Denton 2016

631607
research-article2016
CCP0010.1177/1359104516631607Clinical Child Psychology and PsychiatryDenton et al.
Article
Clinical Child Psychology
and Psychiatry
The assessment of developmental 2017, Vol. 22(2) 260–287
© The Author(s) 2016
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A systematic review DOI: 10.1177/1359104516631607
https://doi.org/10.1177/1359104516631607
journals.sagepub.com/home/ccp
Ruth Denton1, Catherine Frogley1, Sue Jackson1,2,

Mary John1 and Dawn Querstret1
1School of Psychology, University of Surrey, UK
2Psychology, University of the West of England, UK
Abstract
Background: The assessment of children and young people with history of complex
developmental trauma presents a significant challenge to services. Traditional diagnostic
categories such as post-traumatic stress disorder (PTSD) are argued to be of limited value, and
while the proposed ‘Developmental Trauma Disorder’ definition attempts to address this debate,
associated assessment tools have yet to be developed. This review builds on a previous review of
assessment measures, undertaken in 2005.
Aim: To identify trauma assessment tools developed or evaluated since 2004 and determine which
are developmentally appropriate for children or adolescents with histories of complex trauma.
Method: A systematic search of electronic databases was conducted with explicit inclusion and
exclusion criteria.
Results: A total of 35 papers were identified evaluating 29 measures assessing general functioning
and mental health (N = 10), PTSD (N = 7) and trauma symptomatology outside, or in addition
to, PTSD (N = 11). Studies were evaluated on sample quality, trauma/adversity type, as well as
demographic and psychometric data. Distinction was made between measures validated for
children (0–12 years) and adolescents (12–18 years).
Conclusion: Few instruments could be recommended for immediate use as many required
further validation. The Assessment Checklist questionnaires, designed with a developmental and
attachment focus, were the most promising tools.
Keywords
Developmental trauma, complex trauma, assessment, questionnaire, child, adolescent
Introduction
Substantial numbers of children experience adversity in the form of abuse, neglect and maltreat-
ment (Radford et al., 2011). The impact of childhood adversity can be extensive (for review, see
D’Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012), and these children often present
Corresponding author:
Catherine Frogley, School of Psychology, University of Surrey, Guildford GU2 7XH, UK.
Email: c.frogley@surrey.ac.uk
Denton et al. 261
with varied emotional and behavioural difficulties frequently prompting multiple co-morbid diag-
noses from professionals (Ackerman, Newton, McPherson, Jones, & Dykman, 1998; Spinazzola
et al., 2005). Current diagnostic constructs have been criticised for failing to provide adequate con-
ceptualisation of these children’s difficulties (van der Kolk, 2005), while popular standardised
measures may have limited scope to capture the pervasive and complex range of difficulties dis-
played by this population (Achenbach, Dumenci, & Rescorla, 2003; Tarren-Sweeney, 2013a). These
issues complicate the challenge of undertaking meaningful assessment of children and young people
exposed to multiple traumatic experiences during early development (Tomlinson & Philpot, 2008).
A diagnosis of developmental trauma

The traditional psychiatric label given to pathological distress following a traumatic event is post-
traumatic stress disorder (PTSD). The Diagnostic and Statistical Manual of Mental Disorders–Fifth
Edition (DSM-V; American Psychiatric Association (APA), 2013) defines a traumatic event as expo-
sure to actual (or threatened) death, serious injury or sexual violation and is largely conceptualised as
contained within a single incident (Davidson, Hughes, Blazer, & George, 1991). This fails to capture
that child victims of physical, sexual and emotional abuse, or indirect witnesses of domestic violence,
often experience multiple forms of abuse on frequent occasions (Cook et al., 2005; DeJong, 2010;
Dong et al., 2004; Finklehor, Turner, Ormrod, & Hamby, 2009; Streeck-Fischer & van der Kolk,
2000). Moreover, high proportions of children reporting multiple abuse do not meet the criteria for
PTSD in childhood (Pynoos et al., 2008 as cited in van der Kolk et al., 2009; Spinazzola et al., 2005)
and experience difficulties in adulthood which exceed PTSD criteria such as affect regulation, mem-
ory, attention, self-perception, interpersonal relationships, somatisation and systems of meaning
(Roth, Newman, Pelovitz, van der Kolk, & Mandel, 1997; van der Kolk et al., 1996).
To address these issues, van der Kolk (2005) proposed a new diagnostic classification called
‘Developmental Trauma Disorder’ (DTD). DTD captures the multiple or ongoing exposure to
interpersonal violence and disruptions in protective caregiving (van der Kolk et al., 2009) within a
framework of developmental change and disrupted attachment, a position supported by biological
and neurological research (Glaser, 2000). Therefore, behaviours which would have previously
been given separate ‘co-morbid’ diagnostic labels are understood to be a complex, disorganised,
but interrelated pattern of symptoms (D’Andrea et al., 2012; Praver, DiGuiseppe, Pelcovitz,
Mandel, Gaines, 2000). Cook et al. (2005) proposed a similar diagnosis but labelled it ‘Complex
Trauma’. Children with Complex Trauma also meet the criteria for DTD in addition to responding
to every novel experience as a potential threat (Cook et al., 2005). Complex Trauma and DTD have
similarities in their defined domains of difficulty (for a comprehensive discussion of both con-
structs, see Strickler, 2011). As we feel the DTD terminology best captures the dynamic develop-
mental context of the traumatic experiences of children and adolescents, this review will utilise the
phrase ‘developmental trauma’ to define multiple or chronic exposure to interpersonal violence,
emotional abuse, sexual abuse and impaired caregiving in childhood or adolescence. Nonetheless,
it is important to note that some children will not reach these criteria and thus formulation remains
an important alternative to diagnosis. Clinical formulation integrates the child’s symptoms and
context in order to provide a shared understanding of the child and a framework for developing the
most suitable interventions.
Assessing children and adolescents with developmental trauma

Studies suggest that children with histories of developmental trauma are given co-morbid diagno-
ses (Spinazzola et al., 2005), meet sub-threshold levels for a range of disorders (DeJong, 2010)
262 Clinical Child Psychology and Psychiatry 22(2)
or display an array of behaviours outside of diagnostic categories, for example, faecal smearing,
sexualised behaviour and food hoarding (Iwaniec, 2006). Children with complex trauma histo-
ries commonly meet the criteria for a number of internalising and externalising DSM-IV disor-
ders (Ackerman et al., 1998). For example, in one study, up to 40% of these children had at least
one other co-morbid mood, anxiety or disruptive behaviour disorder diagnosis in addition to
symptoms of PTSD (Copeland, Keeler, Angold, & Costello, 2007).
Although children who have experienced childhood or adolescent trauma require a comprehen-
sive, broad and accurate formulation of their difficulties, there are often contextual factors which
impede this process. They are frequently placed in local authority care where their foster carers
have limited knowledge of the child at the point of assessment – a problem particularly on meas-
ures which require symptom ratings for the preceding 6 months (e.g. Child Behaviour Checklist
(CBCL); Achenbach, 1991). While younger children can struggle to articulate their internal emo-
tional experience using verbal expression (van der Kolk, 2005), older children can experience high
levels of shame and distress (Hughes, 1998) and may be reluctant to complete the measures.
Finally, the DTD debate is relatively new, and as such standardised assessment measures have yet
to be developed. Measures commonly utilised have a theoretical basis with the PTSD literature
(Hawkins & Radcliffe, 2006) or cover broad psychopathological perspectives such as the CBCL or
the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1999); neither of which were
designed for a traumatised population.
Purpose and aims of this review

