Investigation of the Psychometric Properties and Treatment Outcomes for a Brief Measure of Trauma Related Symptoms in Adolescents

Abstract

The purpose of this article is to explore the psychometric properties of a brief measure of trauma-related symptoms among adolescents in psychotherapy, the ACORN Trauma Measure, as compared to a general outcome questionnaire called the ACORN Global Distress Measure. The ACORN Trauma Measure includes three trauma-specific items intended to give clinical insight into the possibility of trauma as well as monitor trauma-specific symptoms over the course of treatment. Results showed that correlated highly with the overall Global Distress Scale (GDS) as measured by the Global Distress Measure. Improvement on the Trauma Measure trended with improvement shown on the Global Distress Measure. The results support the clinical utility of using a measure of trauma symptoms in combination with a measure of other common presenting problems of global distress such as symptoms of depression, anxiety, loneliness/social isolation, and daily function in school and elsewhere and self-harm ideation.

Purpose

The purpose of this article is to explore the psychometric properties of a brief measure of trauma related symptoms among adolescents in psychotherapy. Items for the ACORN Trauma Measure (see Appendix A) were crafted by clinicians treating trauma survivors to track the severity of trauma symptoms of their clients over the course of treatment. This was useful in populations where the Global Distress Measure (see Appendix B) could measure the general outcome of treatment, but not shed light on specific trauma symptoms and how their severity changed over time. This is consistent with how other items on the ACORN Global Distress Measure were . The ACORN Trauma Measure and Global Distress Measure share several items.

The ACORN Global Distress Measure measures the construct of Global Distress, also known as the common factor. (Lo Coco et al., 2008; Brophy et al., 1988; Enns et al., 1998; Mueller et al., 1998).

Measuring Trauma

Childhood trauma incidences such as emotional, physical, and sexual abuse contribute to mental health difficulties, poor social functioning, with large costs to public finances (Felitti et al., 1998; Magruder et al., 2017; Norman et al., 2012; Weber et al., 2016). Systematic reviews and meta-analyses have consistently demonstrated correlations between childhood trauma incidences and depression (Humphreys et al., 2020; Infurna et al., 2016; Li et al., 2016; Nanni et al., 2012); childhood trauma and substance use (Basedow et al., 2020; Chen et al., 2010; Setién-Suero et al., 2020); childhood trauma and self-harm (Brown et al.,2018;  Lang & Sharma-Patel, 2011; Thomassin et al., 2016); childhood trauma and poor social functioning (Hjelseng et al., 2020; Scoglio et al., 2020); childhood trauma and bipolar disorder (Quidé et al., 2020); and childhood trauma and mood and anxiety disorders (Copeland et al., 2018; Hughes et al., 2017;  Scott et al., 2012). These findings further support the conclusion that trauma items can be thought of as a subset of the larger domain of global distress. This will be discussed further in the results section of this article.

Those presenting to treatment for support with such global distress related symptoms (depression, anxiety, etc.) may have unidentified underlying trauma incidences that are contributing to poor mental health and psychological functioning (Kessler et al., 2010; Levine, 2010). Likewise, clinicians may mistakenly attribute trauma diagnosis to other adverse mood or emotional experiences (Krupnik, 2019; McCrory et al., 2010; McLaughlin, 2016). Thus, discriminating whether these presenting issues are trauma or general mood and emotional symptomology in this cohort of adolescents during the assessment process may aid to create more effective treatment outcomes.

The extent that clinicians routinely assess for trauma incidences in adolescents in routine practice is largely undocumented. At the same time, assessing for traumatic incidences tells us relatively little about the psychological functioning of the adolescent, with self-report measures generally asking about the prevalence of trauma experiences, such as the Childhood Trauma Questionnaire (Bernstein et al., 2003). Other measures that aim to capture symptoms, such as the University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index for DSM-5, have good psychometric properties, but rely on narrow post-traumatic stress disorder (PTSD) diagnosis related symptoms as outcome criteria, as opposed to a broader psychological assessment of global functioning (Steinberg et al., 2013). Neither of these measures lend themselves well to routine use, with brevity and clinical utility possibly impacting uptake by clinicians. Moreover, other global distress measures don’t generally contain trauma specific items. Thus, the present paper reports on the psychometric properties and treatment outcomes associated with a Trauma Measure which includes other items that correlate with Global Distress. Using a questionnaire that combines trauma-specific items with other global distress items could provide valuable clinical information for clinicians treating populations in which trauma has been likely to occur.

