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Psychologicalassessmentofchildrenindisastersandemergencies.pdf
Psychological assessment of children in disasters and emergencies 179
Psychological assessment of children in disasters and emergencies
Victor Balaban, Ph.D. Project Manager, ORC Macro, Applied Research Division, US
Children and adolescents are among the most vulnerable members of communities affected by disasters and emergencies. There is a tremendous need for a systematic post-disaster psychological assessment of children and adolescents in order to understand better post-traumatic symptomatol- ogy in children and to identify populations that require an early intervention. This article reviews psychological instruments that are suitable for screening children and adolescents in emergency and disaster contexts for four different types of post-traumatic responses: post-traumatic stress disorder; depression; anxiety disorders; and behavioural disorders. A description of each instrument and psychometric data are provided, along with recommendations on the most appropriate instru- ments to be utilised in different emergency environments and a summary of previous post-disaster evaluations that have used each type. In addition to selecting apposite instruments, other important issues that should be taken into account when conducting post-emergency mental health needs appraisals of children and adolescents are discussed.
Keywords: adolescents, anxiety disorders, assessment, children, depression, disasters, mental health, post-traumatic stress disorder, trauma
Introduction Contemporary man-made and natural disasters, such as the 11 September 2001 terrorist attacks in the United States and the December 2004 tsunami in Southeast Asia, as well as ongoing wars, conflicts and natural disasters around the world, have placed increased attention on the need to understand the effects of large-scale disasters and emergencies on children and adolescents. As recently as the 1980s, it was widely assumed that children’s psychological responses to many types of traumatic events were transient and not overly important (Rigamer, 1986). It is now accepted that disasters and emer- gencies can have devastating effects on children and families. Children’s immature ability to comprehend and process the immediate and long-term effects of emergen- cies—including their own injuries and exposure to harrowing events, traumatised or injured parents, loss of loved ones, disruption of daily routines and frightening images in the media—make them among the most vulnerable members of affected commu- nities (Balaban, in press; Balaban et al., in press; Hoven et al., 2005; La Greca et al., 2003; NACCT, 2003; Pfefferbaum, 1997; Yule, 2000). Early and well-organised psychological screening of children and families, employing valid and reliable methods, should be an essential component of a response to disasters and emergencies in order to identify effectively children and adolescents who have persistent trauma-related symptoms and to direct resources towards at-risk paediatric populations (NACCT, 2003; NIMH, 2002; Shalev, Tuval-Mashiach and Hadar, 2004).
Disasters, 2006, 30(2): 178−198. © Overseas Development Institute, 2006 Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
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However, research into children’s psychological responses to disasters and emergencies is still at an early stage. Many of the published studies on children’s psychological responses to disasters and trauma are contradictory and even basic questions, regarding, for instance, age and gender differences, have not yet been resolved (Yule et al., 2000). One reason for the lack of definitive information on the epidemiology of traumatic responses in children is that assessments have been carried out using a range of instru- ments of varying reliability. As a result, there is a tremendous need for a systematic psychological evaluation of children and adolescents after disasters and emergencies so as to establish better the prevalence and aetiology of children’s post-traumatic symptomatology, and to be able to conduct post-emergency and disaster screenings more effectively. The focus of this review is on the use of validated psychological assessment scales as screening and research instruments, rather than as diagnostic measures. Diagnoses are not essential in the early stages of a disaster response when acute stress reactions may be widespread (Shalev, Tuval-Mashiach and Hadar, 2004). Ideally, this article will assist emergency responders and researchers in selecting quickly appropriate tools for crises requiring a rapid appraisal of child and adolescent mental health.
Choosing the appropriate evaluation instrument Psychological assessment is the area of psychology devoted to examining and analysing behaviour and/or psychological characteristics by means of constructing, administer- ing, scoring and interpreting tests and other measurement devices (Anastasi and Urbino, 1996). When conducting post-emergency appraisals, generally, there is not a single ‘best’ instrument. Different instruments that are appropriate for different contexts, and even those that are psychometrically sound, may have other qualities that could limit their usefulness in different types of populations or emergencies. A good psychological instrument should be both reliable and valid, although validity is normally considered to be the gauge of the utility of a test (Anastasi and Urbino, 1996).1
Thousands of rating scales have been developed for appraising hundreds of different constructs, and simply using a well-known instrument without taking into account its specific characteristics and the context in which it will be employed can result in wasted opportunities and effort. For example, the majority of psychological instru- ments were not created to evaluate traumatised populations and so do not consider symptoms that are empirically known to be associated with child and adolescent trauma (Saylor et al., 1999). In addition, many older scales may have impressive bodies of psychometric data behind them but were not developed explicitly for children or may be based on older or unclear definitions of underlying constructs. Newer scales often have been designed to overcome these problems, but may not yet have been used long enough to reach definitive conclusions on their validity or reliability. Until recently, one of the factors that hampered the assessment of trauma-related mental health effects in children and adolescents was a lack of reliable, validated instruments, but there is now a range of acceptable instruments available for evaluating child and adolescent psychopathology (Myers and Winters, 2002a).
