Factor structure and reliability of the Childhood Trauma Questionnaire in a Canadian undergraduate student sample

Child Abuse & Neglect 28 (2004) 889–904

Factor structure and reliability of the Childhood Trauma Questionnaire in a Canadian undergraduate student sample Sandra C. Paivio∗ , Kenneth M. Cramer Department of Psychology, University of Windsor, Windsor, Ont., Canada N9A 3P4 Received 1 March 2003; received in revised form 20 December 2003; accepted 17 January 2004

Abstract Objective: The aims of this study were to examine (1) the psychometric properties of the Childhood Trauma Questionnaire [CTQ; Bernstein, D., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., Sapareto, E., & Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal of Psychiatry, 151, 1132–1136; Bernstein, D., & Fink, L. (1993). Manual for the Childhood Trauma Questionnaire. Unpublished manuscript. Bronx, NY: VA Medical Center] in an undergraduate sample and (2) the prevalence of abuse and neglect in this sample. Method: Principal components analyses (PCA), coefficient alpha, and correlations were used to analyse data for 470 undergraduate students from a mid-western Canadian university. Cut-offs from a short-form of the CTQ [Bernstein, D., & Fink, L. (1998). Manual for the Childhood Trauma Questionnaire. New York: The Psychological Corporation] were used to estimate prevalence. Results: PCA yielded a five-factor solution comprised of emotional, physical, and sexual abuse, as well as emotional, and physical neglect. All factors, except physical neglect, demonstrated good internal consistency and test-retest reliability. This factor structure largely replicated results reported for an adolescent clinical sample [Bernstein, D., Ahluvala, T., Pogge, D., & Handelsman, L. (1997). Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 340–348], with the exception of the physical neglect factor which was comprised of considerably different items. Rates of childhood trauma were largely comparable to those reported for community and student samples in more densely populated regions of North America.

∗

Corresponding author.

0145-2134/$ – see front matter © 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.chiabu.2004.01.011

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Conclusions: The CTQ appears to be a valid measure of abuse and neglect in student samples, although experiences are somewhat differentially identified as different types of abuse and neglect depending on age and patient versus nonpatient status. © 2004 Elsevier Ltd. All rights reserved. Keywords: Childhood trauma; Measurement; Psychometrics; Prevalence

Introduction The purpose of the present study was to examine the factor structure and reliability of the Childhood Trauma Questionnaire (CTQ; Bernstein et al., 1994; Bernstein & Fink, 1993) in a sample of undergraduate students. The CTQ is a promising measure of diverse childhood experiences, but little is known about its psychometric properties in nonreferred student groups. A second and related purpose was to assess the prevalence of childhood abuse and neglect in this student sample which was drawn from a distinct region of North America. Information on local and regional prevalence can contribute to research on the sociocultural factors involved in different types of childhood maltreatment. Despite increased attention to child abuse and neglect in recent years, large numbers of children continue to be victimized by some form of maltreatment (Pilkington & Kremer, 1995). Centrally important to research on the prevalence, causes, and consequences of childhood maltreatment is the need for reliable and valid assessments of diverse childhood experiences in both clinical and nonclinical populations. The CTQ is an easily administered, retrospective, self-report questionnaire that assesses the extent of maltreatment as an interaction between the severity and frequency with which a variety of experiences occurred. In many studies a limited range of childhood experiences are assessed with most research focussing on sexual and physical abuse (e.g., MacMillan et al., 1997), even though maltreatment types are not mutually exclusive and multiple types frequently co-occur in the same family (Briere & Runtz, 1990; Rind, Tromovitch, & Bauserman, 1998). The CTQ allows for a more ecologically valid approach to studying the separate and combined effects of different types of abuse and neglect. Instructions and test items on the CTQ largely are phrased in terms of concrete, objective events and behaviors. Terms such as “trauma,” “abuse,” and “neglect” generally are avoided because these have a subjective, evaluative, and stigmatizing quality that can arouse defensiveness (Bernstein et al., 1994). Such a concrete and objective format also maximizes accuracy of recall. Research suggests that recall for childhood experience is most accurate for concrete events rather than the subjective experience of events (Brewin, Andrews, & Gotlib, 1993). As well, the researcher-defined questionnaire format used in the CTQ may be more sensitive than self-defined formats, which ask respondents whether they were abused (using that term), to less severe experiences. Silvern, Waelde, Baughan, Karyl, and Kaersvang (2000), for example, reported that, among college students, significantly less abuse was reported on selfversus researcher-defined question formats. Thus, the CTQ may be more appropriately used in research with nonclinical samples. Factor structure The CTQ demonstrated good reliability and validity in an initial evaluation study of 286 drug- or alcohol-dependent adult patients (Bernstein et al., 1994). Principal components analyses using the com-

