Address correspondence to: Ricky Greenwald, Psy.D., Child Trauma Institute, P.O. Box 544, Greenfield, MA 01302, USA.
Electronic mail is preferred, and may be sent via Internet to rg@www.ticti.org.
Introduction – overview of the issues
Reviewed Measures:
This is a practical guide to objectively scored measures of child/adolescent post-traumatic stress symptoms. It is geared to the field-based researcher and the practicing clinician, who must balance scientific value with the limitations inherent in clinical practice settings. This is not a comprehensive review, but rather a selective sampling of those instruments most likely to be useful in the above contexts. The full text of this poster is available at www.ticti.org.
Several issues must be considered in selecting instruments for assessing child trauma.
Source of Information
Generally, children are better at identifying their own internal states but worse at describing their own behavior. Parents (and others) are worse at identifying children’s internal states, but better at reporting on observed behavior (Loeber, Green, & Lahey, 1990). Multiple sources of information are essential.
Identified Trauma or Not
The usefulness of scales specific to an identified trauma is limited to assessment of response to that event. If you want to know about the child’s entire post-traumatic burden, you’ll have to ask more general questions, not just questions tied to a specific referenced event.
PTSD vs. All PTS Symptoms
Children and adolescents have a much broader range of clinically significant responses to trauma exposure, beyond those represented by the PTSD diagnostic criteria (Giaconia et al, 1995; Kendall-Tackett, Williams, & Finkelhor, 1993). Also, children may have PTSD-like responses (possibly excepting hyper-arousal) to non-criterion-A experiences, such as major loss, family breakup, or accumulated minor trauma (see Greenwald, in press).
Psychometric Properties
Reported validity should be specific to your population, including age, gender, reading level, cultural background, language, and traumatic stressor. Since a perfect match is unlikely, use your judgment, extend related findings, and compensate with additional assessment strategies (Newman, 2002).
Convenience
If you have money for interviewers and participant compensation, you can get a lot done. Otherwise, you’re generally better off sticking to the “one page” rule for any measure.
Behavior Change
Trauma is often assumed to be the source of problem behaviors (Greenwald, 2002). These behaviors should be tracked directly, in addition to reported PTS symptoms. Sometimes existing data can be used, such as school attendance, grades, discipline referrals, or arrests. When you can relate changes in constructs (such as PTS symptoms) to changes in outcome (such as better grades), you are in a position to discuss theory as well as efficacy.
Health Status
In large-scale studies, statistically significant health-related effects have been noted, for example, a decline in visits to the school nurse following successful trauma treatment (Chemtob, Nakashima, Hamada, & Carlson, 2002).
Related Constructs: Anxiety, Depression, Empathy, Dissociation, Anger
Anxiety and depression are commonly measured in trauma studies, but show a much weaker effect than scales of post-traumatic symptoms. Trauma studies must include PTS scales to ensure sensitivity. Additional scales can be useful for redundancy and/or to further assess a construct of special interest, such as anger in children with conduct problems. Anxiety and depression measures are generally well known and will not be further addressed here.
It’s been hard to find a good empathy measure. However, it may be possible to operationalize empathy, for example, by tracking the type and frequency of aggressive behaviors.
The obvious pick for measuring dissociation is the Adolescent Dissociative Experiences Scale (Armstrong, Putnam, Carlson, Libero, & Smith, 1997), which is available from the Sidran Institute (www.sidran.org). This screener is a widely respected 30 item checklist with good psychometrics and reasonable ease of completion and scoring.
None of the anger measures are perfect, but there are some that may be suitable for specific populations/needs. For example, the Anger Response Inventory (ARI; Tangney 1998) is a very well-designed, thorough, situation-specific measure with child and adolescent forms, which takes about 25 minutes to complete and would thus be most appropriate for resource-rich research projects. The State-Trait Anger Expression Inventory (STAXI; Spielberger, 1996) has some difficult language but is reasonably useful with adolescents as long as someone is available to help with a word here and there.
