Childhood maltreatment, PTSD, and Teen Dating Violence

Christine Wekerle,Ph.D.Associate Professor, Education,

Psychology, PsychiatryThe University of Western Ontario

cwekerle@uwo.ca

“ Violence in intimate relationships can be one…in which great intensity of positive longing, anger, and fear may be combined with a lack of felt security, lapses in attention, dysfluent communication, and unregulated arousal.” (Lyons-Ruth & Jacobvitz, 1999)

Developmental Traumatology Tenets (DeBellis, 2001)

• The biological stress system response varies with individual’s genetics, nature of the stressor, and whether the system can maintain homeostasis or whether it permanently changes due to stressor

• PTSD symptoms are normal responses, but when chronic can lead to adverse brain development

• PTSD symptoms represents pathway to more impairment; intergenerational maltreatment follows PTSD mediation

• Chronic mobilization of the fight/flight response, is the key cause of persistent negative neurological effects and neurobiological changes

• PTSD key causal factor underlying broad range of academic and mental health impairments

Childhood Maltreatment

Mediator:Post-traumatic stress

symptomatology

Poor Mental HealthDating violenceRisky sexual behaviorSubstance abuse

Mediators: Causal Factors Preceding Target Change

• The identification of mediator provides target for cost-effective intervention and ground for evidence-based policy decision.

Predictive Distal Factor: Childhood Maltreatment

Child maltreatment may be the single most preventable and intervenable contributor to child and adult mental illness (DeBellis, 2003)

Effective parenting is the most powerful way to reduce youth problem behaviours (Kumpfer & Alvarado, 2003)

Adverse life events are not random –Child maltreatment associated with more problematic family environments, other high impact negative life events (including overlapping types of maltreatment), poverty etc.(Costello et al., 2002)

Canadian Incidence Study of Reported Child Abuse & Neglect:Caregiver Substance Abuse

65% decreaseOR: 0.35; CI: 0.14, 0.90*

61% increaseOR: 1.61; CI: 1.17, 2.21*

155% increaseOR: 2.55; CI: 1.90, 3.42*

6% decreaseOR: 0.94; CI: 0.63, 1.41

-150%

-100%

-50%

0%

50%

100%

150%

200%

Physical abuse Sexual abuse Neglect Emotional abuse

Child Maltreatment Type

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age & sex of the child + the caregiver's characteristics accounted for *p>0.05

CIS Study: Caregiver Substance Abuse and Environmental Risk Factors

– Poverty (income < $15,000, OR=1.6)– Multiple moves in the past 6 months (3+, OR=5.2)– Unsafe housing (OR=1.9)– Minority racial status (Aboriginal OR=3.4; Other

Minority OR=1.4)– Low caregiver education (OR=1.9)– Criminal activity (OR=4.8)– Involvement in a violent relationship (OR=3.8)– History of childhood maltreatment (OR=3.2)– Mental (OR=2.8) and physical (OR=2.6) health

issues – Lack of social supports (OR=2.6)

DSM-IV PTSD Criteria• Specifier: (1) Acute (< 3 months); (2) Chronic (> 3

months); (3) Delayed Onset (6 months past traumatic stressor)

• Issues: Intensity, proximity, chronicity of stressor, age of child, relationship to perpetrator, presence of supportive and protective caretaker

• Criterion A: Both must be present

(1) traumatic event w/ actual/threatened death or serious injury to threat to physical integrity to self/others

(2) response involved intense fear, helplessness, horror, disorganized or agitated behaviour

DSM-IV PTSD SymptomatologyDSM- IV Symptom Classes:(1) Re-experiencing: recurrent, intrusive thoughts;

bad dreams*; sense of re-living*; physiological reactivity and psychological distress* at cue exposure

(2) Avoidance/Numbing*: avoid thoughts, feelings, places, people, activities related to trauma*; gaps in recall; feeling detached; feeling problems; pessimism about future

(3) Arousal: sleeping, anger, irritability, startle*, hypervigilance, concentration difficulty

* Higher among chronic, abused youth (Fletcher, 2003)