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This paper aims to help bring methodological consistency to future assessments by providing a systematic review of instruments suitable for screening children and ado- lescents in emergency and disaster contexts, and to suggest which instruments might be best for future emergency appraisals.
Methodology The Medline, PsychINFO and Health and Psychosocial Instruments (HaPI) databases were searched for studies from 1974–2004 that used validated psychological instru- ments to assess post-traumatic stress disorder (PTSD), depression, anxiety disorders and behavioural disorders in child or adolescent victims of complex emergencies— defined as wars, terrorist attacks, natural disasters and large-scale transportation or industrial accidents. Instruments that met the following five criteria were included in the review:
• brief—designed to be administered in 60 minutes or less; • in standardised questionnaire format (that is, structured and semi-structured inter-
views were not included); • able to be administered by non-clinicians; • have been used in disaster or emergency contexts or in longitudinal studies of child
and adolescent victims of complex emergencies; and • have published psychometric data behind them.2
Tests that met these criteria were likely to be the most convenient and useful for post-disaster assessments where time, resources and trained personnel may frequently be limited. Two scales, the Trauma Symptom Checklist for Children (TSCC) and the Multi- dimensional Anxiety Scale for Children (MASC), met all the criteria except that they had not been employed in disaster or emergency environments. They are included here because they have specific characteristic that could make them the most appropriate instruments in some emergency settings. Below are descriptions of each disorder and recommendations on the most appro- priate instruments to use in disaster and emergency contexts. Tables 1–4 provide a detailed description of each instrument, information on acquisition and psychometric data, and a summary of post-disaster and emergency assessments where each instrument has been utilised.
Post-traumatic stress disorder Research has established that one potential consequence of exposure to trauma or violence among children is PTSD, an anxiety disorder characterised by persistent reliving of the traumatic event, such as recurring or intrusive thoughts, avoidance of cues associated with the trauma or emotional numbing, and unrelenting physiological hyper-reactivity or arousal (DSM-IV).3 Symptoms of PTSD are among the most
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common types of psychological distress observed in children after a disaster (La Greca et al., 2003; Pfefferbaum, 1997; Pynoos, Goenjian and Steinberg, 1998; Saigh et al., 1999; Yule, 2001). Five instruments met the criteria for review (see Table 1). Of the instruments exam- ined, the PTSD assessment instrument that is most likely to be appropriate for evaluating children across a wide variety of disasters and emergency contexts is the University of California, Los Angeles (UCLA) PTSD Reaction Index (UCLA PTSD-RI). It is designed for use with children and adolescents, has been employed in a variety of emergency environments and has been translated into many languages. In addition, it is inexpensive, simple, fast to administer and score, and has a body of psychometric research to support it. The Impact of Event Scale–Revised (IES-R) is suitable for screening adolescents who have confronted a specific, discrete trauma, but its focus on the effects of a particu- lar event may limit its applicability in contexts where adolescents have been exposed to multiple or ongoing traumas. Furthermore, although it has been used with children and adolescents, it was designed for adults and so may not be the best instrument for child assessments. A shorter, 13-item version of the IES-R (IES-13) has been developed for evaluating children in post-conflict settings, but psychometric data are still limited (Smith et al., 2002). The Child PTSD Symptom Scale (CPSS) is fast to administer and is designed for children. Nevertheless, it is a relatively new instrument with much less available vali- dation data, which may make it more difficult to compare results with those derived from other post-emergency assessment scales. The Posttraumatic Stress Symptoms in Children (PTSS-C) scale is also fast to admin- ister and is designed specifically for assessing younger children exposed to chaotic war environments and traumas. Thus, it may be a useful instrument in those contexts. However, it is a relatively new instrument with little available validation data, which can make it difficult to compare results with those produced by other post-emergency assessments scales. The TSCC has not been employed in disaster settings and hence may not be the best first choice of an emergency PTSD assessment instrument. Yet, it is the only child PTSD instrument apt for use in post-emergency settings that is specifically designed to evaluate children’s responses to sexual abuse. Therefore, it may be useful for assessing children and adolescents in emergencies where rape and sexual trauma are issues.
