J Abnorm Child Psychol DOI 10.1007/s10802-015-0030-y
A Community Study on the Relationship of Posttraumatic Cognitions to Internalizing and Externalizing Psychopathology in Taiwanese Children and Adolescents Shu-Tsen Liu 1,2 & Sue-Huei Chen 1
# Springer Science+Business Media New York 2015
Abstract A growing number of studies indicate that posttraumatic cognitions play a crucial role in the development and maintenance of posttraumatic stress disorder (PTSD). However, the effects of posttraumatic cognitions on general psychopathology beyond PTSD remain unclear. The current study aimed to validate the Chinese version of the Child Posttraumatic Cognitions Inventory (CPTCI-C) and to investigate the relationship between posttraumatic cognitions and psychopathology. A community sample of 285 schoolaged children and adolescents (aged 9–17, 160 [56.1 %] female) reported their trauma-related cognitions on the CPTCI-C and completed measures of symptoms of PTSD, depression, and generalized anxiety. Parents reported their children’s internalizing and externalizing problems. We validated a revised version of the CPTCI-C based on the results of confirmatory factor analyses. The resulting evidence suggests that this revised CPTCI-C possesses good internal consistency, fair 6-week temporal stability, and good concurrent validity. In addition to significant correlations between posttraumatic cognitions and internalizing and externalizing psychopathology, after controlling for age, gender, and trauma types, both the revised CPTCI-C subscale scores conveyed unique contributions to psychological
* Sue-Huei Chen [email protected] 1
Department of Psychology, National Taiwan University, No. 1, Sec. 4, Roosevelt Road, Taipei 106, Taiwan
2
Department of Psychiatry, National Taiwan University Hospital Yunlin Branch, No.579, Sec. 2, Yunlin Rd., Douliou City, Yunlin County 640, Taiwan
distress while only the maladaptive appraisals of the trauma remained weakly associated with externalizing problems. Structural equation modeling analysis showed that maladaptive appraisals of the trauma had a direct longitudinal impact on chronic PTSD severity. No mediation effect of posttraumatic cognitions on the relationship between acute and chronic PTSD activity was observed. The implications of our findings are discussed for the specificity of posttraumatic cognitions to posttraumatic internalizing psychopathology and cognitive interventions that target negative trauma-related cognitions. Keywords Posttraumatic cognitions . Posttraumatic stress disorder . Children and adolescents . Internalizing and externalizing psychopathology Traumatic experiences can significantly alter individuals’ cognitions. For trauma survivors, negative views of self and the world and appraisals about the trauma may impair coping abilities and deprive individuals of sources of support. Moreover, negative posttraumatic cognitions are a major source of distress and are generally viewed as a central pathogenic factor for adult posttraumatic stress disorder (PTSD). Cognitive therapy also ranks as the most effective evidencebased trauma treatment. However, it remains unclear how posttraumatic cognitions influence the development of the externalizing and internalizing dimensions of posttraumatic psychopathology in children and adolescents. Therefore, creating an adequate assessment of posttraumatic cognitions and probing more deeply into the impact of posttraumatic cognitions on general psychopathology are crucial steps for developing successful prevention and intervention strategies for traumatized youth.
J Abnorm Child Psychol
Ehlers and Clark’s Model of PTSD and Development of the Child Posttraumatic Cognitions Inventory Several cognitive models have been proposed to explain the development and maintenance of PTSD (e.g., Brewin et al. 1996; Dalgleish 2004). However, few existing studies of child and adolescent trauma survivors have provided empirical evidence for these cognitive theories. Ehlers and Clark (2000) proposed that negative appraisals of the trauma and its sequelae could drive both development and persistence of PTSD. Ehlers et al. (2003), in a prospective study with child and adolescent survivors of a road traffic accident, confirmed the predictive effect of maladaptive trauma-related appraisals on PTSD severity. The validity of their single-item questionnaire for measuring trauma-related appraisals has been criticized, however, and the Child Posttraumatic Cognitions Inventory (CPTCI; Meiser-Stedman et al. 2009) was subsequently developed. Principal components analysis yielded two subscales for the CPTCI: Fragile person in a scary world (CPTCI-SW) and permanent and disturbing change (CPTCIPC). The CPTCI-SW domain comprises items that are derived from the adult Posttraumatic Cognitions Inventory (Foa et al. 1999) and express negative cognitions about self and the world; the CPTCI-PC subscale is a comprehensive evaluation of maladaptive trauma-related appraisals. The CPTCI has been validated in samples of nonclinical senior high school students and child survivors of injuries/traffic accidents. As depicted by Ehlers and Clark’s model of PTSD, the total score of the CPTCI was shown to be positively related to the severity of PTSD and acute stress disorder (Meiser-Stedman et al. 2009), and mediated the evolution of chronic PTSD as well (Meiser-Stedman, Dalgleish, Glucksman, Yule, & Smith, 2009).
