TRAUMA AND ADOLESCENCE III: ISSUES OF IDENTIFICATION, INTERVENTION, AND SOCIAL POLICY

Adolescent Psychiatry, 2003 by Becker, Daniel F, Daley, Melita, Green, Monica R, Hendren, Robert L, Et al

THE COMMITTEE ON ADOLESCENCE OF THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

Knowledge about the nature, scope, and impact of trauma in adolescence carries with it the imperative to identify those trauma-exposed adolescents who need psychiatric intervention and to provide appropriate assistance to them. To be effective, interventions should prevent long-term noxious effects as well as ameliorate the aftereffects of trauma in those who already show sequelae. A subsequent chapter in this special section deals with interventions. This chapter focuses on the issues involved in identification and intervention, including the need for appropriate training for psychiatrists and other mental health workers.

DIAGNOSTIC ISSUES AND ASSESSMENT

A key part of the enhanced understanding of trauma has been the recognition that there are specific sequelae in the form of symptoms and syndromes. We now have general agreement about posttraumatic symptoms as well as diagnostic criteria for syndromes. These standardized criteria have led to more systematic approaches to the evaluation of trauma victims. They have facilitated community surveys to determine the extent of exposure to trauma and its impact. Assessment methods and diagnostic criteria are still evolving. Although there is not yet a gold standard for assessment of trauma and its sequelae, work has been proceeding rapidly, and there are now many questionnaires and standardized interviews available. These standardized assessment tools have enabled much of the research in the past two decades, which has dramatically increased awareness of the extent to which adolescents in today's world are exposed to a wide range of potentially traumatic experiences.

Asking about Traumatic Experiences

Inquiry about trauma history should be made routinely as part of any comprehensive diagnostic assessment of an adolescent. Special care should be taken to ask about violence exposure, including abuse, in urban youth, runaways, and any teenager with a history of suicidal or delinquent behavior or substance abuse (Clark, Lesnick, and Hegeous, 1997; Steiner, Garcia, and Matthews, 1997). Victims of war and natural disasters should be asked about their experiences and their feelings about these experiences as well as about posttraumatic symptoms. Interviewers often shy away from asking about painful experiences, feeling that it will be too upsetting, but trauma victims are usually willing to talk about such experiences, and the experience of telling their stories can be helpful to them (Weine et al., 1995).

Assessment of Symptoms

The categorization and severity rating of symptoms is an important way of understanding the effects of trauma on individuals. The realization that a similar constellation of symptoms could be found in diverse populations exposed to various kinds of trauma, across different ethnic and cultural backgrounds and age groups, was a landmark in the history of psychiatric nosology. Such studies helped to establish the utility of symptom and behavioral profiles to make diagnoses providing the basis for much of the current research conducted on trauma. The recognition that various symptoms related to traumatic stress can be seen at all ages, even in young children, laid the foundation for much important research.

Although it is important to determine who meets criteria for posttraumatic stress disorder (PTSD) and other disorders, the presence of symptoms and constellations of symptoms that do not meet full criteria for a disorder in the literature also has clinical significance. Subsyndromal conditions, characterized by some but not all symptoms necessary for a diagnosis of PTSD, are common in trauma survivors and can be accompanied by significant impairment (Stein et al., 1997).

Assessing Traumatic Exposure

Another approach is to list a variety of kinds of experiences that would be traumatic for most people and to ask whether the teenager has experienced any of these. This kind of approach has been most developed with regard to violence exposure, for which researchers have developed a number of fairly simple instruments to use in both clinical and nonclinical populations. Support for the validity of this kind of assessment is provided by consistent findings that the level of symptoms and/or impairment is correlated with the degree of violence exposure. For example, Schwab-Stone and colleagues (1999) used a checklist, adapted from an earlier version (Richters and Martinez, 1993), to study the effects of violence exposure on urban youth. The checklist included the following categories: 1) seriously wounded, 2) shot or shot at, 3) attacked or stabbed with a knife, 4) threatened with serious bodily harm, 5) chased by gang or individuals, 6) beaten up or mugged. Questions about these experiences can be answered with yes or no and then the number of yes responses totaled to obtain a numerical score for quantifying violence exposure.

Generally, direct victimization is differentiated from witnessing violence. Thus, adolescents might be asked whether they have ever been beaten up or mugged (direct victimization) or seen someone else beaten up or mugged (witnessing). Some surveys query the relationship of the victim to the witness, under the assumption that witnessing violent victimization of a close friend or relative is worse than seeing a stranger being attacked.