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Stakeholders & Grantors in Cross-Cultural Adaptation of a Trauma Assessment Instrument for Syrian Refugees

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Engagement of grantors and stakeholders in a research project can be vital to its success. In adapting the International Trauma Questionnaire (ITQ) to include cultural idioms of distress for Syrian refugees, grant funding would need to be secured in order to successfully carry through the development, testing, and initial study. Furthermore, partnerships with stakeholders are also important, as it is through their organizations and networks which participants may be gathered, may be a part of the research team itself, or may be members of the populations who will benefit from the research, such as mental health workers, other psychological researchers, the Syrian refugee community, policy makers, among others.

            Grant funders are more than just sources of money to complete a project. Ideally, they would also be partners, advocates, and endorsers, with an equal interest in seeing the project come to completion (Broussard, 2019). Typically, organizations, foundations, and government programs which award grants do so, at least in part, because they identify a need which aligns with their values and mission which usually helps society in some fashion (Grant Funding Expert, n.d.). For research which makes a substantial contribution to a field of study, this can also increase the reputation and notoriety of the organization providing the funding. In writing a grant proposal, one should pay close attention to the details of how the funds are meant to be used, and also the objectives and values of the grantors. The grant proposal application needs to clearly demonstrate the value of the research to society and to the grantor organization. Furthermore, funding agencies do not want their funds to be wasted, so defining a clear budget and purpose for funds awarded is necessary (Resnik & Elliott, 2013). While a funder who is actively engaged with the funds recipient throughout the research process shows a strong engagement partnership, it can also signal problems for researchers, whose research may then represent a conflict of interest or bias, even if unintentional, to produce results which please the grantor (Resnik & Elliott, 2013). A tip for engagement of grantors in increasing odds of being approved for funding is to make contact with them and learn about their goals, using a variety of modalities such as social media, emailing, calling, or having an in-person or virtual meeting to gain an insight into their perspectives (Wright, 2019). Grantmakers themselves should also seek to be involved with both their grantees and community stakeholders which can improve the success rates of the programs and research that they are funding (Enright & Bourns, 2010). For engagement with both grantors and stakeholders, meeting expectations is key – monthly reviews of the project progress and evaluation on which goals have been met and which are needing additional work or re-strategizing can help keep the project on track and maintain accountability.

            Researchers also need to engage with stakeholders. This includes “those involved in program operations,…those served or affected by the program,…[and] those who are intended users of the evaluation findings” (Centers for Disease Control and Prevention, 2012, par. 3), such as other researchers, community members, local leaders, organizations with interest in the research, thought leaders and experts, and others who may benefit from or be impacted by the research being conducted (Geo Funders, 2014). According to Boost Midwest (2020), stakeholders can be identified as being key stakeholders or secondary stakeholders, and it is recommended to create a stakeholder register and assessment. They state that the major benefits of engaging stakeholders are that they “can help provide an accurate sense of the needs and challenges facing the grantee. The more diverse your team’s list of stakeholders can be, then the easier the buy-in for the project and it’s goals will become and the more successful the implementation will be long term” (Boost Midwest, 2020, par. 12). Engaging with diverse stakeholders early in the research process and throughout its timeline, can increase the usefulness, relevancy, and credibility of the study (Preskill & Jones, 2009).

            There are a variety of strategies for engaging stakeholders throughout the research process, and beyond. Sharing updates and information on the project is essential, and a variety of methods can be used to do so. It will be important to consider each group or individual stakeholder and their ability to access such communications (for example, availability of internet service). The use of targeted experiences can be done through digital engagement, and includes sharing webinars, having Slack channels, podcasts, or informal meetups or chats (Young Entrepreneur Council, 2019). Meeting in person with stakeholders, even if infrequently (such as once a year) is also recommended, although talking on the phone may suffice if travel is not possible. Periodic updates can be sent out to stakeholders, through internet services like email newsletters, private emails, text or WhatsApp, or even through postal mail. Asking questions of stakeholders may bring in higher engagement, and also further collaborative efforts and allow stakeholders to share their expertise which may benefit the project.

In conducting research to develop an adaptation of the ITQ for Syrian refugees, it is expected that a number of stakeholders would need to be involved, in addition to one or more grantors. The development, pilot testing with feedback, and pilot testing for validity and reliability checks would best be done in a location close to potential participants and related stakeholders – Jordan was chosen as an appropriate country with high numbers of Syrian refugees while being a safe location to conduct research. Some permissions would likely need to be granted by governmental or organizational groups overseeing research with human subjects. Forming relationships with these groups could be mutually beneficial. Furthermore, stakeholders would ideally also be leaders within the Syrian refugee community, as well as with local mental health or psychology organizations which could provide input on the development of the assessment and would also benefit from being able to see or use the results in providing more comprehensive support or care for Syrian refugees. A cultural expert would also be needed to help broker local needs, as well as provide insight on cultural specificities in both working with and communicating with regional partners and participants, and also practical needs of conducting research such as assistance in renting an office space. Many secondary stakeholders could also exist from international organizations who hold interest in the research, however, too many could overwhelm the project’s immediate scale. A balance of input and output should be sought, and stakeholders could be assessed for their skills type and level of contribution that will improve but not hinder the research process (Preskill & Jones, 2009).


References

Boost Midwest. (September 24, 2020). Grant management: Building stakeholder engagement. https://www.boostmidwest.com/post/grant-management-stakeholder-engagement

Broussard, D. (February 13, 2019). Engage grant funders to be advocates and endorsers. Dickerson Bakker. https://dickersonbakker.com/engage-funders-to-be-advocates-and-endorsers/

Centers for Disease Control and Prevention. (2012). Program evaluation for public health programs: A self-study guide. CDC: Program performance and evaluation office. https://www.cdc.gov/eval/guide/step1/index.htm

Enright, K.P. & Bourns, C. (2010). The case for stakeholder engagement. Stanford social innovation review. https://ssir.org/articles/entry/the_case_for_stakeholder_engagement

Grant Funding Expert. (n.d.). Why does the government give grant money. https://www.grantfundingexpert.org/why-does-the-government-give-grant-money/

Preskill, H. & Jones, N. (2009). A practical guide for engaging stakeholders in developing evaluation questions. Robert Wood Johnson Foundation.

