Assessment of Trauma in Youths

Understanding issues of age, complexity, and associated variables

Kathleen Nader

• Publisher: Taylor & Francis
• Year: 2016
• eBook ISBN: 9781134906031
• Edition: 1
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Assessment of Trauma in Youths: Understanding issues of age, complexity, and associated variables is a collection of articles by well-known specialists in the field of childhood trauma. The articles describe developmental issues in addition to others that are important to the assessment of trauma-exposed youth, to the ongoing refinement of trauma-related diagnoses for children, and to understanding PTSD and more complicated reactions to trauma for young people.

The book explores trauma in very young to middle childhood aged children, trauma in adolescents, childhood complicated trauma, and childhood complicated grief. It considers PTSD and Reactive Attachment Disorder as well as discussing disorders that are under continued study such as Developmental Trauma Disorder, Prolonged Grief Disorder, and Traumatic Grief. In the second half of the book, chapters look at the associated features of childhood traumatic response such as genetics and personality, cortisol, poly-victimization, and guilt and shame. Variables such as cortisol reactivity and guilt/shame may influence or follow traumas in children.

This book was originally published as a special issue of the Journal of Child and Adolescent Trauma.

Introduction

Trauma in Children and Adolescents: Issues Related to Age and Complex Traumatic Reactions

KATHLEEN NADER

Two Suns

Accurate assessment is important to treatment selection, and following traumas is particularly important for children. Traumas may undermine a child’s developmental progression as well as emotional health and functioning. A number of developmental issues influence the nature and accurate assessment of traumatic reactions in children and adolescents. Youth reactions and reporting differ from those of adults, which suggest the need for diagnostic criteria and assessment measures specifically designed for varying developmental age groups. This introductory article discusses trauma-related developmental issues and the structure and nature of posttraumatic stress disorder now debated for adults and children. Also addressed are children’s complicated trauma-related disorders, which are still being tested and for which measures are newly developed or undergoing revision.

In anticipation of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), child-focused researchers and clinicians have been examining the nature and structure of posttraumatic stress disorder (PTSD), the need for PTSD alterations that reflect developmental differences, and the nature of complicated posttraumatic reactions in youths. The field continues to study and elaborate for youths, variations in types of reactions that may be related to development, personality, genetic predisposition, family background, other child or environmental variables, event variations, and variable combinations. The first part of this two-journal special series on understanding and assessing trauma in children and adolescents examines issues related to age and development as well as complex trauma reactions. It highlights articles that address age differences in the manifestation and reporting of PTSD (Scheeringa, this issue; Habib & Labruna, this issue), as well as a discussion of complex traumatic and grief reactions (Ford, this issue; Nader & Salloum, this issue). The following is a discussion of some of the developmental issues relevant to assessment and treatment of trauma in youths.

Trauma and Development

Many professionals have come to believe that all psychopathology is most appropriately viewed in developmental terms (Costello, Foley, & Angold, 2006; Emde & Spicer, 2000). Developmental psychology seeks to understand children’s symptoms and reactions to adversity in relationship to normative adaptation at different developmental stages and to biological, psychological, and social-contextual systems (Costello et al., 2006). Accordingly, clearly defining the nature of youth reactions to trauma requires an understanding of developmental differences and normal aspects of adaptation.

Age and the Emergence of Skills, Traits, and Symptoms

Age and development influence the emergence and levels of youth’s skills (e.g., self-control, perspective-taking), the development of resilience and risk factors (e.g., self-esteem, lifetime adversities), and the effect of exposure to adverse events on a child or adolescent’s life (Nader, 2008). If all goes well in the course of development, children become increasingly less helpless and more skilled, for example, in problem solving, self-regulation, goal attainment, as well as in self-awareness and other-awareness. Periods of proliferation of brain synapses in the first 3 years of life and again at puberty onset mark disorganization, interruption of quantitative developmental improvements, and pruning of unused brain connections (Blakemore & Choudhury, 2006). Working memory increases from infancy onward. Working memory permits delayed imitation of observed behaviors, vicarious learning, and the combining of memories (e.g., of observations or experiences) toward innovation or other goal-directed behaviors (see Barkley, 2001). Increases in verbal and nonverbal working memory assist such skills as social interaction, self-defense, inhibition, and other self-regulation (e.g., memory of pain or of someone’s bad outcome may inspire inhibition of a strong urge to react).