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plete response matrix of 70 items yielded four factor scales of emotional/physical abuse, sexual abuse, physical neglect, and emotional neglect. Findings included internal consistency and test-retest reliability on all dimensions of abuse and neglect before and after approximately 3 months of treatment for the substance-dependence problem. As well, the CTQ demonstrated sensitivity and specificity when compared to assessments based on clinical interviews. Paivio (2001) and Paivio and Patterson (1999) also examined the CTQ in a study of 33 adults undergoing outpatient psychotherapy for child abuse issues. These studies used the complete 70-item questionnaire (Bernstein & Fink, 1993) and the four factor scales that emerged in the original study of substance-dependent patients described above (Bernstein et al., 1994). Paivio (2001) found that, despite significant reductions in psychopathology following therapy, reports of abuse and neglect on the CTQ remained stable from pre- to posttherapy. As well, CTQ factor scales demonstrated good internal consistency and convergent validity with trauma-specific measures of distress. In another study, Paivio and Patterson (1999) found that CTQ scores predicted therapeutic alliance development in the same sample of outpatient survivors. Severity of childhood physical/emotional abuse, physical neglect, and emotional neglect were associated with early alliance difficulties but, as predicted, these associations disappeared over the course of therapy. These findings support the predictive validity of the CTQ factor scales and sensitivity of the measure to changes over time in an adult clinical sample. Bernstein, Ahluvalia, Pogge, and Handelsman (1997) also evaluated the 70-item CTQ in a study of 298 adolescent in-patients. Results using this adolescent sample largely replicated those in the initial study of adult substance-dependent patients (Bernstein et al., 1994), except that emotional and physical abuse items loaded on separate factors. The latter permitted researchers to establish separate criteria for defining “cases” of physical, emotional, and sexual abuse. Lipschitz, Bernstein, Winegar, and Southwick (1999) also assessed the consistency of these hospitalized adolescents’ self-reports of sexual and physical abuse via the CTQ and the Traumatic Experiences Questionnaire for Adolescents (TEQ-A; Winegar & Lipschitz, 1997) which uses a multiple-choice format. They found higher rates of consistency on the CTQ compared to the TEQ-A. These researchers suggested that, because CTQ items assess a range of both severity and frequency of childhood experiences, the CTQ questionnaire may be more sensitive to less severe experiences of abuse and neglect. Again, this makes it particularly suitable for use with nonclinical groups. Overall, the above findings support the utility of the 70-item CTQ (Bernstein et al., 1994; Bernstein & Fink, 1993) in assessing maltreatment histories, at least in clinical samples. However, understanding the factors associated with child abuse and neglect also requires large-scale correlational studies of nonreferred and community groups. Much of this research is conducted using college samples. The CTQ seems ideally suited for use in such nonreferred contexts because it is easily administered, yields continuous data, and likely is sensitive to less severe types of childhood maltreatment. However, a review of the literature yielded only one study on the psychometric properties of the complete 70-item CTQ in a nonreferred context. Rosen and Lee (1996) assessed the reliability and validity of the CTQ in a sample of 1365 male and female US Army soldiers. Their findings showed psychometric properties similar to other studies that support the reliability and validity of the measure. Principal components analyses resulted in four factor scales of emotional/physical abuse, sexual abuse, physical neglect, and emotional neglect. Thus, exploratory analyses replicated the factor structure reported in the original validation study of adult substance-dependent patients (Bernstein et al., 1994), rather than the five-factor solution found for adolescents (Bernstein et al., 1997). Differ-

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ent factor structures found for adult compared to adolescent samples suggest that experiences of emotional and physical abuse, in particular, may have somewhat different meanings for these different age groups. Recently, a short version (28 items) of the CTQ has been developed based on data from seven samples, including 1187 nonreferred female HMO members and 92 male and female college undergraduates (Bernstein & Fink, 1998). This consists of five subscales of emotional, physical, and sexual abuse, and emotional, and physical neglect. Paivio (Paivio & McCullough 2004; Turner & Paivio, 2002) used the CTQ short-form to examine the links between childhood abuse and neglect and dimensions of psychopathology. CTQ scores predicted alexithymia, interpersonal functioning, and self-injurious behavior among university students, thus supporting the predictive validity of the CTQ short-form in nonclinical samples. Two recent studies of the CTQ short-form with nonclinical samples, however, found somewhat conflicting results concerning the stability of the five-factor model. Scher, Stein, Asmundson, McCreary, and Forde (2001) found that the five-factor model best described the data for a community sample, but a study of university students (Wright et al., 2001) found that the five-factor model was significantly less stable for female compared to male students. Thus, different factor structures appear to underlie the CTQ data in studies of different groups. Just as somewhat different structures were found in studies of adults (Bernstein et al., 1994; Rosen & Lee, 1996) compared to adolescents (Bernstein et al., 1997), it is possible that various experiences of maltreatment have different meanings for male and female students or for college students compared to patients. Different meanings attributed to maltreatment experiences has implications for use of the CTQ factor scales for assessing histories of different types of abuse and neglect in different contexts. Prevalence Differing definitions of abuse and neglect partly account for the variability in community prevalence estimates (Pilkington & Kremer, 1995). Sexual abuse, for example, can be restricted to contact experiences and adult perpetrators, or can include exposure to pornography or voyeurism and nonadult perpetrators. Emotional abuse and neglect can be particularly difficult to define resulting in few studies of these childhood experiences. However, even when identical definitions are employed, prevalence rates for different types of abuse and neglect continue to vary across countries, cultures, and regions. For example, there is evidence for higher prevalence of sexual abuse on the west coast of the United States compared to other regions (Dearwater et al., 1998). A recent study also found higher prevalence of physical abuse for women in rural Ontario compared to urban regions of the province (MacMillan et al., 1997). On the other hand, Yamamoto et al. (1999) tested assumptions about the infrequency of childhood physical and emotional abuse in Japan. They found much higher rates than previously estimated; rates that were comparable to those reported in the United States. Continued research on local and regional prevalence of different types of childhood trauma using standardized measures permits further study of the demographic factors that could account for regional differences or moderate the occurrence of childhood maltreatment. As well, baseline data using uniform standards can help to gage the effectiveness of local interventions and allow comparisons across communities (Wynkoop, Capps, & Priest, 1995). The present study, therefore, assessed the prevalence of different types of abuse and neglect among university students in a relatively underpopulated mid-western region of Canada.

