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Development and preliminary validation of a screen for interpersonal childhood trauma experiences among school-going youth in Durban, South Africa a
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Steven J Collings , Sachet R Valjee & Susan L Penning
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School of Applied Human Sciences, Howard College Campus , University of KwaZulu-Natal , Durban , South Africa Published online: 31 May 2013.
To cite this article: Steven J Collings , Sachet R Valjee & Susan L Penning (2013) Development and preliminary validation of a screen for interpersonal childhood trauma experiences among school-going youth in Durban, South Africa, Journal of Child & Adolescent Mental Health, 25:1, 23-34, DOI: 10.2989/17280583.2012.722552 To link to this article: http://dx.doi.org/10.2989/17280583.2012.722552
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JOURNAL OF C H I L D & A D O LES C EN T M EN T A L H EA L T H ISSN 1728-0583 EISSN 1728-0591 http://dx.doi.org/10.2989/17280583.2012.722552
Research Paper
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Development and preliminary validation of a screen for interpersonal childhood trauma experiences among school-going youth in Durban, South Africa Steven J Collings*, Sachet R Valjee and Susan L Penning School of Applied Human Sciences, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa * Corresponding author, email: [email protected] This paper describes the development and preliminary validation of the Developmental Trauma Inventory (DTI), which is a 36-item, retrospective, self-administered screen for interpersonal childhood trauma experiences developed specifically for the South African context. Preliminary validation of the inventory was conducted using a sample of 720 school-going adolescents attending a high school in the Durban Metropolitan area (South Africa). Factor analysis produced the best fit for a 10-factor model (emotional abuse, community assault, domestic assault, poverty, witnessing community violence, witnessing domestic violence, indecent assault, domestic neglect, rape, and domestic injury). Contrary to expectations, items relating to loss and separation (e.g. death of a parent) did not produce a clear factor structure. Identified scales had good internal consistency (0.70 to 0.81), low factor inter-correlations, and high concurrent criterion-related validity in the sense that all scales were significantly correlated with scores on clinical measures of post-traumatic stress disorder (PTSD) and/or complex PTSD. These findings provide preliminary support for the utility of DTI in the South African context.
Introduction Retrospective measures of exposure to interpersonal childhood trauma tend to focus on a relatively narrow range of child abuse experiences (sexual, physical, emotional, or neglect) occurring largely in the home (Bernstein et al. 1994, Bernstein et al. 2003, Dunne et al. 2009, Lobbestael et al. 2009, Thombs et al. 2009). While many of these measures have been found to have sound psychometric properties, concerns have been raised regarding the extent to which such measures adequately capture a child’s full victimisation profile. With respect to the locus of traumatic exposure (i.e. familial versus extra-familial), several authors (e.g. Finkelhor et al. 2005, Zolotor et al. 2009) have argued that comprehensive assessment of a child’s victimisation profile needs to consider both domestic and community exposure to violence. Further, with respect to the mode of exposure (i.e. witnessing versus victimisation), both international and local studies indicate that the impact of interpersonal violence on children does not depend on the mode of exposure (Richters and Martinez 1993, Barbarin and Richter 2001); suggesting the need for vicarious forms of traumatic exposure to be considered as part of a child’s victimisation profile. Further, there are both theoretical and empirical reasons to suggest that there are two broad categories of additional events that may need to be considered if one hopes to adequately capture the range of content domains required for a comprehensive assessment of developmental trauma experiences. First, Terr (1991) refers to Crossover Type I–Type II Trauma, which involves exposure Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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to discreet incidents (e.g. the death of a parent) which may lead to secondary forms of traumatic exposure (e.g. a history of inadequate parenting) which are likely to be chronic in terms of both their nature and effects. Second, there is a growing body of evidence which suggests that traumatic outcomes may arise as a consequence of chronic or repeated exposure to social and/or structural violence, including poverty, displacement, endemic social violence, war, and/or political terrorism (Patel and Kleinman 2003, Qouta, Punamäki and Sarraj 2003, Spinazzola et al. 2005, Kawachi and Subramanian 2006, Shields, Nadasen and Pierce 2008, Kithakye et al. 2010, Klasen et al. 2010, Rockers et al. 2010). While some of these additional content domains may have limited relevance to South African populations, many domains would appear to have clear relevance in a contemporary South African context characterised by: (a) widespread vicarious and direct exposure to both community and domestic violence (Ensink et al. 1997, Barbarin, Richter and deWet 2000, Seedat et al. 2000, Barbarin and Richter 2001, Ward et al. 2001, Foster et al. 2004, Seedat et al. 2004, Gupta et al. 2008, Shields et al. 2008, Shields, Nadasen and Pierce 2009); (b) an estimated 3.4 million children who have experienced the death of one or both parents, with an estimated 1.6–2.4 million of these deaths being due to AIDS (UNICEF/UNAIDS 2010); and (c) estimates of population poverty of 52.9%, with poverty rates for children (at 65.5%) being more extensive than rates for adults (45.2%) (Statistics South Africa 2008). In this context, the aims of this research were threefold: first, to describe the development of a measure of developmental trauma experiences (the Developmental Trauma Inventory, DTI) which was designed to adequately address content domains likely to be relevant to the South African context; second, to explore the factor structure and internal consistency of the DTI factors; and third, to explore the concurrent criterion-related validity of the DTI in relation to post-traumatic outcomes. Development of the DTI Conceptual framework Consistent with the socio-contextual perspective which characterises much of the contemporary work on developmental trauma (Courtois and Ford 2009), the overarching conceptual framework which informed the development of the DTI was the Spaccarelli (1994) transactional model of trauma and trauma reactions. From a transactional perspective, Spaccarelli (1994) maintains that the impact of developmental trauma experiences needs to be understood not simply in terms of objective characteristics of traumatic exposure (i.e. nature, frequency, severity, etc.) but also in terms of ongoing, and potentially bidirectional, transactions between traumatic exposure and a range of mediating/moderating variables including socio-contextual factors (e.g. family conflict, marital separation), negative cognitive appraisals and/or cognitive restructuring, and the presence or absence of social support. In essence, what Spaccarelli would appear to be appealing for is a shift away from somewhat dated stimulus-based models of reactions to traumatic exposure, towards a transactional model in terms of which socio-contextual factors, and trauma related appraisals and/or cognitive restructuring, play a central/determining role with respect to risk of traumatic outcomes. The development of DTI was also informed by theoretical insights gleaned from the literature on complex post-traumatic stress disorder (CPTSD) (Herman 1992a, 1992b) and, more specifically, by work conducted in the field of chronic development trauma (Terr 1991, van der Kolk et al. 1996, Pelcovitz et al. 1997, Roth et al. 1997, Cook et al. 2005, van der Kolk 2005a, 2005b, Cloitre et al. 2009, Ford and Courtois 2009). Simply stated, work on chronic developmental trauma indicates that chronic interpersonal trauma, occurring during developmentally vulnerable periods (e.g. early childhood and early adolescence), tends to be associated with a constellation of symptoms which are not adequately addressed by PTSD (Herman 2009); with traumatic outcomes being mediated/ moderated by the impact of traumatic exposure on developmental trajectories, by socio-contextual factors, and by cognitive adaptations in relation to notions of self, interpersonal relationships, and sense of meaning (Ford and Courtois 2009).
