A cartoon-based assessment tool for complex trauma in children Getting the picture: Jennifer Boyle University of Pennsylvania Committee members: Phyllis.

A cartoon-based assessment tool for complex trauma in children

Getting the picture:

Jennifer BoyleUniversity of Pennsylvania

Committee members:Phyllis Solomon, PhD. – Chair

Julian Ford, PhDEliana Gil, PhD

Extent of the Problem

• Each year in the U.S., more than 3,000,000 allegations of child abuse or neglect are made– 1,000,000 of these are substantiated.

• Total lifetime economic burden resulting from new cases of fatal and nonfatal child maltreatment in the U.S. is $124 billion.

Adverse Childhood Experiences

Adverse Childhood Experiences

Number of ACEs

Percent of Respondents

0 33%

1 26%

2 16%

3 10%

4 or more 12.5%

For people with a single category of exposure, the probability of exposure to any additional category ranged from 65-93%.

The probability of two or more additional exposures ranged from 40-70%.

Childhood traumatic experiences do not occur in

isolation.

Adverse Childhood Experiences

“These childhood exposures should be recognized as the basic causes of morbidity and mortality in adult life” (Felitti et al., 2009, p. 246

Trauma vs. Complex Trauma

Trauma vs. Complex TraumaPost-traumatic Stress Disorder (PTSD):• Single, Type 1 traumatic event• Marked by reexperiencing, avoiding, increased arousal, negative mood

Complex Trauma or Disorders for Extreme Stress Not Otherwise Specified (DESNOS)•Multiple or chronic, Type 2 traumatic events•Marked by alterations in many areas of functioning, including but not limited to PTSD symptoms

Complex Trauma in ChildrenDomain of Impairment

Associated Symptoms

Attachment Uncertainty about the reliability of the world; Problems with boundaries; Distrust and suspiciousness

Biology Sensorimotor developmental problems; Somatization;Increased medical problems

Affect RegulationDifficulty describing internal experience; Difficulty communicating wants/needs; Difficulty with regulating emotions

Dissociation Alterations in states of consciousness; Amnesia;Depersonalization and derealization

Behavioral Regulation Impulse control problems; Self-destructive behavior;Aggression/oppositional behaviors

Cognition Learning difficulties; Problems with language development; Difficulties in attention regulation

Self-Concept Lack of a continuous, predictable self; Low self-esteemGuilt and shame

Adapted from NCTSN (2003)

Diagnostic Issues

Assessment

• Comprehensive• 7 domains of impairment

• Clinical Interview• Obtain info directly from child

• Standardized Measures• 5 tools recommended by the NCTSN

Challenges

Pictorial Instruments

Image from Koala Fear Questionnaire (Muris, Meesters, Mayer, Bogie, Luijten, Geebelen, Bessems, & Smit, 2003)

Pictures coincide with items, adding a visual dimension to the assessment process.

Strengths:• Developmentally appropriate• Improve engagement• Stimulate attention• Address language and literacy difficulties

Notable Pictorial Instruments

Proposed Tool

Cameron Complex Trauma Interview (CCTI)

Cameron

• Pictorial-based, two-part structured interview• Evaluates comprehensive trauma history and symptomology related to complex trauma. • Uses developmentally appropriate language.• Features friendly-looking puppy, Cameron.

Proposed Tool

• CCTI will be an adaptation of the following measures:– Traumatic Events Screening Inventory-Child

Version (TESI-C) (Ford, Davis, Reiser, Fleishcer, & Thomas, 2000)

– Structured Interview for Disorders of Extreme Stress-Adolescent Version (SIDES-A) (Pelcovitz, 2004)

– Developmental Trauma Disorder Structured Interview for Children (DTDSI-C) (Ford, 2012)

Methods: Phase 1- Development

Development of Item Language for Part 1 (trauma history) and Part 2 (symptomology) of the CCTI:

Methods: Phase 1- Development

Development of Cartoon Pictures for Part 1 (trauma history) and Part 2 (symptomology) of the CCTI:

Methods: Phase 2 - Evaluation

Sample:• Master’s level clinicians providing mental

health services to children– Family Practice and Counseling Network, Gil

Institute for Trauma Recovery and Education, Clinicians in the DSW Program at UPenn

– Purposeful snowball sampling approach– Minimum of 25 clinicians

Methods: Phase 2 - Evaluation

Procedure:

Clinical Utility and Feasibility Survey

• 3 part survey:– Part 1: 5-point Likert Scale, exploring degree to

which clinicians agree or disagree with 15 statements evaluating the tool

– Part 2: 3-point Likert Scale, clinicians rank the amount of information gleaned on the NCTSN’s 7 domains of impairment

– Part 3: Clinicians will be asked to provide narrative feedback on the strengths and weaknesses of the CCTI

Data Collection

• Survey results– Sole point of data collection– Clinician will not be asked to provide any information

regarding what was elicited from the client during the trial of the tool.

• Demographic data – Clinician: age, gender, years in practice, level of

schooling, practice setting– Child: age, gender, educational level, current diagnosis– No identifiers will be used; no sensitive information

about either will be obtained.

Data Analysis

Data Analysis

Purpose: Infer whether clinician or child characteristics impact clinician’s evaluation of the tool.

Sample questions to be asked of the data:

1. Is there a link between the age of the child and the clinician’s ratings on cultural and developmental appropriateness?

2. Is there a relationship between the child’s diagnosis and the clinician’s scores on part two (amount of information obtained on domains of impairment)?

3. Is there an association between the clinician’s practice setting and the child’s level of engagement?

Human Subjects Protections

• Clinician Consent

• Confidentiality

• Retention, Payment, Tracking Procedures

• Data Management

References•Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & Marks, J.A. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventative Medicine, 14(4), 245-258.

•Ford, J.D. and the Developmental Trauma Disorder Work Group (2012). Developmental Trauma Disorder Structured Interview for Children. In development.

•Ford JD, Rogcrs K (1997), Empirically-based assessment of trauma and PTSD with children and adolescents. In: Proceedings From The International Society for Traumatic Stress Studies Annual Meeting. Montreal, November.

•Leiner, M., Rescorla, L., Medina, I., Blanc, O., Ortiz, M. (2010). Psychometric comparisons of the Pictorial Child Behavior Checklist with the standard version of the instrument. Psychological Assessment. 22(3):618–27.

•Muris, P., Meesters, C., Mayer, B., Bogie, N., Luijten, M., Geebelen, E., ... & Smit, C. (2003). The Koala Fear Questionnaire: a standardized self-report scale for assessing fears and fearfulness in pre-school and primary school children. Behaviour research and therapy, 41(5), 597-617.

• National Child Traumatic Stress Network. (2003). NCTSN Complex Trauma Task Force white paper on complex trauma in children and adolescents [White paper].

•Pelcovitz, D. (2004). Structured Interview for Disorders of Extreme Stress NOS –Adolescent version (SIDES-A). Unpublished professional manual

•Praver, F., DiGiuseppe, R., Pelcovitz, D., Mandel, F. S., & Gaines, R. (2000). A preliminary study of a cartoon measure for children's reactions to chronic trauma. Child Maltreatment, 5(3), 273-285.