Chinese Cultural Effects on Youth’ Response to and Evaluation of Trauma Culture affects an individual’s view of self in the social context and also shapes protective and risk factors of survivors’ reactions to trauma. To date, the bulk of the information about the prevalence and predictors of pediatric PTSD in Taiwan has been generated mainly from studies of adolescent survivors of the Chi-Chi Earthquake in 1999 (e.g., Chen et al. 2002). However, epidemiological studies of childhood PTSD remain scarce in the general population. Collectivistic Chinese societies are Confucianism-based and emphasize filial piety, selfdiscipline, and social harmony. These societal norms contribute to children’s views of themselves and the world (e.g., selfcriticism, or fulfilling others’ expectations as part of self) and their ways of regulating negative emotions (for an excellent review, see Trommsdorff 2012). Therefore, youth in Chinese societies are expected to have both enhanced needs for social
support and increased risks for developing low self-esteem and a sense that others value them less when experiencing traumas that threatens social connection. Current research evidence has provided preliminary support that self-blaming was one main coping style used by Chinese adolescent survivors with an increased risk for PTSD (Zhang et al. 2010) and has also shown that Taiwanese youth perceived great distress from negative appraisals of detrim e n t a l s o c i a l r e l a t i o n s h i p s ( Wu e t a l . 2 0 0 9 ) . Development of a culturally sensitive measure is a prerequisite to understanding youth’ trauma-related cognitions in Chinese cultural contexts.
Posttraumatic Cognitions and Psychopathology Beyond PTSD PTSD captures only a limited aspect of posttraumatic psychopathology. Posttraumatic cognitions have been positively linked with depression as well as PTSD in child trauma survivors (Leeson and Nixon 2011; Meiser-Stedman, Smith, et al. 2009). This implicates trauma-related appraisals as one possible cognitive risk factor for posttraumatic depression and raises questions about the specificity of posttraumatic cognitions to PTSD. Moreover, the effects of negative posttraumatic cognitions on internalizing psychopathologies other than PTSD and depression, such as generalized anxiety or somatization, have been less well studied. In addition to internalizing psychopathology, externalizing psychopathology can emerge after trauma. Previous studies have consistently shown elevated prevalence of both trauma exposure and PTSD in delinquent juveniles (e.g., Abram et al. 2004). Moreover, for community youth, exposure to interpersonal trauma has been documented as a predictor of aggression (e.g., Evans et al. 2008). With regard to mechanisms for linking traumas and PTSD to externalizing psychopathology, Kerig and Becker (2010) suggested hostile attribution, alienation, acceptance of antisocial coping, and shame as possible cognitive mediating mechanisms. Negative appraisals about the trauma and the self in the social world may lead to persistent feelings of being under threat from a hostile environment and to a shameful sense of lacking the ability to rise above the threat. These feelings in turn foster an increased acceptance of aggression as a way of coping for survival. Negative traumarelated cognitions could therefore be hypothesized as one candidate cognitive risk factor for posttraumatic externalizing psychopathology. However, the research literature is again scant on this question. One recent study of psychologically mistreated children (Leeson and Nixon 2011) failed to demonstrate a significant relationship between trauma-related appraisals and externalizing problems. However, no such conclusion has yet been applied to youth in the community with various types of trauma exposure.
J Abnorm Child Psychol
Objectives of the Present Study First, this study aimed to investigate the psychometric properties of the Chinese version of the CPTCI (CPTCI-C) in Taiwanese children and adolescents. Next, after validating the CPTCI-C, we aimed to examine the relationships between posttraumatic cognitions and childhood internalizing and externalizing psychopathology. Specifically, we sought to test the application of Ehlers and Clark’s (2000) model of PTSD in Taiwanese community children and adolescents.
