MASSACHUSETTS SCHOOL OF PROFESSIONAL PSYCHOLOGY

Complex Trauma Among Court-Involved Youth

Mathilde Pelaprat

B.S., University of California, San Diego, 2004

M.A., Massachusetts School of Professional Psychology, 2008

Submitted in partial fulfillment of the

requirements for the degree of

Doctor of Psychology

2009
 UMI Number: 3382657

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 Copyright 2009

By

Mathilde Pelaprat

n
 READERS' APPROVAL PAGE

Mathilde Pelaprat

Robert Kinscherff, Ph.D., Esq.

Doctoral Project Chairperson

Linda Daniels, Psy.D.

Internal Doctoral Project Committee Member

Penny Haney, Ph.D.

External Doctoral Project Committee Member

Nicholas Covino, Psy.D.

President
Massachusetts School of Professional Psychology
 Acknowledgements

I must admit that I underestimated the magnitude of completing a doctoral project.

At first glance, the term "project" brought to my mind images of a 41 grade science fair

with baking soda volcanoes and a styrofoam solar system. The doctoral project, however,

was altogether a different beast.

Jumping into this volcano was not merely a task of reading and consolidating

articles, but a test in perseverance, patience, and hope. To my dismay, the world did not

become a vacuum to allow me to complete this project without distractions, but I am

fortunate to have a wonderful family and group of friends that carried me through the sad

and frustrating times and celebrated with me during the happy moments.

I would like to thank Dr. Patricia Cone for her help in preparing this project for court

approval. I would also like to thank Dr. Tom Riffin, Director of the Boston Juvenile

Court Clinic for his instrumental help in jumping the last hurdles for court approval and

allowing this project to happen. Thank you to Chief Justice Grace without whose

approval this project would not have been possible. And thank you to Maria Guzman for

helping me gather and prepare the court evaluations for review. I would also like to thank

Dr. Jessica Greenwald O'Brien for donating her time as my discussant to this project.

I would like to acknowledge my committee. Thank you to Dr. Penny Haney for

generously giving her own time for the past year as my external committee member.

Thank you to Dr. Linda Daniels, my committee member and my professor, for your

dedication and support. And to Dr. Robert Kinscherff, thank you for your guidance,

expertise, witticisms and humor - you have made an overwhelming task a fun one, and

iv
you have inspired me throughout the process to be a better clinician, to persevere in the

face of bureaucracy, and to remember that a passion for the work is essential if we are to

effect change (and work with cranky teenagers).

To my wonderful friends thank you for your support. In particular, Danielle and

Pooja, thank you for your undying support. Your friendship means more to me than you

know.

To my parents, thank you for your guidance, support (financial and emotional), and

generally for being pretty great parents. My brother, Etienne, thank you for doing your

dissertation at the same time so that we could help each other through the misery. And to

my sweet and new fiancee, Amanda, you mean the world to me. Thank you for wiping

my tears, sharing in the joy, and choosing to be my companion through the journey of

life.

v
 Complex Trauma Among Court-Involved Youth

Mathilde Pelaprat

Massachusetts School of Professional Psychology

July 2009

Chairperson: Robert Kinscherff, Ph.D., Esq.

Abstract

This study was designed to examine the prevalence of trauma exposure and trauma

symptoms that are present among court-involved youth.

Research shows that experiencing traumatic events during childhood can

significantly impact development and later functioning in negative ways. Studies

examining Post-traumatic Stress Disorder (PTSD) demonstrate that symptoms can persist

for months or years and may interfere with aspects of daily functioning. Recent research

shows that early trauma can affect areas of functioning such as emotion regulation,

attention, memory, concentration, interpersonal relationships, and self-esteem and self-

worth.

The purpose of this study was to examine the types of traumatic events to which

court-involved youth have been exposed and the subsequent symptoms with which they

present. This information will help to better understand the nature and prevalence of

trauma symptoms among a group of high-risk youth with the goal of developing better

resources and treatment to help them.

vi
 Results indicated that many of the court-involved youth in this sample had histories

of chronic and repeated exposure to multiple modes of trauma, and presented with

symptoms of PTSD and Complex PTSD. In general, the more trauma to which a youth

was exposed, the more symptoms with which they presented. The findings also suggested

that the Complex PTSD diagnosis captures trauma symptoms among these youth that the

traditional PTSD does not.

Clinicians should routinely assess for all forms of trauma. Use of established trauma

assessment tools can enhance the process of gathering trauma information from these

youth.

vn
 Table of Contents

Acknowledgements iv
Abstract vi
I. Chapter One: Introduction 1
II. Chapter Two: Literature Review 4
What is Trauma? 4
History of Trauma and PTSD Research 4
The Impact of Trauma on Development 7
Biology and Neurobiology 8
Cognition 10
Affect Regulation 10
Behavioral Regulation 12
Dissociation 12
Attachment 13
Identity and Self-Concept 16
Interpersonal Relationship 17
Beliefs and Systems of Meaning and Understanding 17
Thinking Beyond PTSD 19
Limits of the PTSD Diagnosis 19
77*e Beginning of Complex PTSD 19
Symptoms Associated with Chronic Trauma 21
Formalizing the Complex PTSD Diagnosis 23
Types of Trauma Associated with Complex PTSD 28
Prevalence and Utility of Complex PTSD 28
Complex PTSD Diagnosis 31
Diagnostic Criteria for Disorders of Extreme Stress 32
Developmental Trauma Disorder 34
Youth, Trauma, and the Forensic System 34
Assessment Tools 39
viii
 Structured Interview for Disorders of Extreme Stress 40
Present Study 42
III. Chapter Three: Method 43
Research Design 43
Participants 43
Measures 44
Procedure 52
Confidentiality, Protection of Participants, and Ethical Considerations 53
IV. Chapter Four: Results 55
Descriptive Analysis of All Reports 56
Demographics 56
Court Reports 58
Types of Trauma 59
Descriptive Analysis of Reports Used for Data Analysis 61
Demographics 62
Types of Trauma 63
Individual Trauma Symptoms 67
PTSD Symptoms 69
Complex PTSD Symptoms 70
Symptom Clusters 71
Sum of Symptoms in Each Cluster 71
Clinically Positive Clusters 78
Sum of Positive Clusters 81
Positive PTSD and Complex PTSD Diagnosis 83
Testing 83
Other Diagnosis 83
Data Analysis 86
Demographics and Trauma 87
Gender and the Absence/Presence of Trauma 87

ix
 Age and the Absence/Presence of Trauma 89
Race and the Absence/Presence of Trauma 90
Type of Abuse and Individual Symptoms 91
Physical Abuse and Individual Trauma Symptoms 95
Emotional Abuse and Individual Trauma Symptoms 99
Neglect and Individual Trauma Symptoms 101
Sexual Abuse and Individual Trauma Symptoms 101
Exposure to Community Violence and Individual Trauma Symptoms 114
Exposure to Intimate Partner Violence and Individual Trauma
Symptoms
Other Trauma and Individual Trauma Symptoms 117
Sum of Trauma and Individual Trauma Symptoms 117
Trauma and the Sum of Clusters Symptoms 120
Physical Abuse and Sum of Cluster Symptoms 122
Emotional Abuse and Sum of Cluster Symptoms 124
Neglect and Sum of Cluster Symptoms 125
Sexual A buse and Sum of Cluster Symptoms 125
Exposure to Community Violence and Sum of Cluster Symptoms 126
Exposure to Intimate Partner Violence and Sum of Cluster Symptoms 127
Other Trauma and Sum of Cluster Symptoms 128
Absence of Presence of Trauma and Sum of Cluster Symptoms 128
Sum of Modes of Trauma and Sum of Cluster Symptoms 130
Trauma and Positive Clusters 132
Physical A buse and Positive Clusters 135
Emotional A buse and Positive Clusters 137
Neglect and Positive Clusters 138
Sexual Abuse and Positive Clusters 138
Exposure to Community Violence and Positive Clusters 143
Exposure to Intimate Partner Violence and Positive Clusters 144
Other Trauma and Positive Clusters 144
 Absence/Presence of Trauma and Positive Clusters 144
Sum of Modes of Trauma and Positive Clusters 146
Trauma and the Sum of Positive Clusters 147
Physical Abuse and Sum of Positive Clusters 148
Emotional Abuse and Sum of Positive Clusters 149
Neglect and Sum of Positive Clusters 150
Sexual Abuse and Sum of Positive Clusters 151
Exposure to Community Violence and Sum of Positive Clusters 152
Exposure to Intimate Partner Violence and Sum of Positive Clusters 152
Other Trauma and Sum of Positive Clusters 153
Absence/Presence of Trauma and Sum of Positive Clusters 153
Sum of Modes of Trauma and Sum of Positive Clusters 154
Trauma and PTSD or Complex PTSD Diagnosis 155
Physical Abuse and Trauma Diagnosis 156
Emotional Abuse and Trauma Diagnosis 156
Neglect and Trauma Diagnosis 157
Sexual Abuse and Trauma Diagnosis 157
Exposure to Community Violence and Trauma Diagnosis 159
Exposure to Intimate Partner Violence and Trauma Diagnosis 159
Other Trauma and Trauma Diagnosis 159
Absence/Presence of Trauma and Trauma Diagnosis 159
Sum of Trauma Modes and Trauma Diagnosis 160
Trauma Exposure and Diagnoses Identified in the Reports 160
Trauma Exposure and Trauma-Related Diagnoses in the Reports 161
Trauma Exposure and other Diagnoses 164
V. Chapter 5: Discussion 166
Demographics 166
Prevalence and Qualitative Analysis of Trauma Exposure 168
Prevalence and Qualitative Analysis of Symptom Presentation 170

xi
 Individual Symptoms 170
PTSD and Complex PTSD Clusters and Diagnoses 172
Other Disorders 173
Analysis of Statistically Significant Findings 174
Gender and Trauma Exposure 174
Individual Symptoms 174
PTSD and Complex PTSD Clusters and Diagnoses 179
Implications for Court-Involved Youth 183
Implications for Practice 184
Limitations of Study 186
Record Review 186
Subject Pool 186
Sample Size 187
Data Collection Tool 187
Inter-Rater Reliability 187
Implications for Future Research 188
Conclusions 190
References 191
Appendix A 199
Appendix B 204
Appendix C 205
Appendix D 206

xn
 List of Tables

Table 1 Domains of Impairment in Children Exposed to Complex Trauma 18

Table 2 Overall Distribution of Type of Evaluation by Gender 59

Table 3 Overall Distribution of Trauma Exposure 60

Table 4 List of Other Traumas 61

Table 5 Sample Distribution of Trauma Exposure 64

Table 6 Absent/Present Sample Distribution of Trauma Exposure 65

Table 7 Distribution of Individual Trauma Symptoms 68

Table 8 Results of Chi-Square Analysis for Gender and Absence/Presence of 88

Trauma
Table 9 Chi-Square Analysis: Gender and Absence/Presence of Sexual Abuse 88

Table 10 Chi-Square Analysis: Gender and Absence/Presence of Other Trauma 89

Table 11 Analysis of Variance Results: Age and Absence/Presence of Trauma 90

Table 12 Analysis of Variance Results: Race and Absence/Presence of Trauma 91

Table 13 Chi-Square Analysis: Type of Abuse and Individual Trauma Symptoms 93

Table 14 Chi-Square Analysis: Physical Abuse and Self-Destructive Behavior 95

Table 15 Chi-Square Analysis: Physical Abuse and Suicidal Preoccupation 95

Table 16 Chi-Square Analysis: Physical Abuse and Dissociation/Depersonalization 96

Table 17 Chi-Square Analysis: Physical Abuse and Guilt/Responsibility 96

Table 18 Chi-Square Analysis: Physical Abuse and Nobody Can Understand 97

Table 19 Chi-Square Analysis: Physical Abuse and Digestive System Problems 97

Table 20 Chi-Square Analysis: Physical Abuse and Loss of Previously Sustaining 98

Beliefs
xiii
Table 21 Chi-Square Analysis: Physical Abuse and Affect Regulation 98

Table 22 Chi-Square Analysis: Emotional Abuse and Intrusive Memories 99

Table 23 Chi-Square Analysis: Emotional Abuse and Nightmares/Distressing 99

Dreams

Table 24 Chi-Square Analysis: Emotional Abuse and Self-Destructive Behavior 100

Table 25 Chi-Square Analysis: Emotional Abuse and Permanent Damage 100

Table 26 Chi-Square Analysis: Sexual Abuse and Intrusive Memories 102

Table 27 Chi-Square Analysis: Sexual Abuse and Nightmares/Distressing Dreams 102

Table 28 Chi-Square Analysis: Sexual Abuse and Flashbacks/ Hallucinations/ 103

Sensory Experiences
Table 29 Chi-Square Analysis: Sexual Abuse and Psychological Distress due to 103
Internal or External Stimuli
Table 30 Chi-Square Analysis: Sexual Abuse and Physiological Distress due to 104
Internal or External Stimuli
Table 31 Chi-Square Analysis: Sexual Abuse and Avoid Thoughts, Feelings, 104
Talking About the Trauma

Table 32 Chi-Square Analysis: Sexual Abuse and Diminished Interest 105

Table 33 Chi-Square Analysis: Sexual Abuse and Sleep Problems 105

Table 34 Chi-Square Analysis: Sexual Abuse and Irritability 106

Table 35 Chi-Square Analysis: Sexual Abuse and Hypervigilance 107

Table 36 Chi-Square Analysis: Sexual Abuse and Affect Regulation 107

Table 37 Chi-Square Analysis: Sexual Abuse and Modulation of Anger 108

Table 38 Chi-Square Analysis: Sexual Abuse and Self-Destructive Behavior 108

Table 39 Chi-Square Analysis: Sexual Abuse and Suicidal Preoccupation 109

Table 40 Chi-Square Analysis: Sexual Abuse and Difficulty Modulating Sexual 109
Involvement
Table 41 Chi-Square Analysis: Sexual Abuse and Amnesia 110
Table 42 Chi-Square Analysis: Sexual Abuse and Dissociation or 110
Depersonalization
xiv
Table 43 Chi-Square Analysis: Sexual Abuse and Ineffectiveness 111

