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Measuring adolescents' exposure to violence and related PTSD symptoms: Reliability of an adaptation of the Harvard Trauma Questionnaire Catherine L Ward , Alan J Flisher , Chrisostomos Zissis , Martie Muller & Carl J Lombard Published online: 12 Nov 2009.

To cite this article: Catherine L Ward , Alan J Flisher , Chrisostomos Zissis , Martie Muller & Carl J Lombard (2004) Measuring adolescents' exposure to violence and related PTSD symptoms: Reliability of an adaptation of the Harvard Trauma Questionnaire, Journal of Child & Adolescent Mental Health, 16:1, 31-37, DOI: 10.2989/17280580409486561 To link to this article: http://dx.doi.org/10.2989/17280580409486561

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Journal of Child and Adolescent Mental Health 2004, 16(1): 31–37 Printed in South Africa — All rights reserved

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JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1682–6108

Measuring adolescents’ exposure to violence and related PTSD symptoms: Reliability of an adaptation of the Harvard Trauma Questionnaire Catherine L Ward1*, Alan J Flisher1, Chrisostomos Zissis1, Martie Muller2 and Carl J Lombard2 Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital, Observatory 7925, South Africa Biostatistics Unit, Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa * Corresponding author, e-mail: [email protected]

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Objective — This study aimed to assess the reliability of an adaptation of the Harvard Trauma Questionnaire for use in epidemiological investigations of adolescents’ exposure to violence and related post-traumatic stress disorder (PTSD) symptoms. Method — The exposure items of the Harvard Trauma Questionnaire were adapted for the South African context. The symptoms scale was left intact. Self-report questionnaires were administered on two occasions to 104 students in four high schools in Cape Town, South Africa. Test-retest reliability was assessed using Cohen’s kappa (k) and observed agreement, as well as a concordance correlation coefficient for the symptoms scale. Cronbach’s alpha was used to assess internal consistency of the symptoms scale. Results — All but one item showed at least fair test-retest reliability. Cronbach’s alpha for the symptoms scale was 0.92, and the concordance correlation coefficient between the total symptoms score at time 1 and time 2 was 0.64 (95% CI = 0.51–0.74). Conclusions — Results suggest that the instrument may be sufficiently reliable for use in epidemiological studies of adolescent populations, although this sample is limited in several key respects. Further studies should investigate reliability in broader samples, as well as examining validity.

Introduction Exposure to violence at home and in the community can be a severe traumatic stressor, potentially resulting in serious physical and mental health problems (Jackson and Lorion 2000) such as post-traumatic stress disorder (PTSD). For children and adolescents in particular, both immediate mental health and later development can be prejudiced (Glodich 1998, Gorman-Smith and Tolan 1998, Schwab-Stone et al. 1999). Epidemiological studies provide a means of documenting the extent and effects of violence in large populations, so are an essential first step towards addressing the problem (Flisher 1998). Although several such studies have been conducted in the developed world, very little has been done in the developing world. Even in South Africa, with its very high levels of violence (for instance, the homicide rate is approximately ten times that of the US; Peden and Butchart 1999), few large studies have been done. The toll that violence takes on South African children and adolescents has been documented in studies of specific populations (for instance, Ensink et al. 1997, Peltzer 1999, Zissis, Ensink and Robertson 2000), but large gaps in knowledge remain. There are few studies with community samples and very few epidemiological instruments that have been examined for reliability in the developing world, including South Africa. Furthermore, world-wide, few of the instruments measuring exposure to violence and its consequences that have been developed for adolescent populations are also suitable for large studies. Several of the instruments available for assessing trauma exposure in adolescents require an interview, such as the Posttraumatic Stress Symptoms in

Children measure (Ahmad et al. 2000). Others require responses from parents, such as the Traumatic Events Screening Inventory (Ribbe 1996). Neither format is suitable for an epidemiological survey where questionnaires are administered to large groups of adolescents. For many epidemiological studies, a self-report inventory of exposure to violence that maintains a balance between brevity and comprehensiveness is essential. Most instruments used in current studies of children’s exposure to violence are very short. For instance, the Adolescent SelfReport Trauma Questionnaire, which examines exposure to community and domestic violence, is a mere 14 items long (Horowitz, Weine and Jekel 1995). Similarly, other studies have used short selections of items adapted from the Survey of Children’s Exposure to Violence (Schwab-Stone et al. 1999, Singer et al. 1995). The Survey of Children’s Exposure to Violence itself (Richters and Saltzman 1990) is a comprehensive instrument that explores a range of potentially traumatic experiences. However, it is a complex instrument that is too long for epidemiological surveys that aim to measure more than exposure to violence. Another important and related area is that of the symptoms that are likely to follow from exposure to traumatic events. Although brief self-report instruments for screening for PTSD in children and adolescents are becoming available, such as the Child PTSD Symptom Scale (Foa et al. 2001) and the Children’s PTSD Inventory (Saigh et al. 2001), none were available at the time of this study. Instruments used in South African studies include the Child PTSD Checklist (Amaya-Jackson 1995), the Children’s

