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Validity of the Childhood Trauma Questionnaire in an

Adolescent Psychiatric Population

DAVID P. BER NSTEIN, PH.D., TARUN A AHLUVALIA, B.A., DAVID P OG GE , PH.D.,

A N D LEONARD HANDELSMAN, M.D.

ABSTRACT

Objective: To present initial findings on the validity of a recently developed maltreatment inventory, the Childhood

Trauma Questionnaire CTQ), in a sample of adolescent psychiatric patients. Method: Three hundred ninety-eight male

and female adolescents aged

12

to

17

years) admitted to the inpatient service of a private psychiatric hospital were

given the CTQ as part of a larger test battery. Structured interviews were also conducted with the primary therapists

of 190 of the patients to obtain ratings of abuse and neglect based on all available data, including clinical interviews

with patients and their relatives and information from referring clinicians and agencies. Results: Principal-components

analysis of the CTQ items yielded five rotated factors-emotional abuse, emotional neglect, sexual abuse, physical

abuse, and physical neglect--closely replicating the factor structure in an earlier study of adult patients. The internal

consistency of the CTQ factors was extremely high both in the entire sample and in every subgroup examined. When

CTQ factor scores were compared with therapists’ ratings in a series of logistic regression analyses, relationships

between the two sets of variables were highly specific, supporting the convergent and discriminant validity of the CTQ.

Finally, when therapists’ ratings were used as the validity criterion, the CTQ exhibited good sensitivity for all forms of

maltreatment, and satisfactory or better levels of specificity. Conclusions: These initial findings suggest that the CTQ

is a sensitive and valid screening questionnaire or childhood trauma in an adolescent psychiatric inpatient setting.

J

Am.

Ac ad. Child Adolesc. Psychiatry 1997,36 3):340-348.

Key Words:

abuse, neglect, adolescence, assessment, validity.

Recent studies suggest that childhood trauma and

deprivation are common but frequently underreported

problems among adolescents seen in mental health,

social service, and juvenile justice settings (Cavaiola

and Schiff, 1988; Dembo et al., 1988; Edwall et al.,

1989; Sansonnet-Hayden et al., 1987). Adolescents

Accepted August 15, 1996

Dr. Bernstein is Assistant Profissor of Psychiaty, Mount Sinai School

o f

Medicine, Ne w York, and Director of Clini cal Research, Bronx Veterans Affa irs

Medical C enter? Drug D ependency T reatment Program. Ms. Ahluvalia is a

Doctoral Candidate at Fairleigb Dirkinson University, RutheTford, NJ. Dr.

P o a e

is Director of Psychology at Four Wi nds Hospital, Ketonah, N Y ,

and Assistant Profissor in the Psychology Department, Fairleigh Dirkinson

University. Dr. Handelsman is Associate Profissor of Psycbiaty, Mo unt Sinai

School of Medicine an d Director, Bronx Veterans Affairs M edical Center:

Drug Dependency Tre atm ent Program.

A version

of

this paper was presented at the Fou rth Intern ation al Research

Confirenre on Family Violence, Durham , N H , July I995

Reprint requests to Dr. Bernstein, Brow VA Medical Center, Psychiatry

Service 116A, 130

W

Kingsbridge Road, Bronx, N Y

10468.

0890-8567/97/3603-0340$03.00/001997 by the American Academy

of

Child and Adolescent Psychiatry.

referred for reasons such as substance abuse, delin-

quency, suicide attempts, sexual “acting-out,’’ and run-

ning away from home often have histories of

maltreatment (Cavaiola and Schiff, 1988; Dembo et

al., 1988; Edwall et al., 1989; Sansonnet-Hayden et

al., 1987), but these may not be disclosed during the

course of routine evaluation. The early identification

of such cases is essential, so that interventions can be

made before the consequences of childhood trauma

become chronic. However, until recently, few system-

atic methods for assessing maltreatment in adolescence

have been available and the validation of these measures

has been limited (Dembo et al., 1988; Sanders and

Giolas, 1991). In this report, we present initial findings

on the validity of a recently developed measure for

assessing maltreatment, the Chi ldhood Trauma Ques-

tionnaire (CTQ), in a large, demographically diverse

sample of adolescent psychiatric inpatients.

The CTQ is a 70-item self-report inventory that

provides brief and relatively noninvasive screening of

maltreatment experiences before the age of 18 years.

340

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T H E C T Q I N A D O LE S CE N T S

In studies of adu lt substance abusers, the CTQdemon-

strated excellent test-retest reliability over a 2- to

6-month interval as well as convergence with a struc-

tured trauma interview (Bernstein et al., 1994; Fink

et al.,

1995).

Principal-components analysis

(PCA)

of

the scale yielded four rotated factors which were labeled

physical and em otional abuse, emotion al neglect, sexual

abuse, and physical neglect (Bernstein et al., 1994).