Resnik, D. B., & Elliott, K. C. (2013). Taking financial relationships into account when assessing research. Accountability in research, 20(3), 184–205. https://doi.org/10.1080/08989621.2013.788383

Wright, J. (September 27, 2019). Grant seeking 101: A step-by-step guide to finding and winning grants. sgENGAGE. https://npengage.com/nonprofit-fundraising/grant-seeking-101/

Young Entrepreneur Council, Expert Panel. (September 19, 2019). Five effective methods for     keeping stakeholders engaged. Forbes.             https://www.forbes.com/sites/theyec/2019/09/19/five-effective-methods-for-keeping-stakeholders-engaged/?sh=3cff4a6635b2

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Adaptation of Adult Trauma Assessment Instruments for Children & Adolescents

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Adapting a trauma assessment for children and adolescents can be done based on an existing assessment for adults. Certain considerations need to be made for how children and adolescents understand and experience trauma in ways which are different from adults. Steps which outline how to do this can serve as useful guidelines. Assessment for trauma also can limit the long-term impacts of trauma, such as other psychiatric disorders, impaired functioning, and physical health problems (Berliner et al., 2020).

In some respects, adapting instruments meant for adult assessment to screen for trauma in children is similar to doing cross-cultural adaptations of instruments. Language needs to be understood and relevant for children (Grace et al., 2021), just as terms translated to other languages need to impart the same meanings within differing cultural contexts. Trauma assessments have typically focused on broad age ranges for children and adolescents, such as ages 6 to 17 for the Child Trauma Screen (Lang & Connell, 2018). However, there are dramatic developmental differences between children of different ages, and especially between children and adolescents (Grace et al., 2021). Many prior screens do not account for this, and also “did not report collecting data from children and adolescents on how to better articulate the screening items for them” (Grace et al., 2021, p. 2). Additionally, symptom presentations in children with PTSD are frequently left out of assessments, including somatic symptoms (often stomachaches and headaches), separation anxiety or clinging, regression of developmental skills (such as bedwetting), reckless behaviors, old fears suddenly reemerging, as well as symptoms which overlap with and may be misdiagnosed as attention deficit hyperactivity disorder such as hyperactivity, impulsivity, distractibility, and loss of focus and concentration (Kaminer et al., 2005). In their outline of steps to adapt an assessment cross-culturally, Sousa and Rojjanasrirat (2011) list the crucial fifth step as conducting a pilot study with the intended population, who then give feedback and rate the assessment questions, instructions, and items for their clarity and relevance. This step seems to be largely ignored when adapting assessments to children and adolescents, although it seems to be incredibly important to developing an accurate measure.

Moreover, other suggestions for cross-cultural adaptation would be very useful. Raghavan (2018) describes multiple considerations in this regard. Two of these stand out as particularly important additional considerations when adapting adult assessments for children and adolescents. Firstly, is the understanding of cultural idioms of distress. In this case, understanding how children express themselves and communicate amongst each other is valuable. This would mean that assessments may need to be reviewed every few years to ensure it is matching the current trends of how children and adolescents communicate and the terminology that they use. Another point made by Raghavan (2018) is the impact of interpreters. In this case, it would be the impact of the researcher, clinician, or administrator of the assessment. Considerations on this should be explicitly outlined in the assessment instructions by the development team. For example, a teacher administering an assessment may get a very different response from participants than a stoic but impartial researcher who is a stranger to the child, and also differing from a counselor who specializes in working with children and, even if a stranger, may know how to build safety and rapport with the child in the span of a few minutes.

Another consideration is that children may have trouble rating items on a Likert scale, as their memory and concepts of time differ from adults, so the use of Yes/No questions is preferable (Grace et al., 2021). Assessments which allow the child to self-report rather than relying solely on caregiver reports are more accurate (Sacher et al., 2017), although the use of caregiver reports or interviews can also provide important observations in a variety of contexts from someone who knows the child well (Berliner et al., 2020). It should be noted, however, that children and adolescents are particularly subject to suggestive statements, so assessment items which use first-person statements may lead them to be more likely to agree with those statements even if they do not accurately reflect the child’s experience (Grace et al., 2021).

 An important ethical consideration is if the assessment is being given within a clinical setting. If it is not, such as within a school, assessments which ask about a child’s traumatic exposure may cause distress or traumatization. However, for most children, assessments do not increase distress, although it has a higher likelihood of doing so in children who are having symptoms related to trauma (Berliner et al., 2020). Still, it must be considered if there is availability and access (including parental consent and financial resources) to initiate immediate treatment for a child who screens positively for trauma, as without such services, a trauma screening has the potential for harm (Grace et al., 2020). One other point is that there may be a tendency of assessments to not consider the child’s cultural context, such as those who live in dangerous communities, for whom what might appear as a high symptomology of hypervigilance is, in reality, a critical survival skill in their current situation (Grace et al., 2020).

Furthermore, it must be considered if the child’s family is the source of interpersonal trauma, in which case, an assessment could create intense fear and ramifications for the child at home (Berliner, 2020). This does not mean that such potential children should not be screened at all – in fact, early assessment and treatment is vital to ending abusive situations and providing healing for the child. Rather, that when doing an assessment, a plan should be in place in how to handle such situations. This includes the administrator’s familiarity with mandated reporting laws and procedures in the location the assessment is taken (Berliner, 2020). The context of the family can both be an exacerbator of trauma symptoms or a vital support network and conducting and development of assessments should take this into account, although its most valuable use is for clinicians who are treating traumatic symptoms in a child in working with the family.

