De Fouchier C, Blanchet A, Hopkins W, Bui E, Ait-Aoudia M, Jehel L. Validation of a French adaptation of the Harvard Trauma Questionnaire.
![]()
BackgroundThe Harvard Trauma Questionnaire (HTQ) was developed 25 years ago as a cross-cultural screening instrument to document trauma exposure, head trauma and trauma-related symptoms in refugees. This article aims to: (i) outline the process of revision of Part IV of the HTQ to (a) include the new DSM-5 diagnostic criteria for PTSD, and (b) separate out and more fully develop the refugee-specific functioning items; and (ii) promote a consistent approach to the validation of the HTQ-5 when adapted for use in other cultures and language groups. IntroductionThere are 68.5 million individuals worldwide who are displaced due to conflict, persecution, or generalized violence according to the United Nations High Commissioner for Refugees. Many have been exposed to significant violence, including head injury and torture, and are at risk of high rates of post-traumatic stress disorder (PTSD) and other mental health problems. It is vital to have access to a brief screening tool to identify those at risk for mental health problems associated with disability and dysfunction. Accurate screening of these domains enables those working with refugees to triage more effectively, directing scarce resources appropriately to those most at risk. The Harvard Trauma Questionnaire (HTQ) was developed by the Harvard Program in Refugee Trauma 25 years ago to achieve the latter goal.
The HTQ is a cross-cultural screening instrument that documents trauma exposure, head trauma and trauma-related symptoms in refugees and others exposed to potentially traumatizing experiences. The HTQ comprises four parts: (i) experiences of torture and other traumas frequently experienced by refugees, (ii) a subjective description of the most severe traumatic event(s) experienced, (iii) events associated with head injuries, and (iv) symptoms of PTSD and refugee-specific expressions of functional distress. It was originally validated for three Indochinese refugee populations and exhibited strong psychometric properties in both clinic and low prevalence community samples.
The HTQ has been adapted and norms established for a wide range of refugee populations.The HTQ is the most widely used screening measure for trauma-related symptoms in clinical and research work among refugees worldwide., It has been used in settings where licensed mental health professionals are scarce or non-existent and by licensed mental health clinicians and by primary care health providers in settings where large groups have been traumatized, providing guidance in directing attention to those who require more comprehensive diagnostic assessments. The HTQ is relatively brief, easy to administer and score, easy to adapt and translate for different refugee populations and has been well received amongst bicultural workers/professionals, study participants, and refugee patients and communities. Retaining these features was a strong guiding principle. Although the HTQ has been widely used in large-scale population studies, clinicians can also use it as an outcome rating scale during treatment, relying on change (if any) in the total score over time and on individual symptom items.The diagnostic criteria for PTSD have changed significantly from when the diagnosis of PTSD was introduced in 1980 to the current DSM-5, the American Psychiatric Association’s 2013 version of the Diagnostic and Statistical Manual. Key changes were empirically backed and may yield a different prevalence rate of PTSD in particular refugee populations. The criteria have been expanded to include a new criterion of negative alterations in cognitions and mood associated with the traumatic event(s). In addition, optional specifiers are provided related to two types of dissociation: distortions or disconnectedness experienced in the perception of one’s environment (derealization, feeling as though the environment is unreal) or self (depersonalization, feeling disconnected from one’s body).
Ibrahim and colleagues have validated the PTSD Checklist for DSM-5 (PCL-5) for the DSM-5 PTSD criteria. The original and previously revised HTQ (HTQ-R) utilize the older PTSD criteria from the DSM-III-R and DSM-IV versions respectively., Therefore, these versions of the HTQ will not yield a PTSD diagnosis compatible with the DSM-5. This limits the ability of clinicians and researchers to establish the presence and rate of PTSD in refugee populations consistent with the new diagnostic criteria.We sought to revise the original HTQ to develop a valid and reliable cross-cultural screening instrument to measure the trauma-related symptoms in refugees according to the diagnostic criteria of PTSD in the DSM-5. Specifically, this article aims to: (1) outline the process of revision of Part IV of the HTQ to (a) include the new DSM-5 diagnostic criteria for PTSD, and (b) separate out and more fully develop the refugee-specific functioning items (including renaming this part as ‘culture-specific functioning’); and (2) promote a consistent approach to the validation of the HTQ-5 when adapted for use in other cultures and language groups using reputable methods of establishing the psychometric properties of the measure within that culture. Methods Procedures for adapting the PTSD and culture-specific itemsOur process for adapting the PTSD items of the HTQ measure to render it consistent with the DSM-5 and refining the culture-specific functioning items is similar.