Timing and Analysis of Traumatic Reactions

When only variable-centered versus person-centered approaches are used to assess mental health outcomes, the multiple pathways to that outcome are indistinguishable (Laird, Jordan, Dodge, Pettit, & Bates, 2001). Although individual and subgroup trajectories may differ across time, overall patterns of development may be similar (e.g., between risk groups) or may highlight important differences (e.g., between the genders or in environmental living conditions; Nader, 2008). For example, the peaks in synaptic proliferation (Blakemore & Choudhury, 2006) and in aspects of event-related potential (an electroencephalogram index of attentional resources; Iacano & McGue, 2006) occur earlier for girls than for boys. For example, sociocognitive and behavioral risk factors for aggression occur earlier for boys than for girls, and aggression manifests differently across age groups (Aber, Brown, & Jones, 2003; Rutter, 2003). In young children, acts of physical aggression peak at ages 2 to 3 years and then decline (Tremblay, 2004). In middle childhood, youth engage in a wide range of activities and make judgments increasingly in accordance with gender stereotypes (Steele & Steele, 2005). Youth subgroups (e.g., boys, low socioeconomic status, minorities) demonstrate initial higher risk and higher rates of linear growth on measures of aggression between ages 6 and 12 years. Lower risk youths (e.g., girls, Caucasian) reach similar levels of measured variables by age 12 years (Aber et al., 2003). Normally, children’s self-concepts become more negative or less unrealistically positive in middle childhood (ages 7 to 8 years) and again in early adolescence (followed by a slow increase in self-esteem in later adolescence; Geiger & Crick, 2001; Twenge & Campbell, 2001). Evidence suggests that boys recover self-esteem during high school, and girls recover it during college. As a consequence, some studies have shown a large gender gap in self-esteem during high school. Differences in these trajectories are important for assessment and treatment of youth.

The timing of traumas is important to brain development. Studies that have examined children across time (in comparison with themselves and with groups) must take into account variations in stress sensitivity and manifestation of skills and symptoms by age or stage. For example, animals and human studies have demonstrated the brain’s particular sensitivity to stress during early childhood, adolescence, and old age (Blakemore & Choudhury, 2006; Carrion, Weems, Richert, Hoffman, & Reiss, 2010; De Bellis, 2002; Lupien, McEwen, Gunnar, & Heim, 2009). Exposure to early-life stress has been associated with increased reactivity to stress and cognitive deficits in adulthood. The adolescent prefrontal cortex may be particularly vulnerable to extreme stress. The prefrontal cortex is critically involved in inhibiting the stress response as well as in attention, organization, self-regulation, and planning (Rothbart & Rueda, 2005; Stevens, Kiehl, Pearlson, & Calhoun, 2007).

Development and Psychopathology

Disorders once deemed typically as adult disorders are often reported to have had their onsets during childhood and adolescence (Angold & Egger, 2007). The time of onset of disorders varies among individuals, and prevalence varies by age group. For example, most depressed adolescent boys were probably not depressed as preschool students. Moreover, many disordered preschool students will later be quite well. Evidence has suggested a peak onset for major depression, mania, obsessive-compulsive disorder, phobias, and drug and alcohol disorders in childhood or adolescence (Costello et al., 2006). Disorders that are primarily childhood onset include attention-deficit/hyperactivity disorder (ADHD), autism and non–autistic pervasive developmental disorder, separation anxiety, specific phobia, and oppositional defiant disorder (Costello et al., 2006). Disorders that are primarily adolescent onset disorders include social phobia, panic, substance abuse, depression, anorexia nervosa, and bulimia nervosa. For boys, some studies have suggested that childhood-onset antisocial behavior has antecedents and a course that are different from adolescent-onset deviance (Costello et al., 2006; McBurnett, King, & Scarpa, 2003). Most childhood-onset disorders have more male cases than female cases, whereas most of the adolescent disorders have more female cases than male cases.

Trauma’s Impact on Development

Traumatic events may disrupt a youth’s brain development, developmental skills, talents, personality development, and functioning. Complex traumatic reactions, in particular, result in compromises in a youth’s self-development, which includes self-regulation, self-integrity, and/or ability to experience relationships as nurturing and reliable (Ford & Courtois, 2009). Functional impairment, developmental disruptions, and dangerous symptoms such as suicidality may occur from a subset of trauma symptoms (Nader, 2008; Olfson, Hellman, Blanco, Guardino, & Struening, 2001). Posttrauma changes (e.g., in personality) may influence interrelationships and selection for opportunities at school or in life. For example, agreeableness describes prosocial traits such as politeness, cooperation, and compassion at one end of the continuum, and antisocial traits such as callousness and aggression at the other end (DeYoung et al., 2010). Agreeableness is linked to the mechanisms that allow the understanding of others’ emotions, intentions, and mental states (e.g., empathy, theory of mind) and may be undermined by trauma.

