Using Using Assessment Assessment Measures in Measures in

PracticePracticeShannon Dorsey, Ph.D.Shannon Dorsey, Ph.D.

Duke University School of Duke University School of MedicineMedicine

National Center for Child National Center for Child Traumatic StressTraumatic Stress

Benefits of Using Core Benefits of Using Core Dataset MeasuresDataset Measures

Assess functioning at intakeAssess functioning at intake Traumatic experiences? Traumatic experiences? Trauma Sequelae (e.g., Posttraumatic Stress)?Trauma Sequelae (e.g., Posttraumatic Stress)? Associated symptoms? Associated symptoms?

Gain information to determine treatment Gain information to determine treatment pathpath

Engaging caregivers and other professionals Engaging caregivers and other professionals in the importance of treatmentin the importance of treatment

Assess functioning over timeAssess functioning over time How is treatment going/how is child responding? How is treatment going/how is child responding? Assess improvement at the end of treatmentAssess improvement at the end of treatment

Data for courts, teachers, and other involved Data for courts, teachers, and other involved professionalsprofessionals

Core Clinical Core Clinical CharacteristicsCharacteristics

Majority of information collected already Majority of information collected already as part of intake and clinical interviewas part of intake and clinical interview (e.g., demographics, prior treatment)(e.g., demographics, prior treatment)

Designed so that the you can obtain Designed so that the you can obtain information in the way that best fits with information in the way that best fits with your usual practiceyour usual practice Core characteristics form can be completed Core characteristics form can be completed

during the meeting with the during the meeting with the parent/caregiver or afterwards based on parent/caregiver or afterwards based on your notesyour notes

Trauma History and Trauma History and Detail FormDetail Form

‘‘Structure’ for ensuring inquiry about a Structure’ for ensuring inquiry about a range of traumatic experiences range of traumatic experiences List of 19 potential events and an ‘other’List of 19 potential events and an ‘other’

Provides a guide for ensuring that the Provides a guide for ensuring that the important details of the traumatic important details of the traumatic experience are obtainedexperience are obtained Duration Duration Child’s age(s) at which experiencedChild’s age(s) at which experienced Perpetrator? Perpetrator?

**Update throughout treatmentUpdate throughout treatment* as you * as you become aware of new information or become aware of new information or trauma exposuretrauma exposure

Trauma History and Trauma History and Detail FormDetail Form

Informs Treatment: Course of treatment Informs Treatment: Course of treatment may differ depending on trauma history:may differ depending on trauma history: Single vs. multiple incidentSingle vs. multiple incident Brief vs. extended durationBrief vs. extended duration

Trauma details particularly important: Trauma details particularly important: When addressing trauma triggers and When addressing trauma triggers and

reminders reminders When planning for and conducting gradual When planning for and conducting gradual

exposureexposure

Example: A tale of two trauma historiesExample: A tale of two trauma histories

Trauma History Timeline: Youth Referred for Treatment Trauma History Timeline: Youth Referred for Treatment Hurricane Katrina Hurricane Katrina

   Age In YearsAge In Years

Trauma InformationTrauma Information 00 11 22 33 44 55 66 77 88 9911

0011

1111

2211

3311

4411

5511

6611

7711

88UnUn

kk

Sexual Maltreatment/AbuseSexual Maltreatment/Abuse                                                            

Sexual Assault/RapeSexual Assault/Rape                                                            

Physical Maltreatment/AbusePhysical Maltreatment/Abuse                                                            

Physical AssaultPhysical Assault                                                            

Emotional Abuse/Psychological Emotional Abuse/Psychological MaltreatmentMaltreatment                                                            

NeglectNeglect                                                            

Domestic ViolenceDomestic Violence                                                            

War/Terrorism/Political Violence Inside War/Terrorism/Political Violence Inside U.S.U.S.                                                            

War/Terrorism/Political Violence Outside War/Terrorism/Political Violence Outside U.S.U.S.                                                            

