Substance abuse is a chronic and relapsing condition. It
is often associated with problems in physical, psychological,
emotional, spiritual, and social functioning (Brown,
1998; Landry, 1994). These problems
are not likely to be the result of one specific cause but rather
the result of an accumulation of factors that clients have faced
in their lives (Luthar and Walsh, 1995).
Risk factors associated with substance abuse disorders include
histories of childhood abuse and neglect (Carlson,
1997). In fact, a recent study found that adults with histories
of child abuse have an increased likelihood of heart disease,
cancer, and chronic lung disease, as well as greater risk for
alcoholism, drug abuse, depression, and attempted suicide (Felitti et al., 1998). These findings emphasize
the importance of comprehensive screening and assessment for
individuals with substance abuse disorders and client access
to adequate health care.
Although childhood abuse and neglect disproportionately affect
adult substance abusers and their families, clients' substance
abuse disorders are not often examined within the context of
past abuse or neglect experiences. The reasons for not considering
or eliciting this kind of historical information vary. Treatment
providers may not have comprehensive screening and assessment
measures available. Often, counselors simply fail to ask, or
the intake organization does not instruct them to ask, about
childhood abuse. Yet in some instances disclosure rates have
risen dramatically when substance abuse treatment clients were
asked directly about their experience of child abuse.
Clients may be unable to address traumatic childhood events
because of memory problems that, in the past, have helped them
cope with the trauma (Brown et al., 1999).
Clients' family members may not be available or appropriate
as family historians, and it is not the counselor's role to independently
investigate family histories. Sometimes the immediacy of other
problems causes assessments of child abuse and neglect to be
delayed. Yet without proper screening and assessment, treatment
providers may wrongly attribute symptoms of childhood trauma-related
disorders to consequences of current substance abuse. Mental
health issues often precede, rather than follow from, substance
dependence. Therefore, comprehensive screening for root causes
of clients' presenting symptoms may greatly increase the effectiveness
of treatment.
Counselors face great challenges when screening for and assessing
childhood abuse or neglect. Few adults are comfortable with
a history of violation and neglect. Many abuse survivors are
ashamed of having been victims of childhood physical, emotional,
or sexual abuse and may feel that the abuse was self-induced.
Screening and assessment, therefore, should be designed to reduce
the threat of humiliation and blame and should be done in a safe,
nonthreatening environment. Although family members can be an
important part of a comprehensive assessment (with the client's
consent), treatment providers should be aware of what impact
their involvement may have on the client's safety (or the safety
of the client's children) and which family members the client
considers nonthreatening.
The following sections illustrate the challenges that treatment
staff should anticipate and prepare for when screening for a
history of childhood abuse or neglect and when assessing its
impact on clients with substance abuse disorders.
When screening for and assessing a history of childhood trauma,
the counselor should ask clients to recall and indirectly reexperience
abuse-related events (Briere, 1997). This
process can trigger defense mechanisms--such as denial, minimization,
repression, amnesia, and dissociation (Bernstein
et al., 1994; Briere, 1992a; Cornell
and Olio, 1991)--that diminish the distress associated with
these events and memories (Fink et al., 1995). These mechanisms may cause a client to withhold or ignore
information that is important for the assessment. Adult survivors
of childhood trauma commonly suppress memories of certain traumatic
events or minimize, either consciously or unconsciously, their
symptoms (Brown et al., 1999; Whitfield,
1997a). Frequently, such defense mechanisms relate to the
shame and stigma of the events. Clients may fear retribution
from perpetrators or family members or loss of contact with people
on whom they are emotionally dependent. Minimizing has often
served to protect family members from having to deal with the
criminal justice system (including the possible arrest of the
perpetrator). Also, clients may fear that treatment staff will
assume that they are abusive to their own children and report
them to the police or child protective services (CPS) agencies.
Still others may have never perceived their experiences as abusive
or harmful but rather as normal and deserved.
Certain sociocultural factors may encourage denial and minimization.
For example, there is a social imperative among males to be
strong and silent and unaffected by abuse. Physical abuse is
difficult to evaluate because most males see their abuse as normal
punishment for their behaviors (Langeland and
Hartgers, 1998). Men may self-report child abuse and neglect
less than women because their occurrence implies weakness and
an inability to protect themselves (Evans and
Sullivan, 1995; Holmes et al., 1997).
Recent studies have concluded that sexual abuse of boys is underreported
and undertreated (Holmes and Slap, 1998).
Issues of confidentiality, mandated reporting, and trust may
influence responses to interviews and questionnaires by making
some clients less inclined to reveal personal histories of abuse
or neglect. Reporting requirements may vary from State to State
(see Chapter 6 for more information on
reporting child abuse and neglect). Maryland law, for example,
requires that treatment providers report incidents of childhood
abuse disclosed by adults in substance abuse treatment programs.
An important limitation of most of the research on childhood
abuse is that it relies on retrospective recall of personal events
that usually are not independently corroborated. This is a standard
problem in many areas of research, but particular concerns have
been raised about the retrospective recall of childhood sexual
abuse. The primary concerns have revolved around the "false
memory syndrome" and child sexual abuse that has been forgotten
and later remembered in the context of counseling (Loftus,
1996). Laboratory research on memory indicates that people
may be led to remember events that did not actually happen to
them (Loftus, 1993). These findings have
raised the concern that suggestible clients may be led by therapists
to believe that they were sexually abused as children when they
were not. Other research indicates, however, that people can
only be led to believe that nontraumatic events happened to them
and that they are much more impervious to suggestions that false
traumatic events occurred (Bowman, 1996).
See Farrants, 1998, for a review of the
research on this subject.
Recently, research has suggested that some individuals may
overreport or misrepresent abuse histories or abuse-related symptomatology,
although this does not normally happen (Briere,
1997). In such cases, the client's conscious or unconscious
should be viewed as having significant pathology that may contaminate
the screening and assessment processes. For example, some clients
may report inaccurate abuse histories or symptoms so that they
may receive treatment rather than be incarcerated, may receive
inpatient instead of outpatient treatment, or may qualify for
disability-related entitlements, such as Supplemental Security
Income (LaCoursiere, 1993). Others may
overreport their history of trauma or current trauma-related
symptoms in an effort, consciously or unconsciously, to deny
or minimize their substance abuse disorder. Although overreporting
is probably a less frequent phenomenon than underreporting, staff
should be aware of the possibility that clients may receive secondary
gains from overreporting symptoms or the severity of past abuse.
Just as many clients with substance abuse disorders tell "war
stories," some, with a great deal of experience in treatment
settings, have become experts at giving psychiatric labels to
all their problems.
Clients will benefit from understanding how severe and chronic
physical, emotional, and sexual abuse in childhood can affect
their memory and emotions long after the abuse has ceased. The
long-term consequences of physical battering, for example, might
include minimal or severe brain damage (from learning disabilities
to mental retardation), aggressive behavior and lack of impulse
control, and physical limitations. Childhood abuse or neglect
also may hinder the development of a mature personality, because
it becomes difficult for the abused person to develop a healthy
sense of self. These effects have the potential to seriously
complicate substance abuse treatment.
New neuroimaging techniques--such as positron emission tomography
(PET) scans or functional magnetic resonance imaging (MRI)--have
revealed that chronic abuse may actually affect pathways in the
brain and alter thinking processes. Some studies show reductions
in the volume of the hippocampus, the seat of long-term memory,
in both combat veterans with PTSD and women with PTSD who experienced
severe sexual abuse during childhood (Bremner
et al., 1995; Gurvitz et al., 1995;
Stein et al., 1997). In another study
(Rauch et al., 1996), individuals reliving
abusive episodes had marked decreases in blood flow to the left
brain--most notably to Broca's area, which governs language capacity--and
increased blood flow to the amygdala and limbic system, believed
to be the site of emotion and long-term memory. These findings
suggest that remembering trauma can produce intense emotional
states while at the same time it inhibits individuals' capacity
to verbalize their experiences (van der Kolk,
1996).
Counselors should be aware that clients may not be able to
verbalize feelings when experiencing intense emotional states.
Behavioral treatments such as exposure and desensitization in
a safe therapeutic environment should help clients progressively
manage these states without losing the ability to communicate.
In this way, clients will be able to verbalize feelings instead
of experiencing upsetting symptoms in response to traumatic triggers.
