CiMH Palette of Measures Evaluation Training: UCLA Post Traumatic Stress Disorder Reaction Index (PTSD-RI)

Cricket Mitchell, PhD CIMH Evaluation Consultant

Palette of Measures Evaluation: What You Will Need (slide 1 of 2) • Palette of Measures Data Entry Shell v2 (Excel file) – Developed by CiMH and customized for each participating agency – Holds all data for clients served thru the Palette of Measures project – Demographics, service delivery information, pre- and post- outcome measure data • Palette of Measures Data Dictionary v2 (Word document) – A guide for using the associated data entry shell – Defines each column in the excel file 2

Palette of Measures Evaluation: What You Will Need (slide 2 of 2) • Outcome measures from the two-pronged approach – General Outcome Measure – Target-Specific Outcome Measure(s) –

For example…

• UCLA Post Traumatic Stress Disorder Reaction Index the measure © (PTSD-RI) – Available at no-cost to interested Palette of Measures participating agencies under permissions granted to CiMH by the developers of 3

Overview of Training

• Brief Overview of Palette of Measures evaluation protocol • UCLA Post Traumatic Stress Disorder Reaction Index © : Target-specific measure for trauma – Administration – Scoring – Clinical Utility • Instructions for Palette of Measures data entry and data submissions – Data entry: PTSD-RI – Data entry: Demographics & Services – Data submissions to CiMH 4

Brief Overview of Palette of Measures Evaluation Protocol

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Outcome Assessment

• Palette of Measures providers will track outcomes using data from pre- and post- administrations of standardized measures of functioning • Pre- and Post- a “dose” of treatment / an intervention interval – General measure of youth mental health functioning (e.g., YOQ/YOQ-SR, CANS, Ohio Scales) – Target-specific measure linked to focus of treatment/intervention (e.g., AQ, ECBI, PHQ-9, PTSD-RI, RCADS) • Providers may choose to administer mid-course assessments as well – e.g., at 3-month intervals in usual care 6

A note about the use of standardized assessment measures… (slide 1 of 2) • Assessment is the beginning of developing a relationship with the child and family – Demonstrates a desire to know what the child and family are experiencing – By incorporating standardized assessment measures of functioning, the efficiency and thoroughness of assessment is enhanced 7

A note about the use of standardized assessment measures… (slide 2 of 2) • Using standardized assessment measures of functioning… – Assists in initial clinical impressions – Provides valuable information to guide treatment/interventions – Assesses sufficiency of treatment delivered – Demonstrates treatment-related improvements in child functioning 8

UCLA Post-Traumatic Stress Reaction Index

©

(PTSD-RI)

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CiMH PTSD-RI Training

• Content for today’s training courtesy of: – National Center for Child Traumatic Stress at UCLA • 2004 article in Current Psychiatry Reports by Alan Steinberg, Melissa Brymer, Kelly Decker and Robert Pynoos – National Child Traumatic Stress Network • Video-taped training on the administration and scoring of the PTSD-RI (Alan Steinberg, William Saltzman and Melissa Brymer) – Personal communications with Laura Murray, TF-CBT trainer and expert clinical consultant 10

PTSD-RI Description

• Target-specific measure for clients with exposure to trauma • Assesses the frequency of occurrence of children’s post-traumatic stress reactions – Parent/caregiver report for children age 3 and older – Self-report for children age 7 and older • Available in English and Spanish 11

PTSD-RI Description

• Administration of the full measure takes 20 30 minutes – After initial assessment, only the symptom severity portion need be administered again • Part III ~ 10 minutes to complete • Sensitive to clinical change over time • Valid and reliable • Available for use by CiMH partnering agencies under permissions of the developer 12

PTSD-RI Description

• Part I: 14 items – Assesses lifetime history of exposure to trauma – Yes or No – If more than one trauma, focus on event most currently bothersome • Part II: 13 items – Assesses objective and subjective features of the trauma exposure – Maps on to DSM-IV Criteria A1 & A2 • Part III: 20 items – Assesses the frequency of PTS symptoms during the past month – Maps on to DSM-IV Criteria B, C & D – 5-point Likert scale response options • 0 = None (of the time) • 1 = Little (of the time) • 2 = Some (of the time) • 3 = Much (of the time) • 4 = Most (of the time) 13

Let’s take a look at the PTSD-RI...

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PTSD-RI Administration

• Readability is age 12 – Preferred method of administration is that the measure be read aloud – Can be completed independently • All items should be completed – “Don’t Know” responses are not scored • Parents/caregivers may not know about their child’s exposure to trauma and/or their child’s symptom experience 15

PTSD-RI Administration

• Part I & II: Lifetime history of exposure • Part III: “How much of the time during the past month?” – For Part III, guide the respondent through the Frequency Rating Scale prior to administration • Tear off Page 5 so they can see it while they respond • Explain each response option • Ensure understanding of each response option – “Suppose I ask you how often in the past month you… » … had a headache?” » … did your homework?” » … had green hair?” 16

PTSD-RI Administration

• Part I & II – Administer pre- (only) a dose of treatment, or an intervention interval, focused on trauma • No need to re-administer after initial assessment • Part III – Administer pre- and post- a dose of treatment, or an intervention interval, focused on trauma • PTSD-RI child version completed by client • PTSD-RI parent version completed by mother/mother figure or father/father figure (when available) – Both can be completed for clinical purposes; however, only one should be entered for outcome tracking purposes • Select parent/caregiver who spends most time with client 17

Let’s take a look at the PTSD-RI Scoring Worksheet...

