Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-014-0890-4

ORIGINAL PAPER

Patterns of victimization, suicide attempt, and posttraumatic stress disorder in Greenlandic adolescents: a latent class analysis Sidsel Karsberg • Cherie Armour • Ask Elklit

Received: 2 November 2012 / Accepted: 17 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014

Abstract Aim The current study had two main aims. The first was to identify groups of adolescents based on their similarity of responding across a number of victimizing and potentially traumatic events (PTEs). In doing so, we employed the statistical technique of Latent Class Analysis (LCA). The second aim was to assess the relationship between our resultant classes and the covariates of gender, suicide attempt, and PTSD. Methods Two hundred and sixty-nine Greenlandic school students, aged 12–18 (M = 15.4, SD = 1.84) were assessed for their level of exposure to PTEs. In addition, adolescents were assessed for the psychological impact of these events. A LCA was performed on seven binary indicators representing PTEs. Logistic regression was subsequently implemented to ascertain the relationships between latent classes and covariates. Results Three distinct classes were uncovered: a violence, neglect, and bullying class (class 1), a wide-ranging multiple PTE class (class 2), and a normative/baseline class (class 3). Notably, classes 1 and 2 were largely separated by the presence or absence of sexual PTEs. Individuals who reported having previously attempted suicide were almost six times more likely to be members of class 1 (OR = 5.97) and almost four times more likely to be members of class 2 (OR = 3.87) compared to the baseline class (class 3). Individuals who met the diagnostic criteria for PTSD were five times as likely to be members of class 1 and class 2 (OR = 5.09) compared to the baseline class. No significant associations were found between classes and gender. S. Karsberg (&)
C. Armour
A. Elklit National Centre for Psychotraumatology, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark e-mail: [email protected]

Conclusion The results underline the complexity of the interplay between multiple victimization experiences, traumatization, and suicide attempts. Keywords Adolescents
Victimization
Co-occurring victimization types
PTSD
Suicidal behavior Introduction Recent years have seen an increasing focus on the Greenlandic people’s social problems. Particular focus has been placed on increasing rates of suicide and the high prevalence of alcohol abuse, child sexual abuse (CSA), and violence (in and out of home) [1–4]. Young Greenlandic people appear to be particularly vulnerable in this context. A relatively recent study by Curtis et al. [2] which assessed violence, CSA, and health in Greenland, reported a high prevalence of violence-related experiences. More specifically, younger women (18–24 years) experienced a greater number of violent and CSA experiences compared to older age groups of women; with 58.8 % of younger women reporting experiences of violence in their lifetime and 21.1 % reporting experiences of violence within the last year. The frequency of violence among younger males (18–24 years) was also found to be high compared to older age groups; with 44 % of younger males reporting experiences of lifetime violence and 23 % reporting experiences within the last year. The same pattern was evident for the prevalence of sexual victimizations; the younger age group showed a higher prevalence of sexual assault (women = 33.9 %, men = 10.0 %) and CSA (women = 12.5 %, men = 3.8 %) compared to older age groups. In addition, a national survey of Greenlandic students between the age of 15 and 17 concluded that around 9 % of Greenlandic boys and 28 % of Greenlandic girls had been exposed to CSA in their lifetime [3].

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Another pertinent finding is that since the 1950s the suicide rate has increased dramatically in Greenland and other Inuit communities. Indeed, the rate of suicide in Greenland is among the highest in the world [4]. A Greenlandic study on suicidal behavior concluded that suicides and suicide attempts peak at age 15–24 [4]. In the nationally representative survey mentioned previously [3], it was found that as many as 37 % (52 % girls, 20 % boys) had seriously considered taking their own life, whereas 23 % (33 % girls, 11 % boys) had actively tried to take their own life. Three quarters of the participants (74.9 % of the boys and 76.9 % of the girls) reported that they had known someone who had committed suicide. Victimization and exposure to trauma in childhood and adulthood has been linked to an array of negative outcomes [5]. In particular, children and adolescents are reported as being particularly vulnerable to the development of PostTraumatic Stress Disorder (PTSD) [6, 7]. Research consistently suggests that children who are subjected to maltreatment are at increased risk for behavioral and psychological problems, poor academic outcomes, higher rates of anxiety disorders, depression, suicidal ideation and suicide attempts, eating disorders, conduct/antisocial behavior, psychosis, and substance abuse [6, 8, 9]. CSA has also been linked to a substantially higher risk of being sexually victimized and living in violent relationships in adulthood [10]. Emerging evidence further suggests that victimization in childhood has long-term consequences on adult physical health and health care utilization [5, 11–13]. As noted, victimization in childhood has serious consequences for child development. Extant research further suggests that experiencing multiple types of victimization (as opposed to a singular type) heightens the likelihood of maladjustment among adolescents [14]. Individuals who have experienced co-occurring victimization types are more likely to report more severe symptoms of PTSD [15], more internalizing and externalizing problems [16], more psychological distress, a lower sense of school belonging [17], and greater academic and social difficulties [14] than individuals with no other, or with fewer, types of victimization experiences. The reasons for the negative outcomes are not, however, fully understood. Traditionally, studies have focused on a single type of victimization such as CSA [18] or physical abuse [19], while ignoring other co-occurring victimizations [20]. A growing body of evidence now shows that victimization types do not occur independently [21]. Indeed, it is argued that studies which only include one type of victimization are limited as they do not take into consideration that these experiences rarely occur as a unidimensional phenomenon, and that pure subtypes are a rarity [20, 22–26]. Focusing on single types of victimization is further considered problematic because it obscures potential influences of other types of victimization

