Understanding and Assessing Trauma in Children and Adolescents

Measures, Methods, and Youth in Context

Kathleen Nader

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781135901684
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

In this volume, Kathleen Nader has compiled an articulate and comprehensive guide to the complex process of assessment in youth and adolescent trauma. There are many issues that are important to evaluating children and adolescents, and it is increasingly clear that reliance on just one type of assessment does not provide the most accurate results. From history to recent advances, this book covers a wide range of methods and measures for assessing trauma, including case examples to illustrate the integration of these different facets. Altogether, the broad scope and inclusive depth of this work make it an essential addition to the field of trauma assessment.

Part I

Understanding Trauma in Youths and the Issues Related to Its Assessment

1

How Children and Adolescents Are Affected by Trauma

Because of rapid access to information, children in many nations are exposed, daily, to the world’s multiple stresses. In addition to media exposure, every year millions of children in and outside of the United States are exposed to mass or individual violence (e.g., child abuse, school and community violence, war, terrorist attacks), natural and human-made disasters, severe deprivation, animal attacks, and severe accidents. These experiences may occur when the child is alone or among strangers (e.g., hiking, crossing the street, biking), with family (e.g., car accidents, hostage or war experiences), or in a group (e.g., terrorist attacks, sniper shootings, natural disasters). They may occur once or repeatedly, in less than a day or over a prolonged period. Research has contradicted the notion that young children are more resilient following trauma (Scheeringa, Zeanah, Myers, & Putnam, 2005). Following traumatic experiences, a significant number of children react in ways that substantially disrupt or impair their and their family’s daily lives, their growth and development, and their abilities to function normally (Box 1.1; Fletcher, 2003; La Greca, Silverman, Vernberg, & Roberts, 2002a; Webb, 2004; Wilson, Friedman, & Lindy, 2001). Unresolved traumatic reactions may seriously derail a youth’s life path; task, work, or academic performance; and well-being. Much more information is needed to achieve a full understanding of the manner in which catastrophic experiences affect children over time. Researchers are finding that multimethod and multimeasure assessments increase understanding of the nature of childhood posttraumatic reactions.

Accurate assessment of trauma in children and adolescents as well as in adults requires examination of psychological, biophysiological, sociocultural, and spiritual dimensions of response (Boehnlein, 2001). This book addresses the many issues that are important to evaluating children and adolescents. A youth’s reaction to a stressful event and the symptoms he/she exhibits can be related to many different factors such as aspects of the event (e.g., type and intensity of the trauma, chapter 10), qualities of the child (e.g., age, developmental issues, temperament, gender; chapter 6), facets of the child’s background (e.g., family circumstances, culture, history, support systems, attachment relationships, parenting; chapters 7, chapters 8), and the phase of the youth’s response (e.g., initial or later; stunned or numb vs. grieving or extremely aroused) (Fletcher, 2003; Nader, 2001b; Webb, 2004). Examining the effects of any single element is complicated by the interrelationships of elements (chapter 3; Fletcher, 2003; Nader, 2001b).

BOX 1.1

Case Examples¹

a. Mathew. Mathew was a happy 12-year-old boy with no history of behavior problems. During a lunch out with his best friend’s family, a man in army fatigues entered the restaurant and for more than an hour walked around the room shooting people. Mathew’s best friend, John, and his best friend’s mother were killed. His best friend’s father, Joe, was shot eight times but survived. Joe’s body shielded Mathew. During the long siege, every time Mathew lifted himself up to try to see what was happening, the shooter shot Joe. Mathew was wounded twice in the arms. He witnessed the deaths, mutilation, and injury of many other individuals. He lay under the table thinking how much he wanted to get up and beat up the shooter. After the shooter was shot and killed, the S.W.A.T. team, which were also dressed in army fatigues, entered the restaurant, kicking over bodies. Mathew thought they were more shooters. When one SWAT member reached down to pull him up from under the table, Mathew tried to punch him. Then Mathew tried to awaken his best friend by poking him in the thigh, shaking him, and calling to him. In the ambulance, he saw a mutilated woman and a man “screaming like a girl.”

