The Trauma Symptom Checklist for Young Children (TSCYC): reliability and association with abuse exposure in a multi-site study
Introduction
Despite significant advances in our understanding of psychological trauma and its potential effects and the increased availability of effective treatments for trauma-related conditions, there are surprisingly few standardized, trauma-relevant measures available for children. This relative lack of assessment resources becomes especially significant when one considers the wide variety of traumatic events to which children are regularly exposed. These include natural disasters (Green et al., 1991); physical and sexual child abuse Berliner and Elliott 1996, Kolko 1996; witnessing spousal violence Grych et al 2000, Jaffe et al 1990; war Baker 1990, Sack et al 1986; and physical and sexual assaults by peers or other noncaretakers Boney-McCoy and Finkelhor 1995, Singer et al 1995.
Children’s exposure to such traumas, in turn, has been associated with a wide variety of negative mental health outcomes, including anxiety and depression Fergusson et al 1996, Lanktree et al 1991, Margolin and Gordis 2000, Martinez and Richters 1993, post-traumatic stress and dissociation Elliott and Briere 1994, McLeer et al 1998, Singer et al 1995, anger and aggression Kolbo et al 1996, Lanktree et al 1991, Shakoor and Chalmers 1991, and, especially in sexual abuse victims, sexual symptoms and age-inappropriate sexual behavior Friedrich 1993, Friedrich 1994, Green et al 1991.
Those conducting studies on the potential impacts of traumatic events on children’s mental health have responded to the relative dearth of standardized tests in this area by creating a number of research measures. These include the Children’s PTSD Inventory (Saigh, 1989), Child Post-Traumatic Stress Reaction Index (RI; Pynoos et al., 1993), Child Dissociative Checklist (CDC; Putnam, Helmers, & Trickett, 1993), Children’s Attributions and Perceptions Scale (CAPS; Mannarino, Cohen, & Berman, 1994), Children’s Impact of Traumatic Events Scale-Revised (CITES-R; Wolfe, Gentile, Michienzi, Sas, & Wolfe, 1991), and the Sexual Abuse Fear Evaluation (SAFE; Wolfe & Wolfe, 1986).
Unfortunately, these research measures typically lack the norms and data on clinical psychometrics that are needed before the assessor can determine the actual clinical implication of a given score. For example, in the absence of data on the distribution of scores in the general population, a score of Y on measure X cannot be interpreted in terms of its abnormality and, thus, its specific clinical meaning. Similarly, for optimal applicability to clinical settings, the reliability and validity of a test in clinical groups must be known. Because most research measures typically lack such data, they cannot be applied with confidence in general clinical practice (Briere, 1997).
In contrast to these various research measures, there are only two standardized, normed tests of childhood trauma-related symptomatology available to clinicians: the Trauma Symptom Checklist for Children (TSCC; Briere, 1996), a multiscale self-report measure of trauma-related symptomatology, and the Child Sexual Behavior Inventory (CSBI; Friedrich, 1998), a caretaker-report measure of abnormal sexual behavior frequently seen in sexual abuse victims. The TSCC provides a review of those symptom clusters often associated with trauma in children, but requires that the child be at least 8 years of age for administration. This age limit reflects the concern that younger children may have insufficient cognitive development to fully understand what a given psychological symptom or internal state actually represents, or lack the reading comprehension necessary to respond to written test items regarding that state or symptom. The CSBI avoids this issue by relying on caretaker report, but is limited to a review of sexual behaviors.
The cutoff of 8 years for the TSCC and the absence of other broad-band standardized tests for children under 8 represents a real problem for clinicians specializing in child trauma. Most importantly, many children are first abused, neglected, or otherwise traumatized well before this age. As a result, a significant proportion of children brought to clinics, child crisis centers, or emergency rooms with trauma exposure cannot be evaluated at the level possible for those over age 7.
In the absence of standardized trauma measures, younger children must be assessed either by their responses to clinicians’ questions during a diagnostic or intake interview, or through parent/caretaker symptom report. The first option can be helpful, but the subjectivity of the typical clinical interview means that effective and comprehensive evaluation rests on the abilities and training of the interviewer. Furthermore, such informal assessment is intrinsically non-normative: beyond the clinical experience of the interviewer, such an approach offers little information about whether a specific symptom or behavior represents relatively normal functioning, subclinical difficulties, or clinical levels of disturbance.
The limitations of the regular clinical interview approach can be addressed, in part, through the use of structured interviews with specific items tapping trauma-related symptoms. Examples of this approach are the Clinician-Administered PTSD Scale, Child and Adolescent version (CAPS-C; Nader et al., 1996) and the Children’s Impact of Traumatic Events Scale-Revised (CITES-R; Wolfe et al., 1991). The CAPS-C yields a DSM-IV diagnosis of PTSD, and appears to have reasonable validity in clinical practice (Nader, 1997). However, this interview can take over an hour to administer; a logistic problem that limits its usefulness in many clinical contexts. In addition, by virtue of its focus on PTSD, per se, it does not evaluate the various other psychological difficulties often associated with childhood trauma.
The CITES-R yields scores on scales measuring post-traumatic stress, sexual issues, perceptions of social support after disclosure, and cognitive attributions. Recent research supports the psychometric reliability and validity of the CITES-R (Crouch, Smith, Ezzell, & Saunders, 1999). However, the interview is limited to sexual abuse impacts, does not have established norms for interpreting scores in clinical settings, and requires that the child be at least 8 years of age.