It involves a number of steps: item mapping; expert consultations; generating items according to the new DSM-5 criteria; and drafting, refinement and finalization of the revised measure. Item mappingWe started by mapping the existing 16 HTQ PTSD items to the DSM-5 symptom items to identify what was missing or different. This directed us to which PTSD items needed to be developed for the HTQ-5. Symptom items in HTQ-5SectionDSM-5 PTSD criteria1.Recurrent thoughts or memories of the most hurtful or terrifying eventsB1Recurrent, involuntary and intrusive distressing memories of the traumatic event(s)2.Feeling as though the event is happening againB3Dissociative reactions (e.g. Flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings)3.Recurrent nightmaresB2Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)4.Feeling detached or withdrawn from peopleD6Feelings of detachment or estrangement from others5.Unable to feel emotionsD7Persistent inability to experience positive emotions (e.g.
Inability to experience happiness, satisfaction or loving feelings)6.Feeling jumpy, easily startledE4Exaggerated startle response7.Difficulty concentratingE5Problems with concentration8.Trouble sleepingE6Sleep disturbance (e.g. Symptom items in HTQ-5SectionDSM-5 PTSD criteria1.Recurrent thoughts or memories of the most hurtful or terrifying eventsB1Recurrent, involuntary and intrusive distressing memories of the traumatic event(s)2.Feeling as though the event is happening againB3Dissociative reactions (e.g. Flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings)3.Recurrent nightmaresB2Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)4.Feeling detached or withdrawn from peopleD6Feelings of detachment or estrangement from others5.Unable to feel emotionsD7Persistent inability to experience positive emotions (e.g. Inability to experience happiness, satisfaction or loving feelings)6.Feeling jumpy, easily startledE4Exaggerated startle response7.Difficulty concentratingE5Problems with concentration8.Trouble sleepingE6Sleep disturbance (e.g. Symptom items in HTQ-5SectionDSM-5 PTSD criteria1.Recurrent thoughts or memories of the most hurtful or terrifying eventsB1Recurrent, involuntary and intrusive distressing memories of the traumatic event(s)2.Feeling as though the event is happening againB3Dissociative reactions (e.g. Flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
(Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings)3.Recurrent nightmaresB2Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)4.Feeling detached or withdrawn from peopleD6Feelings of detachment or estrangement from others5.Unable to feel emotionsD7Persistent inability to experience positive emotions (e.g. Inability to experience happiness, satisfaction or loving feelings)6.Feeling jumpy, easily startledE4Exaggerated startle response7.Difficulty concentratingE5Problems with concentration8.Trouble sleepingE6Sleep disturbance (e.g. Symptom items in HTQ-5SectionDSM-5 PTSD criteria1.Recurrent thoughts or memories of the most hurtful or terrifying eventsB1Recurrent, involuntary and intrusive distressing memories of the traumatic event(s)2.Feeling as though the event is happening againB3Dissociative reactions (e.g. Flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings)3.Recurrent nightmaresB2Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)4.Feeling detached or withdrawn from peopleD6Feelings of detachment or estrangement from others5.Unable to feel emotionsD7Persistent inability to experience positive emotions (e.g.
Inability to experience happiness, satisfaction or loving feelings)6.Feeling jumpy, easily startledE4Exaggerated startle response7.Difficulty concentratingE5Problems with concentration8.Trouble sleepingE6Sleep disturbance (e.g. Expert consultationsWe engaged in a series of a dozen expert consultation meetings with a panel of experienced professionals in the field to generate an approach to revising the PTSD symptom and culture-specific functioning sections of the HTQ. The panel consisted of two psychiatrists, one clinical psychologist and two social workers, all researchers and clinicians with 10–40 years of experience working with refugees. These meetings involved iterative feedback and discussion and were consensus driven. The expert panel sought to ensure that items were rendered in a format that gave emphasis to simplicity and straightforward language expression, given the need to translate the measure into multiple languages in settings of low literacy (including in languages where there are limited terms for psychological reactions).