Depression Depressive disorders are mood disorders that include Major Depressive Disorder (unipolar depression), Dysthymic Disorder (chronic, mild depression) and Bipolar Disorder (manic depression) (DSM-IV). Depression is one of the most common responses to stress and trauma. It is important to examine symptoms of depression in post-emergency environments since depressive disorders in children and adolescents can effect functioning and adjustment, including increased risk of illness and interpersonal
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Table 1 Instruments for assessing PTSD
Instrument Description Availability Length/ administration time
Ages Reliability Use in disasters and emergencies
UCLA PTSD Reaction Index for DSM IV (Pynoos, Goenjian and Steinberg, 1998)
To assess post-trauma symptoms and PTSD in children
No cost; [email protected] 22 items 20–30 minutes
6–17 Internal consistency = 0.69–0.8; interrater reliability = 0.88, test– retest reliability = 0.93 over one week; convergent validity = 0.91 with measures of PTSD
Yes, including children exposed to school sniper attack (Pynoos et al., 1987; Nader et al., 1990), to war in Kuwait (Nader et. al., 1993), Israel (Schwarzwald et al., 1993; Laor et al., 1997; Laor, Wolmer and Cohen, 2001), Lebanon (Macksoud and Aber, 1996) and Gaza (Thabet and Vostanis, 1999; 2000), to the Arme- nian (Pynoos et al., 1993; Goenjian et al., 1995) and Northridge (Asar- now et al., 1999) earthquakes, and to Hurricanes Hugo (Shannon et al., 1994), Andrew (Vernberg et al., 1996) and Iniki (Chemtob, Nakashima and Carlson, 2002)
Impact of Event Scale- Revised (IES-R) (Weiss and Marmar, 1997)
To measure symptoms of PTSD after a traumatic event
No cost; available on many websites, such as http://www.swin.edu.au/victims/ resources/assessment/ptsd/ies-r.html
A 13-item version of the IES-R (IES-13) developed for children affected by war is available at http://www.childrenandwar. org/CRIES-13.doc
22 items 10–15 minutes
Used with children as young as seven (not designed for children)
(Validation data only available for adults.) Internal consistency = 0.79–0.90 for subscales, 0.60–0.90 total; interrater reliability not reported; test–retest reliability = 0.79–0.89 over one week; conver- gent validity = 0.41–0.78 with measures of PTSD
Yes, including survivors of a cruise- ship sinking (Yule and Udwin, 1991; Yule, 1992), French children after an industrial accident (Vila et al., 2001), and Croatian (Kuterovac, Dyregrov and Stuvland, 1994), Bosnian-Serb (Papageorgiou et al., 2000) and Bosnian (Smith et al., 2001) children and Cambodian adolescents (Savin
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et al., 1996; Sack, Him and Dickason, 1999) exposed to war. The IES-13 has been used with Bosnian children exposed to war (Smith et al., 2002)
Child PTSD Symptom Scale (CPSS) (Foa et al., 2001)
To evaluate symptoms and functional impairment related to PTSD
No cost; [email protected] 24 items 15 minutes
8–18 Internal consistency = 0.70–0.80 for subscales, 0.89 total; test– retest = 0.63–0.85 for subscales, 0.84 total; interrater reliability not reported; convergent validity = 0.80 with measures of PTSD
Limited: children following North- ridge earthquake (Foa et al., 2001)
Posttraumatic Stress Symptoms in Children (PTSS-C) (Ahmad et al., 2000a)
To identify paediatric post-traumatic symptoms in chaotic disaster contexts
No cost; [email protected]
30 items 30 minutes
6–18 Internal consistency = 0.78–0.88; interrater reliability = 0.94; test– retest reliability not reported; convergent validity = 0.64–0.95 with measures of PTSD
Limited: Kurdish children exposed to war (Ahmad et al., 2000b; Sundelin-Wahlsten, Ahmad and von Knorring 2001)
Trauma Symptom Checklist for Children (TSCC) (Briere, 1996)
To assess PTSD symptoms after trauma, particularly sexual abuse
Licensed through http://www.parinc.com 54 items 20 minutes
7–16 Internal consistency = 0.70–0.90 for subscales, 0.89 total; interrater reliability not reported; test–retest reliability not reported; convergent validity = 0.75–0.82 with measures of PTSD
No
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Table 2 Instruments for assessing depression
Instrument Description Availability Length/ administration time
Ages Reliability Use in disasters and emergencies
Children’s Depression
Inventory (CDI)
To measure
depressive
symptom
severity in
children
Licensed through http://www.mhs.com 27 items
5–10 minutes
7–17 Internal consistency = 0.70–0.89;
interrater reliability not reported;
test–retest reliability = 0.38–0.87;
convergent validity = 0.44–0.62
with measures of depression
Yes, including Lebanese children
exposed to war (Saigh, 1989), US
children exposed to Northridge
earthquake (Asarnow et al., 1999)
and Hurricane Iniki (Chemtob,
Nakashima and Carlson, 2002),
and French children evacuated
after an industrial accident (Vila et
al., 2001)
Depression Self-
Rating Scale (DSRS)
To measure
symptoms of
PTSD after a
traumatic
event
No cost; contact author 18 items 6–13 Internal consistency = 0.54–0.94;
interrater reliability not reported;
test–retest reliability = 0.74;
convergent validity = 0.84 with
measures of depression
