Web-only Feature

Web-only Feature

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

Internet Editor’s Note: Correspondence concerning this article should be addressed to Ashley Simon, 2091 Murray Holladay Road, Suite 17, Salt Lake City UT 84117. Email: ashley@clinical-informatics.com


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


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

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

Measuring Trauma

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

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

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



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


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

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

Insert table 1 about here:

Table 1: Results of Trauma-Specific Items Factor Analysis

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


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

Insert table 2 about here:

Table 2: Comparison of Global Distress Measure and Trauma Measure

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


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

First Assessment

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

Severity Adjusted Effect Size

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


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

Daryl Mahon is an Irish psychotherapist whose research interests are in therapy outcomes and processes. He is a lecturer, as well as providing training to practitioners in psychotherapy processes and outcomes. Daryl has worked largely in the non-profit sector with those from marginalized communities, in addition to running training through his Outcomes Matter company.

Cite This Article

Mahon, D., Brown, G.J., & Simon, A. (2021, November). Investigation of the psychometric properties and treatment outcomes for a brief measure of trauma related symptoms in adolescents. Retrieved from https://societyforpsychotherapy.org/investigation-of-the-psychometric-properties-and-treatment-outcomes-for-a-brief-measure-of-trauma-related-symptoms-in-adolescents-2/


Basedow, L. A., Kuitunen-Paul, S., Roessner, V., & Golub, Y. (2020). Traumatic events and substance use disorders in adolescents. Frontiers in Psychiatry11, 559. https://doi.org/10.3389/fpsyt.2020.00559

Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia, T., Stokes, J., Handelsman, L., Medrano, M., Desmond, D., & Zule, W. (2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse & Neglect27(2), 169–190. https://doi.org/10.1016/s0145-2134(02)00541-0

Brophy, C. J., Norvell, N. K., & Kiluk, D. J. (1988). An examination of the factor structure and convergent and discriminant validity of the SCL-90R in an outpatient clinic population. Journal of Personality Assessment, 52, 334. doi:10.1207/s15327752jpa5202_14

Brown, G. S. J., Simon, A., Cameron, J., & Minami, T. (2015a). A collaborative outcome resource network (ACORN): Tools for increasing the value of psychotherapy. Psychotherapy, 52(4), 412–421. https://doi.org/10.1037/pst0000033

Brown, G. S. J., Simon, A., & Minami, T. (2015b). Are you any good…as a clinician? [Web article]. Retrieved from http://www.societyforpsychotherapy.org/are-you-anygood-as-a-clinician

Brown, R. C., Heines, S., Witt, A., Braehler, E., Fegert, J. M., Harsch, D., & Plener, P. L. (2018). The impact of child maltreatment on non-suicidal self-injury: Data from a representative sample of the general population. BMC Psychiatry18(1), 1-8. https://doi.org/10.1186/s12888-018-1754-3

Chen, L. P., Murad, M. H., Paras, M. L., Colbenson, K. M., Sattler, A. L., Goranson, E. N., Elamin, M. B., Seime, R. J., Shinozaki, G., Prokop, L. J., & Zirakzadeh, A. (2010). Sexual abuse and lifetime diagnosis of psychiatric disorders: Systematic review and meta-analysis. Mayo Clinic Proceedings85(7), 618–629. https://doi.org/10.4065/mcp.2009.0583

Copeland, W. E., Shanahan, L., Hinesley, J., Chan, R. F., Aberg, K. A., Fairbank, J. A., van den Oord, E., & Costello, E. J. (2018). Association of childhood trauma exposure with adult psychiatric disorders and functional outcomes. JAMA Network Open1(7), e184493. https://doi.org/10.1001/jamanetworkopen.2018.4493

Enns, M. W., Cox, B. J., Parker, J. D., & Guertin, J. E. (1998). Confirmatory factor analysis of the Beck Anxiety and Depression Inventories in patients with major depression. Journal of Affective Disorders, 47, 195-200. doi:10.1016/S0165-0327(97)00103-1