Many researchers and counselors now believe that dissociation
is a common and readily available defense against childhood trauma,
since children dissociate more easily than adults (Turkus,
1998). To defend against abuse, the child psychologically
flees (dissociates) from full awareness. Under severe trauma,
especially if inflicted at a young age, parts of the self may
split off, in some cases creating a compartmentalized way of
experiencing the world, with strong or painful emotions and memories
shut off from consciousness. These emotions may surface as intense
fear or anger when the client is under stress or is in situations
that trigger memories of the abuse. In extreme cases, parts
of the self may assume separate identities.
Dissociation serves many purposes. It provides a way out
of an intolerable situation, it numbs pain, and it can erect
barriers (i.e., amnesia) to keep traumatic events and memories
out of awareness. The child may begin by using the dissociative
mechanism spontaneously and sporadically (Courtois,
1988). With repeated victimization, it may become a chronic
defensive pattern that persists into adulthood, resulting in
a dissociative disorder. Arising as a survival mechanism to
protect the child, over time dissociation changes into a pattern
of behavior that interferes with the individual's daily functioning
and ability to interact with others. Sometimes these dissociative
periods can last hours and require emergency psychiatric treatment.
The counselor may see symptoms of dissociation but be unaware
of the cause. For example, the client may "space out" when talking
to the counselor, appearing disoriented or forgetful in order
to avoid an intimate (and seemingly threatening) situation.
The client may be temporarily unresponsive to conversation or
questions, although he may reengage if the counselor persists
in seeking his attention (Briere, 1989).
These periods of disengagement usually last only a few seconds
or minutes. However, they may cause the client to miss important
insights or opportunities for self-examination.
The client may also report or exhibit intense moods that are
out of proportion to the present situation. Rage, terror, overwhelming
sadness, or self-destructive impulses may take hold of the client
as a result of what may appear to be minor issues, and the client
may seem unable to respond to the counselor's attempts to reason
with the client.
Because there can be many causes of such extreme emotional
reactions, it is important to isolate the symptoms of dependency
or withdrawal from those caused by trauma resulting from childhood
abuse.
Dissociative symptoms can mimic the effects of drugs or of
withdrawal from drugs, making it difficult to determine the type
of problem being presented. In victims of trauma, substance
abuse itself can be seen as a method of dissociating for those
who cannot do it successfully through other means. For this
reason, it is common for survivors of child abuse to self-medicate
with substances, thus beginning a process that often leads to
substance abuse and dependence.
Any counselor or treatment provider who might be screening
for and assessing histories of child abuse or neglect must receive
specific training in these issues. The screening process and
followup sessions will invariably involve listening to traumatic
stories. Not all treatment providers will be comfortable hearing
about their clients' experiences of abuse. Some may experience
vicarious trauma or feel overwhelmed by these painful personal
accounts. This may be especially true among counselors whose
own traumatic childhood experiences were not addressed therapeutically.
The counselor's biases from these experiences, regardless of
their similarity to a client's, could have a harmful impact.
If counselors experience intense discomfort and anxiety when
conducting screenings and assessments, the Consensus Panel recommends
that they receive guidance and support from a clinical supervisor
and consider whether they could benefit from therapeutic assistance
to explore the reasons for their discomfort. (For a more detailed
discussion on counselor issues, see Chapter
4.)
Prior training on handling abuse issues can help counselors
"screen" themselves to recognize if they are unprepared to work
with clients who have experienced childhood abuse or neglect.
It is better to find out ahead of time than for the counselor
to risk damaging the therapeutic process by having to confront
personal issues in the middle of it--possibly even ending the
session prematurely, leaving the client confused, feeling abandoned,
or wondering "What's wrong with me?" Many counselors avoid issues
of childhood abuse simply from lack of experience. They need
assurance that the proverbial can of worms that has been opened
can be closed in a reasonable length of time. Proper training
can help counselors better deal with trauma and with secondary
PTSD, sometimes known as "compassion fatigue."
Because adults who were abused or neglected during childhood
can experience significant trauma-related consequences that require
clinical intervention, the Consensus Panel suggests using child
abuse and neglect screening (1) to identify individuals who exhibit
certain signs and symptoms associated with child abuse and neglect
(such as PTSD, major depression, or mood disorders) and (2) to
identify who may benefit from a comprehensive clinical assessment.
Consequently, treatment staff should
Learn and understand ways in which childhood
abuse and neglect can affect adult feelings and behaviors
Identify those individuals who appear to exhibit these symptoms
Identify the trauma-related treatment needs of these clients
Provide or coordinate appropriate treatment services that
will help to meet clients' treatment needs
The consequences of childhood abuse and neglect can dramatically
affect a client's treatment needs. For instance, as noted in
Chapter 1, a history of childhood trauma
can increase the number and intensity of treatment services required,
lengthen the time needed for treatment, and increase the number
of sessions, particularly for male clients (Downs
and Miller, 1996; Felitti, 1991; Felitti et al., 1998; Steinglass,
1987; Young, 1995). The consequences
of childhood abuse and neglect can also affect the psychosocial
supports that such clients may need following treatment (Steinglass,
1987). Screening for childhood abuse or neglect can set
in motion a proactive plan with the following benefits:
Stopping the cycle. Although not
all adults who were abused or neglected during childhood abuse
their own children, they are at greater risk of doing so (Kaufman and Zigler, 1987). Thus, screening
for abuse and neglect can be an important step in stopping the
cycle of abuse in many families.
Decreasing the probability of relapse. Many substance
abusers use alcohol and illicit drugs to self-medicate posttraumatic
stress symptoms related to past physical or sexual abuse or trauma
(Price et al., 1998); clients may abuse
substances to deal with hyperarousal or stress (Clark
et al., 1997; De Bellis, 1997). Since
these are important causes of continued substance-abusing behavior,
addressing them may facilitate treatment and reduce relapse.
Improving a client's overall psychological and interpersonal
functioning. Childhood sexual abuse and neglect may affect
the individual's self-concept, sense of self-esteem, and ability
to self-actualize. They also affect a person's ability to trust,
be intimate, and set limits with others. Identifying a history
of abuse or neglect enables the client to address these issues
as they relate to overall functioning as well as to recovery.
The ability to trust is especially important; difficulties with
trust can impede the client's ability to utilize treatment to
its fullest.
Improving program outcome. Screening for a history
of child abuse or neglect helps to determine the percentage of
abused and neglected individuals who are in a substance abuse
treatment program. Furthermore, screening, combined with assessment,
helps to determine the trauma-related treatment needs of clients.
With this information, programs can make informed decisions
about providing the treatment services that can best meet their
clients' needs.
Clients' treatment needs change over time. For this reason,
counselors must conduct ongoing assessments of their clients'
problems, including substance abuse, health concerns, psychological
problems, family-related stressors, parenting stressors, interpersonal
stressors, social support, and vocational problems. Having up-to-date
information allows counselors to deliver individualized treatment
to each client that meets specific needs and is of the appropriate
length and intensity.
As with psychosocial evaluations, screenings for child abuse
and neglect should be conducted early in a comprehensive assessment
process. However, because denial and minimization are prominent
defense mechanisms associated with childhood trauma and trauma
survivors may feel shame and discomfort answering abuse-related
questions, screenings should also be conducted at different times
throughout the treatment process. Repeated screenings help elicit
information about these traumatic experiences--especially after
trust has been established in the therapeutic relationship.
Treatment providers should be aware, however, that repeated screenings
may give the impression that the therapist does not believe the
client. For clients who typically were disbelieved as children,
this can be an important therapeutic issue. Furthermore, cognitive
and memory impairment caused by substance abuse decreases with
length of sobriety; that is, over time, a client may physiologically be more capable of recalling past experiences if she maintains
sobriety (Leber et al., 1981; Reed
et al., 1992).
The Consensus Panel believes that treatment decisions and
activities are best conducted within the context of a multidisciplinary
treatment team, with members having special knowledge in such
areas as mental health, child abuse and neglect, and family counseling.
Team members should possess varied levels of training and experience.
At the same time, there are different types of treatment settings,
including drop-in centers, residential treatment programs, and
intensive and less intensive outpatient and hospital-based programs.
These varied treatment settings and the composition of the treatment
team will affect screening decisions, including who is available
to conduct them.