Illness/MedicalIllness/Medical                                                            

Serious Injury/AccidentSerious Injury/Accident                                                            

Natural DisasterNatural Disaster                                                            

KidnappingKidnapping                                                         

Trauma Loss or BereavementTrauma Loss or Bereavement                                                            

Forced DisplacementForced Displacement                                                            

Impaired CaregiverImpaired Caregiver                                                            

Extreme Interpersonal ViolenceExtreme Interpersonal Violence                                                            

Community ViolenceCommunity Violence                                                            

Trauma History Timeline: Youth Referred for Treatment of Trauma History Timeline: Youth Referred for Treatment of Sexual AbuseSexual Abuse

   Age In YearsAge In Years

Trauma InformationTrauma Information 00 11 22 33 44 55 66 77 88 99 10101111

1122

1133

1144

1155

1166

1177

1188

UUnnkk

Sexual Maltreatment/AbuseSexual Maltreatment/Abuse                                                            

Sexual Assault/RapeSexual Assault/Rape                                                   

Physical Maltreatment/AbusePhysical Maltreatment/Abuse                                                            

Physical AssaultPhysical Assault                                                            

Emotional Abuse/Psychological Emotional Abuse/Psychological MaltreatmentMaltreatment                                                            

NeglectNeglect                                                            

Domestic ViolenceDomestic Violence                                                            

War/Terrorism/Political Violence War/Terrorism/Political Violence Inside U.S.Inside U.S.                                                            

War/Terrorism/Political Violence War/Terrorism/Political Violence Outside U.S.Outside U.S.                                                            

Illness/MedicalIllness/Medical                                                            

Serious Injury/AccidentSerious Injury/Accident                                                            

Natural DisasterNatural Disaster                                                            

KidnappingKidnapping                                                            

Trauma Loss or BereavementTrauma Loss or Bereavement                                                            

Forced DisplacementForced Displacement                                                         

Impaired CaregiverImpaired Caregiver                                                            

Extreme Interpersonal ViolenceExtreme Interpersonal Violence                                                            

Community Violence Community Violence                                                            

School Violence School Violence                                                            

Summary thus Far…Summary thus Far…

Core Clinical CharacteristicsCore Clinical Characteristics Trauma History and Detail FormTrauma History and Detail Form

Largely information already collectedLargely information already collected Information can be obtained in many Information can be obtained in many

waysways No set way to ask questionsNo set way to ask questions

Next: Standardized Assessment Next: Standardized Assessment Measures used in the CDSMeasures used in the CDS

Standardized Measures: Standardized Measures: BenefitsBenefits

Administration provides an opportunity to Administration provides an opportunity to supplement information gained in the clinical supplement information gained in the clinical interview interview

Provides an opportunity to see where your Provides an opportunity to see where your client falls compared to other kids client falls compared to other kids Clinical range? Borderline range? Clinical range? Borderline range? Likely to meet criteria for a diagnosis PTSD? Likely to meet criteria for a diagnosis PTSD?

Development of standardized measures Development of standardized measures involves administering them to all kinds of involves administering them to all kinds of kids (clinical and not) so that the measures kids (clinical and not) so that the measures discriminate between kids having clinically discriminate between kids having clinically significant problems and those who are not significant problems and those who are not

Standardized Measures in Standardized Measures in the CDSthe CDS

Trauma Symptom Checklist for Children-Trauma Symptom Checklist for Children-Alternate Version (TSCC-A)Alternate Version (TSCC-A)

UCLA PTSD Reaction IndexUCLA PTSD Reaction Index Child Behavior Checklist (CBCL)Child Behavior Checklist (CBCL)

All of these measures have detailed All of these measures have detailed manuals: Review is manuals: Review is essentialessential for for appropriate administration and appropriate administration and interpretationinterpretation This training only provides an introductionThis training only provides an introduction

Manuals for Assessment Manuals for Assessment MeasuresMeasures

TSCC-A TSCC-A Manual is in hard copy and is provided to all Manual is in hard copy and is provided to all

NCTSN centers NCTSN centers UCLA PTSD-RI UCLA PTSD-RI

Supporting materials provided to centers Supporting materials provided to centers electronicallyelectronically

CBCLCBCL Manual available online for all Network centersManual available online for all Network centers

Contact your NCTNS liaison if you have not Contact your NCTNS liaison if you have not received these materialsreceived these materials

