Advancing Child Trauma Screening Practices: An Evidence-Informed Framework for a Pictorial Child Trauma Screening Tool

Child trauma exposure has been identified as a public health crisis, with lifetime victimization/exposure rates for children ages birth to 18 years ranging from 9% to over 50%, depending on the type of victimization (Finkelhor et al., 2013). The Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) defines individual trauma as an event or series of events that one perceives as harmful or life-threatening, and has persistent effects on one’s physical, socio-emotional, and/or psychological well-being. Types of traumatic events experienced by children are wide-ranging and can occur across levels of the child’s ecology, including interpersonal victimization (maltreatment, neglect, peer victimization), intimate partner violence (IPV) exposure, community violence exposure, terrorism, refugee trauma, natural disasters, medical trauma, and traumatic grief, among others (Greeson et al., 2014).

Childhood trauma has been linked with a variety of adverse outcomes across the lifespan, including cognitive, physical, behavioral, socio-emotional, and neurodevelopmental challenges, many of which can persist into adulthood if left untreated (Dye, 2018). Traumatic victimization also increases children’s risk of subsequent traumatic exposures across different settings and perpetrators, a phenomenon referred to as polyvictimization (Turner et al., 2016). A dose-response relationship between exposure and outcomes indicates that the more traumatic exposures a child experiences, the higher their likelihood of experiencing maladaptive outcomes across the lifespan (Ballard et al., 2015; Copeland et al., 2018). For example, among child welfare populations, evidence has shown a 41% increase in trauma symptoms and a 34% increase in other mental health symptoms for each additional traumatic exposure a child reports (Griffin et al., 2011). The rapidly growing body of research on child trauma points to important areas for expansion to better identify and treat child traumatic exposure and sequelae. Accurate identification and treatment of child trauma symptoms requires screening and assessment tools that are not only developmentally- and culturally-sensitive, but also tap into a range of diverse reactions to child trauma. Failure to attend to both of these considerations places children at risk for misdiagnosis, poor treatment planning, and inadequate intervention.

Screening for Child Trauma: Areas of Expansion

Considerations Around Complex Trauma

Trauma screening measures that account for the unique and variable symptom presentation associated with complex trauma in children—rather than those defined only by post-traumatic stress disorder (PTSD) diagnostic symptom clusters—may offer a more comprehensive understanding of children’s traumatic reactions. Complex trauma exposure is characterized by chronic, ongoing, or repetitive traumatic events that are often of an invasive, interpersonal nature, including experiences such as child neglect, exposure to intimate partner violence (IPV), and physical, sexual, and psychological abuse (D’Andrea et al., 2012). Complex traumatic reactions extend beyond criteria for PTSD, and manifest across symptom clusters including attachment, biology, affect regulation, dissociation, behavioral regulation, cognition, and self-concept (Cook et al., 2017; van der Kolk, 2017). Although the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5, American Psychiatric Association, 2013) provides an updated and broadened definition of child PTSD, clinical concern has been raised that the expanded PTSD criteria still do not account for the disruptions to neurodevelopment—and subsequent regulatory challenges and developmental sequelae—that are linked to early and chronic traumatic stress (DeBellis & Zisk, 2014; DePierro et al., 2019; Ford, 2011).

Child trauma measures that screen for symptoms defined by DSM-5 PTSD diagnostic criteria may fail to tap broader developmental indicators of complex trauma, including relational dysregulation, attachment difficulties, and physical and somatic complaints, and thus risk under-identification and missed opportunities for intervention (Ford, 2011). Recent systematic reviews of child trauma screening measures used with child welfare populations (Whitt-Woosley, 2020) and in school settings (Eklund et al., 2018) found that the majority of included measures use PTSD symptom clusters as evidence of traumatic stress. Examples included the University of California at Los Angeles PTSD Reaction Index (UCLA PTSD-RI; Steinberg et al., 2013), the Child Trauma Screen (CTS; Lang & Connell, 2017), the Child PTSD Symptom Scale (Foa et al., 2018), and the Child and Adolescent Trauma Screen (Sachser et al., 2017). Despite the important benefits these tools offer, their emphasis on PTSD criteria may present identification challenges when working with child welfare populations, which have high rates of complexly traumatized children. Greeson et al. (2011) found 70% of their sample of 2,251 foster children and teens had experienced two or more types of interpersonal trauma that constitute complex traumatic stress. If measurement tools lack the nuance necessary to detect the diversity of complex traumatic reactions, children can be inadequately diagnosed, subjected to faulty treatment decisions, or may not be identified for services at all (McMillen et al., 2007; Whitt-Woosley, 2020).

Relational Health and Resilience

Relational health, defined as one’s connectedness to attuned, supportive, and caring adults, has demonstrated significant protective effects among trauma-exposed youth, promoting resilient functioning across cognitive, behavioral, and emotional domains (Hambrick et al., 2019). Clinical researchers have recently found that high levels of relational health can disrupt the dose-response relationship between exposures and outcomes and buffer children from the detrimental effects of increasingly high levels of trauma (Bartlett, 2020). In a study of children ages 6 – 13 years of age with histories of severe trauma and/or maltreatment, Hambrick and colleagues (2019) found that participants’ current relational health was the strongest predictor of children’s physiological, behavioral, and social-emotional functioning. Similar findings have been reported among child welfare-involved samples (Hambrick et al., 2018).

Culture and Trauma

Culture can influence how a child experiences trauma, their appraisal and perception of traumatic experiences, and their responses and reactions (Perry et al., 2019). A child’s culture can shape their belief systems, familial relationships and attachment patterns, and coping skills, all of which can influence a child’s interpretation of a traumatic event and their expression and communication about the experience (Nader, 2007). Cultural differences in the conceptualization of trauma symptoms have been identified, such as the Western method of dichotomizing physical and mental health symptoms, which differs from Eastern medical models that use a more integrated and holistic approach to mind-body connection when framing traumatic reactions (Zheng & Gray, 2015). Cross-cultural differences have also been noted in symptoms related to avoidance, hyperarousal, and cognitive structures related to self-blame (Perry et al., 2019). Moreover, belonging to a collectivist versus individualist culture has also been linked with differences in disclosure, perceptions, interpretations, and healing from trauma (Engelbrecht & Jobson, 2016).


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