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Inventory items Structure of the DTI. Following established best practice (Finkelhor et al. 2005) closed-ended filter questions were used to probe for traumatic experiences. Respondents who did not endorse a particular question were directed to further probes, and respondents who endorsed a particular probe were requested to provide further information relating to the probe. Trauma probes. A large pool of probes for traumatic experiences were sourced from available developmental trauma measures (e.g. Bernstein et al. 1994, Fink et al. 1995, Briere 1995, Bernstein et al. 2003, Briere 2005, Finkelhor et al. 2005, van der Kolk 2005a, Dunne et al. 2009, Lobbestael et al. 2009, Thombs et al. 2009, Zolotor et al. 2009); the clinical and research literature on childhood trauma (e.g. Herman 1992b, Cook et al. 2005, Cloitre et al. 2009, Ford and Courtois 2009); and the literature on forms of childhood adversity (e.g. poverty) which have not conventionally been defined as traumatic experiences (e.g. Patel and Kleinman 2003, Kithakye et al. 2010, Rockers et al. 2010). Initial reduction in this pool of items involved the removal of all redundant items. Thereafter, items were thematically organised into categories defined by different forms of traumatic exposure (i.e. sexual abuse, physical abuse, etc.), with nine discrete categories being identified: sexual abuse, emotional abuse, neglect, physical abuse in the home, physical abuse in the community, witnessing domestic violence, witnessing community violence, loss/separation, and poverty. Finally, an item-analysis was conducted to ensure that items were mutually exclusive, unambiguous, behaviourally specific, and phrased in neutral language [e.g. words such as ‘abused’, which have been found to be associated with reduced rates of self-reported traumatic experiences (Fink et al. 1995), were removed or reworded]. In this process, care was taken to avoid redundancy and to ensure that items were mutually exclusive both within and across forms of trauma. Thus, for example, items such as “Having to wear dirty or torn clothes” or “Having too little to eat” (Lobbestael et al. 2009: 511), which are likely to be reported by children who are physically neglected and by children who are exposed to poverty, were not included in the final scale. Final scale items were scored dichotomously (present or absent) and in terms of lifetime prevalence. Follow-up questions. In cases where traumatic experiences were endorsed, additional information (age at first experience, duration, gender, relationship to the perpetrator, and supportiveness of disclosure) were obtained for an index experience (“The experience that was most upsetting for you”) within each category of abuse. Trauma related reactions were assessed with respect to: fightflight-freeze reactions which are typical of PTSD (“At the time I felt: angry, afraid, and/or numb or in shock”), trauma related causal attributions (“I have felt guilty or to blame for what happened”), and cognitive appraisals/adaptations which have been found, or theorised, to be associated with CPTSD experiences (“Since the experience I have found it hard to trust others”, “The experience changed me in a negative way”, and “Because of the experience I no longer believe that the world is a safe place”) (Ford and Courtois 2009, van der Kolk et al. 2009). All cognitive appraisals/adaptations were scored on a 5-point Likert scale ranging from 1 (not at all) to 5 (extremely). Validation plan Validation of the DTI was conceptualised in terms of three phases: Phase 1, designed to explore the factor structure of the DTI probe items as well as the internal consistency and concurrent validity of identified factors; Phase 2, designed to explore the factor structure and concurrent validity of cognitive appraisal measures; and Phase 3, designed to explore the construct validity of the DTI. The research reported here represents the findings from Phase 1 of this validation process, which was conducted among school-going youth attending a high school in the Durban metropolitan area (South Africa) during 2011. Four general hypotheses were entertained in the research: (a) the statistically derived factor structure for the DTI would parallel the nine categories of trauma exposure identified during the development of the scale; (b) identified factors would demonstrate adequate internal consistency; (c) factor inter-correlations would be generally low, indicating factor independence; and (d) the DTI factor scores would be positively associated with scores on clinical measures of PTSD and CPTSD.
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Method
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Respondents The sampling frame for the study was all students attending a high school located in the Durban Metropolitan area during 2011. Of the 802 learners registered at the school, 752 (94%) consented to participate in the research and 720 (90%) submitted usable questionnaires. Sample characteristics are presented in Table 1. Measures In addition to completing the DTI, respondents completed two clinical measures of posttraumatic stress: • Davidson Trauma Scales (DTS). The DTS (Davidson 2003) is a 17-item scale designed to assess the presence, frequency, and severity of PTSD symptoms. Each of the items on the scale is scored from 0 (none) to 4 (every day) for frequency and from 0 (not at all distressing) to 4 (extremely distressing) for severity, with total scores for frequency and severity being obtained by summing item scores. Davidson reports high test-retest reliability for the scale within a 1-week period (r = 0.86, p < 0.001), with construct validity being demonstrated by high correlations with other measures of PTSD (Davidson 2003). • Self-Report Inventory of Disorders of Extreme Stress (SIDES-SR). Developed by Pelcovitz et al. (1997), the SIDES-SR is a 45-item, self-administered questionnaire, designed to measure symptoms of CPTSD across 6 symptom domains: affective and behavioural dysregulation, dissociation, alterations in attention and consciousness, altered self-perceptions, alterations in relations with others, somatisation, and alterations in systems of meaning. On the SIDES-SR, each symptom domain can be scored in terms of presence (i.e. clinically significant levels of symptom endorsement) and severity (i.e. mean item endorsement for each subscale). Reliability coefficients for SIDES-SR subscales are reported at 0.93 for the total scale, and from 0.68 to 0.82 for the subscales, indicating that scores may reliably be interpreted in a continuous fashion (Luxenberg, Spinazzola and van der Kolk 2001). Procedure Ethical clearance for the research was obtained from the Humanities Ethics Committee at the University of KwaZulu-Natal, with parental consent, and respondent assent, being obtained from all participants. Research questionnaires were administered to groups of consenting participants during Life Orientation lessons; with offers of free counselling support (from the school guidance teacher) and/or free psychological counselling/therapy (at a university clinic) being made to all respondents. Table 1: Sample characteristics (n = 720) Characteristic Age Gender Male Female Grade 8 9 10 11 12 Ethnic group African Coloured White Asian
M (SD) 15.43 (1.78)
n (%)
476 (66.1) 244 (33.9) 150 (20.8) 122 (17.0) 190 (26.4) 154 (21.4) 104 (14.4) 687 (95.4) 19 (2.6) 9 (1.3) 5 (0.7)