Although there are no rigid rules regarding who should conduct
screenings, having certain skills will increase the likelihood
that the screening process is conducted appropriately.
Irrespective of the level of academic credentials, training,
supervision, or specific role within the treatment team, treatment
staff members should all have an understanding of the types of
psychiatric disorders and symptoms that are commonly associated
with a history of childhood abuse and neglect (see Figure
2-1).
They should understand the role of screening and assessment for
a history of trauma, and they should know the types of questions
that constitute a screening for child abuse and neglect.
Moreover, they should have developed a sensitivity to the issues
of child abuse and neglect.
No one should screen for childhood trauma without specific
training and supervision. The Consensus Panel strongly recommends
that counselors administering the screening understand the reasons
for conducting the screening, be knowledgeable about the best
practices for screening, and receive training in conducting the
screening in an empathic manner. They also should understand
the assessment and treatment processes that may follow a positive
screening and be able to explain these processes to the client.
Counselors who conduct screenings will be prompting clients
to recall painful and traumatic events. The reemergence of painful
memories may prompt intense reactions from clients. Clients
may feel drained or distraught afterwards. Treatment staff should
be sensitive to this and prepare for the interview in the following
ways:
Clients should be informed that talking
about such issues may create discomfort and that repressed memories
may emerge unexpectedly following the interview. Clients should
be given a choice to disclose such information, being aware of
the possible aftermath.
Counselors should have proper supervision and support mechanisms
in place for clients in case a crisis occurs following disclosure.
As well as clinical support, this includes having appropriate
mental health practitioners available in case further intervention
is necessary.
Counselors should assess the social and emotional support
available to clients when they return home. If necessary, the
staff can help the client find transportation home after the
screening and then follow up with a telephone call to offer support
or help if needed.
When screening for histories of child abuse or neglect, counselors
ask clients a series of questions designed to elicit information
about childhood trauma. Screenings can be informally divided
into two types: direct questions and standardized screenings.
Direct questions are asked to obtain confirmation of a history
of child abuse and neglect. Standardized screenings are structured
sets of questions that are designed to determine the possible
presence of past child abuse.
Both direct trauma questions and standardized screenings can
be embedded within larger psychosocial assessments. Indeed,
all clients receiving screenings for childhood abuse and neglect
should be evaluated for symptoms of other mental health problems.
When a client denies having a history of child abuse or neglect
but presents symptoms commonly associated with childhood trauma,
treatment staff may need to expand their assessment process to
include a more thorough evaluation of the client's childhood
experiences and behavioral responses to traumatic events. This
information may be useful in understanding the origins of some
of the client's current mental health problems.
Some trauma questions inquire directly about childhood abuse
and neglect experiences.
Depending on the setting (e.g., inpatient, residential, long-term
therapy), expertise of the staff, and other factors, this approach
has been used successfully in eliciting the information being
sought.
Other questions, however, will be about circumstances and experiences
that are often associated with and suggest a history of childhood
abuse or neglect; for example, "Did you ever live away from your
parents?" and, "Were you ever in foster care?" Figure
2-2 lists questions that can be used to conduct a screening
for a history of childhood abuse or neglect.
Several instruments can be used to elicit a history of child
abuse or neglect; five are reviewed below. Some are specifically
designed to collect information about interpersonal traumatic
experiences in childhood. Others are designed to collect information
on a broader topic, such as general mental health or substance
abuse but include a subsection on childhood trauma. These tools
differ widely with regard to primary purpose and level of detail
elicited.
The Consensus Panel has included the following tools for practitioners'
review and possible use. Treatment staff should note that the
Childhood Trauma Questionnaire and the Trauma Symptom Checklist-40
are new, are not well validated, and are used primarily as research
tools. Information about obtaining the instruments listed below
is provided in Appendix D. See also
the Childhood Maltreatment Interview Schedule (CMIS) and other
trauma-oriented tools described later in this chapter. If these
measures are used with non-English-speaking clients, the translations
must be appropriate and carefully applied (e.g., sensitive to
the differences between Spanish used by Puerto Ricans, Mexicans,
and other Latinos).
The fifth edition of ASI is a 161-item multidimensional structured
clinical interview designed to collect information about substance
abuse and client functioning in various life areas for adults
seeking treatment for substance abuse (Fureman
et al., 1990; McLellan et al., 1990).
The ASI is frequently used during intake in treatment programs.
It includes three questions that are used to elicit information
about a history of childhood abuse. It inquires about episodes
of emotional, physical, or sexual abuse in relation to several
people (e.g., mother, father, brother/sister, sexual partner/spouse,
children). The questions are not childhood-specific, and preliminary
research suggests that the ASI trauma questions show stronger
utility as a screen for PTSD than for childhood trauma (Najavits
et al., 1998). The female version of ASI has an additional
question about sexual harassment (CSAT, 1997c). The National Institute on Drug Abuse (NIDA) has developed
an ASI package that includes an introductory brochure, handbook
for program administrators, resource manual, two videotapes,
and training manual (NIDA, 1993).
CTQ is a 10- to 15-minute questionnaire that provides a brief
and relatively noninvasive screening of childhood traumatic experiences
(Bernstein et al., 1994). The 28-item
retrospective self-report evaluates physical, sexual, and emotional
abuse; physical and emotional neglect; and related areas of family
dysfunction, including substance abuse. It includes a minimization/denial
scale for detecting individuals who may be underreporting traumatic
events. This screening tool is notable for the brevity of administration,
range of coverage, and availability of psychometric data (Briere, 1997). Limitations include the absence
of specific items regarding characteristics of the maltreatment
and lack of information regarding age range for traumatic events
(Bernstein et al., 1994; Briere,
1997).
PCRI is a 78-item self-report questionnaire designed for clinical
use. PCRI assesses six areas of parenting, including parental
satisfaction, support, involvement, communication, limit setting,
and autonomy. The measure also includes a validity scale that
will indicate if the client is responding defensively or randomly.
The PCRI handbook provides clear guidelines for interpreting
scores on each scale and identifying areas of risk (Gerard,
1994).
PARQ is a brief self-report questionnaire designed to assess
individuals' perceptions of their childhood experiences of love
and love withdrawal in relation to their mothers and fathers.
PARQ elicits information concerning affection, hostility, neglect,
and undifferentiated rejection. It has been used and evaluated
with many ethnic and cultural groups in the United States and
in numerous countries on several continents. Different versions
of PARQ are included in the Handbook for the Study of Parental
Acceptance and Rejection (Rohner, 1990). The handbook, which summarizes parental acceptance and
rejection theory and evidence, provides information about PARQ
and about using, scoring, and interpreting this self-report.
This measure, however, has no validity scale.
Screen for Posttraumatic Stress
Symptoms (SPTSS)
SPTSS is a brief, 17-item self-report tool used to screen
for PTSD symptoms; it is especially useful for clients with histories
of multiple traumatic events or whose trauma history is unknown
(Carlson, 1997). SPTSS yields a total
score that is the average of the individual item scores. The
item scores can be used to make a provisional assessment regarding
whether clients' symptoms meet DSM-IV criteria for PTSD. It
takes approximately 5 minutes to complete.
TSC-40 is a 40-item self-report tool that evaluates symptomatology
in adults resulting from childhood or adult traumatic experiences
(Elliott and Briere, 1992). TSC-40 (an
expanded version of the Trauma Symptom Checklist-33) consists
of six subscales, which evaluate such things as anxiety, dissociation,
and sexual concerns (Briere and Runtz, 1989). Both TSC-40 and TSC-33 have moderate predictive validity
regarding a wide variety of traumatic experiences (Briere
and Elliott, 1993).
Whether identified during intake or in the context of a subsequent
psychosocial assessment, a positive screening for childhood abuse
or neglect alerts the treatment provider that more information
about the trauma is needed and that a thorough and comprehensive
childhood abuse and neglect assessment is warranted. Thus, the
primary purpose of an assessment is to confirm or discount a
positive screening for childhood abuse or neglect. At the same
time, it is an opportunity to evaluate clients' trauma-related
treatment needs. In general, the more clinical information that
a program has about clients' particular treatment needs, the
better the program can meet them. Under optimal circumstances,
all clients who screen positive for a history of childhood abuse
or neglect should be offered a comprehensive mental health assessment.