Mediators: Causal Factors Preceding Target Change

PTSD symptomatology as mediator

• Teens > frequently endorse intrusive memories, numbness, reminders are distressing, dissociative response, efforts to forget about event, hypervigilance, reliving the event (Fletcher, 2003)

• a significant proportion of adults diagnosed with alcohol dependence experience clinically significant levels of PTSD symptomatology

• individuals who suffer resultant PTSD as a result of childhood maltreatment may use alcohol as a means of coping (Stewart & Israeli, 2002)

• PTSD interfere with relationship functioning

Cross-lagged Structural Model Of Trauma Symptoms As A Predictor Of Child Maltreatment And

Dating Violence For Boys, Adjusted To Include Independent Mediator Paths For Emotional Abuse

Time 1 Time 2

.23**

.62**

.32**

Child Mal-treatment

Trauma Symptoms

Trauma Symptoms

Dating Violence

Dating Violence

Emotional Abuse

Emotional Abuse

.25**

.25**

.38** .41**

Cross-lagged Structural Model Of Trauma Symptoms As A Predictor Of Child Maltreatment And Dating

Violence For Girls, Adjusted To Include Independent Mediator Paths For Anger

Time 1 Time 2

.23** .22*

.75**

.58**

.20**

.19**

.52**

Child Mal-treatment

Dating Violence

Dating Violence

Trauma Symptoms

Trauma Symptoms

Anger Anger

.25**

.16*

Dating Violence Prevention:The Youth Relationships Project

Rationale: Youth with a child maltreatment history at greater risk for relationship violence

Target Age: Mid-adolescence (age 14-17) [By age 14, 55% had romantic relationship; by 17, 80% had romantic relationship, Carver et al., 2003]

Targets: (1) concept of relationships(2) relationships skills(3) social action (mastery via advocacy)

Program: 18 sessions (2-hr) coeducational group format, coeducational facilitation – semi-structured manual

Results: Reduced dating violence involvement, Reduced PTSD symptomatology within a RCT design with child welfare youth(Wolfe, Wekerle et al., 2003)

MAP Feasibility Study: Research Process

• Mean Age of tested youth: 15.5 years

• Ineligibility Rate: Overall 31% (Case closed, AWOL, Discharged, mental health issues, developmental delay, In custody, Not identified client)

• Refusal Rate: Overall 30% (Community: 55%, In-care: 17%; Males: 39%; Females: 19%)

• Reasons given for Refusal: “Just not interested”/ no reason: 65%(Parental Refusal: 14%; “Too busy”: 8%;“Not comfortable sharing”: 5%;Other: 8%)

• Recruitment Rate: Overall 70% (Community: 45%; In-care: 83%;Males: 61%; Females: 81%)

• Reasons given for participation: Money: 59%;“No reason given”: 32%; Other: 9%

• Average testing time: 2.8 hrs (Range = 2.0 to 4.5 hrs)• Avg. Cost/Ss/Testing: $133.11 – Youth paid ON minimum wage/4hrs

Home ($70.21) + $28.00 = $98.21 (>80% youth selected testing at residence)CAMH ($1.90) + $28.00 = $29.90(+$5.00 food/refreshment cost)

Descriptives of the MAP Preliminary Analysis Sample

• Gender: 47 (56%) female, 37 male

• CAS status:– Crown Ward: 32 (42.1%)– Society Ward: 24 (31.6%)– Community Family/Temporary Care:

7(9.2%)– Voluntary Care: 1 (1.3%)

Bullying

• Childhood Experiences of Victimization Questionnaire (CEVQ)– Was Verbally bullied

• 60% endorsed, 50% before grade 6

– Was Physically bullied• 40% endorsed, 34% between 6-8th grade

• Ontario Student Drug Use Survey (OSDUS)– Frequency of being bullied at school (grades 7-

12) since September (past 6 months)• 31% endorsed

– Frequency of bullying at school (grades 7-12) since September (past 6 months)