References

Berliner, L., Meiser-Stedman, R., & Danese, A. (2020). Screening, assessment, and diagnosis in children and adolescents. In Effective Treatments for PTSD, 3rd ed. Forbes, D., Bisson, J.I., Monson, C.M., & Berliner, L., eds. The Guilford Press.

Foa, E.B., Asnaani, A., Zang, Y., Capaldi, S., & Yeh, R. (2018). Psychometrics of the Child   PTSD Symptom Scale for DSM-5 for trauma-exposed children and adolescents. Journal of Clinical Child & Adolescent Psychology, 47(1), 38–46.

Grace, E., Sotilleo, S., Rogers, R., Doe, R., & Olff, M. (2021). Semantic adaptation of the Global Psychotrauma Screen for children and adolescents in the United States. European journal of psychotraumatology, 12(1), 1911080.         https://doi.org/10.1080/20008198.2021.1911080

Kaminer, D., Seedat, S., & Stein, D. J. (2005). Post-traumatic stress disorder in children. World psychiatry : official journal of the World Psychiatric Association (WPA), 4(2), 121–125.

Lang, J., & Connell, C. (2018). The Child Trauma Screen: A follow-up validation. Journal of Traumatic Stress, 31(4), 540-548.

Sachser, C., Berliner, L., Holt, T., Jensen, T.K., Jungbluth, N.J., Risch, E.C., Rosner, R., & Goldbeck, L. (2017). International development and psychometric properties of the Child and Adolescent Trauma Screen (CATS). Journal of affective disorders, 210, 189-195 .

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Assessment of Trauma in Children and Adolescents

The Child Trauma Screen is an assessment tool to identify children ages 6-17 who are experiencing symptoms of traumatic distress (Lang & Connell, 2018). It is short, free, and meant for use by a variety of professionals working with children. It is not meant to be comprehensive and screen for all possible symptoms or reactions, but rather a quick initial step to identify the most common reactions and exposures, for further follow up of clinical treatment or more comprehensive assessment. It is recommended to be conducted using an in-person interview, but it can also be used as a self-report measure, and also recommended to get both reports from the child and the caregiver or multiple caregivers. One concern I noted for the Child Trauma Screen is that all three of the studies listed on its hosted website which found it valid and reliable were all conducted by the creator of the screen (Child Health and Development Institute of Connecticut, Inc., 2021).

The context which I would use this assessment personally is within my practice as a Licensed Professional Counselor and Registered Play Therapist, specializing in treating trauma in children and adolescents. An ethical consideration is that if a child reports any abuse, I would need to report it to the Child Welfare office. Another consideration that I would prefer is to first have several sessions with the child to build rapport and safety before administering the screen, and I would also request that the parent leave the room. The child may not feel comfortable sharing in front of their parent for a variety of reasons, such as not wanting to upset them, fear over their reaction, or the parent instigating the abuse.

Reducing traumatic exposure for children and adolescents may ultimately not be possible, although developing better prevention and interventions to interrupt cycles of abusers could make a large difference. Still, trauma is present in nearly all of our lives (van der Kolk & McFarlane, 1996). In reducing the burden of trauma on children and adolescents, I believe we should instead focus on creating resilient support systems which help children process trauma in healthy ways and develop skills for self- and co-regulation of emotions.

See this image below depicting Bronfenbrenner’s Ecological Theory or socio-ecological model (Stanger, 2011). Using this theory, we could construct levels of systems, which all interact and influence each other, embedding resilience building factors into each level. Such a design might buffer negative mental health impacts for children after experiencing traumatic events.

Here is another image which shows the same concept but in a slightly different way which may be helpful (University of Minnesota, n.d.).

See here for a larger, clearer version from the source website.

This same resource listed multiple ideas on how to apply this model in practical applications. I believe these would apply to reducing the burden of trauma on children, adults, families, communities, society, and so on.

  • Promote individual and family solutions to support mental well-being (e.g., self-efficacy) 
  • Learn and teach others to manage stress and cope with adversity
  • Provide health education to support parent-child/caregiver-child relationships
  • Promote social connections – between family, neighbors, employees, etc.
  • Expand youth development in schools
  • Increase skill-based learning to promote adaptability, coping and resilience  
  • Coordinate mental health prevention efforts at the federal, state, and local levels 
  • Support local communities taking an active role in co-creating solutions
  • Increase collaboration between service organizations to strengthen service coverage, access and the referral process for a more integrative, comprehensive approach
  • Leverage the role of service providers to increase natural social support systems 
  • Fund mental health promotion research and community-based supports 
  • Promote equitable resource allocation

(University of Minnesota, n.d., par. 8).

References

Child Health and Development Institute of Connecticut, Inc. (2021). Child Trauma Screen. https://www.chdi.org/our-work/mental-health/trauma-informed-initiatives/ct-trauma-screen-cts/

Lang, J., & Connell, C. (2018). The Child Trauma Screen: A follow-up validation. Journal of Traumatic Stress, 31(4), 540-548.

Stanger, N. (2011). Moving “eco” back into socio-ecological models: A proposal to reorient ecological literacy into human developmental models and school systems. Human Ecology Review, 18, 167-173.

University of Minnesota. (n.d.). Mental health and well-being ecological model. Center for Leadership Education in Maternal & Child Public Health. https://mch.umn.edu/resources/mhecomodel/

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

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Assessment-Based Ethical Referral of Traumatized Individuals to Psychosocial Services

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When conducting assessments for trauma as a psychologist, it is important to have a plan in place on the provision of mental health services and resources for the client or participant. Those participants who screen as having posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), acute stress disorder (ASD), or who may not qualify for a disorder but still have significant symptoms in amount or severity should be referred for more in-depth assessments or treatment. The International Society for Traumatic Stress Studies (ISTSS) (Forbes et al., 2020) suggests treatments of varying evidence bases for recommendations. This also aligns, and in some cases conflicts, with ethical standards as proposed by the American Psychological Association (APA) (2017) and the International Union of Psychological Science (IUPS) (2008). However, a crucial consideration is the barriers to such treatments, such as cultural factors, socioeconomics, and available resources, which may be difficult to access in some areas of the world.