Table 44 Chi-Square Analysis: Sexual Abuse and Permanent Damage 111

Table 45 Chi-Square Analysis: Sexual Abuse and Nobody Can Understand 112

Table 46 Chi-Square Analysis: Sexual Abuse and Inability to Trust 112

Table 47 Chi-Square Analysis: Sexual Abuse and Revictimization 113

Table 48 Chi-Square Analysis: Sexual Abuse and Despair and Hopelessness 113

Table 49 Chi-Square Analysis: Sexual Abuse and Loss of Previously Sustaining 114
Beliefs
Table 50 Chi-Square Analysis: Exposure to Community Violence and Risk-Taking 115
Behavior
Table 51 Chi-Square Analysis: Exposure to Community Violence and Minimizing 115

Table 52 Chi-Square Analysis: Exposure to Community Violence and Victimizing 116

Others
Table 53 Chi-Square Analysis: Exposure to Intimate Partner Violence and 116
Restricted Range of Affect
Table 54 Analysis of Variance Results: Sum of Trauma Exposure and Individual 118
Trauma Symptoms
Table 55 Analysis of Variance Results: Sum of Cluster Symptoms and Trauma 121
Exposure
Table 56 Analysis of Variance Results: Trauma Exposure and Positive Clusters 134

Table 57 Chi-Square Analysis: Physical Abuse and Alterations in Affect 135

Regulation Cluster Positive
Table 58 Chi-Square Analysis: Physical Abuse and Alterations in 136
Attention/Consciousness Cluster Positive
Table 59 Chi-Square Analysis: Physical Abuse and Alterations in Self-Perception 136
Cluster Positive
Table 60 Chi-Square Analysis: Emotional Abuse and Reexperiencing Cluster 137
Positive
Table 61
Chi-Square Analysis: Emotional Abuse and Hyperarousal Cluster Positive 138
Table 62
Chi-Square Analysis: Sexual Abuse and Reexperiencing Cluster Positive 139
Table 63
Chi-Square Analysis: Sexual Abuse and Avoidance Cluster Positive 139
Table 64
Chi-Square Analysis: Sexual Abuse and Hyperarousal Cluster Positive 140
xv
Table 65 Chi-Square Analysis: Sexual Abuse and Alterations in Affect Regulation 140
Cluster Positive
Table 66 Chi-Square Analysis: Sexual Abuse and Alterations in 141
Attentions/Consciousness Cluster Positive
Table 67 Chi-Square Analysis: Sexual Abuse and Alterations in Self-Perception 141
Cluster Positive
Table 68 Chi-Square Analysis: Sexual Abuse and Alterations in Systems of 142
Meaning Cluster Positive
Table 69 Chi-Square Analysis: Exposure to Community Violence and Alterations 143
in Affect Regulation Cluster Positive
Table 70 Chi-Square Analysis: Exposure to Community Violence and Alterations 143
in Relationships Cluster Positive
Table 71 Chi-Square Analysis: Absence/Presence of Trauma and Alterations in 145
Affect Regulation Cluster Positive
Table 72 Chi-Square Analysis: Absence/Presence of Trauma and Alterations in 145
Relationships Cluster Positive
Table 73 Analysis of Variance Results: Trauma Exposure and Sum of PTSD and 148
Complex PTSD Clusters
Table 74 Significance Levels for Chi-Square Analysis of Trauma Exposure and 156
PTSD and Complex PTSD Diagnosis Positive
Table 75 Chi-Square Analysis: Emotional Abuse and PTSD Diagnosis Positive 157

Table 76 Chi-Square Analysis: Sexual Abuse and PTSD Diagnosis Positive 158

Table 77 Chi-Square Analysis: Sexual Abuse and Complex PTSD Diagnosis 158
Positive
Table 78 Chi-Square Analysis: Absence/Presence of Trauma and PTSD Diagnosis 160
Positive
Table 79 Significance Levels of Chi-Square Analysis for Trauma Exposure and 161
Trauma-Related Diagnosis in Evaluation
Table 80 Chi-Square Analysis: Sexual Abuse and PTSD Diagnosis in Evaluation 162

Table 81 Chi-Square Analysis: Emotional Abuse and PTSD Diagnosis in Report 162

Table 82 Chi-Square Analysis: Absence/Presence of Trauma and Adjustment 163

Disorder
Table 83 Chi-Square Analysis: Neglect and Other Trauma Diagnosis in Report 163

Table 84 Significance Levels for Chi-Square Analysis of Trauma Exposure and 164
Other Diagnosis in Evaluation
Table 85 Chi-Square Analysis: Exposure to Community Violence and Mood 165
Disorder Diagnosis
Table 86 Chi-Square Analysis: Exposure to Community Violence and Substance 165
Abuse Disorder
xvi
 List of Figures

Figure 1 Race Demographics for Suffolk County and Study Sample 57

Figure 2 Distribution of the Sum of Modes of Trauma Experienced 66
Figures Distribution of Sum of Reexperiencing Symptoms 71
Figure 4 Distribution of Sum of Avoidance Symptoms 72
Figure 5 Distribution of Sum of Hyperarousal Symptoms 73
Figure 6 Distribution of Sum of Alteration in Affect Regulation Symptoms 74
Figure 7 Distribution of Sum of Alterations in Consciousness Symptoms 75
Figure 8 Distribution of Sum of Alteration in Self-Perception Symptoms 75
Figure 9 Distribution of Sum of Alteration in Relationships with Others Symptoms 76
Figure 10 Distribution of Sum of Somatization Symptoms 77
Figure 11 Distribution of Sum of Alteration in Systems of Meaning Symptoms 78
Figure 12 Percentage of Youths with Negative or Positive PTSD Clusters 79
Figure 13 Percentage of Youths with Negative or Positive Complex PTSD Clusters 80
Figure 14 Distribution of the Sum of Positive PTSD Clusters 81
Figure 15 Distribution of the Sum of Complex PTSD Clusters 82
Figure 16 Distribution of Trauma-Related Diagnoses in the Reports 84
Figure 17 Distribution of other Mental Health Diagnoses in the Reports 85
Figure 18 Distribution of the Number of Diagnoses in the Report for Each Youth 86
Figure 19 Means of Significant Relationships Between Physical Abuse and Complex 123
PTSD Clusters
Figure 20 Mean Differences in Hyperarousal Symptoms for Non-Emotionally Abused 124
and Emotionally Abused Youths
Figure 21 Mean Differences for All Symptom Clusters Between Sexually Abused and 125
Non-Sexually Abused Youths
Figure 22 Mean Difference in Alteration in Relationship Symptoms for Youths Not 127
Exposed vs. Exposed to Community Violence
Figure 23 Mean Difference in Alteration in Relationship Symptoms for Youths Not 128
Exposed vs. Exposed to Intimate Partner Violence
Figure 24 Mean Differences of Significant Relationships Between the Absence/ 129
Presence of any Trauma and Symptom Clusters

xvii
Figure 25 Mean Number of Affect Regulation Symptoms by the Total Modes of 130
Trauma Experienced

Figure 26 Mean Number of Avoidance Symptoms by the Total Modes of Trauma 13 ]

Experienced
Figure 27 Mean Number of Self-Perception Symptoms by the Total Modes of Trauma 132
Experienced
Figure 28 Sum of Modes of Trauma Experienced and Mean Score for the Affect 146
Regulation Cluster
Figure 29 Physical Abuse and Mean Number of Positive Complex PTSD Clusters 149
Figure 30 Emotional Abuse and Mean Number of Positive PTSD Clusters 150
Figure 31 Sexual Abuse and Mean Number of Positive PTSD and Complex PTSD 151
Clusters
Figure 32 Exposure to Community Violence and Mean Number of Positive Complex 152
PTSD Clusters
Figure 33 Other Trauma and Mean Number of Positive Complex PTSD Clusters 153
Figure 34 Mean Number of Positive Complex PTSD Clusters by Total Modes of 154
Trauma Experienced

xvm
 CHAPTER 1

INTRODUCTION

Each year over 2 million youths become involved in the juvenile justice system in

the United States. A majority of these youths have been exposed to traumatic events and

some develop Post-Traumatic Stress Disorder or other stress-related disorders (Mahoney,

Ford, Ko, & Siegfried, 2004). Approximately half of these youths have at least two

diagnosable mental health disorders and about 10% have both a major mental health

problem and a substance abuse disorder (Mahoney et al., 2004). Unfortunately, only a

small percentage of these children are evaluated for mental health problems or receive

mental health services as part of their court experience. Within this subset of youth, a

smaller percentage is actually thoroughly assessed for trauma history or presence of

trauma-related symptoms.

From September 2006 to June 2007,1 was a psychology intern at the Boston Juvenile

Court Clinic. Many of the court clinic referrals identified school and home behavioral

problems as the basis for the Child in Need of Services (CHINS) petition. A CHINS

petition is a process by which parents, teachers, or police officers enlist the help of the

court to resolve problems such as truancy, running away, behavioral difficulties at home,

or children who have habitual offending at school. I also conducted evaluations on youth

who had been arrested on a delinquency charge and were suspected of having mental

health problems. A common assumption was that the child had some form of Attention-

Deficit Hyperactivity Disorder (ADHD) or other disorder that had been undiagnosed or

improperly treated.

1
 I noticed that many of the youth I evaluated had experienced some type of

maltreatment in their past. Loss of a parent, witnessing domestic violence, physical or

sexual abuse, witnessing violence in their neighborhoods, and bullying were only some

examples of the types of experiences that these youth had encountered. I noticed a pattern

among the court clinic evaluations whereby these youths' trauma histories were related to

their current misconduct (e.g., a child refused to attend school because he was being

bullied). Many of these youth had experienced multiple types of adverse experiences that

could result in symptoms that are consistent the PTSD diagnosis.

I began to wonder about the link between these youths' histories and their current

functioning. The clinical picture was complicated because they were presenting with

trauma-related symptoms that did not quite fit with the criteria required for diagnosis of

Post-Traumatic Stress Disorder in the current DSM-IV. Rather, the recently proposed

Complex PTSD or Disorders of Extremes Stress Not Otherwise Specified (DESNOS)

diagnoses seemed to better describe the types of symptoms with which these youth

presented. I was curious about how often these youths were assessed for trauma histories

and how clinicians were incorporating this information into the formulation and treatment

recommendation sections of the reports.

The current study was developed to explore the prevalence and types of

maltreatment experiences among these court-involved youth. Past juvenile court clinic

evaluations were reviewed to gather information on the presence of PTSD and Complex

PTSD symptoms. A standard data collection form was used to collect information about

the trauma histories and current symptom presentation for court clinic evaluations

reviewed for this study.

2
 The study is inherently limited by whether or not trauma was specifically assessed

and documented in the court clinic evaluations. Consequently, to the extent to which

potentially traumatic experiences and their clinical sequelae were not consistently

assessed, the results are likely to underestimate the true prevalence of trauma histories

and symptoms among these court-involved youth. The study is also limited by sample

size. For the purposes of this study, a small sample of reports was randomly selected

from a pool of clinical evaluations of youths who appeared before a Juvenile Court in

Boston and were referred to the court clinic for an evaluation.

3
 CHAPTER 2

LITERATURE REVIEW

What is Trauma?

A common misconception is that the word trauma refers to the entire experience of a

trauma from the traumatizing event to post-traumatic symptoms. The word "trauma"

refers to an actual event that causes significant distress and fear (Briere & Scott, 2006).

The response and symptoms that follow are referred to as the post-traumatic response.

Types of trauma include natural disasters, interpersonal violence, motor vehicle or

transportation accidents, fires, rape, sexual abuse, physical assault, intimate partner

assault, torture, maltreatment as a child, vicarious exposure to trauma (e.g., emergency

personnel and "first responders"), and witnessing violence (Briere & Scott, 2006).

History of Trauma and PTSD Research

The Post-Traumatic Stress Disorder (PTSD) diagnosis first entered the third revision

of the Diagnostic and Statistical Manual (DSM-III) in 1980 (American Psychiatric

Association, 1980). Research in the area of trauma has since examined prevalence rates,

theories of trauma, post-traumatic symptoms and adaptations, and treatment methods.

The lifetime prevalence of PTSD is approximately 5-10% among the general

population (Lee, 2006). The reported incidence of abuse and neglect has also risen during

the past few decades (Cook, Blaustein, Spinazzola, & van der Kolk, 2003). In 1993, the

Third National Study of Child Abuse and Neglect (NIS-3) collected information about

4
abuse and neglect from 5600 professionals comprising 842 agencies in 42 US counties.

Over 1.5 million children were reported abused and neglected in 1993 with 217,000

exposed to sexual abuse, 338,000 exposed to physical neglect, 212,000 exposed to

emotional neglect, and 381,000 exposed to physical abuse. This was four times the

amount that had been recorded in 1982 (Cook et al., 2003).

Recent statistics show that about 3 million children are reported for new

investigations of abuse and neglect each year (Streeck-Fischer & van der Kolk, 2000).

This translates into approximately 15 in every 1000 children per year. Of these 3 million

reported cases, one million are substantiated with approximately 80% of the abuse and

neglect perpetrated by the children's parents (van der Kolk, 2005). Neglect is reportedly

three times more common than abuse among children (Streeck-Fischer & van der Kolk,

2000).

Kaiser Permanente conducted an Adverse Childhood Experiences survey among

17,337 adult HMO members. Results of this self-report study found that 10.6% had been

emotionally abused, 28.3% had experienced physical abuse, 20.7% had been sexually

abused, 26.9% had been exposed to family substance abuse, 19.4% had been exposed to

family mental illness, 12.7% had witnessed their mothers being battered, 23.3%

experienced parental divorce, and 4.7% had an incarcerated family member (Adverse

Childhood Experiences Study, www.cdc.gov/nccdphp/ACE/prevalence.htm). In a follow-

up study of 8,667 people they also found that 14.8% had been emotionally neglected and

9.9% had been physically neglected (Adverse Childhood Experiences Study,

www.cdc.gov/nccdphp/ACE/prevalence.htm). Other studies among HMO members have

found similar results. One study among 16,000 adult HMO members reported 22% had

5
been sexually abused and 12% had been physically abused as children. Another study

among 1225 adult women HMO members found that 18.4% had been sexually abused,

14.2% had been physically abused, and 24.1 % had experienced emotional abuse in

childhood (Streeck-Fischer & van der Kolk, 2000).

Trauma affects all aspects of society from medical and mental health costs to

psychological tolls on victims and society. The estimated cost of trauma in the US is $94

billion a year including costs for hospitalization, chronic health problems, child welfare,

law enforcement, judicial system, adult mental health treatment, and juvenile

delinquency. This averages to $258 million per day (Cook et al., 2003).