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Method Sample The sample was comprised of 470 students in a single introductory Psychology class that was part of the research participant pool for the Psychology Department at the University of Saskatchewan. The University of Saskatchewan is located in a medium-sized (population: 200,000) city in the Canadian mid-west. It is one of two universities in a rural province of less than one million people and its mandate is to meet the post-secondary educational needs of students in the province. Demographic information for the year 2000 from the University of Saskatchewan (http://www.usask.ca/) indicated that 60% of first year students came from six small cities in the province, and the remaining 40% came from rural areas. Demographics for 429 of students in the initial testing session of the present study are as follows. The sample was 65% female, with a mean age of 19 years (SD = 3.22). They were 89% Caucasian (5% Asian, 3% Aboriginal, 1% Black, 2% mixed race), 95% single (3% married or common-law, 2% separated/divorced). Most (66%) reported an annual family income of less than $59,000 (Canadian). The subgroup of students who voluntarily returned for retesting (n = 87), and received additional course bonus points, did not significantly differ on demographic variables from those in the initial testing session. Overall, this is a relatively homogeneous sample in terms of age, education, socioeconomic status, and race. Measures The Childhood Trauma Questionnaire (CTQ: Bernstein et al., 1994; Bernstein & Fink, 1993) is a retrospective measure of the frequency and severity of different types of abuse and neglect. The original questionnaire consists of 70 items which ask clients to rate the frequency (0 = never true, 5 = very often true) with which various events took place when they “were growing up” (Bernstein & Fink, 1993). In the initial validation study of drug and alcohol dependent patients, results of factor analyses using the entire 70-item response matrix (excluding 3 validity items) yielded four empirically-derived factor scales consisting of items with loadings greater than .40 on the factor (Bernstein et al., 1994). These factors were: physical neglect (11 items, e.g., “There was enough food in the house for everyone”), emotional neglect (16 items, e.g., “People in my family didn’t seem to know or care what I was doing”), physical and emotional abuse (23 items, e.g., “I was punished with a belt, board, cord, or some other hard object,” “People in my family said hurtful and insulting things to me”), and sexual abuse (five items, e.g., “Someone tried to touch me in a sexual way or make me touch them”). A subsequent study of adolescent in-patients (Bernstein et al., 1997) largely replicated these findings with the exception that emotional and physical abuse items loaded on separate factors. Bernstein et al. (1994, 1997) reported internal consistencies for factors ranging from .79 to .96; test-retest reliabilities, before and after 3.6 months of treatment for substance dependence, ranging from .78 to .86. The CTQ also exhibited good convergent validity with measures of posttraumatic stress disorder, dissociation, alexithymia, and depression, and discriminant validity with measures of vocabulary and social desirability (Bernstein et al., 1994). More recently, the complete 70-item CTQ was reduced to a subset of 28 items. This short-form consists of five subscales (five items each) and three validity items assessing minimization/denial. Bernstein and Fink (1998) describe the subscales as follows. Emotional abuse refers to verbal assaults on a child’s sense of worth or well-being, or any humiliating, demeaning, or threatening behavior directed toward a

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child by an older person. Physical abuse refers to bodily assaults on a child by an older person that pose a risk of, or result in, injury. Sexual abuse refers to sexual contact or conduct between a child and an older person, including explicit coercion. Emotional neglect refers to the failure of caretakers to provide basic psychological and emotional needs, such as love, encouragement, belonging and support. Physical neglect refers to failure to provide basic physical needs including food, shelter, and safety. The CTQ shortform also includes three validity items assessing minimization/denial. This standardized short-form was based on the combined data from seven samples (including the above substance dependent and adolescent patients) and demonstrated excellent reliability and validity (Bernstein & Fink, 1998). As well, guidelines were established for classifying scores on each short-form subscale according to the severity of abuse and neglect. These guidelines specified the range of scores that constituted “none to minimal,” “low to moderate,” “moderate to severe,” and “severe to extreme” on each subscale. According to Bernstein and Fink (1998) these ranges were based on data from a nonclinical sample and were successful in identifying “cases” of these specific types of abuse and neglect, with therapist interview ratings as criteria. The lowest level cut scores, used in the present study (see Data Analysis section that follows) succeeded in capturing a high proportion of true maltreatment cases, including those of low severity, while misidentifying as positive an acceptable proportion (less than 20%) of nonmaltreatment cases. Procedure The present study was approved by the Research Ethics Board of the University of Saskatchewan. With informed consent, students in the initial testing session were mass-tested in a single session according to research participant pool procedures in the Psychology Department. Students were administered the 70item CTQ (Bernstein & Fink, 1993) and a demographic questionnaire as part of a battery of measures that were presented in random order. Students received bonus marks toward their course grade for completing the questionnaire package. Research participation was voluntary and researchers were not informed about numbers of students who declined to answer individual questionnaires. The 70-item CTQ (Bernstein & Fink, 1993) was readministered to those students (n = 87) who voluntarily returned for the retesting session which took place after an interval of 8–10 weeks. These participants received an additional bonus point toward their course mark. Data analysis The complete 70-item CTQ (Bernstein & Fink, 1993) was used in factor analyses. The complete 70item response matrix was converted into a covariance matrix to facilitate a confirmatory factor analysis using maximum likelihood algorithms (EQS; Bentler, 1995). This technique assesses the degree to which an expected or hypothesized factor model can effectively reproduce the observed item covariances. The feasibility of the hypothesized four-factor oblique model (Bernstein et al., 1994) and the five-factor oblique model (Bernstein et al., 1997) were assessed using the following six fit indices. The χ2 goodness-of-fit test statistic assesses the magnitude of variance unexplained by the model (so nonsignificance denotes good fit). However, this statistic is sensitive to small deviations from the hypothesized model especially when sample sizes are large (Comrey & Lee, 1992; Hu & Bentler, 1998). As a solution, fit indices that account for sample size were derived, including both the nonnormed and comparative fit indices (NNFI, and CFI; Bentler, 1990, 1995), and the adjusted goodness-of-fit index (AGFI; J¨orskog & S¨orbom, 1996). Values above .90 for each of these three indices suggest good fit. In addition, χ2 /df ratios below 2 (Cole, 1987),