Trauma assessments could occur in at least two different scenarios, either within the context of a research assessment, or in a clinical environment. In a research context, the APA’s Ethical Principles of Psychologists and Code of Conduct (2017) states in section 8.08 that in order to reduce the risk of harm to participants, debriefing should occur quickly following the conclusion of the research. However, this is conflictual with debriefing as an early intervention in a clinical setting following assessment. The ISTSS (Forbes et al., 2020) reviewed evidence and found that debriefing interventions were largely ineffectual, including psychoeducation, in both individual and group interventions. It must be noted, though, that this was specific to those who had been exposed to trauma within the prior three months, and there appeared to be little research included for its use with survivors and refugees of civil war and genocide. This is relevant because the author of this paper, Emily Lutringer, is working to adapt the International Trauma Questionnaire (ITQ) (Cloitre et al., 2018) into cultural idioms of distress for Syrians, who have significant rates of multiple trauma exposures occurring for potentially over a decade (Hassan et al., 2015). In doing an assessment for research purposes, individuals may have been exposed to trauma longer than three months ago. ISTSS (Forbes et al., 2020) guidelines found strong evidence to recommend the following psychological treatments for adults with PTSD: cognitive processing therapy, cognitive therapy, EMDR, trauma-focused CBT, and prolonged exposure.

In conducting clinical assessments, there may be clients who are recently exposed to trauma, and therefore could partake in prevention and early interventions if they show symptoms of trauma on the assessment. ISTSS (Forbes et al., 2020) found that single sessions of EMDR and Group 512 PM had emerging evidence to prevent or treat symptoms of PTSD. Brief dyadic therapy and self-guided internet-based interventions also showed emerging evidence for multiple-session prevention. Stronger evidence was found in early treatment multi-session interventions of trauma-focused CBT, cognitive therapy, and EMDR. Of pharmacological interventions, only hydrocortisone showed emerging evidence.

In any situation in which an individual screens positively for trauma symptoms or PTSD, there may be barriers to accessing the most effective treatments – or even any interventions at all. Firstly, the interventions proposed by ISTSS (Forbes et al., 2020) are primarily Western models, and may not be culturally appropriate in other contexts (Narvaez, 2019). While ISTSS (Forbes et al., 2020) offers a few treatments which may have limited efficacy which could be culturally accessible, such as acupuncture, it is notably lacking in covering the evidence for interventions from indigenous psychologies which would be highly culturally relevant.

Another serious concern is the lack of access, such as low rates of mental health providers, remote areas, high demand with limited availability, and socioeconomic factors (Patel, 2007). Rojas et al. (2019) found that mental health care could be utilized in such situations through the use of internet-based interventions in a variety of formats, such as virtual counseling, phone apps, and specialized video games. As more people worldwide have access to the use of internet and cellphones, these interventions could reach larger populations and at lower costs. There are two caveats to this, though. Firstly, there are still many areas of the world without such internet or cell phone access. Secondly, internet and phone-based interventions appear to have mixed results in their effectiveness, although ISTSS was able to give a standard recommendation for the use of guided internet-based trauma-focused CBT in adults diagnosed with PTSD (Forbes et al., 2020).

Other barriers include stigma and poor mental health literacy (Wong et al., 2019). For example, Syrians typically hold strong stigmas around mental health and may be afraid to seek help for how others may judge them or their families (Hassan et al., 2015). Wong et al. (2019) had positive results in their pilot study evaluating the reduction of stigma through a mental health course in Hong Kong. Similar strategies for psychoeducation and normalization may be valuable when working with people in high-stigma cultures, as they may otherwise resist any PTSD intervention.

 Any mental health resources should include facilities or providers who have experience working with the specific population, to meet the ethical standard of competency (APA, 2017; IUPS, 2008). A researcher would ideally, finding an option that participants could engage in immediately after the study if they chose would allow them to process any trauma that came up without a waitlist. As the assessments are specifically measuring for trauma, a participant may suddenly become aware for the first time that they are suffering from a mental illness and may need immediate support. Furthermore, providing exceptional mental health and other resources is critical to preventing the re-enactment of trauma or intergenerational trauma which could lead to a continued cycle of violence (van der Kolk & McFarlane, 1996). It constitutes the ethical responsibilities of beneficence and nonmaleficence, fidelity and responsibility, justice, and respect for people’s rights and dignity (APA, 2017) not only to individual participants, but in taking a responsibility in the reduction of harm in communities as well.

References

American Psychological Association [APA]. (2017). Ethical Principles of Psychologists and Code of Conduct. https://www.apa.org/ethics/code

Cloitre, M., Shevlin M., Brewin, C.R., Bisson, J.I., Roberts, N.P., Maercker, A., Karatzias, T., Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and Complex PTSD. Acta Psychiatrica Scandinavica. DOI: 10.1111/acps.12956

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict. Geneva: UNHCR.

International Union of Psychological Science [IUPS]. (2008). Universal Declaration of Ethical Principles for Psychologists. https://www.iupsys.net/about/governance/universal-declaration-of-ethical-principles-for-psychologists.html

Narvaez, D.F. (October 20, 2019). Indigenous Psychologies Contrast With Western Psychology. Psychology Today. https://www.psychologytoday.com/us/blog/moral-landscapes/201910/indigenous-psychologies-contrast-western-psychology

Patel, V. (2007). Mental health in low-and middle-income countries. British medical bulletin, 81(1), 81-96.

Rojas, G., Martínez, V., Martínez, P., Franco, P., & Jiménez-Molina, Á. (2019). Improving Mental Health Care in Developing Countries Through Digital Technologies: A Mini Narrative Review of the Chilean Case. Frontiers in public health, 7, 391. https://doi.org/10.3389/fpubh.2019.00391

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

Wong, P. W. C., Arat, G., Ambrose, M. R., Qiuyuan, K. X., & Borschel, M. (2019). Evaluation of a mental health course for stigma reduction: A pilot study. Cogent Psychology, 6(1), Article 1595877. https://doi.org/10.1080/23311908.2019.1595877

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Cross-Cultural Adaptation of Trauma Instruments

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The seven steps provided by Sousa and Rojjanasrirat (2011) for the cultural adaptation of health care assessment instruments primarily focuses on translation. This does include some cultural considerations as well, and they suggest it best to use translators who are not only fluent in both languages, but also from the culture in question, in order to capture meanings accurately rather than a direct word-for-word translation.

