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.