In the present study, our goal was to validate the

CTQ in a psychiatric population of adolescents aged

12 to

17

years. Specifically, we sought to replicate

and extend our original factor-analytic findings in an

adolescent sample and compare patients’ reports on

the CTQ to ratings of maltreatment made by their

primary therapists after discharge, based on all available

data at that time. In the absence of a true “gold

standard,” we selected therapists’ ratings as our validity

criterion because the therapists had extensive contact

with the patients and their families, other members

of the multidisciplinary treatment team, and other

inform ants such referring clinicians and agencies; more-

over, therapists were often able to support their judg-

ments with independent evidence such as knowledge

of child welfare investigations, appearances in family

or criminal court, or removal of the child from the

parental home.

METHOD

Subjects

Thre e hundr ed ninety-eight adolescents adm itted to the inpatient

service of a private psychiatric hospital were given the CTQ as

part of a larger test battery. Therapists’ ratings of maltreatment

were

also obtained for

190

of the adolescent patients. Patients

were heterogeneous with regard

to

age (range =

12

to

17

years,

mean

SD

=

14.9 1.4

years), gender (males

= 43%, n

=

171;

females

=

57%, n

=

227),

and ethnic composition (white

=

67.9%,

Hispanic =

13.3%,

African-American =

11.2%).

Patients also

represented a broad range of family income, from middle- and

upper-income families with private health insurance to families in

poverty (patients with Medicaid coverage

=

51%).

The most

frequent presenting psychiatric problems among the patients were

suicide risk,

48.9%

(male

= 42.9%,

female

= 53.3%,

x

= 4.19,

df = 1,

p

< .05);

substance abuse,

37.8%

(male

= 41.%,

female

=

34.8%,

x

=

1.98,

df

1 , p

> . I ) ;

moo d disorders,

35.2%

(male

=

33.5%,

female

= 36.4%, x

=

0.36, df = 1,

p

>

. I ) ; suicide

attempts,

33.4%

(male

= 23.5%,

female

= 40.9%, z = 13.12,

df 1,

p

< .001);

self-mutilation,

22.8%

(male =

l8.8%,

female =

25.9%, x

=

2.74, df

=

1,

p

< .l);

homicide risk,

21.3%

(male =

28.2%,

female =

16.1%, x = 8.53, d f 1,

p

< .01);

assault,

20.3%

(male

= 31.2%,

female

= 12.1?40,

x

= 21.84, df 1,

p

<

.001);

criminal behavior,

18.3%

(male =

27.1%,

female =

11.6%,

x =

15.45, df 1.p < .001);

learning disabilities,

15.5%

(male

=

18.8%,

female =

12.9%,

x =

2.55, df 1,

p

> . l ) ;

and attention

deficit disorder,

14.2%

(male

= 21.8%,

female

= 8.5%,

x

13.98,

df =

1,

<

.001).

Patients were excluded from the study if

low intelligence (Wechsler Full S ca le I Q

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These terms were reviewed until

it

was clear that the therapist

and interviewer were operating from a common definition; discus-

sions with the therapists were limited to clarifying definitional

issues and did not include discussion of specific case material. Each

case from the CTQ respondent pool treated by that therapist

was then individually reviewed and rated. Identifying information

(name, age, dates of hospitalization) was presented to the therapist

along with a copy of the therapist’s own adm ission note, discharge

summary, and psychosocial history taken from the patient’s hospital

chart. H aving been thus refamiliarized with the case, the therapist

was asked to rate whether the patient had been sexually, physically,

or

emotionally abuse,

or

neglected, according to the standardized

definitions. For each of the four categories, the therapist was asked

to rate the patient as “definitely”

or

“definitely not” maltreated,

or

as “uncertain.” Therapists were instructed

to

base their ratings

on all information available to them, including statements of

patients and their relatives, information provided by referring

clinicians and agencies, and other records. Therapists were also

allowed to draw freely on information obtained by other mem bers

of the multidisciplinary treatment team and were encouraged to

exercise their clinical judgm ent. How ever, therapists were also

strongly encouraged to assign to the “uncertain” category any case

for which they felt less than entirely certain about the patient’s

abuse

or neglect status. Thus, while some cases assigned to the

uncertain gr oup m ay in fact have been victims of abuse

or

neglect,

those assigned to the definitely

or

definitely not abused

or

neglected

groups were considered unambiguous cases.

To

determine whether therapists were able to apply the mal-

treatment definitions in a uniform manner,

two

therapists, a clinical

psychologist and a clinical social worker, were presented with 10

case vignettes. All vignettes were based on real cases that had been

abstracted from patients’ clinical charts and incorpo rated as many

relevant details as possible, including some that were ambiguous

or

contradictory (e.g., abuse allegations that were later recanted).