CPS case managers and court and law enforcement personnel
may already be conducting their own screenings and assessments.
Some systems (such as in Massachusetts) provide multidisciplinary
assessments of client families to avoid duplication and to provide
a more comprehensive service-planning product.
When deciding whether to conduct assessments for a history
of child abuse or neglect, thoughtful consideration should be
given to the following issues: substance abuse, client readiness,
input from all team members, and family involvement.
The treatment team should evaluate (1) clients' current substance
abuse, (2) clients' commitment to the treatment and recovery
process, (3) the quality and length of abstinence, and (4) clients'
risk of relapse. Treatment staff should make these evaluations
on an individual basis and not translate them into a rigid protocol.
For example, a client in the early phases of treatment who is
struggling to make a commitment to abstinence but who has not
yet developed significant psychosocial supports for abstinence
may be at risk for relapse if he attempts to address childhood
abuse issues. (Even so, in some cases the client may be at higher
risk if he does not address these issues.) On the other hand,
a client who has achieved a few years of abstinence and has a
strong commitment to abstinence, but who recently relapsed when
her father made threatening phone calls to her, may be psychologically
prepared to explore her childhood abuse issues while simultaneously
strengthening her recovery program.
Throughout substance abuse treatment and through the multiple
psychosocial assessments and screenings for childhood abuse and
neglect, the treatment team can gain valuable information about
clients' childhoods. Indeed, treatment staff may have enough
information to confirm clients' histories of childhood abuse
and neglect. Staff may have also observed behavioral, emotional,
and psychiatric manifestations of the childhood trauma. However,
unless a formal assessment has been conducted, the staff probably
will not have a thorough understanding of the details, context,
and severity of these traumatic events, or the childhood responses
to them. Similarly, unless they inquire, staff will not know
whether clients (1) recognize themselves as having experienced
abuse or as being affected by such abuse, (2) believe that they
are ready to confront these issues and are willing to do so,
and (3) believe they can handle the consequences without jeopardizing
treatment. Thus, staff members should ask clients to evaluate
their own readiness for confronting child abuse or neglect issues.
At this point, staff should also know something about clients'
current family situations and can work with them to identify
who is safe to involve or to provide support. Some adults in
treatment regress to a state of dependence on their parents--parents
are caring for grandkids, parents are paying for treatment, parents
are the only housing resource after institutional treatment or
incarceration. Abuse is a family issue; its disclosure and the
client's treatment may well disrupt family dynamics and trigger
denial--consequences of particular concern to a dependent adult
client.
Input from all team members
Each member of the treatment team should have a voice in deciding
if and when to conduct assessments for childhood trauma. Each
member will bring a different but valuable perspective about
a client's progress in treatment, risk of relapse, and readiness
to address childhood trauma. Individual team members can also
contribute to discussions about the client's commitment to treatment
and recovery, her psychosocial supports, her current family situation,
and any significant issues that may need to be resolved quickly.
Involving the family
Counselors hold different opinions on when and how much to
involve the family in a client's treatment, but all agree there
are many risks involved that must be carefully weighed against
the potential benefits. This is especially true at the assessment
stage, which usually occurs early in the treatment process when
it is critical to get accurate information and to establish a
relationship of trust with the client. Of foremost importance
must be the client's opinion about whether to involve family
members, and which ones. It is a good idea to obtain the client's
written permission before contacting family; some counselors
will only call a family member with the client present. (Although
the client's current or "chosen" family is likely to be more
supportive and should be encouraged to be involved, these persons
may have less direct knowledge of the client's history of childhood
abuse or neglect.)
Most abuse occurs within the family. For this reason, complicated
dynamics of denial, complicity, guilt, and fear of retribution
may still be in place long after the client and his siblings
have become adults. Grandparents, too, may be ashamed that they
did not or could not protect the victim--or may themselves have
been perpetrators. Family members may resent the client for
opening up old wounds, exposing a family secret, or forcing them
to confront a situation they may have tried to pretend did not
happen. It is important to protect the client from the possibility
of revictimization (Hansen and Harway, 1993).
Family members can sometimes be valuable participants in the
assessment process; however, counselors must maintain client
rights of confidentiality. (For more information on confidentiality,
see Appendix B.) Spouses and significant
others can be sources of information, especially about the current
situation. Grandparents can shed light on intergenerational
patterns of family trauma and violence. Siblings can often provide
useful information about the family, such as intrafamilial violence
during the client's childhood. Because of differences in personality,
age, and development, siblings will often have different perspectives
and even disagree about traumatic events that occurred during
childhood. Also, the family environment and dynamics may have
been different for different siblings. For a more detailed discussion
about involving families, see the "Involvement of the Family
in Treatment" section of Chapter 3.
A multidisciplinary team should conduct a full assessment,
although many assessment tools require professional training
to conduct and interpret--the type of training specifically provided
to clinically licensed psychologists, psychiatrists, and psychiatric
social workers. (Many assessments also can be conducted by marriage
and family therapists and licensed professional counselors.)
A full assessment involves confirming diagnoses, which should
be done only by mental health professionals. Similarly, assessing
histories of childhood trauma can provoke or exacerbate a psychological
or psychiatric emergency, which must be addressed; a psychologist,
clinical social worker, or psychiatric nurse can handle most
situations. If clients have active and severe symptoms of depression,
suicidality, severe anxiety, or other psychiatric crises, and
issues of medication or hospitalization arise, clients should
be evaluated immediately by a psychiatrist.
For these reasons, the Consensus Panel recommends that the
treatment team include a licensed mental health professional
for more formal assessments that may be required. This individual
should have training in childhood trauma, the effects of childhood
trauma on adults, and the different tools that can be used to
assess trauma, as well as having the clinical and licensing requirements
for making diagnoses. The licensed mental health professional
can also provide guidance, training, supervision, and crisis
intervention throughout the assessment process.
Some funding and administrative agencies (e.g., third-party
payors) require that a physician certified by the American Society
of Addiction Medicine (ASAM) make diagnoses. State laws vary
regarding the licensing and training of mental health professionals
and who can conduct assessments and make diagnoses. All team
members should have a good understanding of the relevant regulations
and requirements.
To identify clients' trauma-related treatment needs, the treatment
team should gather information about the traumatic events and
how clients responded to them. These two areas of interest correspond
to the two primary domains of assessment inquiry: (1) assessment
of childhood traumatic events and experiences and (2) assessment
of current mental health, especially symptoms and syndromes that
may relate to childhood trauma. To increase the usefulness of
this information, the evaluation should incorporate a developmental
perspective--that is, perception of the trauma at different ages
(Gussman et al., 1996). Not all clients
with a history of child abuse or neglect will see it as a problem
or view themselves as victims or as "damaged" by the experience.
Treatment providers should be careful not to use labels that
some clients may resist or be uncomfortable with.
The goal of the assessment process is to identify clients'
needs so that treatment can be provided to meet them. To treat
the aftermath of childhood trauma, the treatment team should
identify, in as much detail as possible, the traumatic events
that occurred. The trauma-related assessment is an opportunity
to systematically assess the details and context of the victimization
experience. Examples of event-specific information that are
gathered include
Type of abuse
Physical abuse
Sexual abuse
Psychological abuse
Exploitation
Exposure to domestic violence
Neglect
Evidence of multiple types of abuse (concurrent or serial)
Relationship to the perpetrator (who may be a relative, stranger,
teacher, or caregiver)
Frequency of abusive events
Duration of the abuse
The victim's age at onset and cessation of the abuse
Context of the trauma, including presence of force or fear
Whether the family knew about the abuse
Response of the family to the abuse
Response of the social system, including CPS agencies, foster
care, or placement with relatives
Past mental health counseling or other treatment as a child
In addition to gathering event-specific details, assessing
childhood trauma also involves eliciting information over time
about the subjective experience of these events. How clients
remember a traumatic event can shape the psychological response
more than the actual circumstances. For this reason, childhood trauma assessments
in clinical (as opposed to forensic or research) settings focus
on obtaining qualitative information about traumatic experiences
and responses. Subjective and qualitative details about traumatic
events--such as recollections and perceptions--are needed to
plan and provide appropriate treatment for a client (Carlson,
1997). However, some clients may strongly resist these questions;
others may become very upset and need immediate support from
a mental health professional.
