NEUROPSYCHOLOGICAL ASSESSMENTS OF STUDENTS WITH COMPLEX TRAUMA;

HELPING DEVELOPING BRAINS GET BACK ON TRACK

MAKING A DIFFERENE: FIFTH ANNUAL SURROGATE PARENT CONFERENCE,

FEDERATION FOR CHILDREN WITH SPECIAL NEEDS

NOVEMBER 15, 2016

STEPHANIE MONAGHAN-BLOUT, PSY.D. PEDIATRIC NEUROPSYCHOLOGIST, NESCA

THE MOST VULNERABLE POPULATION: CHILDREN IN INSTITUTIONAL CARE

• US children in foster care 2015 has reached 427,910

• From peak of 524,000 in 2002

• Lowest number of 397,000 in 2012

• -Associated Press, 10/27/16

THE MOST VULNERABLE POPULATION: CHILDREN

Number of children adopted through public welfare

system and number of Massachusetts children adopted

through this system 2010 2011 2012 2013 2014

52,891 50,875 52,035 50,608 50,644

726 724 754 799 589

OUTLINE

-Trauma and the Developing Brain

-Developmental Trauma and FASD: Developing a

Blueprint for Understanding

-Neuropsychological and Psychological Testing

TRAUMA AND THE DEVELOPING BRAIN

TRAUMA

• “Psychological trauma is an affliction of the powerless. At the

moment of trauma, the victim is rendered helpless by overwhelming

force. When that force is of nature, we think of disasters. When that

force is that of other human beings, we speak of atrocities. Traumatic

events overwhelm the ordinary systems of care that give people a

sense of control, connection, and meaning”.

• -Judith Herman, M.D. (1992) Trauma and Recovery

WHAT CONSTITUTES TRAUMA

1. Witnessing domestic violence or community violence

2. Abuse: physical, sexual, or psychological, especially that

occurring within the context of relationship

3. Neglect of physical, social, or emotional needs

WHAT CONSTITUTES TRAUMA: NOT SO SIMPLE

• Neglect, abuse, and witnessing violence often co-occur

• Some children are more vulnerable due to prenatal factors

( exposure to drugs, malnutrition, maternal stress)

• Children are also exposed to secondary impacts such as

maternal depression or physical injuries

DIFFERENTIAL IMPACT OF TRAUMA: WHY KIDS ARE SO VULNERABLE

Developmental Vulnerability

- Helplessness of young children: what is

life-threatening to young children is not the

same as for adults

-Trauma to growing brains alters the

trajectory of development

TWO KEY FACTORS MITIGATING IMPACT OF TRAUMA

Resiliency related to:

• Psychosocial support, including the caregiver’s

response to the traumatized child

• Child’s sense of mastery

CHILDREN’S RESPONSE TO TRAUMATIC EVENTS VARIES

-Stage of development

-Cognitive profile

-Duration, severity, frequency of trauma

-Presence of Protective Factors, especially attachment

A SHORT COURSE IN BRAIN DEVELOPMENT

• Development is “hardwired”-

• Orderly, Sequential Process of Maturation

• Proliferation

• Organization

• Specialization

PROLIFERATION

• During the last trimester of pregnancy and the first 18

months of life, the brain, the brain increases to four

times its size, close to the final weight during adulthood

ORGANIZATION

• After this period of rapid growth, the focus turns to

organization and specialization. Unutilized or redundant

neurons are “pruned” (eliminated) in the service of

greater efficiency.

• Myelinization: Creating neural “superhighways to

optimize efficiency

SPECIALIZATION: SENSITIVE PERIOD OF MAXIMAL

PLASTICITY

• Sensitive period in which brain is maximally receptive

to certain kinds of stimuli to develop certain kinds of

behavior. If these stimuli are not present and if

behavior not reinforced, brain circuit supporting the

behavior do not develop and behaviors will not

continue. “USE IT OR LOSE IT”

IMPORTANCE OF ATTUNED CAREGIVING OR THE CRITICAL IMPORTANCE OF “PEEK-A-BOO”

• When a child has consistent, attuned caretaking:

• -someone comes when they cry to alleviate their fear and discomfort. As they gain

confidence that this will happen, their tolerance grows and they begin to learn how to self-

regulate

• -someone engages with them on more than a functional level, encouraging them to

experience the world. This process develops the capacity to direct and shift attention.