A recent review by Strand, Sarmiento, and Pasquale (2005) discussed the practical properties of
screening and assessment tools for trauma. The review failed to consider age-specific tools and
combined symptomatic and abuse screening tools. Therefore, the purpose of this review was two-
fold: (1) identify trauma assessment measures developed or evaluated since 2004 and (2) deter-
mine which measures are developmentally appropriate for children and adolescent populations
who have suffered developmental trauma.
Method
Search strategy
The following electronic bibliographic databases were searched: MEDLINE, PsycINFO,
PsycARTICLES, Psychology, Behavioural Sciences Collection, PsycBOOKS and Web of Science.
All searches were restricted to work published in English between January 2004 and May 2015.
The following search terms were used: (measure* OR questionnaire OR checklist OR instrument
OR self-report OR observation) OR (assessment AND validity OR reliability OR standardisation
OR comparison OR evaluate AND (abuse OR neglect OR maltreatment OR complex trauma OR
developmental trauma OR adversity OR PTSD OR post traumatic*) AND (child OR children OR
adolescent OR juvenile OR welfare OR looked after). Searches were also undertaken for the symp-
tomatic measures listed in Strand et al.’s (2005) review.
Inclusion criteria
Studies included in the review evaluated the psychometric properties of assessment measures in
participants:
Denton et al. 263
•• Aged 0–18 years;
•• Exposed to multiple traumas including sexual, physical and emotional abuse, witnessing or
experiencing domestic violence, and neglect.
Exclusion criteria
Studies excluded from the review evaluated:
•• Adults (18 years or above);

•• Retrospective instruments of childhood trauma;
•• Measures screening for traumatic experiences;
•• Participants only with experiences of single-event trauma such as road traffic accident;
•• The use, but not evaluation, of assessment measures;
•• Papers published before January 2004;
•• Cross-cultural validation of questionnaires or measures outside of the United Kingdom,
United States, Canada, Australia and Europe.
Quality assessment
The papers were evaluated against a range of criteria including psychometric rigour, sample demo-
graphics, trauma/adversity demographics and the clinical utility of the tool for the assessment of
children and young people with a history of developmental trauma.
Results
A total of 2273 papers focussed on children aged 0–11 years, and 1997 papers focussed on young
people aged 12–18 years were identified. After screening, 35 papers evaluating 29 measures met
the inclusion/exclusion criteria. Demographic information (Tables 1, 3 and 5) and quality of the
measures (Tables 2, 4 and 6) are presented in tabular form. The measures are summarised in three
categories: (1) general functioning and mental health, (2) measures of PTSD and (3) measures of
trauma symptomology outside, or in addition to, PTSD diagnostic criteria, each of which will be
discussed in turn. Distinction is made between measures validated for children (0–11 years), ado-
lescents (12–18 years), or across the whole age range. Information regarding studies’ sample size
and gender can be found in Tables 1, 3 and 5 and will not be discussed within the text of the review.
General functioning and mental health

Ten measures were identified for the assessment of general functioning and mental health (Tables
1 and 2). Of these, one measure (Child Sexual Behaviour Inventory (CSBI); Baker et al., 2008) was
validated for use with children, six (Solution Focused Recovery Scale (SFRS; Kruczek &
Ægisdóttir, 2005), Child and Youth Resilience Measures (CYRM-28; Liebenberg, Ungar, &
LeBlanc, 2013; CYRM-12; Liebenberg, Ungar, & Van de Vijver, 2012), Minnesota Multiphasic
Personality Inventory–Adolescent (MMPI-A; Murray, Glaser, & Calhoun, 2013), Adult Attachment
Interview (AAI; Bailey, Moran, & Pederson, 2007; Madigan, Vaillancourt, McKibbon, & Benoit,
2012), Adolescent Clinical Sexual Behaviour Inventory (ACSBI; Friedrich, Lysne, Sim, & Shamos,
2004; Wherry, Berres, Sim, & Friedrich, 2009), Beck Self Concept Inventory for Youth (BYI-S;
Runyon, Steer, & Deblingerm, 2009) were validated for use with adolescents and three were vali-
dated for both age groups (Global Assessment of Functioning (GAF; Blake, Cangelosi, Johnson-
Brooks, & Belcher, 2007), Children’s Global Assessment Scales (CGAS; Blake et al., 2007) and
Vineland-II (Becker-Weidman, 2009)).
264
Table 1. Demographic data of measures of general functioning and mental health constructs.
Instrument Original author(s) Description Format

Solution Focused Recovery Scale Dolan (1991) 36 items. Likert-style. Positive coping skills specific to childhood Self-report
sexual abuse
Vineland Adaptive Behaviour Sparrow, Cichetti, and Assesses personal and social functioning in communication, Four versions: semi-
Scale-II Balla (2005) motor skills and socialisation domains. Emotional and structured interview,
behavioural difficulties interfering with functioning parent/carer, teacher,
extended interview
Child and Youth Resilience Ungar and Liebenberg 28 items. Assesses resilience across cultural contexts. Likert Self-report
Measure-28 (2005, 2011) Scale
Liebenberg, Ungar, and
Van de Vijver (2012)
Child and Youth Resilience Liebenberg, Ungar, and 12 items. Assesses resilience across cultural contexts Self-report
Measure-12 LeBlanc (2013)
Minnesota Multiphasic Personality Butcher et al. (1992) 478 items. Assesses psychopathology among youth. Large range Self-report
Inventory–Adolescent of clinical and supplementary scales included
Beck Self-Concept Inventory for Beck, Beck, Jolly, and 20 items. Assesses competence and self-worth. Likert-style Self-report
Youth Steer (2001)
Adult Attachment Interview George, Kaplan, and Main Assesses adult representation of attachment. Interviews Semi-structured
(1985) recorded, transcribed and coded. Classified into attachment interview
representation categories: autonomous, dismissing,
preoccupied, unresolved or cannot classify
Global Assessment of Functioning American Psychiatric Assesses level of psychological, social and occupational Clinician rating
Scale Association (APA) (1987) functioning among adults. Ten sections with corresponding
descriptive characteristics for each 10-point increment. Lower
scores suggestive of low level of functioning
Children’s Global Assessment of Shafer et al. (1983) Assesses global functioning among children and adolescents. Clinician rating
Functioning Scale Comparable scoring to the Global Assessment of Functioning
Adolescent Clinical Sexual Friedrich, Lysne, Sim, and 45 items. Assesses range of sexual behaviours among Two versions: self-report
Behaviour Inventory Shamos (2004) adolescents. Scored on 3-point scale and parent report
Child Sexual Behaviour Inventory Friedrich (1998) 38 items. Measure of the frequency of sexual behaviours in Parent report
children aged 2–10 years
Clinical Child Psychology and Psychiatry 22(2)
Table 2. Quality data of the measure of general functioning and mental health constructs.
Instrument Author(s) Age Sample size Trauma/adversity type Sample gender Validity Reliability
Solution Focused Kruczek and Adolescent N = 99 Childhood sexual abuse Female Construct: exploratory factor analysis – 3 Internal: correlations of
Denton et al.
Recovery Scale Ægisdóttir factors explained 38% of the variance individual items to total
(2005) scale (.06–.67)
Coefficient alpha for total
scale (.89)
Discriminant: expected
lack of correlation with
CBCL scales
Vineland Adaptive Becker- Mixed N = 57 Confirmed diagnosis Equal male/ Descriptive data only Descriptive data only
Behaviour Scale-II Weidman of reactive attachment female
(2009) disorder and met criteria
for complex trauma
Child and Youth Liebenberg, Adolescent Sample 1 Two samples multi- Sample 1 Construct: confirmatory factor analysis. Internal: Cronbach’s alpha
Resilience Ungar, and (N = 497) service accessing youth (56.5% male) Good fit 3 latent variables explaining 40.4% (range: .65–.91)
Measure-28 Van de Vijver Sample 2 Sample 2 of variance
(2012) (N = 410) (57.3% male)
Child and Youth Liebenberg, Adolescent Study 1 Sample 1 multi-service Sample 1 (37% Construct: factor analyses identified 12 Internal: Cronbach’s alpha
Resilience Ungar, and (N = 122) accessing youth. Sample female) items with 1 latent structure (α = .84)
Measure-12 LeBlanc (2013) Study 2 2 student population no Sample 2 (53%
(N = 1494) trauma female)
Minnesota Murray, Glaser Adolescent N = 186 Juvenile offender sample. Male (N = 145) Construct: model correctly classified 65.5% Inter-rater: 100%
Multiphasic and Calhoun Range of traumas Female trauma group, 84.3% no trauma group. agreement of trauma
Personality (2013) identified in addition (N = 41) ROC curve analysis (.771) reasonable interview codings
Inventory– to ‘denial of trauma’ predictor of trauma group membership
Adolescent classification
Beck Self-Concept Runyon, Steer, Adolescent N = 100 Adolescents – sexual 80% female Convergent: moderate negative correlations Internal: coefficient alpha
Inventory for and Deblinger. abuse history with CBCL internalising subscale (−.35 to total scale (.94) subscales
Youth (2009) −.41) for total and subscales. (.80)
Moderate correlation with Beck Youth
Inventory-Anxiety (−.45) anger (−.27)
Adult Attachment Bailey, Moran, Adolescent N = 62 Physical and sexual Female only Unresolved status predicted by range Not reported
Interview and Pederson abuse which occurred of factors general maltreatment history,
(2007) before 12 years history of sexual abuse
Convergent: AAI elicited more reports on
physical abuse (91%) compared to childhood
trauma interview (55%). Fewer reported
sexual abuse (62%) compared to (95%)
265
Table 2. (Continued)
266
Instrument Author(s) Age Sample size Trauma/adversity type Sample gender Validity Reliability
Madigan, Adolescent N = 55 Emotional abuse, Female only Sexual abuse history uniquely predicted Inter-rater: coding (80%
Vaillancourt, physical abuse, sexual Unresolved status. concurrence)
McKibbon, and abuse and caregiver Convergent: significant agreement between
Benoit (2012) neglect AAI and Childhood Trauma Questionnaire
on maltreatment experiences
Global Blake, Case N = 22 15 vignettes of physical Male/female Not reported Inter-rater: no trauma
Assessment of Cangelosi, vignettes clinicians abuse, neglect and vignettes history (.68–.73) and with
Functioning Scale Johnson- (4 child, 1 sexual abuse trauma history (.33)
Brooks, and adolescent)
Belcher (2007)
Children’s Global As above As above As above As above Male/female Not reported Inter-rater: no trauma
Assessment Scale vignettes history (.55–.60) and with
trauma history (.38)
Adolescent Friedrich, Adolescents N = 174 Sexual abuse 53.5% female Construct: factor analysis – 5 factors Internal: self-report –
Clinical Sexual Lysne, Sim, explaining 37.6% variance Cronbach’s alpha (α = .86)
Behaviour and Shamos Convergent: self-report – good correlations Test–retest 1 week
Inventory (2004) with Trauma Symptom Checklist for (r = .74)
Children scales (range: .54–.73) Parent report – internal
Parent report – low correlation with TSCC Cronbach’s alpha (α = .84)
scales (range: .36–.44) No test–retest
Total score correlated with CBCL total Correlation between
(.66) parent and self-report
version (.55)
Wherry, Adolescents N = 141 Clinical sample including 55% female Convergent: small correlations between Internal: Cronbach’s alpha
Berres, Sim but not solely consists three factors and CBCL scales (.23–.33) (range: .61–.75) across
and Friedrich. of those referred for Small to moderate against The Symptom three factors
(2009) sexual abuse evaluations Checklist scales (.26–.50)
Child Sexual Baker et al. Child N = 97 Residential care home 76% male Convergent: small to high correlations with Not reported
Behaviour (2008) (clinical or fostered and a CBCL (.13–.7).
Inventory group) control group Non-significant correlation with no of
trauma events (r = .33)
Significant differences between groups
(F(12, 84) = 2.32)
ROC curve: receiver operating characteristic curve; AAI: Adult Attachment Interview; CBCL: Child Behaviour Checklist; TSCC: Trauma Symptom Checklist for Children.
Denton et al. 267
Sample quality
Sample age. The majority of measures were validated against adolescent samples (i.e. partici-
pants aged more than 12 years) with the exception of the CSBI (Baker et al., 2008) which was vali-
dated against a looked after children (LAC) sample and a control group aged between 10 and
12 years, thus limiting its generalisability to children of other ages. Blake et al. (2007) investigated
the GAF and CGAS using a variety of vignettes, but only one of the child trauma case vignettes
featured a child over 12 years.
Trauma/adversity type. Demographic information about the adversity experiences of participants