Standardized Measures: Standardized Measures: Posttraumatic Stress (PTS)Posttraumatic Stress (PTS)

PTS SymptomsPTS Symptoms PTSD Reaction Index (PTSD-RI)PTSD Reaction Index (PTSD-RI) Trauma Symptom Checklist for Trauma Symptom Checklist for

Children-AlternateChildren-Alternate (TSCC-A) (TSCC-A) Symptoms Associated with PTSSymptoms Associated with PTS TSCC-ATSCC-A

Assesses symptoms associated with Assesses symptoms associated with PTS: Depression, Anger, DissociationPTS: Depression, Anger, Dissociation

Standardized Measures: Standardized Measures: Broad Examination of Broad Examination of

FunctioningFunctioningGeneral BehaviorGeneral Behavior Child Behavior Checklist (CBCL)Child Behavior Checklist (CBCL)

Two Domains: Two Domains: Internalizing Problems (e.g., Internalizing Problems (e.g.,

Anxious/Depressed, Somatic Complaints)Anxious/Depressed, Somatic Complaints) Externalizing Problems (e.g., Aggressive Externalizing Problems (e.g., Aggressive

Behavior, Rule-breaking behavior)Behavior, Rule-breaking behavior)

Why Two Measures of Why Two Measures of PTS? PTS?

PTSD-RIPTSD-RI Provides an idea of whether the child might Provides an idea of whether the child might

meet DSM-IV criteria for PTSDmeet DSM-IV criteria for PTSD Information about level of symptoms for each Information about level of symptoms for each

domaindomain Re-experiencingRe-experiencing HypervigalenceHypervigalence AvoidanceAvoidance

TSCC-ATSCC-A PTS symptomsPTS symptoms Associated difficultiesAssociated difficulties Less of a diagnostic measureLess of a diagnostic measure

PTSD-RIPTSD-RI 22 items22 items Child responds on a 5-point scale of Child responds on a 5-point scale of

‘None’ to ‘Most’ regarding how much ‘None’ to ‘Most’ regarding how much of the time has experienced problem of the time has experienced problem during the past monthduring the past month

Determine whether child is likely to Determine whether child is likely to meet criteria by either answering the meet criteria by either answering the specified # of questions at a level of 2 specified # of questions at a level of 2 (‘Some’) for the 3 domains OR an (‘Some’) for the 3 domains OR an overall score of 38 or higheroverall score of 38 or higher

PTSD-RIPTSD-RI

TSCC-ATSCC-A Total of 44 itemsTotal of 44 items Child responds on a scale of 4-point scale from Child responds on a scale of 4-point scale from

‘Never’ to ‘Almost all of the time’ regarding how ‘Never’ to ‘Almost all of the time’ regarding how often problem happens often problem happens

Includes Validity scales Includes Validity scales HyperrespondingHyperresponding: Is this kid saying : Is this kid saying yesyes to everything? to everything?

Can be indicative of a ‘cry for help’Can be indicative of a ‘cry for help’ Might indicate child indiscriminately overendorsed itemsMight indicate child indiscriminately overendorsed items

UnderrespondingUnderresponding: Is this kid saying : Is this kid saying nono to everything? to everything? Can be indicative of avoidanceCan be indicative of avoidance Might indicate child indiscriminately marked ‘0’ on itemsMight indicate child indiscriminately marked ‘0’ on items

SubscalesSubscales PTS symptomsPTS symptoms AnxietyAnxiety Depression Depression AngerAnger DissociationDissociation

TSCC-ATSCC-A Scoring involves determining Scoring involves determining T-scoresT-scores

T-scores allow you to compare that child to other T-scores allow you to compare that child to other kids in the populationkids in the population

Is this child experiencing normal levels of difficulty, or Is this child experiencing normal levels of difficulty, or more difficulty, compared to other kids their age? more difficulty, compared to other kids their age?