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Results Factor analyses Scores on the DTI probe items were subjected to factor analysis to determine whether they formed related but independent factors corresponding to the nine content domains identified for the study (sexual abuse, physical abuse, community violence, witnessing domestic violence, witnessing community violence, emotional abuse, neglect, loss/separation, and poverty). To this end, an approach which utilised exploratory and confirmatory factor analysis was adopted. Questionnaires were randomly assigned to one of two groups, with one group being used for the exploratory analysis and the other for the confirmatory analysis. Factor analyses were performed using SPSS/PASW 18. In each case a principle components analysis was performed, with factors being rotated using the Varimax procedure, and with factors being retained if they met the criteria of: an eigenvalue greater than 1, a scree plot of eigenvalues supporting retention, a factor loading of at least 0.40, and the meaningfulness of identified factors. Table 2 shows that, for both analyses, sampling adequacy was moderately high, with the Bartlett test of sphericity being significant. The exploratory analysis yielded a 10-factor, rather than the expected 9-factor, solution (Table 2). Consistent with expectations, factors were extracted which corresponded to emotional abuse, neglect, poverty, witnessing domestic violence, witnessing community violence, and exposure to community violence. However, the DTI items relating to sexual abuse yielded two distinct factors, with one relating to indecent assault (Indecent assault) and the other relating to penile penetration (Rape). Similarly, items relating to physical abuse in the home yielded two distinct factors (Domestic assault and Domestic injury) (see Table 2). Somewhat unexpectedly, the five items designed to assess loss and separation (death of a parent, death of someone close, living with caretakers other than parents, serious illness/injury of someone close, parental divorce) did not demonstrate any clear factor structure, suggesting that these items may need to be considered independently. The confirmatory factor analysis yielded an identical factor structure with similar factor loadings (Table 2), indicating that the obtained factor structure is both stable and valid. Prevalence of traumatic exposure The prevalence of traumatic exposure for each of the 10 DTI factors is presented in Figure 1; with comparative prevalence rates for loss/separation items being: death of a parent (23%), death of a close person other than a parent (63%), living with caretakers other than a parent (15%), someone close was seriously ill/injured (51%), and parental divorce/separation (28%). Among respondents who reported traumatic exposure, the median age of earliest exposure/ awareness was 0–6 years for poverty; 7–12 years for exposure to all forms of domestic violence, emotional abuse, neglect, and all forms of loss/separation; and 13–18 years for exposure to all forms of sexual abuse, and exposure to both direct and vicarious community violence. With respect to gender differences in exposure: females were more than twice as likely as males to report exposure to rape (OR = 2.4, 95% CI = 1.2–3.8, p = 0.000) or emotional abuse (OR = 2.1, 95% CI = 1.3–2.6, p = 0.016); and males were more than twice as likely to report victimisation in the community (OR = 2.1, 95% CI = 1.5–3.0, p = 0.000). There were no significant gender differences in rates of exposure to all other forms of trauma assessed by the DTI. Table 2: Exploratory (confirmatory) factor structure of items on the developmental trauma inventory
Sample size Sampling adequacy Bartlett’s test of sphericity Number of factors % variance accounted for Iterations for convergence
Exploratory analysis 358 0.78 2377.1*** 10 58.3 6
(Confirmatory analysis) (362) (0.79) (2586.4***) (10) (59.1) (6) Note: Table 2 continues
My caretakers treated me in ways that made me feel ashamed I felt unloved at home Hurtful things were said to me by my caretakers In my caretakers eyes, nothing I said was good enough People in my family called me insulting names Being punched or kicked by a non-family member Being physically attacked by a non-family member A non-family member cutting you with a knife or sharp object Being hit with a stick or some other object by a non-family member A non-family member trying to strangle you A non-family member burning you with a cigarette or flame Being punched or kicked by a family member Being physically attacked by a family member A family member hitting you with a stick or some other object A family member trying to strangle you Family so poor there was not enough food to eat Parents could not afford to send me to the doctor when I was sick Parents did not earn enough money to a support a family I witnessed physical violence in my home My parents hurt each other physically when they argued/fought A family member got medical treatment because of family violence
Item
0.59 (0.58)
0.68 (0.67) 0.79 (0.81) 0.78 (0.79)
0.74 (0.72)
Emotional abuse
0.61 (0.61) 0.57 (0.60)
0.74 (0.74)
0.58 (0.59)
0.73 (0.73)
0.73 (0.74)
Community assault
0.64 (0.64)
0.70 (0.69) 0.78 (0.79) 0.61 (0.62)
Domestic Assault
0.81 (0.81)
0.78 (0.81) 0.63 (0.59)
Poverty
0.69 (0.69)
0.75 (0.74) 0.79 (0.82)
Witness domestic violence
Witness community violence
Table 2: Exploratory (confirmatory) factor structure of items on the developmental trauma inventory (continued)
Indecent Assault
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Domestic neglect Rape
Domestic injury
28 Collings, Valjee and Penning
Community assault
Domestic Assault Poverty
Witness domestic violence
0.76 (0.78) 0.76 (0.77)
0.78 (0.79)
Witness community violence
0.83 (0.85)
0.80 (0.82)
0.58 (0.55)
0.54 (0.58)
Indecent Assault
0.68 (0.68) 0.73 (0.75)
0.75 (0.79) 0.74 (0.74)
Domestic neglect
0.84 (0.85) 0.86 (0.83)
Rape
0.81 (0.80)
0.79 (0.77)
Domestic injury
3.0 (2.9) 2.9 (2.8) 2.2 (2.2) 2.0 (2.0) 2.0 (1.9) 2.0 (1.9) 1.9 (1.9) 1.8 (1.9) 1.7 (1.8) 1.5 (1.6) 8.3 (8.3) 7.9 (8.0) 6.0 (6.4) 5.5 (5.5) 5.5 (5.4) 5.5 (5.4) 5.4 (5.3) 5.2 (5.3) 4.8 (5.0) 4.2 (4.3) 0.81 (0.78) 0.76 (0.78) 0.71 (0.70) 0.72 (0.72) 0.72 (0.71) 0.71 (0.73) 0.70 (0.72) 0.70 (0.71) 0.72 (0.73) 0.73 (0.70)
Emotional abuse
Note: In all cases, statistics for the exploratory analysis are presented first followed by statistics for the confirmatory analysis in parentheses. ***p < 0.001.
Eigenvalue % of variance Internal consistency (α)
I saw someone in the community being beaten, stabbed, or shot I saw someone in the community being killed I saw someone in the community being assaulted Someone touched my sex organs when I did not want them to Someone made you touch their sex organs when you did not want to Someone kissing or touching you in a sexual way Someone making you touch them in a sexual way Spent time away from home and no one cared No one made sure I got up in the morning to go to school I felt no one cared if I lived or died Caretakers did not care when I was unwell or in trouble Unwanted anal sex Unwanted genital sex A family member deliberately burnt you with a cigarette/ flame A family member deliberately cut you with a knife/sharp object
Item
Table 2: Exploratory (confirmatory) factor structure of items on the developmental trauma inventory (continued)
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Collings, Valjee and Penning
Figure 1: Prevalence of different forms of traumatic exposure
62
60
40
49 40
40 32
30
26
20
17 12
10
6
R ap D om e es tic in ju ry
Po
ve
rty
6
N eg le ct
(c om m W un itn ity es vi s D ol om en es ce tic ) as s In au de lt ce nt as C om sa ul m t un ity as sa ul (fa t m Wi t ily n e Em viol ss e nc ot io e) na la bu se
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PER CENT
50
Internal consistency and inter-correlations between subscales Cronbach’s alpha for the DTI factors demonstrated acceptable reliability, with alpha values ranging from 0.70 to 0.81, with a mean of 0.73 (Table 2). Although some factor scores were significantly inter-correlated, correlations were generally low, ranging from 0.01 to 0.28, with a mean of 0.09 (Table 3). These latter findings are consistent with the view that the DTI items form somewhat related although independent factors. The results in Table 3 indicate that death of a parent was not significantly associated with any Table 3: Intercorrelations between DTI factors and loss/separation items Scales/items EM CA DA PO WD WC Factor scales Emotional abuse (EM) __ Community assault (CA) -0.03 __ Domestic assault (DA) -0.12** -0.10* __ Poverty (PO) 0.09* 0.01 -0.14** __ Witness domestic violence (WD) -0.08* -0.05 -0.04 0.01 __ Witness community violence (WC) -0.05 -0.13** -0.08* -0.08* -0.16** __ Indecent assault (IA) -0.08* 0.06 -0.08* -0.14** 0.01 -0.14** Domestic neglect (DN) -0.11** 0.03 0.01 -0.28** 0.10** -0.10* Rape (RA) 0.10** 0.04 -0.13** 0.25** -0.20** -0.15** Domestic injury (DI) -0.09* -0.17** -0.23** 0.12** -0.10** -0.04 Loss/separation items Parental death 0.02 -0.02 0.06 0.03 0.03 -0.03 Death of close person 0.07* -0.01 -0.01 0.02 -0.04 0.09** Having non-parental caretakers 0.10** 0.03 0.07* 0.01 0.01 0.02 Someone close was seriously ill/ 0.04 0.07* 0-0.03 0.01 -0.03 0.10** injured Parental divorce or separation 0.04 -0.01 0.07* 0.06 0.05 -0.01 *
p < 0.05; **p < 0.01.