Methods Participants A total of 351 child and adolescent participants (aged 9–17, mean=13.3±2.7 years, 202 [56.9 %] female) were recruited from three randomly selected public schools located in Douliou, a city of over 100,000 residents of mixed socioeconomic status located in Taiwan’s poorest county, Yunlin. The children were selected on the basis of a two-phase cluster sampling. First, one school each was randomly selected from the 13 elementary schools, three junior high schools, and two senior high schools, and then within each grade at each selected school, three classes were randomly selected. Children with learning disability were excluded. The Trauma-Exposed Sample Sixty-six participants did not report any DSM-IV PTSD Criterion A1 traumatic event, leaving 285 participants (80.1 %) to constitute the trauma-exposed sample for further analyses. As shown in Table 1, of these participants, 28.8 % of the mothers and 33.1 % of the fathers had earned degrees from a college or above, a considerably higher percentage than that observed in the general population (25.1 %), while 6.5 % of the children lived in households below the poverty line (compared with 1.2 % in the general population) (Taiwan Statistical Yearbook of Interior, 2010). In addition, unsurprisingly, since Taiwan has a long history of earthquakes and typhoons, natural disaster (8.8 %) is the most commonly experienced trauma. The follow-up sample comprised 261 trauma-exposed participants and was demographically similar to the initial trauma-exposed sample (aged= 13.4±2.63 years, 147 [56.5 %] female). They completed the CPTCI-C and the Chinese version of the UCLA PTSD Reaction Index for DSM-IV a second time, with an inter-test interval of approximately 6 weeks. However, only 224 cases had complete data in both the first and second assessment, and the missing data rate was as high as 14.2 %. We conducted missing-data analysis and found that there was no significant difference between completers and non-completers with respect to either the total CPTCI-C score or PTSD severity,
Table 1 Demographic and trauma characteristics of the traumaexposed sample The trauma-exposed sample (n=285) M (SD) or % Age (Mean ± SD, years) Gender (%): Male Living with both parents (%) Maternal/paternal education (%) College/ university & above Monthly household income (%) Below the poverty line Time elapsed from the trauma (Mean ± SD, months) Trauma types (%) Natural disaster Interpersonal trauma Traffic accident Medical trauma Full PTSD likely (%) Partial PSTD likely (%) No PTSD (%)
13.5 (2.7) 43.9 84.2 28.8/33.1 6.7 108.0 (49.0)
66.0 8.4 5.3 8.8 16.5 5.3 78.2
CPTCI-C score: t(258)=−0.96, p=0.34, ns; PTSD severity: t(263)=−1.13, p=0.26, ns. Procedures The Institutional Review Board of National Taiwan University Hospital approved this study before recruitment. Eligible children and their parents both signed the informed consent form before assessment. The child and adolescent respondents completed the CPTCI-C and reported PTSD symptoms (in relation to the frightening or traumatic event that currently bothered them the most), depressive symptoms, and severity of generalized anxiety. Behavioral and emotional problems were reported by the parents. At the initial assessment, the child and adolescent participants were gathered together in schools to complete the self-report questionnaires. The participating schoolteachers handed the parent-report measures to the parents/legal guardians at the first assessment and the follow-up CPTCI-C and the measure of PTSD severity to the youth participants 6 weeks later. Each participating child–parent pair was compensated with NT $200 for their participation.
