Chapter Two – AssessmentTreatment-Guide-Chapter-2

As outlined in the last chapter, abused or otherwise traumatized adolescents may experience the full panoply of symptoms, problems, and problematic behaviors.

 

The type and extent of these difficulties vary as a function of the types of trauma the youth has experienced, when in the developmental process they occurred, and their frequency and duration, as well as other biological, psychological, and social variables that might intensify or otherwise moderate the clinical presentation. For this reason, it will rarely be true that any given adolescent will present with exactly the same clinical picture as any other adolescent. This variability means that the treatment of complex posttraumatic disturbance can only occur after some form of psychological assessment is performed.

In ITCT-A, assessment typically includes information from a number of sources, including the adolescent’s self-report, caretaker reports of his or her functioning, collateral reports from caregivers, teachers, and other providers, and psychometric testing. The primary focus of assessment is the adolescent’s safety level, trauma exposure history, and current psychological symptoms or problems. However, information may also be collected on caretaker and family functioning and history, the youth’s developmental history, psychiatric history, cultural background, primary attachment relationships, child protective services involvement and placement history, current school functioning, history of losses, substance use or abuse, medical status, suicidal or homicidal ideations and behavior, current legal issues, coping skills, level of cognitive functioning, and environmental stressors such as community violence. Once consent for release of information is provided, the clinician can gather more complete background information from agencies interacting with the client and family, such as child protective services, schools, and other mental health agencies or professionals.

In matters of truth and justice, there is no difference between large and small problems, for issues concerning the treatment of people are all the same. — Albert Einstein

Evaluation of Current Safety

Most obviously, the first focus of assessment is whether the client is in imminent danger or at risk of hurting others. In cases of ongoing interpersonal violence, it is also very important to determine whether the client is in danger of victimization from others in the immediate future. Most generally, the hierarchy of assessment is as follows:

  • Is there danger of imminent injury or death?
  • Is the client incapacitated (e.g., through intoxication, brain injury or delirium, severe psychosis) to the extent that he or she cannot attend to his or her own safety (e.g., wandering into streets, or unable to access available food or shelter)?
  • Is the client acutely suicidal or a danger to others (e.g., homicidal, or making credible threats to harm someone)?
  • Is the client’s immediate psychosocial environment unsafe (e.g., is he or she immediately vulnerable to maltreatment or exploitation by others)?

The first goal of trauma intervention, when any of these issues are present, is to ensure the physical safety of the client or others, often through referral or triage to emergency medical or psychiatric services, law enforcement, child protection, or social services. It is also important, whenever possible, to involve supportive and less-affected family members, friends, or others who can assist the client in this process.

At a less acute level, questions include:

  • Does the client have a place to stay tonight?
  • When did he or she last eat?
  • When did he or she last get a medical examination? Does he or she need medical care?
  • Is he or she engaged in unsafe sex, IV drug abuse, or other risky behaviors?
  • Does he or she report self-injurious behavior (e.g., self-cutting, self-burning)?
  • Is there evidence of a severe eating disorder?
  • Is he or she being exploited sexually or otherwise by another person? Is a child abuse report indicated?
  • Is he or she involved in a gang? If so, how dangerous is the situation, both to the client and to others?
  • Is he or she attending school, if relevant

 

Evaluation of Trauma-Exposure History

After evaluating immediate safety risks, typically next considered is the adolescent’s trauma history. Common types of trauma are child abuse (physical, sexual, and psychological), emotional neglect, assaults by peers (both physical and sexual), community violence, witnessing violence done to others, traumatic loss, exposure to accidents (e.g., motor vehicle accidents) and disasters, and serious medical illness or injury. Assessment typically involves determining not only the nature of these various traumas, but also their number, type, and age of onset.

The adolescent may not report all significant trauma exposures during the initial assessment session or early in treatment. Instead, important historical events may be disclosed later in therapy, as the child engages more fully with the clinician and experiences a greater sense of trust and safety. The manner in which adolescents, as well as caretakers, are directly queried regarding trauma exposures also will have an impact on the extent to which a complete account is provided (Lanktree & Briere, 2008).

The context in which the assessment is conducted can also affect the extent of trauma information that is disclosed by the adolescent and/or family, whether by interview or on psychological tests. For example, in school settings, the adolescent may not feel as free to divulge information due to concerns about confidentiality, including fear that his or her trauma history or symptoms will be shared with school personnel or other students. In hospital settings, where an adolescent may be assessed for psychological trauma following serious medical illness or condition (e.g., HIV infection, cancer, surgeries) or traumatic injury (e.g., the medical results of an assault or accident), the client and family’s need to cope with urgent or chronic medical issues may lead them to overlook or suppress information regarding prior (or current) abuse or violence.

Because clients may interpret trauma labels in different ways, evaluation of trauma exposure is often more effective when it employs behavioral descriptions of the event (s), as opposed to merely asking about “rape” or “abuse.” This is often best accomplished by using some sort of structured measure or interview that assesses exposure to the major types of traumatic events in a standardized way, since research indicates that direct inquiry about specific trauma history tends to yield more trauma exposure information (e.g., Lanktree, Briere, & Zaidi, 1991). Included in the Appendix of this guide is a version of the Initial Trauma Review (ITR-A; Briere, 2004), adapted for adolescent clients.