Validity ScalesValidity Scales Underresponse: > 70 is Underresponse: > 70 is

unreliable/problematicunreliable/problematic Hyperresponse: > 90 is Hyperresponse: > 90 is

unreliable/problematicunreliable/problematicSubscalesSubscales T-score over 65: Clinically significant T-score over 65: Clinically significant

(serious) problems in that domain(serious) problems in that domain T-score 60-64, subclinical difficulties, but T-score 60-64, subclinical difficulties, but

may well warrant treatmentmay well warrant treatment

TSCC-ATSCC-A

CBCLCBCL Completed by the parent or caregiverCompleted by the parent or caregiver Two versions for different-aged kids Two versions for different-aged kids

Preschool version (99 items): Ages 1 ½ - 5Preschool version (99 items): Ages 1 ½ - 5 School-age version (118 items): Ages 6-18School-age version (118 items): Ages 6-18

Caregiver responds on a scale of 0 “Not Caregiver responds on a scale of 0 “Not True” to 2 “Very True or Often True” True” to 2 “Very True or Often True” regarding how the item describes the regarding how the item describes the child now or within the last 2 monthschild now or within the last 2 months

Subscales differ somewhat depending Subscales differ somewhat depending on the version used on the version used

CBCL SubscalesCBCL Subscales Preschool form (1 ½ - 5)Preschool form (1 ½ - 5)

Emotionally Reactive Emotionally Reactive Anxious/DepressedAnxious/Depressed Somatic Complaints Somatic Complaints Withdrawn Withdrawn Sleep Problems Sleep Problems Attention Problems Attention Problems Aggressive Behavior Aggressive Behavior Other Problems Other Problems

School-age form (6 - 18)School-age form (6 - 18) Withdrawn/Depressed Withdrawn/Depressed Anxious/DepressedAnxious/Depressed Somatic Complaints Somatic Complaints Aggressive Behavior Aggressive Behavior Rule-breaking Behavior Rule-breaking Behavior Social Problems Social Problems Thought Problems Thought Problems Attention Problems Attention Problems

CBCLCBCL

Giving What to Whom, and Giving What to Whom, and When? When?

Children 1.5 - 6 years: All information Children 1.5 - 6 years: All information provided by caregiversprovided by caregivers Core Clinical CharacteristicsCore Clinical Characteristics Trauma History and Detail Trauma History and Detail Child Behavior Checklist Child Behavior Checklist

Children/adolescents 7 years or older: Children/adolescents 7 years or older: Information provided by caregivers and childInformation provided by caregivers and child Core Clinical CharacteristicsCore Clinical Characteristics Trauma History and Detail Trauma History and Detail Trauma Symptom Checklist Children-AlternateTrauma Symptom Checklist Children-Alternate PTSD-Reaction IndexPTSD-Reaction Index Child Behavior ChecklistChild Behavior Checklist

Administer before treatment begins (baseline), Administer before treatment begins (baseline), every three months (if long term treatment) and at every three months (if long term treatment) and at the end of treatment the end of treatment

Treatment Planning Treatment Planning ActivityActivity

7 year old African American male 7 year old African American male referred to you for treatmentreferred to you for treatment

Review information from the clinical Review information from the clinical interview and forensic interviewerinterview and forensic interviewer

Also review information from Also review information from standardized assessmentsstandardized assessments

You receive a referral for treatment for Tyrell, a 7 year You receive a referral for treatment for Tyrell, a 7 year old African American male. Tyrell allegedly was old African American male. Tyrell allegedly was sexually abused at age 6 by his male cousin (who was 4 sexually abused at age 6 by his male cousin (who was 4 years older than Tyrell). Tyrell received a Child years older than Tyrell). Tyrell received a Child Medical Exam (CME) and the CME team confirmed Medical Exam (CME) and the CME team confirmed that he was sexually abused based upon statements that he was sexually abused based upon statements and behavior that were consistent with a child who has and behavior that were consistent with a child who has been sexually abused. Of note, during Tyrell’s CME been sexually abused. Of note, during Tyrell’s CME interview, he picked up both the couch and coffee table interview, he picked up both the couch and coffee table in the interview room and punched the wall when in the interview room and punched the wall when talking about the sexual abuse by his cousin.talking about the sexual abuse by his cousin.