• -someone gives them space to move and toys to play with, creating the opportunity to

develop fine and gross motor skills

• -someone protects them, plays with them and enjoys them, establishing a sense of mutuality

THE STRESS RESPONSE

•The Body’s Alarm System- Enable us to gear

up to respond to threat

STRESS RESPONSE- THE HYPOTHALAMIC-PITUITARY-ADRENAL

CIRCUIT (HPA)

• As the brain recognizes a threat, the hypothalamus

releases corticotropin-releasing hormone (CRH) which

stimulate the pituitary gland to release

Adrenocorticotropin (ACTH) which then prompt the

adrenal glands to release a number of other hormones

IMPACT OF HORMONES

• Switch on systems needed to respond to threat- sympathetic nervous system (Fight or Flight)

• Switch off systems not essential to crisis response – parasympathetic nervous system (Rest and Digest)- included digestive system, reproductive hormones, growth hormones

• Stimulates the release of sugar (glucose) to power muscles and brain to respond to the danger (Cortisol)

• Once danger is passed, Cortisol exerts a feedback loop to shut the production of CRH by the hypothalamus.

CHRONIC EXPOSURE TO STRESS WHAT IF THE LOOP DOESN’T SHUT

DOWN?

• Significant, ongoing stress in early childhood can cause the

HPA feedback loop to become stronger, and with each

reiteration, the loop becomes stronger, leading to a very

sensitive stress response. Which this hypervigilance may be

adaptive in highly dangerous environments, the “life or

death” response to minor irritants results in adjustment

problems in other settings

THE STRESS RESPONSE: REACTING TO THREAT

•Fight

•Flight

•Freeze

REACTING TO THREAT: FIGHT

• Argumentative

• Noncompliant

• Oppositional

• Impulsive

REACTING TO THREAT: FLIGHT

•Distractible

•Gives up quickly

•Avoidant

REACTING TO THREAT: FREEZE

•Problems with Initiation (getting started)

•Problems with Shifting (switching gears)

•Problems with Termination (letting go)

IMPACT OF TRAUMA CHRONIC “FIGHT/FLIGHT/FREEZE?

Cognitive resources mobilized for protection from danger

• Attentional system is geared to be on the lookout for signs of

danger (triggers)

• Arousal “set-points” are fixed (too much, too little)

• Distorts perceptions of people and events

• Drastically limits capacity for flexible thinking and creative

problem solving

• Creates conditions of physical discomfort

IMPACT OF TRAUMA; BEHAVIORAL PRESENTATION

• Attention and EF problems (can look like ADHD)

• Diminished Language Competency

• Behavioral Dysregulation

• Anxiety, Depression, Self-Injurious Behaviors

• Learning Issues

• Weak Social Skills

• Substance Abuse

IMPACT ON HEALTH ADVERSE CHILDHOOD EXPERIENCES STUDY (ACE)

-Data from 1998 survey of more than 17,000 members of

Kaiser Permanente HMO:

-2/3 of respondents reported at least one ACE

-44% reported experiencing sexual, physical or

psychological abuse as children

-20% reported 3 or more ACEs

IMPACT ON HEALTH ADVERSE CHILDHOOD EXPERIENCES STUDY

• Major Findings;

• Study findings report a graded dose-response relationship between

number of ACE and negative health and wellbeing outcomes.

• In other words, the more bad childhood experiences, the more likely

to contend to health risk behaviors (alcohol and other drug abuse,

depression, suicide) and negative health outcomes (heart disease,

cancer, lung disease, liver disease, skeletal fractures

ADVERSE CHILDHOOD EXPERIENCES ACE STUDY

DEVELOPING A BLUEPRINT FOR UNDERSTANDING: DEVELOPMENTAL TRAUMA AND FASD

TRAUMATIZED CHILDREN AT RISK FOR NO DIAGNOSIS OR MIS-DIAGNOSIS

• In one study, 48% of traumatized children did not meet

criteria for any DSM-IV diagnosis

• Traumatized children are often mis-diagnosed as having

ADHD, bipolar disorder, or attachment disorder

DEVELOPMENTAL TRAUMA DISORDER

• A diagnosis proposed by Bessel Van der Kolk to capture

the most salient symptoms seen in children exposed to

complex trauma which occurs on a chronic basis and

may include all forms of trauma (interpersonal, physical,

and environmental)