Useful subjective information can include the following:
What was the client thinking about during
the abuse?
What was the client feeling during the abuse?
As a child, how did the client understand what happened to
her and what does she think about it now?
How does the client think and feel about how the abuse affected
her adulthood and substance abuse; how does the client deal with
the aftereffects of the abuse now?
What feelings are most associated with the abuse experience?
What are the client's memories about the abuse?
What are the client's unique perceptions about the abuse?
What coping strategies does the client use? How effective
are these?
Because the primary purpose of the trauma assessment is to
validate or discount a positive screening for childhood trauma,
the assessment should inquire about childhood symptoms and family
characteristics that are consistent with and suggest a history
of childhood abuse or neglect. Childhood symptoms and behaviors
to consider include
Depression (including thoughts of death,
passive suicidal ideation, and feelings of hopelessness)
Dissociative responses during childhood
Aggressive behavior or other "acting out," including
Early sexual activity or sexualized behavior
Physically abusing or harming pets or other animals
Other destructive behaviors
Poor relationships with one or both parents
Attachment disorder, difficulty trusting others
Excessive passivity
Passive/aggressive behavior, including
Failing school grades
Poor sibling relationships
Obesity or anorexia
Inappropriate age/sexuality formation
Blacked-out timeframes in childhood
Excessive nightmares, extreme fear of darkness, or request
for locks on doors
Family-of-origin characteristics to consider include
The second area that can be evaluated through trauma-related
assessments is the current general mental health of clients,
paying special attention to symptoms that may be related to child
abuse and neglect. These evaluations focus on the cardinal responses
to trauma.
After a highly distressing or traumatic event, individuals
may exhibit posttraumatic stress symptoms. These symptoms include
persistent reexperiencing of the traumatic event through intrusive
thoughts or nightmares, a numbing of responsiveness to or avoidance
of current events, and hyperarousal, such as difficulty sleeping,
poor concentration, irritable outbursts, jumpiness, or hypervigilance.
Clients with PTSD are frequently so preoccupied with their traumatic
experiences that they have trouble focusing on substance abuse
problems. They may also have severe difficulties in social,
economic, vocational, and marital adjustment (Daley
et al., 1993) that are not directly related to their substance
abuse.
Children and adults who have been traumatized may experience
symptoms of dissociation. Dissociation can be defined as the
disruption of the usually integrated functions of consciousness,
memory, identity, and perception (Putnam, 1997). As described above, dissociation is the disconnection
from a full awareness of self or external circumstances. Symptoms
of dissociation include excessive daydreaming, a severe numbing
of emotions, out-of-body experiences, and amnesia of painful
abuse-related memories (Brown et al., 1999; Briere, 1992a, 1995). Individuals may also exhibit severe behavioral regressions,
such as curling up into the fetal position, or exhibit different
intense mood states, such as anger or fear, when discussing their
childhood abuse. These periods of disengagement usually last
only a few seconds or minutes, but they can last for hours (
Whitfield, 1997b). As noted earlier,
for some clients substance abuse may serve the same function
as dissociation (i.e., self-medication to escape the effects
of childhood trauma). It is not clear whether dissociative symptoms
increase for these clients once sobriety is achieved. Counselors
are advised to monitor any such increases in these symptoms.
Most common responses to trauma involve the reexperience or
avoidance of trauma-related experiences (Horowitz,
1976; van der Kolk, 1987).
Reexperience-related symptoms include intrusive thoughts, anxious
and angry feelings, physiological arousal and reactivity to trauma
triggers, and hypervigilance (Carlson, 1997).
Avoidance-related symptoms include the avoidance of thoughts,
feelings, conversations, activities, places, people, or memories
associated with the trauma (American Psychiatric
Association [APA], 1994).
Figure 2-3 illustrates the common
responses to trauma organized by biopsychological domains and
divided into symptoms that represent either reexperiencing or
avoidance.
Adult clients with a history of childhood abuse and neglect
may have a loss of previously sustained beliefs, may feel permanently
damaged and hopeless, and may experience shame. They may have
personality and relational disturbances and may be hostile, self-destructive,
and impulsive. They also can have somatic symptoms, such as
headaches, stomach pain, asthma, and chronic pelvic pain (Felitti, 1991; Herman, 1993). Clients with histories of childhood trauma will often
have multiple symptoms, which can be acute, recurring, and chronic.
The multitude of problems will make diagnosis difficult. The
assessor may interpret the manifestations as PTSD or a personality
disorder.
Irrespective of theoretical orientation, assessors will find
it helpful to look at their clients' symptoms through a developmental
perspective. This approach involves a careful review of the
client's history, beginning with the client's description of
her family and early childhood. The assessor can probe for information
about abusive or neglectful episodes during the client's childhood,
adolescence, and adulthood. From this history, a picture will
emerge of the client's evolving feelings and behaviors. This
will help to clarify how some of the client's present behaviors
and problems have developed over time. Even though the counselor
cannot undo the historical facts, this knowledge about the client's
past will help explain some of the reasons for her current difficulties.
As mentioned earlier, trauma-related assessments involve evaluating
childhood traumatic events and gauging the individual's responses
to these events. In the treatment setting, the two primary groups
of assessment tools are general mental health assessment tools
and trauma-oriented tools. Given the tendency of some victims
of child abuse to become abusers themselves, treatment providers
should also consider using some domestic violence screening tools
as well. (See TIP 25, Substance Abuse Treatment and Domestic
Violence [CSAT, 1997b], especially
pp. 115-126.) The section "Special Considerations and Recommendations"
at the end of this chapter provides some guidelines for policy
and selection concerning the instruments discussed below.
Both groups of tools include self-reports and structured interviews.
Self-reports are typically pen-and-paper questionnaires that
clients fill out. They are often free or inexpensive and take
only a short time to complete. They also may elicit greater
levels of disclosure than clinician-led interviews since clients
may be less inhibited in written self-reports (Newman
et al., 1996). Such qualities make self-reports a good choice
for a first step in the assessment of traumatic experiences and
responses (Carlson, 1997).
Structured interviews consist of an organized and preestablished
set of questions the assessor poses to clients in a face-to-face
interview. As a result, structured interviews allow assessors
to observe clients' affective responses to questions and their
method of interpersonal interaction. Structured interviews are
especially useful in eliciting detailed information, both qualitative
and quantitative, about the clients' experiences and symptoms.
Because they involve a set of predetermined questions and preestablished
areas of inquiry, structured interviews can eliminate some clinician
biases, such as a clinician's desire to avoid areas of discomfort.
Although there is substantial variation among structured interviews,
they are typically time limited, efficient, and comprehensive.
Furthermore, interviews reach those clients who are marginally
literate. This condition may not be obvious to the counselor
at the assessment stage. Information on where to obtain most
of the tools discussed below is provided in Appendix
D.
An important task of trauma-related assessments is to help
the treatment team gain an understanding of clients' general
mental health and to determine whether clients have psychiatric
symptoms or syndromes commonly associated with childhood abuse
or neglect, especially posttraumatic stress symptoms and dissociative
symptoms. In addition to the structured interview and self-report
formats, general mental health assessment tools can be more traditional
psychological tests and inventories.
The purpose of self-reports for general mental health evaluation
is to elicit from clients their own understanding of their mental
health symptoms. These self-reports are inexpensive and efficient.
They can be rapidly completed in a clinical setting, and they
can be used to complement clinical assessments, including interview-based
assessments.
Some mental health self-reports are global and evaluate the
general mental health of clients. For example, the Symptom Checklist-90-Revised
(SCL-90-R) and the shorter version called the Brief Symptom Inventory
address nine symptom dimensions of mental health. In contrast,
some mental health self-reports evaluate specific areas of mental
health. For example, the Profile of Mood States focuses on affective
and emotional functioning, and the Beck Depression Inventory
focuses on depression.
BDI is a 21-item scale designed to measure the severity of
depression by assessing the presence and severity of affective,
cognitive, motivational, vegetative, and psychomotor components
of depression (Beck, 1967). BDI is one
of the most widely used measures of depression in clinical practice.
Substantial research has been conducted to evaluate BDI's reliability,
validity, and utility. A short, 13-item version of the BDI is
also available and has good concurrent validity with the long
form (Beck and Beck, 1972; Gould,
1982).
