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Papers, Docs, and Essays

Adaptation of Adult Trauma Assessment Instruments for Children & Adolescents

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 psychotraumatology12(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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Papers, Docs, and Essays

Assessment-Based Ethical Referral of Traumatized Individuals to Psychosocial Services

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 bulletin81(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 health7, 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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Humanitarianism Papers, Docs, and Essays

Politicization and the loss of neutrality in humanitarian aid

While neutrality and impartiality are ideals of humanitarian aid work, the reality is that in the modern era, these are increasingly difficult to maintain and uphold.

Jones (1998) discusses the relationship between psychiatrists and psychologists with their clients.  She argues that it is not of benefit to the client to remain truly neutral and detached. She uses examples such as in Nazi Germany, where psychiatrists were able to alter their frame of reference to see themselves as treating the nation, detached from the individual patient.  In this way, therapeutic treatment could condone mass extermination as part of the benefit of treating what was viewed to be the maladies of the national health and identity. She goes on to discuss how the Hippocratic Oath, and statements by the American Medical Association and the American Psychiatric Association declare that a physician or psychiatrist should have a responsibility to protect patients from harm and injustice, and advocate for clients through public action. By necessity, then, they cannot remain unattached or avoid politics. In fact, our worldview, culture, ethical codes, training, diagnosis, and treatment are bound by systems of values, which may have consequences. Bias is inevitable, and while to a degree a treating provider may suspend their own values in relation to a client, it is better to disclose and discuss with them such factors. Additionally, there should be a stronger emphasis on dealing with the cultural systems, community and environmental factors rather than on the “deficiencies” of the individual. She also imports the need of cultural context and understanding in how we diagnose and treat clients. When the larger factors are left out, it is not treating the cause of the problem or illness but rather just symptoms of it. Neutrality is an absence of responsibility, a way for the provider to keep their hands clean and removed from ethical dilemmas.

 In my work as a counselor, I can certainly understand why providers might hesitate to deeply advocate for social change for the benefit of their clients. While I think it is an honorable and critically important endeavor, it requires complex considerations of ethical dilemmas, active work for policy changes, and addressing large systemic cultural systems and values which may seem too large to tackle.  When a provider has a full caseload, this task is nearly impossible to devote the time, energy, and resources towards. With a less than full caseload, a provider may not have the income to sustain such activities on their own free time. This creates another dilemma of another societal problem within itself where the financial pay for counselors (although not so for psychiatrists) is too low to accommodate such efforts on a large scale, and/or the work/life balance is off-kilter within our society, and does not support counselors utilizing part of their time to such activities. Additionally, if one is working for an agency, the agency often frowns upon any political activity or social protests or advocacy work which is not specifically sanctioned and approved for their own benefit, and as such, the counselor could be at risk of termination.

Fiona Terry, in her TED talk (2011) discusses how humanitarian action faces multiple scenarios which present “damned if we do, damned if we don’t” situations. For example, it is not uncommon for humanitarian aid supplies to fall inadvertently into the hands of terrorists. However, the war on terror has made it illegal to support terrorist organizations regardless of intentionality.  This may cause some aid organizations to limit where they deliver aid in fear of retribution for inadvertent support to terrorist groups. There is also a paradox in maintaining neutral, and treating soldiers from any side of a conflict, who then may return to the fight, thus prolonging the conflict. The standard moral stance of humanitarian organizations has been that it is better to treat and give aid, than to not, regardless of the outcome. Neutrality is meant to be a tool to provide aid to those who need it most and not be a moral judgement.  However, many organizations are now focused on providing aid as dictated by their donors, which typically falls within certain parameters and furthers the agendas of Western political goals.

Nascimento (2015) goes deeper into these paradoxes, framing it within the history of humanitarianism which originally intended to hold to the ideals of neutrality and impartiality, but due to increasingly complex geopolitical situations and conflicts, this has shifted into what is termed ‘new humanitarianism.’ On the surface, ‘new humanitarianism’ sounds to be an ultimately better strategy, focusing on “much broader and longer-term objectives, such as development or peace” (Nascimento, 2015, p. 1). However, this is complicated for humanitarian organizations working on the ground as it means an intertwining with politics and militarization. One of these problems arises from the imposition of standards which are deemed culturally “good” by the donors to the organizations and their respective governments. This places cultural and political values onto countries who may not subscribe to such notions, and requires that they make certain changes and subscribe to certain conditions in order to receive humanitarian assistance.  This can be seen as a political maneuver at the hands of the countries backing the aid, and create further animosity or backfire completely, causing the loss of aid to critically vulnerable populations who desperately need it. “New humanitarianism’ also started being questioned and challenged in its assumptions by academics and practitioners due to the fact that decisions that had humanitarian implications were increasingly being taken on the basis of political criteria and interests instead of on the victims’ needs” (Nascimento, 2015, p. 4). This also has implications on the fundamental properties of human rights, and the underlying missions of most humanitarian organizations to address these at the most basic level. Morris (1998) agrees with very similar points in his article.

With complex crises, complex and systemic responses from the international community are required to address multiple socio-political, socio-economic, environmental, and cultural factors which are, in the Western view, contributing to the emergency situation (Nascimento, 2015). However, this requires the use of multiple organizations and groups targeting different aspects of the situation, which often do not align with their goals and priorities, and may not communicate and plan effectively as a broad multi-organizational team. These failings have led to a breakdown of humanitarian aid in multiple countries. Worse than a failed humanitarian intervention, critics have proposed that “these actions emphasized the ineffectiveness and lack of professionalism characteristic of classical humanitarian organizations that fed and perpetuated conflicts and crises through their misuse of aid and poor resource distribution” (Nascimento, 2015, p. 3). There has also been an increase in the use of military deployment to provide aid themselves, or to protect and stabilize conditions for humanitarian workers, or while intervening through military force while humanitarian groups simultaneously provide aid, causing confusion in the local population in seeing humanitarianism and the use of acts of war as part of the same coin. “What has been experienced and promoted by this ‘new humanitarianism’, is essentially a misconception of the need for humanitarian aid by an international system that simultaneously denies its own roles in sustaining or addressing complex emergencies and threatens further the capacity of victims of conflict-related disasters to have access to humanitarian assistance and to the enjoyment of their human rights” (Nascimento, 2015, p. 9). Increased coordination between multiple organizations and actors, the removal of politics from conditions for humanitarian aid, and both short-term immediate assistance for basic needs and also long-term strategies to restore peace which utilize and collaborate with, rather than impose, cultural values of the country in conflict or crises, will be important considerations moving forward to provide much needed humanitarian aid.

References

Jones, L. (1998). The question of political neutrality when doing psychosocial work with survivors of political violence. International Review of Psychiatry, 10(3), 239-247.

Morris, N. (1998). Humanitarian aid and neutrality. Conference on the promotion and protections of human rights in acute crisis. London. Retrieved from https://www1.essex.ac.uk/rightsinacutecrisis/report/morris.htm#4

Nasciemnto, D. (2015). One step forward, two steps back? Humanitarian Challenges and Dilemmas in Crisis Settings. The Journal of Humanitarian Assistance. Retrieved from https://sites.tufts.edu/jha/archives/2126

TEDx Talks [username]. (2011). TEDxRC2 – Fiona Terry – The Paradox of Humanitarian Aid . YouTube. Retrieved from https://www.youtube.com/watch?v=J45cWdDEbm0&noredirect=1