What it measures: History of exposure to the child/adolescent’s adverse life events; past and current distress level for each of the endorsed events.
Time Estimate: Administration – 5 minutes; Scoring – 1 minute
Languages: English, German, Spanish, Persian, Swedish
Cost: $16 for packet including Student and Parent forms, with permission to copy.
Description: The 16 items cover a broad range of potential trauma and loss events and ask for an estimate of emotional impact at both the time of occurrence and the present. Available in student and parent forms (LITE-S, LITE-P)
Comments: There is no currently available measure of a child/adolescent’s exposure to possibly traumatic events which is simple, brief, and well validated. Several structured interviews have been developed, as well as a couple of rather cumbersome but thorough paper & pencil instruments. This is the only one-pager I know of. Note that although the language is simple and clear, the format can be a bit confusing for some people. The parent and student forms of the LITE sometimes show modest discrepancies (Greenwald & Rubin, 1999), possibly reflecting parent-child differences in forgetting, willingness to disclose, or access to information. The measures were designed for screening, but for research purposes various scoring systems have been tried. None has been firmly established, but one simple strategy is to sum the number of items that have been endorsed.
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Psychometric Properties: Similar measures of trauma history for adults have been found to have adequate reliability; however, items are occasionally reported on only the initial test or on the retest, but not both (Goodman, Corcoran, Turner, Yuan, & Green, 1998; Knight, Rierdan, Meschede, & Lasardo, 1997). Regarding this type of instrumentation, validation of reported incidents has not yet been studied. The LITE-S and the LITE-P together formed the basis of a clinician rating which correlated with current post-traumatic symptoms CROPS r=.60; PROPS r= .56 (Greenwald & Rubin, 1999; note that the rating of current distress was not included in that version of the LITE). Correlations in other studies: LITE-S/CROPS r=.48-.57; LITE-S/TSCC r=.53-.56 (see Greenwald, Rubin, Russell, & O’Connor, 2002).
Sample Items:
Contact:
Author: Ricky Greenwald, Psy.D.
Purchase: Child Trauma Institute
What it measures: Intrusion and avoidance symptoms related to an identified event.
Time Estimate: Administration – 5 minutes; Scoring – 2 minutes
Languages: Many
Cost: None
Description: This is an 8-item self-report of the child’s intrusion and avoidance responses to a specific identified event.
Comments: The Impact of Events Scale (IES; Horowitz, Wilner, & Alvarez, 1979) is widely used with adults following a critical incident, and 8 of the items have survived norming with children and adolescents (Dyregrov & Yule, 1995; Smith, Perrin, Dyregrov, & Yule, 2003). The IES-8 items only address avoidance and intrusion; five hyperarousal items have been developed more recently, with inconclusive value (Smith et al, 2003). Either way, the focus is on classic PTSD symptoms, and many PTS responses are not detected by this measure. Also, the IES will not detect PTS responses that are not directly related to the referenced event.
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Psychometric Properties: Smith and colleagues (2003) reported the following in their sample of 2,976 war-exposed children, ages 9-14, in Bosnia:
Other types of validity have also been established, with other versions of the instrument.
Sample Items:
Contact: Atle Dyregrov, Ph.D.
atle.dyregrov@psych.uib.no
What it measures: Acute stress symptoms within a month of an identified event.
Time Estimate: Administration – 10 minutes; Scoring – 5 minutes
Languages: English, Spanish
Cost: None
Description: This is a 29-item (2 page) self-report measure of Acute Stress Disorder for children ages 8-17. It includes questions on how the event was experienced at the time, current symptoms, and current resources, social support, and coping.
Comments: The items should be read aloud to children under 10. Further study is underway.
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Psychometric Properties: Kassam-Adams, Baxt, and Shrivastava (2003) report the following in their first sample of 144 recently-injured children and teens:
Sample Items:
Contact: Nancy Kassam-Adams, Ph.D.
nlkaphd@mail.med.upenn.edu
What it measures: PTSD symptoms and diagnosis.