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and a root mean square error of approximation (RMSEA; Rigdon, 1996) below .05 suggest well-fitting models. Failure to find a suitable confirmatory model will invite an exploratory principal components analysis (PCA) with oblique rotation to reveal the underlying factor structure of 67 items in the total scale (excluding three validity items). Both the eigenvalue-above-unity and scree plot inspection criteria will be used to determine the number of suitable factors. Unlike a regression analysis, factors will be extracted in no prescribed order and instead be extracted based on their relative proportion of explained variance in the matrix of item correlations (Tabachnick & Fidell, 2001). Items that loaded >.40 on a factor will be retained and items that load on more than one factor will be assigned to the factor with the highest loading. Internal consistencies and retest reliabilities for each of the factors will be calculated. For all analyses, the alpha level will be set at .05 (two-tailed). Because of the relative homogeneity of the sample, the effects of demographic variables on CTQ factor scores will not be examined. The subset of items that comprise the five subscales (five items each) of the CTQ short-form were used to calculate prevalence of different types of abuse and neglect. Scores above the recommended cut-score for “low” severity on each of the subscales (Bernstein & Fink, 1998) were considered cases of abuse and neglect. This criterion was chosen to emphasize test sensitivity to less severe cases, likely present in this nonreferred group.

Results Factor analyses Confirmatory analysis. For the four-factor model, results showed that the four-factor oblique model did not adequately fit the observed data: χ2 (1312, N = 470) = 5455, p < .001, χ2 /df = 4.16, NNFI = .765, CFI = .777, AGFI = .629, RMSEA = .082. Similarly, the five-factor model oblique model did not adequately fit the observed data: χ2 (1308, N = 470) = 5243, p < .001, χ2 /df = 4.01, NNFI = .777, CFI = .788, AGFI = .650, RMSEA = .080. As such, there was no evidence to support either the hypothesized four- or five-factor models. Exploratory analysis. Given that the confirmatory analysis failed to find an adequate fit to either hypothesized model, we conducted an exploratory factor analysis to determine what factor solution in fact did underlie our data. After attempting several factor extractions using the eigenvalue and scree criteria, the five-factor solution (which denoted 56 of the 67 items as relevant) was chosen for its parsimony, interpretability, and ecological validity. Separate PCA’s for males and females were not different so these data were combined. A PCA yielded five rotated factors that accounted for 53.4% of the variance among items. Data on these factors are presented in Table 1, which includes means and standard deviations, the number of items per factor, and both internal consistency and re-test reliability estimates. We compared CTQ total and factor scores for males and females. Females reported significantly higher levels of sexual abuse compared to males, t (439) = 2.00, p < .05, but no other gender differences were significant. These findings are consistnet with Bernstein et al. (1997). As rough estimates of multivariate variance (Tabachnick & Fidell, 2001, p. 915), eigenvalues were included alongside the proportion of total variance explained by each factor. The five factors were interpreted as Emotional Neglect, Emotional Abuse, Physical Abuse, Sexual

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Table 1 Factor structure and reliability of the Childhood Trauma Questionnaire in an undergraduate sample CTQ

Eigenvalue

Percent of variance

Number of itemsa

Mean

Standard deviation

Cronbach’s alpha

Test-retest reliabilityb

Emotional Neglect Emotional Abuse Physical Abuse Sexual Abuse Physical Neglect Total scale

21.20 7.35 4.10 2.43 2.33

30.27 10.50 5.86 3.46 3.33

19 15 9 6 7 56

37.04 29.51 11.61 7.22 10.87 98.63

16.77 9.23 4.41 3.74 3.80 29.13

.97 .86 .84 .92 .75 .96

.97 .96 .94 .87 .95 .85

Note. CTQ: Childhood Trauma Questionnaire. a Items with loadings >.40, based on principal-components analysis with varimax rotation (n = 407). b Intraclass correlation: retest interval: 8–10 weeks (n = 87).

Abuse, and Physical Neglect. In general, these results concerning factor structure for university students resemble previous findings for clinical and nonreferred samples (Bernstein et al., 1994; Rosen & Lee, 1996), and most closely replicate the five-factor structure reported for adolescent inpatients (Bernstein et al., 1997). In particular, 11 items were misspecified in their designation to either the four- or five-factor hypothesized models in the confirmatory analysis. Despite their deletion, a comparable five-factor model emerged by exploratory methods. Item analysis and comparative solutions We compared the test items comprising each of the factors in the present study to factor items in the initial evaluation study of adult alcohol dependent patients reported in the original CTQ Manual (Bernstein & Fink, 1993). The largest discrepancy between present results and those reported for the patients was in the items comprising the physical neglect factor. Only three of seven physical neglect items in the present study correspond to physical neglect items identified by the adult patients (Bernstein & Fink, 1993). Physical neglect items unique to the present sample referred to inadequate supervision at home, failure to ensure school attendance, and parental substance abuse, rather than living on the streets and failure to provide clothing and medical care. Similarly, only three physical neglect items in the present study are included in the five item physical neglect subscale of the standardized short-form (Bernstein & Fink, 1998). Items unique to the present sample again referred to inadequate supervision and failure to ensure school attendance. Items loading on the other factors were more consistent across studies. For example, 15 of the 19 emotional neglect items in the present study overlap with emotional neglect items in the study of adult alcohol dependent patients (Bernstein & Fink, 1993); 13 of 15 emotional abuse items overlap; 6 of 9 physical abuse items overlap; and 5 of 6 sexual abuse items overlap. Similarly, all items included in the subscales of the standardized short-form (Bernstein & Fink, 1998) loaded on corresponding factor scales in the present study. Finally, we compared CTQ total and factor scores for males and females. Females reported significantly higher levels of sexual abuse compared to males, t (439) = 2.00, p < .05, but no other gender differences were significant. These findings regarding gender are consistent with Bernstein et al. (1997).