Yes, including adolescent survivors
of a cruise-ship sinking (Yule, Udwin
and Murdoch, 1990; Yule, 1992),
Armenian children after earth-
quakes (Goenjian et al., 1995;
Najarian et al., 1996), and Bosnian-
Serb (Papageorgiou et al., 2000)
and Bosnian (Smith et al., 2001)
children exposed to war
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and psychosocial difficulties that can persist long after the depressive episode is resolved (Bolton et al., 2000; Goenjian et al., 1997; Mollica et al., 1997). Depression in children and adolescents is also associated with a greater risk of suicidal behaviour, and in adolescents, there is also an increased danger of substance abuse (Birmaher, Brent and Benson, 1998; Weissman et al., 1999). Two instruments met the criteria for review (see Table 2). The Children’s Depression Inventory (CDI) and the Depression Self-Rating Scale (DSRS) are both good scales to screen quickly and easily for depressive symptoms in younger children and adoles- cents in disaster and emergency contexts. Both have been used in emergency settings and translated into many languages, and both are inexpensive, simple, fast to administer and score, and have a vast amount of psychometric research to support them. While the CDI has a more extensive body of psychometric data behind it, the response format of comparing and choosing from three similar sentences might confuse some children, particularly younger ones and those in non-Western environments.
Anxiety disorders Anxiety disorders are among the most common mental health problems that can manifest themselves in children and adolescents. They can include: generalised anxiety disorder; acute stress disorder; obsessive compulsive disorder; panic disorder; separation anxiety disorder; conduct disorder; agoraphobia; social phobia; and specific phobias (excessive fear of an object or situation, such as dogs, heights and enclosed spaces) (DSM-IV). There is evidence that pre-existing anxiety disorders are a risk factor in relation to developing post-disaster PTSD symptoms, so assessments should ideally include items to differentiate between pre-existing anxiety disorders and post-disaster symptoms (Asarnow et al., 1999; Silverman and Rabian, 1999; Myers and Winters, 2002b). Four instruments met the criteria for review (see Table 3). Of the anxiety scales examined, the Revised Children’s Manifest Anxiety Scale (RCMAS) would be fitting for use in disaster and emergency contexts, as it has been employed in several post- disaster and emergency situations and has a substantial body of psychometric data behind it. A limitation of the RCMAS is that it does not evaluate all DSM-IV symp- toms of anxiety disorders, but this should not be a problem if the instrument is used for post-emergency screening rather than for diagnostic purposes. The State and Trait Anxiety Inventory for Children (STAI-C) has an extensive body of psychometric data to support it but it also does not review all DSM-IV symptoms of anxiety disorders and has only been used in a few post-emergency assessments. The MASC considers all of the DSM-IV symptoms of anxiety disorders and has adequate psychometric properties, but it has not yet been used in emergency contexts. It should be suitable for post-disaster assessments, but the lack of data on post-disaster assessments that have used the MASC may make it more difficult to compare results with those from other post-emergency evaluations. The Revised Fear Survey Schedule for Children (FSSC-R) is narrowly focused on phobic symptoms and, consequently, is not a helpful instrument for reviewing a wide range of anxiety disorders. However, the fears of children constitute an important
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Table 3 Instruments for assessing anxiety
Instrument Description Availability Length/ administration time
Ages Reliability Use in disasters and emergencies
Multidimensional Anxiety Scale for Children (MASC) (March and Parker, 1999)
To assess anxiety symptoms in children
Licensed through http://www.mhs.com 39 items 15 minutes (10-item short form also available)
8–19 Internal consistency = 0.60–0.90; interrater reliability not reported; test–retest reliability = 0.65–0.93; convergent validity = 0.63 with measures of anxiety
No
Revised Children’s Manifest Anxiety Scale (RCMAS) (Reynolds and Richmond, 1985)
To evaluate anxiety symptoms in children
No cost; available on many websites, including http://www.swin.edu.au/ victims/resources/assessment/affect/ rcmas.html
37 items 6–19 Internal consistency = 0.64–0.76 for subscales, 0.69–0.83 total; interrater reliability not reported; test–retest reliability = 0.63–0.85; convergent validity = 0.78–0.85 with measures of anxiety
Yes, including US children evacuated as a result of the Three Mile Island nuclear accident (Handford et al., 1986), Lebanese (Saigh, 1989), Bosnian-Serb (Papageorgiou et al., 2000) and Bosnian (Smith et al., 2001) children exposed to war, British adolescent survivors of a cruise-ship sinking (Yule, Udwin and Murdoch, 1990; Yule, 1992), and US children exposed to Hurricanes Hugo (Lonigan et al., 1994; Shannon et al., 1994) and Iniki (Chemtob, Nakashima and Carlson, 2002) and the Northridge earthquake (Asarnow et al., 1999)
