ABSTRACT
Joseph, an 8 -year-old boy, presents .with behavioral problems at school and is argumentative at home. Maria, a 6 -year-old girl, was observed engaging her dolls in simulated sexual acts at school, but otherwise appears to be experiencing no psychological distress. Austin, a 16-year-old boy, presents with low mood, fatigue, and difficulty concentrating. Shana, a 1 2 -year-old girl, complains of nightmares and difficulty concentrating and has trouble experiencing happiness. Which of these youth has a trauma history? The answer is: all of them.Nearly half of all children will experience a traumatic event at some point during their childhood (Giaconia et al., 1994). Typical traumatic experiences include natural disasters, exposure to war/terrorism, chronic/life-threatening illness, community violence (e.g., school shootings), and interpersonal violence, such as witnessing domestic violence and experiencing sexual and physical abuse (Davis & Siegel, 2000). Many children experience some degree of psychological distress in the aftermath of trauma, although specific prevalence rates are difficult to determine because of the varied nature of symptom presentations in children (Nader, 1997).Assessing the effects of trauma in children and identifying a history of trauma exposure are complex tasks because of the varied responses to trauma. In the case examples just mentioned, Shana presents with some of the typical symptoms of post-traumatic stress disorder (PTSD). A meta-analysis of samples of traumatized children revealed that approximately 36% of children who are exposed to trauma develop PTSD (Fletcher, 1996a). Cohen (1998) notes that “as children mature, they are more likely to exhibit adult-like PTSD symptoms” (p. 7S). However, like Maria in the case example just mentioned, younger children may engage in reenactment of the trauma in play and artwork and may not display the numbing and active avoidance symptoms typical of adult PTSD (Cohen, 1998).As presented in the cases of Joseph and Austin, traumatized children often present with symptoms other than those consistent with PTSD (Nader, 1997). Children can present with
depression, generalized anxiety, behavioral problems, concentration and attention difficulties, and physical symptoms, and they may show no signs of psychological disorder (Nader, 1997). In addition, children diagnosed with disruptive behavior disorders are at higher risk for exposure to trauma as well as development of PTSD subsequent to trauma (Ford et al.,2000). Problems with regulation of emotions, as well as disorganized early attachment patterns and unhealthy subsequent relationships, are especially likely among victims of child maltreatment (Van der Kolk & Fisler, 1994). Thus, knowing a child has a trauma history is useful information, but the presentation can vary greatly, depending on the manifestation of symptoms for a particular child. Assessment of children is even more complex when the trauma history is unknown. Moreover, children with an unknown traumatic experience as the underlying cause of their psychological distress can be characterized as “treatment resistant,” when in reality, a thorough assessment to uncover that trauma history would have changed the treatment strategies used with the child.The purpose of this chapter is to provide clinicians with information regarding models of trauma assessment, ways to detect the presence of a trauma history in youth, as well as strategies for assessing potential behavioral and psychological symptoms common after a trauma, with the use of both global personality measures and trauma-specific assessment tools. Readers should consider this information an introduction, understanding that specialization in this area would certainly require additional training. Useful resources to aid in this training are referenced as appropriate, including reviews of many of the measures being presented (e.g., Ohan, Myers, & Collett, 2002; Strand, Sarmiento, & Pasquale, 2005). In addition, case examples are integrated into each section as illustrations of the measurement strategies being presented. MODELS OF TRAUMA ASSESSMENT
When faced with assessing the intricacies of a child’s reaction to trauma, it is helpful to have an organizing framework. Multiple researchers and clinicians have proposed models of trauma assessment (e.g., Fletcher, 1996a; Webb, 2004). These models generally include three components: understanding the nature of the traumatic event (e.g., type, duration, severity), assessing the variety of individual responses (e.g., posttraumatic symptoms) and influences on those responses (e.g., age/developmental stage, coping style), and evaluating factors in the support system/recovery environment (e.g., social support, culture). These three components provide the organizing framework for the current chapter as well. Identifying and Understanding the Traumatic Event