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PTSD Inventory (Saigh et al. 2001), and Levonn (Richters, Martinez and Valla 1990). Even where these instruments have been adapted for the South African context, there is very little reliability or validity data available. For instance, the Child PTSD Checklist has been shown to correlate in the expected direction (i.e. positively) with exposure to violence (Seedat et al. 2000), giving indication of criterion validity; the split-half reliability of the Children’s PTSD Inventory was found to be good in a rural South African sample (Peltzer 1999); and Levonn has been adapted in various ways for the South African context (Zissis et al. 2000, Ensink et al. 1997). However, in each case, either no further psychometric data, or none at all, are available. One self-report instrument that includes both a sufficiently short but comprehensive survey of exposure to violence, and a measure of PTSD symptoms, is the Harvard Trauma Questionnaire (Mollica et al. 1992). Although it was originally developed for use with Indochinese refugee adults living in the USA, it has been adapted for use in other contexts. For instance, it is widely used in studies of Danish adolescents (Elklit 2002), and has been used in populations as diverse as Guatemalan refugees (Sabin et al. 2003) and adolescents living in Bosnia (Jones 2002). It has been used not only with refugees or those who lived through wars, but also to examine the impact of a natural disaster (Caldera et al. 2001) and that of physical assault (Elklit and Brink 2003). Despite this, we were unable to find a study of reliability and validity in an adolescent population, although one study does find that the HTQ performs ‘quite well’ in comparison to a semi-structured interview with a clinician in Bosnian children ranging in age from one year to twenty (Goldin et al. 2003). This study addresses these gaps in the literature by examining the reliability of the Harvard Trauma Questionnaire, as adapted for the South African context, in a sample of urban South African high school students. Method Sample As part of a larger study investigating adolescent risk behaviour, a sample of students was drawn from grades 8 and 11 at four private schools in Cape Town, South Africa. Access to public-sector schools for this study was highly unlikely as a larger study was soon to be conducted in these schools and administering bulky questionnaires on multiple occasions would be too disruptive. Schools which endorsed a non-mainstream educational philosophy were not eligible for selection. The only other school which satisfied the criteria was also approached, but declined to participate. One school was for boys only, one for girls only and two were co-educational. These latter schools had relatively more male than female students, and so approximately 70% of the student body was male. In this sample, 71 (68%) were male, and 32 (31%) were female (one respondent did not report his/her gender). Ages of the students ranged from 12 to 18 years. Permission for their children’s participation was obtained from all parents via passive consent and all students present at school on the day were included in the sample.

Ward, Flisher, Zissis, Muller and Lombard

In terms of socially defined racial groups, the majority (76) of the sample was white, with 17 coloured, 6 black and 4 asian students (one respondent did not report his/her race). Students were also asked to indicate all the languages they spoke: most of the students (95) spoke English, while 14 spoke Afrikaans and 5 spoke Xhosa. The violence and PTSD items were included in Part 3 of a multi-part questionnaire. All students received Part 1 of the questionnaire, which included demographic information. Since different parts of the questionnaire were weighted differently in the systematic sampling design, only every third or fourth student, chosen at random, received Part 3. Part 3 also included the Beck Depression Inventory and the SelfRating Anxiety Scale. A total of 257 students received Part 3 of the questionnaire over two administrations. Of these, 49 questionnaires were deleted from the analysis, as questionnaires either had the wrong participant numbers and could not be matched, or questionnaires were not completed. A total of 104 participants thus completed questionnaires at both the first and second administrations. Procedure Questionnaires were administered in the classroom, and care was taken to ensure privacy and anonymity. There were two administrations of the questionnaires, ten to fourteen days apart. Students were given the name of a mental health helpline in case any of them was distressed by the questions that were asked. In addition, the research assistants invited anyone who had questions to speak to them privately after the questionnaire had been completed. The assistants were also trained to seek out actively any student who appeared distressed. Measure The first 49 questions of our measure identify a variety of traumatic experiences that are most likely to occur in South Africa, rather than the torture-related events that might have been experienced by the Indochinese refugee population for which the Harvard Trauma Questionnaire was first developed. Thus, for instance, questions about lack of food and water were replaced by questions about shootings and stabbings. A full list of the exposure items is provided in Table 1. In the original Harvard Trauma Questionnaire, respondents were asked to choose one of four options indicating the way in which they had experienced a particular type of violence: as a direct victim, by witnessing it, by hearing it, or that they had not experienced it at all. In our instrument, respondents were asked to choose either ‘yes’ or ‘no’ to indicate whether they had ever experienced any of the different types of violence. Different questions addressed direct experience (‘I have been beaten up by a stranger’) and witnessing (‘I have seen a stranger being beaten up’). Hearing was addressed only in the case of shootings (‘I have heard gunshots’), as exposure by hearing was judged not to be a frequent event in an environment where torture was not likely (as it may be for refugee populations). Questions were included, however, that addressed different degrees of closeness of perpetrator and victim to the adolescent. Hence, there were several questions concerning (for instance) stab-

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Table 1: Items dealing with exposure to violence 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49.

