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Assessment of Trauma Among Juvenile Delinquents

by Matthew Galloucis, Ph.D., DAPA and Heather Francek, M.Ed., M.A., DAPA

Strategies for the Initial Assessment of Trauma Exposure and Trauma Related Responses Among Juvenile Delinquents Youth who have been adjudicated as delinquent by the juvenile justice system can present multiple challenges to mental health professionals who provide clinical services for them. Juvenile delinquency is a legal term referring to youth who have been arrested and adjudicated delinquent for either non-violent (e.g., theft, chronic truancy, vandalism) or violent (e.g., assault, sexual offenses, unlawful use of a weapon and murder) unlawful acts. These youth typically exhibit a persistent and regular pattern of engagement in unlawful behavior.
Many youth exhibiting persistent conduct problems that are associated with delinquency have coexisting psychological and psychiatric disorders (Borduin, Henggeler & Manley, 1995). Estimates of the prevalence of psychiatric conditions among incarcerated youth, not including conduct disorder, ranges from 25 to 40 percent (Young, 1999). A sample of juvenile offenders who were admitted to a detention center in Texas had high rates of major depression (20%), cannabis abuse (46%), and alcohol abuse (28%) (Pliszka, Sherman, Barrow & Irick, 2000). A variety of negative family (e.g., parental divorce, parental abandonment, early loss, abuse, domestic violence, substance abuse) and personal experiences (e.g., sexual victimization, witnessed violence, physical abuse), as well as lifestyle factors (e.g., gang affiliation), collectively increase the risk for psychosocial maladjustment among delinquent youth.

Juvenile delinquents often have a history of trauma exposure. This can involve both witnessed (e.g., seeing a shooting or assault; seeing domestic violence in the home) and personally experienced (e.g., being shot, assaulted, physically or sexually abused) trauma. A significant number of delinquent youth have experienced multiple traumatic events over their lifetime. A recent study of incarcerated juvenile delinquents found that 32% fulfilled criteria for Posttraumatic Stress Disorder (PTSD) and that another 20% had partial symptoms of PTSD (Steiner, Garcia & Matthews, 1997). These problems may be "masked" in the form of negative behaviors contributing to problems in social, academic and emotional adjustment. It is important for mental health professionals to utilize assessment strategies that can assist in identifying a youth's trauma exposure and trauma related responses.

Self-Report Strategies to Assess Trauma Exposure Often youth will not report the full range of their traumatic experiences without a formal assessment of their trauma history. We have found it useful to administer a trauma history questionnaire to youths. There are a number of different measures of trauma exposure that may be useful to clinicians (for a review see Newman, Kaloupek & Keane, 1996; Schlenger, Fairbank,
Jordan & Caddel, 1997). These self-report measures provide a structured and systematic way to obtain a trauma history in a time-limited manner.

These measures include the Childhood Trauma Questionnaire (Bernstein, Ahluvalia, Pogge & Handelsman, 1997), the Trauma History Screen (Allen, Huntoon & Evans, 1999) and the Traumatic Stress Institute Life Event Questionnaire (Traumatic Stress Institute, 1993). Typically, these measures include a brief description of a variety of different traumatic events. The respondent identifies the specific traumatic events they have experienced during their lifetime, the frequency of occurrence of each event and the age at which the trauma occurred. A general distress rating may be used for each
experienced event.

The traumatic life events included in the Traumatic Stress Institute Life Event Questionnaire are similar to the ones used in other measures of trauma exposure. They include impersonal traumas (e.g., natural disasters, motor vehicle accidents resulting in serious loss or physical injuries to self or others; experiencing a life threatening illness or injury), witnessed traumas (e.g., witnessing domestic violence, physical abuse and violence, sexual abuse or sexual assault toward another person; observing dead or
dying people as a result of violence, a disaster or a serious accident), and interpersonal traumas (e.g., personally experienced domestic violence, physical abuse, sexual assault, child sexual abuse).