Time Estimate: Administration – 10 minutes; Scoring – 5 minutes
Languages: English
Cost: None
Description: This self-report form is keyed to the DSM criteria for PTSD. It includes 2 event items, 17 symptom items, and 7 items on whether the symptoms interfere with various types of functioning.
Comments: The wording is a bit complex, many kids will need help completing this.
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Psychometric Properties: Foa, Johnson, Feeny, and Treadwell (2001) reported the following in their first sample of 75 children and teens two years after an earthquake:
Sample Items:
Contact: Edna Foa, Ph.D.
foa@mail.med.upenn.edu
What it measures: PTSD symptoms and diagnosis
Time Estimate: Administration – 5 minutes; Scoring – 5 minutes
Languages: English
Cost: None
Description: This is a 17-item checklist that can be completed by the child or parent, covering the PTSD symptoms.
Comments: This instrument does not assess event or functioning, so if you want a real PTSD diagnosis you’ll have to establish these in some other way. Some of the items are a bit wordy, so younger kids will need help.
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Psychometric Properties: Daviss et al (2000) and Ford et al (1999) reported the following in their samples of 48 injured children ages 7-17, and 165 children in an outpatient psychiatric clinic, ages 6-17, respectively.
Sample Items:
Contact: Julian D. Ford, Ph.D.
ford@PSYCHIATRY.UCHC.EDU
What it measures: PTSD symptoms and PTSD
Time Estimate: Administration – 5-20 minutes (depending on symptom endorsement; Scoring – 1-10 minutes
Languages: English, Spanish, Canadian French
Cost: Manual: $66; Pack of 25 test protocols: $43
Description: This is a structured child/adolescent interview of PTSD symptoms and diagnosis, including qualifying event, symptoms, and current functioning.
Comments: The structured interview is considered the gold standard of PTSD diagnosis, but is too costly to be practical in many treatment and research contexts. This is the quickest of the structured PTSD interviews for kids, without sacrificing anything in validity.
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Psychometric Properties: Saigh (2004) reported the following in samples of 150 stress-exposed children ages 7-18, 6 months after the stressor, and 42 children ages 6-17, some stress-exposed and some not, respectively.
Sample Items:
Contact:
Author: Phillip A. Saigh, Ph.D. PASaigh@aol.com
Purchase: PsychCorp www.PsychCorp.com
What it measures: PTS symptoms and symptom clusters.
Time Estimate: Administration – 15-20 minutes; Scoring – 5-10 minutes
Languages: English, Spanish, French-Canadian
Cost: Manual: $42; pack of 25 tests: $48; scoring forms and programs also available.
Description: This is a 54-item self-report checklist covering a wide range of PTS symptoms. It features the following sub-scales:anxiety, depression, anger, PTS, dissociation, and sexual concerns.
Comments: The TSCC is probably the most widely used measure of children’s PTS symptoms. For many purposes, the TSCC sub-scales can be used in the place of additional measures. It is a bit lengthy, and also takes a few minutes to score. It also fails to address some important aspects of child trauma symptomatology, such as somatic complaints and pessimistic future. The items are clear and well-written. The sexual concern items sometimes raise eyebrows. An alternate form is available which omits the 10 items relating to sexual concerns.
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Psychometric Properties: Various studies using the TSCC (and TSCC-A) indicate that it is reliable (alphas in the mid to high 80s for all scales but Sexual Concerns, which tends to be in the high 60s and low 70s) and has convergent and predictive validity in samples of traumatized and nontraumatized children and adolescents. (For more detail, see full summary at http://www.johnbriere.com/tscc.htm.) Norming sample of about 3,000, ages 8-17.
Sample Items:
Contact:
Author: John Briere, Ph.D.
Purchase: Psychological Assessment Resources, Inc. www.parinc.com
What it measures: PTS symptoms and symptom clusters
Time Estimate: Administration – 20 minutes; Scoring – 10 minutes
Languages: English, Spanish
Cost: None – yet! Will be published soon by PAR.