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on individuals [14]. As Tricket et al. [23] point out, physical abuse is often accompanied by derogation, or scorn, or neglect, whereas CSA can be accompanied by violence or threats of violence, and the act of sexual abuse itself may also be painful; paralleling physical abuse. Lau et al. [20] reported that 46–90 % of child welfare cases involve multiple types of maltreatment. Westen et al. and Claussen and Crittenden [22, 27] reported the co-occurrence of sexual and physical abuse to be 71 and 91 %, respectively. Despite accumulating evidence of the co-occurrence of victimization types [21], few studies have examined victimization groupings [26]. Albeit a limited body of research, it has been suggested that differential combinations of victimization may result in differential negative outcome [28]. However, because of the limited number of studies conducted in this field we still know very little about the causal relationships between the various victimization typologies and subsequent psychological responses; such as suicidal behavior and PTSD. Furthermore, studies that have included multiple victimization styles have most often focused on the co-occurrence of physical and sexual abuse [24]. In a meta review of 29 studies that investigated the incidence and effects of child maltreatment, physical abuse was assessed in all 29, CSA was assessed in 26, psychological or emotional maltreatment was assessed in 12, witnessing domestic or family violence was assessed in 8, and physical neglect was assessed in only 4 studies. Notably, all 5 forms of child maltreatment were assessed in only 1 of the 29 studies [24]. Thus, studies have generally failed to investigate the cooccurrence of a wide range of victimization types as well as the interaction between these multiple victimization types and subsequent psychological reactions. Taken as a whole, the present literature on child and adolescent victimization has mainly focused on singular experiences or has examined few or multiple victimizations by summing the number of types of victimization and assessing the cumulative effect of victimization in relation to adverse outcomes [29]. While this literature has made a significant and important contribution to the extant knowledge base, it does not elucidate the specific types of victimization, or combinations of types of victimization, and how these associate with adverse outcomes. The latent modeling approach of Latent Class Analysis (LCA) broadens research on cumulative counts of victimization by identifying: (1) patterns of specific types of victimization that cooccur, and (2) the risks and adverse problems associated with distinct patterns of victimization [30]. Such information may be useful in informing prevention and intervention programs. Aims and hypotheses The current study had two main aims. The first was to identify underlying groupings of adolescents based on their

Soc Psychiatry Psychiatr Epidemiol

similarity of responding across seven types of victimization. In doing so, we employed the statistical technique of LCA. LCA allows for underlying groups of individuals to be uncovered without making any a priori hypotheses about victimization histories. Prior research using LCA on victimization data uncovered two separate sexual and physical abuse classes [30]. On the basis of this relatively similar study, we could hypothesize that given our predominately sexual and physical trauma indicators, we would uncover a group of individuals who predominately endorse sexual trauma items and a group who predominately endorse physical trauma items. Likewise, based on an alternative body of work related to poly-victimization and the co-occurrence of abuse types [22], we could also hypothesize that we will uncover groups characterized by a variety of co-occurring abuse experiences. However, due to the paucity of research in this area, we did not make any predictions in relation to additional alternative groupings. Our second aim was to assess the relationship between our resultant classes and the covariates of gender, suicide attempt, and PTSD. Prior research suggests that females are more likely to experience sexually related victimization, whereas males are more likely to experience violencerelated victimization [31]. If, as proposed, we found a group of individuals who predominately endorse sexual trauma items and a group who predominately endorse physical trauma items, we hypothesized that female gender would be associated with a sexual trauma class, and that male gender would be associated with a physical trauma class. More generally, we hypothesized that classes which were characterized by multiple types of victimization would be associated with suicide attempt [32, 33] and PTSD [34, 35] compared to a class which was not characterized by victimization. On the basis of previous findings [36], we furthermore hypothesized that PTSD symptomatology and suicide attempts would be correlated.