Theories that explain the etiology of PTSD have included information-processing

theory (Brewin, Dalgleish, & Joseph, 1996), behavior theory (Keane, Zimering, &

Caddell, 1985), socio-biological theory (Christopher, 2004; van der Kolk, McFarlane, &

Weiseath, 1996), socio-cognitive theory (Resick & Schnicke, 1992), and cognitive theory

(Ehlers & Clark, 2000). Despite these varying approaches to understanding PTSD, there

is general consensus in the field that the basic underlying and critical experiences

involved in posttraumatic reactions are intense fear and an extreme sense of being

overwhelmed (Lee, 2006).

In the early 1990s, researchers in the field of trauma began to examine more closely

the long-term effects of chronic trauma such as repeated episodes of physical and sexual

abuse. The concept of a complex trauma reaction as a result of chronic exposure to

traumatic events was proposed around this time (Herman, 1992). Trauma researchers

found that many people who had been victims of severe or prolonged trauma, particularly

that occurred early in life, presented with symptoms that did not fit with the traditional

6
PTSD diagnosis. Trauma studies began to focus on more comprehensive assessment and

articulation of diagnostic criteria for trauma reactions and symptoms among people

exposed to chronic trauma in early life (Roth, Newman, Pelcovitz, van der Kolk, &

Mandel, 1997).

The Impact of Trauma on Development

As researchers expanded their exploration of symptoms resulting from trauma

exposure, they found that trauma can negatively impact virtually all aspects of

functioning and developmental processes. Although responses vary widely among

individuals, trauma exposure can affect maturation, the development of self-regulatory

processes, personality development, and psychological functioning (Briere & Scott, 2006;

Pelcovitz, van der Kolk, Roth, Mandel, Kaplan, & Resick, 1997). Trauma also increases

the risk of developing psychiatric problems such as substance abuse, depression, anxiety,

and even chronic illnesses in adulthood (Briere & Scott, 2006; Adverse Childhood

Experiences Study, www.cdc.gov/nccdphp/ACE/prevalence.htm).

The first years of trauma research, primarily conducted on male combat veterans,

examined the impact of trauma in terms of symptom presentation and yielded a formal

diagnosis of Post-Traumatic Stress Disorder (PTSD). In subsequent years, emphasis was

placed on understanding the interactive effects of trauma on various physiological and

psychological processes. Wilson (2004) found that "stressors... have differential effects

on organismic functioning" (p.8) that change biology, psychology, and behavior. Wilson

also stressed the importance of examining the interaction between the biological and

psychological symptoms and conceptualizing PTSD as a "dynamic stress-response

7
syndrome" (Wilson, 2004, p. 9). Thus, trauma can impact a person as a whole with post-

traumatic symptoms reflecting or contributing to changes in other symptoms, biological

adaptations or behaviors. As research focused on examining the breadth and intensity of

the impact of trauma (both single-episode and chronic) on development, deficits in

various areas of functioning were identified.

Biology and Neurobiology

Our bodies are programmed to respond to significant stressors using the fight-or-

flight response. Our brains assess a threatening situation and determine whether survival

is best achieved through fleeing, fighting, or freezing. Many changes occur in the body

during the stress response: neurotransmitter activity increases, Cortisol is released into the

brain to increase awareness, and the sympathetic nervous system is activated (Wilson,

2004). Stress levels in the environment can alter our hard-wired and genetic processes.

(Cook et al., 2003).

The biological theory behind PTSD is that the body continues to function in a

heightened state of arousal in the absence of the threatening stimuli. That is, the baseline

functions of the body prior to the traumatic event have been altered. The sympathetic

nervous system may continue in an active state of prolonged hyperarousal, presenting as

difficulties with attention and concentration, impulsivity, emotional dysregulation and a

subjective state of anxiety. Cortisol (the "anti-stress" hormone) remains at a lower than

normal level and decreases the body's ability to recover following a stressful event.

Moreover, the brain responds to new stressful stimuli at a higher and more intense rate

than it would have prior to the trauma (van der Kolk, 2002). The body struggles to return

8
to its homeostatic state of functioning prior to the trauma, a process called allostasis

(Wilson, 2004).

Changes at this basic level that are caused by trauma can be observed starting in

infancy. Early deprivation and maltreatment can lead to persisting reactivity to mild

stress. For example, a baby may readily react to small noises in the environment. Among

toddlers and early childhood, problems emerge in the ability to switch from right to left

hemisphere functioning, the ability to filter information, detecting and responding to

threats, recognizing stimuli in the environment, generating a response to perceived

threats, and problems with overall integration of external and internal responses (Cook,

Blaustein, Spinazzola, & van der Kolk, 2003). Generally the right side of the brain,

primarily the emotional side, tends to dominate. Problems with learning, self-

management, and forming interdependent relationships are also seen in early childhood.

In middle childhood and adolescence, problems with executive functioning, self-

regulation, problem-solving, and reality orientation (thought disorder) can also emerge

(Cook et al., 2003).

Chronic trauma can also result in long-term somatic and medical problems such as

cardiovascular problems, metabolic problems, chronic pain, problems with immune

system functioning, digestive system problems, and problems with sexual functioning

(Cook et al., 2003; Adverse Childhood Experiences Study,

www.cdc.gov/nccdphp/ACE/prevalence.htm).

9
 Cognition

Trauma can impact a person's cognitive functioning or a child's cognitive

development. In early childhood, children begin to develop a sense of self and an

understanding of the world around them. Trauma can impact these fundamental beliefs

and values in negative ways. Other problems related to cognitive functioning that have

been linked to childhood maltreatment include lower intellectual quotients (IQs),

disproportionate prevalence in the Pervasive Developmental Disorder spectrum (PDD),

poor academic performance, poor frustration tolerance, avoidance of challenges, less

creativity, problems with attention and reasoning, increased need for special education

services, and a higher school dropout rate (Cook et al., 2003).

Affect Regulation

Trauma can impact emotional development and functioning (Streeck-Fischer, 2000).

The basic emotion believed to be operating during a traumatic event is extreme and

overwhelming fear. The traumatic event becomes encoded into memory as a function of

the feelings experienced during the trauma. Aspects of the trauma including small details

and sensory experiences can become linked to the emotional response. Consequently,

stimuli in the environment that resemble aspects of the traumatic event may elicit a fear

response even when experienced well after the trauma. For example, a young boy who

witnesses his parents fighting while he is watching a particular cartoon on television may

respond to this cartoon with fear or other trauma-related symptoms (e.g., avoidance,

dissociation or irritability) in the future because the cartoon was processed and associated

within the context of a fear response.

10
 Problems with affect regulation among trauma survivors can happen at various

stages of an emotional experience, and problems in one area can affect subsequent areas

of emotional functioning. When someone is feeling an emotion and wants to express it,

the brain and body communicate and undergo a general sequence to accomplish this task.

The brain recognizes and identifies the emotion (e.g., feel sensations in your body that

tell the brain you are feeling an emotion such as anger), processes the emotion (e.g.,

identifies emotion(s) I am feeling at this moment), modulates the emotion (e.g., how

strongly am 1 feeling this and how can I try to calm myself down), expresses the emotion

(e.g., crying, laughing), and the body may try to self-soothe or manage the emotion (e.g.,

body calms down on its own, positive self-talk, deep breathing, distraction, etc.). The

sequence is generally as follows (Cook et al., 2003):

RECOGNIZE -» IDENTIFY -> PROCESS -» MODULATE -» EXPRESS ->

RECOVER

Trauma survivors can have problems at any stage in this process, and problems in

earlier stages can affect those later on. They may experience problems with identifying

and discriminating different emotional states (i.e., what am I feeling right now), problems

with modulating emotions (e.g., constriction, rigidity, lability, or explosiveness),

problems with emotional expression (e.g., talking to someone, distorting the intensity in

their expression of emotion), and they may have an impaired ability to self-soothe (e.g.,

body cannot calm down or calms down much slower than is typical). These problems are

one explanation for trauma survivors developing maladaptive coping strategies to manage

11
their emotions (Cook et al., 2003). Maladaptive coping strategies commonly used include

substance use, dissociation, or self-harm.

These problems also explain why trauma survivors suffer from mood disorders. For

example, childhood sexual abuse increases the odds of major depression later in life by 3

to 5 times (Cook et al., 2003).

Behavioral Regulation

Trauma survivors can also experience problems with under or over controlled

behavior. Over-controlled behavior can be helplessness, lack of power, rigidity,

compulsive behavior, compulsive compliance, rituals, and inflexibility in their behavior.

Under-controlled behavior includes problems with executive functions (e.g., problem-

solving, decision-making, logical thinking), impulse control problems, re-enactment of

the trauma, substance use as an external regulator, and risk-taking behavior (Cook et al.,

2003).

Dissociation

Dissociation is "alterations in conscious awareness that arise, in part, from defensive

changes in otherwise integrated thoughts, feelings, memories, and behavior" used to

reduce feelings in the face of triggers or reminders of the trauma (p. 403, Briere &

Spinazzola, 2005). It can be cognition without affect, affect without cognition, somatic

symptoms, or behaviors that occur without awareness. We all experience mild forms of

dissociation on a regular basis. For example, many people experience "highway

hypnosis" whereby they drive on the highway and when they reach their destination they

12
may have forgotten how long or how they have reached it, or have not realized that time

has gone by and cannot recollect parts of their trip. In the context of trauma, dissociation

is adaptive and helpful in the midst of a traumatic event because, in the face of fear or

terror, the body and mind can escape from the overwhelming emotional experience

(Cook et al., 2003). In some cases, typically survivors of chronic trauma, periods of

dissociation continue to occur even when the survivor is no longer in a stressful or fearful

environment. Dissociative symptoms can take many forms but the general purpose is to

disconnect from one's emotions. Behaviors may become automatic, one may feel

detached from his or her sense of self, one may detach from reality, and one may detach

from emotions.

Attachment

Trauma can significantly impact a developing child's attachment relationships.

Children learn to regulate affect and behavior from their primary caregivers (van der

Kolk, 2005). Children create their own internal working models of the world and

relationships by interacting with their parents. Ideally, parents provide positive modeling

so that children feel safe in the world and can rely on their parents (Bowlby, 1980). The

way children experience attachment in their formative years sets the stage for how they

will function later in life (van der Kolk, 2005).

Healthy attachment helps the child to develop self-regulatory processes, feelings of

safety in the world, a sense of agency, and the ability to communicate with others.

Overall, about 55-65% of children develop a secure attachment with their caregivers.

13
Secure attachments and responsive, supportive parenting can help children recover from

trauma (Cook et al., 2003).

Insecure attachments develop when caregivers do not provide the healthy and

supportive environment that their child requires. Over 80% of maltreated children have

been found to have insecure attachment patterns, leaving them vulnerable to further

abuse. Avoidant attachment occurs when the child experiences rejection from caregiver

and develops a sense of disregard or distrust of their emotions and of relationships with

others. Ambivalent attachment results from invalidation of the child by their parents,

resulting in disconnection from others at the first sign of rejection. Disorganized

attachment patterns occur when the parent is unable to model appropriate self-regulation

and self-soothing for the child. This can result in erratic behavior, switching from feeling

clingy to dismissive about relationships, rigid thinking, helplessness, poor language and

verbal development, problems with affect regulation and stress management, and

problems with empathy (Bowlby, 1980; Cook et al., 2003).

The parent's response to a trauma is critical for a child's healing and recovery. A

positive and supportive response by the parents in the face of a traumatic incident fosters

a child's recovery (van der Kolk, 2005). Positive attachment has been linked to greater

resilience including self-regulation abilities, positive beliefs about self, motivation to

interact with the environment, positive temperament, mastery and autonomy, and sense of

internal locus of control (Cook et al., 2003).

In contrast, if the parent(s) becomes overwhelmed in the face of trauma the child is

more likely to become overwhelmed. Recovery in this case may be a long-term process.

Parents with their own attachment problems are more at risk for poorly responding to

14
their children's needs (Cook et al., 2003). Therefore, there are two (among several) routes

by which attachment problems can develop. The first is when the parent is the

perpetrator, and the others is when parents by way of their own trauma have limited

parenting abilities and are unable to provide positive support to a traumatized child. The

important role of a positive parental response in the face of trauma can be described as

follows:

"complex trauma outcomes are most likely to develop and persist if an infant or child

is exposed to danger that is unpredictable and uncontrollable because the child's

body must allocate resources that are normally dedicated to growth and development

instead of survival. The greatest source of danger, unpredictability, and

uncontrollability for an infant or young child is the absence of a caregiver who

reliably and responsively protects and nurtures the child. The caregiver's ability to

help regulate bodily and behavioral responses provides experiences on 'co-

regulation' that contribute to the acquisition of self-regulatory capacities. Lack of

sustaining regulation with a primary caregiver puts the child at risk for inadequate

development of the capacity to regulate physical and emotional states." (p. 8, Cook

et al., 2003).

Trauma that is experienced at the hands of a parent, however, is particularly

traumatic for a child and significantly compromises a child's understanding of

attachment, trust, and safety (van der Kolk, 2005).

15
 Identity and Self-Concept

Wilson (2004) outlined six core dimensions of the self that are significantly impacted

after a trauma occurs: coherency, connection, continuity, energy, autonomy, and vitality.

After a trauma, a person experiences loss of meaning, loss of continuity, and loss of

intimacy with others. Freud (1916) stated:

"a person is brought so completely to a stop by a traumatic event which shatters the

foundation of his life that he abandons all interest in the present and remains

permanently absorbed in mental concentration upon the past."

Trauma can impact a person so fundamentally that their baseline physiological

functioning and their personality are permanently changed (Wilson, 2004). This is

particularly true in prolonged exposure to trauma. Wilson (2001) listed common

problems associated with the impact of trauma on attachment: alienation, mistrust of

others, guardedness, detachment and isolation, withdrawal, anhedonia, object relations

deficits, self-destructive relationships, impulsiveness, impaired sensuality, inability to

relax, unstable and intense relationships, boundary problems, and anxiety over

abandonment.

In childhood, the relationship with the caregiver can be a significant mitigating factor

in development of a self-concept in the face of trauma. A positive relationship with a

caregiver can help the child develop and maintain a sense of worthiness and competency

following a trauma. However, a negative relationship with the caregiver, or if the

caregiver was the perpetrator of the trauma, can lead to feeling of helplessness,

deficiency, incompetence, self-blame, feeling unlovable, or having a disorganized of

fragmented sense of self (Cook et al., 2003).