Age and Assessing Traumatic Reactions

A number of researchers have pointed out the need for caution in simply “down-aging” existing adult DSM diagnoses in describing a disorder as it applies to children (Meiser-Stedman, Smith, Glucksman, Yule, & Dalgleish, 2008, p. 1326; Nader & Layne, 2009). Identifying age-related differences is a daunting task because of individual variations in the timing of skill development and puberty onset, mixed research findings, and the complexity of variable interrelationships. More study is needed to confirm and specify which events differ among age groups and to separate the effects of, for example, grieving from the effects of trauma. In addition, the importance of including multiple sources of information (e.g., youth, male and female caregiver, teacher/sitter, clinician), different contexts (e.g., home, school, laboratory), and different methods of assessment (e.g., interview, form completion, play methods, observation) has been well established (Egger & Angold, 2006; Kerr, Lunkenheimer, & Olsen, 2007).

Children of the same chronological age vary widely in their functioning age levels (Becker-Weidman, 2009; Nader, 2008). The gap between chronological and functioning age may be especially great among traumatized youths (Becker-Weidman, 2009). For example, some adopted and foster children age 9 or 10 years may function at an age of 4 or 5 years. Because of developmental and functional age-related differences in reporting style, self- and interpersonal skills, coping resources, the ability to label and report affective states, and the nature of reactions, the need for age-related changes in PTSD diagnostic criteria are clear. In addition to changing the PTSD diagnostic criteria are the proposal for developmental trauma disorder and forms of complicated grief reactions in the DSM-V, which are discussed later in this article and series.

Multiple assessment-related factors have influenced outcomes of youth studies. Location (home or laboratory), duration and number of assessment periods, interrelationship variables between child and caregiver or interviewer/observer, the focus of interpretation, and the level of distress produced during the assessment session may all influence findings (Nader, 2008; Rosen & Rothbaum, 1993). For example, in scripted laboratory procedures, Kochanska, Aksan, Penney, and Doobay (2007) found that young children’s positive emotionality (e.g., surgency/extraversion, affiliativeness/agreeableness, approach, pleasure, sociability, and positive anticipation) related negatively to self-regulation, whereas in mother–child interactions, it related positively to self-regulation. Similarly, self-reports of some traits (e.g., empathy) differ from observations (Grynberg, Luminet, Corneille, Grèzes, & Berthoz, 2010). As mentioned earlier, using multiple sources of information is advisable. The importance of including child self-reports when possible is well established. Although most self-report measures are worded for children age 8 years and older (Briere, 2005), researchers have successfully and directly assessed younger children (see Table 1). It is clear that the manner of analysis influences findings. For example, despite correlations between complicated grief (CG) and PTSD, exploratory factor analyses have confirmed the distinctness between CG and PTSD and/or depression for adults (Boelen, van de Schoot, van den Hout, de Keijser, & van den Bout, 2010; Golden, Dalgleish, & Mackintosh, 2007) and for children (Dillen, Fontaine, & Verhofstadt-Denève, 2008, 2009; Melhem et al., 2004). Alternatively, confirmatory factor analyses have found significant overlap between CG and PTSD, especially in reexperiencing (O’Connor, Lasgaard, Shevlin, & Guldin, 2010).

Table 1
Assessment methods for three age groups

Age group	Types of assessment
Young children	• Infants and toddlers – observational methods to assess attachment relationships with caregivers (Ainsworth, Blehar, Waters, & Wall, 1978) • Age 3 years and older and autistic children – observational methods (Angold & Egger, 2007; Lord, Rutter, DiLavore, & Risi, 2003) such as preschool or classroom observations (e.g., Reynolds & Kamphaus, 1998), general play observation (Mogford-Bevan, 2000; K. H. Rubin, 1989), traumatic play observation (Nader, Stuber, & Fletcher, 2005; Scheeringa, Peebles, Cook, & Zeanah, 2001), and videotape observation (Soloman & George, 1999) • Ages 4 or 5 years – coded responses to story stems, dollhouse scenarios or doll play tasks, and puppet-based assessments (Granot & Mayseless, 2001; Stadelmann, Perren, Von Wyl, & Von Klitzing, 2007) • First-grade students – self-report questionnaires (Angold & Egger, 2007; Ialongo, Edelsohn, & Kellam, 2001; Ialongo, Edelsohn, Werthamer-Larsson, & Kellam, 1995) • Age 6 years and older – drawing and symptom descriptions (Angold & Egger, 2007; Valla, Bergeron, & Smolla, 2000)
Middle childhood	• See also methods used for young children • Younger and middle childhood – combination of play and narrative methods (Nader &...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Citation Information
• Preface
• Part I: Understanding and Assessing Trauma in Children and Adolescents: Issues of Age and Complex Reactions
• Part II: Trauma and Associated Variables
• Index