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Table 2 Means, standard deviations, and prevalence of childhood trauma in an undergraduate sample CTQ (C)

Emotional Abuse (8) Physical Abuse (7) Sexual Abuse (5) Emotional Neglect (9) Physical Neglect (7) Minimization/Denial (1)b

Males (n = 153)

Fa

Females (n = 280)

M

SD

P

M

SD

P

7.93 6.51 5.53 9.24 6.27 0.50

3.27 2.47 2.14 3.60 2.17 0.84

30.1 22.2 11.8 45.1 16.3 13.7

9.01 6.29 6.22 9.20 6.11 0.55

4.45 2.67 3.64 4.32 2.00 0.93

37.5 15.7 19.3 37.5 14.6 15.7

6.873∗∗ .783 4.613∗ .023 .641 .374

Note. CTQ: Childhood Trauma Questionnaire short-form; C: cut-scores for “mild” cases recommended by Bernstein and Fink (1998); P: percent above C. a Difference between males and females, df = (1, 428). b Validity scale comprised of three items. ∗ p < .05. ∗∗ p < .01.

Nonetheless, despite the high degree of correspondence across samples, students in the present study had other response patterns that differed from those of the adult patients (Bernstein & Fink, 1993). For example, experiences of insufficient care/protection, food, medical care (identified as physical neglect in the study of adult patients) and being yelled or screamed at (identified as emotional abuse) clustered with emotional neglect items, whereas inadequate love (emotional neglect) clustered with emotional abuse items. Similarly, living on the streets and wearing dirty clothes (physical neglect) clustered with physical abuse items and the sexual abuse factor uniquely included molestation of a sibling. Reliability. Alpha coefficients and test-retest reliabilites (see Table 1) were acceptable for the total scale and all five-factor scales, with the alpha coefficient for physical neglect considered fair (according to current test standards; Cicchetti, 1994). We also assessed the reliability of the CTQ short-form fullscale and subscales (Bernstein & Fink, 1998) in the present sample. Retest reliabilities ranged from .66 to .94, and alpha reliabilities ranged from .70 to .93. Again, in both instances, the physical neglect subscale yielded the lowest reliability coefficients. The mean minimization/denial score was .54 (SD = .81), which is within the acceptable range (i.e., <1; Bernstein & Fink, 1998).Overall, CTQ short-form subscales were suitable for calculating the extent (severity × frequency) and prevalence of emotional, physical, and sexual abuse; and emotional, and physical neglect in this sample. This use of standardized definitions permitted comparison across studies. Prevalence. Prevalence rates were calculated separately for males and females. Again, scores above recommended cut-offs for “low” severity on the CTQ short-form subscales (Bernstein & Fink, 1998) were considered cases of abuse and neglect. Means, standard deviations, and prevalence rates for males and females using the CTQ short-form (along with specific cut-scores for each subscale) are presented in Table 2. It should be noted that means and cut-scores are close in value because, as expected in this nonreferred group, the distributions of CTQ subscale scores were positively skewed, that is, most respondents scored at the low end of the range. Females, shown in Table 2, reported a greater extent of both emotional and sexual abuse compared to males. Present results concerning sexual abuse are largely

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Table 3 Means, standard deviations, and prevalence rates on CTQ subscales for three undergraduate samples Sample

Emotional Abuse (C = 8)

Physical Abuse (C = 7)

Sexual Abuse (C = 5)

Emotional Neglect (C = 9)

Physical Neglect (C = 7)

M (SD)

P

M (SD)

P

M (SD)

P

M (SD)

P

M (SD)

P

Females SK (n = 280) ON (n = 167) NYa (n = 51)

9.0 (4.5) 9.1 (4.4) 10.6 (5.2)

37.5 42.0 –

6.3 (2.7) 6.7 (2.8) 6.3 (2.4)

15.7 22.0 –

6.2 (3.6) 6.5 (4.1) 5.6 (1.4)

19.3 23.0 –

9.2 (4.3) 9.2 (4.1) 9.2 (4.4)

37.5 36.0 –

6.1 (2.0) 6.0 (1.7) 6.1 (1.9)

14.6 13.0 –

Males SK (n = 153) ON (n = 37) NYa (n = 41)

7.9 (3.2) 8.3 (3.7) 8.5 (4.0)

30.1 38.0 –

6.5 (2.5) 7.1 (4.0) 6.9 (3.1)

22.2 24.0 –

5.5 (2.1) 6.6 (4.8) 5.2 (1.0)

11.8 22.0 –

9.2 (3.6) 9.5 (4.3) 9.7 (4.3)

45.1 43.0 –

6.3 (2.2) 6.4 (2.7) 6.8 (2.2)

16.3 16.0 –

Note. CTQ: Childhood Trauma Questionnaire, short-form; C: cut-score for “mild” cases recommended by Bernstein and Fink (1998); P: percent above C; SK: University of Saskatchewan, SK (authors); ON: University of Windsor, ON (Turner & Paivio, 2002); NY: Fordham University, NY (Bernstein & Fink, 1998). a Prevalence estimates were not provided by Bernstein and Fink (1998).

comparable to estimates reported for other nonreferred groups (e.g., Finkelhor, 1994; Gorey & Leslie, 1997; MacMillan et al., 1997). There are few prevalence estimates and criteria for evaluating the extent of other types of abuse and neglect. However, three recent studies (Bernstein & Fink, 1998; Turner & Paivio, 2002; Wright et al., 2001) have used identical CTQ subscales and criteria to estimate the extent of different types of childhood trauma among undergraduate students in metropolitan New York, southern Ontario, and southern California, respectively. Data from three of these undergraduate samples are presented in Table 3. (Separate data for males and females were not reported in the Wright et al. (2001) study, although rates for males and females combined were comparable to combined rates in the present sample.) Means for different types of abuse and neglect for the Saskatchewan students, shown in Table 3, are generally similar to those reported for students in eastern regions of North America, although means for abuse are lower than those reported by Ontario students. Means indicating the extent of emotional abuse and neglect reported by students in all three studies is noteworthy, as is the higher rate and larger variance in sexual abuse reported by male students in Ontario.