Treatment Planning Activity

During the parent interview in the CME, and when she During the parent interview in the CME, and when she called to request treatment, Tyrell’s mother was called to request treatment, Tyrell’s mother was incredibly supportive of her son and expressed a desire incredibly supportive of her son and expressed a desire to get Tyrell help as quickly as possible. She stated to get Tyrell help as quickly as possible. She stated that Tyrell was very irritable and withdrawn (“off to that Tyrell was very irritable and withdrawn (“off to himself more”). She also was worried about the fact himself more”). She also was worried about the fact that Tyrell would have to see his cousin at school and that Tyrell would have to see his cousin at school and at family gatherings and was concerned that Tyrell still at family gatherings and was concerned that Tyrell still liked his cousin. In addition, Tyrell’s mother had a lot liked his cousin. In addition, Tyrell’s mother had a lot of guilt about the fact that the abuse happened while of guilt about the fact that the abuse happened while she was in the home. She became tearful when talking she was in the home. She became tearful when talking about how she should have known the abuse was about how she should have known the abuse was happening so that she could have stopped it.happening so that she could have stopped it.

Treatment Planning Activity

Treatment Planning Treatment Planning ActivityActivity

In your clinical interview with Tyrell’s mother, In your clinical interview with Tyrell’s mother, you also learn that Tyrell has juvenile diabetes you also learn that Tyrell has juvenile diabetes and that his mother is working to make sure that and that his mother is working to make sure that his blood sugar is stabilized. You also find out his blood sugar is stabilized. You also find out that Tyrell has increasingly been having that Tyrell has increasingly been having difficulties in school. In your interview with difficulties in school. In your interview with Tyrell, you notice that, like in the CME, Tyrell is Tyrell, you notice that, like in the CME, Tyrell is very avoidant when asked about the sexual very avoidant when asked about the sexual abuse. Specifically, while you are administering abuse. Specifically, while you are administering the TSCC-A, he climbs under the table. Because the TSCC-A, he climbs under the table. Because you are persistent, however, you provide Tyrell you are persistent, however, you provide Tyrell with writing materials and continue to with writing materials and continue to administer the measure. administer the measure.

Questions for the Questions for the Information thus FarInformation thus Far

What is the primary presenting What is the primary presenting problem? problem?

Are there additional areas of concern? Are there additional areas of concern?

What treatment/models might you be What treatment/models might you be considering? considering?

Supplementing with standardized Supplementing with standardized assessmentsassessments

PTSD-RI ResultsPTSD-RI Results

ScoreScore Cutoff Req. Cutoff Req. Met Met Criteria?Criteria?

Overall ScoreOverall Score 6161 Score >= 38 Yes Score >= 38 Yes (61)(61)

B (Re-exp.)B (Re-exp.) 1616 1 Q at >=2 Yes 1 Q at >=2 Yes (5 Q)(5 Q)

C (Avoid.)C (Avoid.) 2828 3 Q at >=2 Yes 3 Q at >=2 Yes (7 Q)(7 Q)

D (Arousal)D (Arousal) 1717 2 Q at >=2 Yes 4 2 Q at >=2 Yes 4 Q)Q)

Validity Scales:Underreporting: > 70 ProblematicHyperresponse > 90 Problematic

Clinical Scales: > 60 Subclinical > 65 Clinical

TSCC-A ResultsTSCC-A Results

HYP 1 62

CBCL ResultsCBCL Results

Beginning of Treatment:Child Behavior Checklist

C - Clinical RangeB - Borderline Range

Both are highlighted

Questions Regarding Questions Regarding Assessment FindingsAssessment Findings

How do these findings supplement How do these findings supplement referral and clinical information? referral and clinical information?

Do they add anything new? Do they add anything new?

What were the benefits of having all What were the benefits of having all three assessment measures? three assessment measures?

•What areas have improved?

•What areas need additional work?

Follow up Assessment Results

Concerns About Concerns About AssessmentsAssessments TimeTime to administer to administer TimeTime to score to score TimeTime involved to get scores back involved to get scores back EngagementEngagement ‘‘Fit’ with Clinical interview Fit’ with Clinical interview All those questions!!!! All those questions!!!!