Measures Chinese Version of the Child Posttraumatic Cognitions Inventory The original CPTCI is a 25-item self-report measure of children’s trauma-related cognitions that uses a fourpoint Likert scale. The CPTCI and its subscales possessed
J Abnorm Child Psychol
good internal consistency (Cronbach’s alphas were all above 0.75), test–retest reliability (all r were all above 0.70), and convergent validity (Meiser-Stedman, Smith, et al. 2009). With the permission from of one of the CPTCI authors (i.e., Meiser-Stedman, R.), the CPTCI items were translated into Chinese by the first author. The initial results were forwarded to two independent bilingual child psychologists for backtranslation. Subsequently, both authors carefully reviewed the initial back-translations and compared them with the original CPTCI to confirm translational equivalence. The psychometrics of the Chinese version of the CPTCI (CPTIC-C) will be reported in the Results section. Chinese Version of the UCLA PTSD Reaction Index for DSM-IV The UCLA PTSD Reaction Index for DSM-IV (Pynoos et al. 1998) is a self-report measure to assess PTSD symptoms in children and adolescents. The first section of the UCLA PTSD Reaction Index for DSM-IV assesses exposure to different traumatic events and responders can specify their current most disturbing trauma. The second section assesses various peritraumatic reactions. Items 22–25 in this section are used to establish whether children/adolescents respond with fear, horror or helplessness, per DSM-IV Criterion A2 to peritraumatic distress (Elhai et al. 2013). The third section is a checklist of symptoms of PTSD. Respondents are asked to rate the frequency of PTSD symptoms experienced during the preceding month on a five-point Likert scale. The UCLA PTSD Reaction Index for DSM-IV had good psychometric properties (Steinberg et al. 2004). The Chinese version of the UCLA PTSD Reaction Index for DSM-IV demonstrated high internal consistency (Cronbach’s alpha=0.92) and fair 1week test–retest reliability (r=0.80) (Chen et al. 2002). In the current sample, internal consistency was excellent (Cronbach’s alpha=0.90). Children’s Depression Inventory-Taiwan version The Children’s Depression Inventory (CDI; Kovacs 1985) is a widely used self-report scale for depressive symptoms in children and adolescents aged 7 to 17 years. It contains 27 items that assess cognitive, affective and behavioral symptoms of depression during the preceding 2 weeks. The CDI has fair internal consistency, moderate to high test–retest reliability, and satisfactory predictive, convergent, and construct validity in nonclinical populations (Smucker et al. 1986). The Children’s Depression Inventory–Taiwan version has fair internal consistency (Cronbach’s alpha ranges from 0.80 to 0.86) and good test–retest coefficients (r = 0.85) among Taiwanese adolescents (Chen 2008). In the current sample, internal consistency was good (Cronbach’s alpha=0.80).
designed for children and adolescents aged 7 through 18 years. The anxiety subscale of the BYI-II, the Beck Anxiety Inventory for Youth (BAI-Y), reflects youth’ worries about school performance, the future, and negative reactions of others, as well as fear and physiological symptoms associated with anxiety. The Chinese version of BYI-II had good internal consistency (Cronbach’s alpha was above 0.90 for each subscale) and acceptable test–retest reliability (r=0.67 for BAIY) (Cho et al. 2009). In the current sample, internal consistency was excellent (Cronbach’s alpha=0.93). Chinese Version of the Child Behavior Checklist The Child Behavior Checklist (CBCL) (Achenbach 1991) is a parental report concerning the emotional and behavioral problems of children aged 4–18 years during the preceding 6 months. According to Achenbach (1991), two broad-band behavior syndromes—internalizing problems (i.e., Withdrawn, Somatic Complaints, and Anxious/Depressed Moods) and externalizing problems (i.e., Delinquent Behavior and Aggressive Behavior) – were defined. The Chinese version of the CBCL possessed good reliability in a previous validation with Taiwanese youth (Yang et al. 2000). In the current sample, all reliability coefficients were favorable, ranging from 0.80 to 0.91. Chinese Version of the Swanson, Nolan, and Pelham, Version IV Scale The Swanson, Nolan, and Pelham, version IV scale (SNAP-IV)-parent form is a 26-item instrument that uses a four-point Likert scale. There are 18 items that parallel the core symptoms of DSM-IV attention deficit–hyperactivity disorder (ADHD) and eight items based on the DSM-IV oppositional defiant disorder (ODD) symptom criteria (Swanson et al. 2001). The norms and the psychometric properties of the Chinese version of the SNAP-IV have been established in Taiwan (Gau et al. 2008). In the current sample, internal consistency was excellent (Cronbach’s alpha=0.95). Statistical Analyses The Kolmogorov–Smirnov test indicated the non-normality of distribution of the scores of the CPTCI-C. Therefore, in evaluating the psychometric properties of the CPTCI-C, nonparametric analyses were conducted using statistical procedures similar to those used by Meiser-Stedman, Smith, et al. (2009) to evaluate the CPTCI.