16
 Interpersonal Relationships

Chronic trauma can lead to problems with interpersonal relationships. If a caregiver

perpetrated the trauma or abuse, the survivor may struggle to develop healthy

attachments with others. The trauma survivor may also develop relational models that

revolve around their own negative self-perceptions (e.g., no one would want me because

I'm bad). Trust becomes difficult to establish in relationships and survivors may develop

generalized fears or expectations of being maltreated or abandoned in all relationships

(Briere & Spinnazzola, 2005). Trauma symptoms can also interfere with relationships

(e.g., hypervigilance, fear, heightened sensitivity to stimuli, issues with sex and body,

depression/moodiness, etc.)

Beliefs and Systems of Meaning and Understanding

Trauma can also affect a person's belief system. A traumatic experience can often

shatter a person's fundamental beliefs about the world and their trust in others. Trauma

victims may start to see new events through the lens of their prior trauma (van der Kolk,

2002). The impact of trauma is well captured by Wilson (2004):

"psychological trauma causes injury to the mind and its inherent processes and

functions, including the ego, identity, and self-structure. Psychological trauma is

caused by an external event that affects internal psychological phenomena at

multiple levels of functioning and in conscious and unconscious modalities of

awareness and behavior" (p. 12)

The following table is a summary of problems areas in children exposed to trauma

17
Table 1
Domains of Impairment in Children Exposed to Complex Trauma
Attachment
• Uncertainty about the reliability and
predictability of the world
• Problems with boundaries
• Distrust and suspiciousness
• Social isolation
• Interpersonal Difficulties
• Difficulty attuning to other people's emotional
states
• Difficulty with perspective taking
• Difficulty enlisting other people as allies
Biology
• Sensorimotor development problems
• Hypersensitivity to physical contact
• Analgesia
• Problems with coordination, balance, body tone
• Difficulties localizing skin contact
• Somatization
• Increased medical problems across a wide span,
(e.g., pelvic pain, asthma, skin problems,
autoimmune disorders, pseudoseizures)
Affect Regulation
• Difficulty with emotional self-regulation
• Difficulty describing feelings and internal
experience
• Problems knowing and describing internal states
• Difficulty communicating wishes and desires
Dissociation
• Distinct alterations in states of consciousness
• Amnesia
• Depersonalization and derealization
• Two or more distinct states of consciousness,
with impaired memory for state-based events
i i
From Cook, A., Blaustein, M., Spinazzola, J., & van der Kolk, B. (2003). Complex
trauma in children and adolescents. Los Angeles, CA: The National Child Traumatic
Stress Network. Document Number)
Behavioral Control
Poor modulation of impulses
Self-destructive behavior
Aggression against others
Pathological self-soothing behaviors
Sleep disturbances
Eating disorders
Substance abuse
Excessive compliance
Oppositional behaviors
Difficulty understanding and complying with rules
Communication of traumatic past by reenactment ir
day-to-day behaviors or play (sexual, aggressive,
etc.)
Cognition
• Difficulties in attention regulation and executive
function
• Lack of sustained curiosity
• Problems with processing novel information
• Problems focusing on and completing tasks
• Problems with object constancy
• Difficulty planning and anticipating events
• Problems understanding own contribution to what
happens to them
• Learning difficulties
• Problems with language development
• Problems with orientation in time and space
• Acoustic and visual perceptual problems
• Impaired comprehension of complex visual-spatial
patterns
Self-Concept
• Lack of a continuous, predictable sense of self
• Poor sense of separateness
• Disturbances of body image
• Low self-esteem
• Shame and guilt
18
 Thinking Beyond PTSD

Limits of the PTSD Diagnosis

The diagnosis of Post-Traumatic Stress Disorder was primarily created to describe

common symptoms associated with a single traumatic incident. However, as new

information was discovered about the impact of chronic trauma on development,

researchers realized that the diagnosis of PTSD failed to adequately capture the long-term

consequences of chronic and early exposure to trauma (Hall, 1999; van der Kolk &

Pelcovitz, 1999; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). PTSD

more adequately describes symptoms stemming from a circumscribed traumatic incident

(e.g., motor vehicle accident) that the individual experiences as significantly different

from their usual life events, while complex trauma better describes symptoms and

adaptations related to chronic and severe exposure to multiple incidents and multiple

modalities of trauma over time and to the phenomenon of experiencing these symptoms

during crucial periods of developments. Researchers believe that the symptoms resulting

from chronic trauma exposure are sufficiently different from those of PTSD that a

separate diagnosis is warranted that better captures the results of chronic trauma

(Luxenberg, Spinazzola, & van der Kolk, 2001).

The Beginning of Complex PTSD

The notion of a complex form of post-traumatic responses was alluded to in the

1960s in studies of Holocaust survivors but did not gain a strong footing until further

research in the early 1990s (Krystal, 1960; Herman, 1992). In the early 1990's, trauma

researchers began to focus on the long-term consequences of chronic trauma exposure.

19
Researchers conducted a series of studies with the purpose of examining alternate forms

of PTSD and associated types of symptoms. They also set out through the DSM-IV Field

Trials to examine whether the three symptom clusters for PTSD (avoidance,

hypervigilance, reexperiencing of the event) were sufficiently adequate to describe the

symptoms resulting from different types of trauma (Roth, Newman, Pelcovitz, van der

Kolk, & Mandel, 1997).

The impetus for this research came from clinical research reports of different clinical

presentations among people with extensive trauma histories as distinguished from people

with a single traumatic event. Moreover, researchers and clinicians began to realize that

people rarely were diagnosed with only PTSD (Luxenburg, Spinazzola, & van der Kolk,

2001). A National Comorbidity Study (Kessler, Sonnega, & Bromet, 1995) found that

people diagnosed with PTSD were eight times more likely to have had three or more

additional disorders than people without a PTSD diagnosis. Of the people diagnosed with

PTSD, 79% met criteria for at least one additional disorder and 44% of people diagnosed

with PTSD met criteria for at least three other disorders. The most common comorbid

conditions were major depression, anxiety disorders, substance abuse, somatization

disorders, and Axis II disorders. Clinical presentations also included separation anxiety,

phobic disorders, Attention-Deficit/Hyperactivity Disorders, and Oppositional Defiant

Disorder (Streeck-Fischer & van der Kolk, 2000). Thus, the focus shifted from PTSD as a

single diagnosis to a spectrum of post-traumatic disorders (Herman, 1992).

20
 Symptoms Associated with Chronic Trauma

As the focus shifted from "simple" PTSD to a more complex trauma disorder,

clinicians and researchers documented symptoms experienced by persons who reported

multiple traumas in their lifetime. In light of the new information that was gathered about

the impact of chronic trauma on development, researchers began to identify symptom

areas or clusters of impaired functioning that were associated with exposure to chronic

trauma.

Herman (1992) first categorized three general areas of disturbance in patients

reporting chronic trauma (e.g., physical abuse): somatization, dissociation, and

characterological. Common somatic complaints included hypervigilance, feeling anxious,

insomnia, tension headaches, gastrointestinal problems, abdominal, back, and pelvic pain,

and an increased startle reaction. She hypothesized that repetitive trauma experiences

amplified the physiological symptoms normally found in the PTSD diagnosis. Common

dissociative symptoms included suppression, minimization, denial, time and memory

disturbances, and the use of dissociation as a way to cope with stress.

The characterological symptoms revolved around relationship and identity problems

(Herman, 1992). Relationships after exposure to repeated trauma often reflected themes

of fear and helplessness experienced in the perpetrator-victim relationship during the

trauma. For example, a soldier is taken hostage and kept as a prisoner of war. The goal of

the perpetrator is to inflict fear and helplessness upon the victim. Perpetrators may

achieve this goal by restricting food, water, and bathroom privileges to the victim. The

victim then loses his sense of autonomy and control over his body and essentially

becomes dependent upon the perpetrator for basic needs. This dynamic is commonly seen

21
among children who are abused by their parents and also among battered women. In later

relationships these victims may be seen as passive or helpless. They may also experience

their relationships in extremes and have difficulty with balanced and reciprocal

attachment. The outside person may view these relationships as unstable and intense

(Herman, 1992).

Herman (1992) also noted significant identity changes among victims of chronic

trauma. She believed that the values, beliefs, and self-image or basic structures of the self

were changed by the traumatic experience. Victims reported a loss of sense of self and an

overall sense of badness and shame. Their identities appeared fragmented and a sense of

self was diminished or lost (Herman, 1992).

Following Herman's (1992) hallmark article on complex trauma, researchers began

to focus on understanding the developmental issues in the differential impact of trauma

on overall functioning. Trauma impacts people differently at different developmental

stages and chronic trauma in childhood can particularly impact development and

maturation (van der Kolk & Pelcovitz, 1999). Changes in personality functioning and

social development were also linked with chronic trauma histories (van der Kolk &

Pelcovitz, 1999; Luxenburg, Spinazzola, & van der Kolk, 2001). Poor self-regulation,

poorly modulated responses and emotions, and problems with self-definition and stable

sense of self were also cited as long-term outcomes of chronic trauma (Streeck-Fischer

& van der Kolk, 2000).

Research among populations such as battered women, victims of chronic or multiple

forms of child abuse, and concentration camp survivors continued to report other long-

term consequences from chronic trauma exposure (van der Kolk & Pelcovitz, 1999).

22
Trust was another common problem for these trauma survivors. Distrust of others,

inability to predict others, feeling suspicious of others, and intimacy problems were

reported (Streeck-Fischer & van der Kolk, 2000). Altered consciousness states such as

hypermnesia, dissociation, depersonalization, derealization, and amnesia were also

reported (van der Kolk & Pelcovitz, 1999; Streeck-Fischer, 2000).

Formalizing the Complex PTSD Diagnosis

Researchers began to categorize and formalize symptom clusters as more

information was gathered about long-term symptoms of chronic trauma. They began to

conceptualize Complex PTSD as a distinct disorder requiring another diagnostic term

than PTSD (Courtois, 2004).

The threshold criterion for PTSD is a single traumatic event that threatens or does

harm to a person's physical integrity. By contrast, the threshold criterion for Complex

PTSD is broader and emphasizes the dynamics or circumstances of the trauma. The type

of trauma that tends to result in Complex PTSD is one where the person is unable to flee

and/or is in a position of coercive control by the perpetrator(s) (Herman, 1992). In

addition, the impact of multiple incidents is cumulative over time. Childhood abuse,

intimate partner violence, loss of critical attachments, prisoners of war, campaigns of

ethnic cleansing or other war crimes against populations, and chronic illness involving

physical pain and/or multiple medical procedures are examples of chronic and repeated

trauma that may lead to Complex PTSD (Courtois, 2004).

Multiple symptoms are reported with chronic trauma such as depression, anxiety,

self-hatred, dissociation, substance abuse, revictimization, self-destructive behaviors,

23
risk-taking behaviors, problems in interpersonal and intimate relationships, despair,

emotional dysregulation, and medical or somatic problems among many others (Courtois,

2004). Six general areas were created to categorize the myriad symptoms of Complex

PTSD: affect dysregulation, problems with attention and consciousness, alterations in

self-perception, changes in relationships to others, somatization/medical problems, and

changes in belief or system of meaning (Courtois, 2004).

Affect dysregulation is difficulty regulating or managing one's emotions. Some

researchers believe it is the "core dysfunction" stemming from psychological trauma

(Luxenberg, Spinazzola & van der Kolk, 2001). Persons with affect regulation problems

may overreact, become overwhelmed, or have extreme reactions to seemingly benign or

small situations. They may engage in self-destructive behaviors and have problems with

self-soothing (Luxenberg, Spinazzola, & van der Kolk, 2001; Courtois, 2004). This often

translates into impulsive or controlling behaviors (e.g., bingeing and purging) as an

attempt to regain control over one's body. Persons may also engage in risk-taking

behavior such as unsafe sexual practices or other behaviors that reflect deficits in

judgment, emotion regulation or impulse control. Suicidal ideation may also be present

along with self-injurious behavior. There may also be problems modulating anger

(Luxenberg, Spinazzola, & van der Kolk, 2001).

People with complex trauma histories also often exhibit problems with attention and

alterations in consciousness. For example, dissociation is a common symptom in

Complex PTSD. Dissociation is a "disruption in the integration of consciousness,

identity, memory, or perception" (p. 27, Dalenberg, 1999). Persons may only remember

certain aspects of the trauma. Portions of the memory may be cut off as a coping

24
mechanism to avoid dealing with the painful emotions of the traumatic experience.

Forgetfulness or "spacing out" is also common and may indicate dissociation (an

automatic defense outside of conscious control) or suppression (deliberate attempt to

deny or avoid painful memories). The person may also exhibit amnesia for certain

periods in their life. Dissociation is more frequent in persons with multiple traumas in

their life (Luxenberg, Spinazzola, & van der Kolk, 2001).

Disturbance in self-perception is the third symptom cluster in the Complex PTSD

diagnosis. Survivors of chronic trauma often develop a negative perception of

themselves. Victims of chronic trauma may translate the bad things that have happened to

them as an indication that they themselves are bad people. Particularly if the trauma

began in childhood, "these perceptions spring directly from the way young children

interpret the world; their preoperational thinking places them in the center of the

universe, leading them to believe that they have 'caused' their own mistreatment" (p.

378, Luxenberg, Spinazzola, & van der Kolk, 2001). Survivors tend to have an inner

sense of badness and feel damaged, misunderstood, and undesirable (Luxenberg,

Spinazzola, & van der Kolk, 2001). Chronic guilt, a deep sense of shame, and feeling a

sense of responsibility about the trauma are also common reactions among survivors

(Courtois, 2004).

The fourth symptom cluster involves disturbances in relationships. The fundamental

problem in this area of functioning is that the person may have "no healthy template for

interpersonal interactions" (p. 378, Luxenberg, Spinazzola, & van der Kolk, 2001). That

is, the trauma survivor holds a negative and victimizing view of interpersonal

relationships based on their traumatic experiences. Therefore, they may have difficulty

25
trusting others and may not know what "normal" relationships are like. Difficulty with

intimacy is also a common problem (Courtois, 2004).

Research has found that survivors of trauma are more likely to be re-victimized than

people without trauma histories. One theory holds that survivors can only experience

emotion when they are being victimized and therefore they place themselves in

relationships that foster this type of dynamic (Luxenberg, Spinazzola, & van der Kolk,

2001). Chronic trauma may significantly alter the way in which someone views his or her

role in a relationship. For example, children who are victimized by their parents may

develop a model of attachment that is based on the traumatic relationship with their

parents. In therapy, a survivor may also reenact this dynamic with his or her therapist.