Drafting, refinement and finalization of the HTQ-5Our process involved iterations of drafting and refining the items before finalizing the measure. Throughout, we aimed to generate new DSM-5 items while retaining the original HTQ item pool and structure.
This lengthy process was necessary given that some items in the DSM-5 are a composite of several emotional responses, and in some cases, involve complex constructs, requiring careful consideration as to how they will be translated across cultures. Results PTSD symptomsWe developed nine additional items (#17–25) to ensure that each of the DSM-5 symptoms and their variations were included in the HTQ-5 DSM-5 PTSD subscale. We sought to: (i) retain items 1–16 from the original HTQ to promote comparability across studies on those items; and (2) retain the straightforward language and phrasing of the original HTQ to promote ease of understanding for refugees with varied educational backgrounds and a broad range of cultures. The original HTQ had one item (#16) that addressed both DSM criteria B4 and B5 (i.e. Physiological and psychological reactivity). While we considered separating out these symptoms into two items, we determined it was more advantageous to retain the original HTQ in its established form. We also decided to include two items (#24 and #25) for the dissociation specifiers in the HTQ-5 DSM-5 PTSD subscale.
There is limited literature regarding the systematic assessment of dissociation among refugees and the literature in this area has generated a wide prevalence range in relation to this response pattern suggesting that variation in measurement may be implicated., Our clinical experience with diverse refugee groups, however, and that of others who have conducted diagnostic interviews with refugees, suggests that dissociation is a common experience for many refugees who have been exposed to complex trauma as part of their post-traumatic reactions. Identifying those with dissociative symptoms is important for guiding treatment. This task may be challenging in refugees, however, given that culture differentially shapes how dissociation is expressed in keeping with religious and spiritual beliefs and practices. Consistent with the original HTQ, the HTQ-5 DSM-5 PTSD subscale yields a continuous score ranging from 1 to 4.
Each of the 25 items receives a score of ‘1’ (not at all), ‘2’ (a little bit), ‘3’ (quite a bit) or ‘4’ (extremely). The item scores are added, and the total is divided by the number of items, yielding an average item score in which higher scores indicate greater severity of symptoms. The addition of the extra items does not change this index which is why the mean score of ≥2.5 is recommended on a provisional basis to be considered as checklist positive for PTSD, indicating that symptoms are present that may be consistent with the clinical diagnosis of PTSD (although, to strengthen the association with clinical caseness, this cut-off needs to be specified each time the HTQ-5 DSM-5 PTSD subscale is introduced into a new setting or with a new population). The cut-off point of ≥2.5 was established in a population of Southeast Asian psychiatric patients., The revised version (the HTQ-R), with items mapped to the DSM-IV PTSD criteria, was validated in primary healthcare centres in Bosnia and Herzegovina yielding an optimal cut-off point of 2.06. Validity testing on the HTQ-5 DSM-5 PTSD subscale is underway. In the interim, we recommend using the ≥2.5 cut-off established with a clinic population (the most extreme population) to be cautious.We chose to disaggregate a couple of the DSM-5 PTSD criteria, particularly those that include multiple different ways that the criteria may manifest (e.g. D2, persistent and exaggerated negative beliefs or expectations about oneself, others or the world).
![]()
We debated whether to weight the disaggregated items in the same manner as items that are stand-alone items for other criteria when deriving a total cumulative score. Except for four criteria (B4, B5, D2 and D7), the rest of the criteria only have one item in the HTQ-5 DSM-5 PTSD subscale. Two criteria have more than 1 item in the revised instrument: D2 is represented with four separate items (#14, 17, 18 and 23) and D7 is represented by two separate items (#5 and 21). As mentioned previously, we decided to continue to combine B4 and B5 into one item (#16), in keeping with the original HTQ. By giving each of the 25 items equal weight, we are giving more arithmetic weight to the disaggregated criteria in the final cumulative score. One way around this is to down-weight those items (i.e. Their joint scoring should be weighted to be equal to the score given to a criterion where there is only one item response) and to give double weight to the merged item 16.
We decided against this approach as we aimed to make the HTQ-5 DSM-5 PTSD subscale easy to use and score in non-research clinics and in the field by lay practitioners tasked with screening large number of refugees quickly. If a weighting system was employed, practitioners would need to use a scoring algorithm that may unduly complicate the use of the measure in the field. Culture-specific functioning itemsPart IV of the original HTQ included 14 refugee-specific functioning items. An additional 10 items were added to the HTQ-R.
