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Abstract
Childhood trauma continues to be a problem psychosocially, medically, and as well as in the realm of public policy (De Bellis & Ziskm 2014). The Childhood Trauma Questionnaire (CTQ) was developed by Bernstein and Fink (1998) and has been widely used in research relevant to stress, depression, and substance use. The current paper discusses the development of the CTQ, the psychometric properties of the tool, the use and applicability in research, ethnocultural factors that need to be considered, and ethical consideration that are relevant to the tool. Finally, this paper concludes with other considerations to be aware of for future research.
Literature Review
Understanding how experiences impact mental health is key to identifying the severity of their current mental health status, the relationship between the event(s) and presenting mental health issue(s), and the plan to treat the client accordingly. However, understanding the impact of these experiences and the time in which they occurred during an individual’s life can allow a clinician (and researcher) to draw conclusions about how such events impact one’s health. Perry and Pollard (1998) stated that having an understanding of the nature, pattern, and timing of an individual’s experiences can influence subsequent functioning. They further claim that children respond to traumatic experiences and are affected by them in a variety of ways that can be expressed at various timepoints in their lives. Brain function and organization dependent on developmental and environmental experiences that get expressed by genes (Perry & Pollar, 1998; Teicher, 2000, 2002). Additional research conducted by Teicher, Samson, Anderson, and Ohashi (2016) identified physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect can have significant effects on the brain development of children which can be credited for adult psychopathology.
Goodman, Quas, Goldfarb, Gonzalves, and Gonzalez (2019) suggest traumatic events can affect long-term memory and accuracy depending on the impact imposed on an individual. The authors highlight two models related to adverse childhood experiences and the impact on human memory. The impairment model, which states that maltreatment is associated with deficits/distortions in both cognitive and socioemotional processes and also causes changes and/or impairments in neurobiology (Loman & Gunnae, 2010) and brain development (Teicher et al., 2003) might also impact memory. The second model, the conditional adaptation model, argues that maltreatment during childhood leads to “specialized mental functions” to be able to respond to threating and stressful environments (Ayoub & Fischer, 2006; Frankenhuis & de Weerth, 2013). However, it is stated that these specializations do not alter associative processes that affect memory but instead lead to heightened awareness and attention. Goodman and colleagues examined age of maltreatment, type of abuse, traumatic impact, attachment, and psychopathology as predictors of long-term memory. They concluded that the greater the traumatic impact that was experienced, the more accuracy the individual displayed in recalling the event(s). However, the authors noted that developmental factors, individual differences, and interviews moderate the effects of childhood trauma on adulthood memory accuracy related to the event(s).
Adverse childhood experiences have long been associated with individuals who are substance users and/or suffer from addictions. According to Dube and colleagues (2003), it was concluded that for each adverse childhood experience increase, the likelihood for early drug use initiation increased by a factor range of two to four times. The researchers also found evidence suggesting adverse childhood experiences were also associated with parental drug use. Participants with no adverse childhood experiences reported less illicit drug use problems, addiction to drugs, and parental drug use. When comparing participants with no adverse childhood experiences to those with 5 or more adverse childhood experiences, individuals with 5 or more adverse childhood experiences were more likely to report illicit drug use, addiction to drugs, and parental drug use. As a result, the researchers concluded that adverse childhood experience scores had a strong relationship with early drug initiation from childhood to adulthood, drug addiction, and parental drug use.
The Development of the CTQ. Bernstein and colleagues (1994) aimed at creating, testing, and validating a measure that would measure child abuse and neglect retrospectively. According to the authors, participants (n = 286) were identified as being drug or alcohol dependent patients. As mentioned in the literature review, individuals who underwent adverse childhood experiences have been strongly associated with drug use and addiction. Kandel (1998) found evidence suggesting drug use initiation tends to occur during the adolescence time period of development. Thus, Bernstein and colleagues were targeting a group of people in which were becoming increasingly studied to help understand a phenomenon.
To adequately draw conclusions from the 286 participants, the CTQ was administered as part of a battery of tests. Forty patients who were involved in the study were given the CTQ at subsequent months after their initial completion, while a total of 68 patients underwent the Childhood Trauma Interview. The Childhood Trauma interview, an interview created by the authors, is a structured interview in which child abuse and neglect is of focus.