Results Psychometrics of the CPTCI-C
Chinese Version of the Beck Anxiety Inventory for Youth The Beck Youth Inventories of Emotional and Social Impairment-Second Edition (BYI-II; Beck et al. 2005) was
Factor Analyses Confirmatory factor analysis (CFA) was conducted with EQS 6.1. A two-factor model based on the
J Abnorm Child Psychol
original subscales (i.e., CPTCI-PC, CPTCI-SW) was evaluated. We adopted robust maximum likelihood estimation to adjust for the non-normality of the data. Initially, the proposed model had unsatisfactory data fit: Satorra-Bentler χ2 (274)= 631.28, p
A Community Study on the Relationship of Posttraumatic Cognitions to Internalizing and Externalizing Psychopathology in Taiwanese Children and Adolescents Shu-Tsen Liu 1,2 & Sue-Huei Chen 1
# Springer Science+Business Media New York 2015
Abstract A growing number of studies indicate that posttraumatic cognitions play a crucial role in the development and maintenance of posttraumatic stress disorder (PTSD). However, the effects of posttraumatic cognitions on general psychopathology beyond PTSD remain unclear. The current study aimed to validate the Chinese version of the Child Posttraumatic Cognitions Inventory (CPTCI-C) and to investigate the relationship between posttraumatic cognitions and psychopathology. A community sample of 285 schoolaged children and adolescents (aged 9–17, 160 [56.1 %] female) reported their trauma-related cognitions on the CPTCI-C and completed measures of symptoms of PTSD, depression, and generalized anxiety. Parents reported their children’s internalizing and externalizing problems. We validated a revised version of the CPTCI-C based on the results of confirmatory factor analyses. The resulting evidence suggests that this revised CPTCI-C possesses good internal consistency, fair 6-week temporal stability, and good concurrent validity. In addition to significant correlations between posttraumatic cognitions and internalizing and externalizing psychopathology, after controlling for age, gender, and trauma types, both the revised CPTCI-C subscale scores conveyed unique contributions to psychological
* Sue-Huei Chen [email protected] 1
Department of Psychology, National Taiwan University, No. 1, Sec. 4, Roosevelt Road, Taipei 106, Taiwan
2
Department of Psychiatry, National Taiwan University Hospital Yunlin Branch, No.579, Sec. 2, Yunlin Rd., Douliou City, Yunlin County 640, Taiwan
distress while only the maladaptive appraisals of the trauma remained weakly associated with externalizing problems. Structural equation modeling analysis showed that maladaptive appraisals of the trauma had a direct longitudinal impact on chronic PTSD severity. No mediation effect of posttraumatic cognitions on the relationship between acute and chronic PTSD activity was observed. The implications of our findings are discussed for the specificity of posttraumatic cognitions to posttraumatic internalizing psychopathology and cognitive interventions that target negative trauma-related cognitions. Keywords Posttraumatic cognitions . Posttraumatic stress disorder . Children and adolescents . Internalizing and externalizing psychopathology Traumatic experiences can significantly alter individuals’ cognitions. For trauma survivors, negative views of self and the world and appraisals about the trauma may impair coping abilities and deprive individuals of sources of support. Moreover, negative posttraumatic cognitions are a major source of distress and are generally viewed as a central pathogenic factor for adult posttraumatic stress disorder (PTSD). Cognitive therapy also ranks as the most effective evidencebased trauma treatment. However, it remains unclear how posttraumatic cognitions influence the development of the externalizing and internalizing dimensions of posttraumatic psychopathology in children and adolescents. Therefore, creating an adequate assessment of posttraumatic cognitions and probing more deeply into the impact of posttraumatic cognitions on general psychopathology are crucial steps for developing successful prevention and intervention strategies for traumatized youth.
J Abnorm Child Psychol
Ehlers and Clark’s Model of PTSD and Development of the Child Posttraumatic Cognitions Inventory Several cognitive models have been proposed to explain the development and maintenance of PTSD (e.g., Brewin et al. 1996; Dalgleish 2004). However, few existing studies of child and adolescent trauma survivors have provided empirical evidence for these cognitive theories. Ehlers and Clark (2000) proposed that negative appraisals of the trauma and its sequelae could drive both development and persistence of PTSD. Ehlers et al. (2003), in a prospective study with child and adolescent survivors of a road traffic accident, confirmed the predictive effect of maladaptive trauma-related appraisals on PTSD severity. The validity of their single-item questionnaire for measuring trauma-related appraisals has been criticized, however, and the Child Posttraumatic Cognitions Inventory (CPTCI; Meiser-Stedman et al. 2009) was subsequently developed. Principal components analysis yielded two subscales for the CPTCI: Fragile person in a scary world (CPTCI-SW) and permanent and disturbing change (CPTCIPC). The CPTCI-SW domain comprises items that are derived from the adult Posttraumatic Cognitions Inventory (Foa et al. 1999) and express negative cognitions about self and the world; the CPTCI-PC subscale is a comprehensive evaluation of maladaptive trauma-related appraisals. The CPTCI has been validated in samples of nonclinical senior high school students and child survivors of injuries/traffic accidents. As depicted by Ehlers and Clark’s model of PTSD, the total score of the CPTCI was shown to be positively related to the severity of PTSD and acute stress disorder (Meiser-Stedman et al. 2009), and mediated the evolution of chronic PTSD as well (Meiser-Stedman, Dalgleish, Glucksman, Yule, & Smith, 2009).