State and Trait Anxiety Inventory for Children (STAI-C) (Spielberger, Gorsuch and Lushene, 1968)
To gauge anxiety symptoms in children
Licensed through http://www.mindgarden.com
40 items 30 minutes
8–18 Internal consistency = 0.82–0.87; interrater reliability not reported; test–retest reliability = 0.31–0.71; convergent validity = 0.63–0.75 with measures of anxiety
Limited: Lebanese adolescents exposed to war (Saigh, 1985) and French children evacuated after an industrial accident (Vila et al., 2001)
Revised Fear Survey Schedule for Children (FSSC-R) (Wolpe and Lang, 1964)
To provide quantitative information on children’s fears and phobias
Licensed through http://www.edits.net 80 items 30 minutes
7–18 Internal consistency = 0.90; inter- rater reliability not reported; test– retest reliability = 0.80; convergent validity scores not reported
Limited: Lebanese adolescents exposed to war (Saigh, 1985) and British adolescent survivors of a cruise-ship sinking (Yule, Udwin and Murdoch, 1990; Yule, 1992)
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analytical area in determining their post-disaster functioning, so the FSSC-R could be used in conjunction with other assessment instruments if time and resources allow. This point is discussed in more depth in the conclusion.
Behavioural disorders Exposure to traumatic events can result in a variety of forms of disruptive behaviour and numerous behavioural disorders in children and adolescents. The DSM-IV cate- gorises behavioural disorders into three main types: Attention Deficit/Hyperactivity Disorder; Conduct Disorder; and Oppositional Defiant Disorder. Behaviour assessments are most often administered to parents, teachers or other caretakers, since children are not always reliable reporters of their own actions. Four instruments met the criteria for review (see Table 4). Of the behavioural measures considered, the Pediatric Emotional Distress Scale (PEDS) is the only one designed for rapid behavioural assessment of young children following trauma; it may be the most appropriate for a behavioural evaluation in post-disaster settings where testing must be conducted quickly. It is a new instrument, however, with relatively little validation data to support it, which may make it more difficult to compare results with those from other post-emergency appraisals. The other scales reviewed, the Revised Behavior Problem Checklist (RBPC), the Child Behavior Checklist (CBCL) and the Conners Rating Scales-Revised (CRS-R) have extensive bodies of psychometric data behind them. Nonetheless, they do not include specific trauma-related items and take longer to administer, and thus would not be suitable for post-emergency assessments.
Discussion Careful screening and needs assessments using valid and reliable instruments can facili- tate an effective intervention targeted at children and families following a disaster and/or mass violence. Appraisal instruments for disasters and emergencies should be fast and cost-effective in terms of administration, as well as clinically and psycho- metrically sound. Brief instruments are usually preferable in order to avoid burdening families, aid workers, health care professional and the children themselves. An ideal child and adolescent post-emergency assessment battery would include measures of symptoms associated with multiple disorders, that is, PTSD, depression and anxiety, as well as an independent evaluation of the child’s behaviour by an adult. Two exam- ples follow:
Example 1. When evaluating children in a post-conflict or post-disaster setting, an excellent assessment could be assembled containing the following instruments:
• an apposite 10–20 item questionnaire designed to appraise levels of exposure to stressors connected with particular types of disaster, that is, a war, hurricane or earthquake questionnaire;
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Table 4 Instruments for assessing behaviour
Instrument Description Availability Length/ administration time
Ages Reliability Use in disasters and emergencies
Pediatric Emotional Distress Scale (PEDS) (Saylor et al., 1999)
To measure post-traumatic behavioural problems in children
No cost; [email protected] 21 items 10–15 minutes
2–10 Internal consistency = 0.72–0.78 for subscales, 0.85 total; interrater reliability = 0.47–0.64 for subscales, 0.65 total; test–retest reliability = 0.55–0.61 for subscales, 0.56 total; convergent validity = 0.59–0.86 for subscales with measures of externalising behaviour
Limited: parents of US children after hurricanes (Stokes et al., 1995)
Revised Behavior Problem Checklist (RBPC) (Quay and Peterson, 1983)
Rating problem behaviour in adolescents and young children
Licensed through http://www.parinc.com 89 items 20 minutes
5–18 Internal consistency = 0.73–0.94 for subscales; interrater reliability = 0.52–0.85; test–retest reliability = 0.79–0.91; convergent validity not reported
Limited: US children evacuated as a result of the Three Mile Island nuclear accident (Handford et al., 1986)
Child Behavior Checklist (CBCL) (Achenbach, 1999)
General behaviour scale to assess children and adolescents