• 34% endorsed

Emotional Maltreatment

• CEVQ– Witness verbal abuse to another adult

• 70% endorsed, 63% occurred before grade 6

– Witness physical abuse to another adult• 43% endorsed, 55% occurred before grade 6

– Victim of verbal abuse by parents• 74% endorsed, 59% occurred before grade 6

• CTQ (growing up as a child … )– Family said hurtful or insulting things

• 72% endorsed

– Being called “stupid,” “lazy,” or “ugly” by family• 72% endorsed

Physical Maltreatment• CEVQ

– Being pushed, grabbed, or shoved as a way to hurt

• 65% endorsed, 61% before grade 6, 81% parental perpetration

– Being kicked, bit or punched as a way to hurt• 43% endorsed, 56% before grade 6, 78% parental

perpetration

• Childhood Trauma Questionnaire (CTQ; “While growing up as a child …”)– Being hit so hard it left marks:

• 62% endorsed

– Being punished with belt, cord, hard objects: • 57% endorsed

Sexual Maltreatment

• CEVQ– Being touched or forced to touch other’s private

part• 32% endorsed, 54% before grade 6

– Being coerced into having sex• 26% endorsed, 43% before grade 6 & 30% high

school

• CTQ (growing up as a child … )– Being forced to do or watch sexual things

• 20% endorsed

– Being molested• 20% endorsed

Neglect

• CTQ (growing up as a child …)– Not having enough to eat

• 40% endorsed

– Parent too drunk or high to take care of the family

• 22% endorsed

– Had to wear dirty cloth• 25% endorsed

Posttraumatic Stress Disorder Symptomatology

• Trauma Symptom Checklist for Children (TSCC)– Feeling afraid something bad might

happen• 75% endorsed

– Remembering things that happened that I didn’t like

• 74% endorsed

– Bad dreams or nightmare• 63%

Maltreatment and Trauma

TSCC total CEVQ total CTQ totalTSCC total 0.34* 0.16CEVQ total 0.74*CTQ totalp<0.05*; p<0.01**

Correlations: Combined sample

TSCC totalCEVQ total CTQ totalTSCC total 0.08 -0.14CEVQ total 0.78**CTQ total

.

Correlations: Male Only

p<0.05*; p<0.01**

TSCC totalCEVQ total CTQ totalTSCC total 0.53** 0.42*CEVQ total 0.75**CTQ total

Correlations: Female Only

p<0.05*; p<0.01**

MAP Feasibility Study: Preliminary Result

• 90% of female adolescents had experienced either one or more forms of sexual abuse, and almost 80% of male had experience either one or more forms of physical abuse.

• The severity and duration of maltreatment experience is associated with the number and acuteness of PTSD symptomatology

• While in general PTSD symptomatology is associated with the four indicators of poor developmental health in maltreated adolescents, there are stark gender differences: – PTSD symptomatology in maltreated female adolescents is associated with: 1)

internalizing symptoms, 2) victimization in dating violence, 3) risky sexual behavior – illicit drug-use as part of their sexual activity, 4) experienced difficulty in stopping drug and alcohol even if they wanted to

– PTSD symptomatology in maltreated male adolescents is associated with: 1) externalizing behaviors, 2) perpetration and victimization in dating violence, 3) risky sexual behavior – un-protected sexual activities, 4) more illicit drug use

Childhood Maltreatment

PTSD Symptomatology

Poor Mental HealthDating violenceRisky sexual behaviorSubstance abuse

Childhood Maltreatment

PTSD Symptomatology

Poor Mental HealthDating violenceRisky sexual behaviorSubstance abuse

MAP Feasibility Study: Preliminary Result

• Testing the full mediation model:– Feasibility has small sample size, not enough statistical

power – awaits MAP Longitudinal Study– Only partial mediation of PTSD symptomatology in the

relationship between childhood maltreatment and internalizing symptom in female, and between maltreatment and victimization in dating violence in the combined sample.

– Encourages continued research on PTSD symptomatology as a key mediator of diverse teen outcomes

– No current maltreatment-specific PTSD intervention for teens exists; may need gender-specific intervention