Chinese Cultural Effects on Youth’ Response to and Evaluation of Trauma Culture affects an individual’s view of self in the social context and also shapes protective and risk factors of survivors’ reactions to trauma. To date, the bulk of the information about the prevalence and predictors of pediatric PTSD in Taiwan has been generated mainly from studies of adolescent survivors of the Chi-Chi Earthquake in 1999 (e.g., Chen et al. 2002). However, epidemiological studies of childhood PTSD remain scarce in the general population. Collectivistic Chinese societies are Confucianism-based and emphasize filial piety, selfdiscipline, and social harmony. These societal norms contribute to children’s views of themselves and the world (e.g., selfcriticism, or fulfilling others’ expectations as part of self) and their ways of regulating negative emotions (for an excellent review, see Trommsdorff 2012). Therefore, youth in Chinese societies are expected to have both enhanced needs for social
support and increased risks for developing low self-esteem and a sense that others value them less when experiencing traumas that threatens social connection. Current research evidence has provided preliminary support that self-blaming was one main coping style used by Chinese adolescent survivors with an increased risk for PTSD (Zhang et al. 2010) and has also shown that Taiwanese youth perceived great distress from negative appraisals of detrim e n t a l s o c i a l r e l a t i o n s h i p s ( Wu e t a l . 2 0 0 9 ) . Development of a culturally sensitive measure is a prerequisite to understanding youth’ trauma-related cognitions in Chinese cultural contexts.
Posttraumatic Cognitions and Psychopathology Beyond PTSD PTSD captures only a limited aspect of posttraumatic psychopathology. Posttraumatic cognitions have been positively linked with depression as well as PTSD in child trauma survivors (Leeson and Nixon 2011; Meiser-Stedman, Smith, et al. 2009). This implicates trauma-related appraisals as one possible cognitive risk factor for posttraumatic depression and raises questions about the specificity of posttraumatic cognitions to PTSD. Moreover, the effects of negative posttraumatic cognitions on internalizing psychopathologies other than PTSD and depression, such as generalized anxiety or somatization, have been less well studied. In addition to internalizing psychopathology, externalizing psychopathology can emerge after trauma. Previous studies have consistently shown elevated prevalence of both trauma exposure and PTSD in delinquent juveniles (e.g., Abram et al. 2004). Moreover, for community youth, exposure to interpersonal trauma has been documented as a predictor of aggression (e.g., Evans et al. 2008). With regard to mechanisms for linking traumas and PTSD to externalizing psychopathology, Kerig and Becker (2010) suggested hostile attribution, alienation, acceptance of antisocial coping, and shame as possible cognitive mediating mechanisms. Negative appraisals about the trauma and the self in the social world may lead to persistent feelings of being under threat from a hostile environment and to a shameful sense of lacking the ability to rise above the threat. These feelings in turn foster an increased acceptance of aggression as a way of coping for survival. Negative traumarelated cognitions could therefore be hypothesized as one candidate cognitive risk factor for posttraumatic externalizing psychopathology. However, the research literature is again scant on this question. One recent study of psychologically mistreated children (Leeson and Nixon 2011) failed to demonstrate a significant relationship between trauma-related appraisals and externalizing problems. However, no such conclusion has yet been applied to youth in the community with various types of trauma exposure.
J Abnorm Child Psychol
Objectives of the Present Study First, this study aimed to investigate the psychometric properties of the Chinese version of the CPTCI (CPTCI-C) in Taiwanese children and adolescents. Next, after validating the CPTCI-C, we aimed to examine the relationships between posttraumatic cognitions and childhood internalizing and externalizing psychopathology. Specifically, we sought to test the application of Ehlers and Clark’s (2000) model of PTSD in Taiwanese community children and adolescents.