Methods Participants A convenience sample1 of two hundred and sixty-nine Greenlandic students was selected from four schools; two state secondary schools, one high school, and one boarding

Table 1 Descriptive statistics and victimization experiences from Greenlandic adolescents N

%

269

100

Mean age (SD)

15.4 (1.84)

/

Sex (girls/boys) (n = 265)

151/114

56.1/42.4

Participants

School Boardingschool, Qasigianguit

67

25

GU Asiaat

105

39

State school, Aasiaat State school, Qasigianguit

54 43

20 16

Education of parents Mothers/fathers

242/222

90/82.5

9 years or less

115/119

47.5/53.6

10–12 years

53/40

19.7/18

13–15 years

46/40

17.1/18

16 years or more

28/23

10.4/10.4

Both parents

65

24.7

One parent

170

64.6

Other arrangements

28

10.6

Lives with (n = 263)

NLE frequencies (all/females/males) Physical assault

22/14/7

8.2/9.3/6.1

Rape

25/21/4

9.3/13.9/3.5

Threatened to be beaten Bullying

58/36/20 51/35/15

21.6/23.8/17.5 18.6/25.2/9.6

Sexual abuse

27/22/5

10/14.6/4.4

Physical abuse

20/13/6

7.4/8.6/5.3

Severe childhod neglect

23/12/11

8.6/7.9/9.6

Attempted suicide

50/38/11

18.6/25.2/9.6

36/29/7

17.1/24.6/7.9

a

Prevalence PTS n = 211 a

The probable PTSD prevalence rates are derived from a reduced sample size of 211 respondents who answered the PTSD measure

school. In keeping with the recommended minimum sample size of 250, the current sample size of 269 was deemed adequate [37]. The students were between 12 and 18 years old (M = 15.4, SD = 1.8). One hundred and fifty-one (57 %) participants were female. On average, there were 20 students per class. The only inclusion criterion was that the students should be within the age range of 12–18 years old. There were no exclusion criteria. (Further demographic information about the students can be seen in Table 1).

1

Please note that an earlier publication is available [45] which describes this sample in detail. This earlier publication was predominately descriptive in nature presenting event prevalences by total sample and by gender groups. Logistic regression was estimated using PTSD as a dependant variable and demographics as independent variables. Thus, the research question of the previous publication differs substantially from that of the current piece of research which identifies victimization typologies and outcome.

Procedures Prior to the study, the questionnaire package had been translated from Danish to Greenlandic by two bilingual psychologists. The study was approved by the headmasters of the four schools. The respective teachers of each class

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were informed about the purpose and objective of the study. In all classrooms, short power point presentations (15 min) were given by the first author. The objective of this presentation was to enhance the students’ understanding of the purpose of the study and the structure of the questionnaires. In all schools, except the high school, the presentation was translated to Greenlandic by a teacher. The students then filled out a questionnaire package containing questions concerning demographic variables, exposure to traumatic events, and psychological responding. The students were free to choose whether they wanted a Greenlandic version or a Danish version. The questionnaires were mainly filled out in the class room. On occasion, students were requested to sit alone in the corridor or in other more private places, to complete the questionnaire. All requests of this nature were granted. Students were informed that their answers were anonymous and that their participation was voluntary. Only one of the students chose not to participate. It was requested that students answered as truthfully as possible, despite the somewhat uncomfortable subject matter. The students spent approximately 1 h filling out the questionnaires. Due to lingual or cultural differences, teachers for each class assisted in providing translations and/or explanations of questions from the students. The students were informed of several local helplines to call if they needed to talk to someone after filling out the questionnaires. In addition, they were given contact information of the first author in case they needed additional help in any way. No contact has been made up to the time of writing. The study was ethically approved by the national research ethical committee of Greenland. Measures The first part of the questionnaire contained questions about demographic variables such as gender (0 = males, 1 = females), age, living arrangements (living with one parent, living with both parents, other arrangements), and parents’ education [state school (9 years of education), high school or similar (10–12 years of education), Bachelor’s Degree or similar (13–15 years of education), Master’s Degree or similar (16? years of education)]. Parent’s education was chosen as a rough measure of socioeconomic status. More detailed socioeconomic information was not queried given that other studies (e.g., [38]) have shown that adolescents’ knowledge of their parents’ income and occupational status is limited and thus not reliable. The last part of the questionnaire contained a list of 19 potentially traumatic events (PTEs) and negative life events (NLEs): (1) traffic accident, (2) other serious accidents, (3) physical assault, (4) rape, (5) witnessed other people being injured or killed, (6) came close to being