The seven steps are:

  1. Initial translation from the original language of the instrument into the language sought for adaptation by two translators. One of translators should also possess fluency in the scientific terminology of the discipline being used, while the other should not be, but still familiar with common expressions related to the discipline.
  2. Initial synthesis – comparing both the original and translated instruments by a separate translator for accuracy of meanings. Any discrepancies would be handled by a meeting between all translators to decide on the best meaning to use.
  3. The newly updated translated instrument from the previous step is then back-translated to the original language by two other translators who have never seen the original instrument. These translators should possess similar qualities to the initial two translators.
  4. Secondary synthesis – The two back-translated instruments are compared, and any discrepancies are similarly resolved as the initial synthesis by consensus, and all versions of both the translated versions and back-translated versions are compared.
  5. Pilot test the first draft of the instrument with individuals who speak the target language only and are not bi-lingual. The participants rate the questions, instructions, and items on the assessment itself for being clear or unclear. The use of an expert panel who are within the discipline or have knowledge of it is also recommended for this step to evaluate the clarity.
  6. Preliminary stage testing with participants who are bilingual. This often is skipped over in testing instruments, but it can be a valuable step if it is incorporated.
  7. Complete full testing with the final draft of the translated instrument using a sample from the target population. This test can help to iron out any final inconsistencies or issues, and can be used to determine the general validity and reliability of the instrument.

Raghavan (2018) shares recommendations when conducting assessments for survivors of torture, but, these suggestions are also highly useful to consider for any cross-cultural adaptation of assessments and instruments. These recommendations are based in the premise that cultural contextual factors are critically important to understanding, assessing, and treating how individuals from differing backgrounds express, conceptualize, and experience mental illness. Some researchers believe that inconsistencies in assessments and instruments cross-culturally are not due to actual differences in the rates and underlying symptomology of a mental illness, but rather that the measurement tool does not accurately portray definitions or options which reflect the cultural viewpoint of those being assessed.

These strategies include:

  1. Cultural idioms of distress. How mental illness manifests within a culture, how it is commonly understood and described, and experienced. Many collectivistic cultures use somatic symptoms to express mental distress, for example.
  2. Impact of Interpreters. When clients or participants must use an interpreter to communicate with a provider or researcher, the true meaning of what they try to convey may be misconstrued or lost. Furthermore, the skills and bias of the interpreter may alter both the meaning of the client/participant and the clinician/researcher, and the interpreter may suffer from secondary trauma. It would be best to use a researcher/clinician who is already fluent in the client’s language, but, if this is not possible, using an interpreter is still a better option than not using one.
  3. Cross-cultural equivalence of measures. Five criteria are proposed to determine if measures are equivalent in differing cultures, such as being contextually relevant, differences in the cultural understanding of constructs, or if the method of data collection itself creates a response bias, or is inaccessible to some.
  4. Adaptation and Translation of Measures. Here Raghavan (2018) seems to agree with the steps of translation proposed by Sousa and Rojjanasrirat (2011).
  5. Use of culture-specific normative data. This consists of the baseline sample to which the assessment would be comparing. For example, the normative data would be the general rate of PTSD among community members in Guatemala, but the assessment would be measuring rates of PTSD of Guatemalan refugees. Rather than comparing to PTSD rates among worldwide populations, this ensures that there is accuracy within a cultural framework.

In reviewing a study by Oe et al. (2020), the researchers did make use of the above steps by Sousa and Rojjanasrirat (2011) and recommendations by Raghavan (2018). They used a Japanese-developed trauma screen, the TEC-J, and compared this with the Global Psychotrauma Screen (GPS) which was developed elsewhere and then modified/translated for use in Japan using the guidelines by Sousa and Rojjanasrirat (2011). The use of the TEC-J is important because it was developed internal to the culture in question, and therefore included culturally relevant considerations in its design (Oe et al., 2020). However, this may be outdated, as the TEC-J was developed in the 1990s and therefore avoided asking about highly taboo topics in Japan such as childhood sexual abuse. It is unclear whether this would still be such a taboo today to the point that it would be avoided on an instrument all together. In their analysis, Oe et al. (2020) consider cultural factors which may have impacted the scores particularly on the GPS, including response bias as mentioned by Raghavan (2018). One limitation, which is mentioned by the authors (Oe et al., 2020), is that the sample was skewed to those with severe trauma and who were seeking help; in other words, no normative data for comparison (Raghavan, 2018).

References

Raghavan, S. S. (2019). Cultural Considerations in the Assessment of Survivors of Torture. Journal of Immigrant and Minority Health, 21(3), 586-595. http://dx.doi.org/10.1007/s10903-018-0787-5

Sousa, V.D. & Rojjanasrirat, W. (2011). Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline. Journal of Evaluation in Clinical Practice, 17, 268–274. 

Oe, M., Kobayashi, Y., Ishida, T., Chiba, H., Matsuoka, M., Kakuma, T., Frewen, P. & Olff, M. (2020). Screening for psychotrauma related symptoms: Japanese translation and pilot testing of the Global Psychotrauma Screen. European Journal of Psychotraumatology, 11(1). 

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Papers, Docs, and Essays

Using the International Trauma Questionnaire (ITQ) in Diverse Global Populations

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Photo by Anthony Shkraba on Pexels.com

The International Trauma Questionnaire (ITQ) was developed based on the criteria for posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD) as outlined in the International Classification of Diseases, 11th ed. (ICD-11) (Cloitre et al., 2018). The ICD-11 is a covers physical and mental health illnesses and serves as a diagnostic guide and is widely used worldwide (World Health Organization [WHO], 2019). The ITQ has been translated and utilized within many populations and cultures. This is in contrast to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the primary diagnostic manual used for mental disorders in the U.S. (American Psychological Association [APA], 2009). The literature on the ITQ’s use within cultures in the Middle East, Africa, and Asia will be examined.

