What is a Trauma Screening Tool or Process?
Trauma screening is designed to be able to be administered to every child within a given system (such as child welfare) to determine whether he or she has experienced trauma, displays symptoms related to trauma exposure, and/or should be referred for a comprehensive trauma-informed mental health assessment. Trauma screening can include a particular tool or a more formalized process. Trauma screening should evaluate the presence of two critical elements:
(1) Exposure to potentially traumatic events/experiences, including traumatic loss
(2) Traumatic stress symptoms/reactions
Not all children who experience negative events suffer posttraumatic or trauma-specific reactions as a result. Trauma screening should measure a wide range of experiences, identify common reactions and symptoms of trauma (e.g., PTSD, dissociation), as well as other commonly reported difficulties (e.g., anger, behavior problems, depression, anxiety). With proper training, professionals or paraprofessionals from various child-serving systems—pediatric/medical settings, schools, home visiting programs, and domestic violence programs/shelters—can administer the screening.
Screening typically covers the following types of traumatic stress symptoms/reactions:
- Avoidance of trauma-related thoughts or feelings
- Intrusive memories of the event or nightmares about the event
- Hyper-arousal or exaggerated startle response
- Irritable or aggressive behavior
- Behavioral problems
- Interpersonal problems
- Other problems based on the developmental needs and age of the child
The following case example highlights the role trauma screening plays in understanding a child’s history of trauma and its role in subsequent behaviors.
CASE EXAMPLE Joshua: Screening Process
Joshua is a 12-year-old Caucasian boy whom child welfare placed with his grandmother several months ago. His behavior has declined since his middle sibling was placed in the same home. He reacts strongly when his sister gets more attention than he gets. In therapy, Joshua says that he gets angry with her easily and that being around her is “like all this old stuff coming back again.” His moods shift from flat to volatile with frequent angry outbursts, verbal and physical aggression toward family members, and multiple signs of physiological arousal (e.g., difficulty sleeping, trouble concentrating, edginess, and irritability). He was recently diagnosed with Oppositional Defiant Disorder and ADHD.
Joshua’s grandmother, who has a history of childhood trauma, has become increasingly depressed and overwhelmed by his emotional outbursts and has difficulty consistently caring for the children. Child Protective Services (CPS) has become re-involved and is considering a more intensive level of care for Joshua.
What additional information do you need to develop a case management plan for Joshua? What events in Joshua’s current situation concern you? What other services might he need? If you would consider further screening or assessment, what questions about Joshua would you hope to answer?
You may wonder how Joshua’s experiences have affected him. He has been exposed to several potentially traumatizing events, but not all of these events may have had a harmful effect.
A trauma screening reveals that Joshua has suffered multiple traumatic events, including being locked in dark closets for hours at a time, being forced to watch his biological father fondle his youngest sibling, being isolated and denied food and water for more than a day at a time, unpredictable violence by his father, and ongoing substance use by both parents. As his sister was present during the abuse, she serves as a powerful reminder to Joshua. His trauma symptoms include irritability, difficulty concentrating, avoidance of discussing the abuse, being on “hyper alert,” and having nightmares.
Given the results of this screening, the case management plan should include referring Joshua to a trained provider for a more comprehensive trauma-focused mental health assessment of the accuracy of the diagnoses and his current treatment needs.
*Adapted from the Child Welfare Trauma Training Toolkit.
Types of Screening Tools
Clinicians may administer the trauma screening in a number of ways depending on the age and developmental stage of the child and on the child’s relationship with the caregiver and other collateral informants in his or her life. For example, in very young children, it is difficult to screen specifically for “trauma symptoms.” Rather, a provider may screen for exposure to traumatic events and social and emotional difficulties, such as attachment difficulties or mood dysregulation. As the child gets older, it may be more appropriate to screen specifically for trauma symptoms.
Most screening tools are for use by professionals with a range of training and experience. However, providers using a screening tool should consider (1) factors such as age, race, linguistic skills, and cognitive/developmental capabilities; (2) whether the client is among the populations for which the tool has been validated and normed; and (3) if there are factors which might affect the reliability and validity of the tool for this particular client.
- Child-Completed Tool (Self-Report)—Child-completed tools are appropriate for children, typically ages eight and above, who are able to read and complete the questions. These measures provide the child with an opportunity to verbalize his or her responses aloud or in writing.
- Caregiver-Completed Tool—For infants, toddlers, young children (ages 0-8), or children with developmental delays, it is more appropriate to have a caregiver complete the trauma screening either by providing written responses to the questions/items or through an interview by the provider.
- Provider-Completed—The caseworker, clinician, or other professional can administer certain tools as he/she reviews and integrates available information on a child (e.g., court reports, interviews with caregivers and teachers, other questionnaires, and behavioral observations). These tools can be useful in consolidating a range of information in one place so that it is readily accessible.
Engaging Families in the Screening Process
To engage families in the screening process, the individual administering the tool should consider the following:
- Explain the purpose and use of the screening tool and process. Say why you need to know this information, how you will use what you gather, how it may benefit the child/family, and who will have access to the information in the future. Emphasize that the information is confidential in most cases, unless the child endorses harm to self or others or the clinician has concerns regarding child abuse.
- After the client/family has completed the trauma screening, share the results and show how you are using the information. For example, “It’s clear from the forms that you filled out that your daughter is having a really hard time with nightmares and fear of things that remind her of her brother getting hurt. We call this ‘Post-Traumatic Stress.’ To help her, I would like to refer you to a therapist who specializes in treating children with these problems.”
- Make sure to thank the child for completing the tool or process, particularly if he or she disclosed a new trauma. Explain that the child’s feelings and trauma reactions are normal and expected, given what he or she has lived through.
- Consider the potential burden of the trauma screening to family members in terms of time and effort, and highlight the potential benefits, such as helping to link them to appropriate providers and services. Some families may be discouraged by the process; others may be comfortable with it. When clinicians explain the purpose and use of the screening tools and share the results, they enhance the benefits to families.