Some of these 24 items were reworded to be easier to comprehend and 6 further items were added to the HTQ-5 across six domains of social functioning to more fully assess each domain, Skills, Physical, Intellectual, Emotional, Social, and Spiritual/Existential (SPIESS). The new items covered the skills and talents (i.e. Feeling that the skills you had before your trauma are no longer useful or valued, work brings back bad memories, your fellow workmates are disturbing to be around), physical (i.e. Feeling too sick to work or do house chores, feeling your body has gone downhill) and intellectual functioning (i.e. Feeling overwhelmed by work) domains. The SPIESS items were designed to assess each refugee’s self-perception of his or her psychosocial functioning.
Functioning was deemed to be of keen concern for refugees, perhaps a more primary focus of concern than DSM-derived PTSD symptoms. Since the development of the original HTQ, various versions of the refugee-specific functioning items were developed relevant for different cultural groups (e.g.
Bosnian, Iraqi, Tibetan) as what is considered functional and how distress may be expressed varies across diverse populations and cultures.,The original HTQ has been used widely in civilian refugee populations. Most of these studies used the items in the HTQ that correspond to PTSD items in the DSM-III and DSM-IV. Not a lot of research has been conducted on the culture-specific symptoms (called refugee-specific symptoms in the original HTQ) to date.
These culture-specific functioning items need additional research. We have therefore not included those items in the HTQ-5 DSM-5 PTSD subscale that now focuses exclusively on DSM-5 PTSD items and the two dissociative specifiers. Implications of this decision include that only the DSM-derived symptoms are subjected to evaluation of criterion validity. The culturally sensitive sub-scales should be validated in other ways.The SPIESS is intended to be incorporated as part of the screening for refugees, to identify important functional areas for referral and/or treatment. It is also relevant for use with non-refugees. The HTQ and other refugee trauma checklists have primarily focused on symptoms., The SPIESS section of the HTQ-5 has been included as a culturally valid avenue of dealing with this limitation. We structured the SPIESS so that each domain now has five items.
The SPIESS instrument is intended to be able to be independently administered from the HTQ-5 DSM-5 PTSD subscale and to be used with it and measures of a wide spectrum of other disorders. It should be modified for each ethnic or cultural group and for their concrete situation. In order to improve the ecological validity of the scale, adaptations for the population’s setting (e.g. Refugee camps, residential centres, rural or urban community areas and rich or poor countries) and demographics (e.g. Age, gender and education) should be made. Some of the SPIESS items overlap with symptoms of Complex PTSD (C-PTSD) as formulated in the ICD-11. High scores on those items may be an indication of C-PTSD and greater functional impairment, rather than PTSD, which has implications for a different treatment approach.
Procedures to validate and test reliabilityThe HTQ-5 DSM-5 PTSD subscale is in the process of being validated and undergoing reliability testing to determine its psychometric properties for screening for PTSD consistent with the DSM-5 criteria in diverse refugee populations. Adapted versions of the instrument should be developed and validated for each population in keeping with the local language and cultural differences as per recommendations of Mollica and colleagues. Validity and reliability tests could also be conducted in various settings, including: (i) in primary healthcare settings, as primary care providers (PCPs) are the principal source of care for many refugees in countries of resettlement and must be equipped to diagnose (and treat) PTSD in these survivors; and (ii) in places of displacement and in refugee camps with administration by trained paraprofessionals. The cut-off score should be established for community-based non-clinical vs. Clinic samples. The SPIESS also needs to undergo psychometric testing to determine how well it detects refugees who are struggling with difficulty functioning in various important domains of their life. Community-based validation studies of the original version of the HTQ have been conducted in many countries and populations, including Cambodia, Bosnia and Herzegovina and Timor-Leste.