Re-victimization may also be a result of a distorted "warning system" in

relationships. The chronic trauma survivor may become accustomed to fear and danger as

a "normal" component to relationships. They may anticipate fear and danger as an

inevitable and expected part of their future relationships. Therefore, they may not be

aware of warning signs in future relationships as compared to someone who has a healthy

experience and view of relationships (Luxenberg, Spinazzola, & van der Kolk, 2001).

This view of relationships is linked to the risk-taking behaviors in which trauma

survivors frequently engage. Their internal gauge for safety and danger in relationships

may be radically different than persons without a chronic trauma history.

Somatization is the fifth area of disturbance. Chronic trauma exposure produces a

baseline shift in homeostatic processes in the body. The natural hard-wired stress

response with which we are all born is shifted at the most basic level and produces

significant behavioral and physiological problems. The limbic system, involved in

26
assessing emotional stimuli, is disrupted and leads to problems in emotional processing.

The nervous system becomes overresponsive which results in a lower threshold for

response to environmental stimuli and an exaggerated startle response. This explains why

many trauma survivors seem "jumpy" to sounds of doors slamming or other common

environmental noises that they find startling.

Trauma also impacts the endocrine system resulting in significant changes in

hormone production. Stress hormones prepare the body to react in dangerous situations.

Once the environmental stressor is gone, the body releases Cortisol to suppress the stress

hormone. In trauma victims, Cortisol is underproduced resulting in a chronically elevated

level of stress hormones in the body. Consequently, the body is almost in a constant state

of stress response waiting for the next traumatic event. While this is adaptive in the face

of chronic trauma, this causes significant problems in functioning when a survivor is no

longer in an immediately or potentially dangerous situation (Luxenberg, Spinazzola, &

van der Kolk, 2001). Norepinephrine and catecholamines are overproduced which results

in sleep problems, sensitivity to stimuli, and anxiety. Increased opioid production

produces an analgesic effect in response to triggers or stimuli in the environment that are

similar to those present during the trauma (Luxenberg, Spinazzola, & van der Kolk,

2001). This may be one reason why survivors appear to dissociate or "space out"

randomly, particularly if the trigger is not easily identified.

The last cluster of symptoms involves changes in systems of meaning. Chronic

trauma survivors struggle to make meaning about why they were victimized. The

traumatic experience challenges their belief system about themselves and others, and

27
undermines a belief in a just world. Survivors may take on a fatalistic approach to life

and feel helpless and anhedonic (Luxenberg, Spinazzola, & van der Kolk, 2001).

Types of Traumas Associated with Complex PTSD

In general, higher rates of complex post-traumatic symptoms are associated with

interpersonal trauma and more incidents of direct exposure to trauma (van der Kolk,

2002). Interpersonal trauma includes physical abuse, sexual abuse, torture, and other

traumas where one person upon another inflicts pain, fear, or harm. Early life onset of

trauma is associated with more symptoms and problems than late onset (van der Kolk,

Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Therefore, chronic trauma experienced in

childhood and early formative years increases the likelihood of developing Complex

PTSD.

Prevalence and Utility of Complex PTSD Diagnosis

Several studies have been conducted since the Complex PTSD diagnosis was first

conceptualized. The most comprehensive study to date is the DSM-IV Field Trial studies

conducted from 1991 to 1992. Over 500 participants were involved in the Field Trials

and the data yielded several interesting findings about Complex Trauma.

The Field Trial studies examined trauma-related symptoms among clinical and

community populations. The researchers used the Disorders of Extreme Stress Not

Otherwise Specified (DESNOS) diagnosis (also known as Complex PTSD) as a guide for

assessing symptoms and examining correlations with types of trauma. The results

demonstrated that most participants that met the DESNOS diagnosis also met the PTSD

28
diagnosis; only 6% of the sample had DESNOS without PTSD. Early onset trauma

correlated with more lifetime DESNOS and PTSD (61%) as compared to late onset with

33% combined DESNOS/PTSD and 27% PTSD alone. Therefore, trauma incurred at a

younger age was associated with an increased likelihood for developing DESNOS

symptoms (van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005).

Longer exposure to trauma was also correlated with later DESNOS symptoms. The

authors wrote "trauma that is prolonged, that first occurs at an early age and that is of an

interpersonal nature, can have significant effects on psychological functioning above and

beyond PTSD symptomatology" (p. 394, van der Kolk, Roth, Pelcovitz, Sunday, &

Spinazzola, 2005). These findings suggest that the DESNOS/Complex PTSD diagnosis

captures symptoms from chronic trauma that are not readily captured by the standard

PTSD diagnosis. The authors stressed the importance of examining information

processing, perception, affect regulation, impulse control, personality development, and

other comorbid conditions when patients present with a chronic trauma history.

Another set of researchers examined the Field Trial data for the presence of Complex

PTSD in victims exposed to sexual and physical abuse (Roth, Newman, Pelcovitz, van

der Kolk, & Mandel, 1997). The original Field Trial sample consisted of 395 participants

from a clinical setting and 128 people from the community who voluntarily sought

treatment. For this study, a total of 234 participants who were 81% female and 89%

Caucasian were included. Participants were administered the Potential Stressor Events

Interview, the Structured Clinical Interview for DSM-IIIR, the Diagnostic Interview

Scheduled, and the Structured Interview for Disorders of Extreme Stress (SIDES).

Participants were placed into three groups based on their history: sexual abuse only,

29
physical abuse only, and combined sexual and physical abuse. The participants were also

categorized by duration of trauma, acute (less than one year) versus chronic abuse (2+

years), and by age of onset of the trauma, early (before age 13) versus late (after age 13).

Results found that early onset abuse was twice as likely to become chronic when

compared to late onset abuse. Seventy-six percent of those with a sexual abuse history

met both PTSD and Complex PTSD diagnoses as compared to physical abuse (53%).

Half of the participants met the criteria for lifetime Complex PTSD. In women, the

highest risk for meeting Complex PTSD criteria was the presence of both sexual abuse

and physical abuse.

These results indicate that physical abuse and sexual abuse are each risk factors for

Complex PTSD. The combination of physical and sexual abuse is correlated with an

increased risk for Complex PTSD as compared to physical or sexual abuse alone. The

researchers found that the Complex PTSD diagnosis seemed to better capture the long-

term impact of sexual abuse compared to physical abuse. They believe that sexual abuse

involved more shame, secrecy/isolation, intrusiveness, and boundary violations that led a

victim to use more extreme coping skills such as dissociation (Roth, Newman, Pelcovitz,

van der Kolk, & Mandel, 1997). The authors emphasized the importance of routinely

assessing for Complex PTSD symptoms among survivors of physical and sexual abuse.

The same study found that the Complex PTSD diagnosis had high utility and that

clinicians were reliable and consistent in their diagnosis.

Complex PTSD/DESNOS has also been examined among children with histories of

sexual abuse. Hall (1999) examined records from 100 children ages 3 to 7 to assess the

presence of complex trauma symptoms. The records were taken from two separate child

30
abuse treatment programs in Canada. The purpose of the study was to examine whether

the Complex PTSD diagnosis captured the characteristic long-term symptoms from

sexual abuse that seemed to be spread out in various disorders including PTSD,

somatization disorders, and dissociative identity disorder. The records of 36 males and 63

females were examined, with 50% of the kids from single mother homes and 49% from

lower income homes. The researchers examined family history, abuse history, symptoms,

presenting problems, and diagnoses from records such as school and medical records.

Ten child subjects did not met PTSD criteria, 32 partially met PTSD criteria, and 57

child subjects met the full criteria for PTSD. The study found that 58% of the children

meeting full PTSD also met all seven of the cluster criteria for DESNOS and 77% met

criteria for at least six clusters of the DESNOS diagnosis. They also found that children

who met PTSD diagnostic criteria had at least twice as many negative events as those that

did not meet PTSD criteria. The authors concluded that clinicians should consider the

cumulative effect of trauma when assessing trauma symptoms. They recommended

thinking about interpersonal trauma as a process rather than a single event with mediating

or moderating factors such as family support and the personal meaning of the trauma.

Developmental stage at the time of the trauma is an additional and critical factor to

consider when developing a treatment plan (Hall, 1999).

Complex PTSD Diagnosis

In the current DSM-IV-TR, DESNOS/Complex PTSD is alluded to in the associated

features of the PTSD section (American Psychiatric Association, 2000). Currently there

is an initiative by trauma researchers to formally introduce DESNOS/Complex PTSD as a

31
diagnosis in the next revision of the DSM. The following are the proposed diagnostic

criteria for Disorders of Extreme Stress Not Otherwise Specified (DESNOS) or Complex

PTSD developed subsequent to the DSM-IV Field Trial for PTSD (Luxenberg,

Spinazzola, van der Kolk, 2001).

DIAGNOSTIC CRITERIA FOR DISORDERS OF EXTREME STRESS (DESNOS)2

I. Alterations in Regulation of Affect and Impulses

(A and 1 ofB-F required)

A. Affect Regulation (2)

B. Modulation of Anger (2)

C. Self-Destructive

D. Suicidal Preoccupation

E. Difficulty Modulating Sexual Involvement

F. Excessive Risk-taking

II. Alterations in Attention or Consciousness

(A or B required)

A. Amnesia

B. Transient Dissociative Episodes and Depersonalization

III. Alterations in Self-Perception

(Two ofA-F required)

A. Ineffectiveness

B. Permanent Damage

Numbers in parentheses indicate number of subscale items required for endorsement of

subscale. Only one item required for endorsement of all other subscales.

32
 C. Guilt and Responsibility

D. Shame

E. Nobody Can Understand

F. Minimizing

IV. Alterations in Relations With Others

(One ofA-C required)

A. Inability to Trust

B. Revictimization

C. Victimizing Others

V. Somatization

(Two ofA-E required)

A. Digestive System

B. Chronic Pain

C. Cardiopulmonary Symptoms

D. Conversion Symptoms

E. Sexual Symptoms

VI. Alterations in Systems of Meaning

(A or B required)

A. Despair and Hopelessness

B. Loss of Previously Sustaining Beliefs

33
 Developmental Trauma Disorder

Developmental Trauma Disorder (DTD) is another diagnostic name that has been

proposed to identify the various symptoms that emerge from chronic trauma exposure

during childhood. The basis for DTD is the "notion that multiple exposures to

interpersonal trauma, such as abandonment, betrayal, physical or sexual assaults, or

witnessing domestic violence have consistent and predictable consequences that affect

many areas of functioning" (p. 10, van der Kolk, 2005). While the proposed symptoms

are similar, emphasis is placed on the impact of trauma on development since it is

believed that trauma has its strongest impact during the first ten years of life (van der

Kolk, 2005). Developmental trauma disorder is emerging as the likely name in the next

DSM rather than Complex PTSD, because it emphasizes the developmental nature of the

trauma adaptations.

Youth, Trauma and the Forensic System

Studies have been conducted that examine the symptom presentation of youth who

have been exposed to trauma. Within this population, a small amount of research has

explored the particular symptom presentation of youth who are court-involved for either

criminal or civil reasons (e.g., child abuse, parental fitness).

One such study examined the symptom presentation and psychiatric co-morbidity of

children diagnosed with PTSD who were court-involved secondary to being removed

from their homes due to abuse and/or neglect charges against the parents (Famularo,

Fenton, Kinscherff, & Augustyn, 1996). One hundred seventeen children aged 6 to 12

were interviewed using the Diagnostic Interview for Child and Adolescents - Child

34
version (DICA-Child). The study compared a group of maltreated children who met

criteria for PTSD to maltreated children who did not meet PTSD criteria. Results showed

that ADHD, brief psychotic disorder or psychotic disorder NOS, and anxiety disorder

were more common among the PTSD children than the comparison group. Suicidal

ideation was greater in the PTSD group with 14.6% of the PTSD children reporting

transient suicidal ideation versus 1.3% of the non-PTSD children. The study found that

the brief experience of psychosis (impaired reality testing) was more reminiscent of the

trauma as opposed to resembling the more classic symptoms of schizophrenia such as

bizarre delusions, flat affect, and poor logic. Interestingly, the study found no correlation

between PTSD and formal behavioral problems such as Oppositional Defiant Disorder or

Conduct Disorder, suggesting that behavioral problems among these youth may not be a

result of PTSD. Moreover, treating the PTSD symptoms alone may not help in treating

the behavioral problems (Famularo, Fenton, Kinscherff, & Augustyn, 1996).

One study examined the relationships between childhood victimization, running

away, and delinquency (Kaufman & Widom, 1999). Approximately 500,000 children run

away each year in the United States. Research has shown that 5 to 80 percent of children

who run away report abuse in the home (Kaufman & Widom, 1999). Although there are

many theories to explain why children run away, one theory is that these children are

trying to escape abusive or destructive homes. The purpose of the study was to examine

how running away increases delinquency in abused versus non-abused children. Two

models were presented: mediator versus moderator. The mediator model proposes that

childhood victimization increases the risk of running away, which in turn increases the

risk of delinquency. The moderator model suggests that the interaction of childhood

35
victimization and running away leads to an increase in delinquency. That is, running

away impacts abused or neglected children differently than non-abused children

(Kaufman & Widom, 1999).

The study was designed as a 20-year prospective study and included children who

had been abused before age 11 and their delinquency status had been court-substantiated.

The actual sample consisted of 50 males and 50 females, predominantly White, with an

average age of 28 years. Demographic comparisons between the abused and non-abused

groups found that abused children had finished less school (1 l l grade versus 121 +grade)

and held a lower-paying job (Kaufman & Widom, 1999).

The results found that victims of abuse were more likely to run away than non-

victims. Severity of abuse was correlated with chance of arrest and found that more

severe abuse increased the likelihood of arrest. The findings supported the moderator

model of childhood victimization, running away and delinquency. Therefore, the

interaction of running away and childhood victimization has a different impact on

chances of delinquency than each factor alone. This also indicates that running away

impacts abused children differently than non-abused children (Kaufman & Widom,

1999).

A similar study examined child maltreatment histories among runaway and

delinquent children (Famularo, Kinscherff, Fenton, & Bolduc, 1990). The study focused

on the relationship between the type of court involvement and the various histories of

abuse. Results found that 42% of delinquents and 52% of status offenders has suffered

some type of maltreatment. A higher rate of abuse was observed among youth

committing violent crimes versus non-violent crimes. Among runaways, 74% had

36
histories of maltreatment, with sexual abuse rates seven times higher among runaways

than status offenders (Famularo, Kinscherff, Fenton, & Bolduc, 1990).