The most common approach to assessing a history of trauma in children involves interviewing the identified child and his or her primary caregiver(s). Ideally, each interview should include direct inquiries about the occurrence of potentially traumatic events (Cohen, 1998). In cases where a caregiver is suspected of abuse, only the child and the nonoffending parent should be the interviewees. Generally, it is important to ask about history of exposure to a variety of events (e.g., all forms of abuse and neglect, natural disasters and accidents, serious illness/injury, etc.). For the child interview, developmentally appropriate language should be used to describe the trauma. Specific information about the nature of the trauma(s) should be gathered, including frequency, duration, and severity. Clinicians should also ask about the child’s emotional state during and after the trauma as well, specifically referencing fear,
helplessness, horror, and emotional numbing or “shock.” Extensive guidelines for conducting this type of interview are available in numerous clinician handbooks (e.g., Cohen, 1998; Newman, 2002; Wilson & Keane, 2004).Because of the number of details required to comprehensively assess the nature of the trauma, the use of structured interviewing and/or a written report is strongly recommended in lieu of or in addition to clinician-designed interviews. Several clinician-administered caregiver interviews and self-report measures for older children and adolescents have displayed sound psychometric properties. Of these, some include both assessment of exposure to trauma and subsequent PTSD symptoms. Thus, they are only listed here and are discussed more fully in the section on assessment of individual reactions, because that is their primary focus. These measures include the Children’s PTSD-Reaction Index (CPTS-RI; Pynoos, Rodriguez, Steinberg, Stuber, & Frederick, 1998); the Childhood PTSD Interview (CPTSDI; Fletcher, 1996b); and the Children’s PTSD Inventory (CPTSDI; Saigh et al., 2000).Unlike these dual-purpose tools, the sole purpose of the Traumatic Events Screening Inventory (TESI; Ribbe, 1996) is to identify the presence of a trauma history in children aged 4 to 18. The TESI measures exposure to a wide variety of traumatic events, with the use of DSM-IV (American Psychiatric Association, 1994) criteria. The TESI has self-report and parent-report versions, both of which have shown excellent psychometric properties in preliminary studies (Ribbe, 1996).Other measures have been designed to assess specific types of childhood traumas. For assessing various forms of child maltreatment (i.e., emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect), the Childhood Trauma Questionnaire (CTQ; Bernstein & Ahluvalia, 1997) was originally developed with adults who were maltreated as children, but has been modified for use down to 12 years of age. This measure has excellent psychometric properties and is an efficient way of assessing various forms of childhood maltreatment (Ohan et al., 2002).The use of anatomically detailed (AD) dolls to assess exposure to sexual abuse has been empirically supported as well (Maan, 1991). The use of AD dolls is particularly useful with very young children or even older youths with limited language skills. However, researchers are clear that the use of AD dolls requires training in standardized assessment procedures (see Maan, 1991, for a summary of these procedures). Although they are not widely used, other measures have been proposed to assess additional specific types of trauma, such as exposure to community violence (Cooley, Turner, & Beidel, 1995) and sexual abuse (Levy, Markovic, Kalinowski, Ahart, & Torres, 1995; Spaccarelli, 1995).Clearly, age is a factor in the selection of a measure of trauma exposure. For young children, caregiver reports are very important. However, it is critical that children who are verbal are also interviewed, to maximize the likelihood of disclosure. For older children and adolescents, written self-report questionnaires can be helpful, especially because of their brevity and ease of administration. As indicated previously, several options for assessment of exposure have not yet been presented because they are built into broader symptom measures. In cases where trauma history is highly likely (e.g., in an at-risk population, or when trauma exposure is already documented and the assessment is intended to gather additional information), one of those measures would be a logical choice because the need for assessing symptoms is likely. For a true screening tool, the TESI is an excellent option for clinicians because of the wide range of applicable ages and the ease of administration.Case Example: Six-year-old Maria was referred to a community mental health center after her school counselor observed her engaging her dolls in simulated sexual acts. According to the counselor, she displayed no other signs of psychological distress. During the intake
interview, Maria was asked if any bad things had ever happened to her. She initially denied this, but then added “Well, one time I got in trouble for yelling at my mom.” Maria’s mother was also asked a general question about the possibility of Maria experiencing any traumatic events, but her mother also denied a trauma history. Because of the school counselor’s suspicions of sexual abuse, the TESI was administered separately to Maria and her mother. Although her mother continued to deny knowledge of Maria experiencing any traumatic events, Maria acknowledged that her neighbor had “touched [her] private parts” on several occasions. Thus, her trauma history was revealed and the clinician was able to follow up with additional investigation of her posttraumatic reactions.