IA
RA
DI
__ -0.05 __ 0.04 -0.07 __ -0.05 -0.11** 0.02
__
-0.03 -0.02 0.03 0.03
DN
0.02 -0.02 0.03 0.03
-0.01 0.01 -0.05 -0.09** -0.02 -0.08* -0.02 -0.11**
0.10** 0.01
0.04 -0.08*
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DTI scale scores, while other items designed to measure loss and separation (parental divorce, serious illness or injury to a close person other than a parent, someone close died, and having non-parental caretakers) were each significantly correlated with two or more DTI scale scores. Concurrent validity Apart from the measures of direct and vicarious exposure to community violence, all the DTI factors were positively associated with the clinical presence of PTSD and with clinically significant scores on at least two CPTSD domains (Table 4). Scores for Community assault were not significantly associated with PTSD outcomes, but significantly associated with clinically significant scores on three CPTSD domains; while score for witnessing community violence were significantly associated with PTSD but not with scores on any CPSTD domains. From Table 4 it is evident that death of a parent was not significantly associated with any post-traumatic outcome scores, while other items designed to measure loss and separation (parental divorce, serious illness or injury to a close person other than a parent, someone close died, and having non-parental caretakers) were each significantly correlated with scores on at least one post-traumatic outcome measure. Discussion These findings provide only partial support for the hypothesised nine-factor model of developmental trauma experiences. Although six of the hypothesised factors emerged in the factor analysis (i.e. emotional abuse, neglect, physical abuse in the community, witnessing domestic violence, witnessing community violence, and poverty), the analysis suggested that sexual abuse comprised two discrete factors (indecent assault and rape) and that physical abuse comprised one factor relating to domestic assault and a second factor relating to domestic injury as a result of burning or cutting. Although these derived factors are both intuitively and conceptually meaningful, they constitute factors which have not been identified in previous studies conducted largely in developed Table 4: Correlations between DTI factors, loss/separation items, and traumatic symptomatology Clinical presence CPTSD
PTSD
Affective dysreg- Dissoulation ciation
Negative selfDisrupted percep- relation- Somatitions ships sation
Disrupted sense of meaning
0.23*** 0.04 0.16** 0.16** 0.17** 0.08* 0.15** 0.17** 0.13** 0.09*
0.11** 0.05 0.09 0.07 0.07 0.06 0.07 0.07 0.06 0.10*
0.13** 0.10* 0.13** 0.12** 0.14** 0.02 0.14** 0.14** 0.05 0.05
0.16** 0.09* 0.11** 0.11** 0.13** 0.06 0.19** 0.19** 0.10* 0.06
0.13** 0.07 0.15** 0.11** 0.09* 0.04 0.12** 0.12** 0.06 0.04
0.23** 0.07 0.17** 0.10* 0.14** 0.08 0.12** 0.12** 0.07 0.10*
0.11** 0.08* 0.08* 0.08* 0.08* 0.03 0.11** 0.11** 0.12** 0.03
0.03 0.09* 0.09* 0.03 0.01
0.05 0.07 0.05 0.03 0.01
0.01 0.03 0.06 0.02 0.01
0.07 0.05 0.08* 0.04 0.03
0.05 0.08* 0.07 0.01 0.01
0.04 0.10** 0.15** 0.09* 0.08*
0.06 0.03 0.13** 0.05 0.03
Factors/items
Factor Emotional abuse Community assault Domestic assault Poverty Witness domestic violence Witness community violence Indecent assault Domestic neglect Rape Domestic injury Loss/separation items Parental death Death of a close person Having non-parental caretakers Someone close was ill/injured Parental divorce/ separation *
p < 0.05; **p < 0.01.
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countries (e.g. Bernstein et al. 1994, 2003, Dunne et al. 2009, Lobbestael et al. 2009, Thombs et al. 2009), suggesting that validation procedures conducted in developed countries may not necessarily be applicable to the South African context. A somewhat unexpected finding was that items relating to loss and separation did not emerge as a distinct factor. Four of the five loss/separation items—parental divorce, serious illness or injury to a close person other than a parent, someone close died, and having non-parental caretakers— were, however, significantly correlated with both interpersonal trauma experiences and with post-traumatic outcomes, suggesting that these forms of loss and separation may be associated with Crossover Type 1–Type II Trauma in the manner suggested by Terr (1991). The finding that the death of a parent was unrelated to either traumatic exposure or to traumatic outcomes was a surprising finding of the study, as the death of a parent has been identified by Terr (1991) as a key form of loss and separation which is likely to be associated with both risk of traumatic exposure and with subsequent post-traumatic outcomes. Although the reasons for this negative finding are far from clear, it is possible that the loss of a parent is associated with psychological sequelae which are not adequately captured by measures of either PTSD or CPTSD; with further research on this matter being strongly indicated. Findings relating to the second hypothesis, indicate that identified factors had moderate to strong internal consistency, indicating that factors can reliably be interpreted in a continuous fashion; while the exploration of factor inter-correlations (third hypothesis) indicated that while there were some significant inter-correlations between factors, these correlations were generally low, indicating that the DTI items form somewhat related although independent factors. The analysis of the association between factor scores and scores on clinical measures of PTSD and CPTSD indicate that, with the notable exception of direct and vicarious exposure to community violence, all the DTI factors were significantly associated with clinical outcomes on the PTSD measure and with clinical outcomes on at least two measures of CPTSD. Thus, with the exception of findings for community violence, our findings are consistent with the view that developmental trauma is likely to be associated with symptoms of both PTSD and CPTSD (Ford and Courtois 2009), and provide support for the concurrent validity of the DTI. The discrepant findings obtained for community violence replicate findings obtained in a previous study of South African adolescents (Ward et al. 2001). As was the case in our study, Ward and her colleagues found that PTSD outcomes were associated with witnessing community violence but not with direct victimisation by a community member. The findings reported in this paper extend these findings by indicating that witnessing community violence is associated with symptoms of PTSD, but not with symptoms of CPTSD, while victimisation by a community member is associated with symptoms of CPTSD, but not with symptoms of PTSD. The reasons for this pattern of findings are, however, far from clear, with further, possibly qualitative, research being indicated to further explicate these discrepant findings. Conclusions and limitations The study findings support several aspects of the reliability and validity of the DTI including its factorial validity, internal consistency, factor independence, and concurrent validity. Taken together, these findings suggest that the DTI is a promising new instrument for the assessment of developmental trauma in the South African context, with further validation of the inventory being indicated. Limitations of this study, which need to be addressed in future research, include the fact that the data were obtained from school-going youth attending a high school in an urban area. Cross-validation of the findings with other samples (e.g. rural school-going youth, out-of-school youth, general population samples, clinical samples) is clearly indicated, to establish the generalisability of the study findings. Further, it is possible that research which is not grounded in a socio-contextual paradigm may have produced different findings relating to the nature and relative priority of trauma probes relevant to children’s victimisation profiles.
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Acknowledgement — This work is based on research supported by the National Research Foundation (NRF). Any opinion, findings and conclusions or recommendations expressed in this material are those of the authors and therefore NRF does not accept any liability in regard thereto.