Description: This is a care-taker checklist covering a wide range of PTS symptoms for children ages 3-12. It includes 90 items and features the following sub-scales:anxiety, depression, anger, PTS (and further PTSD subscales), dissociation, and sexual concerns.
Comments: This is a new instrument which will be particularly valuable for children who are too young to respond for themselves. It has many of the same features as the TSCC. It is on the long side, but the sub-scales are informative and may be used in place of additional measures focused on those constructs.
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Psychometric Properties: In a multi-site sample of 219 traumatized children (Briere et al, 2001), the TSCYC clinical scales had good reliability (alpha values for the clinical scales ranged from .81 for Sexual Concerns to .93 for PTSD-Total, with an average value of .87) and were predictive of exposure to childhood sexual abuse, physical abuse, and witnessing domestic violence. (For more detail, see full summary at http://www.johnbriere.com/tscyc.htm.)
Sample Items:
Contact:
Author: John Briere, Ph.D.
Purchase: Psychological Assessment Resources, Inc. www.parinc.com
What it measures: PTS symptoms and PTSD diagnosis.
Time Estimate: Administration – 10 minutes; Scoring – 2 minutes
Languages: English, Spanish (?)
Cost: None
Description: This is a 43-item self-report checklist of PTS and other stress-related symptoms, for teens.
Comments: Simple language, short phrases, especially suited to urban teens. There are no event or functioning items but it does include 17 PTSD symptom items, which can be scored separately.
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Psychometric Properties: King, King, Leskin and Foy (1995) modified the original instrument for use with teens, most notably in detecting exposure to violence among urban teens, and exposure to trauma among juvenile delinquents (Foy, Wood, King, King, & Resnick, 1997). The modified LASC has been normed with several thousand adolescents in community and clinical samples, and has been used in a number of trauma studies.
Sample Items:
Contact:
David W. Foy, Ph.D. David.Foy@pepperdine.edu
What it measures: PTS symptoms
Time Estimate: Administration – 5 minutes; Scoring – 1 minute
Languages: German, Spanish, Bosnian, Persian, Dutch, Italian, Finnish
Cost: $16 for packet including Student and Parent forms, with permission to copy.
Description: This is a 24-item self-report for children and adolescents, covering a broad range of PTS symptoms.
Comments: One of the interesting consequences of utilizing the full spectrum of post-traumatic stress symptoms (as opposed to only the PTSD symptoms) is that this instrument has been equally sensitive to boys and girls in picking up trauma-related distress. This can be used as a stand-alone but was designed as a companion to the PROPS; although there is some overlap, each instrument takes advantage of the respective strengths of the respondent.
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Psychometric Properties: Greenwald and Rubin (1999) and Greenwald, Rubin, Jurkovic et al (2002) have presented multiple studies indicating good internal consistency, test-retest reliability, criterion validity, convergent and discriminant validity, and sensitivity to change. Children were ages 7-17 in a variety of countries and settings including community samples, incarcerated youth, war refugees, and clinical populations.
Sample Items:
Contact:
Author: Ricky Greenwald, Psy.D.
Purchase: Child Trauma Institute
What it measures: PTS symptoms
Time Estimate: Administration – 5 minutes; Scoring – 1 minute
Languages: German, Spanish, Bosnian, Persian, Dutch, Italian, Finnish
Cost: $16 for packet including Student and Parent forms, with permission to copy.
Description: This is a 32-item parent report covering a broad range of PTS symptoms.
Comments: One of the interesting consequences of utilizing the full spectrum of post-traumatic stress symptoms (as opposed to only the PTSD symptoms) is that this instrument has been equally sensitive to boys and girls in picking up trauma-related distress. This can be used as a stand-alone but was designed as a companion to the CROPS; although there is some overlap, each instrument takes advantage of the respective strengths of the respondent.