We have developed a brief trauma history questionnaire (Adolescent Life Event Questionnaire) that is adapted from these previously mentioned measures. This consists of 20 stressful and traumatic life events. Several of the items assess direct and indirect exposure to violence. This is particularly important when assessing this population due to the high rates of exposure to violence they often experience. We have also included several events that are relevant to this population but are not included in other measures (e.g., "removed from home and placed in foster care or other placements by the Department of Children and Family Services"; having an
abortion, and pregnancy). The youth is also given the opportunity to describe other events not included in the questionnaire that they have experienced and perceive as "traumatic or very disturbing." The youth estimates the frequency and age of occurrence of the events they experienced. They also are asked to indicate if they are "still disturbed by the event" (yes or no). For those events they are still disturbed by, the youth provides a general distress rating using a 10 point scale (0 = not at all disturbed, 10 = extremely disturbed). We verbally define several of the items (e.g., "physically abused by another person"; "sexually abused by another person"; "emotionally abused by another person") prior to having the youth complete the questionnaire.

A clinician should not rely on a youthıs responses to these measures as the only criterion of trauma exposure. We have seen cases in which there is a well-documented trauma in a youthıs history but he or she will not report this when completing the questionnaire. This can provide an opportunity to explore the reasons for this omission with the youth. Comparing a youthıs responses with collateral information regarding his or her history and documented historical information in the record is recommended. Often a youthıs self-reported trauma exposure based on these measures is greater
than what has been reported previously in prior assessments that have not included a systematic review of the youthıs trauma exposure. This may include a wider range of different types of traumatic events experienced (i.e., witnessed and personally experienced trauma).

Self-Report Strategies to Assess Trauma-Related Responses: Several other brief measures can be used to assess the impact of traumatic events (for a review see Nader, 1997). Although these should not be used solely for making a DSM-IV diagnosis of PTSD, they do provide useful assessment information for treatment planning. The Revised Impact of Event Scale (IES-R) (Weiss & Marmar, 1997) is a 22 item self-report scale that measures intrusive, hyperarousal and avoidant PTSD symptoms. The respondent is asked to indicate how distressing each symptom has been for a 1-week time frame. The scoring scheme for the distress ratings consist of 0, 1, 2, 3, and 4 for the responses of "not at all", "a little bit", "moderately", "quite a bit" and "extremely."

The IES-R intrusion symptoms include items such as "pictures about it popped into my mind", "I thought about it when I didn't mean to" and "I had dreams about it." Avoidance symptoms include items such as "I stayed away from reminders about it", "I tried not to talk about it" and "my feelings about it were kind of numb." Hyperarousal symptoms include items such as "I felt irritable and angry", "I had trouble staying asleep", "I was jumpy and easily startled" and "I felt watchful and on guard." Subscale scores are obtained by summing the scores for the non-missing items comprising each
subscale and obtaining the mean. Adolescent normative data is not currently available for the IES-R. However, item scores that are at least 3 (e.g. "quite a bit" distressing) are suggestive of clinically significant levels of symptom distress that warrant further attention.

Most of the adolescents we have administered the IES-R to who have adequate reading ability for their age are able to complete this measure with little difficulty. If a youth has poor reading ability the clinician may read each item to the youth and have them complete the ratings. We then use the results as an aid in interviewing the youth further about the symptoms they reported. Younger youth and youth who have cognitive limitations may be administered the Childıs Reaction to Traumatic Events Scale (CRTES) (Jones, 1994). This is a revision of the childrenıs version of the Impact of Event Scale. One problem with the CRTES is that it does not measure all the symptoms of PTSD based on DSM-IV (e.g., hyperarousal symptoms).  We also administer a self-report measure of depression because depression is often a complication of trauma exposure. These include the Children's Depression Inventory (Kovacs, 1992) or the Reynolds Adolescent Depression Inventory (Reynolds, 1987). For a more comprehensive norm referenced assessment of trauma related symptomatology the Trauma Symptom Checklist for Children (Briere, 1996) is recommended. The Childrenıs Impact of Traumatic Events Scale-Revised (Wolfe, Gentile, Michienzi, Sas & Wolfe, 1991) can be used to assess traumatic responses resulting from sexual abuse.