Mathew began to behave violently and self-destructively. He provoked fights or carried weapons into areas frequented by aggressive weapon-carrying adolescents. He became violent in response to specific traumatic reminders: whenever he wore boots like the shooter, whenever anyone poked him in the thigh (as he had poked his friend), or whenever anyone grabbed him on the arm (as the SWAT member had). After a teacher grabbed Mathew’s arm, Mathew hit him. He anesthetized himself from the emotional pain with alcohol and marijuana. Mathew was hospitalized twice. He later stated that he learned to be a criminal and a drug addict in the hospital and when he went AWOL with other “inmates.” Mathew’s mother took him to other clinicians before she finally found a childhood trauma specialist during his second hospitalization. By then, he was taking hard drugs and frequently fighting violently with others. He poked at the sites of his wounds with pencils and other objects and later found pleasure in drawing blood into the needle before injecting drugs (see Table 17.1 for a comparison of early and current symptoms).

The trauma program psychiatrist who conducted Mathew’s initial intake evaluation told the ongoing therapist not to get her hopes up. “We will be lucky to keep him alive through high school,” he said. At age 15, Mathew began each treatment session disavowing the need for therapy. Mathew then readily described his experiences and often engaged in spontaneous play that re-created the shooter endangering others, his feelings of helplessness, the need to fight back without being shot, and his desire to protect the friend who was shot to death. For a few weeks, he moved to the floor and regressed to the play and toys of a very young child. During a period of time that he refused to go to therapy, Mathew served as rescuer for his troubled friends and allowed himself to be endangered during his rescue efforts. He was stabbed during one friend’s rescue. (Case example continued in other chapters.)

b. Tony. An earthquake of 5.6 magnitude partially collapsed an elementary school gymnasium during third-period gym class. Twenty-three children and two teachers were injured. Five children were killed. Tony (age 8) was in the gym when the earthquake collapsed the two outer walls. He sustained multiple injuries. His leg was broken in three places, and his hip was fractured. Tony was hospitalized for 3 weeks and required a period of physical recuperation after he returned home. Before the gym collapsed, Tony was a good student, well-behaved, and well-liked by his peers and by adults. Following the earthquake, he was nervous and jumpy. He became anxiously attached to his mother and refused to go back to school. To her distress, he would not let his mother leave his physical proximity. At first, he told the story of the earthquake over and over. Later, he had periods of nervous quiet or of expressing fears of disaster recurrence. Tony was easily distracted by sounds or movement. He became frightened when the windows rattled. When his peers visited, he began to scream and cover his ears if they hovered or more than one of them talked at the same time. He couldn’t stand for them to touch him. Tony had difficulty concentrating and frequently engaged in angry outbursts. He startled easily, cried out in his sleep nightly, and complained of stomachaches. (Case example continued in other chapters.)

c. Laticia. When she was 17, Laticia’s best friend was injured fatally when the two girls were robbed. Laticia sat next to Tanya’s bed while she lingered near death for days before dying. Laticia became preoccupied with thoughts of what Tanya must have been feeling while she was dying. Although Tanya was unconscious, she seemed to react to Laticia’s presence. Laticia engaged in repeated risky activities such as driving at excessive speeds on the freeway and running across tracks when trains were coming.

d. Lonnie and David. Following a long series of hospital procedures, a 3-year-old girl described elaborate dreams of trying to get away from the “cutters” coming to cut her. A 5-year-old boy with relapsed leukemia dreamed repeatedly of spacemen coming to take him to their planet. In his early dreams, he was afraid of them. He died a few months after he developed a comfortable relationship with them in his dreams.