was limited across all studies. Predominantly measures were evaluated using participants who had
childhood sexual abuse experiences, for example, the CSBI (Baker et al., 2008). Most authors
failed to document the severity of exposure to trauma and whether other forms of abuse had
occurred. For example, the ACSBI (Friedrich et al., 2004) was evaluated with participants who had
been referred for sexual abuse evaluations. Less than half of the sample (24.1%) reported unwanted
sexual experiences, but these were not defined in terms of type, frequency or age at occurrence.
While Runyon et al. (2009) did provide sufficient demographic information about the sexual abuse
experiences of participants in their evaluation of the BYI-S, they did not report whether the sample
had other abuse or adversity experiences which could have confounded their results.
Other studies mixed participants with single- and multiple-incident traumas. The AAI studies
(Bailey et al., 2007; Madigan et al., 2012) utilised samples with mixed trauma experiences, some
of which did not reflect developmental trauma. For example, Madigan et al. reported higher num-
bers of single-incident non-caregiver perpetrated sexual abuse among their participants. The
CYRM study samples included ‘multiple-service-using-youth’ supported by a range of mental
health, child welfare and education services (Liebenberg et al., 2013; Liebenberg et al., 2012). A
proportion of the sample included participants with experiences of single-incident trauma, but the
lack of demographic data makes it difficult to determine whether participants would fit the DTD
definition. Given that the CYRM measures were not designed for a developmental trauma popula-
tion, they are unlikely to be valuable for clinical assessment.
Three studies attempted to account for developmental trauma in their sampling with arguably
limited success. While Murray et al. (2013) acknowledged that the effects of developmental trauma
may extend beyond the traditional PTSD diagnoses, the MMPI-A was only validated with a spe-
cific population (Juvenile Offenders). Baker et al.’s (2008) evaluation of the CSBI utilised a sam-
ple of LAC who likely experienced multiple trauma histories. Becker-Weidman (2009) was one of
few authors to acknowledge the current literature on complex trauma, suggesting that subscales of
the Vineland-II map onto some domains of the complex trauma diagnosis (Cook et al., 2005).
Becker-Weidman’s sample met the diagnostic criteria for both reactive attachment disorder and
complex trauma and thus may be most representative of children and young people with a history
of developmental trauma.
Reliability and validity. The majority of measures evidenced good reliability in the form of alpha
coefficient ratings for the entire scale and the within-scale factors (Table 2); however, there were a
notable number of validity and utility limitations in all studies.
Many studies utilised the CBCL (Achenbach, 1991) to assess discriminant validity. At times this
failed to provide adequate evidence of validity where positive associations were not identified (e.g.
SFRS; Kruczek & Ægisdóttir, 2005). The low or absent correlations between the CBCL (parent
report) and the SFRS (self-report) may have been confounded by the low correlation sometimes
reported between parent and adolescent reports of behaviour and emotional distress
(Seiffge-Krenke & Kollmar, 1998). The SFRS seemingly has poor face validity, for example, the
Social Engagement factor included uniquely loading items such as ‘Sleep OK’ (Item 3) and ‘Stand
up for myself’ (Item 5). These are not social engagement behaviours and did not correlate with Self
Care and Interpersonal Assertion, respectively, as one would expect. Neither measures of the
CYRM were examined for discriminant validity during development (Liebenberg et al., 2013;
Liebenberg et al., 2012), and the Vineland-II study (Becker-Weidman, 2009) was limited by being
purely descriptive (only mean values and standard deviations were reported).
Other studies lacked sensitivity, for example, Murray et al.’s (2013) MMPI-A model made more
accurate classifications for the no-trauma history cases than trauma history cases. The CBCL
(Achenbach, 1991) was unable to identify 41% of children who met the criteria for problematic
sexual behaviours according to the CSBI (Baker et al., 2008). Meanwhile, the BYI-S showed
promise for identifying levels of self-esteem among adolescents with a history of sexual abuse
(Runyon et al., 2009). Out of the 90% of participants who scored below average self-esteem, 53
had scores classified as ‘lower than average’ and 37 had scores classified as ‘much lower than aver-
age’. This suggests that the BYI-S is sensitive enough to discriminate qualitative differences in
self-esteem among a sample with primarily below average scores.
The factor structure of the ACSBI has been questioned after studies reported differing results of
either five- or three-factor structures (Friedrich et al., 2004; Wherry, Berres et al., 2009, respectively).
Wherry, Berres et al. (2009) argued this was due to their sample not including participants referred
for sexual abuse evaluations; however, both studies investigated the ACSBI with a mixed sample of
adolescents with or without sexual abuse histories, all of whom were being treated for psychiatric
difficulties. The actual reason for the variation in factor structure arguably remains unclear.
The AAI studies raised questions about the measure’s utility. Both studies reported that without
probe questions, reports of abuse were low and thus prevented an assessment of ‘Unresolved sta-
tus’ (Bailey et al., 2007; Madigan et al., 2012). The AAI reflects a move away from traditional
diagnostic classification systems to broader concepts, such as attachment status, which may be
more useful in future conceptualisations of developmental trauma.
Conclusion – general functioning and mental health. The majority of measures of general functioning
provided inadequate demographic information in relation to participants’ experiences of adversity,
thereby limiting the conclusions that can be drawn about their utility with a DTD population. The
MMPI-A and Vineland-II studies made reference to complex trauma and the CSBI utilised a LAC
sample; however, the studies were limited by factors such as the use of specific populations, simple
descriptive data and restricted age ranges. The BYI-S appeared good at distinguishing between
qualitative differences in low self-esteem but was marred by utilising a female-only sample about
whom there was limited information about concurrent abuse experiences. As such these measures
require further evaluation with greater demographic information before they can be recommended
for use with the developmental trauma populations.
PTSD
Seven measures were identified for assessment based on PTSD diagnostic criteria (Tables 3 and 4).
Of these measures, three were validated for use with children (two versions of the CBCL-PTSD
subscale (Dehon & Scheeringa, 2006; Loeb, Stettler, Gavila, Stein, & Chinitz, 2011), and Child
Dissociative Checklist (CDC; Wherry, Neil, & Taylor, 2009), one for use with adolescents
(Adolescent Dissociative Experiences Scale (ADES; Keck Seeley, Perosa, & Perosa, 2004)) and
three were developed or validated for use across the age range (a third version of the CBCL-PTSD
(Rosner, Arnold, Groh, & Hagl, 2012; Sim et al., 2005), the University of Los
Denton et al. 269
Table 3. Demographic data for measures of post-traumatic stress disorder.
Instrument Original author(s) Description Format Original population

