation with threat, or impaired capacity to
perceive threat, including misreading of safety and
danger cues
C. 2. Impaired capacity for self-protection, including extreme
risk-taking or thrill-seeking
C. 3. Maladaptive attempts at self-soothing (e.g., rocking and
other rhythmical movements, compulsive masturbation)
C. 4. Habitual (intentional or automatic) or reactive self-harm
C. 5. Inability to initiate or sustain goal-directed behavior
D. Self and Relational Dysregulation. The child exhibits
impaired normative developmental competencies in
their sense of personal identity and involvement in
relationships, including at least three of the following:
D. 1. Intense preoccupation with safety of the caregiver or
other loved ones (including precocious caregiving) or
difficulty tolerating reunion with them after separation
D. 2. Persistent negative sense of self, including self-loathing,
helplessness, worthlessness, ineffectiveness, or
defectiveness
D. 3. Extreme and persistent distrust, defiance or lack of
reciprocal behavior in close relationships with adults or
peers
D. 4. Reactive physical or verbal aggression toward peers,
caregivers, or other adults
D. 5. Inappropriate (excessive or promiscuous) attempts to
get intimate contact (including but not limited to
sexual or physical intimacy) or excessive reliance on
peers or adults for safety and reassurance
D. 6. Impaired capacity to regulate empathic arousal as
evidenced by lack of empathy for, or intolerance of,
expressions of distress of others, or excessive
responsiveness to the distress of others
E. Posttraumatic Spectrum Symptoms. The child exhibits at
least one symptom in at least two of the three PTSD
symptom clusters B, C, & D.
F. Duration of disturbance (symptoms in DTD Criteria B, C,
D, and E) at least 6 months.
G. Functional Impairment. The disturbance
causes clinically significant distress or
impairment in at least two of the following
areas of functioning:
• Scholastic: under-performance, non-attendance,
disciplinary problems, drop-out, failure to complete
degree/credential(s), conflict with school personnel,
learning disabilities or intellectual impairment that cannot be
accounted for by neurological or other factors.
• Familial: conflict, avoidance/passivity, running away,
detachment and surrogate replacements, attempts to
physically or emotionally hurt family members, nonfulfillment of responsibilities within the family.
• Peer Group: isolation, deviant affiliations, persistent
physical or emotional conflict, avoidance/passivity,
involvement in violence or unsafe acts, ageinappropriate affiliations or style of interaction.
• Legal: arrests/recidivism, detention, convictions,
incarceration, violation of probation or other court orders,
increasingly severe offenses, crimes against other
persons, disregard or contempt for the law or for
conventional moral standards.
• Health: physical illness or problems that cannot be fully
accounted for physical injury or degeneration, involving
the digestive, neurological (including conversion
symptoms and analgesia), sexual, immune,
cardiopulmonary, proprioceptive, or sensory systems, or
severe headaches (including migraine) or chronic pain or
fatigue.