Chapter 2—Screening and Assessing Adults For Childhood Abuse and Neglect

Substance abuse is a chronic and relapsing condition. It is often associated with problems in physical, psychological, emotional, spiritual, and social functioning (Brown, 1998; Landry, 1994). These problems are not likely to be the result of one specific cause but rather the result of an accumulation of factors that clients have faced in their lives (Luthar and Walsh, 1995). Risk factors associated with substance abuse disorders include histories of childhood abuse and neglect (Carlson, 1997). In fact, a recent study found that adults with histories of child abuse have an increased likelihood of heart disease, cancer, and chronic lung disease, as well as greater risk for alcoholism, drug abuse, depression, and attempted suicide (Felitti et al., 1998). These findings emphasize the importance of comprehensive screening and assessment for individuals with substance abuse disorders and client access to adequate health care.

Although childhood abuse and neglect disproportionately affect adult substance abusers and their families, clients' substance abuse disorders are not often examined within the context of past abuse or neglect experiences. The reasons for not considering or eliciting this kind of historical information vary. Treatment providers may not have comprehensive screening and assessment measures available. Often, counselors simply fail to ask, or the intake organization does not instruct them to ask, about childhood abuse. Yet in some instances disclosure rates have risen dramatically when substance abuse treatment clients were asked directly about their experience of child abuse.

Clients may be unable to address traumatic childhood events because of memory problems that, in the past, have helped them cope with the trauma (Brown et al., 1999). Clients' family members may not be available or appropriate as family historians, and it is not the counselor's role to independently investigate family histories. Sometimes the immediacy of other problems causes assessments of child abuse and neglect to be delayed. Yet without proper screening and assessment, treatment providers may wrongly attribute symptoms of childhood trauma-related disorders to consequences of current substance abuse. Mental health issues often precede, rather than follow from, substance dependence. Therefore, comprehensive screening for root causes of clients' presenting symptoms may greatly increase the effectiveness of treatment.

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Challenges to Accurate Screening and Assessment

Counselors face great challenges when screening for and assessing childhood abuse or neglect. Few adults are comfortable with a history of violation and neglect. Many abuse survivors are ashamed of having been victims of childhood physical, emotional, or sexual abuse and may feel that the abuse was self-induced. Screening and assessment, therefore, should be designed to reduce the threat of humiliation and blame and should be done in a safe, nonthreatening environment. Although family members can be an important part of a comprehensive assessment (with the client's consent), treatment providers should be aware of what impact their involvement may have on the client's safety (or the safety of the client's children) and which family members the client considers nonthreatening.

The following sections illustrate the challenges that treatment staff should anticipate and prepare for when screening for a history of childhood abuse or neglect and when assessing its impact on clients with substance abuse disorders.

Underreporting Trauma History or Symptoms

When screening for and assessing a history of childhood trauma, the counselor should ask clients to recall and indirectly reexperience abuse-related events (Briere, 1997). This process can trigger defense mechanisms--such as denial, minimization, repression, amnesia, and dissociation (Bernstein et al., 1994; Briere, 1992a; Cornell and Olio, 1991)--that diminish the distress associated with these events and memories (Fink et al., 1995). These mechanisms may cause a client to withhold or ignore information that is important for the assessment. Adult survivors of childhood trauma commonly suppress memories of certain traumatic events or minimize, either consciously or unconsciously, their symptoms (Brown et al., 1999; Whitfield, 1997a). Frequently, such defense mechanisms relate to the shame and stigma of the events. Clients may fear retribution from perpetrators or family members or loss of contact with people on whom they are emotionally dependent. Minimizing has often served to protect family members from having to deal with the criminal justice system (including the possible arrest of the perpetrator). Also, clients may fear that treatment staff will assume that they are abusive to their own children and report them to the police or child protective services (CPS) agencies. Still others may have never perceived their experiences as abusive or harmful but rather as normal and deserved.

Certain sociocultural factors may encourage denial and minimization. For example, there is a social imperative among males to be strong and silent and unaffected by abuse. Physical abuse is difficult to evaluate because most males see their abuse as normal punishment for their behaviors (Langeland and Hartgers, 1998). Men may self-report child abuse and neglect less than women because their occurrence implies weakness and an inability to protect themselves (Evans and Sullivan, 1995; Holmes et al., 1997). Recent studies have concluded that sexual abuse of boys is underreported and undertreated (Holmes and Slap, 1998).

Issues of confidentiality, mandated reporting, and trust may influence responses to interviews and questionnaires by making some clients less inclined to reveal personal histories of abuse or neglect. Reporting requirements may vary from State to State (see Chapter 6 for more information on reporting child abuse and neglect). Maryland law, for example, requires that treatment providers report incidents of childhood abuse disclosed by adults in substance abuse treatment programs.

Repressed Memories

An important limitation of most of the research on childhood abuse is that it relies on retrospective recall of personal events that usually are not independently corroborated. This is a standard problem in many areas of research, but particular concerns have been raised about the retrospective recall of childhood sexual abuse. The primary concerns have revolved around the "false memory syndrome" and child sexual abuse that has been forgotten and later remembered in the context of counseling (Loftus, 1996). Laboratory research on memory indicates that people may be led to remember events that did not actually happen to them (Loftus, 1993). These findings have raised the concern that suggestible clients may be led by therapists to believe that they were sexually abused as children when they were not. Other research indicates, however, that people can only be led to believe that nontraumatic events happened to them and that they are much more impervious to suggestions that false traumatic events occurred (Bowman, 1996). See Farrants, 1998, for a review of the research on this subject.

Overreporting Trauma History or Symptoms

Recently, research has suggested that some individuals may overreport or misrepresent abuse histories or abuse-related symptomatology, although this does not normally happen (Briere, 1997). In such cases, the client's conscious or unconscious should be viewed as having significant pathology that may contaminate the screening and assessment processes. For example, some clients may report inaccurate abuse histories or symptoms so that they may receive treatment rather than be incarcerated, may receive inpatient instead of outpatient treatment, or may qualify for disability-related entitlements, such as Supplemental Security Income (LaCoursiere, 1993). Others may overreport their history of trauma or current trauma-related symptoms in an effort, consciously or unconsciously, to deny or minimize their substance abuse disorder. Although overreporting is probably a less frequent phenomenon than underreporting, staff should be aware of the possibility that clients may receive secondary gains from overreporting symptoms or the severity of past abuse. Just as many clients with substance abuse disorders tell "war stories," some, with a great deal of experience in treatment settings, have become experts at giving psychiatric labels to all their problems.

Coexisting Psychiatric Disorders

A number of studies have found that childhood maltreatment and trauma are significant risk factors for later psychiatric problems (Beitchman et al., 1992; Neumann et al., 1996; Polusny and Follette, 1995; Trickett and McBride-Chang, 1995). Indeed, individuals with a history of childhood trauma--such as being sexually abused, being physically assaulted, or repeatedly witnessing violence--often develop psychopathology during adulthood (Beitchman et al., 1992; Bryer et al., 1987; Malinosky-Rummell and Hansen, 1993; Pollock et al., 1990; Roesler and Dafler, 1993). Thus, many adults receiving treatment for substance abuse who have a history of childhood abuse and neglect will have a coexisting psychiatric disorder (seeFigure 2-1 ). As mentioned in Chapter 1, abuse and neglect during childhood are particularly associated with major depression, suicidal thoughts, posttraumatic stress disorder (PTSD), and dissociative symptoms (Briere and Runtz, 1990a; Craine et al., 1988; Felitti et al., 1998; Rowan and Foy, 1993; Rowan et al., 1994). In treatment programs for veterans, where PTSD symptoms are often assumed to be occupation related, a history of childhood abuse can be particularly difficult to identify. Childhood abuse also has been associated with borderline personality disorders (Herman et al., 1989), as well as dissociative amnesia and dissociative identity disorder (Brown et al., 1999; Briere, 1997; Briere and Conte, 1993; Ross et al., 1990). Given the potential for coexisting psychiatric disorders in this population, treatment providers should not rely only on self-assessment tools and patient feedback.

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Figure 2-1: Symptoms and Syndromes Associated With Childhood Abuse and Neglect. Most Common Responses Helplessness Low self-esteem Guilt Shame Anxiety Depression (more...)

Neuropsychological Consequences Of Childhood Abuse

Clients will benefit from understanding how severe and chronic physical, emotional, and sexual abuse in childhood can affect their memory and emotions long after the abuse has ceased. The long-term consequences of physical battering, for example, might include minimal or severe brain damage (from learning disabilities to mental retardation), aggressive behavior and lack of impulse control, and physical limitations. Childhood abuse or neglect also may hinder the development of a mature personality, because it becomes difficult for the abused person to develop a healthy sense of self. These effects have the potential to seriously complicate substance abuse treatment.