I have heard gunshots. I have seen a stranger being beaten up. I have seen someone I know (not a family member) being beaten up. I have seen a member of my family being beaten up. I have been beaten up by a stranger. I have been beaten up by someone I know (not a family member). I have been beaten up by a member of my family. I have seen a stranger get stabbed. I have seen a stranger get shot. I have seen someone I know (not a family member) get stabbed. I have seen someone I know (not a family member) get shot. I have seen a member of my family get stabbed. I have seen a member of my family get shot. A stranger threatened to stab me. A stranger threatened to shoot me. Someone I know threatened to stab me. Someone I know threatened to shoot me. A member of my family threatened to stab me. A member of my family threatened to shoot me. I have been stabbed by a stranger. I have been shot by a stranger. I have been shot by someone I know. I have been stabbed by someone I know. I have been shot by a member of my family. I have been stabbed by a member of my family. I have been chased by a gang. I have been kidnapped. A stranger tried to rape me. Someone I know tried to rape me. A family member tried to rape me. A stranger raped me. Someone I know raped me. A family member raped me. I have seen a dead body of a stranger. I have seen the dead body of a family member (not at a funeral). I have seen the dead body of someone I know who was not a family member (not at a funeral). I have seen a stranger trying to commit suicide. I have seen someone I know trying to commit suicide. I have seen a member of my family trying to commit suicide. Grown ups in my home hit each other. Grown ups in my home scream at each other. Grown ups in my home hit me. Grown ups in my home always scream at me. I have seen a stranger get stabbed in my home. I have seen a stranger get shot in my home. I have seen someone I know get stabbed in my home. I have seen someone I know get shot in my home. I have seen a member of my family get stabbed in my home. I have seen a member of my family get shot in my home.

bings that addressed strangers, acquaintances and family members separately, first as victims and then as perpetrators. The second section consists of thirty symptom items unaltered from the original Harvard Trauma Questionnaire, of which the first sixteen are derived from the DSM-III-R criteria for Post-Traumatic Stress Disorder. Respondents are asked to indicate whether these symptoms have been experienced in the past week. The remaining fourteen items describe symptoms that may result from exposure to traumatic events but that are not required for diagnosis. A total

score, reflecting the severity of trauma-related symptoms, is obtained by scoring all 30 questions. Items in this section included ‘recurrent nightmares’ and ‘feeling detached or withdrawn from people’. All symptom items are given in Table 2. Questionnaires were developed in English and translated into Afrikaans and Xhosa and the translations were checked by back translation. Any discrepancies between translations were resolved by a consensus decision. Questionnaires were administered in each respondent’s language of choice.

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Table 2: Items dealing with PTSD symptoms 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79.

Recurrent thoughts or memories of the most hurtful or terrifying events. Feeling as though the event is happening again. Recurrent nightmares. Feeling detached or withdrawn from people. Unable to feel emotions. Feeling jumpy and easily startled. Difficulty concentrating. Trouble sleeping. Feeling on guard. Feeling irritable or having an outburst of anger. Avoiding activities that remind you of the traumatic or hurtful event. Inability to remember parts of the most traumatic or hurtful events. Less interest in daily activities. Feeling as if you don’t have a future. Avoiding thoughts or feelings associated with the traumatic or hurtful events. Sudden emotional or physical reaction when reminded of the most traumatic or hurtful events. Feeling that people do not understand what happened to you. Difficulty performing work on daily tasks. Blaming yourself for things that have happened. Feeling guilty for having survived. Hopelessness. Feeling ashamed of the hurtful or traumatic events that have happened to you. Spending time thinking about why these things happened to you. Feeling as if you are going crazy. Feeling that you are the only one who has suffered these events. Feeling that others are hostile towards you. Feeling that you have no-one to rely on. Finding out or being told by other people that you have done something that you cannot remember. Feeling as if you are split into two people and one of you is watching what the other is doing. Feeling someone you trusted betrayed you.

Analysis Test-retest reliability for individual items was computed by two methods: Cohen’s kappa (k) (Cohen 1960) and observed agreement. The former indicates whether agreement between the two administrations is beyond chance, while the latter refers to the percentage of cases where there was agreement between the two administrations. Kappa values were then characterised using descriptive terms:

Measuring adolescents' exposure to violence and related PTSD symptoms: Reliability of an adaptation of the Harvard Trauma Questionnaire.

Objective - This study aimed to assess the reliability of an adaptation of the Harvard Trauma Questionnaire for use in epidemiological investigations ...
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