Some vignettes combined material from different cases in order

to provide a sufficient pool of maltreatment experiences of different

types. T h e therapists w ere asked to review the standardized defini-

tions and rate each vignette in terms of the presence

or

absence

of four types of maltreatment: physical, sexual, and emotional

abuse and physical neglect. Their ratings were compared w ith those

of a senior clinician with expertise in the maltre atmen t area (D .P.B.).

Mean values for agreement between the raters and the expert

were extremely high: physical abuse,

=

.9; sexual abuse, =

1.0;

emotional abuse, = .9; and physical neglect, = .9.

Once cases were assigned to the definitely abused

or

neglected

category, specific detailed information was gathered concerning

dura tion, age of occurrence, nature and severity of abuse

or

neglect,

identity of the perpetrators, and medical and legal consequences

of the maltreatment. A gain, therapists were encouraged to respond

by using the “uncertain” category if the information sought was

in any way incomplete

or ambiguous.

Table 1 indicates that the therapists were often able to cite

independent corroborative data to support their judgments about

patients’ maltreatment status, such as knowledge of C hild Protective

Service investigations, crimin al

or

family co urt chargeslappearances,

prior psychiatric

or

medical care for trauma-related problems,

or

removal of the child from the parental home.

Procedures

T h e

CTQ

was given approximately

1

week after admission as

part of a clinical psychological test battery that included a variety

T BLE 1

Percentage of Maltreatment Cases in Which

Therapists Cited Independent Evidence to Support Their

Ratings of Abuse and Neglect

Percent

n)

of Cases Supported

by Independent Data“

Sexual Physical Physical

Abuse Abuse Neglect

n

= 43)

YZ 61) ( n = 41)

CPS report 39.5 (17)

50.8 (31) 51.2 (21)

Criminal court 20.9 (9)

3.3 (2)

0.0 0)

Family court

16.3 (7) 18.0 (11)

22.0 (9)

Psychiatric care

32.6 (14)

31.1 (19) 48.8 (20)

Medical care N A

14.8 (9) N A

Removal from home 14.0 (6) 31.1 (19)

43.9 (18)

Any of the above 62.8 (27) 67.7 (42)

75.6 (31)

“

Chil d Protective Service (CPS) investigation; criminal

or

family

court appearance; patient received prior psychiatric

or

medical care

for consequences of abuse

or

neglect; patient removed from home.

N A

=

information not available.

of self-administered questio nnaire s, as well as the WISC-I11 (Psycho-

logical Corporation, 1991) and the WRAT-111 (Wilkinson, 1993).

Approximately

25%

of patients admitted to the hospital were not

given the C T Q , either because low intelligence (Wechsler Full

S ca le I Q

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T H E C T Q IN A D O L E SC E N TS

CTQ

(e.g., test report summaries) were excluded from this review.

Interviews could not be conducted with the therapists of the

remaining patients because the therapists were no longer available.

No differences were found between adolescents with and without

therapist ratings on age, gender,

or

ethniciry or on any of the

CTQ factors, except for a small bu t significant difference in physical

abuse scores (patients with therapist ratings

=

14.5 ? 8.0, patients

without therapist ratings = 12.5

?

6.1;

t =

.84, df 296,p < .01).

Statistics

The factorial structure of the CTQ was investigated by PCA

with varimax rotation. Separate PCAs in males and females pro-

duced nearly identical results,

so

subsequent analyses were per-

formed using the combined sample. Seven items were excluded

from the PCA: a three-item validity scale and four items with very

low communalities (multiple R

<

.2) with the other CTQ items.

The validity scale, which was designed to detect maltreatment

underreporting, is described elsewhere (D. Bernstein, H. Jelley, L.

Handelsman, unpublished). Four-, five-, and six-factor solutions

were attempted and the five-factor solution was chosen because of

its evident content validiry (in the four-factor solution, items

reflecting physical and emotional abuse loaded highly on a single

large factor, while in the six-cluster solution, the physical neglect

items were dispersed among two small factors). Items were assigned

to the single factor on which they loaded most highly (all items

had factor loadings equal to

or

greater than

.4

on at least one

factor). Internal consistency reliability of the CTQ factors was

determined by Cronbach’s a

Scoring algorithms for the CTQ were based on analyses of five

separate normative samples, including the adolescents described

here, representing a broad range of age, gender, income, ethnicity,

and diagnosis (total N 979)

(D.

Bernstein, unpublished study).

Although an extensive discussion of algorithm development is

beyond the scope of this report, a brief summary is as follows.

Items were first assigned to factors based on their loadings in two

independent factor-analytic studies. Although an initial study of

adult substance abusers resulted in a four-factor solution (Bernstein

et al., 1994), the five-factor solution reported here in which physical

and emotional abuse items loaded on separate factors was preferred

for its face validity. An effort was then made to reduce the total

number of items with the goal of producing a shorter version of

the scale. Item-factor correlations and Cronbach’s a

values (i.e.,

internal consistency reliabilities) were examined across the five

validation samples and items were either dropped

or

retained

depending on their performance. This resulted in a final set of

algorithms consisting of 50 total items, in addition to the three-

item validity scale: emotional abuse, 12 items; physical abuse, 7

items; sexual abuse, 7 items; emotional neglect, 16 items; and

physical neglect,

8

items. Scores on the five factors are obtained

by taking the sum of the unweighted item raw scores.