New neuroimaging techniques--such as positron emission tomography (PET) scans or functional magnetic resonance imaging (MRI)--have revealed that chronic abuse may actually affect pathways in the brain and alter thinking processes. Some studies show reductions in the volume of the hippocampus, the seat of long-term memory, in both combat veterans with PTSD and women with PTSD who experienced severe sexual abuse during childhood (Bremner et al., 1995; Gurvitz et al., 1995; Stein et al., 1997). In another study (Rauch et al., 1996), individuals reliving abusive episodes had marked decreases in blood flow to the left brain--most notably to Broca's area, which governs language capacity--and increased blood flow to the amygdala and limbic system, believed to be the site of emotion and long-term memory. These findings suggest that remembering trauma can produce intense emotional states while at the same time it inhibits individuals' capacity to verbalize their experiences (van der Kolk, 1996).

Counselors should be aware that clients may not be able to verbalize feelings when experiencing intense emotional states. Behavioral treatments such as exposure and desensitization in a safe therapeutic environment should help clients progressively manage these states without losing the ability to communicate. In this way, clients will be able to verbalize feelings instead of experiencing upsetting symptoms in response to traumatic triggers.

Dissociation

Many researchers and counselors now believe that dissociation is a common and readily available defense against childhood trauma, since children dissociate more easily than adults (Turkus, 1998). To defend against abuse, the child psychologically flees (dissociates) from full awareness. Under severe trauma, especially if inflicted at a young age, parts of the self may split off, in some cases creating a compartmentalized way of experiencing the world, with strong or painful emotions and memories shut off from consciousness. These emotions may surface as intense fear or anger when the client is under stress or is in situations that trigger memories of the abuse. In extreme cases, parts of the self may assume separate identities.

Dissociation serves many purposes. It provides a way out of an intolerable situation, it numbs pain, and it can erect barriers (i.e., amnesia) to keep traumatic events and memories out of awareness. The child may begin by using the dissociative mechanism spontaneously and sporadically (Courtois, 1988). With repeated victimization, it may become a chronic defensive pattern that persists into adulthood, resulting in a dissociative disorder. Arising as a survival mechanism to protect the child, over time dissociation changes into a pattern of behavior that interferes with the individual's daily functioning and ability to interact with others. Sometimes these dissociative periods can last hours and require emergency psychiatric treatment.

The counselor may see symptoms of dissociation but be unaware of the cause. For example, the client may "space out" when talking to the counselor, appearing disoriented or forgetful in order to avoid an intimate (and seemingly threatening) situation. The client may be temporarily unresponsive to conversation or questions, although he may reengage if the counselor persists in seeking his attention (Briere, 1989). These periods of disengagement usually last only a few seconds or minutes. However, they may cause the client to miss important insights or opportunities for self-examination.

The client may also report or exhibit intense moods that are out of proportion to the present situation. Rage, terror, overwhelming sadness, or self-destructive impulses may take hold of the client as a result of what may appear to be minor issues, and the client may seem unable to respond to the counselor's attempts to reason with the client.

Because there can be many causes of such extreme emotional reactions, it is important to isolate the symptoms of dependency or withdrawal from those caused by trauma resulting from childhood abuse.

Dissociative symptoms can mimic the effects of drugs or of withdrawal from drugs, making it difficult to determine the type of problem being presented. In victims of trauma, substance abuse itself can be seen as a method of dissociating for those who cannot do it successfully through other means. For this reason, it is common for survivors of child abuse to self-medicate with substances, thus beginning a process that often leads to substance abuse and dependence.

Counselor Issues

Any counselor or treatment provider who might be screening for and assessing histories of child abuse or neglect must receive specific training in these issues. The screening process and followup sessions will invariably involve listening to traumatic stories. Not all treatment providers will be comfortable hearing about their clients' experiences of abuse. Some may experience vicarious trauma or feel overwhelmed by these painful personal accounts. This may be especially true among counselors whose own traumatic childhood experiences were not addressed therapeutically. The counselor's biases from these experiences, regardless of their similarity to a client's, could have a harmful impact. If counselors experience intense discomfort and anxiety when conducting screenings and assessments, the Consensus Panel recommends that they receive guidance and support from a clinical supervisor and consider whether they could benefit from therapeutic assistance to explore the reasons for their discomfort. (For a more detailed discussion on counselor issues, see Chapter 4.)

Prior training on handling abuse issues can help counselors "screen" themselves to recognize if they are unprepared to work with clients who have experienced childhood abuse or neglect. It is better to find out ahead of time than for the counselor to risk damaging the therapeutic process by having to confront personal issues in the middle of it--possibly even ending the session prematurely, leaving the client confused, feeling abandoned, or wondering "What's wrong with me?" Many counselors avoid issues of childhood abuse simply from lack of experience. They need assurance that the proverbial can of worms that has been opened can be closed in a reasonable length of time. Proper training can help counselors better deal with trauma and with secondary PTSD, sometimes known as "compassion fatigue."

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Screening for a History of Child Abuse or Neglect

Because adults who were abused or neglected during childhood can experience significant trauma-related consequences that require clinical intervention, the Consensus Panel suggests using child abuse and neglect screening (1) to identify individuals who exhibit certain signs and symptoms associated with child abuse and neglect (such as PTSD, major depression, or mood disorders) and (2) to identify who may benefit from a comprehensive clinical assessment. Consequently, treatment staff should

• Learn and understand ways in which childhood abuse and neglect can affect adult feelings and behaviors
• Identify those individuals who appear to exhibit these symptoms
• Identify the trauma-related treatment needs of these clients
• Provide or coordinate appropriate treatment services that will help to meet clients' treatment needs

The Need for Screening

Adults who were abused as children are more likely to use drugs or alcohol (Dembo et al., 1989; Singer et al., 1989; Zierler et al., 1991); therefore, they are more likely to be in treatment for substance abuse.

The consequences of childhood abuse and neglect can dramatically affect a client's treatment needs. For instance, as noted in Chapter 1, a history of childhood trauma can increase the number and intensity of treatment services required, lengthen the time needed for treatment, and increase the number of sessions, particularly for male clients (Downs and Miller, 1996; Felitti, 1991; Felitti et al., 1998; Steinglass, 1987; Young, 1995). The consequences of childhood abuse and neglect can also affect the psychosocial supports that such clients may need following treatment (Steinglass, 1987). Screening for childhood abuse or neglect can set in motion a proactive plan with the following benefits:

• Stopping the cycle. Although not all adults who were abused or neglected during childhood abuse their own children, they are at greater risk of doing so (Kaufman and Zigler, 1987). Thus, screening for abuse and neglect can be an important step in stopping the cycle of abuse in many families.
• Decreasing the probability of relapse. Many substance abusers use alcohol and illicit drugs to self-medicate posttraumatic stress symptoms related to past physical or sexual abuse or trauma (Price et al., 1998); clients may abuse substances to deal with hyperarousal or stress (Clark et al., 1997; De Bellis, 1997). Since these are important causes of continued substance-abusing behavior, addressing them may facilitate treatment and reduce relapse.
• Improving a client's overall psychological and interpersonal functioning. Childhood sexual abuse and neglect may affect the individual's self-concept, sense of self-esteem, and ability to self-actualize. They also affect a person's ability to trust, be intimate, and set limits with others. Identifying a history of abuse or neglect enables the client to address these issues as they relate to overall functioning as well as to recovery. The ability to trust is especially important; difficulties with trust can impede the client's ability to utilize treatment to its fullest.
• Improving program outcome. Screening for a history of child abuse or neglect helps to determine the percentage of abused and neglected individuals who are in a substance abuse treatment program. Furthermore, screening, combined with assessment, helps to determine the trauma-related treatment needs of clients. With this information, programs can make informed decisions about providing the treatment services that can best meet their clients' needs.

When Should Screenings Be Conducted?

Clients' treatment needs change over time. For this reason, counselors must conduct ongoing assessments of their clients' problems, including substance abuse, health concerns, psychological problems, family-related stressors, parenting stressors, interpersonal stressors, social support, and vocational problems. Having up-to-date information allows counselors to deliver individualized treatment to each client that meets specific needs and is of the appropriate length and intensity.