The ITQ is an instrument which measures an individual’s level of PTSD and CPTSD. It is brief, easy to understand, and is designed for individuals to be able to fill it out themselves (Cloitre et al., 2018). It was developed to serve as a diagnostic tool, because the ICD-11 uses a narrative description of symptoms format rather than specific diagnostic criteria. The development of the ITQ focused on inclusion of questions which addressed the core symptoms, rather than every possible symptom. The majority of the questions use a Likert scale of 1-5. An individual taking the assessment can be diagnosed with PTSD or CPTSD, but not both. Early analyses of the ITQ found some questions to have poor reliability, so they were removed or changed. Additionally, the ITQ was found to work well within both community and clinical populations. The ITQ has been translated into at least 28 languages, has a version for children and adolescents, and is freely available in the public domain (The International Trauma Consortium, n.d.). The ITQ has been found to be valid and reliable among many populations internationally, however, additional adaptations to match cultural context and idioms of distress could be useful in capturing the true experience of trauma for many populations.

In the Middle East, a study of Syrian refugees in Lebanon (Vallieres et al., 2018) tested the use of the ITQ and the ICD-11 in their accuracy in measuring PTSD and CPTSD within this group. They found that CPTSD was more common than PTSD, and there were high amounts of traumatic exposure. The most distressing events as rated by participants were the deaths of loved ones, being separated from family and friends, forced displacement, and bombings. Overall, participants found that the ITQ seemed to accurately reflect their experiences. Limitations of the ITQ were that it lacked any questions related to somatic symptoms such as amnesia and poor concentration (Vallieres et al., 2018), or fainting, dizziness, weakness, and chronic pain, all of which are common cultural idioms of mental and emotional distress for Syrians (Barkil-Oteo et al., 2018). Another issue is that some participants showed hesitancy in answering, exhibiting signs of paranoia and hypervigilance. To address this, trust and rapport may first need to be built with the person administering the ITQ. However, the use of the ITQ helped create a language and normalization for participants and assisted them in opening up in subsequent therapy sessions (Vallieres et al., 2018). Overall, both the ICD-11 and the ITQ were found be culturally viable within this population in this study.

In Africa, Owczarek et al. (2019) tested the ITQ among community members in Kenya, Ghana, and Nigeria. In this study, the ITQ was found to be a valid assessment within these different cultural populations, with a very good internal consistency. There were some differences in the types of traumatic exposures between the countries, as well as levels of PTSD and CPTSD. The limitations described by the authors discuss the lack of generalizability, as the sample demographics were different from the general population, such as having a much higher rate of higher education, which has been shown to be correlated with lower levels of PTSD symptoms. Additionally, the data collection was done online, limiting access. Another study by Barbieri et al. (2019) compared the rates of PTSD and CPTSD between the DSM-V and the ITQ in a clinical sample of African refugees in Italy. 79% of the participants met the criteria for PTSD using the DSM-V. Using the ITQ, 38% met criteria for PTSD and 30% for CPTSD, with a combined total of 68%, showing a statistically significant difference compared to the DSM-V. Understandably, this population of treatment-seeking refugees showed much higher rates of both PTSD and CPTSD than in the study of community members by Owczarek et al. (2019), but it also found the ITQ to be a valid measure for this population (Barbieri et al., 2019).

Examining the ITQ in Asia, Tian et al. (2020) found that the assessment had good validity and reliability among Chinese young adults. They found that the rate of CPTSD was significantly higher at 13.35% as compared to PTSD at 5.85%. One possible explanation is the high rate of childhood maltreatment in China, and early trauma exposure is a major risk factor for CPTSD, in addition to other cultural factors. This study also measured posttraumatic growth (PTG), a heightened state of resilience. PTG was lower among those with CPTSD symptoms than those with PTSD only. Limitations of this study were also a lack of generalizability due to the narrowness of the sample, and that all participants had experienced at least one traumatic event. Another study examined the validity of the ITQ in young adults across multiple Asian cultures – China, Hong Kong, Japan, and Taiwan (Ho et al., 2020). This study also found that PTSD and CPTSD were valid separate diagnoses using the ITQ within these populations, and the association of increased childhood negative experiences (though not necessarily traumatic) correlated with higher rates of CPTSD. This study also found higher rates of CPTSD than PTSD, like Tian et al. (2020).

From these studies, it appears that the ITQ is indeed valid across multiple populations in determining PTSD and CPTSD, and validating the legitimacy of these two related, but different, diagnoses. Despite initial impressions that there should be more specific cultural adaptations more than language translations, these studies show that symptomology of these disorders remains in similar clusters cross-culturally. Still, there is a continued question of if these results would shift if the questions were adapted to use the specific cultural idioms and expressions of emotional distress. As there do not appear to be any studies which modify the ITQ in such a way, there is no current way to compare this.

References

American Psychological Association. (2009, October). ICD vs. DSM. Monitor on Psychology, 40(9). http://www.apa.org/monitor/2009/10/icd-dsm

Barbieri, A., Visco-Comandini, F., Alunni Fegatelli, D., Schepisi, C., Russo, V., Calò, F., Dessì, A., Cannella, G., & Stellacci, A. (2019). Complex trauma, PTSD and complex PTSD in African refugees. European Journal of Psychotraumatology, 10(1), 1700621–1700621.                   https://doi.org/10.1080/20008198.2019.1700621

Barkil-Oteo, A., Abdallah, W., Mourra, S., & Jefee-Bahloul, H. (2018). Trauma and resiliency: A tale of a Syrian refugee. American journal of psychiatry, 175(1), 8-12.

Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire: development of a self‐report measure of ICD‐11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138(6), 536–546. https://doi-org.tcsedsystem.idm.oclc.org/10.1111/acps.12956

Ho, G., Hyland, P., Shevlin, M., Chien, W. T., Inoue, S., Yang, P. J., Chen, F. H., Chan, A., & Karatzias, T. (2020). The validity of ICD-11 PTSD and Complex PTSD in East Asian cultures: findings with young adults from China, Hong Kong, Japan, and Taiwan. European journal of psychotraumatology, 11(1), 1717826. https://doi.org/10.1080/20008198.2020.1717826

Owczarek, M., Ben-Ezra, M., Karatzias, T., Hyland, P., Vallieres, F., & Shevlin, M. (2020). Testing the Factor Structure of the International Trauma Questionnaire (ITQ) in African Community Samples from Kenya, Ghana, and Nigeria. Journal of Loss & Trauma, 25(4), 348–363. https://doi.org/10.1080/15325024.2019.1689718

The International Trauma Consortium. (n.d.). International Trauma Questionnaire. https://www.traumameasuresglobal.com/itq

Tian, Y., Wu, X., Wang, W., Zhang, D., Yu, Q., & Zhao, X. (2020). Complex posttraumatic stress disorder in Chinese young adults using the International Trauma Questionnaire (ITQ): A latent profile analysis. Journal of affective disorders, 267, 137–143. https://doi.org/10.1016/j.jad.2020.02.017

Vallières, F., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., Byrne, S., Shevlin, M., Murphy, J., & Hyland, P. (2018). ICD‐11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire. Acta Psychiatrica Scandinavica, 138(6), 547–557. https://doi-org.tcsedsystem.idm.oclc.org/10.1111/acps.12973

World Health Organization. (2019).  International Statistical Classification of Diseases and Related Health Problems (ICD). https://www.who.int/standards/classifications/classification-of-diseases

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Symptoms of PTSD and Complex PTSD in Western Cultures & Syrian Culture

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Post-traumatic stress disorder (PTSD) is a psychological disorder which is included in both the DSM and the ICD-11, but only the ICD-11 explicitly includes a distinction of Complex PTSD (CPTSD) (Cloitre et al., 2019). The inclusion of CPTSD is important, as it encompasses research on how PTSD manifests within prolonged or repeated trauma exposure, particularly in early childhood, but also include the impacts of cultural and collective trauma (Hirschberger, 2018), such as that which is experienced in mass catastrophic events such as war, genocide, slavery, colonization, racial trauma (Comas-Díaz et al., 2019), etc., and intergenerational trauma (Yehuda & Lehrner, 2018). The civil war in Syria, ongoing since 2011, is one example of such a significant collective trauma, which may have lasting intergenerational trauma effects. However, the Western medical-style model of diagnosis of mental illnesses does not explicitly account for cultural differences in how Syrians experience, understand, and express trauma.

Van der Kolk and McFarlane (1997), who provide a deep understanding of the multitude of ways that trauma can manifest beyond what manuals like the DSM provide or ICD-11 provide, write that “experiencing trauma is an essential part of being human; history is written in blood” (p.3). Traumatic experiences can vary in their intensity, and whether they develop into the pathology of PTSD depends on their context, and the coping skills of the individual experiencing the event. Some people can process such traumatic exposures in ways which allow them to return to healthy functioning, while others do not. Those that develop PTSD start to develop unhealthy defense mechanisms and behaviors to avoid even subtle reminders of the trauma, which can affect the entire way that they structure their lives. “The core issue is the inability to integrate the reality of particular experiences, and the resulting repetitive replaying of the trauma in images, behaviors, feelings, physiological states, and interpersonal relationships” (van der Kolk & McFarlane, 1997, p.7). In most cases, PTSD is spurned from a singular event, or tightly clustered events, while CPTSD occurs when there is repeated or prolonged exposure to traumatic situations, such as child abuse at a critical stage of development. Due to the nature of PTSD broadly, trauma victims tend to reenact (usually subconsciously) the trauma in other aspects of their lives, leading to continued traumatic experiences, further deepening the complexity of CPTSD (Foa et al., 2009).

Whole societies and cultures can also be traumatized and can follow “roughly similar patterns of adaptation and disintegration” (van der Kolk & McFarlane, 1997, p. 3) as traumatized individuals. States can react to traumatized populations in various ways – in the U.S. it is typically with some immediate compassion, but a fallback on an attitude of blaming victims as their own responsibility for the trauma, seeking to maintain the status quo, and projecting a message of safety for society (van der Kolk & McFarlane, 1997). When considering the case of Syria, the authoritarian regime has sought to eradicate trauma narratives and instead impose their own version of the story through such tactics as monopolizing higher education to maintain their power and enforce their political agenda. (Al Azmeth et al., 2020). Matos et al. (2021) found that “…war severely disrupted Syrians’ sense of collective self, and that they repeatedly engaged in search for meaning, appraisals of the war, and reappraisals of shattered beliefs, life goals, and sense of purpose, both during wartime and in resettlement” (p.1).

Vallieres et al. (2018) conducted a study of Syrian refugees in Lebanon, using the International Trauma Questionnaire (ITQ) and the ICD-11 in examining both CPTSD and PTSD levels and validity for this population. They found that CPTSD was more prevalent than PTSD, and that the ICD-11 and ITQ were cross-culturally applicable – with some limitations. The levels of traumatic exposure were high, with the events ranked as most distressing by participants being forced displacement, bombings, and losing loved ones both through unexpected deaths and forced separations. Participants shared that they felt that the questionnaire seemed to be understanding of their experience. One noted limitation was that common symptoms were amnesia and lack of concentration, but these weren’t addressed in the ITQ questionnaire. Participants also felt some of the questions were irrelevant to their situation and cultural context. It was also noted that completing the questionnaire was unfamiliar and challenging to many refugees – so it may be that the use of such assessments give poor reliability within this cultural context. Furthermore, the trauma of some participants made them hesitant in answering some of the questions, invoking what would appear to be paranoia and hypervigilance. The authors suggest that the use of such questionnaires or assessments may first require a building of rapport and trust with the person administering them. This challenges the Western model of research, in which the researcher is to remain unbiased and emotionally removed from the participants (Jhangiani & Tarry, 2014).