• DTD was not included in DSM-V

DTD SYMPTOMS

A. Exposure to multiple or prolonged adverse events over a period of at least one year

beginning in childhood or early adolescence

B. Affective and Physiological Dysregulation

C. Attentional and Behavioral Dysregulation, impaired development of sustained

attention, learning, or coping with stress,

D. Self and Relational Dysregulation, impaired normative development of sense of personal

identity and involvement in relationships, including at least three of the following:

DTD SYMPTOMS

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, non-fulfillment of responsibilities within the family

• Peer Group: isolation, deviant affiliations, persistent physical or emotional conflict,

avoidance/passivity, involvement in violence or unsafe acts, age inappropriate affiliations or style of

interaction

TWO KEY FACTORS MITIGATING IMPACT OF TRAUMA

Resiliency related to:

• Psychosocial support, including the caregiver’s response to

the traumatized child

• Child’s sense of mastery

NATIONAL CHILD TRAUMATIC STRESS NETWORK COMPLEX TRAUMA TASK FORCE

ARC model:

• Building secure Attachments between child and

caregivers

• Enhancing Self-Regulatory capacities

• Increasing Competencies across multiple domains

FETAL ALCOHOL SPECTRUM DISORDER:

THE INVISIBLE DISORDER

• Children exposed outside of a small window of days in the first trimester

may not manifest the physical markers BUT

• Neurobehavioral features may be as or more impairing

PREVALENCE

• In the general population? Thought to be 2-5% of all children in the

US

• In Massachusetts? Estimated developmental disabilities related to

FASD is between 1,423-3,559 children (compared to ASD 1,027)

• Study of foster care children referred to clinic for behavioral

problems- 81% had FASD not previously detectec (Chasnoff, 2015)

ALCOHOL EXPOSURE HOW MUCH IS TOO MUCH? NO ONE KNOWS

• -About 20% of women drink during pregnancy

• -Binge drinking at critical periods may be more damaging than

chronic use at a lower rate.

• -Question- Who binge drinks? The same group that is most

likely to get pregnant (young women)

BRAIN DAMAGE RESULTING FROM PRENATAL ALCOHOL

photo: Clarren, 1986

FACIES IN FETAL ALCOHOL SYNDROME

Discriminating Features Associated Features

Epicanthal folds

Low nasal bridge

Minor ear anomalies

Micrognathia

Short palprebral fissure

Indistinct philtrum

Thin upper lip

In the young child Streissguth, 1994

IMPACT ON INTELLECTUAL ABILITY

• Biggest single cause of mental retardation (Intellectual Disability) is alcohol exposure

• -Mean IQ of children with FAS=70

• -Heavy exposure but no physical feature=80

• -Conflicting findings about children with lower levels of exposure

• -Interaction of other factors such as maternal health and lack of resources

IMPACT ON SENSORY PROCESSING

• Self regulatory capacity extremely impaired (0-60)

• -Difficulties with screening and integrating sensory inputs; often

needs continuous sensory input to stay regulated (need to be

moving constantly)

• -Combination of poor attention, limited impulse control and

high reactivity- do not respond well to surprises

• -Do well with structure

IMPACT ON ATTENTION; NOT YOUR GARDEN VARIETY ADHD

- Major attentional deficits for ADHD

- Focus and Sustain

• Major attentional deficits for FASD

Encode and Shift

IMPACT ON EXECUTIVE FUNCTION

- Problem solving and Planning

- Concept Formation and Set Shifting

- Fluency

- Inhibitory Control

- Working Memory

- What were you thinking?

IMPACT ON LEARNING AND MEMORY

- Difficulties with rote verbal learning

- Better with contextual learning (stories)

- Research is mixed on nonverbal learning; is it memory issues

or problems with lower order skills (visual spatial)

IMPACT ON LANGUAGE

• Research is mixed; retrospective studies show deficits in

word comprehension, naming ability, articulation,

grammatical and semantic abilities, and receptive and

expressive language deficits.