Methods Participants A total of 351 child and adolescent participants (aged 9–17, mean=13.3±2.7 years, 202 [56.9 %] female) were recruited from three randomly selected public schools located in Douliou, a city of over 100,000 residents of mixed socioeconomic status located in Taiwan’s poorest county, Yunlin. The children were selected on the basis of a two-phase cluster sampling. First, one school each was randomly selected from the 13 elementary schools, three junior high schools, and two senior high schools, and then within each grade at each selected school, three classes were randomly selected. Children with learning disability were excluded. The Trauma-Exposed Sample Sixty-six participants did not report any DSM-IV PTSD Criterion A1 traumatic event, leaving 285 participants (80.1 %) to constitute the trauma-exposed sample for further analyses. As shown in Table 1, of these participants, 28.8 % of the mothers and 33.1 % of the fathers had earned degrees from a college or above, a considerably higher percentage than that observed in the general population (25.1 %), while 6.5 % of the children lived in households below the poverty line (compared with 1.2 % in the general population) (Taiwan Statistical Yearbook of Interior, 2010). In addition, unsurprisingly, since Taiwan has a long history of earthquakes and typhoons, natural disaster (8.8 %) is the most commonly experienced trauma. The follow-up sample comprised 261 trauma-exposed participants and was demographically similar to the initial trauma-exposed sample (aged= 13.4±2.63 years, 147 [56.5 %] female). They completed the CPTCI-C and the Chinese version of the UCLA PTSD Reaction Index for DSM-IV a second time, with an inter-test interval of approximately 6 weeks. However, only 224 cases had complete data in both the first and second assessment, and the missing data rate was as high as 14.2 %. We conducted missing-data analysis and found that there was no significant difference between completers and non-completers with respect to either the total CPTCI-C score or PTSD severity,
Table 1 Demographic and trauma characteristics of the traumaexposed sample The trauma-exposed sample (n=285) M (SD) or % Age (Mean ± SD, years) Gender (%): Male Living with both parents (%) Maternal/paternal education (%) College/ university & above Monthly household income (%) Below the poverty line Time elapsed from the trauma (Mean ± SD, months) Trauma types (%) Natural disaster Interpersonal trauma Traffic accident Medical trauma Full PTSD likely (%) Partial PSTD likely (%) No PTSD (%)
13.5 (2.7) 43.9 84.2 28.8/33.1 6.7 108.0 (49.0)
66.0 8.4 5.3 8.8 16.5 5.3 78.2
CPTCI-C score: t(258)=−0.96, p=0.34, ns; PTSD severity: t(263)=−1.13, p=0.26, ns. Procedures The Institutional Review Board of National Taiwan University Hospital approved this study before recruitment. Eligible children and their parents both signed the informed consent form before assessment. The child and adolescent respondents completed the CPTCI-C and reported PTSD symptoms (in relation to the frightening or traumatic event that currently bothered them the most), depressive symptoms, and severity of generalized anxiety. Behavioral and emotional problems were reported by the parents. At the initial assessment, the child and adolescent participants were gathered together in schools to complete the self-report questionnaires. The participating schoolteachers handed the parent-report measures to the parents/legal guardians at the first assessment and the follow-up CPTCI-C and the measure of PTSD severity to the youth participants 6 weeks later. Each participating child–parent pair was compensated with NT $200 for their participation.