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injured or killed, (7) threatened to be beaten, (8) neardrowning, (9) suicide attempt, (10) robbery/theft, (11) pregnancy/abortion, (12) serious illness, (13) death of someone close, (14) divorce, (15) CSA, (16) physical abuse, (17) severe childhood neglect, (18) humiliation or persecution by others (bullying), and (19) absence of a parent. Students were asked to point out which of these events they had been exposed to, and which they had witnessed or heard about someone else being exposed to. In the introduction of the study, which was made by the first author, the distinction of direct and indirect exposure was explained, but the 19 NLEs were not defined or elaborated further before or during the study. This list of events was selected on the basis of prior research and clinical experience [39], covering both events that meet the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) A1 Criterion [40], and alternative NLEs. These NLEs were included given intense negative experiences in the family environment can be associated with traumatic responses in adolescents [8]. Psychometric data are not yet available for the PTE items, but data from prior studies [34, 39, 41–46] support the frequency with which these events are experienced by youths across nations and cultures and their potentially traumatizing effects [34]. It is likely that the use of the event list may be advantageous as it promotes recognition rather than recall, which is less distressing in the report of emotionally stressful events [47]. Furthermore, the anonymity of self-report questionnaires may have made it easier for the students to report taboo-related subjects compared to an interview. Although the event questionnaire has not been validated, it seems to function well across cultures [34]. Although the original survey included 19 PTEs, the present study only included a reduced number of these PTEs. The main focus of the article was PTSD, suicide attempts, and gender. The seven chosen victimization types (see Fig. 1) have been found to have some of the strongest links to these covariates [31], providing a strong rationale for using the seven chosen PTEs rather than all 19 PTEs.

The Harvard Trauma Questionnaire Part IV (HTQ) The HTQ [48] was used to estimate the level of present PTSD. The HTQ consists of 31 items, out of which the first 17 correspond to the PTSD symptoms in the DSM-IV. The items were scored on a 4-point Likert scale (1 = not at all, 4 = extremely). Given that diagnostic interviews were not performed with the participants, they were not fully diagnosed; therefore, the PTSD cases referred to in the current study are cases of probable PTSD. The HTQ-IV measures the intensity of three symptom groups of PTSD: Reexperiencing (criteria B), Avoidance/numbing (criteria C)

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Fig. 1 Profile plot of three victimization classes. Class 1 = physical assault, threats of violence, neglect, and humiliation or persecution from others class; class 2 = rape, threats of violence and sexual abuse class; class 3 = baseline class

and Hyperarousal (criteria D). To meet the diagnostic criteria for PTSD, it is necessary to have at least one symptom from the re-experiencing symptom cluster, three or more symptoms from the Avoidance/numbing symptom cluster, and two or more symptoms from the Hyperarousal symptom cluster. Good validity and reliability on the HTQ has been reported cross-culturally [48, 49]. Despite this however, it still appears that certain items may carry different meanings across cultures. For instance, the item referring to ‘‘not being able to remember the traumatic experience well’’ has been shown to have low item-total correlations cross-culturally [49]. The internal consistency of the scale was acceptable with a Cronbach’s Alpha of 0.95 for the total scale and 0.73, 0.81, and 0.80 for the Re-experiencing, Avoidance/numbing, and Hyperarousal subscales, respectively. This is consistent with the internal consistency of the HTQ scale in similar studies from Denmark and Iceland where the Cronbach’s Alphas of the total scale was reported to be 0.90 and 0.97, respectively, and the Cronbach’s Alphas of the subscales was reported to be 0.74,

0.79, 0.78 and 0.79, 0.84, 0.85 for the Re-experiencing, Avoidance/numbing and Hyperarousal subscales, respectively [39, 41].