T o examine the convergence between CTQ scores and therapists’

ratings of maltreatment, a series of logistic regression analyses was

performed in which the five CTQ factors were entered simultane-

The sensitivity and specificity of the CTQ factors for therapists’

ratings of abuse and neglect were determined using statistical

sofnvare for nonparametric receiver operating characteristic (ROC)

analysis (Vida, 1993). ROC analysis calculates the sensitivity and

specificity

of

a scale for every possible cutoff score, allowing the

investigator to select the test threshold that yields the best balance

of false-negative and false-positive errors

for

his

or

her purposes

(Hsiao et al., 1989; Mossman and Somoza, 1991). As the CTQ

is intended as a screening measure, we were more concerned with

minimizing false-negative errors (i.e., the nondetection of true

cases) than false-positive errors. Furthermore, noncases of childhood

maltreatment are almost impossible to verify definitively (Briere,

1992), suggesting that criterion variables like therapists’ ratings are

likely to produce false-negative errors of their own, leading to

underestimates

of

the true specificity of trauma questionnaires. For

these reasons,

o u r

cutoff scores for the CTQ were set to emphasize

test sensitivity over specificity.

RESULTS

A PCA of the CTQ items was performed to examine

the factor structure of the questionnaire. PCA yielded

five rotated factors, accounting together for 55 of

the variance between items (Table

2).

The five factors

were interpreted as emotional abuse, emotional neglect,

sexual abuse, physical abuse, and physical neglect,

closely replicating the findings of a previous study in

adult substance abusers (Bernstein et al., 1994). The

factors were highly internally consistent, both in the

sample as a whole and in separate subsamples of males

and females and younger and older adolescents (Table

2).

Intercorrelations among the five factors ranged from

r = .34 to r = .75 with a median of r = .51 (Table 2).

When therapists were asked to rate the presence or

absence of maltreatment in a subsample of 190 adoles-

cent patients, 23 of patients n = 43) were classified

as definitely sexually abused, 33 n= 6 2 ) as physically

abused, 33

( n

= 6 2 ) as emotionally abused, and 22

n

=

41)

as physically neglected. Fifty-six percent of

the subsample n = 107) were judged to have at least

one form of childhood trauma, while 39 n = 7 3 )

received ratings of two or more forms of trauma.

Point-biserial correlations between CTQ factor

scores and therapist interview ratings showed that de-

ously and therapists’ ratings

of

the presence or absence of mal-

spite substantial overlap between different forms of

treatment were used as the (dichotomous) dependent variables. An maltreatment , convergent correlations (e.g., correla-

additional series of logistic regressions was performed in which

variables were entered hierarchically in sets, with gender entered tions between CTQ factor

and

thera-

first, the

CTQ

factors second, and the interactions between gender pist ratings) were in general larger than discriminant

and the CTQ factors third. Cases that were rated as “uncertain”

correlations (i.e., correlations between CTQ factor

were excluded from all of these analyses (12 cases of sexual abuse,

9

cases of physical abuse,

9

cases of emotional abuse, and

5

cases “Ores

and nonanalogous

therapist

3)*

of neglect).

T o examine further the specificity of the relationship

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TABLE

Factor Structure and Internal Consistency of Childhood Trauma Questionnaire (CTQ in 398

Male and Female Adolescent Psychiatric Patients

Eigen- Percent Reliability (Cronbach's

a)d

CTQ Factor Itemsb Mean (SD)' value Variance Male Female 12-14 yr 15-17 yr Total

I. Emotional abuse

17 42.1 (17.2) 21.9

34.8

.94 .95 .95 .95 .95

11. Emotional neglect

22 52.8 (19.5)

4.8 7.6 .95 .94 .94 .95 .94

111. Sexual abuse

7 11.3 (7.3) 3.7

5.8

.87 .92 .90 .92 .9

1

IV. Physical abuse

7 13.4 (7.1)

2.4

3.9

.89

.91 3 0 .9 1 .90

V. Physical neglect 10 16.8 (6.9) 1.9 3.0 .80 .82 .80 .82 .8 1

Total scale 63 136.5 (47.0) 55.1 .96 .97 .96 .97

.97

Intercorrelations among factors: emotional abuse with emotional neglect,

r =

.62, sexual abuse,

r =

.43, physical abuse,

r

= .77, physical

neglect,

r

= .56, emotional neglect with sexual abuse, r = .33, physical abuse, r = .49, physical neglect, r = .50, sexual abuse with physical

abuse, r = .43, physical neglect, r = .43, physical abuse with physial neglect, r = .55, all correlations, p < .001.

tems loading greater than

.4

based on principal-components analysis; items assigned to single factor with highest loading.