Child Behaviour Wolfe, Gentile, and
20 items from the CBCL; Caregiver Sexual abuse sample
Checklist-PTSD Wolfe (1989) a global measure of
emotional and behavioural
difficulties in children and
young people. Scored on
3-point Likert Scale
Child Behaviour Dehon and 15 items from the CBCL. Caregiver See Table 4
Checklist-PTSD Scheeringa (2006) Adapted from Wolfe et al.
(1989)
Child Behaviour Sim et al. (2005) Three subscales from Caregiver See Table 4
Checklist-PTSD CBCL items: PTSD
Scale (7 items) PTSD/
Dissociation Scale (16
items), Dissociation Scale
(3 items)
UCLA-PTSD Pynoos, Rodriguez, 48-item semi-structured Clinician Children exposed to
Reaction Index Steinberg, Stuber, interview to assess Armenian earthquake
and Friedrick (1998) exposure to traumatic
events and PTSD
symptoms according to
DSM-IV criteria
Child PTSD Foa, Johnson, Feeny, 24 items. Assesses PTSD Caregiver Children exposed to
Symptom Scale and Treadwell (2001) diagnosis and symptom natural disaster
severity in children and
young people. 17 items
correspond to DSM-IV
symptoms
Child Dissociative Putnam, Helmers, 20-item measure to assess Self-report Sexual abuse, other
Checklist and Trickett (1993) dissociative symptoms abuse, dissociative
disorders and control.
100% female
Adolescent Armstrong, Putnam, 30 items. Assesses for Self-report Clinical sample with
Dissociative Carlson, Libero, and symptoms of pathological various diagnoses
Experiences Scale Smith (1997) dissociation against a control group
CBCL: Child Behaviour Checklist; PTSD: post-traumatic stress disorder; DSM-IV: The Diagnostic and Statistical Manual of
Mental Disorders–Fourth Edition.
Angeles–Post-Traumatic Stress Disorder–Reaction Index (UCLA-PTSD-RI; Elhai et al., 2013;