Analysis The current LCA was based on binary data from adolescents from Greenland who answered questions in relation to a series of PTEs. The LCA was based on adolescents’ experiences of seven victimization types, including but not limited to, CSA, physical abuse, and bullying (humiliation/ persecution by others) (See Table 1). LCA assesses if underlying heterogeneous sub-groups exist within a single homogeneous sample. In other words, LCA uncovers groups of individuals based on their similarity of responding across a number of binary indicators. Therefore, in the current analysis, this exploratory and iterative model building technique created groups of adolescents based on similar PTE histories. LCA is iterative in that a

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series of latent class models are specified and estimated. In the current analysis, we specified and estimated two to five latent classes. Haagenars and McCutcheon [50] reported that probable membership of a latent class (posterior probabilities) is deemed by estimating the prevalence of each class while simultaneously estimating specific item endorsement probabilities. The former parameter is termed class probabilities and the latter is termed item probabilities. Several fit indices are consulted, in addition to consideration for parsimony and substantive meaning, to determine which latent class model, from the two-class to five-class solution, is an optimal fit to the data. In the current study, we consulted the Akaike Information Criteria (AIC) [51], the Bayesian Information Criterion (BIC) [52] and the sample size adjusted BIC (SSABIC) [53], in addition to consideration of the Entropy value [54] and the Lo–Mendell–Rubin adjusted likelihood ratio test (LRT) [55]. Better fitting models are indicated by lower values of the AIC, BIC and the SSABIC. Yang [56] reported that the best single fit indice for optimal model selection is the SSABIC. Clearer classification in any given model is indicated by entropy values which reach 1. A non-significant LRT indicates that a latent class model with one less class may be the more parsimonious option. Once the optimal class solution was established, multinomial logistic regression was implemented using the covariates of gender, suicide attempt, and PTSD. All analyses were conducted using Mplus version 6 [57].

Table 2 Fit indices for latent class models two to five

2C

AIC

BIC

SSABIC

Entropy

1,228.634

1,282.554

1,234.994

0.747

LRT (p) 133.678 0.0000

3C

1,224.949

1,307.627

1,234.703

0.807

4C

1,228.031

1,339.467

1,241.177

0.888

19.254 0.0455 12.636 0.3319

5C

1,231.269

1,371.462

1,247.807

0.880

12.483 0.3155

6C

1,236.583

1,405.534

1,256.514

0.896

10.452 0.3540

AIC Akaike information criterion, BIC Bayesian Information Criterion, SSABIC sample size adjusted BIC, LRT (p) = Lo–Mendell– Rubin adjusted LRT value and associated significance level

Table 3 Frequencies of the seven victimization types across and within classes Class 1 (11.9 %)

Class 2 (12.6 %)

Class 3 (75.5 %)

Physical assault

13 (40.6 %)

6 (17.6 %)

Rape Threats of violence

0 22 (68.8 %)

21 (61.8 %) 14 (41.2 %)

3 (1.5 %)

Physical abuse

10 (31.3 %)

10 (29.4 %)

0

CSA

0

27 (79.4 %)

0

Neglect

15 (46.9 %)

8 (23.5 %)

Bullying

21 (65.6 %)

13 (38.2 %)

4 (2 %) 22 (10.8 %)

0 17 (8.4 %)

Results Table 1 reports demographics, frequencies of the seven victimization types, endorsement rates of suicide attempt and the prevalence of probable PTSD in the current sample. LCA Latent class models consisting of two to six classes were specified and estimated in Mplus 6. The corresponding fit indices are presented in Table 2. The AIC value and the SSABIC value were lowest for the three-class solution, whereas the BIC value was lowest for the two-class solution. The LRT value becomes non-significant for the four-class solution suggesting that the three-class model may be more parsimonious. The three-class solutions’ entropy value (0.807) indicated clear classification, compared to the two-class solution. Taking all fit indices into consideration and based on Yang’s [56] recommendation that the SSABIC is a superior indicator of fit, the three-class solution was deemed the preferred option in the current study.