Method

Measures

For the ACORN Trauma Measure (see Appendix A) each item is scored on a five point-Likert scale, with anchors ranging from Almost never (0) to Almost always (4). Likewise, the ACORN Global Distress Measure (see Appendix B) is scored in this way (five point-Likert scale, with anchors ranging from Almost never (0) to Almost always (4)). Questionnaires are scored by taking the mean of all non-missing items. The reliability (Cronbach’s alpha) is .87 for the ACORN Trauma Measure and .88 for the ACORN Global Distress Measure.

Results

The sample consisted of 572 individuals who completed at least one trauma questionnaire and 43,141 individuals who completed at least one Global Distress Measure.

Factor analysis of the Trauma Measure revealed that the trauma items correlated highly with the Global Distress Factor. Factor loadings are shown next to each trauma-specific item below:

Insert table 1 about here:

Table 1: Results of Trauma-Specific Items Factor Analysis

Item	Correlation with Global Distress Factor
Feel like you weren’t inside your body?	.63
Have a physical reaction when reminded of an upsetting experience? (For example, heart beating fast, stomach pain, sweating, etc.)	.73
Have upsetting thoughts or images when reminded of a past experience?	.76

In the table that follows, we report the Effect Size for individuals who completed each measure, after adjusting for severity at the first assessment as well as diagnosis. This metric is known as Severity Adjusted Effect Size (SAES) (Brown et al., 2015a, Brown et al., 2015b). The First Assessment row reports the Global Distress Score at the intake session. The Global Distress Score is found by taking the mean of all non-missing items.

Insert table 2 about here:

Table 2: Comparison of Global Distress Measure and Trauma Measure

Measure: Global Distress
Variable	N	Mean	Standard Deviation
First Assessment	43141	1.29	0.73
SAES	19501	0.82	1.01
Measure: Trauma
First Assessment	572	1.42	0.76
SAES	327	0.74	1.06

These results indicate a high degree of internal consistency between the measures. Therefore, from a construct validity point of view, these items can be considered part of the global distress construct rather than representing a clearly separate psychometric construct. That said, knowledge of trauma can be meaningful for the clinician’s treatment approach.

First Assessment

            In the group that filled out a Global Distress Measure, the intake Global Distress Score is on average lower (M=1.29, SD .73) compared to the group that filled out a Trauma Measure (M=1.42, SD=.76). A two-tailed t-test revealed that this difference is statistically significant (p<.001).

Severity Adjusted Effect Size

            In the group that filled out a Global Distress Measure, the Severity Adjusted Effect Size (SAES) is on average higher (M=.82, SD 1.01) compared to the group that filled out a Trauma Measure (M=.74, SD=1.06). A two-tailed t-test revealed that this difference is not statistically significant (p>.1) or clinically meaningful.

Summary

The results support the utility of using a Trauma Measure that also measures Global Distress, as is the case with the ACORN Trauma Measure. The measure provides clinicians with insight into understanding which clients are affected by trauma and allows for the monitoring of trauma-specific symptoms over the course of treatment. As our factor analysis comparing trauma-specific items and the Global Distress construct shows, it is possible to measure both trauma specific symptoms and Global Distress concurrently within a single questionnaire. The benefit of this approach is to monitor the client’s trauma-specific symptoms while concurrently measuring the client’s global distress score over the course of treatment with items that measure symptoms of depression, anxiety, loneliness/social isolation, and daily function in school and elsewhere, self-harm ideation and substance abuse. The ACORN Trauma Measure utilizes maximum efficiency of a client’s time while providing an assessment of trauma symptoms that might otherwise be missed by a clinician.