Although age and gender played a role, the study found that among the delinquents,

those with a history of child maltreatment had a significantly greater probability of

having committed a violent crime than those with no abuse history. Among status

offenders, those who had been maltreated had a significantly greater probability of being

in the runaway group than those with no abuse histories. This suggests that violence is

associated with a history of maltreatment, with those committing a violent crime being

twice as likely to have been victims of physical abuse than the rest of the delinquent

group. Moreover, runaway status offenders are more likely to have been maltreated, and

seven times more likely to have been sexually maltreated. Overall, children who runaway

or turn to violence are more likely to have experienced maltreatment (Famularo,

Kinscherff, Fenton, & Bolduc, 1990).

Another study examined the prevalence of psychiatric disorders among adolescents

exposed to domestic violence and physical abuse (Pelcovitz, Kaplan, DeRosa, Mandel, &

Salzinger, 2000). Research has shown that the most common trigger for marital conflict

is disagreement over child rearing and as the frequency of marital conflict increases, the

risk for child abuse also increases. The study examined the psychological functioning of

adolescents exposed to domestic violence versus domestic violence and physical abuse. A

total of 89 physically abused adolescents, 32 exposed to interpersonal violence and 59 not

exposed to interpersonal violence, were matched to a sample of 96 non-abused

adolescents. Assessment tools used in the study were the Conflict Tactics Scale (measure

coping styles with conflict), Family Disagreements Interview (structured interview to

37
gather information about abusive behavior among family members), Sexual Behavior

Screen (used to screen out adolescents with a sexual abuse history), Kiddie-Schedule for

Affective Disorders and Schizophrenia (semi-structured diagnostic interview for 6 to 17-

year olds), and other measures of family cohesion and adaptability, parent-child bonds,

and parents' psychiatric disorders (Pelcovitz, et al., 2000).

Results found that adolescents exposed to physical abuse and witnessing

interpersonal violence were at greater risk for psychiatric disorders than exposure to

violence alone. Specifically, adolescents exposed to both forms of trauma were five times

more likely to be currently depressed, four times more likely to have oppositional defiant

disorder (ODD), and were at greater risk for developing PTSD. When controlling for

physical abuse, exposure to interpersonal violence significantly predicted PTSD,

Seasonal Affective Disorder (SAD), depression, and ODD. Anxiety disorders, dysthymia,

ADHD and Conduct Disorder were not significantly different between groups. However,

anxiety disorders among adolescents exposed to both forms of trauma were more specific

to trauma versus generalized anxiety disorder, and they were at greater risk for more

severe forms of dysthymia and meet criteria for major depressive disorder (Pelcovitz, et

al., 2000).

Taken together, these studies indicate that delinquent and court-involved youths tend

to have higher rates of maltreatment and subsequent problems as compared to youths

who are not court-involved.

38
 Assessment Tools

Thorough investigation of trauma symptoms and history is an important component

in the identification and effective treatment of trauma symptoms. Comparing a person's

pre-trauma and post-trauma functioning can describe the impact of the trauma on baseline

functioning (Wilson, 2004). Knowing the frequency, duration, severity and intensity of

the trauma and the impact of the trauma on the core self are all important for proper

treatment (Wilson, 2004).

Trauma-informed psychological testing and structured tools can provide objective

data about a person's trauma history and current functioning (Briere, 2006). Trauma-

based assessment tools include structured interviews, self-report measures, and

checklists. Some tools focus primarily on assessing PTSD symptoms such as the Post-

traumatic Stress Disorder Scale (Foa, 1995), and the Detailed Assessment of Post-

Traumatic Stress (Briere, 2001). Self-report checklists such as the Trauma Symptom

Inventory (TSI; Briere, 1995) and the Trauma Symptom Checklist for Children (TSCC;

Wolpaw, Ford, Newman, Davis, & Briere, 2005) provide information about trauma

symptoms and functioning that may otherwise not be captured through interview.

Structured interviews consist of interview questions that are intended to gather specific

information about a particular disorder or area of functioning. Several structured

interview scales assess trauma symptoms.

Two validated assessment tools currently exist for Disorders of Extreme Stress

(Complex PTSD). The Self-Report Inventory for Disorders of Extreme Stress (SIDES-

SR) is a 45-item questionnaire that measures the baseline severity of DESNOS.

Symptoms in all six clusters and symptoms changes over time are assessed with this tool

39
(Luxenburg, Spinazzola, & van der Kolk, 2001). The second validated tool is the

Structured Interview for Disorders of Extreme Stress (SIDES) and resembles the

questions on the SIDES-SR.

Structured Interview for Disorders of Extreme Stress

The Structured Interview for Disorders of Extreme Stress (SIDES) is a 45-item

structured interview that assesses symptoms of DESNOS. The questions are divided into

the six symptom clusters of DESNOS and for each question the subject is asked to rate

the severity, duration, and frequency of the symptom on a 4-point scale. The questions

help to gather information that pertains to both a possible DESNOS diagnosis and to the

impact of the trauma on the subject. The SIDES helps to pinpoint the most severe and

important clinical issues to address first. Studies have found that the tool is a reliable and

valid measure of symptoms related to trauma and traumatic stress (van der Kolk &

Pelcovitz, 1999).

The SIDES was first developed in the mid-1990s as a tool to assess the types of

symptoms resulting from trauma exposure that may not otherwise be captured by the

PTSD diagnosis (Pelcovitz, van der Kolk, Roth, Mandel, Kaplan, & Resick, 1997). One

study examined results from the SIDES comparing three dimensions: early onset

interpersonal abuse, late onset interpersonal abuse, and persons exposed to a disaster. At

the time the study was conducted, the researchers were still gathering information about

DESNOS and the different symptom clusters. The study participants were the same as

those in the DSM-IV Field Trial Studies.

40
 The SIDES captures symptoms in seven clusters: regulation of affect and impulse,

attention and consciousness, self-perception, perception of the perpetrator, relations with

others, somatization, and systems of meaning. Trauma history was assessed using the

Potential Stressful Events Interview. Results found more females in the early and late

onset trauma groups than in the disaster group. Also, the disaster group had more married

participants than the early or late onset groups. Significant differences in six out of seven

subscales were found between the early onset compared to disaster groups and the late

onset compared to disaster groups, with more symptoms present in the early and late

onset abuse groups. The study also found high inter-rater reliability for the SIDES. The

perception of the perpetrator cluster was dropped from the SIDES and eventually the

DESNOS criteria because of low reliability (Pelcovitz et al., 1997).

This study demonstrated that the SIDES is a reliable tool for assessing symptoms of

DESNOS and a useful tool to assess whether a person suffers from trauma symptoms not

captured by the PTSD diagnosis (Pelcovitz et al., 1997).

A second study was conducted to assess the validity of the SIDES among 74

survivors of childhood sexual abuse that had been diagnosed with PTSD. The researchers

used the SIDES to assess the six DESNOS symptom clusters. The participants were also

administered other trauma assessment tools that measure symptoms in the different

DENOS clusters. The results showed strong correlations between the SIDES and the

other trauma assessment tools. The SIDES was found to be a valid and reliable measure

of trauma symptoms among sexual abuse survivors (Zlotnick & Pearlstein, 1997).

41
 Present Study

The present study explored the prevalence and types of trauma and post-traumatic

symptoms among court involved youth referred to the court clinic for evaluation. A

standard data collection form (Appendix A) was used to assess the frequency and

modality of trauma exposure and the types of symptoms present.

It was hypothesized that these youth would demonstrate a wide range of trauma

symptoms and modalities of trauma exposure. Prevalence rates for trauma exposure and

symptoms were calculated to measure the frequency and types of trauma experienced by

these youth. Information about symptom presentation was qualitatively compared to the

current PTSD and Complex PTSD diagnoses to explore whether these diagnoses capture

the clinical presentation of these youth.

42
 CHAPTER 3

METHOD

The present study examined the prevalence and types of trauma and post-traumatic

symptoms among court-involved youth who were referred for court clinic evaluation.

Research Design

The current study involved reviewing past juvenile court clinic evaluations using a

structured questionnaire that investigated the frequency and nature of trauma exposure

among court-involved youths referred for court clinic evaluations as reflected in those

evaluation reports. Prevalence rates were calculated based on the questionnaire responses.

The questionnaire responses were also analyzed to explore relationships between

modality of trauma experienced and symptom presentation. Symptoms reported in the

court clinic evaluations were compared to current PTSD and Complex PTSD/DESNOS

symptom criteria to investigate whether these diagnoses captured the clinical presentation

described in the evaluation.

Participants

The juvenile court clinic evaluations are the work product of the Juvenile Court

system. Approval for access to and review of juvenile court clinic evaluations was

obtained from the Chief Justice of the Juvenile Court (or his/her designee). Informed

consent from youth (or the parents or legal guardians) who were referred for court-

ordered evaluations was not required to review court clinic evaluations because the

reports belong to the Juvenile Court and data was gathered based on reports from

43
evaluations that had already been conducted. Additionally, these evaluations were

conducted "in anticipation of litigation" and are therefore exempt from HIP A A

requirements and conducted after a Lamb warning that waives any psychotherapist-

patient confidentiality under Massachusetts law and makes the use of these reports

entirely subject to the discretion of the Juvenile Court. However, confidentiality of the

youth was still maintained as described in the confidentiality section below and no

individually identifiable information was revealed.

Measures

The primary assessment tool was the questionnaire outlined in Appendix A. Items on

the questionnaire were designed to assess a wide range of trauma factors such as modality

of trauma, frequency, and symptoms. The term "client" implied the child, but in some

cases information in the report was also gathered from parents, other family members, the

Department of Children and Families (DCF), and other third party members. Information

regarding trauma exposure and symptoms that was gathered and documented in the report

was included in the coding as part of the "client" information. The following is a

description of each item to be coded on the data collection form.

Item 1: Sex

• Coding of the child's sex as male, female, transgender, or other.

Item 2: Age

• Coding of the child's age in years.

Item 3: Race

• Coding of the child's race as identified in the court clinic report.

44
Item 4: Ethnicity

• Coding of the child's ethnicity as identified in the court clinic report.

Item 5: Grade Level

• Coding of the child's current grade level as identified in the court clinic

report.

Item 6: First Court Report

• Coding of whether this was the first court clinic report that was conducted for

this child. If yes, then the age of first involvement was noted. The type of

case that required a previous court clinic report was also documented (e.g.,

CHINS, Delinquency). However, the history of prior evaluations may be

unknown to the current evaluator as there is no statewide database for

clinicians to check, so this variable could only be considered an

approximation and was limited in its accuracy.

Item 7: Type of Evaluation

• The type of evaluation for the court report currently being reviewed was

documented as identified in the court report. In this study, only CHINS and

Delinquency court clinic reports were reviewed. In Delinquency cases, only

68A pre-adjudication cases were included. For CHINS cases, the types of

case were noted (e.g., Stubborn, Runaway, Habitual Offender, and Truancy).

Item 8: Physical Abuse

• For the purposes of this project, physical abuse was defined as follows:

"causing or attempting to cause physical pain or injury. It can result

from punching, beating, kicking, burning, or harming a child in other
ways. Sometimes, an injury occurs when a punishment does not fit a

45
 child's age or condition." (www.nctsnet.org, National Child Traumatic
Stress Network, 2008).

• "Single event" indicated that only one instance of physical abuse was

reported/documented in the report.

• "Multiple events" indicated that two or more separate events of physical

abuse were reported/documented in the report.

• "Client denied" indicated that the report documented that the client denied

any history of physical abuse.

• "No information available" indicated that no information regarding exposure

to physical violence was available in the report.

Item 9: Emotional Abuse/Psychological Maltreatment

• For the purposes of this project, emotional abuse/psychological maltreatment

was defined as follows:

"Psychological maltreatment means a repeated pattern of caregiver

behavior or extreme incident(s) that convey to children that they are
worthless, flawed, unloved, unwanted, endangered, or only of value in
meeting another's needs" (APSAC, 1995, p.2)
"Psychological maltreatment includes (a) spurning, (b) terrorizing, (c)
isolating, (d) exploiting/corrupting, (e) denying emotional
responsiveness, and (f) mental health, medical, and educational
neglect." (Hart, Brassard, Binggeli, & Davidson, 2002).

"Single event" indicated that only one instance of emotional

abuse/psychological maltreatment was reported/documented in the report.

"Multiple events" indicated that two or more separate events of emotional

abuse/psychological maltreatment were reported/documented in the report.

"Client denied" indicated that the report documented that the client denied

any history of emotional abuse/psychological maltreatment.

46
 • "No information available" indicated that no information regarding exposure

to emotional abuse/psychological maltreatment was available in the report.

Item 10: Neglect

• For the purposes of this project, child neglect was defined as follows:

"when a parent or guardian does not give a child the care it needs
according to its age, even though the parent or guardian can afford to
give that care or is offered help to give that care. Neglect can mean not
giving food, clothing, and shelter. It can mean that a parent or guardian
is not bringing the child to medical or mental health treatment or not
giving the child prescribed medicines the child needs. Neglect can also
mean neglecting the child's education. Keeping a child from school or
from special education can be neglect. Neglect also includes exposing a
child to dangerous environments. It can mean poor supervision for a
child, including putting the child in the care of someone not capable of
caring for children. And neglect can mean abandoning a child or
expelling it from home." (www.nctsnet.org, National Child Traumatic
Stress Network, 2008).

• "Single event" indicated that only one instance of neglect was

reported/documented in the report.

• "Multiple events" indicated that two or more separate events of neglect were

reported/documented in the report.

• "Client denied" indicated that the report documented that the client denied

any history of neglect.

• "No information available" indicated that no information regarding exposure

to neglect was available in the report.

Item 11: Sexual Abuse/Rape

• For the purposes of this project, sexual abuse and rape was defined as

follows:

"Child sexual abuse includes a wide range of sexual behaviors that take
place between a child and an older person or alternatively between a

47
 child and another child/adolescent. Behaviors that are sexually abusive
often involve bodily contact, such as in the case of sexual kissing,
touching, fondling of genitals, and intercourse. However, behaviors
may be sexually abusive even if they do not involve contact, such as in
the case of genital exposure ("flashing"), verbal pressure for sex, and
sexual exploitation for purposes of prostitution or pornography"
(www.nctsnet.org, National Child Traumatic Stress Network, 2008).