'Sum of unweighted raw item scores.

dSample sizes for reliability analyses: males, n = 171; females,

n

= 227; 12- to 14-year-olds, n

=

148; 15- to 17-year-olds, n = 247;

entire sample,

n

=

398.

between CTQ scores and therapists' maltreatment rat-

ings, a series of logistic regression analyses was per-

formed with the five CTQ factors entered

simultaneously and each form of maltreatment rated

by the therapists serving in tu rn as a separate depend ent

variable. These analyses indicated that the relationship

between CTQ factors an d analogo us therapists' ratings

was highly specific (Table 3). When therapists' ratings

of the presence or absence of sexual abuse were used

as the depend ent measure, only the CTQ sexual abuse

factor made a unique positive contribution to the

logistic regression model, as indicated by a significant

odds ratio; moreover, CTQ physical neglect was in-

versely related to therapists' ratings of sexual abuse.

Similarly, therapists' ratings of physical abuse were

uniquely predicted by the C TQ 's physical abuse factor.

Therapists' ratings of emotional abuse were positively

associated with the CTQ's physical abuse and emo-

tional abuse factors

(the latter at a trend level of

significance), while sh owing a negative association with

the physical neglect factor. Finally, therapists' ratings

of physical neglect were associated only with the CT Q' s

physical and emotional neglect factors. Thus, when

the CTQ factors were allowed to compete with one

TABLE 3

Relationship Between Childhood Trauma Questionnaire (CTQ) Factors and Therapists' Maltreatment Ratings in Adolescent Psychiatric

Patients: Correlational and Logistic Regression Analyses

Therapists' Maltreatment Ratings

Sexual Abuse Physical Abuse Emotional Abuse Physical Neglect

CTQ

Factors

r

Odds'

r

Oddsb

r

Oddsb

r

Oddsb

Sexual abuse

.72*** 1.37 '

.22*** 0.98

.24*** 1.02

.27*** 1.04

Physical abuse .27*** 1.03 .59 ** 1.21***

.46***

1.11 '

.30 1.04

Emotional abuse

.32*** 1

oo .49*** 1 oo .46***

1.04'

.28*** 0.96

Physical neglect

.20***

0.84 ' .42*** 1.01

.24*** 0.92**

.42*** 1.13***

Emotional neglect

.16** 1.01 .37*** 1.01 .30*** 1.01

.36 '* 1.03**

Point-biserial correlations between CTQ factors and therapists' maltreatment ratings. Sexual abuse,

n

= 167; physical abuse,

n

= 169;

emotional abuse, n = 169; physical neglect,

n

= 173.

esults of logistic regression analyses. Odds greater than one indicate positive association between CTQ factors and therapists' ratings;

odds less than one indicate negative (i.e., inverse) association. Sexual abuse, n = 167; physical abuse,

n

= 169; emotional abuse,

n =

169;

physical neglect,

n

= 173.

* p

< . l ;

* * p

< .05;

* * * p<

.01.

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another in the same regression model, their correspon-

dence with equivalent therapists’ ratings was quite

precise. No significant interactions between gender

and the CTQ factors were found, indicating that

relationships between therapists’ ratings of mal-

treatment and the CTQ factors were equivalent in

male and female patients.

ROC analysis was then used to determine the sensi-

tivity and specificity of the CTQ factors at various test

thresholds (i.e., cutoff scores), when therapists’ ratings

of maltreatment were used as the criterion. These

analyses indicated that the

CTQ

succeeded in detecting

a high proportion of abused and neglected patients,

based on therapists’ ratings, while keeping false-positive

errors to acceptable levels (Table 4) . In keeping with

the CTQ‘s intended purpose as a screening instrument,

we selected the following cutoff scores to emphasize

test sensitivity over specificity: sexual abuse, 9; physical

abuse, 12; emotional abuse, 30; and physical neglect,

12.

When these respective cutoff scores were used, the

CTQ‘s sexual abuse factor correctly classified more

than four out of five sexually abused patients, based

on therapists’ ratings, and about three out of four

patients without sexual abuse. Similarly, the physical

abuse factor correctly identified more than four fifths

of physically abused patients and nearly three quarters

of patients without physical abuse. The emotional

abuse factor correctly classified nearly four fifths of

emotionally abused patients and over seven out of ten

patients without emotional abuse. Finally, the physical

neglect factor correctly identified nearly four fifths of

physically neglected patients and more than 6 out of

10 patients without physical neglect. The area under

the ROC curve was significant for all forms of mal-

treatment we examined, indicating that the CTQ im-

proved the likelihood of detecting true cases of abuse

and neglect over that which would be expected by

chance, given the base rates of these forms of trauma

in the sample (Table 4) .