Steinberg et al., 2013) and Child PTSD Symptom Checklist (CPSC; Milot et al., 2013)).
Sample quality
Sample age. The majority of measures were validated against samples spanning a wide age
range. In one case, participants’ ages ranged from 6 to 18 years (CPSC; Milot et al., 2013). Three
instruments were validated in child-only populations in four studies (Table 4), while the ADES
was the only measure validated within an adolescent population (11–18 years; Keck Seeley
et al., 2004).
Table 4. Quality information for measures of PTSD.
270
Instrument Author(s) Age Sample size Adversity type Sample gender Validity Reliability
CBCL-PTSD Rosner, Child N = 36 Foster children. German: 44% Convergent: no correlation with CAPS-CA (.21) Internal: Cronbach’s
Version 1 Arnold, Groh, female Area under curve analysis for DSM-IV PTSD (.53), alpha (α = .73)
and Hagl ICD-10 (.75)
(2012)
CBCL-PTSD Dehon and Child N = 61 Mixed single and 55.7% male Convergent: moderate correlations with parent Internal: Cronbach’s
Version 2 Scheeringa multiple-event interview (r = .66) and internalising (r = .57) and alpha for 2- to
(2006) trauma externalising (r = .42) subscales 3-year version
26.2% met PTSD Correlation to PTSD diagnosis (r = .66) (α = .83), for 4- to
criteria Construct: accounted for 46% variance 18-year form (.87)
Discriminant: sensitivity (75%), specificity (84.4%)
for PTSD diagnosis
Significant (p < .05) differences between PTSD/
non-PTSD
Loeb, Stettler, Child N = 51 Multiple 68.6% male Discriminant: DSM-IV – sensitivity (60%) and Internal: Cronbach’s
Gavila, Stein, trauma. Mostly specificity (80%) alpha (α = .79)
and Chinitz interpersonal, small DC:0–3 – sensitivity (67%) and specificity (63%)
(2011) number single- No significant difference for children who met
event trauma. criteria for PTSD (DC:0–3)
6% met DSM-IV Significant difference for children who met DSM-
criteria for PTSD IV criteria for PTSD (p < .05)
No significant difference for UCLA-PTSD scores
Rosner et al. Mix Small (N = 36) Foster children. 44% female Convergent: no correlation with CAPS-CA (.29) Internal: Cronbach’s
(2012) Area under curve analysis for PTSD DSM-IV alpha (α = .67)
(rho = .75, p < .05), ICD-10 (rho = .53)
CBCL-PTSD Sim et al. Child N = 1293 Child community, 50% male Construct: CFA suggested adequate fit for Internal: coefficient
Version 3 (2005) psychiatric, and hypothesised 3-factor model alphas (range:
sexual abuse Inter-scale correlations: moderate to good (range: .70–.85)
samples r = .51–.90)
Control sample Convergent: TSCC correlated to 2/3 scales
(N = 419) Dissociation correlation to 2/3 scales
Milot et al. Mix N = 239 Physical neglect 56.5% male Construct: the model fit the data Internal: Cronbach’s
(2013) Convergent: PTSD scale correlated to TSCYC alpha (range:
(r = .65) and CDC (r = .58) .39–.55)
Dissociation scale correlated to TSCYC (r = .37)
and CDC (r = .58)
(Continued)
Denton et al.
Instrument Author(s) Age Sample size Adversity type Sample gender Validity Reliability
Rosner et al. Mix N = 36 Foster children 44% female Convergent: no correlation with CAPS-CA (.12) Internal: Cronbach’s
(2012) Area under curve for PTSD DSM-IV (rho = .51), alpha (α = .63)
ICD-10 (rho = .37)
UCLA–Post- Steinberg et al. Mix N = 6291 Mixed multiple 55.5% female Convergent: TSCC PTS (r = .75) Internal: Cronbach’s
Traumatic Stress (2013) and single-incident Discriminant: other subscales (r = .54–.67) alpha (range:
Disorder–Reaction traumas .86–.91)
Index
Elhai et al. As above As above As above As above Convergent: 5-factor model best fits Not measured
(2013) Inter-correlations between some factors was high
(.86–.89)
Child PTSD Gillihan, Mix N = 91 Sexual abuse and 100% female Convergent: PTSD module of K-SADS Internal: good to
Symptom Scale Aderka, PTSD diagnosis (74.5–76.5%) excellent
Conklin, Symptom-based diagnostic agreement between Test–retest.
Capaldi, and the CPSS-SR and CPSS-I was excellent (85.5%) One week on self-
Foa (2013) report (r = .86)
Inter-rater: CPSS
clinician (r = .87)
Child Dissociative Wherry, Neil, Child N = 232 Physical and sexual 61% female Convergent: Significant differences between SA Internal: Cronbach’s
Checklist and Taylor abuse and no SA (p < .001) and PA and no PA (p < .001). alpha (range:
(2009) Construct: 3-factor model accounted for 46% of .69–.83)
variance
Adolescent Keck Seeley, Adolescent N = 65 Sexual abuse or no 100% female Better predictor of clinical group membership Internal: Cronbach’s
Dissociative Perosa, and sexual abuse (87%) than non-clinical membership (68%). alpha (α = .94)
Experiences Scale Perosa (2004) No significant difference between children with or
without a diagnosis of PTSD
CAPS-CA: Clinician Administered Post-Traumatic Stress Disorder Scale–Child and Adolescent; CBCL: Child Behaviour Checklist; CDC: Child Dissociative Checklist; CFA: confirmatory factor analysis;
CPSS-SR: Child Post-Traumatic Stress Disorder Symptom Scale–Self Report Version; CPSS-I: Child Post-Traumatic Stress Disorder Symptom Scale–Interview Version; DC:0–3: Diagnostic Classification
of Mental Health and Developmental Disorders of Infancy and Early Childhood; K-SADS: Kiddie Schedule for Schizophrenia and Affective Disorders; PA: physical abuse; PTS: post-traumatic symptoms;
PTSD: post-traumatic stress disorder; SA: sexual abuse; TSCC: Trauma Symptom Checklist for Children; TSCYC: Trauma Symptom Checklist for Young Children; UCLA-PTSD: University of Los
Angeles–Post-Traumatic Stress Disorder Scale; DSM-IV: The Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition; ICD-10: International Statistical Classification of Diseases–Tenth Revision.
271
Trauma/adversity type. Across the majority of studies, demographic information regarding adver-
sity type was sparse and samples were often contaminated through combinations of participants
who had experienced multiple or single-event traumas (Dehon & Scheeringa, 2006; Elhai et al.,
2013; Loeb et al., 2011; Steinberg et al., 2013). Of the studies which focused on interpersonal
trauma, there were different adversities reported for each sample such as sexual abuse (Gillihan,
Aderka, Conklin, Capaldi, & Foa, 2013; Keck Seeley et al., 2004), historical physical and sexual
abuse (Wherry, Neil, & Taylor, 2009) and neglect (Milot et al., 2013). Often, although adversity
type was labelled, the authors failed to document whether other forms of abuse had occurred in
conjunction with those documented (e.g. Gillihan et al., 2013; Keck Seeley et al., 2004). Only one
study considered the complex trauma debate and utilised a sample of fostered children who reported
past experiences of one or more traumatic events. Although the authors elaborate on the type of
events that were measured, children in out of home care who have experienced multiple traumatic
events are highly likely to be reflective of a developmental trauma population (Rosner et al., 2012).
Reliability and validity. A range of reliability and validity evaluations were carried out in all studies in
the PTSD category including assessments of convergent validity, sensitivity and factor structure. The
majority of measures demonstrated good alpha coefficient ratings for the entire scale and within
measure subscales (Table 4). However, although early validation studies of the CBCL-PTSD showed
good internal reliability (Sim et al., 2005), further studies reported acceptable (Rosner et al., 2012) or
poor internal reliability (Milot et al., 2013) suggesting it is not stable across different samples.
Most authors reported correlations with other trauma-focused measures such as the Trauma
Symptom Checklist for Children (TSCC; Briere, 1996) as evidence of convergent validity (Sim
et al., 2005; Steinberg et al., 2013), with high correlations reported for theoretically similar sub-
scales. However, some instruments recorded poor correlation reports, such as the pre-school ver-
sion of the CBCL-PTSD subscale (Dehon & Scheeringa, 2006) which demonstrated no significant
correlation to the UCLA-PTSD-RI (Loeb et al., 2011), and the CBCL-PTSD subscales (Sim et al.,
2005) which demonstrated poor correlations with a Clinical Administered PTSD measure despite
significant correlations to DSM-IV criteria (Loeb et al., 2011; Rosner et al., 2012).
Some measures demonstrated a lack of sensitivity. For example, although the ADES was better
at predicting clinical or non-clinical group membership, there was no significant difference in the
average scores of clinical participants with or without a PTSD diagnosis (Keck Seeley et al., 2004).
Similarly Sim et al.’s (2005) PTSD subscale showed two clinical groups as undistinguishable from
each other, although the absence of trauma assessment may have skewed the results. Receiver
operating characteristic (ROC) curve analyses of the CBCL-PTSD subscales revealed that only the
pre-school CBCL-PTSD scale had the capacity to predict PTSD at a level significantly different
from chance. However Dehon’s CBCL-PTSD scale was criticised for its maximum sensitivity
which appeared to reflect generic rather than trauma-related distress (Loeb et al., 2011).
Some measures recorded weak factor structures, for example, the UCLA-PTSD-RI. Nonetheless,
the measure showed high between-factor correlations even in the five-factor modification (Elhai
et al., 2013). Similarly, support was reported for Sim et al.’s (2005) PTSD and Dissociation scales;
however, investigation of the longer PTSD/Dissociation scale revealed a two-factor structure
rather than the one-factor structure suggested by the author (Milot et al., 2013).
Conclusion – PTSD. The lack of appreciation for developmental difference in children and young
people who have experienced symptoms of trauma is a significant limitation within this category as
few measures were designed for children or adolescents alone. The results do not provide support
for any of the CBCL-PTSD scales; however, the samples were small and specific, therefore repli-
cation with larger and more diverse samples is necessary. The UCLA-PTSD-RI study (Elhai et al.,
Denton et al. 273
2013; Steinberg et al., 2013) utilised the most robust sample size and statistical analysis; however,
the poor distinction between single and multiple-incident traumas may limit its assessment utility.
The UCLA-PTSD-RI focuses on PTSD diagnostic criteria and was not designed for a maltreated
population; therefore, it would not be recommended as a stand-alone assessment tool.
Measures of trauma symptomatology outside PTSD criteria

A total of 11 measures were identified which assessed trauma symptomology outside, or in addi-
tion to, PTSD diagnostic criteria (Tables 5 and 6). Of these, nine were validated for children
(Trauma Symptom Checklist for Young Children (TSCYC; Gilbert, 2004; Pollio, Glover-Orr, &
Wherry, 2008; Wherry, Graves, & King, 2008), TSCYC - Short Form (TSCYC-SF; Wherry,
Corson & Hunsaker, 2013), Assessment Checklist for Children (ACC; Tarren-Sweeney, 2007),
Brief Assessment Checklist for Children (BAC-C; Tarren-Sweeney, 2013b), Trauma Assessment
for Young Children (TAYC; Strickler, 2011), Child Paediatric Emotional Distress Scale (Saylor,
Cupit, Reynolds & Taylor, 1999), Story Stem Assessment Profile (Hodges, Steele, Kaniuk,
Hillman, and Asquith, 2009), Trauma Play Scale (Findling, Bratton & Henson, 2006; Myers,
Bratton, Hagen, & Findling, 2011) and Dominic Interactive Assessment (de la Osa, Ezpeleta,
Granero, Olaya, & Domenech, 2011)) and two for adolescents (Assessment Checklist for
Adolescents (ACA; Tarren-Sweeney, 2013a) and Brief Assessment Checklist for Adolescents
(BAC-A; Tarren-Sweeney, 2013b)). None were developed or validated for use across the age
range.
Sample quality
Sample age. The measures within this category were largely designed and validated within child
populations (2–12 years). Only two measures, the ACA (Tarren-Sweeney, 2013a) and the BAC-A
(Tarren-Sweeney, 2013b), were validated against an adolescent population (12–18 years).
Trauma/adversity type. Most commonly, measures were evaluated against samples of participants
who had experienced one type of adversity, for example, all studies on the TSCYC, including those
on the short-form of the measure, utilised participants who had been exposed to sexual abuse (Gil-
bert, 2004; Pollio et al., 2008; Wherry et al., 2013; Wherry et al., 2008). Failure to document the
presence of other forms of adversity and/or whether trauma was single-event or ongoing was com-
mon across studies. Of note were the studies investigating the PEDS (Spilsbury et al., 2005) and
DIA (de la Osa et al., 2011). These studies investigated samples of children, high proportions of
whom rated themselves as having both exposure to violence and expectation of event re-occur-
rence. This suggests these samples were exposed to chronic and possibly ongoing trauma and
would potentially meet the criteria for DTD.
A selection of studies included multiple trauma samples that would likely meet developmental
trauma criteria. Strickler (2011) evaluated the TAYC on a sample of children with experience of
‘interpersonal trauma’ including domestic violence, sexual abuse, physical abuse and/or emotional
abuse. Similarly, the ACC (Tarren-Sweeney, 2007), ACA (Tarren-Sweeney, 2013a), BAC, BAC-A
(Tarren-Sweeney, 2013b) and the Story Stem Assessment Profile (Hillman, 2011) were evaluated
against data from samples of LAC and young people who had experienced various social adversi-
ties and multiple forms of maltreatment in their lifetime.
Reliability and validity. The majority of measures demonstrated good reliability in the form of Cron-
bach’s alpha coefficient ratings (Table 6). One instrument demonstrated poor internal reliability for
Table 5. Demographic information for measures of trauma not including PTSD.