• -Significant problems with social pragmatic skills- provide

insufficient organization and information for listeners and

fail to consider perspective of listener

IMPACT ON SOCIAL FUNCTIONING

• A little hard to tease out the contributing factors

- High rate of behavioral issues- hyperactivity is annoying

- Impulsivity AND slow processing (they do something before they can

even conceptualize

- Cognitive rigidity/perseveration

- Social pragmatic deficits

- -poor social savvy- are often dupes for more predatory peers and adults

IMPACT ON VISUOSPATIAL ABILITY

• Not a lot of information

• -Problems with visuospatial construction tasks; some suggest a

constructional apraxia (can’t figure out how to sequence steps

to build something)

IMPACT ON ACADEMIC FUNCTIONING

• Deficits in math overall, with specific problems with

basic numerical processing (estimation)

• - Problems with reading and spelling also common.

IMPACT ON EMOTIONAL FUNCTIONING

• -Increased rate of mood disturbance

• (may be mediated by relationship with mother interactions)

• -Increased rate of externalizing behaviors (but this may be

influenced by a poor match between child abilities and

environmental expectations

SECONDARY DISABILITIES

• Conduct Problems in School >60%

• Mental Health Problems >90 %

• Court Involvement -45-60%

• ( estimates in prison population-60%)

• Alcohol or Drug Dependence 30-45%

• Unplanned Pregnancy

• Victim of Domestic Violence

• Dependent Living >80%

THE COST OF FAILING TO DIAGNOSE

• Children are being misdiagnosed , and thus do not

receive the treatment they need, while being given

interventions they don’t need and won’t work

• e.g. behavioral therapies

PROTECTIVE FACTORS

Nurturing, stable home, good quality of home

Never experiencing violence

Being diagnosed FAS rather than FAE

Diagnosis before the age of 6

Riley

INEFFECTIVE STRATEGIES

• Punishment

• Inaction

• Failure to generalize learning to problematic situations (e.g. generic counseling)

• Behavior plans that

• Do not adequately map the A B Cs (antecedent-behavior-consequences

• Do not identify the student’s current skill sets

• Do not teach skills

• Do not include the child in their development

SCHOOL STRATEGIES I AVOID BEHAVIORALLY BASED INTERVENTIONS;

THERE IS NO “CHOICE” INVOLVED

• The emotional/physical reactivity, poor impulse control, difficulties with problem solving and

inefficient language of children with FASD make them a poor candidate for programs using

strategies such as a level system, or point system leading to delayed rewards. These systems imply

that a child has some choice about their behavior and can make a plan to achieve a desired goal.

These children also struggle with the executive function processes necessary to work through the

“if-then” , “why” and “how” thinking necessary to make a plan to achieve a goal and to hold on that

thinking in the face of distractions or challenges.

• Without good self-regulatory processes, they are not able to keep their equilibrium when

surprised, frightened or disappointed, and promise of something happening in the future will not

make any difference, except to make them feel bad bout themselves and resentful of others.

SCHOOL STRATEGIES SUPPORTING SELF-REGULATION

• Ongoing, in-the-moment support for self-regulation which will then facilitate learning in academic, social and

behavioral areas. These strategies include helping him manage his sensory needs, monitoring physical and

emotional responses and providing labeling language to help him express his needs.

• -An example might be the use of a 5 point scale to help him recognize gradients of feelings and needs (The

Incredible 5 Point Scale (2003), Buron, K.D. and Curtis, M.).

• -Having a “safe place” within the classroom where s/e can go when he feels upset or dysregulated is key to

developing self-regulation. This spot should be equipped with a few items of his choice that he finds

comforting. These might include an MP3 player with headphones for music, some drawing materials, and/or

some stuffed animals. The criteria for inclusion should be their comforting value to the specific child This is

not a place for video games or other high interest toys.

SCHOOL STRATEGIES II SENSORY ISSUES

- MANAGING SENSORY STIMULI- THESE KIDS CAN’ SCREEN OUT

EXTRANEOUS/IRRELEVANT STIMULI. THEY NEED SMALL CLASS SIZE,

PREDICTABLE SCHEDULE AND CONSISTENT STAFFING. “BUSY”

CLASSROOM ENVIRONMENTS SHOULD BE AVOIDED AT ALL COST;

THE ROOM SHOULD BE FREE OF CLUTTER, WITH MATERIALS KEPT IN

CLOSED OR COVERED CUPBOARDS AND THERE SHOULD BE PLENTY

OF CLEAR WALL SPACE, WHICH HELPS STUDENTS FOCUS ON WHAT

IS POSTED. THE ROOM SHOULD BE DECORATED/ARRANGED IN A

WAY THAT REDUCES AMBIENT NOISE, E.G. USE OF CARPETING,

CLOTH COVERED SURFACES AND USING BOOKSHELVES AND

DIVIDERS TO CREATE MINI-SPACES.