• "Single event" indicated that only one instance of sexual abuse was

reported/documented in the report.

• "Multiple events" indicated that two or more separate events of sexual abuse

were reported/documented in the report.

• "Client denied" indicated that the report documented that the client denied

any history of sexual abuse.

• "No information available" indicated that no information regarding exposure

to sexual abuse was available in the report.

Item 12: Exposure to Community/School Violence

• For the purposes of this project, Community/School Violence was defined as

follows:

"Community and school violence include predatory violence (robbery,

for example) and violence that comes from personal conflicts between
people who are not family members. It may include brutal acts such as
shootings, rapes, stabbings, and beatings. Children may experience
trauma as both victims and perpetrators of violence. They also can be
affected as witnesses (for example, seeing someone killed or simply
hearing gunfire).

Indicators of school violence include fatal and nonfatal student

victimization, nonfatal teacher victimization, students being threatened
or injured with a weapon at school, fights at school, and students
carrying weapons to school. Formal definitions of school violence
range from very narrow to very broad. The Center for the Prevention of
School Violence, for example, defines it broadly as "any behavior that
violates a school's educational mission or climate of respect or
jeopardizes the intent of the school to be free of aggression against

48
 persons or property, drugs, weapons, disruptions, and disorder."
Students, teachers, and administrators alike can be victims of school
violence" (www.nctsnet.org, National Child Traumatic Stress Network,
2008).

• "Single event" indicated that only one instance of community/school

violence was reported/documented in the report.

• "Multiple events" indicated that two or more separate events of

community/school violence were reported/documented in the report.

• "Client denied" indicated that the report documented that the client denied

any history of community/school violence.

• "No information available" indicated that no information regarding exposure

to community/school violence was available in the report.

Item 13: Exposure to Intimate Partner Violence (Domestic Violence)

• For the purposes of this project, Intimate Partner Violence/Domestic

Violence was defined as follows:

"Domestic violence is sometimes called intimate partner violence,

domestic abuse, or battering. It includes actual or threatened physical or
sexual violence or emotional abuse between adults in a child's home
environment. Domestic violence can be directed toward a current or
former spouse or relationship partner, whether they are heterosexual or
same-sex partners" (www.nctsnet.org, National Child Traumatic Stress
Network, 2008).

• "Single event" indicated that only one instance of intimate partner

violence/domestic violence was reported/documented in the report.

• "Multiple events" indicated that two or more separate events of intimate

partner violence/domestic violence were reported/documented in the report.

• "Client denied" indicated that the report documented that the client denied

any history of intimate partner violence/domestic violence.

49
 • "No information available" indicated that no information regarding exposure

to intimate partner violence/domestic violence was available in the report.

Item 14: Other

• "Other" types of trauma can include natural disasters, refugee status, war

trauma, terrorism, motor vehicle accidents, and medical trauma.

• "Single event" indicated that only one instance of another type of trauma

was reported/documented in the report. A brief description of the type of

trauma was documented on the data form as described in the court report.

• "Multiple events" indicated that two or more separate events of another type

of trauma were reported/documented in the report. A brief description of the

types of trauma was documented on the data form as described in the court

report.

• "Client denied" indicated that the report documented that the client denied

any history of any other type of trauma.

• "No information available" indicated that no information regarding exposure

to any other type of trauma was available in the report.

Iteml5:PTSD

• This item provided a checklist for the types of symptoms documented in the

report that are criteria for the diagnosis of Post-Traumatic Stress Disorder.

Symptoms were coded as documented/described by the court clinician in the

report.

Item 16: Complex PTSD

50
 • This item provided a checklist for the types of symptoms documented in the

report that are criteria for the diagnosis of Complex PTSD. Symptoms were

coded as documented/described by the court clinician in the report. In

general, for both PTSD and Complex PTSD symptoms, a positive score was

noted when the clinician specifically identified the symptoms or if the

clinician described the symptom. For example, if the clinician wrote in the

report "the youth has brief moments where she remembers the trauma and

this causes her distress", it was inferred that this youth was experiencing

flashbacks.

Item 17: Trauma Assessment/Testing

• This item documented whether or not a specific tool was reported as being

used by the clinician for assessing trauma that is separate from the interview.

This data will help to understand what types of assessment tools (if any)

clinicians may be using to help them in their trauma assessment. A

description section was provided to document the type of assessment tool

used by the clinician.

Item 18: Trauma Diagnosis

• This item documented the trauma diagnosis given in the report (if

applicable).

Item 19: Other Diagnoses

• This item documented other diagnoses that were identified in the report.

Description sections were available under each diagnosis for diagnostic

specifiers.

51
 Item 20: Meets Criteria for Trauma Diagnosis based on symptoms reported in

evaluation

• This item was designed to identify whether the youth met criteria for a

trauma diagnosis based on the symptoms documented in the report.

Procedure

Permission to access, review, and photocopy court clinic evaluations was requested

and granted from the Chief Justice of the Juvenile Court. Court clinic reports were

accessed at the Boston Juvenile Court Clinic. Photocopies of the reports were made to

protect the integrity of the original copies in case of pen/pencil marks for aid in coding. A

log of the docket numbers and names of the court clinic reports reviewed was maintained

at the Boston Juvenile Court Clinic to monitor photocopy status and destroyed status (i.e.,

photocopy shredded) for the court's records (Appendix C). Once approval was granted to

conduct the research at the BJCC as described in this proposal, no deviations were made

from the current protocol without notification to the Chief Justice of the Juvenile Court or

his/her designee, and the Massachusetts School of Professional Psychology Internal

Review Board for review of ethical principles, confidentiality, and re-approval. No

deviations were made and no re-approval was needed for this study.

Court reports from the past 3 years (2006-2008) were used in the study in order to

access the most recent statistics. The purpose of this was to avoid collecting data from

court reports that date back to more than 10 years ago when research and awareness

about the long-term developmental effects of exposure to trauma in childhood were less

52
known, therefore it would have been less documented in the actual reports and could

have skewed the data.

Sixty court clinic reports were randomly selected and reviewed for the project. The

random selection procedure was completed with Thomas Riffin, Psy.D., Director of the

Boston Juvenile Court Clinic. Data was collected from each report using the Data

Collection Form (Appendix A). A letter of support to conduct this research was obtained

from Dr. Riffin (Appendix D). Confidentiality was maintained at all levels of data

collection as described in detail below. All overhead costs and materials of conducting

this research in the juvenile court clinic, including paper and ink for photocopying, were

provided by this writer.

Confidentiality, Protection of Participants, and Ethical Considerations

The court clinic evaluations are property of the Massachusetts Juvenile Court.

Reports were reviewed only after permission was obtained from the Chief Justice of the

Juvenile Court or his/her designee. Permission to photocopy court clinic reports was

requested for ease of data collection and analysis. A copy of the letter requesting

permission can be found in Appendix B3. Identifying information (e.g., name, address,

docket number, date of birth) was kept confidential and was not used or included in data

analysis or in the write-up of results. To insure the anonymity of the court clinician who

conducted the evaluation, the original first page and signature page of the report was

removed from the report and photocopied by the BJCC Administrative Assistant. The

copied pages then had the clinician's name redacted, and the redacted pages along with

3
Parts of the letter have been taken from a previous doctoral project by Jane Cleveland
(Cleveland, 2002).

53
the remainder of the report were provided to the researcher for scoring. All court clinic

reports were kept by the investigator in a locked filing cabinet. Court clinic reports were

shredded once information was obtained using the data collection form. Identifying

information was not recorded on the data collection forms.

Confidentiality and data collection was collected in accordance with the American

Psychological Association's ethical standards as stated in the "Ethical Principles of

Psychologists and Code of Conduct" (American Psychological Association, 2002).

54
 CHAPTER 4

RESULTS

The purpose of this study was to examine the prevalence of trauma and trauma

symptoms among court-involved youth. The study also explored possible relationships

between modes of trauma and trauma symptoms. It is important to remember that reports

of trauma exposure and symptoms are based on the clinician's observation, collateral

contacts, and interview as documented in the report. This issue will be further discussed

in chapter five in the section dealing with limitations of the study.

During the process of coding the court clinic reports, it was found that the reports

conducted among youth who had previous court evaluations provided less historical

information because the clinician would frequently state "please refer to previous court

evaluation for more information about background and developmental history." These

second or third court reports contained little or no information about trauma history.

Therefore, this subset of court reports was omitted during the data analysis to provide a

more accurate representation of the relationships between documented trauma and

symptom presentation.

Another change that was made for ease of data analysis concerned the presence

versus the absence of trauma. In the original coding form, presence of trauma was

separated into "single event" and "multiple events" while the absence of trauma coded as

"client denied" and "no information available." During analysis, it was found that these

four categories reduced statistical power and also created a confound in chi-square

analyses due to low expected versus observed percentages. The cause of this was

55
primarily because very few of the youths who had been exposed to a certain type of

trauma had only experienced a single event. The large majority of the youths had been

exposed to multiple events of a certain type of trauma. Moreover, in a few of the trauma

modes only multiple events were reported. Therefore, these variables were re-coded into

absent (i.e., client denied and no information available) versus present (i.e., single event

and multiple events) trauma variables for the majority of the statistics concerning

relationships between trauma exposure and symptom presentation. Further specifics will

be descnbed in section three of this chapter prior to the reporting of statistical analyses.

The first section of this chapter consists of some demographic and prevalence

information for all of the court reports reviewed in this study. The second part of this

chapter provides demographic and prevalence information for the court reports used in

the data analysis (i.e., youths for whom this was the first court report). The second

section also compares the demographics of the first court report youths versus the non-

first court report youths in order to examine any significant demographic differences. The

third part of this chapter describes results from statistical analyses exploring relationships

among the variables.

Descriptive Analysis of All Reports

Demographics

A total of sixty court clinic evaluations were reviewed. Gender distribution was

predominantly male (N=41, 68%) as compared to female (N=19, 32%). Mean age was

14.75 years with the following distribution: 10 years (N=l), 11 years (N=l), 12 years

56
(N=2), 13 years (N=7), 14 years (N=9), 15 years (N=22), 16 years (N=13), and 17 years

(N=5).

According to the 2000 Census for Suffolk County, race demographics were

Caucasian (57.6%), African-American (22.2%), Hispanic (15.5%), and Asian-American

(7%). The current sample distribution was Caucasian (N=8, 13.3%), African-American

(N=17, 28.3%), Hispanic (N=15, 25%), Asian-American (N=3, 6%), Biracial (N=2,

3.3%), and Unknown (n=15, 25%). Based on the demographics available in the reports,

rates of minorities were slightly higher in the sample as compared to the general

population of Suffolk County, however there remains 25% from the sample with no

identified race or ethnicity (based on the information provided in the report).

Race Demographics for Suffolk County and Study Sample

• Suffolk County
• Study Sample

White African- Hispanic Asian- Biracial Unknown

American American

Figure 1. Percentage distribution of race demographics by category for Suffolk

County and the study sample (N=60).

According to a recent report from the Juvenile Justice Advisory Committee for the state

of Massachusetts, minority populations made up 24% of the entire juvenile justice

57
population in 2006. However, minorities accounted for 53% of juveniles sent to

alternative lockup programs (in 2005), 61% of secure detention placements (in 2007),

45% of probation placements (in 2006), and 62% of DYS commitments (in 2007), and

64% of the total DYS committed population as of January 1, 2008 (Citizens for Juvenile

Justice, 2008).

Court Reports

The majority of the youths were undergoing their first court clinic evaluation. The

number of first court clinic reports was 41 (68%), versus non-first court clinic report

(N=19, 32%). Among those who had undergone prior court clinic evaluations, the

distribution of ages at the time of the first court clinic report was as follows: 8 years

(N=l, 1.7%), 10 years (N=3, 5%), 11 years (N=l, 1.7%), 12 years (N=3, 5%), 13 years

(N=3, 5%), 14 years (N=4, 6.7%), 15 years, (N=2, 3.3%), and 16 years (N=2, 3.3%).

CHINS Stubborn was the most common current evaluation type (N=20, 33.3%),

followed by Delinquency (N=14, 23.3%), CHINS Truancy (N=10, 16.7%), CHINS

Habitual Offender (N=9, 15%), and CHINS Runaway (N=7, 11.7%). Among the youths

who had prior court clinic evaluations, the distribution of prior evaluation types was

CHINS Runaway (N=4, 6.7%), CHINS Stubborn (N=4, 6.7%), CHINS Habitual

Offender (N=4, 6.7%), CHINS Truancy (N=3, 5%), Delinquency (N=2, 3.3%), and Care

and Protection (N=2, 3.3%).

Chi-square analysis was used to explore any relationships between gender and

current evaluation type. The following table summarizes the findings.

58
Table 2

Overall Distribution of Type of Evaluation by Gender

Runaway Stubborn zrz. ~ Truancy Delinquency
Qj-fe nc } er
Female 3(15.8%) 10(52.6%) 2(21.1%) 1 (5.3%) 1 (5.3%)
Male 4(9.8%) 10(24.4%) 5(12.2%) 9(22.0%) 13(31.7%)

Statistical analysis revealed a significant relationship between gender and evaluation

type (%2 = 10.251, p<.05). Given the distribution of evaluations, boys were more likely to

be court-involved for delinquency purposes, and girls were more likely to be involved for

a CHINS Stubborn.

Types of Trauma

Prevalence information was calculated for each type of trauma across all reports. The

following table provides a summary of the frequency and percentages of trauma

exposure.

59
Table 3

Overall Distribution of Trauma Exposure

Frequency (N) Percentage (%)

Physical Abuse
Single Event 2 3.3
Multiple Events 18 30.0
Client Denied 13 21.7
No Information Available 27 45.0
Emotional Abuse
Single Event 0 0.0
Multiple Events 13 21.7
Client Denied 8 13.3
No Information Available 39 65.0
Neglect
Single Event 0 0.0
Multiple Events 17 28.3
Client Denied 8 13.3
No Information Available 35 58.3
Sexual Abuse
Single Event 2 3.3
Multiple Events 4 6.7
Client Denied 12 20.0
No Information Available 42 70.0
Exposure to Community Violence
Single Event 1 1.7
Multiple Events 26 43.3
Client Denied 6 10.0
No Information Available 27 45.0
Exposure to Intimate Partner
Violence (parents or in their own
relationships)
Single Event 1 1.7
Multiple Events 15 25.0
Client Denied 8 13.3
No Information Available 36 60.0
Other Trauma
Single Event 16 26.7
Multiple Events 9 15.0
Client Denied 0 0.0
No Information Available 35 58.3

60
 The most common form of trauma exposure as reported by the court clinicians in

their reports was exposure to community violence with 45% of the sample having been

exposed to some form of violence. Physical abuse (33.3%) was the second most common

form of trauma, followed by neglect (28.3%), exposure to intimate partner violence

(26.7%), emotional abuse (21.7%), and sexual abuse (10.0%). Over 40% of the sample

had also been exposed to other types of trauma. The following table is a summary of the

types other traumas with frequencies. Multiple events include cases when the youth was

exposed to a variety of other types of trauma (e.g., death of a parent and parental drug

use).