 

Evaluation of Trauma-Relevant Symptoms

An optimal assessment of adolescent symptomatology includes an estimation of current psychological functioning and potential targets for treatment. The results of such assessment, in turn, will determine whether an immediate clinical response is indicated, as well as what specific treatment modalities (e.g., cognitive interventions, therapeutic exposure, family therapy, or psychiatric medication) might be most helpful. Further, when the same tests or interview-based assessments are administered on multiple occasions (e.g., every three or four months), the ongoing effects of clinical intervention can be evaluated, allowing the clinician to make mid-course corrections in strategy or focus when specific symptoms are seen to decrease or exacerbate (Briere, 2001).

For some adolescents, multiple trauma exposures such as abuse, neglect, family and community violence, relational losses, and injuries or illnesses may occur concomitantly, resulting in a more complex clinical picture. In addition, gender-related, developmental, and cultural factors may affect how any given symptom manifests. For this reason, it is usually preferable to administer multiple tests, if possible, tapping a variety of different symptoms, rather than a single measure, and to take mediating demographic, social, and cultural issues into account.

When using psychological tests, standardized trauma assessment measures are usually preferable to those without norms or validation studies. These tests may involve caretaker reports of the adolescent’s symptoms and behaviors or self-reports of their own distress and/or behavioral disturbance. In addition, such measures may be either generic or trauma-specific.

The choice of whether to use self- or caretaker-reports of adolescent symptoms can be difficult, since each approach has its own potential benefits and weaknesses. Self-report measures allow the adolescent to directly disclose his or her internal experience or problems, as opposed to the clinician relying on “second hand” reports of a parent or caretaker. However, the youth’s report may be affected by his or her fears of disclosure, or denial of emotional distress (Elliott & Briere, 1994). Similarly, caretaker report of the youth’s symptomatology has the potential benefit of providing a more objective report of the client’s symptoms and behaviors, yet may be compromised by parental denial, guilt, or preoccupation with the adolescent’s trauma (Friedrich, 2002). Caretakers also may have difficulty accurately assessing the adolescent’s internal experience, especially if the adolescent, for whatever reason, avoids describing those experiences to the caretaker, or the caretaker has had minimal ongoing contact with the adolescent (Lanktree et al., 2008). For these reasons, it is recommended that the assessment of traumatized adolescents involve both self- and caretaker-report interviews and measures whenever possible, so that the advantages of each methodology can be maximized, and the child’s actual clinical status can be triangulated by virtue of multiple sources of information (Lanktree et al., 2008; Nader, 2007).

Assessment-Driven Treatment

In combination, carefully selected psychological tests and/or detailed clinical interviews – along with other forms of information – can help determine the extent of the adolescent’s trauma-related symptomatology, as well as any other psychological difficulties (e.g., depression) that also may be present. Understanding the adolescent’s emotional experience and behavioral responses, in turn, can help the clinician devise an effective treatment regimen that is relevant to the client’s specific clinical presentation and needs. When assessment is repeated over time, it can also signal the need to change or augment the treatment focus as needed. For example, ongoing evaluation may suggest a shift in therapeutic focus when posttraumatic stress symptoms begin to respond to treatment but other symptoms continue relatively unabated.

Assessment-Treatment Flowchart

The actual transformation of test and interview results, and collateral information, into a specific treatment plan occurs in ITCT-A using theAssessment-Treatment Flowchart, adolescent form (ATF-A), presented in the Appendix. This matrix not only helps guide the initial treatment plan, but also provides a serial reassessment of symptoms and possible interventions on a regular basis thereafter. Unfortunately, because the development of standardized measures for posttraumatic outcomes in adolescents is in its relative infancy, not all problems listed in the ATF-A have corresponding psychological tests that aid in their evaluation. In such instances, or when psychological testing is for some reason not possible, the clinician should rely on the youth’s self-report, his or her behavior and responses in the intake session and in therapy, parent report, data from other systems (e.g., legal, academic, child welfare), and interview-based clinical impressions to address ATF-A items.

Completion of the ATF-A thus proceeds in the following steps:

At intake:

  1. Review all assessment data, the adolescent’s interview-based self-report of symptoms and problems, parent or caretaker interview-based report of the adolescent’s symptoms and problems, collateral data such as school reports, other caregiver (e.g., health care professionals, other therapists), juvenile justice reports, etc.
  2. Proceed through each of the 19 items of the ATF-A for the “Intake” column, rating the treatment priority (ranging from 1 [“Not currently a problem, do not treat”] to 4 [“Most problematic, requires immediate attention”]) for each item based on the data collected at step 1.

At each following assessment period (typically every three months, unless circumstances require more frequent evaluations):

Review the last prioritization of symptoms and problems and, based on repeat assessment, re-prioritize the focus of treatment based on the client’s current clinical and social status. In some cases, reassessment and treatment reconfiguration will occur prior to a three-month assessment period, generally when some new event intercedes (e.g., a crisis or life event) or a significant treatment event (e.g., a breakthrough or newly uncovered information) alters the therapy trajectory. The ATF-A has rating columns for three assessment periods beyond the intake session, which generally corresponds to up to 9 months. Additional ATF-A pages may be added, as needed, for therapy that exceeds 9 months, or when emergent issues require assessment in shorter intervals. See later in this chapter for an example of a completed ATF-A, rated at two time-points.