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The majority of respondents were classified into class 3 (71.7 %) which was characterized by individuals who had low probabilities of endorsement of all victimization types and thus can be referred to as the baseline/normative class. Class 2 (15.3 %) was characterized by individuals who had the highest likelihood of endorsement of most victimization types but in particular had high probabilities of endorsement of rape, threats of violence, and CSA compared to alternative victimization types. Class 2 will therefore be referred to as the rape, threats of violence and CSA class. Class 1 (13.0 %) was the smallest of all three classes and was characterized by relatively high probabilities of endorsement of physical assault, threats of violence, neglect, and humiliation or persecution from others in comparison to alternative victimization types. Class 1 will therefore be referred to as the physical assault, threats of violence, neglect, and humiliation or persecution from others class. The frequencies of the victimization types across classes are presented in Table 3. The profile plot indicating the probability of endorsement, across each of the three classes, for each victimization type, is presented in Fig. 1.

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Logistic regressions Logistic regression was conducted using the covariates of gender, suicide attempt, and PTSD to determine if individuals of female gender, those who reported attempting suicide, and those who met the diagnostic criteria for PTSD would be more likely to be members of classes 1 and 2 compared to the baseline class; class 3. Individuals who reported having previously attempted suicide were significantly more likely to be members of class 1 (OR = 5.97, CI = 2.34–15.22) and class 2 (OR = 3.87, CI = 1.57– 9.49). In addition, individuals who met the diagnostic criteria for PTSD were significantly more likely to be members of class 1 (OR = 5.09; CI = 2.09–12.39) and class 2 (OR = 5.09; CI = 2.08–12.44). Meeting PTSD diagnostic criteria was associated with both class 1 and class 2 to the same degree. No significant associations were found between classes and gender. PTSD and suicide attempts Of the participants (n = 87) who did not report any PTSD symptoms, 8 (9.2 %) reported having attempted suicide. Of the participants (n = 58) who met the diagnostic criteria for one of the PTSD symptom clusters, eight (13.8 %) reported having attempted suicide. Of the participants (n = 30) who met the diagnostic criteria for two of the PTSD symptom clusters, six (20 %) reported having attempted suicide. Of the participants (n = 36) who met the full diagnosis for probable PTSD, 16 (44.4 %) reported having attempted suicide.

Discussion This study aimed to model the PTE histories of Greenland adolescents. A LCA on PTEs revealed that three heterogeneous classes best represented victimization histories of Greenlandic adolescents. Latent classes were based on data from seven victimization experiences which have been previously strongly linked to suicide attempts and PTSD; (1) physical assault, (2) rape, (3) threats of violence, (4) CSA, (5) physical abuse, (6) neglect, and (7) bullying. The three resultant latent classes varied both quantitatively and qualitatively. In other words, the classes differed quantitatively across all victimization variables and differed qualitatively as the probability of endorsement for items did not uniformly increase or decrease across classes. One of the victimization classes was characterized with sexual experiences (i.e., Rape and CSA; albeit in addition to other victimization experiences) and the other was characterized by victimization experiences which were predominately of a physical or violent nature in the absence of sexual

victimization experiences. Thus, although class 1 and class 2 can be differentiated by their endorsement probabilities of sexual experiences, there was not a great deal of variation in the endorsement probabilities of physical/violent experiences, and thus the distinction between the classes was not as clear cut as proposed in Nooner et al. [30]. Since classes 1 and 2 were both characterized by multiple victimization experiences, these findings support the views of Mullen et al. [58] that ‘‘children who are victims of one form of abuse are more likely to also experience other forms of abuse’’. None of the classes were predominately or only characterized with sexual experiences. In class 2, rape and CSA were highly prevalent but so were threats of violence and bullying. This suggests that adolescents, who experience CSA and/or rape, often experience multiple other victimization types that in turn may affect them negatively. From a clinical perspective, this means treatment which is solely directed at dealing with sexual victimization issues may be insufficient as it only deals with a part of the problem. Suicide attempts and membership of classes In accordance with our hypotheses, the likelihood of membership in class 1 and class 2 compared to class 3 was significantly increased for those individuals who reported having previously attempted suicide. The strong relationship between the victimization classes and suicide attempts compared to the baseline class suggests that the victimization experiences may have caused a vulnerability which increases the likelihood of suicide attempt compared to their peers who have experienced only a few, or no, victimization types. Our results are consistent with several studies that highlight the association between childhood abuse and chronic self-destructive acts and suicidal behaviors [59, 60]. The association between suicide attempt and class 1 was stronger than that reported for class 2 (indicated by higher odds ratios) suggesting that the higher prevalence of neglect, threats of violence, persecution or humiliation by others, and physical assaults in combination is more likely to lead to suicide attempts than the more moderate prevalence of these victimization types in addition to rape and CSA. The literature on the relationship between different victimization types and suicidal behavior is mixed. Brown et al. [61], and Fergusson et al. [62] found that CSA was more strongly associated with suicide attempt risk than physical abuse or neglect, suggesting, that between 9 and 20 % of all those who attempt suicide have a history of CSA. This would lead us to believe that the association between suicide attempt and class 2 should have been stronger than the association between suicide attempt and class 1; however, others have found that victims of physical