Researchers seeking to validate the HTQ-5 DSM-5 PTSD subscale may use similar approaches in a community setting or conduct a validation study in a primary care setting.,In the later studies, receiver operating characteristic (ROC) analysis have been applied to assess the psychometric properties of the HTQ sub-scale for PTSD. The area under the curve (AUC) is used to estimate the diagnostic accuracy of the instrument independently of its specificity and sensitivity., Using this approach, internal consistency can be estimated, sensitivity and specificity determined, and context-specific cut-off scores for the HTQ-5 DSM-5 PTSD subscale established. DiscussionLimitations to the cross-cultural validity of the earlier versions of the HTQ have been described. The content and formulation of the HTQ-5 DSM-5 PTSD subscale symptom items and SPIESS questionnaire items might need to be changed when adapting the instrument to different cultural populations. We encourage others to conduct studies in diverse populations to validate the HTQ-5 DSM-5 PTSD subscale and promote the identification of those at risk for developing psychological disorders and those with probable need for mental health services and support secondary and tertiary prevention efforts.
Clinicians and researchers can customize the HTQ-5 depending on the populations they seek to use it with, in order to include cultural idioms of post-traumatic stress in the PTSD criteria. Additional disability and dysfunction items can be added to the SPIESS in order to determine impairments in social functioning relevant to the specific population.,It should be noted that the final two items of the HTQ-5 DSM-5 PTSD subscale ask about depersonalization i.e. Feeling as if something reminds you of the trauma but it feels like a dream, that it is not happening to you, and/or that it is not real (item 24) and derealization i.e. Feeling people or objects around you are strange or not real (item 25).
These two recurrent or persistent types of dissociation are common in refugee populations but are not part of the core constellation of the Criteria B to E PTSD symptoms in the DSM-5. They are included as specifiers for PTSD.
Given the chronic, severe and sometimes life-threatening nature of the traumas that refugees commonly experience, it is not surprising that some may have experienced peritraumatic dissociation and/or post-traumatic dissociation when faced with reminders of their trauma or other stressors. When others seek to validate the HTQ-5 DSM-5 PTSD subscale, particularly with populations with less dissociation or who have experienced a single acute event, they may want to consider alternate scoring systems that do not include items 24 and 25 in the continuous score. In addition to dissociation, some researchers have pointed to the possible overlap between PTSD and psychotic disorders, advocating for including PTSD with secondary psychotic features in the DSM.
It is important to screen for other mental health conditions in addition to PTSD. The HTQ-5 does not assess for depression and anxiety, nor for such experiences as humiliation, resilience, post-traumatic growth, anger, aggression and challenges in social functioning, all of which are common in refugees.In keeping with the traditional scoring system of the HTQ, deriving a mean score from the total number of items, we aimed to make the scoring relatively straightforward.
It is possible that the prevalence rates of PTSD may differ in some populations when using the HTQ-5 DSM-5 PTSD subscale compared with earlier versions given the significant changes to the PTSD construct in the DSM-5. We have kept all of the original HTQ PTSD items in the new HTQ-5 DSM-5 PTSD subscale to allow for comparison. The HTQ-5 is available upon request. ConclusionThe next step for the HTQ-5 instrument is for researchers to conduct validity and reliability testing and establish cut-off scores in specific populations and contexts. It is expected that the HTQ-5 will be widely utilized by clinicians and researchers who work with refugee populations, just as the earlier versions of the HTQ were used., The HTQ-5 holds promise for facilitating the screening of refugees for the presence of PTSD according to contemporary diagnostic criteria and for studying the impact of PTSD and its association with other conditions of interest in refugee populations. Ultimately, this revised instrument and the associated SPIESS culture-specific functioning scale should promote the early identification of refugees at risk for debilitating symptoms of PTSD and functional impairment, thereby guiding triage and treatment and enhancing the well-being of members of vulnerable refugee populations.Conflicts of interest: None declared.
There are no valid and reliable cross-cultural instruments capable of measuring torture, trauma, and trauma-related symptoms associated with the DSM-III-R diagnosis of posttraumatic stress disorder (PTSD). Generating such standardized instruments for patients from non-Western cultures involves particular methodological challenges. This study describes the development and validation of three Indochinese versions of the Harvard Trauma Questionnaire (HTQ), a simple and reliable screening instrument that is well received by refugee patients and bicultural staff. It identifies for the first time trauma symptoms related to the Indochinese refugee experience that are associated with PTSD criteria. The HTQ's cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations.© Williams & Wilkins 1992. All Rights Reserved.
![]() Comments are closed.
|
Details
AuthorWrite something about yourself. No need to be fancy, just an overview. Archives
March 2023
Categories |