When the CTQ factors were used to estimate the

prevalence of maltreatment in the sample as a whole,

39.0 of patients

n =

153) met the cutoff score for

sexual abuse, 44.7 n = 178) for physical abuse,

45.5 n= 180) for emotional abuse, and 48.9 n=

194) for physical neglect; 71.9 n= 286)

of

patients

met the cutoff score for at least one form of mal-

treatment, and 5 1.3 a= 204) for two or more forms

of maltreatment.

A

significantly greater proportion of

female patients met

CTQ

cutoff scores for sexual abuse

(female =

47.8 ,

male =

27.4 , x

=

16.77,

df = I ,

p < .001)

and emotional abuse (female

=

51.8 ,

male

=

37.1 ,

x =

8.47,

df =

1

p < . O l ,

but rates

TABLE 4

Sensitivity and Specificity (With Confidence Intervals) of Childhood Trauma Questionnaire (CTQ

Factors for Therapists’ Ratings of Maltreatment in Adolescent Psychiatric Patients

~~

Sexual Abuse“ Physical Abuseb Physical Neglect‘ Emotional Abused

(Range = 7-35) (Range

=

7-35) (Range

=

8 4 0 ) (Range

=

12-60)

Cut‘ Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity Cut f Sensitivity Specificity

8

9

10

1 1

12

13

14

15

16

17

18

3 6 (.71-.94) .68 (.59-.76) .97 (37 -.9 9)

.86 (.71-.94)

.76 (.67 -33 ) .94 (34 -.98 )

3 4 ( .69-.93)

.79 (.71- 36) .94 (34-. 98)

.84 (.69-.93) .82 (.7 3-3 8)

37

(.76-.94)

.79 (.64-39)

.86 (.79-3 2) .82 (.70-.90)

.79 (.64-39)

.90 (.82-.94) .79 (.6 6-3 8)

.77 (.61-38)

.92 (.85-.96) .77 (.6 5- 37 )

.74 (.59-.92) .92 (.85-.96)

.74 (.61-34)

.70 (.54-32) .94 (3 7- .9 7) .71 (.58-.81)

.70

(.54-32) .94 ( 3 8 - 3 8 ) .68 (.54-.79)

.67 (.51-30)

.96 (.90-.99) .61 (.48-.73)

.35 (.26-.44)

.48 (.39-.58)

.59 (.49-.68)

.64 (.54-.72)

.73 (.63-.81)

.77 (.68-34)

.82 (.73-38)

.84 (.75-.90)

.85 (.77-.91)

. 8 9 ( 3 - . 9 4 )

. 8 9 ( 3 - . 9 4 )

1.0 (.91-1.0)

.95 (.82-.99)

.93 (.79-.98)

.80

(.65-.91)

.78 (.62-29)

.68 (.52-31)

.61 (.44-.75)

.54 (.38-.69)

.54 (.38-.69)

.59 (.42-.73)

.51

(.35-.67)

0.0 0.0-.03)

.20 (.14-.29)

.36 (.28-.44)

.50 (.41-.58)

.61 (.53-.70)

.73 (.64-30)

.78 (.70-34)

.83 (.75-39)

.87 (.80-.92)

.90 (.83-.94)

.91 (.85-.95)

26 .87 (.76-.94)

27 .84 (.72-.92)

28 .79 ( .6 6 .8 8)

29 .79 (.66 -38 )

30

. 79 ( .66 .88)

31 .76 (.63-3 5)

32 .74 (.61-.84)

33

.73 (.60-.83)

34 .69 ( .5 6.8 0)

35 .65 (.51-.76)

36 .61 (.48-.73)

.59 (.49-.68)

.61 (.52-.70)

.67 (.57-.76)

.72 ( .62-2 0)

.72 (.63-.80)

.73 ( .64 .81)

.75 (.66-33)

.75 ( .66.83)

.78 (.68-34)

.78 (.69-235)

.63 (.53-.72)

~ ~~~

“T ru e positives =

43,

true negatives =

124,

area under the receiver operating characteristic (ROC) curve

=

0.88

(SE

=

0.04),

z =

8.10,

’True positives =

6 2 ,

true negatives =

110,

area under the ( ROC ) curve =

0.85

(SE = 0.03),

z

=

7.72,

p <

.0001.

‘True positives =

41,

true negatives =

135,

area under the ( ROC ) curve = 0.78 (SE =

0.04), z

=

5.37,

p

< .0001.

dTrue positives =

6 2 ,

true negatives =

109,

area under the (ROC) curve =

0.78

(SE

= 0.04), z = 6.17, p < .0001.

‘Cutoff scores for CTQ sexual abuse, physical abuse, and physical neglect factors.

fCutoff scores

for

CTQ emotional abuse factor.

p <

.0001.