As with psychosocial evaluations, screenings for child abuse and neglect should be conducted early in a comprehensive assessment process. However, because denial and minimization are prominent defense mechanisms associated with childhood trauma and trauma survivors may feel shame and discomfort answering abuse-related questions, screenings should also be conducted at different times throughout the treatment process. Repeated screenings help elicit information about these traumatic experiences--especially after trust has been established in the therapeutic relationship. Treatment providers should be aware, however, that repeated screenings may give the impression that the therapist does not believe the client. For clients who typically were disbelieved as children, this can be an important therapeutic issue. Furthermore, cognitive and memory impairment caused by substance abuse decreases with length of sobriety; that is, over time, a client may physiologically be more capable of recalling past experiences if she maintains sobriety (Leber et al., 1981; Reed et al., 1992).

Who Should Conduct Screenings?

The Consensus Panel believes that treatment decisions and activities are best conducted within the context of a multidisciplinary treatment team, with members having special knowledge in such areas as mental health, child abuse and neglect, and family counseling. Team members should possess varied levels of training and experience. At the same time, there are different types of treatment settings, including drop-in centers, residential treatment programs, and intensive and less intensive outpatient and hospital-based programs. These varied treatment settings and the composition of the treatment team will affect screening decisions, including who is available to conduct them.

Although there are no rigid rules regarding who should conduct screenings, having certain skills will increase the likelihood that the screening process is conducted appropriately. Irrespective of the level of academic credentials, training, supervision, or specific role within the treatment team, treatment staff members should all have an understanding of the types of psychiatric disorders and symptoms that are commonly associated with a history of childhood abuse and neglect (see Figure 2-1 ). They should understand the role of screening and assessment for a history of trauma, and they should know the types of questions that constitute a screening for child abuse and neglect. Moreover, they should have developed a sensitivity to the issues of child abuse and neglect.

Training and supervision

No one should screen for childhood trauma without specific training and supervision. The Consensus Panel strongly recommends that counselors administering the screening understand the reasons for conducting the screening, be knowledgeable about the best practices for screening, and receive training in conducting the screening in an empathic manner. They also should understand the assessment and treatment processes that may follow a positive screening and be able to explain these processes to the client.

Counselors who conduct screenings will be prompting clients to recall painful and traumatic events. The reemergence of painful memories may prompt intense reactions from clients. Clients may feel drained or distraught afterwards. Treatment staff should be sensitive to this and prepare for the interview in the following ways:

• Clients should be informed that talking about such issues may create discomfort and that repressed memories may emerge unexpectedly following the interview. Clients should be given a choice to disclose such information, being aware of the possible aftermath.
• Counselors should have proper supervision and support mechanisms in place for clients in case a crisis occurs following disclosure. As well as clinical support, this includes having appropriate mental health practitioners available in case further intervention is necessary.
• Counselors should assess the social and emotional support available to clients when they return home. If necessary, the staff can help the client find transportation home after the screening and then follow up with a telephone call to offer support or help if needed.

Types of Screenings

When screening for histories of child abuse or neglect, counselors ask clients a series of questions designed to elicit information about childhood trauma. Screenings can be informally divided into two types: direct questions and standardized screenings. Direct questions are asked to obtain confirmation of a history of child abuse and neglect. Standardized screenings are structured sets of questions that are designed to determine the possible presence of past child abuse.

Both direct trauma questions and standardized screenings can be embedded within larger psychosocial assessments. Indeed, all clients receiving screenings for childhood abuse and neglect should be evaluated for symptoms of other mental health problems. When a client denies having a history of child abuse or neglect but presents symptoms commonly associated with childhood trauma, treatment staff may need to expand their assessment process to include a more thorough evaluation of the client's childhood experiences and behavioral responses to traumatic events. This information may be useful in understanding the origins of some of the client's current mental health problems.

Direct trauma questions

Some trauma questions inquire directly about childhood abuse and neglect experiences. Depending on the setting (e.g., inpatient, residential, long-term therapy), expertise of the staff, and other factors, this approach has been used successfully in eliciting the information being sought. Other questions, however, will be about circumstances and experiences that are often associated with and suggest a history of childhood abuse or neglect; for example, "Did you ever live away from your parents?" and, "Were you ever in foster care?" Figure 2-2 lists questions that can be used to conduct a screening for a history of childhood abuse or neglect.

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Figure 2-2: Direct Questions To Screen for a History of Childhood Abuse or Neglect. The following questions can be used to help screen for a history of childhood abuse or neglect. They can be asked as written. However, they can also be asked in (more...)

Standardized screening instruments

Several instruments can be used to elicit a history of child abuse or neglect; five are reviewed below. Some are specifically designed to collect information about interpersonal traumatic experiences in childhood. Others are designed to collect information on a broader topic, such as general mental health or substance abuse but include a subsection on childhood trauma. These tools differ widely with regard to primary purpose and level of detail elicited.

The Consensus Panel has included the following tools for practitioners' review and possible use. Treatment staff should note that the Childhood Trauma Questionnaire and the Trauma Symptom Checklist-40 are new, are not well validated, and are used primarily as research tools. Information about obtaining the instruments listed below is provided in Appendix D. See also the Childhood Maltreatment Interview Schedule (CMIS) and other trauma-oriented tools described later in this chapter. If these measures are used with non-English-speaking clients, the translations must be appropriate and carefully applied (e.g., sensitive to the differences between Spanish used by Puerto Ricans, Mexicans, and other Latinos).

Addiction Severity Index (ASI)

The fifth edition of ASI is a 161-item multidimensional structured clinical interview designed to collect information about substance abuse and client functioning in various life areas for adults seeking treatment for substance abuse (Fureman et al., 1990; McLellan et al., 1990). The ASI is frequently used during intake in treatment programs. It includes three questions that are used to elicit information about a history of childhood abuse. It inquires about episodes of emotional, physical, or sexual abuse in relation to several people (e.g., mother, father, brother/sister, sexual partner/spouse, children). The questions are not childhood-specific, and preliminary research suggests that the ASI trauma questions show stronger utility as a screen for PTSD than for childhood trauma (Najavits et al., 1998). The female version of ASI has an additional question about sexual harassment (CSAT, 1997c). The National Institute on Drug Abuse (NIDA) has developed an ASI package that includes an introductory brochure, handbook for program administrators, resource manual, two videotapes, and training manual (NIDA, 1993).

Childhood Trauma Questionnaire (CTQ)

CTQ is a 10- to 15-minute questionnaire that provides a brief and relatively noninvasive screening of childhood traumatic experiences (Bernstein et al., 1994). The 28-item retrospective self-report evaluates physical, sexual, and emotional abuse; physical and emotional neglect; and related areas of family dysfunction, including substance abuse. It includes a minimization/denial scale for detecting individuals who may be underreporting traumatic events. This screening tool is notable for the brevity of administration, range of coverage, and availability of psychometric data (Briere, 1997). Limitations include the absence of specific items regarding characteristics of the maltreatment and lack of information regarding age range for traumatic events (Bernstein et al., 1994; Briere, 1997).

Parent-Child Relationship Inventory (PCRI)

PCRI is a 78-item self-report questionnaire designed for clinical use. PCRI assesses six areas of parenting, including parental satisfaction, support, involvement, communication, limit setting, and autonomy. The measure also includes a validity scale that will indicate if the client is responding defensively or randomly. The PCRI handbook provides clear guidelines for interpreting scores on each scale and identifying areas of risk (Gerard, 1994).

Parental Acceptance and Rejection Questionnaire (PARQ)

PARQ is a brief self-report questionnaire designed to assess individuals' perceptions of their childhood experiences of love and love withdrawal in relation to their mothers and fathers. PARQ elicits information concerning affection, hostility, neglect, and undifferentiated rejection. It has been used and evaluated with many ethnic and cultural groups in the United States and in numerous countries on several continents. Different versions of PARQ are included in the Handbook for the Study of Parental Acceptance and Rejection (Rohner, 1990). The handbook, which summarizes parental acceptance and rejection theory and evidence, provides information about PARQ and about using, scoring, and interpreting this self-report. This measure, however, has no validity scale.

Screen for Posttraumatic Stress Symptoms (SPTSS)

SPTSS is a brief, 17-item self-report tool used to screen for PTSD symptoms; it is especially useful for clients with histories of multiple traumatic events or whose trauma history is unknown (Carlson, 1997). SPTSS yields a total score that is the average of the individual item scores. The item scores can be used to make a provisional assessment regarding whether clients' symptoms meet DSM-IV criteria for PTSD. It takes approximately 5 minutes to complete.