BSI is a short form of SCL-90-R and is designed to reflect
the psychological symptom patterns of psychiatric and medical
clients (Derogatis, 1992; Derogatis
and Spencer, 1982; Derogatis et al., 1973). BSI takes approximately 10 minutes to administer and
has 53 items. It evaluates the same nine symptom dimensions
as SCL-90-R and includes measurements of the severity of the
disorder, the intensity of symptoms, and the number of client-reported
symptoms. Because of its brevity, it can be used in initial
assessments, as part of a test battery, and for monitoring client
progress. More than 300 studies have evaluated the reliability,
validity, and utility of BSI.
POMS is a 65-point objective rating scale designed to measure
six identifiable mood states (McNair et al.,
1992). POMS measures tension/anxiety, depression/dejection,
anger/hostility, vigor/activity, fatigue/inertia, and confusion/bewilderment.
It is primarily used as a measure of mood states in psychiatric
outpatients and as a measure for assessing changes in those clients.
POMS elicits information regarding mood states in the week prior
to administration of the assessment.
This is a brief, multidimensional inventory designed to screen
for a broad range of psychological problems and symptoms of psychopathology
(Derogatis, 1994; Derogatis
and Spencer, 1982). SCL-90-R takes approximately 15 minutes
to administer and contains 90 items. It measures nine primary
dimensions of mental health: somatization, obsession-compulsion,
interpersonal sensitivity, depression, anxiety, hostility, phobic
anxiety, paranoid ideation, and psychoticism. It includes measurements
of the severity of the disorder, the intensity of symptoms, and
the number of client-reported symptoms. It is a useful tool
to measure treatment progress. Extensive research has been conducted
to evaluate the tool's reliability, validity, and utility.
There are several structured interviews that elicit general
mental health information. They are used as the framework for
a systematic review of the client's mental health, in particular
to explore whether clients have psychiatric symptoms or syndromes
associated with childhood abuse or neglect. Thus, while structured
mental health interviews may be comprehensive and explore multiple
domains of mental health, when used in the context of evaluating
a history of childhood trauma these tools are especially valuable
for systematically reviewing whether there are symptoms of posttraumatic
stress or dissociation. Typically, structured mental health
interviews are grounded in the system laid out in the Diagnostic
and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)
(APA, 1994).
The most recent version of DIS, version 4, is designed to
elicit data relating to most DSM-IV adult diagnoses on both a
lifetime and current basis. Current disorder is defined for
four time periods: the last 2 weeks, the last month, the last
6 months, and the last year. Each diagnosis is based on clients'
meeting a minimum number of criteria. Since clients need not
meet all criteria, individuals may be assessed for the severity
of each diagnosis by counting how many of the criteria they meet.
Across diagnoses, severity may be determined by the number of
different diagnoses present, the total number of symptoms, how
many years they have had the symptoms, and the degree of functional
impairment. DIS also asks for the age at time of the last symptom,
the age at which the first symptom appeared, and whether medical
care was ever sought for the symptoms. Virtually all response
categories are close-ended and precoded, with explicit instructions.
After the interviewer follows these instructions, a computer
makes the actual diagnosis. The computer also provides information
such as the age of onset and termination of syndromes, the total
number of symptoms ever manifested, diagnosis with earliest onset,
total number of lifetime diagnoses, and the number of types of
current diagnoses (Robins et al., 1981).
MINI was designed as a brief structured interview to screen
for the major psychiatric disorders in DSM-IV (Sheehan
et al., 1994). It contains 120 questions covering 17 Axis
I disorders from DSM-IV. Unlike longer interviews, MINI focuses
on a core set of diagnostic questions for each disorder and considers
only those timeframes that are useful in making decisions in
clinical settings. MINI has two to four screening questions
per disorder with followup questions for positively endorsed
screening questions. MINI assesses information regarding major
depressive episodes, dysthymia, mania, anxiety disorders, obsessive-compulsive
disorder, substance abuse disorders, psychotic disorder, anorexia
nervosa, bulimia nervosa, PTSD, suicidality, antisocial disorder,
somatization disorder, and attention deficit-hyperactivity disorder.
MINI has high validation and reliability scores and can be administered
in approximately 15 minutes (Sheehan et al.,
1994). A computerized version of MINI is available that
can be administered by the client or the paraprofessional.
There is also MINI Plus, which is a more elaborate, detailed
structured interview than the shorter MINI. It elicits all the
symptoms listed in the symptom criteria for DSM-IV for 24 major
Axis I diagnostic categories, one Axis II disorder, and suicidality.
It elicits information on the impairment criteria and about
the major subtypes of each disorder covered. MINI Plus takes
approximately 30 to 45 minutes to administer.
PRISM is a psychiatric diagnostic interview designed to produce
diagnoses of DSM-IV mental health and substance-related disorders
(Hasin et al., 1992, 1996). The PRISM includes a systematic set of procedures for
differentiating primary disorders, substance-induced disorders,
and the expected effects of intoxication and withdrawal. There
are two formats for PRISM. The DSM-IV PRISM assesses for substance
dependence and abuse, primary affective disorders, primary anxiety
disorders, primary psychotic disorders, eating disorders, personality
disorders, and substance-induced disorders. The PRISM-Longitudinal
(PRISM-L) is designed for clinical trials that require collected
data on the course of mental health and substance abuse disorders
over time. PRISM takes between 90 and 150 minutes to administer,
depending on the history and response style of the client.
SADS provides detailed descriptions of the current episodes
of illness, the severity of manifestations of major dimensions
of psychopathology, and past psychopathology and functioning
relevant to an evaluation of diagnosis, prognosis, and overall
severity of disturbance. By using a progression of questions
and criteria, it also provides information for making diagnoses
(Spitzer and Endicott, 1978). There are
various versions of SADS, some of which have been published and
widely used.
SCID-I is an extremely detailed interview tool that comprehensively
reviews all DSM-IV Axis I disorders (First
et al., 1997). This comprehensive interview guides clinicians
through an evaluation of mood disorders, anxiety disorders, dissociative
disorders, cognitive disorders, somatoform disorders, substance-related
disorders, psychotic disorders, eating disorders, sleep disorders,
impulse-control disorders, adjustment disorders, sexual and gender
identity disorders, and factitious disorders, as well as disorders
usually first identified in infancy, childhood, or adolescence.
SCID-I materials include a clinician version, a 160-page user's
guide, an administration booklet, and score sheets. SCID does
not have to be administered in its entirety; individual disorder
units--for example, those covering depression, substance abuse,
and anxiety--can be administered separately. Potentially irrelevant
units--for example, schizophrenia--can be omitted from the assessment
battery.
There are numerous other standardized tests of cognitive,
personality, and psychosocial functioning that traditionally
are administered, scored, and interpreted by psychologists and
that may be helpful in the mental health assessment of adults
with a history of child abuse or neglect. For example, neuropsychological
testing, intelligence testing, and objective and projective personality
assessments can be useful components of a comprehensive psychological
assessment. Such psychological assessments should be conducted
or supervised by a licensed psychologist who is specifically
trained to conduct, evaluate, and interpret these tools.
Trauma-related assessments are important because they can
help the treatment team understand the types of childhood traumatic
events experienced by clients, their subjective response and
perceptions of these events, and common current symptoms that
may result from childhood trauma. A variety of trauma-oriented
assessment tools have been developed to accomplish these tasks.
Trauma-oriented assessment tools include structured interviews
and self-report instruments. The tools differ with regard to
the types of information they elicit. For example, some structured
interviews and self-report assessments evaluate trauma events,
some evaluate trauma events and trauma symptoms, and some evaluate
only trauma symptoms, such as dissociation. Some tools focus
specifically on childhood trauma, such as child abuse and neglect.
However, other tools examine a broad range of traumatic events.
These tools may examine childhood trauma along with natural
disasters and other types of trauma that might cause posttraumatic
reactions. Most trauma-oriented tools described in this section
are based on trauma-related clinical research and were developed
for research, not for clinical or program-specific purposes.
However, these tools can be used clinically.
Decisions regarding the types of instruments to use should
be influenced by the purpose of the assessment, the setting of
the assessment, the population being treated, and the individual
client and the severity of his problems. For example, in a program
that treats homeless veterans with substance abuse disorders,
it would be important to include broad-based tools that evaluate
the effects of exposure to combat as well as childhood trauma.
