Ci MH Palette of Measures Evaluation Training UCLA

Ci. MH Palette of Measures Evaluation Training: UCLA Post Traumatic Stress Disorder Reaction Index (PTSD-RI) Cricket Mitchell, Ph. D CIMH Evaluation Consultant

Palette of Measures Evaluation: What You Will Need (slide 1 of 2) • Palette of Measures Data Entry Shell v 2 (Excel file) – Developed by Ci. MH 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 v 2 (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© (PTSD-RI) – Available at no-cost to interested Palette of Measures participating agencies under permissions granted to Ci. MH by the developers of the measure 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 Ci. MH 4

Brief Overview of Palette of Measures Evaluation Protocol 5

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, PTSDRI, 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) 9

Ci. MH 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, TFCBT 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 2030 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 Ci. MH 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 A 1 & A 2 • 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. . . 14

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. . . 18

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 A 1 (Part II) • To be met, >1 “Yes” on Q#s 15 -21 – Criterion A 2 (Part II) • To be met, >1 “Yes” on Q#s 22 -26 – Criterion A • To be met, exposure to trauma and A 1 and A 2 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 Q 14 & Q 20 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 PTSD-RI Items • B 1) recurrent and intrusive thoughts • Q#3* • B 2) recurrent distressing dreams • Q#5 • B 3) acting or feeling as if event recurring • Q#6 • B 4) intense psychological distress at cues • Q#2 • B 5) physiological reactivity to cues • 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 C 1) avoids thoughts, feelings or talks C 2) avoids activities, places or people C 3) inability to recall important aspect C 4) decreased interest in activities C 5) feelings of detachment C 6) restricted range of affect C 7) 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 D 1) difficulty falling or staying asleep D 2) irritability or outbursts of anger D 3) difficulty concentrating D 4) hypervigilance D 5) exaggerated startle response PTSD-RI Items • Q#13 • Q#4 • Q#16 • 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 subclinical, 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 D 4 … 3 B 1 … 7 C 4 • AF = Associated Feature (i. e. , guilt, avoidance) 28

Clinical Utility of the PTSD-RI • Informs clinician about specific posttraumatic 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? 31

Palette of Measures Data Entry and Data Submissions 32

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 Parent Report: (ages 3 -18) Self-Report: (ages 7 -18) Assessment P-PTSD 1 C-PTSD 1 • 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. 35

Palette of Measures Data Entry: PTSD-RI Mid-PTSD-RI Client ID# Date of Parent Report: Assessment (ages 3 -18) Self-Report: (ages 7 -18) Assessment Interval P-PTSDM C-PTSDM • 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. . . 37

Palette of Measures Data Entry: Demographics & Services (1 of 2) Client Information: Client ID# DOB Primary (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 Date of First Session Focus 1 Date of Total # Completed Last 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 Ci. MH 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 Ci. MH: – Use You. Send. It, or another secure web-based transfer site, to submit data electronically • You. Send. It (www. You. Send. It. com) is a vendor that supports the secure transfer of electronic data (encrypted and passwordprotected) – Mail a password-protected CD to Ci. MH and submit the password separately (via email or phone) – Email an encrypted, password-protected file(s) to Ci. MH 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, Ph. D • Email: cmitchell@cimh. org • Cell phone: 858 -220 -6355 44