Using Assessment Measures in Practice

1. Using Assessment Measures in Practice Shannon Dorsey, Ph.D. Duke University School of Medicine National Center for Child Traumatic Stress

2. Benefits of Using Core Dataset Measures • Assess functioning at intake • Traumatic experiences? • Trauma Sequelae (e.g., Posttraumatic Stress)? • Associated symptoms? • Gain information to determine treatment path • Engaging caregivers and other professionals in the importance of treatment • Assess functioning over time • How is treatment going/how is child responding? • Assess improvement at the end of treatment • Data for courts, teachers, and other involved professionals

3. Core Clinical Characteristics • Majority of information collected already as part of intake and clinical interview • (e.g., demographics, prior treatment) • Designed so that the you can obtain information in the way that best fits with your usual practice • Core characteristics form can be completed during the meeting with the parent/caregiver or afterwards based on your notes

4. Trauma History and Detail Form • ‘Structure’ for ensuring inquiry about a range of traumatic experiences • List of 19 potential events and an ‘other’ • Provides a guide for ensuring that the important details of the traumatic experience are obtained • Duration • Child’s age(s) at which experienced • Perpetrator? • *Update throughout treatment* as you become aware of new information or trauma exposure

5. Trauma History and Detail Form • Informs Treatment: Course of treatment may differ depending on trauma history: • Single vs. multiple incident • Brief vs. extended duration • Trauma details particularly important: • When addressing trauma triggers and reminders • When planning for and conducting gradual exposure • Example: A tale of two trauma histories

8. Summary thus Far… • Core Clinical Characteristics • Trauma History and Detail Form • Largely information already collected • Information can be obtained in many ways • No set way to ask questions • Next: Standardized Assessment Measures used in the CDS

9. Standardized Measures: Benefits • Administration provides an opportunity to supplement information gained in the clinical interview • Provides an opportunity to see where your client falls compared to other kids • Clinical range? Borderline range? • Likely to meet criteria for a diagnosis PTSD? • Development of standardized measures involves administering them to all kinds of kids (clinical and not) so that the measures discriminate between kids having clinically significant problems and those who are not

10. Standardized Measures in the CDS • Trauma Symptom Checklist for Children-Alternate Version (TSCC-A) • UCLA PTSD Reaction Index • Child Behavior Checklist (CBCL) • All of these measures have detailed manuals: Review is essential for appropriate administration and interpretation • This training only provides an introduction

11. Manuals for Assessment Measures • TSCC-A • Manual is in hard copy and is provided to all NCTSN centers • UCLA PTSD-RI • Supporting materials provided to centers electronically • CBCL • Manual available online for all Network centers • Contact your NCTNS liaison if you have not received these materials

12. Standardized Measures: Posttraumatic Stress (PTS) PTS Symptoms • PTSD Reaction Index (PTSD-RI) • Trauma Symptom Checklist for Children-Alternate (TSCC-A) Symptoms Associated with PTS • TSCC-A • Assesses symptoms associated with PTS: Depression, Anger, Dissociation

13. Standardized Measures: Broad Examination of Functioning General Behavior • Child Behavior Checklist (CBCL) • Two Domains: • Internalizing Problems (e.g., Anxious/Depressed, Somatic Complaints) • Externalizing Problems (e.g., Aggressive Behavior, Rule-breaking behavior)

14. Why Two Measures of PTS? • PTSD-RI • Provides an idea of whether the child might meet DSM-IV criteria for PTSD • Information about level of symptoms for each domain • Re-experiencing • Hypervigalence • Avoidance • TSCC-A • PTS symptoms • Associated difficulties • Less of a diagnostic measure

15. PTSD-RI • 22 items • Child responds on a 5-point scale of ‘None’ to ‘Most’ regarding how much of the time has experienced problem during the past month • Determine whether child is likely to meet criteria by either answering the specified # of questions at a level of 2 (‘Some’) for the 3 domains OR an overall score of 38 or higher

16. PTSD-RI

17. TSCC-A • Total of 44 items • Child responds on a scale of 4-point scale from ‘Never’ to ‘Almost all of the time’ regarding how often problem happens • Includes Validity scales • Hyperresponding: Is this kid saying yes to everything? • Can be indicative of a ‘cry for help’ • Might indicate child indiscriminately overendorsed items • Underresponding: Is this kid saying no to everything? • Can be indicative of avoidance • Might indicate child indiscriminately marked ‘0’ on items • Subscales PTS symptomsAnxiety Depression AngerDissociation

18. TSCC-A • Scoring involves determining T-scores • T-scores allow you to compare that child to other kids in the population • Is this child experiencing normal levels of difficulty, or more difficulty, compared to other kids their age? Validity Scales • Underresponse: > 70 is unreliable/problematic • Hyperresponse: > 90 is unreliable/problematic Subscales • T-score over 65: Clinically significant (serious) problems in that domain • T-score 60-64, subclinical difficulties, but may well warrant treatment