In a program that targets suburban substance-abusing women,
it would be more important to use tools that focus on childhood
trauma. However, in a program that has a substantial group of
single inner-city mothers who left abusive husbands, it would
be important to use tools that can examine childhood and recent
abuse experiences.
There is no standard trauma-oriented assessment tool, and
no single tool can be considered truly comprehensive. Each has
a slightly different purpose, with different strengths and weaknesses.
Although extremely valuable, trauma-oriented assessment tools
differ with regard to the groups on which they were normed (e.g.,
undergraduate students, male combat veterans, psychiatric clients).
As a result, none of these tools should be considered the definitive
answer to conducting trauma-oriented assessments. Rather, wisely
selected, each of these tools can be a valuable component of
a comprehensive assessment process.
The following self-report tools are designed primarily to
make assessments of histories of childhood traumatic events,
such as physical, sexual, and emotional abuse.
This assessment consists of 170 items clustered into seven
scales: physical punishment, sibling physical punishment, perception
of discipline, sibling perception of discipline, sibling perception
of punishment, deserving punishment, and sibling deserving punishment
(Rausch and Knutson, 1991). An unusual
feature of this tool is the inclusion of scales that elicit information
about clients' perceptions and attributions regarding their maltreatment,
an important feature since subjective evaluation of one's victimization
can have an important impact on symptoms and treatment. Also,
this assessment tool elicits the respondents' reports of the
maltreatment of siblings, permitting a greater assessment of
the family environment.
This questionnaire assesses rejection, degradation, isolation,
corruption, denial, emotional responsiveness, exploitation, verbal
and physical terrorism, exposure to violence, unreliable and
inconsistent care, controlling and stifling independence, and
physical neglect. Although the focus of CMQ is on psychological
abuse and neglect, it also assesses physical and sexual abuse
(Demaré, 1993). CMQ elicits information
about the frequency of maltreatment on or before the age of 17.
Like the structured interview form of TAA (see below), this
brief 17-item tool assesses a wide range of potentially traumatic
events. It evaluates the same set of issues and elicits the
same basic information as the interview version of the instrument.
It takes approximately 10 to 15 minutes, depending on the number
of traumatic childhood experiences.
TES evaluates a fairly wide range of both childhood and adult
traumas (Elliott and Briere, 1992). Of
the 30 specific traumas examined by this tool, one third focus
on interpersonal and environmental childhood traumas. The interpersonal
traumas assessed include physical, sexual, and psychological
abuse, and exposure to spousal abuse. TES elicits details regarding
the characteristics of child abuse, including age at first and
last event, relationship to the abuser, and both past and current
levels of distress about the abuse. TES also elicits significant
detail regarding sexual abuse.
The following self-report tools are designed primarily to
assess symptoms and syndromes related to childhood trauma, especially
PTSD and dissociation. Some of these can be used to make a diagnosis
of PTSD.
Dissociative Experiences Scale
(DES)
This brief 28-item tool elicits information about the frequency
of a wide range of pathological and normative dissociative experiences
(Bernstein and Putnam, 1986; Bernstein
et al., 1994). DES assesses dissociative amnesia, gaps in
awareness, derealization, depersonalization, absorption, and
imaginative involvement. It takes approximately 5 to 10 minutes
to complete DES, and it has been the subject of substantial research
efforts to evaluate reliability, validity, and utility.
Modified PTSD Symptom Scale:
Self-Report Version (MPSS-SR)
Adapted from the PDS, MPSS-SR is a 17-item tool used to measure
PTSD symptoms and make a tentative assessment about whether clients'
symptoms meet DSM-IV criteria for PTSD (Falsetti
et al., 1993). MPSS-SR yields scores for frequency and severity
of PTSD symptoms and takes approximately 10 to 15 minutes to
complete.
Penn Inventory for Posttraumatic
Stress Disorder
This 26-item tool assesses most, but not all, DSM-IV symptoms
for PTSD, as well as a few symptoms that are not directly related
to DSM-IV criteria (Hammarberg, 1992,
1996). This tool asks clients to select
one statement of four that best describes their feelings. The
inventory takes approximately 5 to 15 minutes to complete.
Posttraumatic Stress Diagnostic
Scale (PDS)
PDS is a 49-item tool that assesses all DSM-IV criteria for
PTSD. It is designed to measure the severity of PTSD symptoms
related to a single, identified traumatic event and to make a
preliminary DSM-IV diagnosis for PTSD (Foa,
1996; Foa and Meadows, 1997).
PDS includes a total severity score that primarily reflects
symptom frequency. The tool provides a preliminary evaluation
of DSM-IV PTSD diagnostic status, a symptom number count, a symptom
severity rating, and a rating of the level of impairment of functioning.
PDS takes approximately 10 to 15 minutes to complete.
Trauma Symptom Inventory (TSI)
TSI is a 100-item test designed to evaluate posttraumatic
stress and other psychological consequences of traumatic events,
including the effects of rape, spousal abuse, physical assault,
combat, major accidents, natural disasters, and childhood abuse.
TSI has 10 scales that measure the extent to which a client
reports trauma-related symptoms. These scales evaluate anxious
arousal, depression, anger/irritability, intrusive experiences,
defensive avoidance, dissociation, sexual concerns, dysfunctional
sexual behavior, impaired self-reference, and tension-reduction
behavior (Briere, 1995, 1996). TSI includes 12 critical items that can help to identify
potential problems that may require immediate attention, such
as suicidal ideation or behavior, psychosis, and self-mutilation.
It has three validity scales that can be useful in identifying
response trends that invalidate test results. TSI requires approximately
20 minutes to complete.
Some trauma-oriented assessment tools focus primarily on traumatic
events, some focus on traumatic symptoms, and some evaluate both
traumatic events and symptoms. The following structured interview
tools are designed primarily to assess histories of child abuse
and neglect. Some of these tools focus narrowly on maltreatment
issues, while others examine childhood abuse and neglect within
the context of a broad range of potentially traumatic events.
CMIS is a 46-item tool based on behavioral descriptions; it
assesses emotional, physical, and sexual abuse. It evaluates
five primary domains: (1) level of parental physical availability,
(2) level of parental psychological availability, (3) parental
disorder (e.g., history of psychiatric or substance abuse disorder
treatment), (4) psychological, physical, emotional, sexual,
or ritualistic abuse, and (5) perception of physical and sexual
abuse status (Briere, 1992b). Within
each domain, questions probe the age of onset, the relationship
to the abuser, and the severity of the abuse. CMIS limits the
assessment to events that occurred before age 17. A short version,
CMIS-SF, contains most of the items of the original tool but
with less detail (Briere, 1992b).
CTI involves 49 screening items plus multiple followup probes
for those items that are scored positive (Fink
et al., 1995). CTI evaluates six categories of events: childhood
separation and loss, physical neglect, emotional abuse or assault,
physical abuse or assault, exposure to violence, and sexual abuse
or assault. CTI takes approximately 30 to 90 minutes, depending
on the number of childhood trauma experiences. It is useful
for collecting detailed information about a wide range of childhood
traumatic events and for quantifying the frequency, duration,
and severity of these events. CTI involves queries about persons
involved, the nature of the events, the age at time of events,
the frequency of events, threats during events, the clients'
speaking about the events, and the nature of injuries sustained
(Carlson, 1997).
Evaluation of Lifetime Stressors
(ELS)
ELS combines a 56-item self-report questionnaire with a semistructured
interview to collect detailed information about potentially traumatic
events (Krinsley, 1996; Krinsley
et al., 1997). Positive responses to the self-report are
followed up with more specific questions in the semistructured
interview. ELS evaluates a wide range of potentially traumatic
events. Nearly 30 different events are asked about, including
accidents, illnesses, disasters, criminal violence, combat, and
physical and sexual assault and abuse. This assessment includes
questions about symptoms and experiences that suggest childhood
trauma. The self-report questionnaire takes approximately 10
to 20 minutes to complete, while the followup interview can take
1 to 3 hours.