SCHOOL STRATEGIES DIRECTLY ADDRESS LEARNING ISSUES

• Children with FASD have a range of learning issues which need to be addressed directly

and explicitly. Language may be a relative strength, but good verbal ability may mask

problems with higher level conceptual skills

SCHOOL STRATEGIES EXECUTIVE FUNCTION

• Concrete strategies individually customized for the child.

• For instance, the use of checklists can help with grasping the concept of time and

sustained effort. Child and teacher can develop a list of the work that needed to get

done to get to the break, with the child checking off each task as it was completed. When

he grew tired or frustrated we could look at the list to see how much more needed to

get done before the break. “Forecasting” what will be coming also helps manage

frustration, An example is developing an agreement about how to sequence tasks ("1

long, 2 medium, 3 quick").

SCHOOL STRATEGIES WHEN A CHILD “LOSES IT”; SUCCESS DEPENDS ON

PLANNING AHEAD

• Children with FASD will inevitably lose control and may engage in unsafe

behaviors, including, at times, aggression. The most important strategy to manage

these episodes is to understanding the triggers for such behaviors (being

frightened, surprised, frustrated or having to "switch gears" from a preferred

activity to a non-preferred activity) and to address issues proactively before he

becomes triggered

• -Remember, once a child becomes emotionally aroused, he is unavailable for

any higher level cognitive activity such as talking about a problem situation. At

these times, it is best to avoid eye contact (which is a challenge), stop talking

and, if needed, activate a safety plan which removes possible triggers such as

other children.

SCHOOL STRATEGIES WHEN A CHILD LOSES IT

• - Power strategies, such as using a firm voice and issuing ultimatums are notably ineffective

once a child has lost control of their emotions.

• Once the episode is over and the child has calmed down, it is important to engage him in a

conversation about the event, although expectations for insight and behavior change should

be low.

• Be very careful about making assumptions about what s/he may have been thinking.

• Also be VERY explicit when trying to explain something or someone.

• Finally, It is crucial that the child be helped to "fix" things by apologizing or making

reparations.

NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL TESTING

•Neuropsychological Testing – how a person

learns and problem solves from a cognitive point

of view

•Psychological Testing- how a person manages and

makes sense of emotional experience

NEUROPSYCHOLOGICAL TESTING

•Methods

• Neuropsychology attempts to connect brain function with

behavior. It relies on quantifiable activities that can be transformed

by statistical procedures into scores that allow comparison

between performances at different times, between individuals, and

between ages.

• Z scores, T Scores, Standard Scores, Scaled Scores

NORMAL DISTRIBUTION

QUALITATIVE ASSESSMENT

• Behavioral Observations

• Overt signs of distress, changes in arousal levels,

• Changes in demeanor over time-

• Differences related to domain being assessed

Analysis of patterns of scores

• Consistency/inconsistency

• Abrupt changes, good or bad

• Response to Intervention

• Impact of validation

• Effect of offer of modification

• Change in persistence

HISTORY

• Provides the context of who a child is

-History should include family history, medical history,

progress through developmental milestones, educational

progress, placement history, therapeutic and other

interventions, collateral interview (caretakers, teachers,

therapists, etc)

STANDARDIZED TESTING

• Measures used for the assessment should be identified and findings

reported and explained.

• Should include exploration of domains important for learning and

problem solving; cognitive, academic, language, visual

perceptual/spatial reasoning, memory, attention, executive function,

social-emotional functioning.

IMPRESSIONS- SPELLING IT OUT

• Really important to explicitly discuss how the child’s

issues interact with other elements of his/her profile

Attention Social

• Learning Adaptive

RECOMMENDATIONS KEYS TO DEVELOPING EFFECTIVE STRATEGIES

• Knowledge of Child’s learning profile (Attention/Learning/Social Challenges?)

