Presentation on theme: "A cartoon-based assessment tool for complex trauma in children"— Presentation transcript:
1 A cartoon-based assessment tool for complex trauma in children Getting the picture:A cartoon-based assessment tool for complex trauma in childrenJennifer BoyleUniversity of PennsylvaniaCommittee members:Phyllis Solomon, PhD. – ChairJulian Ford, PhDEliana Gil, PhD
2 Extent of the ProblemEach year in the U.S., more than 3,000,000 allegations of child abuse or neglect are made1,000,000 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.
4 Adverse Childhood Experiences Number of ACEsPercent of Respondents33%126%216%310%4 or more12.5%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 TraumasSingle-incident, unexpected events or emergencies such as natural disasters, accidents, and illnesses.Type 2 TraumasRepetitive 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 eventMarked by reexperiencing, avoiding, increased arousal, negative moodComplex Trauma or Disorders for Extreme Stress Not Otherwise Specified (DESNOS)Multiple or chronic, Type 2 traumatic eventsMarked by alterations in many areas of functioning, including but not limited to PTSD symptomsPTSDComplex Trauma
8 Complex Trauma in Children Domain of ImpairmentAssociated SymptomsAttachmentUncertainty about the reliability of the world; Problems with boundaries; Distrust and suspiciousnessBiologySensorimotor developmental problems; Somatization;Increased medical problemsAffect RegulationDifficulty describing internal experience; Difficulty communicating wants/needs; Difficulty with regulating emotionsDissociationAlterations in states of consciousness; Amnesia;Depersonalization and derealizationBehavioral RegulationImpulse control problems; Self-destructive behavior;Aggression/oppositional behaviorsCognitionLearning difficulties; Problems with language development; Difficulties in attention regulationSelf-ConceptLack of a continuous, predictable self; Low self-esteemGuilt and shameAdapted from NCTSN (2003)
9 Diagnostic IssuesChildren exposed to ongoing, multiple, or repeated trauma often fit diagnostic criteria for:Major depressive disorderAttention-deficit/hyperactivity disorder (ADHD)Oppositional defiant disorder (ODD)Conduct disorderAnxiety disordersEating disordersSleep disordersCommunication disordersSeparation anxiety disorderReactive attachment disorder
10 Assessment Comprehensive Clinical Interview Standardized Measures Treatment PlanningInterventionComprehensive7 domains of impairmentClinical InterviewObtain info directly from childStandardized Measures5 tools recommended by the NCTSN
11 Challenges Standardized Measures Traumatized Children Verbal interview or self-report formatRequire reading/language skillsRely heavily on caregiver inputTraumatized ChildrenStruggle to describe internal statesDeficits in attention, abstract reasoning, and executive function skillsCaregiver input unreliable
12 Pictorial Instruments Pictures coincide with items, adding a visual dimension to the assessment process.Strengths:Developmentally appropriateImprove engagementStimulate attentionAddress language and literacy difficultiesImage 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 problemsKoala 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 traumaNo longer in print
14 Cameron Complex Trauma Interview (CCTI) Proposed ToolCameron Complex Trauma Interview (CCTI)Pictorial-based, two-part structured interviewEvaluates 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 ReviewLanguage AdaptationSubmit to ExpertsRevise 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 ScaleSubmit Images and Matching Items to ReviewersRevise and Retest
18 Methods: Phase 2 - Evaluation Sample:Master’s level clinicians providing mental health services to childrenFamily Practice and Counseling Network, Gil Institute for Trauma Recovery and Education, Clinicians in the DSW Program at UPennPurposeful snowball sampling approachMinimum of 25 clinicians
19 Methods: Phase 2 - Evaluation Procedure:Review consent form, demographic survey, CCTI Instruction Manual, and CCTI, viaUtilize the CCTI with at least one child, ages 5 to 11, with history of exposure to multiple types of traumatic eventsComplete 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 toolPart 2: 3-point Likert Scale, clinicians rank the amount of information gleaned on the NCTSN’s 7 domains of impairmentPart 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 collectionClinician will not be asked to provide any information regarding what was elicited from the client during the trial of the tool.Demographic dataClinician: age, gender, years in practice, level of schooling, practice settingChild: age, gender, educational level, current diagnosisNo identifiers will be used; no sensitive information about either will be obtained.
22 Data Analysis Descriptive Statistics Cross-Tabulation Coding Clinicians’ demographic informationChild’s demographic informationFrequencies, Measures of Central TendencyResults of parts 1 and 2 of the survey data5 subscales comprising part 1 of the survey dataCross-TabulationDemographic information will be cross-tabulated and analyzed using Chi Squares of survey results.CodingData 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 ConsentConfidentialityRetention, Payment, Tracking ProceduresData Management
25 ReferencesFelitti, 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 manualPraver, 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),