National Women's Study Event
History (NWSEH)
NWSEH elicits detailed information about traumatic experiences
and evaluates a range of potentially traumatic events, including
rape, attempted sexual assault, molestation, physical assault,
accidents, disasters, exposure to death or serious injury, and
death of a friend or family member (Resnick,
1996a; Resnick et al., 1996). The
NWSEH is used to evaluate thoroughly the first, most recent,
and worst rape experiences; a single molestation; attempted sexual
assault; and physical assault experience. The tool asks about
the client's age at the time of the event, familiarity with assailant,
relationship to assailant, fear of injury, actual injury, substance
abuse by assailant, and whether the incident was reported. The
tool contains 17 screening items with probes for positive answers
to screening questions. Depending on the number of positive
screening items, the test takes approximately 15 to 30 minutes
to conduct.
Trauma Assessment for Adults
(TAA)
TAA is a 13-item tool that evaluates a range of potentially
traumatic events, including accidents, combat, disasters, serious
illness, physical and sexual assaults, assaults with weapons,
exposure to death or serious injury, and death or murder of a
family member (Resnick, 1996b; Resnick
et al., 1996). TAA evaluates in detail childhood sexual
assault, including threat, injury, and penetration. For each
positive response, the tool elicits information regarding age
at first or only time, age at last time, and the perception that
the client would be killed or injured.
CAPS is a 30-item structured interview that measures symptoms
of PTSD and acute stress disorder related to up to three traumatic
events; it can be used to make diagnoses for DSM-IV PTSD and
acute stress disorder (Blake, 1994; Blake et al., 1995; Weathers
and Litz, 1994). CAPS elicits information regarding all
DSM-IV PTSD symptoms, improvements in symptoms since a previous
CAPS administration, general response validity, and overall PTSD
symptom severity. CAPS also obtains information regarding five
associated symptoms: guilt over acts, survivor guilt, gaps in
awareness, depersonalization, and derealization. Overall, CAPS
is extremely detailed and thorough. It takes approximately 30
to 60 minutes to administer. There are two versions of the CAPS:
the CAPS-DX elicits information to make a current or lifetime
diagnosis of PTSD, and the CAPS-SX assesses symptoms over the
past week.
It is important that treatment programs develop written protocols
regarding screening and assessment of histories of childhood
abuse and neglect. All staff members should be familiar with
these protocols and have a good understanding of the policies
and procedures. Assessment protocols should describe such issues
as
When screenings and assessments should
be conducted
Who conducts screenings and assessments
What type of data gathering is conducted
What type of collateral data is gathered and by whom, and
what limitations are made by confidentiality regulations
How information is synthesized
The role of each team member
What instruments are used
Who interprets the assessment findings
How screening and assessment findings are presented and discussed
How screening and assessment findings are documented
How screening and assessment findings are incorporated into
treatment plans
To conduct trauma-oriented assessments in a treatment program,
the treatment team will need the assistance of mental health
professionals and consultants with specific expertise in assessing
and treating adults with childhood abuse and trauma. This can
be expensive, and many programs do not have the funds to hire
individuals with this level of expertise. To help address these
cost concerns, the Consensus Panel makes the following recommendations:
Train staff. It is less expensive
to have one or more staff members receive the appropriate training
than to rely exclusively on outside consultants. Ongoing training
and continuing education are also vital to retain members of
a treatment team. Training helps build team morale and confidence
in a field that experiences a high rate of turnover.
Prioritize assessments. Although all clients should
be screened for childhood trauma, staff can prioritize who receives
comprehensive assessments. Clients who are not willing or able
to participate in treatment related to childhood trauma might
not require thorough assessments at that time.
Establish university relationships. Program administrators
can establish alliances with local universities, university faculty,
and researchers to help screen, assess, train, and supervise.
Contracts with universities can be less expensive than with
consultant groups. Many universities have faculty with skills
in this area who can supervise graduate students to assist staff
in community-based programs.
Use volunteers. Programs can consider developing
a pool of volunteer mental health professionals that includes
both practicing and retired clinicians. Programs should contact
local mental health associations and professional societies,
most of which provide pro bono work.
Obtain and use inexpensive screening and assessment tools. There is a wide variety of screening and assessment tools.
Some are expensive and proprietary, while others are available
free or at low cost. Some are available through the Internet.
Appendix D provides contact information
for many such tools.
Establish community partnerships. Programs should
identify all relevant regional resources, such as local community
mental health centers, mental health associations and societies,
and CPS agency representatives, and seek to collaborate with
them.
Explore alternative funding. Programs can consider
using funding streams that are not normally associated with substance
abuse treatment to help pay for trauma-oriented assessments.
These may include funding from mental health and child assistance
agencies, the Justice Department's Office for Victims of Crime,
and private community organizations.
Screening and assessment tools have many limitations. Prominent
among them is a lack of standardization and adequate psychometric
study of many measures (Briere, 1992b).
Many instruments focus on only one or two types of trauma, such
as physical or sexual abuse (Briere and Runtz,
1990b; Bryer et al., 1987). Similarly,
the technical or psychometric characteristics of these tools
(such as reliability and validity) can vary considerably. The
concerns about reliability and validity are compounded when employing
these measures with ethnically and racially diverse populations.
Intrinsic characteristics of individuals' response to trauma--such
as denial, minimization, and dissociation--can make it difficult
to validate these tests, because it is often hard to validate
the specific events. Given these limitations, the Consensus
Panel recommends that treatment providers not overemphasize standardized
tests.
Although certain assessment tools are described as comprehensive,
it should be understood that no single tool is a truly comprehensive
approach to conducting a screening or an assessment. Rather,
standardized tests should be used as guidelines and as valuable
tools to create a framework for conducting screenings and assessments.
These tools should be used only in the context of comprehensive
clinical assessments conducted by multidisciplinary treatment
teams.
With the current emphasis by managed care organizations on
brief treatments, it may be difficult in that setting to obtain
authorization to assess childhood abuse and neglect. Some prefer
that clients be sober for a length of time before doing so.
Treatment staff should be aware that such difficulties may occur
so that they can develop strategies to justify the additional
costs of these focused and specialized assessments and subsequent
treatment. Usually a mental health professional will need to
request the authorization. For a more detailed discussion on
managed care, see Chapter 7 of this TIP,
and TIP 27, Comprehensive Case Management for Substance Abuse
Treatment (CSAT, 1998a). See also
the recommendations under "Cost Concerns" above.
There are many potential barriers to successful screenings
and assessments of childhood trauma. To reduce some of these
barriers, the Consensus Panel recommends the following:
Be sensitive to cultural concerns. Values about corporal punishment vary considerably among
cultures. What is considered abusive in one culture may be acceptable
behavior in another. Staff should not be biased against people
from ethnic and cultural minorities when reporting incidents
of suspected abuse; however, it does appear that such a bias
exists. Ethnic and cultural minorities are more likely to be
reported for child abuse and neglect than are White Americans,
and in most regions of the country White Americans are less likely
to be involved with CPS agencies (Buriel et
al., 1979). Community surveys have found that child abuse
occurs equally at all socioeconomic levels; however, reported
cases show a disproportionate representation of children from
lower socioeconomic strata. It is likely that treatment professionals
are more apt to determine that abuse occurs in disadvantaged
families because this is in accord with the stereotypes of where
abuse occurs (Finkelhor, 1993).
Recognize potential language differences. Language
differences can impede clear communication. Both written and
spoken language should be simple and easy to understand. Clients
with low levels of literacy or for whom English is a second language
should be assisted in understanding self-reports.
Become aware of gender issues. Treatment staff should
understand that clinicians are less likely to ask men about their
childhood abuse and neglect histories and that men are less likely
than women to talk about these histories. Much of the trauma-related
research has focused on women, particularly regarding battering,
spousal abuse, rape, and incest. As a result, most assessment
instruments have been normed on women. Overall, there is a lack
of gender-specific instruments.
Be nonjudgmental and sensitive. Because most individuals
who were abused or neglected during childhood were maltreated
by authority figures, they may approach the assessment process
with fear, distrust, and performance or evaluation concerns (
Briere, 1997). Consequently, those who
screen and assess for childhood abuse and trauma should try to
provide a safe and nonjudgmental testing environment and to address
the issue of childhood trauma in a gradual and sensitive manner
(Armstrong, 1996; Courtois,
1995).
The resources listed in Appendix E provide information and expertise on issues related to childhood
abuse and neglect.
Site Map
Help
Account
Cart
Home