Discussion When examined empirically through confirmatory factor analyses, the structure of the 70-item CTQ in the present sample of undergraduates was not comparable to that reported for clinical samples (Bernstein et al., 1994, 1997). Nonetheless, the five-factor solution extracted in the present study most closely replicated the five-factor solution reported for a sample of adolescent inpatients (Bernstein et al., 1997). Those factors are described as emotional, physical, and sexual abuse, as well as emotional, and physical neglect. The total scale and first four factors demonstrated good to excellent internal consistency and testretest reliability with both male and female students, and alpha reliability of the physical neglect factor

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was fair. Items comprising the first four of these factors overlapped considerably with corresponding factors in clinical samples (Bernstein et al., 1994, 1997). However, the physical neglect factor in the present study was comprised of different items compared to the corresponding factor derived from an adult clinical sample (Bernstein & Fink, 1993; Bernstein et al., 1994). The CTQ short-form subscales used to calculate prevalence of abuse and neglect in the present study demonstrated good to excellent reliability and, again, physical neglect was marginal to fair. Rates of sexual abuse among male and female students were comparable to those reported for other regions of North America and internationally. For example, Finkelhor (1994) reviewed surveys from several countries and concluded that, on an international basis, most estimates of child sexual abuse for females cluster around 20%, and for males (who have been surveyed less often) they fall between 3% and 11%. A review of 16 North American surveys of child sexual abuse (Gorey & Leslie, 1997) indicated 16.8% for females and 7.9% for males (corrected for response bias). In terms of physical abuse, rates for the present sample of Saskatchewan students, particularly females, shown in Table 2, are somewhat lower than rates in a recent survey of almost 10,000 Ontario residents (MacMillan et al., 1997). In that study, child physical abuse was reported by 31.2% of males and 21.3% of females. The higher rates of physical abuse among males compared to females is consistent with MacMillan et al. (1997). In terms of direct comparisons across studies using the CTQ, scores for abuse and neglect in the present study, in general, were comparable to CTQ scores reported for students in more densely populated, eastern regions of North America (Bernstein & Fink, 1998; Turner & Paivio, 2002; Wright et al., 2001). The means for all types of abuse and neglect among females, shown in Table 3, also are comparable to CTQ means reported for a sample of nonreferred female members of an HMO in the northwestern Unites States (Bernstein & Fink, 1998) and to means for males and females reported for a community sample (n = 154) of comparable age in Memphis, Tennessee (Scher et al., 2001), with the exception of emotional abuse and neglect. Rates of emotional abuse and neglect for all students, shown in Table 3, particularly females, were considerably higher than rates reported by Scher et al. (emotional abuse, M = 6.91 [3.74] for males and M = 5.52 [2.58] for females; emotional neglect, M =7.12 [3.80] for males and M = 6.28 [2.35] for females). Several issues warrant discussion. First, the consistent emergence of abuse and neglect subscales across samples supports the construct validity of the CTQ. Thus, the CTQ seems adequate for assessing the full range of severity of diverse childhood maltreatment experiences, and these experiences have similar meaning across samples. However, the meanings are not identical. For example, the five factors that emerged from data in this student sample most closely resembled results for adolescent patients (Bernstein et al., 1997) rather than findings for adult groups (Bernstein et al., 1994; Rosen & Lee, 1996). It appears that, for younger respondents who are reporting on more recent events, experiences of emotional and physical abuse are identified as distinct events that do not necessarily coexist. On the other hand, for adults who are reporting on more distal events, experiences of emotional and physical abuse occur together. These discrepancies could be a function of memories blurring over time, adults having a more wholistic or integrated perspective of childhood experiences, or the salience of experiences of being criticized, insulted, scapegoated, and yelled or screamed at for young people. Present results also indicated somewhat different items comprising individual factors across samples. This was most evident for the construct of physical neglect. Physical neglect experiences that were unique to the Saskatchewan students referred to lack of supervision at home and failure to ensure school attendance, rather than wearing dirty clothes or living on the streets, which seems more typical of neglected children in large urban centres. As well, the empirically derived factor scale and short-form subscale of physical neglect (Bernstein & Fink, 1998) were least internally consistent for these university students. This low level

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of internal consistency suggests more diverse life experiences in the area of physical neglect. Together, these findings reflect the fact that various events are differentially identified as different types of abuse and neglect depending on one’s life experiences. Nonetheless, present findings largely support the CTQ’s suitability for use in large-scale correlational studies of the effects of different types of childhood trauma in university student samples. It is noteworthy that the CTQ reliably assessed both concrete experiences of physical and sexual abuse, as well as more subjective experiences of emotional abuse and neglect. There currently are few studies of the specific effects of emotional maltreatment even though these childhood experiences have been linked to different types of psychopathology, particularly depression, anxiety, and emotion regulation difficulties (Felitti et al., 1998; Turner & Paivio, 2002; Yamamoto et al., 1999). Present findings suggest that the CTQ is a promising measure for this type of research. The present analyses also resulted in acceptable stability and internal consistency for the short-form subscales of the CTQ (Bernstein & Fink, 1998). This made them suitable for calculating the prevalence of different types of child abuse and neglect (retrospectively reported) in this distinct and relatively underresearched region of North America. Although direct comparisons across studies using other measures and measurement methods are not possible, the general convergence of prevalence estimates using the CTQ with those reported in studies of other student and nonreferred samples, increases confidence in the CTQ as a valid measure of abuse and neglect experiences. The one anomalous finding was the relatively high rate and large variance in sexual abuse reported on the CTQ by male students in southern Ontario compared to male students in both Saskatchewan and New York. Future research is needed to determine whether these reflect true regional differences and the factors contributing to these possible differences. In terms of physical abuse, rates were generally lower for this student group compared to community and student rates reported for more densely populated, eastern regions of North America (MacMillan et al., 1997; Turner & Paivio, 2002), particularly physical abuse among females. The lower rate of physical abuse among female students from rural Saskatchewan is inconsistent with findings that physical abuse was higher for rural, compared to urban females, in Ontario (MacMillan et al., 1997). The lower rate in the present study partly reflects CTQ items which tap only more severe forms of physical abuse (e.g., being hit with hard objects, beatings that left marks, or that required medical attention) and, unlike the Ontario questionnaire (MacMillan et al., 1997), do not include less severe experiences (e.g., being pushed and shoved). The reported prevalence of physical abuse among these Saskatchewan students, shown in Table 2, was comparable to rates of severe abuse in the Ontario community survey (Macmillan et al., 1997). Finally, our results concerning emotional abuse and neglect merit discussion. Items in these subscales refer to subjective experiences of feeling loved, wanted, or emotionally close to family members. Research indicates that recall for subjective experiences is less accurate than recall for more concrete behaviors and events (Brewin et al., 1993). However, the comparable extent of these experiences across four student samples, from different regions of North America, supports the validity of these reports. These findings indicated that large numbers of college and university students report childhood experiences defined by researchers as constituting emotional abuse and neglect. While it is important not to minimize the significance of these findings, it should be noted that criteria used in the present study included mild as well as severe cases. A recent study of 9508 HMO patients in the United States (Felitti et al., 1998) reported a prevalence rate of 11.1% for “psychological abuse,” which is much lower than the rate reported by university students using the CTQ. This discrepancy in prevalence estimates likely