Licensed through http://www.aseba.org 118 items 45 minutes
6–18 (CBCL/ 11⁄2–5 designed for children aged 11⁄2– 5 years also available)
Internal consistency = 0.78–0.97; interrater reliability = 0.93–0.96; test–retest reliability = 0.95–1.00; convergent validity = 0.88 with measures of behavioural disorders
Limited: mothers of Armenian children exposed to earthquakes (Najarian et al., 1996), Israeli children after SCUD missile attacks (Laor, Wolmer and Cohen, 2001) and French children evacuated after an industrial accident (Vila et al., 2001)
Conners Rating Scales-Revised (CRS-R) (Conners et. al, 1998)
To assess Attention Deficit/Hyper- activity Disor- der (ADHD) in children and adolescents
Licensed through http://www.mhs.com 80 items 15–20 minutes
3–17 Internal consistency = 0.73–0.94; interrater reliability not reported; test–retest reliability = 0.47–0.85; convergent validity = 0.84–0.96 with measures of ADHD
Limited: teachers of Lebanese adolescents exposed to war trauma (Saigh, 1989) and parents of French children evacuated after an indus- trial accident (Vila et al., 2001)
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• the 20-item UCLA PTSD-RI for assessing symptoms of PTSD; • either the 26-item DSRS or the 27-item CDI for examining symptoms of depression;
and • the 37-item RCMAS for gauging symptoms of anxiety.
The 17-item PEDS could be administered simultaneously to the children’s parents and/or primary caretakers in order to assess independently trauma-related behaviour. Used together, these instruments would form a battery of approximately 93–103 questions for children and 17 for adults that would be inexpensive and relatively easy to administer in less than one hour, and would provide excellent data for directing resources and designing psychosocial relief programmes.
Example 2. In a situation where children are being appraised after a natural disaster and time and resources are more limited, a very brief assessment could be assembled containing:
• an assessment questionnaire designed for the type of disaster, that is, a hurricane or earthquake questionnaire of 10 items or less;
• the 20-item UCLA PTSD-RI; • the 10-item CDI; and • the 10-question, short version of the MASC.
The 17-item PEDS could also be administered to the children’s parents and/or primary caretakers. Used together, these instruments would form a battery of approxi- mately 50 questions for children and 17 questions for adults, which would be inex- pensive and easy to administer in approximately 20–30 minutes, and would provide psychometrically valid data without unduly burdening families, aid workers, health care professionals or the children themselves. If time and resources allow, tests designed for specific issues and contexts should also be kept in mind. For instance, in situations where rape, sexual abuse and gender-based violence are issues, the TSCC can be used to review children’s responses to sexual abuse. Furthermore, as noted above, children’s fears are an important area to examine in determining their post-disaster functioning and in helping them to return to normal family and school routines, so the FSSC-R could be employed in this regard.
Factors in designing post-emergency child psychological assessments In addition to selecting the correct instrument, recent research suggests a number of important factors to take into consideration when planning post-disaster assessments of children and adolescents, including:
1) The need to evaluate severity and the type of trauma It is essential that the type, nature and duration of trauma be appraised in children exposed to disasters and emergencies. Several studies have suggested that there are significant relationships between the type and severity of trauma that children are
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exposed to (children exposed to a variety of traumas over long periods (emergencies) versus children in the aftermath of a single, relatively circumscribed event) and the outcome in relation to PTSD, anxiety and depression (Saylor and DeRoma, 2002; Pynoos et al., 1998; Yule, 2001). Various questionnaires have been designed to evaluate levels of exposure to numerous types of disasters, such as wars, hurricanes, earth- quakes and fires. These are not mental health assessment tools themselves, but they are important in terms of their ability to identify at-risk children and adolescents, and whenever possible, they should be part of post-disaster mental health assessments (for a review, see Saylor and DeRoma, 2002).
2) The need to assess multiple disorders As discussed above, a post-disaster and emergency evaluation should not be limited to the prevalence of any single psychological disorder. While a great deal of the current knowledge of children’s psychological responses to disasters is based on research on PTSD, the latter is only one of a range of possible reactions to trauma. Traumatised children can exhibit a variety of trauma-based symptoms, including anxiety, depres- sion, somatic disturbances, learning problems, oppositional behaviour and conduct disorder (Goenjian et al., 1995; Sack et al., 1994; 1995; Saigh et al., 1999; Weissman et al., 1999; Yule, 1999; 2001).