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abuse and CSA have a similar risk of suicidal behavior [63]. One possible explanation for the increased odds ratios as they relate to class 1 and suicide attempt may relate to the frequency, duration, and intensity of the victimization experienced. We did not examine these characteristics, and so it is plausible that individuals in class 1 have more severe abuse histories than those in class 2, despite the fact that those in class 2 endorse a greater number of experiences. It is also plausible that individuals in class 1 have been subjected to additional risk factors. Notably, the subjects in class 1 had a higher probability of endorsing the experience of severe childhood neglect compared to those in class 2. Severe childhood neglect is a typical characteristic of a dysfunctional family, and therefore negative experiences in relation to childhood neglect, will most often be experienced repeatedly and continuously by the child. Neglect is often correlated to several other negative variables such as substance abuse, poverty, lower education level of the parents, and other adverse life circumstances [64]. The continuous strain that often accompanies severe neglect may therefore in turn be more damaging than the experiences that are characteristic for class 2. PTSD and membership of classes The development of PTSD has frequently been linked to CSA and physical abuse [65], and sexual and physical assaults [66]. In concordance with this, individuals from class 1 and 2 were over five times as likely to meet the criteria for PTSD compared to the baseline class. Notably, individuals with a probable PTSD diagnosis were equally likely to be members of class 1 and 2 compared to class 3, thus suggesting that the combinations of victimization types in each other class were equally traumatizing. Given that many studies find that CSA, sexual assaults, and especially rape are traumas more likely to precipitate PTSD compared to physical victimization, one may have expected that the likelihood of experiencing PTSD would have been increased for members of class 2. Indeed, it is also a common finding that multiple trauma exposure increases the risk of developing PTSD [65] again suggesting that the likelihood of experiencing PTSD would have been increased for members of class 2 given that they endorsed a greater number of PTEs. Two potential explanations of why both class 1 and class 2 were equally traumatizing in the current study are possible. First, as discussed above, albeit that individuals in class 2 report experiencing a greater number of PTEs including sexual experiences perhaps such experiences occurred less frequently, over a shorter duration, and with less intensity compared to those of individuals in class 1. Thus, the traumatizing effects of the varying trauma types may have been balanced out. Second, there may be a threshold effect in relation to

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multiple trauma exposure. In other words, although the experience of multiple traumas has been shown to be more detrimental than the experience of one trauma, perhaps there is a cut-off where the damaging effect of multi victimization peaks. Examining the difference between the explanatory power of specific single traumatic experiences versus different clusters of multiple traumatic experiences in PTSD may thus be a very interesting future research trajectory. PTSD and suicide attempts In accordance with previous findings which report an association between PTSD and suicide attempt [36], PTSD appeared to be concordant with suicide attempt in the current study. Indeed, our data show that the more PTSD symptoms the participants reported (indicative of meeting the diagnostic criteria for 1, 2, and 3 PTSD symptom clusters), the higher the proportion of participants who had attempted suicide. Although the data do not provide information on the direction of the causality, it seems plausible that PTSD in some ways exacerbates the risk of suicide attempt post-victimization, so that the risk of attempted suicide gets remarkably higher, the more PTSD symptoms the victims display. Gender differences Surprisingly, being a female gender did not significantly increase the likelihood of membership in class 2 which was characterized by multiple PTEs including those of a sexual nature. This finding was contrary to our hypothesis, given that it is a common finding that experiences of rape and CSA are more prevalent in girls than boys. Indeed, large sample studies have consistently reported higher prevalence rates of CSA in girls than in boys [67] as well as higher prevalence rates of rape and sexual assaults in girls than in boys [68]. This is also the case in Greenland [2, 45]. It is also somewhat surprising that male gender was not a significant predictor of group membership in class 1 which was predominately characterized by physical/violent PTEs. Boys are usually over-represented among children registered for physical abuse and violence-related experiences. However, among older, teenage children, a large national British survey reported that more girls than boys were registered for physical abuse [69]. A possible explanation may therefore be that the boys are more often physically abused and punished in their younger years, while the girls are more exposed to physical punishment than the boys in their teenage years and thus the gender differences are evened out in adolescence. Unfortunately, as we did not inquire about the age at time of victimization experiences, we can only speculate on this matter. Certain cultural