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partly reflects sample and measurement differences. The sample in the Felitti et al. (1998) study consisted of middle-aged males and females and psychological abuse was assessed using a yes-no response format to only two items. However, rates of emotional abuse among students in the present study also were higher than rates reported for a community sample of comparable age using the identical CTQ short-form subscales (Scher et al., 2001). Overall, emotional abuse and neglect have been studied less frequently than more concrete types of maltreatment, partly because of difficulties defining these experiences. Present results highlight the importance of using standardized definitions and criteria to compare and interpret findings across studies. Our findings support the CTQ short-form as a promising measure for continued research on the effects of these more subtle and relatively under-researched types of childhood maltreatment. Conclusions that can be drawn from present results are limited by several factors. First, the CTQ, like other retrospective self-report measures, relies on the accuracy of people’s memories even though memory for childhood experience, in general, is fallible and certain types of psychopathology are associated with memory biases and distortions (Brewin et al., 1993; Maughan & Rutter, 1997). Although research generally supports the accuracy of retrospectively obtained abuse histories (Brewin et al., 1993), the present study included no corroborating data. Our findings also provide no information about convergent and divergent validity of the CTQ and provide only limited information about such variables as ethnicity and place of residence (e.g., farm or city) when respondents were growing up. Thus, we were not able to assess the effects of these variables on different types of childhood trauma. As well, this was a sample of convenience and no specific hypotheses were tested. Finally, results from these university students cannot be generalized to the general population in this region. Despite these methodological limitations, our results add to previous findings supporting the utility of the CTQ in research with clinical samples. In general, the present findings additionally support use of the CTQ in large scale correlational and prevalence studies of college students. One possible caveat concerns validity of the physical neglect subscale in studies using student samples. Continued research on the psychometric properties of the CTQ will contribute to test standardization and the development of criteria and norms for evaluating the extent of diverse childhood experiences.

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Cicchetti, D. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6, 284–290. Cole, D. A. (1987). Utility of confirmatory factor analysis in test validation research. Journal of Consulting and Clinical Psychology, 55, 584–594. Comrey, A. L., & Lee, H. B. (1992). A first course in factor analysis (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates. Dearwater, S. R., Coben, J. H., Campbell, J. C., Nah, G., Glass, N., McLoughlin, E., & Bekemeier, B. (1998). Prevalence of intimate partner abuse in women treated at community hospital emergency departments. Journal of the American Medical Association, 280, 433–438. Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M., & Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245–258. Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse & Neglect., 18, 409–417. Gorey, K., & Leslie, D. (1997). The prevalence of child sexual abuse: Integrative adjustment for potential response and measurement bias. Child Abuse & Neglect, 21, 391–397. Hu, L., & Bentler, P. M. (1998). Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification. Psychological Methods, 3, 424–453. J¨oreskog, K. G., & S¨orbom, D. (1996). LISREL 8: A guide to the program and applications. Chicago: SPSS Inc. Lipschitz, D., Bernstein, D., Winegar, R., & Southwick, S. (1999). Hospitalized adolescents’ reports of sexual and physical abuse: A comparison of two self-report measures. Journal of Traumatic Stress, 12, 641–654. Maughan, B., & Rutter, M. (1997). Retrospective reporting of childhood adversity: Issues in assessing long-term recall. Journal of Personality Disorders, 11, 19–33. MacMillan, H., Flemming, J., Trocme, N., Boylem, K., Wong, M., Racine, Y., Beardslee, W., & Offord, D. (1997). Prevalence of child physical and sexual abuse in the community: Results from the Ontario Health Supplement. Journal of the American Medical Association, 278, 131–135. Paivio, S. C. (2001). Stability of self-reports of child abuse and neglect before and after therapy for child abuse issues. Child Abuse & Neglect, 25, 1053–1068. Paivio, S. C., & McCullough, C. (2004). Alexithymia as a mediator between childhood trauma and self-injurious behaviors. Child Abuse & Neglect, 28, 339–354. Paivio, S. C., & Patterson, L. A. (1999). Alliance development in therapy with adult survivors of child abuse. Psychotherapy: Theory/Research/Practice/Training, 36, 343–354. Pilkington, B., & Kremer, J. (1995). A review of the epidemiological research on child sexual abuse: Community and college student samples. Child Abuse Review, 4, 84–98. Rigdon, E. E. (1996). CFI versus RMSEA: A comparison of two fit indexes for structural equation modeling. Structural Equation Modeling, 3, 369–379. Rind, B., Tromovitch, P., & Bauserman, R. (1998). A meta-analytic examination of assumed properties of child sexual abuse using college samples. Psychological Bulletin, 124, 22–53. Rosen, L. N., & Lee, M. (1996). The measurement of childhood trauma among male and female soldiers in the US Army. Military Medicine, 16, 342–345. Scher, C. D., Stein, M. B., Asmundson, G. J. G., McCreary, D. R., & Forde, D. R. (2001). The Childhood Trauma Questionnaire in a Community Sample: Psychometric properties and normative data. Journal of Traumatic Stress, 14, 843–857. Silvern, L., Waelde, L., Baughan, B., Karyl, J., & Kaersvang, L. (2000). Two formats for eliciting retrospective reports of child sexual and physical abuse: Effects on apparent prevalence and relationships to adjustment. Child Maltreatment: Journal of the American Professional Society on the Abuse of Children, 5, 236–250. Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics (4th ed.). Needham Heights, MA: Allyn & Bacon. Turner, A., & Paivio, S. C., (2002). A lexithymia as a transmission mechanism between childhood trauma, social anxiety, and limited social support. Poster presented at the American Psychological Association convention, Chicago, IL. Winegar, R. W., & Lipschitz, D. S. (1997, June). The reliability of adolescent reports of maltreatment and a comparison of different inquiry formats. Paper presented at the fifth International Family Violence Research Conference, Durham, NH, USA. Wright, K. D., Asmundson, G. J. G., McCreary, D. R., Scher, C., Shadha, H., & Stein, M. B. (2001). Factorial validity of the Childhood Trauma Questionnaire in men and women. Depression and Anxiety, 13, 179–183.