Trauma Symptom Checklist-40 (TSC-40)

TSC-40 is a 40-item self-report tool that evaluates symptomatology in adults resulting from childhood or adult traumatic experiences (Elliott and Briere, 1992). TSC-40 (an expanded version of the Trauma Symptom Checklist-33) consists of six subscales, which evaluate such things as anxiety, dissociation, and sexual concerns (Briere and Runtz, 1989). Both TSC-40 and TSC-33 have moderate predictive validity regarding a wide variety of traumatic experiences (Briere and Elliott, 1993).

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Formal Assessment for a History of Child Abuse Or Neglect

Whether identified during intake or in the context of a subsequent psychosocial assessment, a positive screening for childhood abuse or neglect alerts the treatment provider that more information about the trauma is needed and that a thorough and comprehensive childhood abuse and neglect assessment is warranted. Thus, the primary purpose of an assessment is to confirm or discount a positive screening for childhood abuse or neglect. At the same time, it is an opportunity to evaluate clients' trauma-related treatment needs. In general, the more clinical information that a program has about clients' particular treatment needs, the better the program can meet them. Under optimal circumstances, all clients who screen positive for a history of childhood abuse or neglect should be offered a comprehensive mental health assessment.

CPS case managers and court and law enforcement personnel may already be conducting their own screenings and assessments. Some systems (such as in Massachusetts) provide multidisciplinary assessments of client families to avoid duplication and to provide a more comprehensive service-planning product.

When Should Assessments Be Conducted?

When deciding whether to conduct assessments for a history of child abuse or neglect, thoughtful consideration should be given to the following issues: substance abuse, client readiness, input from all team members, and family involvement.

Substance abuse issues

The treatment team should evaluate (1) clients' current substance abuse, (2) clients' commitment to the treatment and recovery process, (3) the quality and length of abstinence, and (4) clients' risk of relapse. Treatment staff should make these evaluations on an individual basis and not translate them into a rigid protocol. For example, a client in the early phases of treatment who is struggling to make a commitment to abstinence but who has not yet developed significant psychosocial supports for abstinence may be at risk for relapse if he attempts to address childhood abuse issues. (Even so, in some cases the client may be at higher risk if he does not address these issues.) On the other hand, a client who has achieved a few years of abstinence and has a strong commitment to abstinence, but who recently relapsed when her father made threatening phone calls to her, may be psychologically prepared to explore her childhood abuse issues while simultaneously strengthening her recovery program.

Client readiness

Throughout substance abuse treatment and through the multiple psychosocial assessments and screenings for childhood abuse and neglect, the treatment team can gain valuable information about clients' childhoods. Indeed, treatment staff may have enough information to confirm clients' histories of childhood abuse and neglect. Staff may have also observed behavioral, emotional, and psychiatric manifestations of the childhood trauma. However, unless a formal assessment has been conducted, the staff probably will not have a thorough understanding of the details, context, and severity of these traumatic events, or the childhood responses to them. Similarly, unless they inquire, staff will not know whether clients (1) recognize themselves as having experienced abuse or as being affected by such abuse, (2) believe that they are ready to confront these issues and are willing to do so, and (3) believe they can handle the consequences without jeopardizing treatment. Thus, staff members should ask clients to evaluate their own readiness for confronting child abuse or neglect issues.

At this point, staff should also know something about clients' current family situations and can work with them to identify who is safe to involve or to provide support. Some adults in treatment regress to a state of dependence on their parents--parents are caring for grandkids, parents are paying for treatment, parents are the only housing resource after institutional treatment or incarceration. Abuse is a family issue; its disclosure and the client's treatment may well disrupt family dynamics and trigger denial--consequences of particular concern to a dependent adult client.

Input from all team members

Each member of the treatment team should have a voice in deciding if and when to conduct assessments for childhood trauma. Each member will bring a different but valuable perspective about a client's progress in treatment, risk of relapse, and readiness to address childhood trauma. Individual team members can also contribute to discussions about the client's commitment to treatment and recovery, her psychosocial supports, her current family situation, and any significant issues that may need to be resolved quickly.

Involving the family

Counselors hold different opinions on when and how much to involve the family in a client's treatment, but all agree there are many risks involved that must be carefully weighed against the potential benefits. This is especially true at the assessment stage, which usually occurs early in the treatment process when it is critical to get accurate information and to establish a relationship of trust with the client. Of foremost importance must be the client's opinion about whether to involve family members, and which ones. It is a good idea to obtain the client's written permission before contacting family; some counselors will only call a family member with the client present. (Although the client's current or "chosen" family is likely to be more supportive and should be encouraged to be involved, these persons may have less direct knowledge of the client's history of childhood abuse or neglect.)

Most abuse occurs within the family. For this reason, complicated dynamics of denial, complicity, guilt, and fear of retribution may still be in place long after the client and his siblings have become adults. Grandparents, too, may be ashamed that they did not or could not protect the victim--or may themselves have been perpetrators. Family members may resent the client for opening up old wounds, exposing a family secret, or forcing them to confront a situation they may have tried to pretend did not happen. It is important to protect the client from the possibility of revictimization (Hansen and Harway, 1993).

Family members can sometimes be valuable participants in the assessment process; however, counselors must maintain client rights of confidentiality. (For more information on confidentiality, see Appendix B.) Spouses and significant others can be sources of information, especially about the current situation. Grandparents can shed light on intergenerational patterns of family trauma and violence. Siblings can often provide useful information about the family, such as intrafamilial violence during the client's childhood. Because of differences in personality, age, and development, siblings will often have different perspectives and even disagree about traumatic events that occurred during childhood. Also, the family environment and dynamics may have been different for different siblings. For a more detailed discussion about involving families, see the "Involvement of the Family in Treatment" section of Chapter 3.

Who Should Conduct Assessments?

A multidisciplinary team should conduct a full assessment, although many assessment tools require professional training to conduct and interpret--the type of training specifically provided to clinically licensed psychologists, psychiatrists, and psychiatric social workers. (Many assessments also can be conducted by marriage and family therapists and licensed professional counselors.) A full assessment involves confirming diagnoses, which should be done only by mental health professionals. Similarly, assessing histories of childhood trauma can provoke or exacerbate a psychological or psychiatric emergency, which must be addressed; a psychologist, clinical social worker, or psychiatric nurse can handle most situations. If clients have active and severe symptoms of depression, suicidality, severe anxiety, or other psychiatric crises, and issues of medication or hospitalization arise, clients should be evaluated immediately by a psychiatrist.

For these reasons, the Consensus Panel recommends that the treatment team include a licensed mental health professional for more formal assessments that may be required. This individual should have training in childhood trauma, the effects of childhood trauma on adults, and the different tools that can be used to assess trauma, as well as having the clinical and licensing requirements for making diagnoses. The licensed mental health professional can also provide guidance, training, supervision, and crisis intervention throughout the assessment process.

Licensing issues

Some funding and administrative agencies (e.g., third-party payors) require that a physician certified by the American Society of Addiction Medicine (ASAM) make diagnoses. State laws vary regarding the licensing and training of mental health professionals and who can conduct assessments and make diagnoses. All team members should have a good understanding of the relevant regulations and requirements.

Clinical Trauma Assessment

To identify clients' trauma-related treatment needs, the treatment team should gather information about the traumatic events and how clients responded to them. These two areas of interest correspond to the two primary domains of assessment inquiry: (1) assessment of childhood traumatic events and experiences and (2) assessment of current mental health, especially symptoms and syndromes that may relate to childhood trauma. To increase the usefulness of this information, the evaluation should incorporate a developmental perspective--that is, perception of the trauma at different ages (Gussman et al., 1996). Not all clients with a history of child abuse or neglect will see it as a problem or view themselves as victims or as "damaged" by the experience. Treatment providers should be careful not to use labels that some clients may resist or be uncomfortable with.

Significant traumatic events

The goal of the assessment process is to identify clients' needs so that treatment can be provided to meet them. To treat the aftermath of childhood trauma, the treatment team should identify, in as much detail as possible, the traumatic events that occurred. The trauma-related assessment is an opportunity to systematically assess the details and context of the victimization experience. Examples of event-specific information that are gathered include

• Type of abuse

  • Physical abuse
  • Sexual abuse
  • Psychological abuse
  • Exploitation
  • Exposure to domestic violence
  • Neglect
• Evidence of multiple types of abuse (concurrent or serial)
• Relationship to the perpetrator (who may be a relative, stranger, teacher, or caregiver)
• Frequency of abusive events
• Duration of the abuse
• The victim's age at onset and cessation of the abuse
• Context of the trauma, including presence of force or fear
• Whether the family knew about the abuse
• Response of the family to the abuse
• Response of the social system, including CPS agencies, foster care, or placement with relatives
• Past mental health counseling or other treatment as a child
• How and when the abuse was disclosed
• Social consequences of the abuse
• Legal consequences of the abuse

Subjective experience of the events

In addition to gathering event-specific details, assessing childhood trauma also involves eliciting information over time about the subjective experience of these events. How clients remember a traumatic event can shape the psychological response more than the actual circumstances. For this reason, childhood trauma assessments in clinical (as opposed to forensic or research) settings focus on obtaining qualitative information about traumatic experiences and responses. Subjective and qualitative details about traumatic events--such as recollections and perceptions--are needed to plan and provide appropriate treatment for a client (Carlson, 1997). However, some clients may strongly resist these questions; others may become very upset and need immediate support from a mental health professional.