Soc Psychiatry Psychiatr Epidemiol

circumstances may also be attributable to this finding. Indeed, data suggest that sexual abuse and rape is over three times more prevalent in Greenlandic adolescent males than in Danish, Icelandic, and Lithuanian adolescent males [39, 41, 42] and that violence-related experiences are more common among Greenlandic girls than girls from many European and Asian countries. Indeed, a study on violence among Greenlandic people, reported a very high prevalence of violence-related experiences among young women (58.8 % reported experiences of violence in their lifetime and 21.1 % reported violence within the last year) [2]. The prevalence in this study was also high compared to the males. In the present study, 23.8 % of the girls vs. 17.2 % of the boys had been threatened to be beaten, 9.3 % of the girls vs. 6.1 % of the boys had been exposed to physical assault, and 23.2 % of the girls vs. 13.2 % of the boys had been exposed to humiliation or persecution by others. In a range of epidemiological studies from multiple countries, the reported prevalence of violence-related experiences was lower than the prevalence among Greenlandic girls, and the prevalence was most often higher among the boys than the girls [34, 42, 49]. Thus, Greenlandic girls indeed seem to be more vulnerable to experiences of violence compared to both girls and boys from other countries.

implies that examining PTSD symptomatology is essential in clinical assessments of adolescents.

Implications

Conclusion

As would be expected, the majority of the adolescents (71.7 %) were in the baseline class with few or no victimization experiences. However, almost a third of the adolescents reported being exposed to multiple victimization experiences. This prevalence is very high compared to previous research reporting co-occurring experiences of victimization [24, 26]. This may be attributable to methodological differences. However, since the Greenlandic society has been associated with high rates of alcohol abuse, violence, suicide attempts, and sexual abuse [1–4], the family environment of Greenlandic children and adolescents may also likely explain some of the higher prevalence of multiple victimization experiences. Given that multiple victimization has been found to be significantly more damaging than single victimization experiences, this is a matter of great concern. Thus, the high rate of Greenlandic adolescents who experience multiple victimization in addition to the known association between multiple victimization experiences, PTSD, and suicide attempts, calls for immediate attention on the living conditions of Greenlandic children and adolescents. The high association between PTSD symptomatology and suicide attempts also calls for attention, and indicates that victimized adolescents who display many PTSD symptoms are at a particular risk of attempting suicide. This in turn

The LCA revealed three distinct classes. Two of which endorsed multiple victimizations; one of the victimization classes was characterized with sexual experiences and the other was not, whereas a third class was deemed a normative baseline class given its low endorsement across all seven victimizations. In accordance with our hypotheses, the likelihood of membership in class 1 and class 2 compared to class 3, was significantly increased for those individuals who reported having previously attempted suicide and those who met PTSD diagnostic criteria. No significant associations were found between classes and gender. The association between suicide attempt and class 1 was stronger than that reported for class 2. Individuals from class 1 and 2 were over five times as likely to meet the criteria for PTSD compared to the baseline class. Two interpretations were suggested: (1) the two combinations of victimization types are equally traumatizing (2) Multiple trauma exposures rule out the influence of specific differences between trauma types. Furthermore, we found a strong relationship between PTSD symptomatology and suicide attempts. This finding is particularly important in clinical practice. The present study underlines the complexity of the interplay between multiple victimization experiences, traumatization, and suicide attempt.

Limitations There are several limitations to this study. The primary limitation is that the study is based only on students’ selfreports. This could have produced a response bias. Further, it is possible that there was a certain degree of variation in participants’ understanding of the specific victimization items; this variation results from the definitions of victimization types not being further elaborated on for the students. It is another limitation that the teachers were present in the classroom while the students were filling out the questionnaires and that there was no neutral Greenlandic-speaking person present. Furthermore, because a convenience sample was used, the representativeness of the sample is questionable. As alluded to earlier, the current study did not examine at what age the victimization was experienced, and we did not examine the frequency, duration, and intensity with which events were experienced. Also, only a single item was used to measure attempted suicide. However, the present study highlights the importance of gathering such information in studies of victimization.

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Soc Psychiatry Psychiatr Epidemiol Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. 17.

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