Trauma Symptom Briere Johnson, 90 items. Assesses trauma- Caregiver Sexual abuse
Checklist for Young Bissada, Damon, related symptoms in
Children Crouch, Gil & Ernst children. 8 subscales: anxiety,
(2001) depression, anger and
abnormal sexual behaviour.
Two validity scales assessing
over/under reporting
Trauma Symptom Wherry, Corson, 32 items. Assesses trauma- Caregiver Sexual abuse
Checklist for Young and Hunsaker related symptoms in children
Children–Short (2013)
Form
Assessment Tarren-Sweeney 120 items. Assesses Caregiver Looked after
Checklist for (2007) behaviours, emotional states, children
Children traits and relating to others,
as manifested among children
in care. 10 clinical scales and
2 self-esteem scales
Brief Assessment Tarren-Sweeney 20 items. Designed to Caregiver Looked after
Checklist for (2013b) screen/monitor emotional children
Children and behavioural difficulties
experienced by children in
out-of-home care. Developed
from 120-item Assessment
Checklist
Trauma Assessment Strickler (2011) 10 items. Assesses symptoms Self- Children with
for Young Children of trauma in young children report or without
and interpersonal
caregiver trauma history
Child Paediatric Saylor, Cupit, 21 items. Assesses Caregiver Children
Emotional Distress Reynolds, and symptomatology in children experiencing
Scale Taylor (1999) following stressful and/or various single-event
traumatic event traumas
Trauma Play Scale Findling, Bratton, Observation-based measure Clinician Children with and
and Henson (2006) of play behaviours in children rated without complex
exposed to trauma. Five trauma history
subscales: intense play,
repetitive play, play disruption,
avoidant play behaviour and
expression of negative affect
Story Stem Hodges, Steele, Assessment profile captures Clinician Children with and
Assessment Profile Kaniuk, Hillman, effects of abuse in young rated without trauma
and Asquith (2009) children. Asked to continue a history
narrative; interview analysed
against specific themes
Dominic Interactive Valla, Bergeron, and 91 items. Assesses psychiatric Self- General population
Assessment Smolla (2000) symptoms related to common report no trauma history
mental health disorders based
on seven DSM-III-R and DSM-
IV diagnoses.
(Continued)
Denton et al. 275