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine14(4), 245-258. https://doi.org/10.1016/S0749-3797(98)00017-8

Hjelseng, I. V., Vaskinn, A., Ueland, T., Lunding, S. H., Reponen, E. J., Steen, N. E., Andreassen, O. A., & Aas, M. (2020). Childhood trauma is associated with poorer social functioning in severe mental disorders both during an active illness phase and in remission. Schizophrenia Research, S0920-9964(20)30118-3. Advance online publication. https://doi.org/10.1016/j.schres.2020.03.015

Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi, D., Butchart, A., Mikton, C., Jones, L., & Dunne, M. P. (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. The Lancet Public Health2(8), e356–e366. https://doi.org/10.1016/S2468-2667(17)30118-4

Humphreys, K. L., LeMoult, J., Wear, J. G., Piersiak, H. A., Lee, A., & Gotlib, I. H. (2020). Child maltreatment and depression: A meta-analysis of studies using the Childhood Trauma Questionnaire. Child Abuse & Neglect102, 104361. https://doi.org/10.1016/j.chiabu.2020.104361

Infurna, M. R., Reichl, C., Parzer, P., Schimmenti, A., Bifulco, A., & Kaess, M. (2016). Associations between depression and specific childhood experiences of abuse and neglect: A meta-analysis. Journal of Affective Disorders190, 47–55. https://doi.org/10.1016/j.jad.2015.09.006

Kessler, R.C., McLaughlin, K.A., Green, J.G., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., Aguilar-Gaxiola, S., Alhamzawi, A. O., Alonso, J., Angermeyer, M., Benjet, C., Bromet, E., Chatterji, S., de Girolamo, G., Demyttenaere, K., Fayyad, J., Florescu, S., Gal, G., Gureje, O… Williams, D. R. (2010). Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. British Journal of Psychiatry, 197(5), 378–385. doi:10.1192/bjp.bp.110.080499

Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9), 1-7.  https://doi.org/10.3928/0048-5713-20020901-06

Krupnik, V. (2019). Trauma or adversity? Traumatology, 25(4), 256–261. https://doi.org/10.1037/trm0000169

Lambert, M., Burlingame, G., Umphress, V., Hansen, N., Vermeersch, D., Clouse, G. & Yanchar, S. (1996). The reliability and validity of the Outcome Questionnaire. Clinical Psychology and Psychotherapy, 3, 249-258. https://doi.org/10.1002/(SICI)1099-0879(199612)3:4<249::AID-CPP106>3.0.CO;2-S

Lang, C. M., & Sharma-Patel, K. (2011). The relation between childhood maltreatment and self-injury: a review of the literature on conceptualization and intervention. Trauma, Violence & Abuse12(1), 23–37. https://doi.org/10.1177/1524838010386975

Levine, P. A. (2010). In an unspoken voice: How the body releases trauma and restores goodness. North Atlantic Books.

Li, M., D’Arcy, C., & Meng, X. (2016). Maltreatment in childhood substantially increases the risk of adult depression and anxiety in prospective cohort studies: Systematic review, meta-analysis, and proportional attributable fractions. Psychological Medicine, 46(4), 717-730. doi:10.1017/S0033291715002743

Lo Coco, G., Chiappelli, M., Bensi, L., Gullo, S., Prestano, C., & Lambert, M. J. (2008). The factorial structure of the outcome questionnaire-45: A study with an Italian sample. Clinical Psychology and Psychotherapy, 15, 418-423. doi:10.1002/cpp.601

Magruder, K. M., McLaughlin, K. A., & Elmore Borbon, D. L. (2017). Trauma is a public health issue. European Journal of Psychotraumatology, 8(1), 1375338. https://doi.org/10.1080/20008198.2017.1375338

McCrory, E., De Brito, S. A., & Viding, E. (2010). Research review: The neurobiology and genetics of maltreatment and adversity. Journal of Child Psychology and Psychiatry, and Allied Disciplines51(10), 1079–1095. https://doi.org/10.1111/j.1469-7610.2010.02271.x

McLaughlin, K. A. (2016). Future directions in childhood adversity and youth psychopathology. Journal of Clinical Child and Adolescent Psychology45(3), 361–382. https://doi.org/10.1080/15374416.2015.1110823

Miller, S. & Duncan, B. & Brown, J. (2003). The Outcome Rating Scale: A preliminary study of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2, 91-100.