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Development and preliminary validation of a screen for interpersonal childhood trauma experiences among school-going youth in Durban, South Africa a
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Steven J Collings , Sachet R Valjee & Susan L Penning
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School of Applied Human Sciences, Howard College Campus , University of KwaZulu-Natal , Durban , South Africa Published online: 31 May 2013.
To cite this article: Steven J Collings , Sachet R Valjee & Susan L Penning (2013) Development and preliminary validation of a screen for interpersonal childhood trauma experiences among school-going youth in Durban, South Africa, Journal of Child & Adolescent Mental Health, 25:1, 23-34, DOI: 10.2989/17280583.2012.722552 To link to this article: http://dx.doi.org/10.2989/17280583.2012.722552
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JOURNAL OF C H I L D & A D O LES C EN T M EN T A L H EA L T H ISSN 1728-0583 EISSN 1728-0591 http://dx.doi.org/10.2989/17280583.2012.722552
Research Paper
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Development and preliminary validation of a screen for interpersonal childhood trauma experiences among school-going youth in Durban, South Africa Steven J Collings*, Sachet R Valjee and Susan L Penning School of Applied Human Sciences, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa * Corresponding author, email: [email protected] This paper describes the development and preliminary validation of the Developmental Trauma Inventory (DTI), which is a 36-item, retrospective, self-administered screen for interpersonal childhood trauma experiences developed specifically for the South African context. Preliminary validation of the inventory was conducted using a sample of 720 school-going adolescents attending a high school in the Durban Metropolitan area (South Africa). Factor analysis produced the best fit for a 10-factor model (emotional abuse, community assault, domestic assault, poverty, witnessing community violence, witnessing domestic violence, indecent assault, domestic neglect, rape, and domestic injury). Contrary to expectations, items relating to loss and separation (e.g. death of a parent) did not produce a clear factor structure. Identified scales had good internal consistency (0.70 to 0.81), low factor inter-correlations, and high concurrent criterion-related validity in the sense that all scales were significantly correlated with scores on clinical measures of post-traumatic stress disorder (PTSD) and/or complex PTSD. These findings provide preliminary support for the utility of DTI in the South African context.
Introduction Retrospective measures of exposure to interpersonal childhood trauma tend to focus on a relatively narrow range of child abuse experiences (sexual, physical, emotional, or neglect) occurring largely in the home (Bernstein et al. 1994, Bernstein et al. 2003, Dunne et al. 2009, Lobbestael et al. 2009, Thombs et al. 2009). While many of these measures have been found to have sound psychometric properties, concerns have been raised regarding the extent to which such measures adequately capture a child’s full victimisation profile. With respect to the locus of traumatic exposure (i.e. familial versus extra-familial), several authors (e.g. Finkelhor et al. 2005, Zolotor et al. 2009) have argued that comprehensive assessment of a child’s victimisation profile needs to consider both domestic and community exposure to violence. Further, with respect to the mode of exposure (i.e. witnessing versus victimisation), both international and local studies indicate that the impact of interpersonal violence on children does not depend on the mode of exposure (Richters and Martinez 1993, Barbarin and Richter 2001); suggesting the need for vicarious forms of traumatic exposure to be considered as part of a child’s victimisation profile. Further, there are both theoretical and empirical reasons to suggest that there are two broad categories of additional events that may need to be considered if one hopes to adequately capture the range of content domains required for a comprehensive assessment of developmental trauma experiences. First, Terr (1991) refers to Crossover Type I–Type II Trauma, which involves exposure Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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to discreet incidents (e.g. the death of a parent) which may lead to secondary forms of traumatic exposure (e.g. a history of inadequate parenting) which are likely to be chronic in terms of both their nature and effects. Second, there is a growing body of evidence which suggests that traumatic outcomes may arise as a consequence of chronic or repeated exposure to social and/or structural violence, including poverty, displacement, endemic social violence, war, and/or political terrorism (Patel and Kleinman 2003, Qouta, Punamäki and Sarraj 2003, Spinazzola et al. 2005, Kawachi and Subramanian 2006, Shields, Nadasen and Pierce 2008, Kithakye et al. 2010, Klasen et al. 2010, Rockers et al. 2010). While some of these additional content domains may have limited relevance to South African populations, many domains would appear to have clear relevance in a contemporary South African context characterised by: (a) widespread vicarious and direct exposure to both community and domestic violence (Ensink et al. 1997, Barbarin, Richter and deWet 2000, Seedat et al. 2000, Barbarin and Richter 2001, Ward et al. 2001, Foster et al. 2004, Seedat et al. 2004, Gupta et al. 2008, Shields et al. 2008, Shields, Nadasen and Pierce 2009); (b) an estimated 3.4 million children who have experienced the death of one or both parents, with an estimated 1.6–2.4 million of these deaths being due to AIDS (UNICEF/UNAIDS 2010); and (c) estimates of population poverty of 52.9%, with poverty rates for children (at 65.5%) being more extensive than rates for adults (45.2%) (Statistics South Africa 2008). In this context, the aims of this research were threefold: first, to describe the development of a measure of developmental trauma experiences (the Developmental Trauma Inventory, DTI) which was designed to adequately address content domains likely to be relevant to the South African context; second, to explore the factor structure and internal consistency of the DTI factors; and third, to explore the concurrent criterion-related validity of the DTI in relation to post-traumatic outcomes. Development of the DTI Conceptual framework Consistent with the socio-contextual perspective which characterises much of the contemporary work on developmental trauma (Courtois and Ford 2009), the overarching conceptual framework which informed the development of the DTI was the Spaccarelli (1994) transactional model of trauma and trauma reactions. From a transactional perspective, Spaccarelli (1994) maintains that the impact of developmental trauma experiences needs to be understood not simply in terms of objective characteristics of traumatic exposure (i.e. nature, frequency, severity, etc.) but also in terms of ongoing, and potentially bidirectional, transactions between traumatic exposure and a range of mediating/moderating variables including socio-contextual factors (e.g. family conflict, marital separation), negative cognitive appraisals and/or cognitive restructuring, and the presence or absence of social support. In essence, what Spaccarelli would appear to be appealing for is a shift away from somewhat dated stimulus-based models of reactions to traumatic exposure, towards a transactional model in terms of which socio-contextual factors, and trauma related appraisals and/or cognitive restructuring, play a central/determining role with respect to risk of traumatic outcomes. The development of DTI was also informed by theoretical insights gleaned from the literature on complex post-traumatic stress disorder (CPTSD) (Herman 1992a, 1992b) and, more specifically, by work conducted in the field of chronic development trauma (Terr 1991, van der Kolk et al. 1996, Pelcovitz et al. 1997, Roth et al. 1997, Cook et al. 2005, van der Kolk 2005a, 2005b, Cloitre et al. 2009, Ford and Courtois 2009). Simply stated, work on chronic developmental trauma indicates that chronic interpersonal trauma, occurring during developmentally vulnerable periods (e.g. early childhood and early adolescence), tends to be associated with a constellation of symptoms which are not adequately addressed by PTSD (Herman 2009); with traumatic outcomes being mediated/ moderated by the impact of traumatic exposure on developmental trajectories, by socio-contextual factors, and by cognitive adaptations in relation to notions of self, interpersonal relationships, and sense of meaning (Ford and Courtois 2009).