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of physical abuse and physical neglect did not differ

between the two genders (physical abuse: female =

48.0 , male = 40.4 , x = 2.32,

df

= 1, p > .1;

physical neglect: female = 50.4 , male = 46.8 , x =

0.52,

df

1,

p

>

.1).

DISCUSSION

These findings replicate our previous factor-analytic

results and provide initial support for the validity of

the

CTQ

in an adolescent psychiatric population. PCA

of the CTQ resulted in a five-factor solution nearly

identical with that obtained in a sample of substance-

abusing adults (Bernstein et al., 1994 ). T h e only excep-

tion was that in the adolescents, physical and em otional

abuse items loaded on separate factors, while in the

adults, they loaded on a single factor. The internal

consistency reliability of the

CTQ

factors was extremely

high, both in the adolescent sample as a whole and

in every subgroup we examined. Furthermore, when

CTQ

factor scores were compared with therapists’

maltreatment ratings based on all available data, rela-

tionships between the tw o sets of variables were highly

specific, supporting the convergent and discriminant

validity of the

CTQ.

Finally, when therapists’ ratings

were used as the validating criterion, the CTQexhibited

good sensitivity for all forms of maltreatment we exam-

ined, along with satisfactory or better levels of specific-

ity, suggesting that the CTQ is an effective screening

measure for childhood trauma in an adolescent psychi-

atric setting.

These findings also add to a growing literature

indicating a high prevalence of abuse and neglect in

clinically referred adolescents. More than 50 of the

sample were rated as abused

or

neglected by their

therapists, and more than

70%

reported maltreatment

on the questionnaire. T hese prevalence rates were com-

parable with

or

greater than those reported in previous

studies of similar populations (Cavaiola and Schiff,

1988; De m bo et al., 1 988; Edwall et al., 1989; Sanson-

net-Ha yden et al., 1 98 7). Cons istent with previous

studies, we found that reports o f sexual abuse were more

frequent among adolescent girls than boys (Finkelhor,

19 94) . Adolescent girls were also more likely to report

histories of emotional abuse; however, given the rarity

with which emotional abuse has been assessed, further

studies will be needed to replicate this gender difference

in other adolescent samples.

In this study, we used an “all data” validation

strategy that capitalized on the fact that patients’ pri-

mary therapists were privy to information from multiple

sources, including in m any cases indepe nden t corrobo-

rative data that could be used to support their judg-

ments, such as knowledge of Child Protective Service

investigations, court appearances, and removal of the

child from the parental hom e. Furthermore, t he rather

lengthy period of hospitalization (an average stay of 1

to

2

months) gave therapists the chance to make

extended observations of patients and their relatives

and to develop a degree of rapport with patients in a

sheltered setting that often fosters the disclosure of

maltreatment. That therapists rarely made use of the

“uncertain” rating category, even though they were

repeatedly encouraged to do so, attests to their confi-

dence in their judgments.

Although

our

findings suggest that adolescents’ self-

reports of childhood trauma are usually credible, in

tha t they are consistent with therapists’ “best estimate”

ratings, it will also be important to investigate the

sources of both false-negative and false-positive re-

porting errors. There is some evidence that response

biases such as the need for social desirability and

defense mechanisms such as repression may lead to

the underreporting of maltreatment (Guenther and

Frey, 1990; Joub ert, 199 1); on th e other hand , deliber-

ately false allegations of abuse by adolescents, although

apparently rare (Everson and Boat, 1 989 ), may produc e

false-positive trau m a reports in some instances. T o

address these issues, we are reviewing the records of o ur

adolescent patients i n cases in which their questionn aire

responses and therapists’ ratings differed, as well as

comparing patients’

CTQ responses to their profiles

on the validity scales of the Minnesota Multiphasic

Personality Inventory-2 (Ha thaw ay and M cKinley,

198 9). These a nd similar studies should increase ou r

understanding of the exceptional circumstances in

which adolescents’ trauma reports may not be val-

idly interpreted.

These findings need to be considered in light of

certain limitations. First, therapists’ maltreatment rat-

ings do not constitute a “gold standard” in the true

sense. Although therapists were kept blind to patients’

CTQ responses, their ratings were not entirely inde-

pendent, in that they were based in part o n information

provided by the patient. Furthermore, therapists’ rat-

ings themselves are subject to possible errors, because

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T H E C T Q

I N

A D O L E S C E N T S

corroborating suspected maltreatment cases can be

diffi-

cult, and definitively verifying noncases, nearly impossi-

ble (Briere, 1992). Previous research suggests that the

nondetection of true maltreatment cases (i.e., false

negatives) is more common than the false detection

of noncases (i.e., false positives) (Briere, 1992). Some

true cases of abuse or neglect might therefore be

detected by a questionnaire but be unknown to thera-

pists, a misclassification that would underestimate the

specificity of the test by misclassifying true-positive

cases on the questionnaire as false positives. This might

occur, for example, if some adolescents felt more com-

fortable disclosing their maltreatment histories on a

questionnaire than in a clinical interview or therapy

session. In support of this view, many of the adolescents

rated as “uncertain” by their therapists were classified

as positive maltreatment cases by the

CTQ 5

of 11

uncertain cases of sexual abuse, 7 of 9 uncertain cases

of physical abuse, 6 of 9 uncertain cases of emotional

abuse, and

4

of

5

uncertain cases of neglect. Estimates

of the specificity of the CTQ given in this report are

therefore best regarded as representing the lower limit

of the true specificity of the questionnaire.