• Sensitivity to Child’s temperamental style (is this a fight, flight or freeze kind of kid?)

• Direct Approach to Stress response (“Don’t worry” isn’t going to help. Validation and

modifications can make a huge difference)

• Teach skills that are lacking (e.g. phonological processing AND breaking down a problem

AND self-soothing)

STRATEGIES AND INTERVENTIONS

- Start with accurate profile of strengths and challenges .

- Specifically address areas of concern with suggestions appropriate to the child. For example, children

with visual perceptual issues may have a harder time using graphic organizers because they are so

easily overwhelmed with visual complexity.

- Set priorities; what’s most important right now and what is the child open to doing?

- Remember that higher level skills such as language processing and emotional awareness require good

foundational skills

- Remember, resilience is strongly related to connectedness and mastery e.g. is he loved by someone

and is he good at something? Is there a good Boys and Girls Club program that he can be part of?

Does his family belong to a church that can be supportive?

HOW IS PSYCHOLOGICAL TESTING DIFFERENT

• Psychological Testing attempts to capture the lens through

which a person tries to make sense of his experience. Emerging

from the work of the founders of modern psychology in the

early 20th century, the early tests (many of which are still in use)

were based on the psychoanalytic/psychodynamic model that

proposed that people “project” their inner experience onto the

world around them.

HOW IS PSYCHOLOGICAL TESTING DIFFERENT

• We now have many tests that attempt to quantify psychological traits and constellations

that are soundly situated in psychometric principles and modern statistics. However,

these tests often fail to capture the dynamic nature of emotional reactions

• Although many people have tried to develop scoring systems for projective tests, there

are many serious questions about validity and reliability, starting with the biases of the

tester.

• At the same time, these projective measures can give us a vivid picture of someone’s

internal world that cannot be captured by ratios and percentages

WHEN SHOULD PSYCHOLOGICAL TESTING BE CONDUCTED

• From a Special Education Perspective (need to balance

documentation and privacy)

• Can be helpful in getting initial special education eligibility (but

may be overkill)

• Necessary to document need for out of district placement

• Essential for any residential placement

WHEN SHOULD PSYCHOLOGICAL TESTING BE CONDUCTED

• From a Clinical Perspective

• When there is concern about a thought disorder

• When there is concern about suicidality

• When the person is having trouble expressing their concerns

and worries

• When there are questions about diagnosis and treatment.

WHEN SHOULD PSYCHOLOGICAL TESTING NOT BE CONDUCTED

• When the person is in the throes of a severe

emotional/behavioral episode (wait until they are out of the

hospital and are stabilized)

• When there are concerns about privacy and confidentiality, e.g.

application to private school.

• When the person is willing and capable of taking about their

feelings and situation and is not experiencing functional

impairments

WHEN SHOULD CAUTION BE USED (MAKE SURE YOU KNOW WHAT YOU ARE MEASURING)

• People with significant visual perceptual issues who may have difficulty – e.g.

Nonverbal Learning Disability

• People with significant language issues who may have trouble expressing

and organizing their ideas

• People with significant cognitive limitations who may struggle with the

intellectual/abstract nature of the tasks- e.g. Intellectual Disability

• People with significant deficits in social cognition- e.g. Autism Spectrum

Disorder

• Very young children (under 7 years).

BIOGRAPHY

• Dr. Monaghan-Blout is a graduate of Bowdoin College and Boston University. She worked for many

years as an adolescent and family therapist before obtaining her doctoral degree at Antioch New England

Graduate School. She completed an internship in pediatric neuropsychology and child psychology at

North Shore University Hospital, Manhasset, New York, and a postdoctoral fellowship at HealthSouth

Braintree Rehabilitation Hospital. She has served two terms on the Board of Directors of the

Massachusetts Neuropsychological Society and has just completed her term as the President. She is

also a member of the Trauma Learning and Policy Initiative group, which is sponsored by Massachusetts

Advocates for Children and Harvard Law School. Dr. Monaghan-Blout enjoys working with children and

adolescents with complex learning and emotional profiles. She has a particular interest in children of

international and high risk domestic adoption and others contending with the impact of trauma.

• Dr. Monaghan-Blout is the mother and stepmother of four children and the grandmother of six. She

enjoys playing ice hockey, reading urban fantasy, and quilting.