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Inventory items Structure of the DTI. Following established best practice (Finkelhor et al. 2005) closed-ended filter questions were used to probe for traumatic experiences. Respondents who did not endorse a particular question were directed to further probes, and respondents who endorsed a particular probe were requested to provide further information relating to the probe. Trauma probes. A large pool of probes for traumatic experiences were sourced from available developmental trauma measures (e.g. Bernstein et al. 1994, Fink et al. 1995, Briere 1995, Bernstein et al. 2003, Briere 2005, Finkelhor et al. 2005, van der Kolk 2005a, Dunne et al. 2009, Lobbestael et al. 2009, Thombs et al. 2009, Zolotor et al. 2009); the clinical and research literature on childhood trauma (e.g. Herman 1992b, Cook et al. 2005, Cloitre et al. 2009, Ford and Courtois 2009); and the literature on forms of childhood adversity (e.g. poverty) which have not conventionally been defined as traumatic experiences (e.g. Patel and Kleinman 2003, Kithakye et al. 2010, Rockers et al. 2010). Initial reduction in this pool of items involved the removal of all redundant items. Thereafter, items were thematically organised into categories defined by different forms of traumatic exposure (i.e. sexual abuse, physical abuse, etc.), with nine discrete categories being identified: sexual abuse, emotional abuse, neglect, physical abuse in the home, physical abuse in the community, witnessing domestic violence, witnessing community violence, loss/separation, and poverty. Finally, an item-analysis was conducted to ensure that items were mutually exclusive, unambiguous, behaviourally specific, and phrased in neutral language [e.g. words such as ‘abused’, which have been found to be associated with reduced rates of self-reported traumatic experiences (Fink et al. 1995), were removed or reworded]. In this process, care was taken to avoid redundancy and to ensure that items were mutually exclusive both within and across forms of trauma. Thus, for example, items such as “Having to wear dirty or torn clothes” or “Having too little to eat” (Lobbestael et al. 2009: 511), which are likely to be reported by children who are physically neglected and by children who are exposed to poverty, were not included in the final scale. Final scale items were scored dichotomously (present or absent) and in terms of lifetime prevalence. Follow-up questions. In cases where traumatic experiences were endorsed, additional information (age at first experience, duration, gender, relationship to the perpetrator, and supportiveness of disclosure) were obtained for an index experience (“The experience that was most upsetting for you”) within each category of abuse. Trauma related reactions were assessed with respect to: fightflight-freeze reactions which are typical of PTSD (“At the time I felt: angry, afraid, and/or numb or in shock”), trauma related causal attributions (“I have felt guilty or to blame for what happened”), and cognitive appraisals/adaptations which have been found, or theorised, to be associated with CPTSD experiences (“Since the experience I have found it hard to trust others”, “The experience changed me in a negative way”, and “Because of the experience I no longer believe that the world is a safe place”) (Ford and Courtois 2009, van der Kolk et al. 2009). All cognitive appraisals/adaptations were scored on a 5-point Likert scale ranging from 1 (not at all) to 5 (extremely). Validation plan Validation of the DTI was conceptualised in terms of three phases: Phase 1, designed to explore the factor structure of the DTI probe items as well as the internal consistency and concurrent validity of identified factors; Phase 2, designed to explore the factor structure and concurrent validity of cognitive appraisal measures; and Phase 3, designed to explore the construct validity of the DTI. The research reported here represents the findings from Phase 1 of this validation process, which was conducted among school-going youth attending a high school in the Durban metropolitan area (South Africa) during 2011. Four general hypotheses were entertained in the research: (a) the statistically derived factor structure for the DTI would parallel the nine categories of trauma exposure identified during the development of the scale; (b) identified factors would demonstrate adequate internal consistency; (c) factor inter-correlations would be generally low, indicating factor independence; and (d) the DTI factor scores would be positively associated with scores on clinical measures of PTSD and CPTSD.
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Method
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Respondents The sampling frame for the study was all students attending a high school located in the Durban Metropolitan area during 2011. Of the 802 learners registered at the school, 752 (94%) consented to participate in the research and 720 (90%) submitted usable questionnaires. Sample characteristics are presented in Table 1. Measures In addition to completing the DTI, respondents completed two clinical measures of posttraumatic stress: • Davidson Trauma Scales (DTS). The DTS (Davidson 2003) is a 17-item scale designed to assess the presence, frequency, and severity of PTSD symptoms. Each of the items on the scale is scored from 0 (none) to 4 (every day) for frequency and from 0 (not at all distressing) to 4 (extremely distressing) for severity, with total scores for frequency and severity being obtained by summing item scores. Davidson reports high test-retest reliability for the scale within a 1-week period (r = 0.86, p < 0.001), with construct validity being demonstrated by high correlations with other measures of PTSD (Davidson 2003). • Self-Report Inventory of Disorders of Extreme Stress (SIDES-SR). Developed by Pelcovitz et al. (1997), the SIDES-SR is a 45-item, self-administered questionnaire, designed to measure symptoms of CPTSD across 6 symptom domains: affective and behavioural dysregulation, dissociation, alterations in attention and consciousness, altered self-perceptions, alterations in relations with others, somatisation, and alterations in systems of meaning. On the SIDES-SR, each symptom domain can be scored in terms of presence (i.e. clinically significant levels of symptom endorsement) and severity (i.e. mean item endorsement for each subscale). Reliability coefficients for SIDES-SR subscales are reported at 0.93 for the total scale, and from 0.68 to 0.82 for the subscales, indicating that scores may reliably be interpreted in a continuous fashion (Luxenberg, Spinazzola and van der Kolk 2001). Procedure Ethical clearance for the research was obtained from the Humanities Ethics Committee at the University of KwaZulu-Natal, with parental consent, and respondent assent, being obtained from all participants. Research questionnaires were administered to groups of consenting participants during Life Orientation lessons; with offers of free counselling support (from the school guidance teacher) and/or free psychological counselling/therapy (at a university clinic) being made to all respondents. Table 1: Sample characteristics (n = 720) Characteristic Age Gender Male Female Grade 8 9 10 11 12 Ethnic group African Coloured White Asian
M (SD) 15.43 (1.78)
n (%)
476 (66.1) 244 (33.9) 150 (20.8) 122 (17.0) 190 (26.4) 154 (21.4) 104 (14.4) 687 (95.4) 19 (2.6) 9 (1.3) 5 (0.7)