The Psychometric Properties of the CTQ. After completing data collection, the data suggested four factors existed in the CTQ. The four items that were initially identified were physical abuse, emotional abuse, sexual abuse, and physical neglect. At this point in time, emotional neglect had not yet been established in the initial version of the CTQ, nor had the three additional minimization questions been established as a part of the measure. The addition of the emotional neglect subscale and the three minimization questions would eventually be established in the final version that was published in 1997. In addition, the CTQ yielded strong test-retest reliability (intraclass correlation = 0.88) for the 40 patients who were given the CTQ after their initial completion. Furthermore, convergence between the CTQ and the Childhood Trauma Interview was strong and was indicative of strong stability over time between the CTQ and the Childhood Trauma Interview. The authors concluded there was strong initial support for the CTQ.
The CTQ in which would eventually be published in 1997 by Bernstein and Fink would undergo more additions and testing. The published version of the questionnaire currently has a total of 28 items. Emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect each consist of five items. Each item-response is based on a five-point Likert-type scale ranging from Never True to Very Often True. The scores of each item are then summed to create an overall index score. The total score ranges from five to 25, with a score of 25 being the high score possible and indicating sever maltreatment. According to the testing guidelines, an individual’s scores can be compared to other data which is supplemented with examples to aid in interpreting scores.
The three items remaining in the 28-item measure is known as the Minimization/Denial Scale. These three items are intended to pick up on underreporting of maltreatment or false negatives. It is suggested that these items are going to be made apparent when there are low trauma scores. To understand these items in relation to the measure itself, the testing guidelines for the CTQ states that for each item (of the specific 3 items), each time the items are rated as Very Often True (the highest score possible for each item), a single point is given to each of them. As such, this three-item scale has scores ranging from zero to three. The testing guidelines provide detailed instructions as to how these scores should be handled should a person score a one, two, or three. Additional data would be needed to understand if abuse and neglect truly are/were absent or not.
Cut-off scores were established after validating the measure and subsequently testing the measure among a randomly selected “normal” sample of female members. There were four classifications that were established: none (or minimal), low (to moderate), moderate (to severe), and severe (to extreme). The measure would undergo further testing to establish norms. According to the Pearson Website (n.d.), the sexual abuse subscale has an internal consistency ranging from 0.93 to 0.95. The emotional neglect subscale has an internal consistency of 0.88 to 0.92. The emotional abuse subscale has an internal consistency of 0.84 to 0.89. Finally, the physical abuse subscale has an internal consistency ranging from 0.81 to 0.86. No internal consistency coefficients are reported for the physical neglect subscale, according to the Pearson website. The site states the test-retest coefficient over a three-and-a-half-month period of time is approximately 0.80. Finally, the site states that the factor analysis for the five-factor CTQ model demonstrates good validity due to the model showing structural invariance.
To further understand the psychometric properties of the CTQ, the measure has also been used in a community sample. Previous research has largely focused on clinical samples. However, Scher, Stein, Asmundson, McCreary, and Forde (2011) applied the CTQ in a community sample to understand the psychometric properties and establish norms for this measure in a non-clinical sample. In this study, Scher and colleagues had a combined total of 1,007 male and female responders from the state of Tennessee. The age range of the sample was 18 – 65. Six hundred thirty-seven responses came from females. Of particular interest (but to little surprise), only five participants identified as Hispanics, and only seven participants identified as Asians. A total of 428 participants identified as Black and 539 identified as White. Participants were recruited via a random digit generator as they were contacted by phone. Consistent with Bernstein and Fink’s model, Scher and colleagues also yielded a five-factor model. The measure yielded strong internal consistency (α = .91), consistent with the internal consistency of the CTQ applied in clinical samples. The sexual abuse subscale had an internal consistency of 0.94. The emotional neglect subscale had an internal consistency of 0.85. The emotional abuse subscale had an internal consistency of 0.83. The physical abuse subscale had an internal consistency ranging from 0.69. Finally, the physical neglect subscale had an internal consistency of .58. Internal consistency discrepancies clearly exist for the emotional abuse and physical abuse subscale in relation to the community sample. Overall, however, Scher and colleagues suggested the CTQ was a reliable tool not only for clinical samples but also non-clinical samples.