Ways to Complete the Ways to Complete the AssessmentAssessment

Put assessment on the agenda and Put assessment on the agenda and connect it to treatmentconnect it to treatment

Using the waiting room: self-Using the waiting room: self-administered formatadministered format

During the session: interview format During the session: interview format With youth…allows for collection of With youth…allows for collection of

additional ‘data,’ physiological signsadditional ‘data,’ physiological signs * For youth, ask follow-up questions * For youth, ask follow-up questions afterafter

you’ve completed the measureyou’ve completed the measure Parents with reading problemsParents with reading problems

Complete over 1-2 sessions (balance with Complete over 1-2 sessions (balance with engagement)engagement)

Making Assessments Child-Making Assessments Child-involved and Helping involved and Helping Motivate CompletionMotivate Completion

Use developmentally appropriate strategies…Use developmentally appropriate strategies… For school-age youth and young adolescentsFor school-age youth and young adolescents

Dry erase board/chalk board for marking answersDry erase board/chalk board for marking answers Small rewards for each ‘set’ of questions completed Small rewards for each ‘set’ of questions completed

(attention span and age determines whether this is 5 (attention span and age determines whether this is 5 questions or an entire questionnaire)questions or an entire questionnaire)

For all youth (and parents)For all youth (and parents) Praise for ‘hard work’ completing questionsPraise for ‘hard work’ completing questions

Complete one or two measure each session so Complete one or two measure each session so that session can include therapeutic activitiesthat session can include therapeutic activities

Giving Feedback to Giving Feedback to Families and YouthFamilies and Youth

Meet individually with the parent—draw picture when Meet individually with the parent—draw picture when possiblepossible

Connect what they’ve told you in the clinical interview Connect what they’ve told you in the clinical interview to what you saw on the measures:to what you saw on the measures: ““From what you’ve told me, and from your responses on these From what you’ve told me, and from your responses on these

questions, seems clear that Tyrell is having some problems questions, seems clear that Tyrell is having some problems related to the sexual abuse, and he’s having more difficulties related to the sexual abuse, and he’s having more difficulties than other kids his age. He’s having trouble sleeping, he’s than other kids his age. He’s having trouble sleeping, he’s having problems with anger…”having problems with anger…”

““Does that fit with your feeling about how he’s doing? Am I on Does that fit with your feeling about how he’s doing? Am I on target?” target?”

Connect treatment plan to improving child’s functioningConnect treatment plan to improving child’s functioning ““TF-CBT is specifically designed to help kids deal with TF-CBT is specifically designed to help kids deal with

symptoms related to difficult experiences like sexual abuse. symptoms related to difficult experiences like sexual abuse. When we’re done with treatment, I expect that Tyrell will be When we’re done with treatment, I expect that Tyrell will be feeling better and will be having a lot less problems with feeling better and will be having a lot less problems with worries, anger, and sleeping. To make sure we’ve been worries, anger, and sleeping. To make sure we’ve been successful with treatment, we’ll do these measures again at the successful with treatment, we’ll do these measures again at the end so both you and I can feel confident that Tyrell is doing end so both you and I can feel confident that Tyrell is doing better and is ready to be done with therapy. Sound okay?”better and is ready to be done with therapy. Sound okay?”

Questions? Questions?

Small tests of changeSmall tests of change Assessment is great area for using small tests of Assessment is great area for using small tests of

change (PDSAs)change (PDSAs) Try using assessment measures with one client, Try using assessment measures with one client,

report back to teamreport back to team Ask families how the results help them Ask families how the results help them

understand the difficulties their child is understand the difficulties their child is experiencingexperiencing

Ask families about their questions related to Ask families about their questions related to the measuresthe measures

Uncomfortable giving feedback to families? Uncomfortable giving feedback to families? Role play with other cliniciansRole play with other clinicians

Contact InformationContact Information

Assessment Measure or Clinical Assessment Measure or Clinical Questions:Questions:

Ernestine.briggs@duke.eduErnestine.briggs@duke.edu Lebert@psych.duhs.duke.eduLebert@psych.duhs.duke.edu

InForm/Database Program Questions:InForm/Database Program Questions: NCTSN@dcri.duke.eduNCTSN@dcri.duke.edu