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PTSD-RI Scoring

• There are two ways that item responses can be scored 1. To assist with initial clinical impressions and diagnostic formulation • Items map on to each of the four criteria in DSM-IV for Post Traumatic Stress Disorder, 309.81

2. To assess the overall severity of current post traumatic stress symptomotology • Sum of all symptom frequency items in Part III 19

PTSD-RI Scoring

• Each DSM-IV Criterion is established separately • DSM-IV Criterion A – Exposure to trauma (Part 1) • At least 1 “Yes” on Q#s 1-13 – Criterion A1 (Part II) • To be met, >1 “Yes” on Q#s 15-21 – Criterion A2 (Part II) • To be met, >1 “Yes” on Q#s 22-26 – Criterion A • To be met, exposure to trauma and A1 and A2 met 20

PTSD-RI Scoring

• DSM-IV Criteria B, C, and D – Based on Part III: Questions 1-20 – Transfer each item’s response score onto the scoring sheet next to the appropriate Question # – PTSD-RI items map directly on to DSM-IV criteria • Except Q14 & Q20 which assess associated features • Severity score for each Criterion is the sum of the items that map on to that Criterion • Each Criterion is met (to assist in your diagnostic impressions) if a minimum number of symptoms are “present” (see slides 22-24) – Symptom Cutoff Score

>3

– A score of

3 or 4

(much or most of the time) indicates that a symptom is “present” 21

PTSD-RI Scoring DSM-IV Criterion B (re-experiencing)

Met if >1 of the 5 symptoms present* (*score 3 or 4)

DSM-IV Criteria

• B1) recurrent and intrusive thoughts • B2) recurrent distressing dreams • B3) acting or feeling as if event recurring • B4) intense psychological distress at cues • B5) physiological reactivity to cues

PTSD-RI Items

• Q#3* • Q#5 • Q#6 • Q#2 • Q#18 22

PTSD-RI Scoring DSM-IV Criterion C (avoidance)

Met if >3 of the 7 symptoms present* (*score 3 or 4)

DSM-IV Criteria

• C1) avoids thoughts, feelings or talks • C2) avoids activities, places or people • C3) inability to recall important aspect • C4) decreased interest in activities • C5) feelings of detachment • C6) restricted range of affect • C7) sense of foreshortened future

PTSD-RI Items

• Q#9 • Q#17 • Q#15 • Q#7 • Q#8 • Q#10 or Q#11 • Q#19 23

PTSD-RI Scoring DSM-IV Criterion D (increased arousal)

Met if >2 of the 5 symptoms present* (*score 3 or 4)

DSM-IV Criteria

• D1) difficulty falling or staying asleep • D2) irritability or outbursts of anger • D3) difficulty concentrating • D4) hypervigilance • D5) exaggerated startle response

PTSD-RI Items

• Q#13 • Q#4 • Q#16 • Q#1 • Q#12 24

PTSD-RI Scoring PTSD Severity Overall/Total Score

• Based on Part III: Questions 1-20 • Transfer each item’s response score onto the scoring sheet next to the appropriate Question # – For one item score, transfer only the higher number of two Question responses • Q#s 10 or 11 • Note that the Parent Scoring Worksheet also states to select higher score between Q#s 3 and 21.

– Items 14 and 20 are omitted (Associated Features) • A total of 17 items are summed to determine the PTSD Severity Overall/Total Score 25

Clinical Utility of the PTSD-RI

• PTSD Severity Overall/Total Score – Possible scores range from 0 to 68 – Clinical cutpoint is 38 or higher – Scores in the high 20’s and 30’s indicate sub clinical, yet significant levels of PTS reactions that are appropriate for intervention 26

Clinical Utility of the PTSD-RI

• Asks about a broad range of traumatic events – Primary reason for referral may not be only history of trauma exposure – Structured questions can help elicit additional information about exposure to traumatic events – Often, children have not been asked directly about traumatic events they’ve experienced 27

Clinical Utility of the PTSD-RI

• Although not a diagnostic tool, the PTSD-RI can inform clinical impressions – Items map directly onto DSM-IV Criteria for PTSD, 309.81

– Each item/question in Part III is labeled with subscript indicating the specific DSM-IV 309.81 criterion (letter and number) that it assesses • e.g., 1 D4 … 3 B1 … 7 C4 • AF = Associated Feature (i.e., guilt, avoidance) 28

Clinical Utility of the PTSD-RI

• Informs clinician about specific post traumatic stress reactions that are most bothersome to this particular child – Helps prioritize symptoms for intervention – Guides specific techniques that will be used – Guides psycho-education • Not all symptoms need to be normalized for each child presenting with PTSD or PTS reactions 29

Clinical Utility of the PTSD-RI

• Research has shown that certain types of treatment approaches are better for certain aspects of PTS symptoms – e.g., • avoidance responds best to

in vivo

types of exposure • sleep disturbances would suggest the use of behavioral regimens and/or relaxation techniques • significant rumination and self-blame would indicate the need for cognitive interventions 30

Clinical Utility of the PTSD-RI

• Comparisons of pre/post scores reveal areas of clinical improvement – e.g., • Does the child’s Overall/Total PTSD Severity Score decrease substantially?