e. Joanie. Until Joanie was age 12, her father and his friends repeatedly molested her. Her mother failed to protect or validate her. At age 12, Joanie threatened to go to the police, and the molestation stopped. After that, she felt empowered regarding men. She convinced herself that she was the user and not the used during her multiple relationships. She later realized that it was a false sense of control. Also as an adult, Joanie was very punishing to her female friends for any perceived betrayal, even if they only disagreed with one of her creative opinions. (Case example continued in other chapters.)

f. Sheila. Sheila’s mother had wanted a son. The mother had neglected Sheila, who was repeatedly injured, was molested as a child, and was raped as an adolescent. When she felt helpless and unlovable for any reason, it re-evoked the distress of her earlier traumas. As a youth and as an adult, she wore her “boy boots” and dressed like a young boy when she was feeling very helpless and unlovable. She said that it made her feel safer.

g. Laurie. Molested as a child by her mother’s boyfriend, Laurie, a competent executive, often, when fatigued or stressed, felt helpless and became childlike in her speech and mannerisms. In treatment, she expressed concern about undermining her own authority by seeking the opinions of supportive (young and old) employees about simple matters she would normally handle herself.

¹ For protection of the youths described and their confidentiality, the names and other identifying details have been changed in all case examples. Cases may be composites of two or more cases.

© Nader, 2006.

Multiple factors also contribute to the accuracy or inaccuracy of scale development and of assessment of the differences among groups of youths. Among these factors are the method of selection of subjects (e.g., random, matched, self-), preparation for assessment (e.g., training, briefing regarding the event, community preparation, sample selection; chapter 4), the interview or other method of scale completion (e.g., interviewers, interview style; sources of information; the circumstances of measure completion, observation, or interview; chapters 4, chapters 9 through chapters 13), and the scales and measures used (e.g., their adaptation for children and cultures; validity and reliability; comprehensiveness; chapters 4, chapters 7, chapters 11, chapters 13).

The History of Assessing Trauma in Youths

Prior to 1980² the assessment of childhood traumatic response was accomplished primarily through clinical case examination (Carey-Trefzer, 1949; Bloch, Silber, & Perry, 1956; Newman, 1976) and/or review of case records (Levy, 1945). Terr’s examination of children following a school bus kidnapping (Terr, 1979, 1981b, 1983a) and other studies of children exposed to violence and disaster (Eth & Pynoos, 1985a) demonstrated the effectiveness of directly interviewing children regarding their experiences and responses. The need for a more systematic statistical analysis of children’s traumatic reactions resulted in the application of a number of research instruments. These instruments included measures of depression (e.g., Birleson, 1981), anxiety (e.g., Reynolds & Richmond, 1978), fear (e.g., Ollendick, 1983), and “caseness” (Rutter & Graham, 1967; Elander & Rutter, 1996), as well as applying adult trauma scales to children (e.g., Horowitz, Wilner, & Alvarez, 1979). After a sniper opened fire on a crowded elementary school playground in south-central Los Angeles in 1984, the necessity for an emergency revision of Frederick’s (1985) 16-item Adult Posttraumatic Stress Reaction Index marked the emergence of trauma scales for children (Nader, Pynoos, Fairbanks, & Frederick, 1990; Pynoos et al., 1987). Over the past 2 decades, a number of measures have been developed and revised to reflect a growing knowledge of children’s posttraumatic reactions.