While there are several measures available to assess DSM-IV related PTSD symptomatology, there has been limited research to address the impact of trauma exposure on an individualıs cognition. There is an increased interest regarding the impact of trauma exposure on beliefs about the world, self and others. Although currently there is limited research on this topic with adolescents, there are self-report measures available that can provide useful information for treatment planning with adolescents.  The Traumatic Stress Institute Belief Scale (Pearlman & Saakvitne, 1995) assesses disruptions in beliefs about safety, trust, esteem, intimacy and control. The recently developed Posttraumatic Cognitions Inventory (PTCI) assesses trauma-related thoughts and beliefs that are associated with posttraumatic psychopathology (Foa, Ehlers, Clark, Tolin & Osillo, 1999).  This 33 item scale is comprised of three subscales that measure negative cognitions about self, negative cognitions about the world and self-blame.

Each item reflects a particular belief. The respondent rates how much they agree with the belief using a 7 point scale (1 = totally disagree; 7 = totally agree). Higher scores reflect greater disruptions of the beliefs and assumptions measured by the PTCI.
Types of cognitions that are assessed by the PTCI:  Unsafe world: "The world is a dangerous place", "I have to be on guard all the time", "You never know when some
thing terrible will happen" ? General negative view of self: "I am inadequate", "I am a weak person", "I can't stop bad things from happening to me? Perceived permanent changes related to the trauma: "I have permanently changed for the worse", "I will
never be able to feel normal emotions again" ? Alienation from self and others: "I feel isolated and set apart from others", "I feel like I don't know myself anymore? Hopelessness: "I have no future", "Nothing good can happen to me anymore"? Negative interpretations of symptoms: "My reactions since the event mean I am going crazy", "Other people with the same experience would be O.K. now"?  Self-trust:
"I can't trust that I will do the right thing", "I can't rely on myself"?  Self-blaming: "It happened to me because of the way I acted", "I am ashamed of myself" "There is something wrong with me as a person"? Other-trust: "People are not what they seem", "You can never know who will harm you", "I can't rely on other people"

Conclusions: Juveniles who are involved in the criminal justice system have multiple risk
factors associated with exposure to psychological trauma. Clinician's working with this population must be able to accurately assess the youth's trauma exposure and trauma related responses. Obtaining this assessment information can help clinicians to gain a more comprehensive understanding of the multiple factors that may be contributing to a youthıs delinquent behavior. The self-report screening measures we have reviewed should be used in conjunction with collateral reports, clinical interviewing and psychological testing to make a formal diagnosis of PTSD. Failure to adequately assess and treat these problems can significantly increase the probability of negative outcomes among these youth. assessment of trauma among juvenile delinquents

References
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2. Bernstein, D., Ahluvalia, T., Pogge, D. & Handelsman, L. (1997). Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child and Adolescent Psychiatry, 36(3), 340-348.
3. Borduin, C.M., Henggeler, S.W. & Manley, C.M. (1995). Conduct and oppositional disorders. In V. B. Van Hasselt & M. Hersen (Eds.), Handbook of adolescent psychopathology: A guide to diagnosis and treatment (pp.349-383). Lexington Books: New York.
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About the Authors

Matthew Galloucis, Ph.D., DAPA
Dr. Matthew Galloucis attended Loyola University of Chicago where he obtained his doctorate degree. He has had training and experience with adolescents and adults at a variety of inpatient and outpatient settings in the Chicago area. Dr. Galloucis has worked as a staff psychologist at the Cook County Juvenile Court in Chicago. Dr. Galloucis is the co-author of an empirical study on the psychological impact of trauma exposure on paramedics that is "in-press". He is currently a licensed clinical psychologist in Illinois, working in a correctional setting with adolescents.

Heather M. Francek, M.Ed., M.A., DAPA
Ms. Heather Francek received her master's degree in special education from the University of Arizona and her master's degree in clinical psychology from the Illinois School of Professional Psychology. Ms. Francek is the co-author of an empirical study on the psychological impact of trauma exposure on paramedics that is "in-press". She has served as a staff psychologist at Cook County Juvenile Center's Forensic Clinical Services Department in Chicago and as a special education teacher at an alternative school for behaviorally and emotionally disturbed youth. She is currently a licensed clinical professional counselor in Illinois and a nationally certified psychologist.


   


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