Useful subjective information can include the following:

• What was the client thinking about during the abuse?
• What was the client feeling during the abuse?
• As a child, how did the client understand what happened to her and what does she think about it now?
• How does the client think and feel about how the abuse affected her adulthood and substance abuse; how does the client deal with the aftereffects of the abuse now?
• What feelings are most associated with the abuse experience?
• What are the client's memories about the abuse?
• What are the client's unique perceptions about the abuse?
• What coping strategies does the client use? How effective are these?

Childhood symptoms and family characteristics

Because the primary purpose of the trauma assessment is to validate or discount a positive screening for childhood trauma, the assessment should inquire about childhood symptoms and family characteristics that are consistent with and suggest a history of childhood abuse or neglect. Childhood symptoms and behaviors to consider include

• Depression (including thoughts of death, passive suicidal ideation, and feelings of hopelessness)
• Dissociative responses during childhood
• Aggressive behavior or other "acting out," including

  • Early sexual activity or sexualized behavior
  • Physically abusing or harming pets or other animals
  • Other destructive behaviors
• Poor relationships with one or both parents
• Attachment disorder, difficulty trusting others
• Excessive passivity
• Passive/aggressive behavior, including

  • Failing school grades
  • Poor sibling relationships
  • Obesity or anorexia
• Inappropriate age/sexuality formation
• Blacked-out timeframes in childhood
• Excessive nightmares, extreme fear of darkness, or request for locks on doors

Family-of-origin characteristics to consider include

• Parental substance abuse
• Battering within the family
• Involvement with CPS agencies or foster care
• Placement with foster parents or relatives
• Severe discipline during childhood
• Traumatic separations and losses

General mental health symptoms

The second area that can be evaluated through trauma-related assessments is the current general mental health of clients, paying special attention to symptoms that may be related to child abuse and neglect. These evaluations focus on the cardinal responses to trauma.

Posttraumatic stress symptoms

After a highly distressing or traumatic event, individuals may exhibit posttraumatic stress symptoms. These symptoms include persistent reexperiencing of the traumatic event through intrusive thoughts or nightmares, a numbing of responsiveness to or avoidance of current events, and hyperarousal, such as difficulty sleeping, poor concentration, irritable outbursts, jumpiness, or hypervigilance. Clients with PTSD are frequently so preoccupied with their traumatic experiences that they have trouble focusing on substance abuse problems. They may also have severe difficulties in social, economic, vocational, and marital adjustment (Daley et al., 1993) that are not directly related to their substance abuse.

Dissociation symptoms

Children and adults who have been traumatized may experience symptoms of dissociation. Dissociation can be defined as the disruption of the usually integrated functions of consciousness, memory, identity, and perception (Putnam, 1997). As described above, dissociation is the disconnection from a full awareness of self or external circumstances. Symptoms of dissociation include excessive daydreaming, a severe numbing of emotions, out-of-body experiences, and amnesia of painful abuse-related memories (Brown et al., 1999; Briere, 1992a, 1995). Individuals may also exhibit severe behavioral regressions, such as curling up into the fetal position, or exhibit different intense mood states, such as anger or fear, when discussing their childhood abuse. These periods of disengagement usually last only a few seconds or minutes, but they can last for hours ( Whitfield, 1997b). As noted earlier, for some clients substance abuse may serve the same function as dissociation (i.e., self-medication to escape the effects of childhood trauma). It is not clear whether dissociative symptoms increase for these clients once sobriety is achieved. Counselors are advised to monitor any such increases in these symptoms.

Most common responses to trauma involve the reexperience or avoidance of trauma-related experiences (Horowitz, 1976; van der Kolk, 1987). Reexperience-related symptoms include intrusive thoughts, anxious and angry feelings, physiological arousal and reactivity to trauma triggers, and hypervigilance (Carlson, 1997). Avoidance-related symptoms include the avoidance of thoughts, feelings, conversations, activities, places, people, or memories associated with the trauma (American Psychiatric Association [APA], 1994). Figure 2-3 illustrates the common responses to trauma organized by biopsychological domains and divided into symptoms that represent either reexperiencing or avoidance.

Table

Figure 2-3: Common Responses to Childhood Trauma Among Adults.

Adult clients with a history of childhood abuse and neglect may have a loss of previously sustained beliefs, may feel permanently damaged and hopeless, and may experience shame. They may have personality and relational disturbances and may be hostile, self-destructive, and impulsive. They also can have somatic symptoms, such as headaches, stomach pain, asthma, and chronic pelvic pain (Felitti, 1991; Herman, 1993). Clients with histories of childhood trauma will often have multiple symptoms, which can be acute, recurring, and chronic. The multitude of problems will make diagnosis difficult. The assessor may interpret the manifestations as PTSD or a personality disorder.

Irrespective of theoretical orientation, assessors will find it helpful to look at their clients' symptoms through a developmental perspective. This approach involves a careful review of the client's history, beginning with the client's description of her family and early childhood. The assessor can probe for information about abusive or neglectful episodes during the client's childhood, adolescence, and adulthood. From this history, a picture will emerge of the client's evolving feelings and behaviors. This will help to clarify how some of the client's present behaviors and problems have developed over time. Even though the counselor cannot undo the historical facts, this knowledge about the client's past will help explain some of the reasons for her current difficulties.

Assessment Tools

As mentioned earlier, trauma-related assessments involve evaluating childhood traumatic events and gauging the individual's responses to these events. In the treatment setting, the two primary groups of assessment tools are general mental health assessment tools and trauma-oriented tools. Given the tendency of some victims of child abuse to become abusers themselves, treatment providers should also consider using some domestic violence screening tools as well. (See TIP 25, Substance Abuse Treatment and Domestic Violence [CSAT, 1997b], especially pp. 115-126.) The section "Special Considerations and Recommendations" at the end of this chapter provides some guidelines for policy and selection concerning the instruments discussed below.

Both groups of tools include self-reports and structured interviews. Self-reports are typically pen-and-paper questionnaires that clients fill out. They are often free or inexpensive and take only a short time to complete. They also may elicit greater levels of disclosure than clinician-led interviews since clients may be less inhibited in written self-reports (Newman et al., 1996). Such qualities make self-reports a good choice for a first step in the assessment of traumatic experiences and responses (Carlson, 1997).

Structured interviews consist of an organized and preestablished set of questions the assessor poses to clients in a face-to-face interview. As a result, structured interviews allow assessors to observe clients' affective responses to questions and their method of interpersonal interaction. Structured interviews are especially useful in eliciting detailed information, both qualitative and quantitative, about the clients' experiences and symptoms. Because they involve a set of predetermined questions and preestablished areas of inquiry, structured interviews can eliminate some clinician biases, such as a clinician's desire to avoid areas of discomfort. Although there is substantial variation among structured interviews, they are typically time limited, efficient, and comprehensive. Furthermore, interviews reach those clients who are marginally literate. This condition may not be obvious to the counselor at the assessment stage. Information on where to obtain most of the tools discussed below is provided in Appendix D.

General mental health assessment tools

An important task of trauma-related assessments is to help the treatment team gain an understanding of clients' general mental health and to determine whether clients have psychiatric symptoms or syndromes commonly associated with childhood abuse or neglect, especially posttraumatic stress symptoms and dissociative symptoms. In addition to the structured interview and self-report formats, general mental health assessment tools can be more traditional psychological tests and inventories.

Mental health self-reports

The purpose of self-reports for general mental health evaluation is to elicit from clients their own understanding of their mental health symptoms. These self-reports are inexpensive and efficient. They can be rapidly completed in a clinical setting, and they can be used to complement clinical assessments, including interview-based assessments.

Some mental health self-reports are global and evaluate the general mental health of clients. For example, the Symptom Checklist-90-Revised (SCL-90-R) and the shorter version called the Brief Symptom Inventory address nine symptom dimensions of mental health. In contrast, some mental health self-reports evaluate specific areas of mental health. For example, the Profile of Mood States focuses on affective and emotional functioning, and the Beck Depression Inventory focuses on depression.

