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 .