Second, we could have used other approaches to

validate the trauma histories obtained with the CTQ.

For example, child welfare records could have been

used as the validating criterion, rather than therapists’

ratings. However, this strategy also has its limitations.

For example, many cases of abuse and neglect never

come to the attention of child welfare agencies (Fin-

kelhor, 1994) and a variety of factors can affect the

accuracy of Child Protective Service reports (Eckenrode

et

al., 1988). In fact, the corroboration of childhood

trauma faces inherent difficulties, such as the passage

of time and the secrecy often surrounding these experi-

ences (Briere, 1992). An absolute means of verification

(i.e., a true “gold standard”) is therefore rarely available.

For this reason, we used an “all data” validation

strategy, in which therapists were asked

to pool

informa-

tion from multiple sources rather than relying on a

single source of corroboration. However, studies using

a variety of methodological approaches will be needed

to fully address this complex issue.

Third, the elapsed time between patients’ completion

of the CTQ and administration of the therapist inter-

views might have influenced our findings, although

the direction

of

any possible effect is difficult to deter-

mine. O n the one hand, certain cases may have appeared

less ambiguous in hindsight than they

did

in vivo; on

the other hand, the deterioration of memory over

time may have produced greater ambiguity in case

determination. Although we attempted to mitigate

against such factors by providing therapists with copies

of their own reports from the hospital charts, it is still

conceivable that a shorter interval might have produced

different results. Finally, our findings regarding sensitiv-

ities, specificities, cutoff scores, and other results of

the ROC analyses are most conservatively generalized

to adolescent inpatient settings until they can be repli-

cated in other groups of adolescent patients (e.g.,

outpatients).

Our findings support the use of the

CTQ

for both

research and clinical purposes. Research on the causes

and consequences of child abuse and neglect has often

been hampered by unvalidated instruments (Briere,

1992). Ou r validation of the

CTQ

using an operation-

ally defined external criterion-therapists’ ratings that

capitalized on all available data about the patient-

should help provide a more solid methodological basis

for maltreatment assessment in future research.

As

a clinical instrument, the

CTQ

provides rapid

screening for history of child abuse and neglect. When

used in conjunction with other available data, it may

help to identify adolescents who, by virtue of their

trauma histories, are at risk for developing a broad

range of psychiatric symptoms and behavior problems,

including posttraumatic stress disorder, addictions, de-

pression, delinquency, and self-injurious behavior

(Kendall-Tackett et al., 1993). Moreover, the scale

gives clinicians a means of initiating a dialog with

adolescents about sensitive topics that might otherwise

go undisclosed. Querying adolescents about their ques-

tionnaire responses during follow-up interviews or ther-

apy sessions can lead to the disclosure of further details,

such as the identity of perpetrators, victimization of

other family members, and whether the reported mal-

treatment was in the past or is still ongoing. Although

clinicians should exercise caution regarding the poten-

tially distressing nature of this material, allowing pa-

tients to explore these issues at their own pace (Brooks,

1985)) a discussion of adolescents’ questionnaire re-

sponses may reveal important additional information

about childhood events and open up a therapeutic

dialog in which maltreatment experiences can begin

to be explored.

J .

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B E R N S T E I N E T A L.

As is the case for any psychological test, however,

the CTQ is not a substitute for a clinician’s own

judgment. The CTQ‘s proper clinical use is as a

screening instrument;

it

is no t itself a “gold stan dar d’

for assessing childhood trauma . Clinical judgm ent m ust

therefore be used in interpreting responses to the

questionn aire, taking i nto accou nt all available informa-

tion about the patient. When used as part of an

integrated evaluation procedure, the

CTQ can provide

informarion that may help clinicians make informed

treatment decisions.

In conclusion, research suggests that childhood mal-

treatment is often underreported in clinical settings

but that systematic assessments may increase rates of

disclosure (Briere and Zaidi,

1989).

Adolescents may

be reluctant to reveal such experiences in interviews

or therapy sessions, not only because of feelings of

shame and guilt, but also because of their need for

autonomy and frequent ambivalence about authority

(Erikson,

1969).

T h e CTQ offers adolescents the op-

portunity to disclose traumatic experiences in a self-

report format that may be congruent with their own

needs for privacy. O u r findings suggest tha t it is a

sensitive and valid means

of

screening adolescents for

a history of childhood maltreatment.

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