Assessment Tarren-Sweeney 120 items. Assesses Caregiver Looked after
Checklist for (2013a) behaviours, emotional states, children
Adolescents traits and manners of relating
to others. Includes 10 clinical
scales and 2 self-esteem
scales. For adolescents in out-
of-home care 12–17 years
Brief Assessment Tarren-Sweeney 20 items. Brief screening tool Caregiver Looked after
Checklist for (2013b) for use by social or health children
Adolescents professionals without child
mental health qualification.
For adolescents in out-of-
home-care (12–17 years)
PTSD: post-traumatic stress disorder; DSM-IV: The Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition;
DSM-III-R: The Diagnostic and Statistical Manual of Mental Disorders–Third Edition–Revised.
both children with and without traumatic histories (TAYC; Strickler, 2011]), although this was one
of the few studies investigating a self-report measure. Spilsbury et al. (2005) demonstrated good
internal reliability for the PEDS after adjustments were made to the model suggesting that the
original was not appropriate within a complex trauma population.
Only two studies reported test–retest reliability for the measures (Myers et al. 2011; Strickler,
2011) with good results, although Strickler’s investigation of the TAYC was based solely on the
non-clinical sample. Evidence of convergent validity was reported against other known PTSD
measures such as the UCLA-PTSD-RI (Wherry et al., 2013; Wherry et al., 2008), or the PTSD
Diagnostic Interview for Children and Adolescents Scale (DICA; Pollio et al., 2008). A measure of
sexual behaviour (CSBI; Baker et al., 2008) was also used to establish the validity of the sexual
behaviour subscale of the TSCYC (Wherry et al., 2008). A selection of studies made comparisons
against general measures of emotional and behavioural functioning such as the Revised Problem
Behaviour Checklist (Spilsbury et al., 2005) or the CBCL (Strickler, 2011). While several studies
reported correlations to the CBCL measure as evidence of convergent validity (de la Osa et al.,
2011; Tarren-Sweeney, 2007, 2013a, 2013b; Wherry et al., 2013; Wherry et al., 2008), one study
argued that a low correlation to the externalising scale of the CBCL demonstrated evidence of
discriminant validity in their measure (TAYC; Strickler, 2011).
Discriminant validity was also reported in significant differences between groups of children
with and without a history of trauma. This was found to be true for the Trauma Play Scale (Myers
et al., 2011), Story Stem Assessment profile (Hillman, 2011) and the TSCYC (Pollio et al., 2008).
Some also measured sensitivity by ROC under the curve analysis to assess the ability of the meas-
ure to detect PTSD diagnosis (Pollio et al., 2008) or CBCL clinical range scores (de la Osa et al.,
2011).
Conclusion – trauma symptomology outside PTSD criteria. A greater number of studies evaluating
measures of trauma symptomatology outside PTSD criteria utilised looked after child samples who
had been exposed to multiple traumas and were most likely to meet criteria for DTD. Other studies
restricted their investigations to samples with experience of one type of adversity and at times,
details about the type, severity, and chronicity were absent. The TSCYC (Gilbert, 2004; Pollio
Table 6. Quality information for measures of trauma not PTSD.
276
Instrument Author(s) Child/ Sample size Adversity type Sample Validity Reliability
adolescent gender
Trauma Gilbert (2004) Child N = 388 Sexual abuse Unknown Convergent: correlation between Internal: Cronbach’s
Symptom and non-sexual theoretically related scales alpha (range: 81–.93)
Checklist for abuse Criterion: matched sample abused/
Young Children non-abused (N = 45). Sensitivity
(75.56), specificity (86.67)
Pollio, Glover- Child N = 34 Substantiated Equal male: Convergent: correlation with PTSD Internal: Cronbach’s
Orr, and sexual abuse female scales of DICA (t = 4.13–4.22) alpha (range: .73–.91)
Wherry (2008) 32% met Correlation with PTSD scales for
criteria for those with PTSD (p < .001)
PTSD
Wherry, Graves, Mix N = 172 Sexual abuse 64% female Convergent: correlation with CBCL
and King (2008) (r = .54–.84), UCLA-PTSD (r = .34–
.59), TSCC (r = .47–.29 and CSBI
(r = .44–.72)
Trauma Wherry, Child N = 295 Sexual abuse 62% female Convergent: supported for scales Internal: 8-factor model
Symptom Corson, and of anger, sexual concerns, anxious acceptable-to-excellent
Checklist for Hunsaker (2013) and depressed (r = .53–.83). reliability for each factor
Young Children– Correlations between the TSCYC Cronbach’s alpha (range:
Short Form sexual concerns scale and CSBI .77–.91)
(r = .42–.60), TSCYC and UCLA-
PTSD-RI (r = .47–.75)
Assessment Tarren-Sweeney Child N = 412 Children in Equal male: Convergent: correlation to CBCL Internal: high across
Checklist for (2007) long-term female (r = 89 for boys, r = .90 for girls). clinical scales Cronbach’s
Children foster and Content: CFA suggested adequate alpha (range: .70–.96)
kinship care fit for 10-factor model
Brief Assessment Tarren-Sweeney Child N = 347 As above As above Convergent: moderate to strong Internal: Cronbach’s
Checklist for (2013b) (from ACC correlations with ACC subscales alpha (α = .89)
Children sample) (r = .32–.96). Moderate to strong
correlations with CBCL subscales
(r = .41–.82) and DSM-oriented scale
scores (r = .34–.64)
(Continued)
adolescent gender
Denton et al.
Trauma Strickler (2011) Child N = 47 Children 57.4% female Convergent: correlations between Internal: Cronbach’s
Assessment for with/without child and parent reports (r = .01– alpha with trauma
Young Children interpersonal .46) with TSCYC PTSD subscale (α = .48) and without
traumas (r = .59 for trauma, r = .41 for total trauma (α = .56)
sample) Test–retest: at 2 weeks
Discriminant: low correlation with (r = .79), based on the
CBCL externalising subscales in non-clinical sample
trauma group (r = .24)
Child Paediatric Spilsbury et al. Child N = 383 Children Equal gender Convergent: Correlations to Internal: 2-factor model
Emotional (2005) witnessing Revised Behaviour Problem Cronbach’s alpha (range:
Distress Scale domestic Checklist (r = .21–.73) .80–.82)
violence The 3-factor model did not fit
(CFI = .84). Correlation between
factors (r = .38–1.0)
EFA indicated 2-factor model
(CFI: .97; r = .17)
Trauma Play Findling, Bratton, Child N = 12 Children with/ Mainly male Insufficient power to detect changes Inter- and intra-rater
Scale and Henson without trauma between groups reliability: good
(2006) history (r = .85–.98)
Myers, Bratton, Child N = 7 Matched Mainly male Discriminant: significant difference Internal reliability
Hagen, and pairs typically between groups for average and (r = .74)
Findling (2011) developing subscale scores (p < .001) Inter-rater reliability:
children (with consensus (86%)
original sample)
Story Stem Hillman (2011) Child N = 206 Maltreated, Equal gender Discriminant: significant differences Internal: mean
Assessment non-maltreated between three groups (p < .05). Cronbach’s alpha
Profile clinical sample Maltreated sample more defensive- (α = .52; range: .40–.87)
and control avoidance, insecurity and Across groups of themes
disorganisation (range: .74–.87)
277
278
adolescent gender
Dominic de la Osa, Child N = 55 Interpersonal Mainly male Convergent: correlation with
Interactive Ezpeleta, violence 85% CBCL total (r = .42, p < .05). Some
Assessment Granero, Olaya, 72.7% DSM-IV correlations between theoretically
and Maria diagnosis unrelated scales
Domenech Correlation with DICA no. of
(2011) symptoms (r = .05–.34)
Sensitivity (52.6%) and specificity
(81.5%) for CBCL clinical range
score
Assessment Tarren-Sweeney Adolescent N = 372 In long-term 54% male, Content validity: 7-factor model Internal reliability
Checklist for (2013a) foster and 46% female accounted for 51% score variance Cronbach’s alpha
Adolescents kinship care Convergent: High correlation with clinical scales (.73–.89)
(Australia, CBCL total scores for boys (r = .90) total clinical score (.95)
New Zealand and girls (r = .88)
and Canada) Discriminant (moderate r = −.56)
78% ‘clinic against unpublished measure of pro-
referred status’ social behaviours
Brief Assessment Tarren-Sweeney Adolescent N = 230 64% ‘clinic 54% male Convergent. High correlation Internal reliability:
Checklist for (2013b) From above referred status’ between ACC and BAC-A total Cronbach’s alpha
Adolescents sample. (r = .94) problem scores (r = .88) (α = .87)
High area under curve
correlation to CBCL
clinical range scores
(r = .93–.94) and clinical
range ACA (.96–.99)
ACC: Assessment Checklist for Children; BAC-A: Brief Assessment Checklist for Adolescents; CBCL: Child Behaviour Checklist; CFI: confidence intervals; CSBI: Child Sexual
Behaviour Inventory; DICA: Diagnostic Interview for Children and Adolescents; EFA: exploratory factor analysis; PTSD: post-traumatic stress disorder; TSCC: Trauma Symp-
tom Checklist for Children; TSCYC: Trauma Symptom Checklist for Young Children; UCLA-PTSD: University of Los Angeles–Post-Traumatic Stress Disorder; UCLA-PTSD-
RI: University of Los Angeles–Post-Traumatic Stress Disorder–Reaction Index; CFA: confirmatory factor analysis; DSM: The Diagnostic and Statistical Manual of Mental Disorders;
DSM-IV: The Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition; ACA: Assessment Checklist for Adolescents.
Denton et al. 279
et al., 2008; Wherry et al., 2013; Wherry et al., 2008) demonstrated psychometric strengths but has
largely been studied within a sexual abuse population. The TAYC (Strickler, 2011) benefits from a
self-report format and the authors’ consideration of complex trauma and age-appropriate cognitive
and social skills in its development. The Assessment Checklists (Tarren-Sweeney, 2007, 2013a,
2013b) had the most robust sample size and statistical analysis and demonstrated utility for trauma-
related psychopathology within a clinically relevant population. However, there is no self-report
component, and the authors warned that the brief versions of the Assessment Checklist’s (Tarren-
Sweeney, 2013b) should not replace comprehensive, multi-informant assessment. Nonetheless,
they show promise as an assessment tool (both brief and fuller versions) for a developmental
trauma population.
Discussion
The field of trauma assessment has grown over the last decade, with 42 papers evaluating assess-
ment instruments identified since Strand et al.’s (2005) review. The current review identified that
few assessment measures have been robustly investigated to generate confidence in their use with
children and adolescents who have suffered developmental trauma. The majority of studies utilised
samples that were demographically ill-defined, too small or too specific (e.g. participants who
reported only one form of abuse). The focus on sexual abuse has meant that there are a number of
assessment measures that could be recommended for use with children and/or adolescents with a
history of sexual abuse (TSCYC (Briere et al., 2001), CSBI (Baker et al., 2008), SFRS (Kruczek
& Ægisdóttir, 2005) BYI-S (Runyon et al., 2009), CPSC (Milot et al., 2013) and ADES (Keck
Seeley et al., 2004)). However, studies failed to highlight whether victims were subject to single or
multiple-event sexual trauma; therefore, caution should be exercised in their use. The lack of atten-
tion to demographic information suggests that researchers have not engaged sufficiently with the
evidence that abuse rarely occurs in isolation from other adversities (Dong et al., 2004).
A definition of trauma in research

The challenge for researchers is to remain focused on the unique impact of cumulative trauma
(Briere, Kaltman, & Green, 2008) and the research suggesting multiple- and single-trauma experi-
ences result in different trauma symptomatology profiles (Green et al., 2000; Jonkman, Verlinden,
Bolle, Boer, & Lindauer, 2013). Despite qualitatively distinct outcomes for children who experi-
ence interpersonal trauma and abuse versus road traffic accidents and natural disasters (Cook et al.,
2005), this review suggests that researchers continue to group participants together under an all-
encompassing ‘trauma’ label, with little consideration of the type, frequency or developmental
context within which the experience occurred. Future studies need to provide detailed demographic
data so that instruments’ validation population is clearly defined and subsequent generalisation to
maltreatment populations is appropriate.
The assessment checklist tools

