1. A cartoon-based assessment tool for complex trauma in children
Getting the picture:
A cartoon-based assessment tool for complex trauma in children
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 %
Divorce %
Mental Illness %
Domestic Violence %
Criminal Behavior 6%
Abuse
Psychological 11%
Physical %
Sexual %
Neglect
Emotional %
Physical %

4. Adverse Childhood Experiences
Number of ACEs
Percent of Respondents
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.

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
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
PTSD
Complex Trauma

8. Complex Trauma in Children
Domain 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 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 Clinical Interview Standardized Measures
Treatment Planning
Intervention
Comprehensive
7 domains of impairment
Clinical Interview
Obtain info directly from child
Standardized Measures
5 tools recommended by the NCTSN

11. Challenges Standardized Measures Traumatized Children
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
Pictures coincide with items, adding a visual dimension to the assessment process.
Strengths:
Developmentally appropriate
Improve engagement
Stimulate attention
Address language and literacy difficulties
Image from Koala Fear Questionnaire (Muris, Meesters, Mayer, Bogie, Luijten, Geebelen, Bessems, & Smit, 2003)

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 4-12.
Angie/Andy Cartoon Trauma Scales (Praver, DiGiuseppe, Pelcovitz, Mandel, & Gaines, 2000)
Measured symptoms related to complex trauma
No longer in print

14. Cameron Complex Trauma Interview (CCTI)
Proposed Tool
Cameron Complex Trauma Interview (CCTI)
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.
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
Development of Item Language for Part 1 (trauma history) and Part 2 (symptomology) of the CCTI:
Item Review
Language Adaptation
Submit to Experts
Revise and Resubmit

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

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
Procedure:
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

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

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:
Is there a link between the age of the child and the clinician’s ratings on cultural and developmental appropriateness?
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)?
Is there an association between the clinician’s practice setting and the child’s level of engagement?
Do I need this slide? Or can I just describe these when I’m talking about the analyses?

24. Human Subjects Protections
Clinician Consent
Confidentiality
Retention, Payment, Tracking Procedures
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),