The second evaluation option (parent-report measures) may be helpful to the extent that it involves standardized assessment and allows the clinician to compare a child’s symptomatology to what would be normative for a child of his or her sex and age. Unfortunately, with the exception of the Child Sexual Behavior Inventory (CSBI; Friedrich, 1998), the only standardized, normed parent/caretaker-report tests available to clinicians are generic [e.g., the Child Behavior Checklist (CBCL); Achenbach, 1991] and do not tap post-traumatic symptoms to any major extent. As has been suggested for generic adult measures (Briere, 1997), clinical reliance on generic tests may mean that the post-traumatic symptoms of many abused or traumatized children go unassessed or, in some cases, are misinterpreted as evidence of other forms of disturbance.
An additional problem with parent/caretaker reports of children’s symptoms is the second-hand nature of this approach. Whenever the clinician relies on a caretaker’s report of a child’s functioning, there is the risk that the reporting parent’s perceptions are biased by his or her personal concerns, psychopathology, limited contact with the child, or other motivations to see (or present) the child as more or less symptomatic than may actually be the case (Briere & Elliott, 1997). As a result, in the absence of additional data, it is not always clear to what extent the caretaker’s responses on caretaker-report measures reflects actual symptomatology in the child.
In response to these various issues, the TSCYC (Briere, in press) was developed. This test is a 90-item caretaker-report measure that can be used to assess trauma symptoms in children from ages 3 to 12. Caretakers rate each symptom on a 4-point scale [from 1 (not at all) to 4 (very often)] according to how often it has occurred in the previous month. Unlike other parent/caretaker report measures, the TSCYC contains specific scales to ascertain the validity of caretaker reports and evaluates a range of post-traumatic symptoms. In addition, on completion of normative studies, the TSCYC will allow comparison of a given child’s caretaker-reported symptoms in a given area to a large, representative sample of caretaker reports from the general population.
Because caretaker-report measures introduce a new source of potential difficulties, that of intentional or inadvertent misreporting of the child’s psychological status, the TSCYC includes additional features that assess the caretaker’s rating style and actual familiarity with the child. In this regard, the TSCYC contains two validity scales that assess potential over-report (Atypical Response) and under-report (Response Level) of the child’s symptoms. Furthermore, the TSCYC includes an item that asks “[o]n average, how many hours do you spend in the same place (for example, at home) with him or her each week, not counting when he or she is asleep?” which is rated on a scale from 1 (0–1 hours) to 7 (over 60 hours).
The TSCYC contains eight clinical scales, Post-traumatic Stress-Intrusion (PTS-I), Post-traumatic Stress-Avoidance (PTS-AV), Post-traumatic Stress-Arousal (PTS-AR), Sexual Concerns (SC), Dissociation (DIS), Anxiety (ANX), Depression (DEP), and Anger/Aggression (ANG), as well as a summary post-traumatic stress scale, Post-traumatic Stress-Total (PTS-TOT). These scales allow a detailed evaluation of post-traumatic stress symptoms (and a tentative PTSD diagnosis), as well as providing information on other symptoms such as anxiety, depression, anger, and abnormal sexual behavior. Typical items of the TSCYC are: Looking sad, Bad dreams or nightmares, Living in a fantasy world, Pretending to have sex, Drawing pictures about an upsetting thing that happened to him or her, and Throwing things at friends or family members.
This paper describes the reliability of the TSCYC and its association with several forms of child trauma/maltreatment in a multisite clinical sample. A future paper will outline the convergent validity of this measure with reference to other common tests of abuse- or trauma-specific symptomatology.
Section snippets
Methods
The preliminary version of the TSCYC consisted of 120 items, adapted and expanded from the TSCC to assess caretaker report of children as young as 3 years of age. Items were written by the first author to tap each of the six symptom groups evaluated by the scales of the TSCC (i.e., Post-traumatic Stress, Sexual Concerns, Dissociation, Anxiety, Depression, and Anger), adjusted to reflect the caretaker’s perspective. There was no attempt, however, to create TSCYC items that matched existing TSCC
Validity sample characteristics
The validity sample consisted of caretaker-reports of 219 children, collected by six clinicians or researchers. The mean age of these children was 7.1 years (SD = 2.6), major racial representations were Non-Hispanic Caucasian (N = 80, 38.3%), Black/African American (N = 53, 25.4%), and Hispanic (N = 58, 27.8%), and the majority of children were female (N = 115, 62.8%). According to clinician determination of the child’s maltreatment history, using whatever interview protocol was normally
Discussion
This report documents the psychometric characteristics of a new caretaker-report test of post-traumatic symptoms in younger children. The clinical scales of the TSCYC appear to demonstrate good reliability and to be associated with exposure to maltreatment in a clinical sample of generally maltreated children. The TSCYC scales most associated with different types of childhood abuse were those measuring post-traumatic stress, followed by sexual concerns and dissociation. The three mood-related
Acknowledgements
The first author thanks the following expert panel members for their feedback on the initial version of the TSCYC: Lucy Berliner, MSW; Eve Carlson, PhD; Mark Chaffin, PhD; Judith Cohen, MD; Kathleen Faller, PhD; Bill Friedrich, PhD; Eliana Gil, PhD; Cheryl Lanktree, PhD; Julie Lipovsky, PhD; and Margaret Stuber, MD.
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