Beck Depression Inventory (BDI)

BDI is a 21-item scale designed to measure the severity of depression by assessing the presence and severity of affective, cognitive, motivational, vegetative, and psychomotor components of depression (Beck, 1967). BDI is one of the most widely used measures of depression in clinical practice. Substantial research has been conducted to evaluate BDI's reliability, validity, and utility. A short, 13-item version of the BDI is also available and has good concurrent validity with the long form (Beck and Beck, 1972; Gould, 1982).

Brief Symptom Inventory (BSI)

BSI is a short form of SCL-90-R and is designed to reflect the psychological symptom patterns of psychiatric and medical clients (Derogatis, 1992; Derogatis and Spencer, 1982; Derogatis et al., 1973). BSI takes approximately 10 minutes to administer and has 53 items. It evaluates the same nine symptom dimensions as SCL-90-R and includes measurements of the severity of the disorder, the intensity of symptoms, and the number of client-reported symptoms. Because of its brevity, it can be used in initial assessments, as part of a test battery, and for monitoring client progress. More than 300 studies have evaluated the reliability, validity, and utility of BSI.

Profile of Mood States (POMS)

POMS is a 65-point objective rating scale designed to measure six identifiable mood states (McNair et al., 1992). POMS measures tension/anxiety, depression/dejection, anger/hostility, vigor/activity, fatigue/inertia, and confusion/bewilderment. It is primarily used as a measure of mood states in psychiatric outpatients and as a measure for assessing changes in those clients. POMS elicits information regarding mood states in the week prior to administration of the assessment.

Symptom Checklist-90-Revised (SCL-90-R)

This is a brief, multidimensional inventory designed to screen for a broad range of psychological problems and symptoms of psychopathology (Derogatis, 1994; Derogatis and Spencer, 1982). SCL-90-R takes approximately 15 minutes to administer and contains 90 items. It measures nine primary dimensions of mental health: somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. It includes measurements of the severity of the disorder, the intensity of symptoms, and the number of client-reported symptoms. It is a useful tool to measure treatment progress. Extensive research has been conducted to evaluate the tool's reliability, validity, and utility.

Structured mental health interviews

There are several structured interviews that elicit general mental health information. They are used as the framework for a systematic review of the client's mental health, in particular to explore whether clients have psychiatric symptoms or syndromes associated with childhood abuse or neglect. Thus, while structured mental health interviews may be comprehensive and explore multiple domains of mental health, when used in the context of evaluating a history of childhood trauma these tools are especially valuable for systematically reviewing whether there are symptoms of posttraumatic stress or dissociation. Typically, structured mental health interviews are grounded in the system laid out in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (APA, 1994).

Diagnostic Interview Schedule (DIS)

The most recent version of DIS, version 4, is designed to elicit data relating to most DSM-IV adult diagnoses on both a lifetime and current basis. Current disorder is defined for four time periods: the last 2 weeks, the last month, the last 6 months, and the last year. Each diagnosis is based on clients' meeting a minimum number of criteria. Since clients need not meet all criteria, individuals may be assessed for the severity of each diagnosis by counting how many of the criteria they meet. Across diagnoses, severity may be determined by the number of different diagnoses present, the total number of symptoms, how many years they have had the symptoms, and the degree of functional impairment. DIS also asks for the age at time of the last symptom, the age at which the first symptom appeared, and whether medical care was ever sought for the symptoms. Virtually all response categories are close-ended and precoded, with explicit instructions. After the interviewer follows these instructions, a computer makes the actual diagnosis. The computer also provides information such as the age of onset and termination of syndromes, the total number of symptoms ever manifested, diagnosis with earliest onset, total number of lifetime diagnoses, and the number of types of current diagnoses (Robins et al., 1981).

Mini International Neuropsychiatric Interview (MINI)

MINI was designed as a brief structured interview to screen for the major psychiatric disorders in DSM-IV (Sheehan et al., 1994). It contains 120 questions covering 17 Axis I disorders from DSM-IV. Unlike longer interviews, MINI focuses on a core set of diagnostic questions for each disorder and considers only those timeframes that are useful in making decisions in clinical settings. MINI has two to four screening questions per disorder with followup questions for positively endorsed screening questions. MINI assesses information regarding major depressive episodes, dysthymia, mania, anxiety disorders, obsessive-compulsive disorder, substance abuse disorders, psychotic disorder, anorexia nervosa, bulimia nervosa, PTSD, suicidality, antisocial disorder, somatization disorder, and attention deficit-hyperactivity disorder. MINI has high validation and reliability scores and can be administered in approximately 15 minutes (Sheehan et al., 1994). A computerized version of MINI is available that can be administered by the client or the paraprofessional.

There is also MINI Plus, which is a more elaborate, detailed structured interview than the shorter MINI. It elicits all the symptoms listed in the symptom criteria for DSM-IV for 24 major Axis I diagnostic categories, one Axis II disorder, and suicidality. It elicits information on the impairment criteria and about the major subtypes of each disorder covered. MINI Plus takes approximately 30 to 45 minutes to administer.

Psychiatric Research Interview for Substance and Mental HealthDisorders (PRISM)

PRISM is a psychiatric diagnostic interview designed to produce diagnoses of DSM-IV mental health and substance-related disorders (Hasin et al., 1992, 1996). The PRISM includes a systematic set of procedures for differentiating primary disorders, substance-induced disorders, and the expected effects of intoxication and withdrawal. There are two formats for PRISM. The DSM-IV PRISM assesses for substance dependence and abuse, primary affective disorders, primary anxiety disorders, primary psychotic disorders, eating disorders, personality disorders, and substance-induced disorders. The PRISM-Longitudinal (PRISM-L) is designed for clinical trials that require collected data on the course of mental health and substance abuse disorders over time. PRISM takes between 90 and 150 minutes to administer, depending on the history and response style of the client.

Schedule for Affective Disorders and Schizophrenia (SADS)

SADS provides detailed descriptions of the current episodes of illness, the severity of manifestations of major dimensions of psychopathology, and past psychopathology and functioning relevant to an evaluation of diagnosis, prognosis, and overall severity of disturbance. By using a progression of questions and criteria, it also provides information for making diagnoses (Spitzer and Endicott, 1978). There are various versions of SADS, some of which have been published and widely used.

Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)

SCID-I is an extremely detailed interview tool that comprehensively reviews all DSM-IV Axis I disorders (First et al., 1997). This comprehensive interview guides clinicians through an evaluation of mood disorders, anxiety disorders, dissociative disorders, cognitive disorders, somatoform disorders, substance-related disorders, psychotic disorders, eating disorders, sleep disorders, impulse-control disorders, adjustment disorders, sexual and gender identity disorders, and factitious disorders, as well as disorders usually first identified in infancy, childhood, or adolescence. SCID-I materials include a clinician version, a 160-page user's guide, an administration booklet, and score sheets. SCID does not have to be administered in its entirety; individual disorder units--for example, those covering depression, substance abuse, and anxiety--can be administered separately. Potentially irrelevant units--for example, schizophrenia--can be omitted from the assessment battery.

Psychological tests and inventories

There are numerous other standardized tests of cognitive, personality, and psychosocial functioning that traditionally are administered, scored, and interpreted by psychologists and that may be helpful in the mental health assessment of adults with a history of child abuse or neglect. For example, neuropsychological testing, intelligence testing, and objective and projective personality assessments can be useful components of a comprehensive psychological assessment. Such psychological assessments should be conducted or supervised by a licensed psychologist who is specifically trained to conduct, evaluate, and interpret these tools.

Trauma-oriented tools

Trauma-related assessments are important because they can help the treatment team understand the types of childhood traumatic events experienced by clients, their subjective response and perceptions of these events, and common current symptoms that may result from childhood trauma. A variety of trauma-oriented assessment tools have been developed to accomplish these tasks.

Trauma-oriented assessment tools include structured interviews and self-report instruments. The tools differ with regard to the types of information they elicit. For example, some structured interviews and self-report assessments evaluate trauma events, some evaluate trauma events and trauma symptoms, and some evaluate only trauma symptoms, such as dissociation. Some tools focus specifically on childhood trauma, such as child abuse and neglect. However, other tools examine a broad range of traumatic events. These tools may examine childhood trauma along with natural disasters and other types of trauma that might cause posttraumatic reactions. Most trauma-oriented tools described in this section are based on trauma-related clinical research and were developed for research, not for clinical or program-specific purposes. However, these tools can be used clinically.