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Psychometric Properties: Greenwald and Rubin (1999) and Greenwald, Rubin, Jurkovic et al (2002) have presented multiple studies indicating good internal consistency, test-retest reliability, criterion validity, convergent and discriminant validity, and sensitivity to change. Children were ages 7-17 in a variety of countries and settings including community samples, war refugees, and clinical populations. For more details, see www.ticti.org.
Sample Items:
Contact:
Author: Ricky Greenwald, Psy.D.
Purchase: Child Trauma Institute
What it measures: Problem behaviors and other observable symptoms
Time Estimate: Administration – 5 minutes; Scoring – 0 minutes
Languages: Any
Cost: None
Description: This structured interview is an individualized parent rating of the severity of the child’s primary presenting problems.
Comments: The PRS is administered in an interview by having the parent describe the main concerns and rate them on a 0-10 scale of severity. This is face valid, fairly quick, and fits easily within a standard clinical interview or assessment protocol. The same rater should be used on each occasion.
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Psychometric Properties: The PRS (Greenwald, 1996) is a reverse variant of the goal attainment scale, which has been found to be a valid and reliable assessment format (Emmerson & Neely, 1988). It has been used in several trauma treatment studies and appears to be sensitive to change in post-traumatic status.
Sample Items:
Contact: Author: Ricky Greenwald, Psy.D.
Purchase: Child Trauma Institute
Armstrong, J. G., Putnam, F. W., Carlson, E. B., Libero, D. Z., & Smith, S. R. (1997). Development and validation of a measure of adolescent dissociation: the Adolescent Dissociative Experiences Scale. Journal of Nervous and Mental Disease, 185, 491-497.
Briere, J. (1996). Trauma Symptom Checklist for Children (TSCC) professional manual. Odessa, FL: Psychological Assessment Resources.
Briere, J., Johnson, K., Bissada, A., Damon, L., Crouch, J., Gil, E., Hanson, R., & Ernst, V. (2001). The Trauma Symptom Checklist for Young Children (TSCYC): Reliability and association with abuse exposure in a multi-site study. Child Abuse & Neglect, 25, 1001-1014.
Chemtob, C. M., Nakashima, J., Hamada, R., & Carlson, J. G. (2002). Brief treatment for elementary school children with disaster-related posttraumatic stress disorder: A field study. Journal of Clinical Psychology, 58, 99-112.
Daviss, W. B., Mooney, D., Racusin, R., Ford, J. D., Fleischer, A., & McHugo, G. (2000). Predicting post-traumatic stress after hospitalization for pediatric injury. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 576-583.
Dyregrov, A. & Yule, W. (1995, November). Screening measures: The development of the UNICEF screening battery. Presented at the annual meeting of the International Society for Traumatic Stress Studies, Boston, MA.
Emmerson, G. J. & Neely, M. A. (1988). Two adaptable, valid, and reliable data-collection measures: Goal attainment scaling and the semantic differential. The Counseling Psychologist, 16, 261-271.
Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. H. (2001). The Child PTSD Symptom Scale: A preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30, 376-384.
Ford, J. D., Racusin, R., Ellis, C., Daviss, W. B., Reiser, J., Fleischer, A., & Thomas, J. (2000). Child maltreatment, other trauma exposure, and posttraumatic symptomatology among children with Oppositional Defiant and Attention Deficit Hyperactivity disorders. Child Maltreatment, 5, 205-217.
Foy, D. W., Wood, J. L., King, D. W., King, L. A., & Resnick, H. S. (1997). Los Angeles Symptom Checklist: Psychometric evidence with an adolescent sample. Assessment, 4, 377-384.
Giaconia, R. M., Reinherz, H. Z., Silverman, A. B., Pakiz, B., Frost, A. K., & Cohen, E. (1995). Traumas and posttraumatic stress disorder in a community population of older adolescents.Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1369-1380.
Goodman, L., Corcoran, C., Turner, K., Yuan, N., & Green, B. L. (1998). Assessing traumatic event exposure: General issues and preliminary findings for the Stressful Life Events screening questionnaire. Journal of Traumatic Stress, 11, 521-542.