3) Independent assessment of children’s behaviour Gauging the mental health of children often requires input from several informants. Children have generally been found to be able to report accurately their own internal states, but they are frequently not reliable observers of their own behaviour. Adults, by contrast, are normally reliable observers of children’s behaviour, but have a tendency to underestimate children’s internal distress (Jensen et al., 1999; Loeber et al., 1991). Whenever possible, assessments of children should include an adult’s evaluation of the child’s behaviour. However, this should not be a substitute for an appraisal of the children themselves.
4) Assessment of family members, especially mothers If possible, the mental health status of primary caretakers should be reviewed at the same time as children. An assortment of studies has indicated that parental adjustment is an important predictor of children’s mental health outcomes, particularly maternal reactions (Laor, Wolmer and Cohen, 2001; McFarlane, Policansky and Irwin, 1987; Pynoos et al., 1987; Smith et al., 2001).
5) Functional status Whenever possible, instruments that include questions about social and behavioural functioning should be used when assessing children and adolescents in disaster and emergency contexts. Appropriate and adaptive behaviour may be very different following emergencies, so the presence of symptoms does not always indicate functional disability, nor does the absence of reported symptoms signify lack of distress (see, for instance, Bolton, Neugebauer and Ndogoni, 2002; Sack et al., 1995; Shalev, Tuval-Mashiach and Hadar, 2004).
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6) Age and developmental differences Although the impact of age on children’s post-traumatic behaviour and psycho- pathology are not yet well understood,4 it is critically important that any assessment instruments used in an evaluation be age and developmentally appropriate, that is, post-emergency appraisals of young children must take into account their limited verbal skills and different ways of reacting to stress. For example, children too young to verbalise their symptoms may not be able to express signs of numbing and withdrawal, and re-experiencing symptoms may manifest themselves in the form of play re-enactment, rather than flashbacks or intrusive thoughts (Eth, Silverstein and Pynoos, 1985; Scheeringa et al., 1995). Not all paediatric instruments are equally applicable to all children. Instruments for younger children must be carefully constructed using age-appropriate language and concepts, and it is very important that any instrument be used with children of the age it was developed for. In addition, there is evidence that children’s reporting of physical symptoms is strongly influenced by the level of cognitive development as well as by family, parents, peers, and school and community environments (Rhee, 2003). It is likely that similar factors may also influence children’s reporting of psycho- logical symptoms. There is a need for further studies that address these complicated developmental issues.
7) Risk and resilience factors Various studies have identified risk factors that affect the response to trauma and recovery, including exposure to previous traumas, pre-existing psychopathology and lack of social support (Caffo and Belaise, 2003; Pfefferbaum, 1997). Other studies of trauma- tised child populations have also indicated that family displacement and parental loss can add to the effects of the original trauma itself (Norris et al., 2002). Ideally, post- emergency assessments and screenings would include questions to weigh up these and other potential risk factors, as a way of identifying populations of children and adolescents that may be at greater risk of developing trauma-related psychopathology. While most research on the effects of trauma has focused on negative impacts, recent research has also begun to evaluate positive changes (often referred to as ‘post- traumatic growth’ or ‘adversarial growth’) that may also occur following trauma (see, for instance, Tedeschi et al., 1998; Linley and Joseph, 2004). In general, it has been found that the majority of adults exposed to disaster and emergencies show resilience and do not develop trauma-related psychopathology (Shalev, Tuval-Mashiach and Hadar, 2004), but comparable data on children and adolescents are not yet available. Future work should include the identification and testing of measures of resilience and adversarial growth in children and adolescents.
8) Cross-cultural differences Any scale must be used with caution when the population being reviewed is different from the one on which the test was validated. Many assessment instruments may not be fittingly sensitive to cultural and ethnic variability; and simply translating an instru- ment into another language does not necessarily mean that the same symptoms or
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disorders are being appraised across cultures. Even when language is not an issue, original validation studies of an instrument may not be sufficient to establish cut-off scores in a new setting or population. For example, a test validated in a middle-class clinical population may need to be revalidated for use in a non-Western context or in an inner city population exposed to chronic violence (Kleinman and Good, 1986; Mollica et al., 2002). If time and resources allow, there are several strategies that can maximise the cross- cultural validity of existing scales in settings where they have not been validated or of new scales being developed in cross-cultural environments. The first step would be to use ethnographic methods, such as key informant interviews, focus groups, free listing and pile sorts, to determine what symptoms people may be experiencing because of trauma, and to learn the names and symptoms of comparable locally recognised responses to trauma. The next step would be to translate the scale into the local language(s). Accurate translation and back translation are particularly important when considering mental health since even minor mistranslations of expressions regarding mental and emotional states can often substantially alter the meaning of questions. Finally, a pilot study should be conducted to examine the validity of the instrument. At a minimum, an instrument should be shown to have adequate internal reliability, as well as sufficient convergent validity with other measures of the same disorder. For more detailed expla- nations of the process of instrument development and validation, see, for instance, Anastasi and Urbino, 1996, Bolton, 2001 and Mollica et al., 1992. Even when using an instrument that has been employed in a cross-cultural setting, it is not always clear from published articles whether or how it has actually been validated for all the cultures in the locations where it has been utilised. It is always best, therefore, to contact the developer and/or the publisher of an instrument to determine how much validity an instrument has within any particular culture. The fact that very few instruments have been validated in non-Western populations does not mean that psychological assessments using existing instruments cannot be carried out. The comparison by Guarnaccia et al. (1993) of anxiety and depression disorders and a local disorder, ‘ataques de nervios’, in the aftermath of the floods in Puerto Rico, and the comparison by Bolton (2001) of depression and a locally recog- nised grief syndrome, ‘agahinda gakabije’, in post-genocide Rwanda, are examples of how this can be accomplished. No studies currently exist that directly compare the psycho- logical responses to disaster of children in one culture with those of another, and future research should concentrate on understanding the impact of cultural factors on pae- diatric responses to disasters and emergencies (Hinshaw and Nigg, 1999; Yule, 2001).