Interview questions for the ATF-A:

Especially for those who do not use psychological tests, but also to expand upon existing test data, we list below possible interview topics for each ATF-A item. These are merely possibilities, however, and the clinician may choose other, equally relevant questions, especially in terms of crafting inquiries specific to the youth’s circumstances, trauma history, age, culture, etc.

Table 1. Possible Interview Question Topics

ATF-A item Possible question topics
1. Safety-environmental
  1. Does the client have a place to stay tonight
  2. Is he/she afraid that someone might hurt him/her
  3. Does he/she feel safe at home
  4. Is anyone making him/her do anything he he/she doesn’t want to do
  5. Is there continuing danger from past perpetrators
2. Caretaker support issues
  1. Does the client feel like parent(s) or family members “are on your side”
  2. Does he/she feel that his/her parent(s) take good care of him/her
  3. Is there someone in his/her family whom he/she can talk to
  4. Are parent(s)/family supportive of him/her being in therapy
  5. Does he/she feel loved by parent(s) or family members
3. Anxiety Extent of:

  1. Anxiety or feeling scared
  2. Panic attacks (define, if necessary)
  3. Worrying
  4. Feeling like something bad is about to happen
  5. Insomnia at night because he/she is worrying about the future
4. Depression Extent of:

  1. Feelings of sadness
  2. Depression
  3. Crying over the last week
  4. Feeling really down
  5. Feeling hopeless about the future
5. Anger/aggression Extent of:

  1. Getting into fights
  2. Feeling angry
  3. Getting mad at people
  4. Getting into trouble because of his/her anger
  5. Hitting or hurting people or animals
6. Low self-esteem Extent of:

  1. Feeling bad about himself/herself
  2. Self-criticism
  3. Not liking himself/herself
  4. Putting himself/herself down
  5. Feeling unattractive or unintelligent
7. Posttraumatic stress Extent of trauma-related:

  1. Bad dreams
  2. Flashbacks (define, if necessary)
  3. Feeling tense or on edge
  4. Avoiding people or places or situations that remind him/her about bad things that have happened
  5. Not being able to have feelings, even though he/she thinks he/she should have them
8. Attachment insecurity Extent of:

  1. Trust of people in general
  2. Worry that people will leave/abandon him/her or not be close to him/her anymore
  3. Friends in his/her social network
  4. Need to keep people at a distance
  5. Feeling empty inside when people aren’t around him/her
9. Identity issues Extent of:

  1. Not really knowing who he/she is
  2. Being confused about what he/she wants in life
  3. Standing up for himself/herself in conflicts or arguments
  4. Self-confidence
  5. Understanding himself/herself and why he/she does things
10. Relationship problems Extent of:

  1. Having trouble making friends
  2. Getting into arguments with his/her girlfriend/boyfriend/friends
  3. Staying around friends or sexual/romantic partners even when they are hurtful to him/her
  4. Problems with people in close relationships
  5. Relational “break-ups”
11. Suicidality Extent of:

  1. Thoughts about suicide
  2. Previous suicide attempts
  3. Wanting to die
  4. Making suicide plans
  5. Doing dangerous things in the hopes he/she might die
12. Safety-risky behaviors Extent of:

  1. Engaging in dangerous behaviors
  2. Driving too fast
  3. Prostitution or sex for food/shelter/drugs
  4. Doing dangerous things for fun
  5. Possession or use of guns or knives
13. Dissociation Extent of:

  1. “Spacing out”
  2. Watching himself/herself from outside of his/her body
  3. Feeling like things are unreal
  4. Doing things and not remembering them later (without substance abuse)
  5. Feeling disconnected from things, or watching things from a distance
14. Substance abuse Extent of:

  1. Alcohol use
  2. Recreational drug use (determine drugs of choice)
  3. Abuse of prescription drugs
  4. Trying to stop using drugs or alcohol but not being able to
  5. Getting into trouble because of drug or alcohol abuse
15. Grief After determining time since major loss, extent of:

  1. Sadness about the loss of person
  2. Missing the person
  3. Seeing or hearing the person although he/she is not actually present
  4. Preoccupation with, and intrusive thoughts about, the person
  5. Pretending that the person isn’t dead or gone
16. Sexual concerns and/or dysfunctional behaviors Extent of:

  1. Guilt, worry, or fear about sexual things
  2. Sexual problems
  3. Multiple sex partners in the last three months
  4. Involvement in sexual behavior for non- sexual reasons (e.g., attention, power, self-esteem)
  5. Unsafe sexual behavior
17. Self-mutilation Extent of:

  1. Cutting on self without suicidal intent
  2. Burning himself/herself with cigarettes or matches
  3. Hurting himself/herself to reduce emotional distress or triggered memories
  4. Punching walls or other immovable objects
  5. Biting self or pulling out hair