Greenwald, R. (1996). Psychometric review of the Problem Rating Scale. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation, pp. 242-243. Lutherville, MD: Sidran.
Greenwald, R. (2002). The role of trauma in conduct disorder. Journal of Aggression, Maltreatment, and Trauma, 6, 5-23.
Greenwald, R. (in press). Child trauma handbook: A guide for helping trauma-exposed children and adolescents. Binghamton, NY: Haworth.
Greenwald, R. & Rubin, A. (1999). Brief assessment of children’s post-traumatic symptoms: Development and preliminary validation of parent and child scales. Research on Social Work Practice, 9, 61-75.
Greenwald, R., Rubin, A., Jurkovic, G. J., Wiedemann, J., Russell, A. M., O’Connor, M. B., Sarac, T., Morrell, T. R., & Weishaar, D. (2002, November). Psychometrics of the CROPS & PROPS in multiple cultures/translations. Poster session presented at the annual meeting of the International Society for Traumatic Stress Studies, Baltimore.
Greenwald, R., Rubin, A., Russell, A. M., & O’Connor, M. B. (2002, November). Brief assessment of children’s and adolescents’ trauma/loss exposure. Poster session presented at the annual meeting of the International Society for Traumatic Stress Studies, Baltimore.
Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of Events Scale: A measure of subjective stress. Psychological Medicine, 41, 209-218.
Kassam-Adams, N., Baxt, C., & Shrivastava, N. (2003, October). Development of the Acute Stress Checklist for Children (ASC-Kids). Poster presented at the 19th Annual Meeting of the International Society of Traumatic Stress Studies, Chicago.
King, L. A., King, D. W., Leskin, G., & Foy, D. W. (1995). The Los Angeles Symptom Checklist: A self-reporte measure of posttraumatic stress disorder. Assessment, 2, 1-17.
Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164-180.
Knight, J. A., Rierdan, J., Meschede, T., & Lasardo, M. (1997, November). Stability of life event inventories as measures of potentially-traumatic exposure. Poster session presented at the annual meeting of the International Society for Traumatic Stress Studies, Boston.
Loeber, R., Green, S. M., & Lahey, B. B. (1990). Mental health professionals’ perception of the utility of children, mothers, and teachers as informants on childhood psychopathology. Journal of Clinical Child Psychology, 19, 136-143.
Newman, E. (1992). Assessment of PTSD and trauma exposure in adolescents. Journal of Aggression, Maltreatment, & Trauma, 6, 59-77.
Russell, A. M., O’Connor, M. B., Greenwald, R., & Rubin, A. (2002). Trauma and post-traumatic stress among disadvantaged urban children in Scotland. Unpublished data. Cited in Greenwald, R., Rubin, A., Russell, A. M., & O’Connor, M. B. (2002, November). Brief assessment of children’s and adolescents’ trauma/loss exposure. Poster session presented at the annual meeting of the International Society for Traumatic Stress Studies, Baltimore.
Saigh, P. A. (2004). Children’s PTSD Inventory [Manual]. San Antonio, TX: PsychCorp.
Smith, P., Perrin, S., Dyregrov, A., & Yule, W. (2003). Principal components analysis of the impact of event scale with children at war. Personality and Individual Differences, 34, 315-322.
Spielberger, C. D. (1996). State-Trait Anger Expression Inventory: Professional manual. Odessa, FL: Psychological Assessment Resources.
Tangney, J. P. (1998?). Overview of the Anger Response Inventories (ARI). Unpublished manuscript. Available from the author: Department of Psychology, George Mason University, 4400 University Drive, Fairfax VA 22030-4444.
The institute provides therapy, training, consultation, information, and resources for those who work with trauma-exposed children, adolescents, and adults. If you would like more information about our services, or you just have a general question, please contact our team.
For our physical address, please email info@ticti.org or call 413.774.2340.
Trauma Institute
& Child Trauma Institute
285 Prospect Street
Northampton, MA, 01060 USA