Conclusion Use of validated rating scales can allow for a fast, cost-effective assessment of behaviour and psychopathology that can facilitate screening and identification of at-risk children and can be used to direct resources in times of crisis, as well as for results to be sub- sequently compared across different periods of time, groups and places. Information
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collected using psychometrically sound instruments can also provide data for further programme evaluations, treatment planning and longitudinal studies to track patterns of development of post-traumatic effects in children and adolescents. This discussion has concentrated on instruments for evaluating children, but it is also important to consider the interpersonal, social and cultural contexts in which child assessments take place. Disasters and emergencies are inherently stressful events and appraisals should ideally be conducted in environments where children feel safe to express themselves and in ways that will not cause any additional anxiety. The design of a post-emergency assessment must be based on careful consideration of realities in a particular place. For example, younger children may be afraid of being separated from their parents or parents in some cultures may not consent to children reviewing themselves, and so it may be appropriate in some locations to conduct child evaluations at the same time as adult and family assessments. When designing post-disaster assessments it is also important to consider the role of resilience and the goal of promoting mental health and not focus exclusively on illness and psychopathology. Ideally, future research will centre on identifying patterns of child trauma, resilience, coping and recovery after disasters and emergencies, and the development of relevant public health tools and instruments, including simple, reliable and valid measures of children’s mental health outcomes. Finally, it should be emphasised that while self-report symptom checklists and questionnaires like the ones reviewed in this paper are important public health tools for assessing mental health, and are extremely useful for screening and epidemio- logical research, they should not be the sole criteria for making clinical diagnoses. No checklist can replace a mental health professional. However, when properly adminis- tered, with awareness of their strengths and limitations, validated behavioural and psychosocial assessment instruments can serve as essential public health measures for determining the prevalence of psychological distress and behavioural symptoms among children and adolescents during and following disasters and emergencies.
Correspondence Victor Balaban, Ph.D., Project Manager, ORC Macro, 3 Corporate Square, NE, Suite 370, Atlanta, GA 30329, US. Telephone: +1 404 592 2238; fax: +1 404 321 3688; e-mail: [email protected].
Endnotes 1 When choosing psychological assessment instruments, it is important to note that some are in the
public domain while others must be licensed. In general, it is useful first to contact the source to find out about the use of an instrument, since there are often different ways in which they can be employed, that is, some licensed instruments can be used at no charge if the person responsible for the test is involved; or if one of the developers is a US government employee, then in some cases, the test can be used free by a US government agency. Further information on rating scales can generally
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be located using reference resources like Tests in Print (Murphy et al., 2002), the Mental Measurements Yearbook (Plake, Impara and Spies, 2003) and electronic databases such as Health and Psychosocial Instruments (HaPI).
2 For each instrument, available psychometric data are reported regarding: internal consistency; interrater reliability coefficients; test–retest reliability coefficients; and convergent validity, either with regard to clinician diagnoses or other measures. Because the focus of this review is on the use of instruments for screening, rather than for diagnoses, measures of the construct validity of the underlying diagnostic categories are not reported.
3 The Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV), published by the American Psychiatric Association, is the main diagnostic reference for diagnosing psychological disorders used by mental health professionals in the US. Internationally the DSM-IV and the International Classifi- cation of Diseases (ICD-10) are both used.
4 There is evidence that younger children may be more likely to develop PTSD than adolescents and adults, and that girls may be at greater risk than boys, but overall the evidence on whether age and developmental level are risk factors or protective factors remains ambiguous. In particular, there is an urgent need for data on the effects of post-traumatic stress on children less than eight years of age (Kerig, 2000; Shannon et al., 1994; Yule et al., 2000).
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