• Does the child’s symptomotology improve in all domains of post-traumatic stress reactions?

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Palette of Measures Data Entry and Data Submissions

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Palette of Measures Data Entry Shell

• There is a separate spreadsheet in the excel workbook (aka database) for each type of data: – Demographics & Services – Pre- General outcome measure – Post- General outcome measure – Pre- Target-specific measure(s) – Post- Target-specific outcome measure(s) • Specific outcome measure spreadsheets included in each agency’s database varies across Palette of Measures project participants 33

Palette of Measures Data Entry Shell

• In addition to the spreadsheets that hold data...

– There is an

Instructions

spreadsheet • Basic data entry instructions • Contact information for T.A. (Cricket Mitchell) – There is a

Data Lists

spreadsheet at the end of the workbook that you will not use • Data Lists populate the pull-down menus in other spreadsheets 34

Palette of Measures Data Entry: PTSD-RI

Pre-PTSD-RI Client ID# Date of Assessment Parent Report:

(ages 3-18)

P-PTSD1 Self-Report:

(ages 7-18)

C-PTSD1 •There is a separate spreadsheet for Pre-PTSD-RI data, Post-PTSD-RI data, and Mid-PTSD-RI data •In each spreadsheet, there is a separate field for the Total/Overall Severity Score for each informant •In the event of missing data, leave the fields blank/empty. Do not enter text into any of the fields.

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Palette of Measures Data Entry: PTSD-RI

Mid-PTSD-RI Date of Assessment Assessment Parent Report:

(ages 3-18)

Interval P-PTSDM Self-Report:

(ages 7-18)

C-PTSDM Client ID# •For agencies who will conduct mid-treatment assessments, indicate the Assessment Interval in the Mid-PTSD-RI spreadsheet by selecting from the available pull-down menu •e.g., 1 st mid-treatment assessment, 2 nd mid-treatment assessment 36

But, before you enter any outcome data, you’ll enter Demographics & Service Delivery Information...

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Palette of Measures Data Entry: Demographics & Services

(1 of 2)

Client Information:

Client ID# DOB Primary (DSM-IV code) (DSM-IV code) Gender Ethnicity Language Primary Axis I Secondary Axis I Therapist ID •Use a unique identifier for Client ID# •Categorical variables will have pull-down menus from which you’ll select an option (e.g., gender, ethnicity, language) •Dates should be entered as xx/xx/xxxx •Axis I diagnoses s/b the numeric DSM-IV code •Therapist ID is optional 38

Palette of Measures Data Entry: Demographics & Services

(2 of 2)

Focus 1 of Treatment

Focus1 Date of First Session Date of Last Session Total # Completed of Sessions Focus 1?

(if Focus 1 not completed) Completed (if Services not completed) Reason Services?

Reason •Select Focus from pull-down menu (e.g., anxiety, depression) •The shell will hold data for up to 4 foci, or treatment targets •Enter Date of First Session •The remaining fields are to be completed at the end of treatment targeting this particular focus (e.g., Date of Last, # Sessions) •2 levels of “Completed?” • Treatment targeting this particular focus • Overall service delivery 39

Palette of Measures Data Submissions

(slide 1 of 3) • Data submissions to CiMH will occur twice a year throughout the duration of the project – The end of each May (reflecting all clients served from the initiation of the project through the end of that April) – The end of each December (reflecting all clients served from the initiation of the project through the end of that November) –

Note that this is the anticipated schedule; actual data submission dates may vary slightly

• An email notice will be sent to Palette of Measures site leads approximately one month in advance of each data submission deadline 40

Data Submissions

(slide 2 of 3) • Providers may choose from among the following methods for submitting their Palette of Measures Excel databases to CiMH: – Use YouSendIt, or another secure web-based transfer site, to submit data electronically • YouSendIt ( protected) www.YouSendIt.com

) is a vendor that supports the secure transfer of electronic data (encrypted and password – Mail a password-protected CD to CiMH and submit the password separately (via email or phone) – Email an encrypted, password-protected file(s) to CiMH and submit the password separately (via email or phone) 41

Data Submissions

(slide 3 of 3) • After data are submitted, sites continue to enter new data into the same database – Always reflects an ongoing, historical record of clients served through the Palette of Measures project • Every effort is made to distribute reports within two months of each data submission – Aggregate and site/agency-specific reports 42

Questions

43

The End

Contact Information

•Cricket Mitchell, PhD •Email: [email protected]

•Cell phone: 858-220-6355 44