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Results Factor analyses Scores on the DTI probe items were subjected to factor analysis to determine whether they formed related but independent factors corresponding to the nine content domains identified for the study (sexual abuse, physical abuse, community violence, witnessing domestic violence, witnessing community violence, emotional abuse, neglect, loss/separation, and poverty). To this end, an approach which utilised exploratory and confirmatory factor analysis was adopted. Questionnaires were randomly assigned to one of two groups, with one group being used for the exploratory analysis and the other for the confirmatory analysis. Factor analyses were performed using SPSS/PASW 18. In each case a principle components analysis was performed, with factors being rotated using the Varimax procedure, and with factors being retained if they met the criteria of: an eigenvalue greater than 1, a scree plot of eigenvalues supporting retention, a factor loading of at least 0.40, and the meaningfulness of identified factors. Table 2 shows that, for both analyses, sampling adequacy was moderately high, with the Bartlett test of sphericity being significant. The exploratory analysis yielded a 10-factor, rather than the expected 9-factor, solution (Table 2). Consistent with expectations, factors were extracted which corresponded to emotional abuse, neglect, poverty, witnessing domestic violence, witnessing community violence, and exposure to community violence. However, the DTI items relating to sexual abuse yielded two distinct factors, with one relating to indecent assault (Indecent assault) and the other relating to penile penetration (Rape). Similarly, items relating to physical abuse in the home yielded two distinct factors (Domestic assault and Domestic injury) (see Table 2). Somewhat unexpectedly, the five items designed to assess loss and separation (death of a parent, death of someone close, living with caretakers other than parents, serious illness/injury of someone close, parental divorce) did not demonstrate any clear factor structure, suggesting that these items may need to be considered independently. The confirmatory factor analysis yielded an identical factor structure with similar factor loadings (Table 2), indicating that the obtained factor structure is both stable and valid. Prevalence of traumatic exposure The prevalence of traumatic exposure for each of the 10 DTI factors is presented in Figure 1; with comparative prevalence rates for loss/separation items being: death of a parent (23%), death of a close person other than a parent (63%), living with caretakers other than a parent (15%), someone close was seriously ill/injured (51%), and parental divorce/separation (28%). Among respondents who reported traumatic exposure, the median age of earliest exposure/ awareness was 0–6 years for poverty; 7–12 years for exposure to all forms of domestic violence, emotional abuse, neglect, and all forms of loss/separation; and 13–18 years for exposure to all forms of sexual abuse, and exposure to both direct and vicarious community violence. With respect to gender differences in exposure: females were more than twice as likely as males to report exposure to rape (OR = 2.4, 95% CI = 1.2–3.8, p = 0.000) or emotional abuse (OR = 2.1, 95% CI = 1.3–2.6, p = 0.016); and males were more than twice as likely to report victimisation in the community (OR = 2.1, 95% CI = 1.5–3.0, p = 0.000). There were no significant gender differences in rates of exposure to all other forms of trauma assessed by the DTI. Table 2: Exploratory (confirmatory) factor structure of items on the developmental trauma inventory
Sample size Sampling adequacy Bartlett’s test of sphericity Number of factors % variance accounted for Iterations for convergence
Exploratory analysis 358 0.78 2377.1*** 10 58.3 6
(Confirmatory analysis) (362) (0.79) (2586.4***) (10) (59.1) (6) Note: Table 2 continues
My caretakers treated me in ways that made me feel ashamed I felt unloved at home Hurtful things were said to me by my caretakers In my caretakers eyes, nothing I said was good enough People in my family called me insulting names Being punched or kicked by a non-family member Being physically attacked by a non-family member A non-family member cutting you with a knife or sharp object Being hit with a stick or some other object by a non-family member A non-family member trying to strangle you A non-family member burning you with a cigarette or flame Being punched or kicked by a family member Being physically attacked by a family member A family member hitting you with a stick or some other object A family member trying to strangle you Family so poor there was not enough food to eat Parents could not afford to send me to the doctor when I was sick Parents did not earn enough money to a support a family I witnessed physical violence in my home My parents hurt each other physically when they argued/fought A family member got medical treatment because of family violence
Item
0.59 (0.58)
0.68 (0.67) 0.79 (0.81) 0.78 (0.79)
0.74 (0.72)
Emotional abuse
0.61 (0.61) 0.57 (0.60)
0.74 (0.74)
0.58 (0.59)
0.73 (0.73)
0.73 (0.74)
Community assault
0.64 (0.64)
0.70 (0.69) 0.78 (0.79) 0.61 (0.62)
Domestic Assault
0.81 (0.81)
0.78 (0.81) 0.63 (0.59)
Poverty
0.69 (0.69)
0.75 (0.74) 0.79 (0.82)
Witness domestic violence
Witness community violence
Table 2: Exploratory (confirmatory) factor structure of items on the developmental trauma inventory (continued)
Indecent Assault
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Domestic neglect Rape
Domestic injury
28 Collings, Valjee and Penning
Community assault
Domestic Assault Poverty
Witness domestic violence
0.76 (0.78) 0.76 (0.77)
0.78 (0.79)
Witness community violence
0.83 (0.85)
0.80 (0.82)
0.58 (0.55)
0.54 (0.58)
Indecent Assault
0.68 (0.68) 0.73 (0.75)
0.75 (0.79) 0.74 (0.74)
Domestic neglect
0.84 (0.85) 0.86 (0.83)
Rape
0.81 (0.80)
0.79 (0.77)
Domestic injury
3.0 (2.9) 2.9 (2.8) 2.2 (2.2) 2.0 (2.0) 2.0 (1.9) 2.0 (1.9) 1.9 (1.9) 1.8 (1.9) 1.7 (1.8) 1.5 (1.6) 8.3 (8.3) 7.9 (8.0) 6.0 (6.4) 5.5 (5.5) 5.5 (5.4) 5.5 (5.4) 5.4 (5.3) 5.2 (5.3) 4.8 (5.0) 4.2 (4.3) 0.81 (0.78) 0.76 (0.78) 0.71 (0.70) 0.72 (0.72) 0.72 (0.71) 0.71 (0.73) 0.70 (0.72) 0.70 (0.71) 0.72 (0.73) 0.73 (0.70)
Emotional abuse
Note: In all cases, statistics for the exploratory analysis are presented first followed by statistics for the confirmatory analysis in parentheses. ***p < 0.001.
Eigenvalue % of variance Internal consistency (α)
I saw someone in the community being beaten, stabbed, or shot I saw someone in the community being killed I saw someone in the community being assaulted Someone touched my sex organs when I did not want them to Someone made you touch their sex organs when you did not want to Someone kissing or touching you in a sexual way Someone making you touch them in a sexual way Spent time away from home and no one cared No one made sure I got up in the morning to go to school I felt no one cared if I lived or died Caretakers did not care when I was unwell or in trouble Unwanted anal sex Unwanted genital sex A family member deliberately burnt you with a cigarette/ flame A family member deliberately cut you with a knife/sharp object
Item
Table 2: Exploratory (confirmatory) factor structure of items on the developmental trauma inventory (continued)
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Journal of Child and Adolescent Mental Health 2013, 25(1): 23–34 29
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Collings, Valjee and Penning
Figure 1: Prevalence of different forms of traumatic exposure
62
60
40
49 40
40 32
30
26
20
17 12
10
6
R ap D om e es tic in ju ry
Po
ve
rty
6
N eg le ct
(c om m W un itn ity es vi s D ol om en es ce tic ) as s In au de lt ce nt as C om sa ul m t un ity as sa ul (fa t m Wi t ily n e Em viol ss e nc ot io e) na la bu se
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PER CENT
50
Internal consistency and inter-correlations between subscales Cronbach’s alpha for the DTI factors demonstrated acceptable reliability, with alpha values ranging from 0.70 to 0.81, with a mean of 0.73 (Table 2). Although some factor scores were significantly inter-correlated, correlations were generally low, ranging from 0.01 to 0.28, with a mean of 0.09 (Table 3). These latter findings are consistent with the view that the DTI items form somewhat related although independent factors. The results in Table 3 indicate that death of a parent was not significantly associated with any Table 3: Intercorrelations between DTI factors and loss/separation items Scales/items EM CA DA PO WD WC Factor scales Emotional abuse (EM) __ Community assault (CA) -0.03 __ Domestic assault (DA) -0.12** -0.10* __ Poverty (PO) 0.09* 0.01 -0.14** __ Witness domestic violence (WD) -0.08* -0.05 -0.04 0.01 __ Witness community violence (WC) -0.05 -0.13** -0.08* -0.08* -0.16** __ Indecent assault (IA) -0.08* 0.06 -0.08* -0.14** 0.01 -0.14** Domestic neglect (DN) -0.11** 0.03 0.01 -0.28** 0.10** -0.10* Rape (RA) 0.10** 0.04 -0.13** 0.25** -0.20** -0.15** Domestic injury (DI) -0.09* -0.17** -0.23** 0.12** -0.10** -0.04 Loss/separation items Parental death 0.02 -0.02 0.06 0.03 0.03 -0.03 Death of close person 0.07* -0.01 -0.01 0.02 -0.04 0.09** Having non-parental caretakers 0.10** 0.03 0.07* 0.01 0.01 0.02 Someone close was seriously ill/ 0.04 0.07* 0-0.03 0.01 -0.03 0.10** injured Parental divorce or separation 0.04 -0.01 0.07* 0.06 0.05 -0.01 *
p < 0.05; **p < 0.01.