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R´esum´e Objectif: Les deux buts de cette e´ tude furent d’examiner (1) les caract´eristiques psychom´etriques du Childhood Trauma Questionnaire [CTQ; Bernstein, D., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., Sapareto, E., & Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal of Psychiatry, 151, 1132–1136; Bernstein, D., & Fink, L. (1993). Manual for the Childhood Trauma Questionnaire. Unpublished manuscript. Bronx, NY: VA Medical Center] dans un e´ chantillon d’´etudiants de premier cycle et (2) la pr´evalence des mauvais traitements et de la n´egligence dans ce mˆeme e´ chantillon. M´ethode: Des analyses des composantes principales, le co-efficient alpha et les corr´elations ont servi a` analyser les donn´ees de 470 e´ tudiants dans une universit´e situ´ee dans la partie ouest-centrale du Canada. Des portions d’une version raccourcie du questionnaire [Bernstein, D., & Fink, L. (1998). Manual for the Childhood Trauma Questionnaire. New York: The Psychological Corporation] ont servi a` e´ valuer la pr´evalence. R´esultats: Cinq facteurs ressortent de l’analyse des composantes principales: les mauvais traitements physiques, e´ motionnels et sexuels et la n´egligence e´ motionnelle et physique. Tous ces facteurs sauf la n´egligence physique ont une bonne coh´erence interne et une fiabilit´e lorsqu’il s’agit de tester et re-tester. On a retrouv´e ces cinq facteurs dans une e´ tude ant´erieure dont les participants e´ taient des adolescents tir´es d’un e´ chantillon clinique [Bernstein, D., Ahluvala, T., Pogge, D., & Handelsman, L. (1997). Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 340–348], a` l’exception cependant du facteur n´egligence physique qui englobait des composantes clairement diff´erentes. Les taux de traumatisme infantile sont semblables a` ceux qu’on a observ´e dans des e´ chantillons d’´etudiants et de membres de collectivit´es vivant dans des r´egions nord-am´ericaines o`u la densit´e de la population est plus grande. Conclusions: Le questionnaire semble eˆ tre une mesure valide des mauvais traitements et de la n´egligence dans des e´ chantillons d’´etudiants, quoique les exp´eriences de mauvais traitements et de n´egligence apparaissent diff´erentes selon l’ˆage et selon le fait que la personne est un patient ou non. Resumen Objetivo: Los objetivos de este estudio fueron examinar (1) las propiedades psicom´etricas del Childhood Trauma Questionnaire [CTQ; Bernstein, D., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., Sapareto, E., & Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal of Psychiatry, 151, 1132–1136; Bernstein, D., & Fink, L. (1993). Manual for the Childhood Trauma Questionnaire. Unpublished manuscript. Bronx, NY: VA Medical Center] en una muestra de estudiantes universitarios y (2) la prevalencia de maltrato y abandono en esta muestra. M´etodo: Se utilizaron an´alisis de componentes principales (ACP), coeficientes alpha y correlaciones para analizar los datos de 470 estudiantes universitarios de una universidad del medio-oeste de Canada. Para estimar la prevalencia se utilizaron las puntuaciones de “corte” de una versi´on reducida del CTQ [Bernstein, D., & Fink, L. (1998). Manual for the Childhood Trauma Questionnaire. New York: The Psychological Corporation]. Resultados: Los ACP proporcionaron una soluci´on de cinco factores que incluye maltrato f´ısico, emocional, abuso sexual, negligencia emocional y f´ısica. Todos los factores, excepto la negligencia f´ısica, demostraron buena consistencia interna y fiabilidad test-retest. Esta estructura factorial replic´o de manera adecuada los resultados notificados en un estudio realizado con una muestra de adolescentes [Bernstein, D., Ahluvala, T., Pogge, D., & Handelsman, L. (1997). Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 340–348] con la excepci´on del factor de

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negligencia f´ısica que estuvo formado por items considerablemente diferentes. Las tasas de trauma infantil fueron claramente comparables con aquellas notificadas por muestras de estudiantes y muestras comunitarias en regiones m´as densamente pobladas de Norteam´erica. Conclusiones: El CTQ parece ser una medida v´alida de maltrato y negligencia en muestras de estudiantes a pesar de que las experiencias son identificadas de manera diferencial como diferentes tipos de maltrato o negligencia dependiendo de la edad y del status (paciente vs. no paciente) del sujeto.