Decisions regarding the types of instruments to use should be influenced by the purpose of the assessment, the setting of the assessment, the population being treated, and the individual client and the severity of his problems. For example, in a program that treats homeless veterans with substance abuse disorders, it would be important to include broad-based tools that evaluate the effects of exposure to combat as well as childhood trauma. In a program that targets suburban substance-abusing women, it would be more important to use tools that focus on childhood trauma. However, in a program that has a substantial group of single inner-city mothers who left abusive husbands, it would be important to use tools that can examine childhood and recent abuse experiences.

There is no standard trauma-oriented assessment tool, and no single tool can be considered truly comprehensive. Each has a slightly different purpose, with different strengths and weaknesses. Although extremely valuable, trauma-oriented assessment tools differ with regard to the groups on which they were normed (e.g., undergraduate students, male combat veterans, psychiatric clients). As a result, none of these tools should be considered the definitive answer to conducting trauma-oriented assessments. Rather, wisely selected, each of these tools can be a valuable component of a comprehensive assessment process.

Self-reports that evaluate histories of traumatic events

The following self-report tools are designed primarily to make assessments of histories of childhood traumatic events, such as physical, sexual, and emotional abuse.

Assessing Environments III, Form SD

This assessment consists of 170 items clustered into seven scales: physical punishment, sibling physical punishment, perception of discipline, sibling perception of discipline, sibling perception of punishment, deserving punishment, and sibling deserving punishment (Rausch and Knutson, 1991). An unusual feature of this tool is the inclusion of scales that elicit information about clients' perceptions and attributions regarding their maltreatment, an important feature since subjective evaluation of one's victimization can have an important impact on symptoms and treatment. Also, this assessment tool elicits the respondents' reports of the maltreatment of siblings, permitting a greater assessment of the family environment.

Childhood Maltreatment Questionnaire (CMQ)

This questionnaire assesses rejection, degradation, isolation, corruption, denial, emotional responsiveness, exploitation, verbal and physical terrorism, exposure to violence, unreliable and inconsistent care, controlling and stifling independence, and physical neglect. Although the focus of CMQ is on psychological abuse and neglect, it also assesses physical and sexual abuse (Demaré, 1993). CMQ elicits information about the frequency of maltreatment on or before the age of 17.

Trauma Assessment for Adults (TAA)--Self-Report

Like the structured interview form of TAA (see below), this brief 17-item tool assesses a wide range of potentially traumatic events. It evaluates the same set of issues and elicits the same basic information as the interview version of the instrument. It takes approximately 10 to 15 minutes, depending on the number of traumatic childhood experiences.

Traumatic Events Scale (TES)

TES evaluates a fairly wide range of both childhood and adult traumas (Elliott and Briere, 1992). Of the 30 specific traumas examined by this tool, one third focus on interpersonal and environmental childhood traumas. The interpersonal traumas assessed include physical, sexual, and psychological abuse, and exposure to spousal abuse. TES elicits details regarding the characteristics of child abuse, including age at first and last event, relationship to the abuser, and both past and current levels of distress about the abuse. TES also elicits significant detail regarding sexual abuse.

Self-reports that evaluate trauma symptoms

The following self-report tools are designed primarily to assess symptoms and syndromes related to childhood trauma, especially PTSD and dissociation. Some of these can be used to make a diagnosis of PTSD.

Dissociative Experiences Scale (DES)

This brief 28-item tool elicits information about the frequency of a wide range of pathological and normative dissociative experiences (Bernstein and Putnam, 1986; Bernstein et al., 1994). DES assesses dissociative amnesia, gaps in awareness, derealization, depersonalization, absorption, and imaginative involvement. It takes approximately 5 to 10 minutes to complete DES, and it has been the subject of substantial research efforts to evaluate reliability, validity, and utility.

Modified PTSD Symptom Scale: Self-Report Version (MPSS-SR)

Adapted from the PDS, MPSS-SR is a 17-item tool used to measure PTSD symptoms and make a tentative assessment about whether clients' symptoms meet DSM-IV criteria for PTSD (Falsetti et al., 1993). MPSS-SR yields scores for frequency and severity of PTSD symptoms and takes approximately 10 to 15 minutes to complete.

Penn Inventory for Posttraumatic Stress Disorder

This 26-item tool assesses most, but not all, DSM-IV symptoms for PTSD, as well as a few symptoms that are not directly related to DSM-IV criteria (Hammarberg, 1992, 1996). This tool asks clients to select one statement of four that best describes their feelings. The inventory takes approximately 5 to 15 minutes to complete.

Posttraumatic Stress Diagnostic Scale (PDS)

PDS is a 49-item tool that assesses all DSM-IV criteria for PTSD. It is designed to measure the severity of PTSD symptoms related to a single, identified traumatic event and to make a preliminary DSM-IV diagnosis for PTSD (Foa, 1996; Foa and Meadows, 1997).

PDS includes a total severity score that primarily reflects symptom frequency. The tool provides a preliminary evaluation of DSM-IV PTSD diagnostic status, a symptom number count, a symptom severity rating, and a rating of the level of impairment of functioning. PDS takes approximately 10 to 15 minutes to complete.

Trauma Symptom Inventory (TSI)

TSI is a 100-item test designed to evaluate posttraumatic stress and other psychological consequences of traumatic events, including the effects of rape, spousal abuse, physical assault, combat, major accidents, natural disasters, and childhood abuse. TSI has 10 scales that measure the extent to which a client reports trauma-related symptoms. These scales evaluate anxious arousal, depression, anger/irritability, intrusive experiences, defensive avoidance, dissociation, sexual concerns, dysfunctional sexual behavior, impaired self-reference, and tension-reduction behavior (Briere, 1995, 1996). TSI includes 12 critical items that can help to identify potential problems that may require immediate attention, such as suicidal ideation or behavior, psychosis, and self-mutilation. It has three validity scales that can be useful in identifying response trends that invalidate test results. TSI requires approximately 20 minutes to complete.

Structured interviews that evaluate histories of child abuse and neglect

Some trauma-oriented assessment tools focus primarily on traumatic events, some focus on traumatic symptoms, and some evaluate both traumatic events and symptoms. The following structured interview tools are designed primarily to assess histories of child abuse and neglect. Some of these tools focus narrowly on maltreatment issues, while others examine childhood abuse and neglect within the context of a broad range of potentially traumatic events.

Child Maltreatment Interview Schedule (CMIS)

CMIS is a 46-item tool based on behavioral descriptions; it assesses emotional, physical, and sexual abuse. It evaluates five primary domains: (1) level of parental physical availability, (2) level of parental psychological availability, (3) parental disorder (e.g., history of psychiatric or substance abuse disorder treatment), (4) psychological, physical, emotional, sexual, or ritualistic abuse, and (5) perception of physical and sexual abuse status (Briere, 1992b). Within each domain, questions probe the age of onset, the relationship to the abuser, and the severity of the abuse. CMIS limits the assessment to events that occurred before age 17. A short version, CMIS-SF, contains most of the items of the original tool but with less detail (Briere, 1992b).

Childhood Trauma Interview (CTI)

CTI involves 49 screening items plus multiple followup probes for those items that are scored positive (Fink et al., 1995). CTI evaluates six categories of events: childhood separation and loss, physical neglect, emotional abuse or assault, physical abuse or assault, exposure to violence, and sexual abuse or assault. CTI takes approximately 30 to 90 minutes, depending on the number of childhood trauma experiences. It is useful for collecting detailed information about a wide range of childhood traumatic events and for quantifying the frequency, duration, and severity of these events. CTI involves queries about persons involved, the nature of the events, the age at time of events, the frequency of events, threats during events, the clients' speaking about the events, and the nature of injuries sustained (Carlson, 1997).

Evaluation of Lifetime Stressors (ELS)

ELS combines a 56-item self-report questionnaire with a semistructured interview to collect detailed information about potentially traumatic events (Krinsley, 1996; Krinsley et al., 1997). Positive responses to the self-report are followed up with more specific questions in the semistructured interview. ELS evaluates a wide range of potentially traumatic events. Nearly 30 different events are asked about, including accidents, illnesses, disasters, criminal violence, combat, and physical and sexual assault and abuse. This assessment includes questions about symptoms and experiences that suggest childhood trauma. The self-report questionnaire takes approximately 10 to 20 minutes to complete, while the followup interview can take 1 to 3 hours.