Syrians express trauma and mental illness differently from Western societies. A study on PTSD and CPTSD using the ICD-11 in the US did not include questions or measures on somatic symptoms (Cloitre et al., 2019). The above study on Syrian refugees by Vallieres et al. (2018) similarly did not include somatic symptoms. However, somatic descriptions were commonly found as expressions of mental illness, distress, and trauma in other studies (Barkil-Oteo, 2018; Borho et al., 2021; Hassan et al., 2015). Barkil-Oteo et al. (2018) state that traditional, even culturally adapted, measures were insufficient in capturing the true range of symptoms experienced by refugees, who, in addition to prior trauma exposures, have “both repeated and ongoing traumatic triggers (fear from the past, current uncertainties, new traumas)” (p.9). They noted high prevalence of fainting, dizziness, weakness, and chronic pain in this population which had been ruled out of medical causes. Patients often first presented with such physical complaints before sharing emotional or mental distress. Borho et al. (2021) found a high correlation between somatic complaints and traumatic exposures, stress, and depression and anxiety symptoms in Syrian refugees in Germany. Syrians “do not separate somatic experience and psychological symptoms, because body and soul are interlinked in explanatory models of illness” (Hassan et al., 2015, p. 22).  One explanation for this emphasis on psychical symptoms is that mental illness is not well understood and is highly stigmatized in Syrian culture. Furthermore, the cultural framework within both Islam and Christianity (the primary religions of Syria) is that suffering is a part of being alive and does not need special interventions unless it is severe. However, with the increased normalization of mental health within host countries and among communities of refugees, knowledge and awareness of mental health and PTSD are growing and losing some of their stigma.

Hasan et al. (2015) provide a comprehensive overview of culturally specific idioms of distress for Syrian peoples. For example, saying one is tired or their psyche is tired “refers to a general state of ill being and may stand for a range of emotional symptoms, but also for relationship difficulties” (Hassan et al., 2015, p. 22). Ruminative thoughts are attributed to the influence of the devil, and severe mental and emotional disorders are sometimes considered to be the work of mischievous or evil spirits such as jinn. Symptoms of mental distress, which can also be comorbid with PTSD and CPTSD include such things as anxiety, depression, cognitive difficulties, helplessness, anger or aggression, and extreme stress, are often described in proverbs or metaphors. Western-trained professionals may misconstrue these as psychotic indicators. An example of a somatic description of fear or anxiety is a literal sensation of one’s heart crumbling or falling. An example of a metaphorical description for helplessness is “the eye sees but the hand is short or cannot reach” (Hassan et al., 2015, p. 23).

There is very little research on Syrians’ mental health, including trauma rates and responses, from before the onset of the war in 2011. Therefore, much of the research today comes from Syrian refugees residing outside of Syria. Furthermore, nearly all the research is focused on trauma exposures and PTSD rather than CPTSD. As noted previously, notions of mental illness and trauma are becoming increasingly normalized in this population, so, the conceptualizations and experiences of trauma may also be shifting to align more with those of the host countries’. Collective trauma is extensive in the case of the Syrian war, and the primary coping method of social connection (Hassan et al., 2015) – of extreme importance in collectivistic cultures – is radically disrupted, damaging possible resilience pathways for many Syrians.

References

Al Azmeh, Z., Dillabough, J., Fimyar, O., McLaughlin, C., Abdullateef, S., Aloklah, W. A., … &      Kadan, B. (2021). Cultural trauma and the politics of access to higher education in    Syria. Discourse: Studies in the Cultural Politics of Education, 42(4), 528-543.

Barkil-Oteo, A., Abdallah, W., Mourra, S., & Jefee-Bahloul, H. (2018). Trauma and resiliency: A    tale of a Syrian refugee. American journal of psychiatry, 175(1), 8-12.

Borho, A., Morawa, E., Schmitt, G.M. et al. (2021). Somatic distress among Syrian refugees          with residence permission in Germany: analysis of a cross-sectional register-based study. BMC Public Health 21, 896. https://doi.org/10.1186/s12889-021-10731-x

Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M.     (2019). ICD‐11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress   Disorder in the United States: A population‐based study. Journal of Traumatic Stress,   32(6), 833–842.

Comas-Díaz L, Hall, G. N., & Neville, H. A. (2019). Racial trauma: theory, research, and      healing: introduction to the special issue. The American Psychologist, 74(1), 1–5.

Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective Treatments for PTSD.        Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.).        New York, NY: The Guilford Press. 

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel,          J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel,          P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of      Syrians: A Review for Mental Health and Psychosocial Support staff working with     Syrians Affected by Armed Conflict. Geneva: UNHCR.

Hirschberger, G. (2018). Collective trauma and the social construction of meaning. Frontiers of     Psychology, 9, 1441.

Jhangiani, R. & Tarry, H. (2014). Conducting research in social psychology. Principles of social     psychology – 1st international ed.             https://opentextbc.ca/socialpsychology/chapter/conducting-research-in-social-            psychology/

Matos, L., Costa, P.A., Park, C.L., Indart, M.J., & Leal, I. (2021). ‘The war made me a better   person’: Syrian refugees’ meaning-making – Trajectories in the aftermath of collective        trauma. Int. J. Environ. Res. Public Health, 18. https://doi.org/10.3390/ijerph18168481

Vallières, F., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., … & Hyland, P.       (2018). Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable            within a treatment-seeking sample of Syrian refugees living in Lebanon?. Global Mental       Health, 5. DOI: 10.1111/acps.12973

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming            Experience on Mind, Body, and Society. New York, NY: The Guilford Press.  Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: Putative role   of epigenetic mechanisms. World Psychiatry, 17(3), 243–257