IA
RA
DI
__ -0.05 __ 0.04 -0.07 __ -0.05 -0.11** 0.02
__
-0.03 -0.02 0.03 0.03
DN
0.02 -0.02 0.03 0.03
-0.01 0.01 -0.05 -0.09** -0.02 -0.08* -0.02 -0.11**
0.10** 0.01
0.04 -0.08*
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DTI scale scores, while other items designed to measure loss and separation (parental divorce, serious illness or injury to a close person other than a parent, someone close died, and having non-parental caretakers) were each significantly correlated with two or more DTI scale scores. Concurrent validity Apart from the measures of direct and vicarious exposure to community violence, all the DTI factors were positively associated with the clinical presence of PTSD and with clinically significant scores on at least two CPTSD domains (Table 4). Scores for Community assault were not significantly associated with PTSD outcomes, but significantly associated with clinically significant scores on three CPTSD domains; while score for witnessing community violence were significantly associated with PTSD but not with scores on any CPSTD domains. From Table 4 it is evident that death of a parent was not significantly associated with any post-traumatic outcome scores, while other items designed to measure loss and separation (parental divorce, serious illness or injury to a close person other than a parent, someone close died, and having non-parental caretakers) were each significantly correlated with scores on at least one post-traumatic outcome measure. Discussion These findings provide only partial support for the hypothesised nine-factor model of developmental trauma experiences. Although six of the hypothesised factors emerged in the factor analysis (i.e. emotional abuse, neglect, physical abuse in the community, witnessing domestic violence, witnessing community violence, and poverty), the analysis suggested that sexual abuse comprised two discrete factors (indecent assault and rape) and that physical abuse comprised one factor relating to domestic assault and a second factor relating to domestic injury as a result of burning or cutting. Although these derived factors are both intuitively and conceptually meaningful, they constitute factors which have not been identified in previous studies conducted largely in developed Table 4: Correlations between DTI factors, loss/separation items, and traumatic symptomatology Clinical presence CPTSD
PTSD
Affective dysreg- Dissoulation ciation
Negative selfDisrupted percep- relation- Somatitions ships sation
Disrupted sense of meaning
0.23*** 0.04 0.16** 0.16** 0.17** 0.08* 0.15** 0.17** 0.13** 0.09*
0.11** 0.05 0.09 0.07 0.07 0.06 0.07 0.07 0.06 0.10*
0.13** 0.10* 0.13** 0.12** 0.14** 0.02 0.14** 0.14** 0.05 0.05
0.16** 0.09* 0.11** 0.11** 0.13** 0.06 0.19** 0.19** 0.10* 0.06
0.13** 0.07 0.15** 0.11** 0.09* 0.04 0.12** 0.12** 0.06 0.04
0.23** 0.07 0.17** 0.10* 0.14** 0.08 0.12** 0.12** 0.07 0.10*
0.11** 0.08* 0.08* 0.08* 0.08* 0.03 0.11** 0.11** 0.12** 0.03
0.03 0.09* 0.09* 0.03 0.01
0.05 0.07 0.05 0.03 0.01
0.01 0.03 0.06 0.02 0.01
0.07 0.05 0.08* 0.04 0.03
0.05 0.08* 0.07 0.01 0.01
0.04 0.10** 0.15** 0.09* 0.08*
0.06 0.03 0.13** 0.05 0.03
Factors/items
Factor Emotional abuse Community assault Domestic assault Poverty Witness domestic violence Witness community violence Indecent assault Domestic neglect Rape Domestic injury Loss/separation items Parental death Death of a close person Having non-parental caretakers Someone close was ill/injured Parental divorce/ separation *
p < 0.05; **p < 0.01.
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countries (e.g. Bernstein et al. 1994, 2003, Dunne et al. 2009, Lobbestael et al. 2009, Thombs et al. 2009), suggesting that validation procedures conducted in developed countries may not necessarily be applicable to the South African context. A somewhat unexpected finding was that items relating to loss and separation did not emerge as a distinct factor. Four of the five loss/separation items—parental divorce, serious illness or injury to a close person other than a parent, someone close died, and having non-parental caretakers— were, however, significantly correlated with both interpersonal trauma experiences and with post-traumatic outcomes, suggesting that these forms of loss and separation may be associated with Crossover Type 1–Type II Trauma in the manner suggested by Terr (1991). The finding that the death of a parent was unrelated to either traumatic exposure or to traumatic outcomes was a surprising finding of the study, as the death of a parent has been identified by Terr (1991) as a key form of loss and separation which is likely to be associated with both risk of traumatic exposure and with subsequent post-traumatic outcomes. Although the reasons for this negative finding are far from clear, it is possible that the loss of a parent is associated with psychological sequelae which are not adequately captured by measures of either PTSD or CPTSD; with further research on this matter being strongly indicated. Findings relating to the second hypothesis, indicate that identified factors had moderate to strong internal consistency, indicating that factors can reliably be interpreted in a continuous fashion; while the exploration of factor inter-correlations (third hypothesis) indicated that while there were some significant inter-correlations between factors, these correlations were generally low, indicating that the DTI items form somewhat related although independent factors. The analysis of the association between factor scores and scores on clinical measures of PTSD and CPTSD indicate that, with the notable exception of direct and vicarious exposure to community violence, all the DTI factors were significantly associated with clinical outcomes on the PTSD measure and with clinical outcomes on at least two measures of CPTSD. Thus, with the exception of findings for community violence, our findings are consistent with the view that developmental trauma is likely to be associated with symptoms of both PTSD and CPTSD (Ford and Courtois 2009), and provide support for the concurrent validity of the DTI. The discrepant findings obtained for community violence replicate findings obtained in a previous study of South African adolescents (Ward et al. 2001). As was the case in our study, Ward and her colleagues found that PTSD outcomes were associated with witnessing community violence but not with direct victimisation by a community member. The findings reported in this paper extend these findings by indicating that witnessing community violence is associated with symptoms of PTSD, but not with symptoms of CPTSD, while victimisation by a community member is associated with symptoms of CPTSD, but not with symptoms of PTSD. The reasons for this pattern of findings are, however, far from clear, with further, possibly qualitative, research being indicated to further explicate these discrepant findings. Conclusions and limitations The study findings support several aspects of the reliability and validity of the DTI including its factorial validity, internal consistency, factor independence, and concurrent validity. Taken together, these findings suggest that the DTI is a promising new instrument for the assessment of developmental trauma in the South African context, with further validation of the inventory being indicated. Limitations of this study, which need to be addressed in future research, include the fact that the data were obtained from school-going youth attending a high school in an urban area. Cross-validation of the findings with other samples (e.g. rural school-going youth, out-of-school youth, general population samples, clinical samples) is clearly indicated, to establish the generalisability of the study findings. Further, it is possible that research which is not grounded in a socio-contextual paradigm may have produced different findings relating to the nature and relative priority of trauma probes relevant to children’s victimisation profiles.
Journal of Child and Adolescent Mental Health 2013, 25(1): 23–34
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Acknowledgement — This work is based on research supported by the National Research Foundation (NRF). Any opinion, findings and conclusions or recommendations expressed in this material are those of the authors and therefore NRF does not accept any liability in regard thereto.
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