National Women's Study Event History (NWSEH)

NWSEH elicits detailed information about traumatic experiences and evaluates a range of potentially traumatic events, including rape, attempted sexual assault, molestation, physical assault, accidents, disasters, exposure to death or serious injury, and death of a friend or family member (Resnick, 1996a; Resnick et al., 1996). The NWSEH is used to evaluate thoroughly the first, most recent, and worst rape experiences; a single molestation; attempted sexual assault; and physical assault experience. The tool asks about the client's age at the time of the event, familiarity with assailant, relationship to assailant, fear of injury, actual injury, substance abuse by assailant, and whether the incident was reported. The tool contains 17 screening items with probes for positive answers to screening questions. Depending on the number of positive screening items, the test takes approximately 15 to 30 minutes to conduct.

Trauma Assessment for Adults (TAA)

TAA is a 13-item tool that evaluates a range of potentially traumatic events, including accidents, combat, disasters, serious illness, physical and sexual assaults, assaults with weapons, exposure to death or serious injury, and death or murder of a family member (Resnick, 1996b; Resnick et al., 1996). TAA evaluates in detail childhood sexual assault, including threat, injury, and penetration. For each positive response, the tool elicits information regarding age at first or only time, age at last time, and the perception that the client would be killed or injured.

A structured interview tool that evaluates both traumatic events and symptoms

The structured tool described below is designed to evaluate both events and symptoms.

Clinician-Administered Posttraumatic Stress Disorder Scale (CAPS)

CAPS is a 30-item structured interview that measures symptoms of PTSD and acute stress disorder related to up to three traumatic events; it can be used to make diagnoses for DSM-IV PTSD and acute stress disorder (Blake, 1994; Blake et al., 1995; Weathers and Litz, 1994). CAPS elicits information regarding all DSM-IV PTSD symptoms, improvements in symptoms since a previous CAPS administration, general response validity, and overall PTSD symptom severity. CAPS also obtains information regarding five associated symptoms: guilt over acts, survivor guilt, gaps in awareness, depersonalization, and derealization. Overall, CAPS is extremely detailed and thorough. It takes approximately 30 to 60 minutes to administer. There are two versions of the CAPS: the CAPS-DX elicits information to make a current or lifetime diagnosis of PTSD, and the CAPS-SX assesses symptoms over the past week.

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Special Considerations and Recommendations

Screening and Assessment Protocols

It is important that treatment programs develop written protocols regarding screening and assessment of histories of childhood abuse and neglect. All staff members should be familiar with these protocols and have a good understanding of the policies and procedures. Assessment protocols should describe such issues as

• When screenings and assessments should be conducted
• Who conducts screenings and assessments
• What type of data gathering is conducted
• What type of collateral data is gathered and by whom, and what limitations are made by confidentiality regulations
• How information is synthesized
• The role of each team member
• What instruments are used
• Who interprets the assessment findings
• How screening and assessment findings are presented and discussed
• How screening and assessment findings are documented
• How screening and assessment findings are incorporated into treatment plans
• Supervision by licensed mental health providers
• Mandated reporting policy and procedures

Cost Concerns

To conduct trauma-oriented assessments in a treatment program, the treatment team will need the assistance of mental health professionals and consultants with specific expertise in assessing and treating adults with childhood abuse and trauma. This can be expensive, and many programs do not have the funds to hire individuals with this level of expertise. To help address these cost concerns, the Consensus Panel makes the following recommendations:

• Train staff. It is less expensive to have one or more staff members receive the appropriate training than to rely exclusively on outside consultants. Ongoing training and continuing education are also vital to retain members of a treatment team. Training helps build team morale and confidence in a field that experiences a high rate of turnover.
• Prioritize assessments. Although all clients should be screened for childhood trauma, staff can prioritize who receives comprehensive assessments. Clients who are not willing or able to participate in treatment related to childhood trauma might not require thorough assessments at that time.
• Establish university relationships. Program administrators can establish alliances with local universities, university faculty, and researchers to help screen, assess, train, and supervise. Contracts with universities can be less expensive than with consultant groups. Many universities have faculty with skills in this area who can supervise graduate students to assist staff in community-based programs.
• Use volunteers. Programs can consider developing a pool of volunteer mental health professionals that includes both practicing and retired clinicians. Programs should contact local mental health associations and professional societies, most of which provide pro bono work.
• Obtain and use inexpensive screening and assessment tools. There is a wide variety of screening and assessment tools. Some are expensive and proprietary, while others are available free or at low cost. Some are available through the Internet. Appendix D provides contact information for many such tools.
• Establish community partnerships. Programs should identify all relevant regional resources, such as local community mental health centers, mental health associations and societies, and CPS agency representatives, and seek to collaborate with them.
• Explore alternative funding. Programs can consider using funding streams that are not normally associated with substance abuse treatment to help pay for trauma-oriented assessments. These may include funding from mental health and child assistance agencies, the Justice Department's Office for Victims of Crime, and private community organizations.

Screening and Assessment Interpretation Concerns

Screening and assessment tools have many limitations. Prominent among them is a lack of standardization and adequate psychometric study of many measures (Briere, 1992b). Many instruments focus on only one or two types of trauma, such as physical or sexual abuse (Briere and Runtz, 1990b; Bryer et al., 1987). Similarly, the technical or psychometric characteristics of these tools (such as reliability and validity) can vary considerably. The concerns about reliability and validity are compounded when employing these measures with ethnically and racially diverse populations. Intrinsic characteristics of individuals' response to trauma--such as denial, minimization, and dissociation--can make it difficult to validate these tests, because it is often hard to validate the specific events. Given these limitations, the Consensus Panel recommends that treatment providers not overemphasize standardized tests.

Although certain assessment tools are described as comprehensive, it should be understood that no single tool is a truly comprehensive approach to conducting a screening or an assessment. Rather, standardized tests should be used as guidelines and as valuable tools to create a framework for conducting screenings and assessments. These tools should be used only in the context of comprehensive clinical assessments conducted by multidisciplinary treatment teams.

Priorities of Managed Care

With the current emphasis by managed care organizations on brief treatments, it may be difficult in that setting to obtain authorization to assess childhood abuse and neglect. Some prefer that clients be sober for a length of time before doing so. Treatment staff should be aware that such difficulties may occur so that they can develop strategies to justify the additional costs of these focused and specialized assessments and subsequent treatment. Usually a mental health professional will need to request the authorization. For a more detailed discussion on managed care, see Chapter 7 of this TIP, and TIP 27, Comprehensive Case Management for Substance Abuse Treatment (CSAT, 1998a). See also the recommendations under "Cost Concerns" above.

Counselor-Client Relationships

There are many potential barriers to successful screenings and assessments of childhood trauma. To reduce some of these barriers, the Consensus Panel recommends the following:

• Be sensitive to cultural concerns. Values about corporal punishment vary considerably among cultures. What is considered abusive in one culture may be acceptable behavior in another. Staff should not be biased against people from ethnic and cultural minorities when reporting incidents of suspected abuse; however, it does appear that such a bias exists. Ethnic and cultural minorities are more likely to be reported for child abuse and neglect than are White Americans, and in most regions of the country White Americans are less likely to be involved with CPS agencies (Buriel et al., 1979). Community surveys have found that child abuse occurs equally at all socioeconomic levels; however, reported cases show a disproportionate representation of children from lower socioeconomic strata. It is likely that treatment professionals are more apt to determine that abuse occurs in disadvantaged families because this is in accord with the stereotypes of where abuse occurs (Finkelhor, 1993).
• Recognize potential language differences. Language differences can impede clear communication. Both written and spoken language should be simple and easy to understand. Clients with low levels of literacy or for whom English is a second language should be assisted in understanding self-reports.
• Become aware of gender issues. Treatment staff should understand that clinicians are less likely to ask men about their childhood abuse and neglect histories and that men are less likely than women to talk about these histories. Much of the trauma-related research has focused on women, particularly regarding battering, spousal abuse, rape, and incest. As a result, most assessment instruments have been normed on women. Overall, there is a lack of gender-specific instruments.
• Be nonjudgmental and sensitive. Because most individuals who were abused or neglected during childhood were maltreated by authority figures, they may approach the assessment process with fear, distrust, and performance or evaluation concerns ( Briere, 1997). Consequently, those who screen and assess for childhood abuse and trauma should try to provide a safe and nonjudgmental testing environment and to address the issue of childhood trauma in a gradual and sensitive manner (Armstrong, 1996; Courtois, 1995).

The resources listed in Appendix E provide information and expertise on issues related to childhood abuse and neglect.

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Bookshelf ID: NBK64895

https://www.ncbi.nlm.nih.gov/books/NBK64895/