Mueller, R., Lambert, M. J., & Burlingame, G. (1998). Construct validity of the Outcome Questionnaire: A confirmatory factor analysis. Journal of Personality Assessment70, 248-262. https://doi.org/10.1207/s15327752jpa7002_5

Nanni, V., Uher, R., & Danese, A. (2012). Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression: A meta-analysis. The American Journal of Psychiatry169(2), 141–151. https://doi.org/10.1176/appi.ajp.2011.11020335

Norman, R. E., Byambaa, M., De, R., Butchart, A., Scott, J., & Vos, T. (2012). The long-term health consequences of child physical abuse, emotional abuse, and neglect: A systematic review and meta-analysis. PLOS Medicine9(11), e1001349. https://doi.org/10.1371/journal.pmed.1001349

Quidé, Y., Tozzi, L., Corcoran, M., Cannon, D. M., & Dauvermann, M. R. (2020). The impact of childhood trauma on developing bipolar disorder: Current understanding and ensuring continued progress. Neuropsychiatric Disease and Treatment16, 3095–3115. https://doi.org/10.2147/NDT.S285540

Ridge, N., Warren, J., Burlingame, G., Well, G. & Tumblin, K. (2009). Reliability and validity of the Youth Outcome Questionnaires Self-Report. Journal of Clinical Psychology, 65, 1115-112. doi: 10.1002/jclp.20620

Scoglio, A. A. J., Reilly, E. D., Girouard, C., Quigley, K. S., Carnes, S., & Kelly, M. M. (2020). Social functioning in individuals with post-traumatic stress disorder: A systematic review. Trauma, Violence, & Abusehttps://doi.org/10.1177/1524838020946800

Scott, K. M., McLaughlin, K. A., Smith, D. A., & Ellis, P. M. (2012). Childhood maltreatment and DSM-IV adult mental disorders: Comparison of prospective and retrospective findings. The British Journal of Psychiatry: The Journal of Mental Science200(6), 469–475. https://doi.org/10.1192/bjp.bp.111.103267

Setién-Suero, E., Suárez-Pinilla, P., Ferro, A., Tabarés-Seisdedos, R., Crespo-Facorro, B., & Ayesa-Arriola, R. (2020). Childhood trauma and substance use underlying psychosis: A systematic review. European Journal of Psychotraumatology11(1), 1748342. https://doi.org/10.1080/20008198.2020.1748342

Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7.  Archives of Internal Medicine, 166, 1092-1097. doi:10.1001/archinte.166.10.1092.

Steinberg, A. M., Brymer, M. J., Kim, S., Briggs, E. C., Ippen, C. G., Ostrowski, S. A., Gully, K. J., & Pynoos, R. S. (2013). Psychometric properties of the UCLA PTSD reaction index: Part I. Journal of Traumatic Stress26(1), 1–9. https://doi.org/10.1002/jts.21780

Thomassin, K., Shaffer, A., Madden, A., & Londino, D. L. (2016). Specificity of childhood maltreatment and emotion deficit in nonsuicidal self-injury in an inpatient sample of youth. Psychiatry Research244, 103–108. https://doi.org/10.1016/j.psychres.2016.07.050

Weber, S., Jud, A., & Landolt, M. A. (2016). Quality of life in maltreated children and adult survivors of child maltreatment: A systematic review. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation25(2), 237–255. https://doi.org/10.1007/s11136-015-1085-5


Submit a Comment

Your email address will not be published. Required fields are marked *