Uses in Research. As mentioned in the literature review, there is a strong need to characterize childhood stress and understand the impacts it has on an individuals’ neurobiological make-up, cognitive development, social development, and substance use patterns, especially as environments continue to evolve as well as individuals. Dr. Byron Adinoff, an established stress, and addiction psychiatrist and researcher, led a group of researchers to investigate stress and childhood trauma/adversity in a group of male alcohol-dependent veterans. The CTQ was one of the measures used in the research study. According to their findings, the data suggested that childhood trauma was a significant predictor of drinking severity in alcohol-dependent males and was magnified when stress was ongoing. As such, it was concluded that early childhood trauma and adversity may, in fact, sensitize stress-response systems (Eames et al., 2014).
Zarrati, Bermas, and Sabet (2019) aimed to investigate the mediating role of what they defined as mental pain in the relationship between childhood trauma and suicidal ideation. A total of 371 students at a university in Tehran, Iran were recruited to participate in the study. As part of the study, participants completed the CTQ, the mental pain scale of Orbach and Mikulincer (OMMP), and the Beck suicide ideation scale (BSSI). Based on their analyses, the authors concluded that childhood trauma had both direct and indirect influences on suicidal thoughts through what was defined as mental pain. However, the authors made a clear distinction that their sample were students. Thus, it was suggested in their study to examine a clinical sample to identify if results hold true.
The CTQ has also been used to study adolescents in Turkey. Turan and Tras (2017) recruited participants in grads nine through 12, ranging 15 – 18 years of age. In all, there were a total of 567 students participating in the study. Specifically, the researchers were interested in understanding the relationship between traumatic experiences during childhood and the participants’ perceived social support. In conjunction with the CTQ, the Scale of Perceived Social Support was also used. The data suggested significant differences existed in the physical, emotional, and sexual abuse subscales such that male students experienced higher scores in comparison to females – inconsistent with other prior research. Additionally, the researchers also concluded that those who have experienced physical, emotional, and sexual abuse had lower perceptions of social support compared to those who had not experienced such abuse.
As shown in the previous parts of this review, the use of the CTQ has been applied in various types of groups (clinical vs. non-clinical) and across people worldwide. Because of the strength of this measure, the need to adapt the CTQ became apparent. Thus, the measure was translated into various languages such as German, Spanish (Spain), Portuguese (Brazilian population), Italian, and French. Hernandez and colleagues (2013) aimed to validate the CTQ in Spanish (Spain). Participants were 185 inpatient and outpatient females. The age range for the participants was 18 – 65 years with a mean age of about 41 and were recruited at various mental health facilities throughout Reus, Spain. For the purposes of validating this measure in Spanish, the CTQ was translated into Spanish and was then back translated and was verified by master-level and PhD-level psychologists along with psychiatrists. The researchers conducted a CFA which yielded strong fit indices in support of the CTQ translated into Spanish, mirroring the original 28-item CTQ in English. Reliability for the CTQ-Spanish were comparable to the original version. However, it should be noted that the validation of the CTQ-Spanish was strictly used in a sample of Spaniard females. The researchers did not specify if the measure was applicable to other Spanish-speaking populations such as Spanish-speaking Latinos.
Ethnocultural Factors. Thombs and colleagues (2007) later analyzed data previously collected and published by Scher et al., (2001). Specifically, Thombs et al. sought to understand if childhood trauma/adversity differed between black and white participants in the Memphis sample. Specifically, the physical, emotional, and sexual abuse scales of the CTQ were examined for this particular analysis. After controlling for total physical abuse scale scores, Thombs and colleagues concluded that black participants were significantly more likely to report being punished with a physical object as compared to whites. However, data suggested that whites were more likely to have been hit to the point of marks appearing on their skin, were likely to have been hard enough for someone else to notice, and were more likely to believe they had been physically abused as compared to blacks. Thus, the authors concluded
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