Measures Chinese Version of the Child Posttraumatic Cognitions Inventory The original CPTCI is a 25-item self-report measure of children’s trauma-related cognitions that uses a fourpoint Likert scale. The CPTCI and its subscales possessed
J Abnorm Child Psychol
good internal consistency (Cronbach’s alphas were all above 0.75), test–retest reliability (all r were all above 0.70), and convergent validity (Meiser-Stedman, Smith, et al. 2009). With the permission from of one of the CPTCI authors (i.e., Meiser-Stedman, R.), the CPTCI items were translated into Chinese by the first author. The initial results were forwarded to two independent bilingual child psychologists for backtranslation. Subsequently, both authors carefully reviewed the initial back-translations and compared them with the original CPTCI to confirm translational equivalence. The psychometrics of the Chinese version of the CPTCI (CPTIC-C) will be reported in the Results section. Chinese Version of the UCLA PTSD Reaction Index for DSM-IV The UCLA PTSD Reaction Index for DSM-IV (Pynoos et al. 1998) is a self-report measure to assess PTSD symptoms in children and adolescents. The first section of the UCLA PTSD Reaction Index for DSM-IV assesses exposure to different traumatic events and responders can specify their current most disturbing trauma. The second section assesses various peritraumatic reactions. Items 22–25 in this section are used to establish whether children/adolescents respond with fear, horror or helplessness, per DSM-IV Criterion A2 to peritraumatic distress (Elhai et al. 2013). The third section is a checklist of symptoms of PTSD. Respondents are asked to rate the frequency of PTSD symptoms experienced during the preceding month on a five-point Likert scale. The UCLA PTSD Reaction Index for DSM-IV had good psychometric properties (Steinberg et al. 2004). The Chinese version of the UCLA PTSD Reaction Index for DSM-IV demonstrated high internal consistency (Cronbach’s alpha=0.92) and fair 1week test–retest reliability (r=0.80) (Chen et al. 2002). In the current sample, internal consistency was excellent (Cronbach’s alpha=0.90). Children’s Depression Inventory-Taiwan version The Children’s Depression Inventory (CDI; Kovacs 1985) is a widely used self-report scale for depressive symptoms in children and adolescents aged 7 to 17 years. It contains 27 items that assess cognitive, affective and behavioral symptoms of depression during the preceding 2 weeks. The CDI has fair internal consistency, moderate to high test–retest reliability, and satisfactory predictive, convergent, and construct validity in nonclinical populations (Smucker et al. 1986). The Children’s Depression Inventory–Taiwan version has fair internal consistency (Cronbach’s alpha ranges from 0.80 to 0.86) and good test–retest coefficients (r = 0.85) among Taiwanese adolescents (Chen 2008). In the current sample, internal consistency was good (Cronbach’s alpha=0.80).
designed for children and adolescents aged 7 through 18 years. The anxiety subscale of the BYI-II, the Beck Anxiety Inventory for Youth (BAI-Y), reflects youth’ worries about school performance, the future, and negative reactions of others, as well as fear and physiological symptoms associated with anxiety. The Chinese version of BYI-II had good internal consistency (Cronbach’s alpha was above 0.90 for each subscale) and acceptable test–retest reliability (r=0.67 for BAIY) (Cho et al. 2009). In the current sample, internal consistency was excellent (Cronbach’s alpha=0.93). Chinese Version of the Child Behavior Checklist The Child Behavior Checklist (CBCL) (Achenbach 1991) is a parental report concerning the emotional and behavioral problems of children aged 4–18 years during the preceding 6 months. According to Achenbach (1991), two broad-band behavior syndromes—internalizing problems (i.e., Withdrawn, Somatic Complaints, and Anxious/Depressed Moods) and externalizing problems (i.e., Delinquent Behavior and Aggressive Behavior) – were defined. The Chinese version of the CBCL possessed good reliability in a previous validation with Taiwanese youth (Yang et al. 2000). In the current sample, all reliability coefficients were favorable, ranging from 0.80 to 0.91. Chinese Version of the Swanson, Nolan, and Pelham, Version IV Scale The Swanson, Nolan, and Pelham, version IV scale (SNAP-IV)-parent form is a 26-item instrument that uses a four-point Likert scale. There are 18 items that parallel the core symptoms of DSM-IV attention deficit–hyperactivity disorder (ADHD) and eight items based on the DSM-IV oppositional defiant disorder (ODD) symptom criteria (Swanson et al. 2001). The norms and the psychometric properties of the Chinese version of the SNAP-IV have been established in Taiwan (Gau et al. 2008). In the current sample, internal consistency was excellent (Cronbach’s alpha=0.95). Statistical Analyses The Kolmogorov–Smirnov test indicated the non-normality of distribution of the scores of the CPTCI-C. Therefore, in evaluating the psychometric properties of the CPTCI-C, nonparametric analyses were conducted using statistical procedures similar to those used by Meiser-Stedman, Smith, et al. (2009) to evaluate the CPTCI.
Results Psychometrics of the CPTCI-C
Chinese Version of the Beck Anxiety Inventory for Youth The Beck Youth Inventories of Emotional and Social Impairment-Second Edition (BYI-II; Beck et al. 2005) was
Factor Analyses Confirmatory factor analysis (CFA) was conducted with EQS 6.1. A two-factor model based on the
J Abnorm Child Psychol
original subscales (i.e., CPTCI-PC, CPTCI-SW) was evaluated. We adopted robust maximum likelihood estimation to adjust for the non-normality of the data. Initially, the proposed model had unsatisfactory data fit: Satorra-Bentler χ2 (274)= 631.28, p