Even without adequate validation data, the review highlighted an overreliance on measures
designed for existing clinical populations. Very few standardised measures were designed for use
with a developmental trauma population, a weakness that has previously been highlighted by other
authors (DeJong, 2010; Tarren-Sweeney, 2013a). The Assessment Checklist tools developed by
Tarren-Sweeney (2007, 2013a, 2013b) were the only measures designed to encapsulate the perva-
sive effects of developmental trauma experiences that have been observed and documented by
clinicians and researchers in the field (Cook et al., 2005; DeJong, 2010; Octoman, McLean, &
Sleep, 2014; van der Kolk, 2005). Children and young adolescents in out-of-home placements are
likely to represent the extremity of the maltreatment spectrum (DeJong, 2010) as they are highly
likely to have experienced multiple forms of abuse, abandonment and general maltreatment
(Browne & Lynch, 1999) which mirror the multiple chronic traumas argued to precede DTD (van
der Kolk, 2005). One of the major strengths of the Assessment Checklists was the design of age-
specific versions developed for children and adolescents.
A developmental context
The need for a developmentally appropriate conceptualisation of the impact of maltreatment has
long been discussed (Cichetti & Toth, 1995). There is strong consensus of a statistically significant
risk between childhood maltreatment and developmental deficits (Thornberry, Ireland, & Smith,
2001). However, measurement of such emotional and behavioural delays must be given appropri-
ate developmental consideration (Downs, 1993). The timing of abuse experiences has been associ-
ated with discrete symptom profiles among children and adolescents (Keiley, Howe, Dodge, Bates,
& Petit, 2001; Thornberry et al., 2001) as well as in later adulthood (Thornberry, Henry, Ireland, &
Smith, 2010). Advances in the field of neuropsychology support this with identification of volumic
changes to specific regions of the brain dependant on abuse timing (Andersen et al., 2008; DeBellis
et al., 1999). Maltreatment occurring in multiple developmental periods increases the risk of devel-
oping internalising and externalising problems and lower IQ compared with incidence in one
developmental period (Jaffee & Maikovich-Fong, 2010). Therefore, when assessing the impact of
developmental trauma on children and adolescents, utilising measures developed and validated for
specific developmental periods is prudent.
This review identified a significant divide in developmentally appropriate measures of trauma
for children and adolescents. Interestingly, the majority of tools developed solely for adolescents
examined general functioning and mental health factors, whereas those designed for solely chil-
dren often focused on trauma-related symptomatology outside of DSM diagnostic criteria. In the
assessment of PTSD, adolescents were predominantly grouped with children as young as 7 years
old (Blake et al., 2007; Elhai et al., 2013; Steinberg et al., 2013). This replicates Strand et al.’s
(2005) conclusion that there is a lack of adolescent measures of trauma symptoms beyond PTSD.
Tarren-Sweeney (2013a) highlighted that expression of behavioural and emotional difficulties
within the maltreated population varies by developmental level and without a developmental
framework, age-appropriate behaviours could be inappropriately pathologised. Many studies iden-
tified in this review included samples of children and adolescents in restricted age groups (e.g.
10–12 or 14–18 years), or those which crossed over developmental periods (e.g. up to 22 years;
Liebenberg et al., 2013) suggesting the impact of developmental stage was not considered. This
may also be due to the lack of age-specific assessment tools currently available to researchers in
the field since many of the tools included in this review were validated for a wide age range span-
ning from early childhood into early adulthood.
The developmental trauma debate

A challenge presented within the reviewed papers is the lack of consistency in the theoretical
understanding of these children and adolescents’ difficulties. There has been an emphasis on trying
to conform to a diagnostic classification system, for example, DSM-IV PTSD, but failure to recog-
nise the complexity of presenting difficulties, leading to multiple co-morbid diagnoses. The major-
ity of authors failed to engage with the developmental trauma debate; however, studies including
Denton et al. 281
LAC largely acknowledged the need for broader conceptualisation of maltreatment experiences.
Moreover, there appeared to be an emerging recognition of the need to examine other psychologi-
cal and behavioural constructs (e.g. self-esteem, dissociation, attachment and sexual behaviour)
beyond PTSD criteria.
The dilemmas of seeking to diagnose children and adolescents with histories of developmental
trauma against the current classification system are well-documented (Spinazzola et al., 2005).
Although the DTD debate attempted to address these challenges, the proposal was not accepted
into the new edition of the DSM (DSM-V; APA, 2013). Critics have suggested its inclusion would
weaken the authority of current classification systems by failing to clearly distinguish between
DTD symptoms and syndromes already widely accepted, such as Borderline Personality Disorder
(for a review of the debate, see Schmid, Petermann, & Fegert, 2013). Researchers have highlighted
the limitations of overreliance on diagnostic constructs with developmentally traumatised popula-
tions due to their narrow constraints and the often atypical presentations observed in these children
(DeJong, 2010). However, with access to Child and Adolescent Mental Health Services (CAMHS)
being largely diagnosis-led, many children are failing to receive adequate mental health care provi-
sion (Minnis & Del Priore, 2001), often resulting in carers managing high levels of complexity and
risk alone (Sturgess & Selwyn, 2007). Clinicians and researchers have called for a multi-strand
approach when working with developmentally traumatised populations including the use of psy-
chological formulation and multi-agency working (Golding, 2010). Incorporating these principles
into assessment protocols could limit an overreliance on narrow assessment tools while accounting
for the wide range of contextual factors these young people present with (Callaghan, Young, Pace,
& Vostanis, 2004). Ongoing research into the clinical utility of DTD and associated tools is required
to determine how a developmental perspective on trauma can be incorporated into current diagnos-
tic systems.
Conclusion
Given that childhood adversity has profound implications on a child’s development, leads to dif-
ficulties across multiple domains of functioning and is likely to minimise the chances of realising
their potential, trauma-informed assessment is fundamental. Despite some methodological short-
falls, there are a growing variety of assessment tools available such as the TSCYC (Briere et al.,
2001), TAYC (Strickler, 2011) and ACC/BAC-C (Tarren-Sweeney, 2007, 2013b) for children and
the ACA/BAC-A (Tarren-Sweeney, 2013a, 2013b) for adolescents. Future research needs to vali-
date the measures with well-defined samples, as well as inductively developing new measures or
tools to assess the range of pervasive difficulties that are sensitive to the child’s cognitive and
social developmental stage. For clinicians seeking to assess these children, the incorporation of
multiple methods of assessment, including psychological formulation and developmentally appro-
priate tools, is recommended.
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
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Author biographies
Ruth Denton is currently completing her Practitioner Doctorate in Clinical Psychology at the University of
Surrey. She is passionate about working with children and young people with complex attachment needs and
hopes to use the findings of this study to further this work.
Catherine Frogley is currently completing her Practitioner Doctorate in Clinical Psychology at the University of
Surrey. Catherine is interested in the treatment of children and young people who have experienced childhood
trauma and attachment difficulties. She is currently conducting research in this area and has previously published
work investigating the treatment of adults with a diagnosis of emotionally-unstable personality disorder.
Sue Jackson is a Chartered Psychologist specialising in the psychosocial impact and treatment of chronic
health conditions. In addition to managing an extensive research portfolio, she is a currently an associate
lecturer at the University of Plymouth and a visiting lecturer on the Clinical Psychology Doctorate Programme
at the University of Surrey. Dr Jackson is the first psychologist to serve on the Medical Advisory Committee
for the Pituitary Foundation.
Mary John is a Clinical Psychologist and Family Therapist who has worked with children and families in
multiple contexts within education and the NHS physical and mental health services. She has also been
involved in training professionals within legal, educational and health and social care sectors.
Denton et al. 287
Dawn Querstret is a Lecturer in Clinical Psychology and Chartered Health Psychologist at the University of
Surrey. Dawn is interested in both the short-term (acute) and longer-term (chronic) health consequences of
inability to recover adequately between work shifts, and in developing online interventions and mobile apps
to improve recovery from work-related stress and mental health conditions. She is currently leading research
investigating the efficacy of online mindfulness interventions for occupational health and wellbeing, and is
involved in research to assess the feasibility of online mindfulness for people with chronic conditions, for
example, multiple sclerosis, stroke and fibromyalgia.

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Ruth Denton1, Catherine Frogley1, Sue Jackson1,2,

A diagnosis of developmental trauma

Assessing children and adolescents with developmental trauma

Purpose and aims of this review

•• Adults (18 years or above);

General functioning and mental health

Instrument Original author(s) Description Format

Trauma/adversity type. Demographic information about the adversity experiences of participants

Table 3. Demographic data for measures of post-traumatic stress disorder.

Instrument Original author(s) Description Format Original population

Angeles–Post-Traumatic Stress Disorder–Reaction Index (UCLA-PTSD-RI; Elhai et al., 2013;

Measures of trauma symptomatology outside PTSD criteria

Instrument Original author(s) Description Format Original population

Instrument Original author(s) Description Format Original population

A definition of trauma in research

The assessment checklist tools

The developmental trauma debate

Declaration of Conflicting Interests

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