19. TSCC-A

20. CBCL • Completed by the parent or caregiver • Two versions for different-aged kids • Preschool version (99 items): Ages 1 ½ - 5 • School-age version (118 items): Ages 6-18 • Caregiver responds on a scale of 0 “Not True” to 2 “Very True or Often True” regarding how the item describes the child now or within the last 2 months • Subscales differ somewhat depending on the version used

21. CBCL Subscales • Preschool form (1 ½ - 5) • Emotionally Reactive  Anxious/Depressed • Somatic Complaints  Withdrawn • Sleep Problems  Attention Problems • Aggressive Behavior  Other Problems • School-age form (6 - 18) • Withdrawn/Depressed  Anxious/Depressed • Somatic Complaints  Aggressive Behavior • Rule-breaking Behavior  Social Problems • Thought Problems  Attention Problems

22. CBCL

23. Giving What to Whom, and When? • Children 1.5 - 6 years: All information provided by caregivers • Core Clinical Characteristics • Trauma History and Detail • Child Behavior Checklist • Children/adolescents 7 years or older: Information provided by caregivers and child • Core Clinical Characteristics • Trauma History and Detail • Trauma Symptom Checklist Children-Alternate • PTSD-Reaction Index • Child Behavior Checklist • Administer before treatment begins (baseline), every three months (if long term treatment) and at the end of treatment

24. Treatment Planning Activity • 7 year old African American male referred to you for treatment • Review information from the clinical interview and forensic interviewer • Also review information from standardized assessments

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

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

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

28. Questions for the Information thus Far • What is the primary presenting problem? • Are there additional areas of concern? • What treatment/models might you be considering? • Supplementing with standardized assessments

29. PTSD-RI Results ScoreCutoff Req. Met Criteria? Overall Score 61 Score >= 38 Yes (61) B (Re-exp.) 16 1 Q at >=2 Yes (5 Q) C (Avoid.) 28 3 Q at >=2 Yes (7 Q) D (Arousal) 17 2 Q at >=2 Yes 4 Q)

30. TSCC-A Results Validity Scales: Underreporting: > 70 Problematic Hyperresponse > 90 Problematic Clinical Scales: > 60 Subclinical > 65 Clinical HYP1 62

31. CBCL Results Beginning of Treatment: Child Behavior Checklist C - Clinical Range B - Borderline Range Both are highlighted

32. Questions Regarding Assessment Findings • How do these findings supplement referral and clinical information? • Do they add anything new? • What were the benefits of having all three assessment measures?

33. Follow up Assessment Results • What areas have • improved? • What areas need • additional work?

34. Concerns About Assessments • Time to administer • Time to score • Time involved to get scores back • Engagement • ‘Fit’ with Clinical interview • All those questions!!!!

35. Ways to Complete the Assessment • Put assessment on the agenda and connect it to treatment • Using the waiting room: self-administered format • During the session: interview format • With youth…allows for collection of additional ‘data,’ physiological signs * For youth, ask follow-up questions after you’ve completed the measure • Parents with reading problems • Complete over 1-2 sessions (balance with engagement)

36. Making Assessments Child-involved and Helping Motivate Completion • Use developmentally appropriate strategies… • For school-age youth and young adolescents • Dry erase board/chalk board for marking answers • Small rewards for each ‘set’ of questions completed (attention span and age determines whether this is 5 questions or an entire questionnaire) • For all youth (and parents) • Praise for ‘hard work’ completing questions • Complete one or two measure each session so that session can include therapeutic activities

37. Giving Feedback to Families and Youth • Meet individually with the parent—draw picture when possible • Connect what they’ve told you in the clinical interview to what you saw on the measures: • “From what you’ve told me, and from your responses on these questions, seems clear that Tyrell is having some problems related to the sexual abuse, and he’s having more difficulties than other kids his age. He’s having trouble sleeping, he’s having problems with anger…” • “Does that fit with your feeling about how he’s doing? Am I on target?” • Connect treatment plan to improving child’s functioning • “TF-CBT is specifically designed to help kids deal with symptoms related to difficult experiences like sexual abuse. When we’re done with treatment, I expect that Tyrell will be feeling better and will be having a lot less problems with worries, anger, and sleeping. To make sure we’ve been successful with treatment, we’ll do these measures again at the end so both you and I can feel confident that Tyrell is doing better and is ready to be done with therapy. Sound okay?”

38. Questions? • Small tests of change • Assessment is great area for using small tests of change (PDSAs) • Try using assessment measures with one client, report back to team • Ask families how the results help them understand the difficulties their child is experiencing • Ask families about their questions related to the measures • Uncomfortable giving feedback to families? Role play with other clinicians

39. Contact Information Assessment Measure or Clinical Questions: • Ernestine.briggs@duke.edu • Lebert@psych.duhs.duke.edu InForm/Database Program Questions: • NCTSN@dcri.duke.edu