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

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

1 A cartoon-based assessment tool for complex trauma in children Getting the picture: Jennifer Boyle University of Pennsylvania Committee members: Phyllis Solomon, PhD. – Chair Julian Ford, PhD Eliana Gil, PhD

2 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.

3 Adverse Childhood Experiences Household Dysfunction Substance Abuse 27% Divorce 23% Mental Illness 17% Domestic Violence 13% Criminal Behavior 6% Abuse Psychological 11% Physical 28% Sexual 21% Neglect Emotional 15% Physical 10%

4 Adverse Childhood Experiences 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.

5 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

6 Trauma vs. Complex Trauma Type 1 Traumas Single-incident, unexpected events or emergencies such as natural disasters, accidents, and illnesses. Type 2 Traumas Repetitive or ongoing events such as physical and sexual violence, emotional and verbal abuse, neglect, bullying, acts of terrorism, and combat

7 Trauma vs. Complex Trauma PTSD Complex Trauma Post-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

8 Complex Trauma in Children Domain of ImpairmentAssociated Symptoms Attachment Uncertainty about the reliability of the world; Problems with boundaries; Distrust and suspiciousness Biology Sensorimotor developmental problems; Somatization; Increased medical problems Affect Regulation Difficulty 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-esteem Guilt and shame Adapted from NCTSN (2003)

9 Diagnostic Issues Children exposed to ongoing, multiple, or repeated trauma often fit diagnostic criteria for: Major depressive disorder Attention-deficit/hyperactivity disorder (ADHD) Oppositional defiant disorder (ODD) Conduct disorder Anxiety disorders Eating disorders Sleep disorders Communication disorders Separation anxiety disorder Reactive attachment disorder

10 Assessment Comprehensive 7 domains of impairment Clinical Interview Obtain info directly from child Standardized Measures 5 tools recommended by the NCTSN

11 Challenges Standardized Measures Verbal interview or self-report format Require reading/language skills Rely heavily on caregiver input Traumatized Children Struggle to describe internal states Deficits in attention, abstract reasoning, and executive function skills Caregiver input unreliable

12 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

13 Notable Pictorial Instruments Pictorial Child Behavior Checklist (Leiner, Rescorla, Medina, Blanc, & Ortiz, 2010) Pictures added to widely used standardized instrument measuring behavior problems Koala Fear Questionnaire (KFQ) (Muris et al., 2003) Standardized instrument assessing fears and fearfulness in children Angie/Andy Cartoon Trauma Scales (Praver, DiGiuseppe, Pelcovitz, Mandel, & Gaines, 2000) Measured symptoms related to complex trauma No longer in print

14 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.

15 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)

16 Methods: Phase 1- Development Item ReviewLanguage AdaptationSubmit to ExpertsRevise and Resubmit Development of Item Language for Part 1 (trauma history) and Part 2 (symptomology) of the CCTI:

17 Methods: Phase 1- Development Create Coinciding Images, Visual Likert Scale Submit Images and Matching Items to Reviewers Revise and Retest Development of Cartoon Pictures for Part 1 (trauma history) and Part 2 (symptomology) of the CCTI:

18 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

19 Methods: Phase 2 - Evaluation Review consent form, demographic survey, CCTI Instruction Manual, and CCTI, via Utilize the CCTI with at least one child, ages 5 to 11, with history of exposure to multiple types of traumatic events Complete Clinical Utility and Feasibility Survey online at the SurveyMonkey site Procedure:

20 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

21 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.

22 Data Analysis Clinicians’ demographic information Child’s demographic information Descriptive Statistics Results of parts 1 and 2 of the survey data 5 subscales comprising part 1 of the survey data Frequencies, Measures of Central Tendency Demographic information will be cross-tabulated and analyzed using Chi Squares of survey results. Cross-Tabulation Data from part 3 of the survey will be transcribed, coded, and categorized Coding

23 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?

24 Human Subjects Protections Clinician Consent Clinician Consent Confidentiality Confidentiality Retention, Payment, Tracking Procedures Retention, Payment, Tracking Procedures Data Management Data Management Clinician Consent Clinician Consent Confidentiality Confidentiality Retention, Payment, Tracking Procedures Retention, Payment, Tracking Procedures Data Management Data Management

25 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), 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), 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),


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