It has become clear that reliance on just one type of assessment is not the most accurate approach to assessing youths’ posttrauma reactions. Accuracy increases as assessments are made using more than one method (e.g., scales, observations, interviews) and measuring more than one aspect of the youth’s experience (e.g., perceptions of the traumatic experience, reactions to it, support received from others during and after). A more accurate understanding of the course of youths’ traumatic reactions also relies on repeated measurement over time with many of the same measures (see Caspi, 1998; Rothbart & Bates, 1998; Shiner, Tellegen, & Masten, 2001). The traumatic experience needs to be understood in context, as an experience embedded in a child’s life, as one experience in a network of other experiences, and as a set of circumstances that can be experienced differently by different people. Some researchers have begun to explore the wider context of the traumatic experience, attempting to identify important mediating and moderating factors associated with children’s traumatic reactions and symptoms, examining the success of alternate treatments, and assessing the long-term effects of the traumatic experience over time (Greenwald, 2002b; La Greca et al., 2002a; Nader, 2001b). Nevertheless, current understanding of childhood traumatic reactions has been limited or confused by (1) the lack of detailed information about children’s lives prior to their traumatic experiences, (2) mixed methods and study results (sometimes based on small sample sizes), (3) unidentified mediating and moderating variables, (4) inadequate information about grouping or outcome variables; (5) the need to identify the changing nature of symptoms over time, and (6) the lack of detailed studies of children before and after traumas and at intervals across the life span.

Current Assessment Tools

Over the last several years, measures for school-age youths’ self-reports of posttraumatic stress disorder (PTSD) and other symptoms have been created and revised (chapter 11; Table 11.1). A number of measures, interviews, and methods have been developed to assess other aspects of trauma in youths and to address specific types of traumatic experience (chapters 10 through 15). Scales, tests, and interviews for assessing neurobiological responses (chapter 2), exposure rates and levels (chapter 10), complicated trauma and traumatic grief reactions (chapter 10), adult reports (chapter 13), observational methods (chapter 12), information processing and dissociation (chapter 13), comorbid disorders (chapter 15), and associated symptoms (chapters 14, chapters 15) are discussed in this book. Measures of child attributes such as temperament, attachment style, personality type, self-esteem, coping, life satisfaction, and trait anxiety are discussed as well (chapters 5 through 9, chapters 15).

The Need for Accurate Assessment

The potential early and long-term negative consequences of unresolved traumatic response underscore the need for accurate assessment of childhood trauma (Table 1.2). Failure to resolve moderate to severe traumatic reactions or specific symptoms may lead to long-term consequences that interfere, over time, with the child’s ability to engage in productive behaviors and to function adequately socially, academically, professionally, and personally (La Greca et al., 2002a, 2002b; Nader, 2001b; Silverman, Reinherz, & Giaconia, 1996). A number of init...

Table of contents

• Cover Page
• Half Title page
• ROUTLEDGE PSYCHOSOCIAL STRESS SERIES
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword
• Preface
• Acknowledgments
• Part I Understanding Trauma in Youths and the Issues Related to Its Assessment
• 1 How Children and Adolescents Are Affected by Trauma
• 2 How Children and Adolescents' Brains Are Affected by Trauma
• 3 Are There Different Pathways to a Symptom or Set of Symptoms?
• 4 The Nature of Assessing Traumatized Children and Adolescents
• 5 Risk and Resilience Factors Trauma's Mediator, Moderator, or Outcome Variables
• Part II Aspects of Youth and Environment: Their Influence on the Assessment of Trauma
• 6 The Nature of the Child
• 7 Culture and Family Background
• 8 Attachment
• Part III Methods and Measures for Assessing Trauma in Youths
• 9 Interviewing Children and Adolescents Following Traumatic Events
• 10 The Nature of the Event Assessing Exposure Levels and Complicated Reactions
• 11 Self-Reports of Trauma Symptoms School-Age Children and Adolescents
• 12 The Use of Projective Tests in the Evaluation of Trauma
• 13 Adult Reports Parent, Teacher, and Clinician Assessments of Trauma
• Part IV Assessing Additional Trauma Symptoms
• 14 The Integration of Information Following Traumas Information Processing and Dissociation
• 15 Assessing Comorbidity and Additional Symptoms
• Part V Pulling it All Together
• 16 Writing Reports Regarding Traumatized Youths
• 17 An Afterword Some Conclusions About Assessing Trauma in Youths
• Glossary
• References
• Author Index
• Subject Index