Table 4

List of Other Traumas

Single Events Multiple Events

Type Frequency Type Frequency
• Death of a parent 6 • Exposure to parental drug use 2
• Finding out a parent is not 2 • Death of multiple relatives 4
their biological parent • Divorce or separation of parents 1
• Incarcerated family member 1 Loss of relationship with one or 3
• Family rejecting of more family members
homosexual orientation 1 Changes in caregiver 1
• Divorce, separation, or loss of
relationship with a parent 8
• Death of a sibling 1

Descriptive Analysis of Reports Used for Data Analysis

During the process of coding the court clinic reports, many of the reports conducted

on youth with previous court clinic involvement were lacking in historical information,

61
particularly in the area of trauma exposure. Many of the clinicians referred the reader to

previous court clinic reports where the information had been originally documented. This

inadvertently created an underreporting of trauma exposure. To correct this and obtain

more accurate information, only youths for whom this was the first court report were

included. For the purposes of the data analysis in this study, a total of 41 court reports

(first court reports) were used to explore relationships between trauma exposure and

symptom presentation. Below is the demographic information for the 41 court reports

used in the statistical analysis described in the third section of this chapter.

Demographics

A total of 41 court reports were used in the data analysis. The sample was comprised

of 27 boys (65.9%) and 14 girls (34.1%). Mean age was 14.61, with the following

distribution: 10 years (N=l), 11 years (N=l), 12 years (N=2), 13 years (N=5), 14 years

(N=7), 15 years (N=12), 16 years (N=10), and 17 years (N=3).

Minorities in this subset were similarly over-represented as compared to the Boston

Census from 2000 for Suffolk County (www.boston.com/census). According to the 2000

Census for Suffolk County, race demographics were Caucasian (57.6%), African-

American (22.2%>), Hispanic (15.5%), and Asian-American (7%). The sample

distribution was Caucasian (N=4, 9.8%), African-American (N=10, 24.4%), Hispanic

(N=13, 31.7%), Asian-American (N=3, 7.3%), Biracial (N=l, 2.4%), and Unknown

(N=T0, 24.4%). Demographics of youths who present before the Boston Juvenile Court

was again unknown, therefore it is unknown whether the distribution in this study is

typical of youths involved with the juvenile justice system.

62
 Grade in school ranged from fourth to eleventh grade with the following distribution:

4,h grade (N=l), 6th grade (N=3), 7th grade (N=4), 8th grade (N=4), 9th grade (N=6), 10th

grade (N=5), and 11th grade (N=3). Grade was not documented in fifteen of the court

reports.

The most common evaluation type was CHINS Stubborn (N=l 7, 41.5%), followed

by CHINS Truancy (N=8, 19.5%), Delinquency (N=6, 14.6%), CHINS Runaway (N=5,

12.2%), and CHINS Habitual Offender (N=5, 12.2%).

No significant differences were found between first-court report youth versus non-

first court report youth for gender (^2 = .368, p>.05), age (F=l .204, p>.05), race

(Z2 = 6.003, p>.05), grade (F=.073, p>.05), and type of evaluation ( j 2 = 8.106, p>.05).

Types of Trauma

Prevalence information was calculated for each type of trauma across the reports

used in the sample. The following table provides the frequency and percentages of trauma

exposure.

63
Table 5

Sample Distribution of Trauma Exposure

Frequency (N) Percentage

Physical Abuse
Single Event 2 4.9
Multiple Events 11 26.8
Client Denied 11 26.8
No Information Available 17 41.5
Emotional Abuse
Single Event 0 0.0
Multiple Events 7 17.1
Client Denied 8 19.5
No Information Available 26 63.4
Neglect
Single Event 0 0.0
Multiple Events 9 22.0
Client Denied 8 19.5
No Information Available 24 58.5
Sexual Abuse
Single Event 2 4.9
Multiple Events 4 9.8
Client Denied 11 26.8
No Information Available 24 58.5
Exposure to Community Violence
Single Event 0 0.0
Multiple Events 19 46.3
Client Denied 6 14.6
No Information Available 16 39.0
Exposure to Intimate Partner
Violence
Single Event 0 0.0
Multiple Events 8 19.5
Client Denied 8 19.5
No Information Available 25 61.0
Other Trauma
Single Event 13 31.7
Multiple Events 7 17.1
Client Denied 0 0.0
No Information Available 21 51.2

64
 Only three of the trauma types contained single event frequencies (physical abuse,

sexual abuse, and other trauma). Maintaining the four categories of trauma type during

data analysis reduced the statistical power. Therefore, trauma exposure was recoded into

presence and absence of trauma. This allowed for more statistical power, without

sacrificing too much detailed information because most of the youths were exposed to

multiple incidents of a certain type of trauma. The following table outlines the frequency

of each trauma type when recoded for presence or absence of trauma.

Table 6

Absent/Present Sample Distribution of Trauma Exposure

Absent Present
N % N %
Physical Abuse 28 68.3 13 31.7
Emotional Abuse 34 82.9 7 17.1
Neglect 32 78.0 9 22.0
Sexual Abuse 35 85.4 6 14.6
Exposure to Community Violence 22 53.7 19 46.3
Exposure to Intimate Partner Violence 33 80.5 8 19.5
Other Trauma 21 51.2 20 48.8

The most common type of trauma was Exposure to Community Violence (46.3%),

followed by Physical Abuse (31.7%), Neglect (22.0%), Exposure to Intimate Partner

Abuse (19.5%), Emotional Abuse (17.1%), and Sexual Abuse (14.6%). Over half of the

sample had been exposed other types of trauma (descriptions above). Nearly one-third of

the youths had been physically abused and nearly one-half have witnessed or been

victims of community violence. Roughly one out of five youths has been a victim of

65
emotional abuse, neglect, or intimate partner violence, and almost one out of six youths

was a victim of sexual abuse. Overall, 82.9% of the youths had been exposed to at least

one type of trauma.

Many of the youths had been exposed to multiple modes of trauma (e.g., physical

abuse and emotional abuse). A new variable was created called "Sum of Trauma Types",

which totaled the modes of trauma to which each youth had been exposed (e.g., physical

abuse present + emotional abuse present + neglect present). The maximum number for

this variable was 7, because only 7 forms of trauma were coded. The following figure

summarizes the frequency of the Sum of Trauma Types variable.

Distribution of the Sum of Modes of Trauma

Experienced

40

J,
35

30

25
20

15

10
5
0
Zero One Two Three Four Five
Sum of Trauma Modes

Figure 2. Distribution of the total amount of different modes of trauma to which

each youth was exposed (N=41).

Only 17.1% of the youths had no exposure to trauma. Among the rest, 17.1% were

exposed to one type of trauma (N=7), 36.6% were exposed to two types of trauma

(N=15), 12.2% were exposed to three types of trauma (N=5), 12.2% were exposed to four

66
types of trauma (N=5), and 4.9% were exposed to five types of trauma (N=2). Over one-

third were exposed to two different types of trauma, and two-thirds were exposed to two

or more types of trauma.

Individual Trauma Symptoms

Data was analyzed for the frequency of individual trauma symptoms. The table

below summarizes the presence or absence of each individual symptom for PTSD and

CPTSD.

67
Table 7

Distribution of Individual Trauma Symptoms

Absent Present
N % N %
PTSD - Reexperiencing Cluster
• Intrusive Memories 37 90.2 4 9.8
• Nightmares, Distressing Dreams 40 97.6 1 2.4
• Flashbacks, Hallucinations, Sensory Experiences 40 97.6 1 2.4
• Psychological distress due to internal or external 40 97.6 1 2.4
stimuli
• Physiological distress due to internal or external 40 97.6 2.4
stimuli
PTSD - Avoidance Cluster
• Avoid thoughts, feelings, or talking about it 40 97.6 1 2.4
• Avoid places 41 100.0 0 0.0
• Difficulty remembering aspects of the trauma 41 100.0 0 0.0
• Diminished interest or participation in significant 38 92.7 3 7.3
activities
• Feelings of detachment or estrangement form others 32 78.0 9 22.0
• Restricted range of affect 28 68.3 13 31.7
• Sense of foreshortened future
41 100.0 0 0.0
PTSD - Hyperarousal Cluster
• Difficulty falling or staying asleep 32 78.0 9 22.0
• Irritability or outbursts of anger 28 68.3 13 31.7
• Difficulty concentrating 28 68.3 13 31.7
• Hypervigilance 36 87.8 5 12.2
• Exaggerated startle response 39 95.1 2 4.9
Complex PTSD - Alterations in Affect Regulation
Cluster
• Affect Regulation 18 43.9 23 56.1
• Modulation of Anger 16 39.0 25 61.0
• Self-Destructive 33 80.5 8 19.5
• Suicidal Preoccupation 35 85.4 6 14.6
• Difficulty Modulating Sexual Involvement 37 90.2 4 9.8
• Excessive Risk-taking 19 46.3 22 53.7
Complex PTSD - Alterations in Attention or
Consciousness Cluster
• Amnesia 40 97.6 1 2.4
• Transient Dissociative Episodes and 37 90.2 4 9.8
Depersonalization
Complex PTSD - Alterations in Self-Perception Cluster

68
 • Ineffectiveness 80.5 8 19.5
• Permanent Damage 35 85.4 6 14.6
• Guilty and Responsibility 39 95.1 2 4.9
• Shame 38 92.7 3 7.3
• Nobody Can Understand 38 92.7 3 7.3
• Minimizing 22 53.7 19 46.3
Complex PTSD - Alterations in Relationships with
Others Cluster
• Inability to Trust 31 75.6 10 24.4
• Revictimization 37 90.2 4 9.8
• Victimizing others 28 68.3 13 31.7
Complex PTSD - Somatization Cluster
• Digestive System 39 95.1 2 4.9
• Chronic Pain 39 95.1 2 4.9
• Cardiopulmonary Symptoms 39 95.1 2 4.9
• Conversion Symptoms 39 95.1 2 4.9
• Sexual Symptoms 41 100.0 0 0.0
Complex PTSD - Alterations in Systems of Meaning
Clusters
• Despair and Hopelessness 33 80.5 8 19.5
• Loss of Previously Sustaining Beliefs 37 90.2 4 9.8

Almost all of the symptoms of PTSD and CPTSD were endorsed. These symptoms

received positive scores by either being specifically identified in the report, or if they

were described by the clinician. Only avoidance of places, difficulty remembering

aspects of the trauma, and a sense of foreshortened future within the PTSD diagnosis, and

sexual symptoms within the CPTSD diagnosis were not endorsed.

PTSD Symptoms

Affect regulation problems within the Avoidance cluster of PTSD, and the

Hyperarousal cluster of PTSD seemed to be the areas of highest symptom endorsement

within the PTSD cluster. Nightmares, flashbacks, psychological distress, physiological

distress, and avoidance of thoughts/feelings/talking were each only endorsed once

69
(2.4%). Diminished interest in activities and exaggerated startle responses were endorsed

less than ten percent of the time.

Approximately ten percent of the youths presented with intrusive memories and

hypervigilance. Nearly one-fifth of the youths had problems in the area of sleep

disturbance and feelings of detachment or estrangement from others. One-third of the

youths presented with restricted range of affect, irritability or outbursts of anger, and

difficulty concentrating.

Complex PTSD symptoms

The majority of endorsed symptoms of Complex PTSD revolved around problems

with affect regulation, self-perception, and relationships with others. The most infrequent

symptoms were amnesia and sexual symptoms. Guilt/responsibility, digestive problems,

chronic pain, cardiopulmonary symptoms, and conversion symptoms were present 5% of

the time. Approximately seven percent of the youths had endorsed shame and a sense that

no one could understand them. Ten percent of youths presented with difficulty

modulating sexual involvement, transient dissociative episodes or depersonalization,

revictimization, and loss of previously sustaining beliefs. Approximately fifteen percent

endorsed suicidal preoccupation and feelings of permanent damage. Nearly twenty

percent engaged in self-destructive behaviors, endorsed feelings of ineffectiveness, and

endorsed feelings of despair and hopelessness. One-quarter felt and inability to trust

others, and almost one-third had victimized others. Over half of the youths had problems

with affect regulation, excessive risk-taking, and modulation of anger, and nearly half

tended to minimize their trauma exposure or trauma symptoms.

70
 Symptom Clusters

Sum of symptoms in each cluster

The sums of endorsed symptoms within each symptoms cluster was calculated for

each youth (e.g., intrusive memories + nightmares + psychological distress for the

reexperiencing cluster). The following figures summarize the frequency of sums of

symptoms for each cluster in the PTSD and Complex PTSD diagnoses.

Distribution of Sum of Reexperiencing

Symptoms

Zero One Two Three Four Five

Sum of Reexperiencing Symptoms

Figure 3. Distribution of the percentage of youths who have a total of zero, one, two,

three, four, or five symptoms in the Reexperiencing cluster (N=41).

The majority of youths presented with no symptoms (N=37, 90.2%) within the

Reexperiencing cluster. Nearly five percent presented with one symptom (N=2, 4.9%). A

sum of two symptoms and four symptoms were each endorsed by one youth (2.4% each).

71
 Distribution of Sum of Avoidance Symptoms

70

Zero One Two Three Four Five Six Seven

Sum of Avoidance Symptoms

Figure 4. Distribution of the percentage of youths who have a total of zero, one, two,

three, four, five, six, or seven symptoms in the Avoidance cluster (N=41).

In the Avoidance cluster, the majority of the youths presented with no symptoms (N=25,

61.0%). Over one-fifth presented with one symptom (N=9, 22.0%), while just under ten

percent had two symptoms (N=4, 9.8%) and three symptoms (N=3, 7.2%).

72
 Distribution of Sum of Hyperarousal Symptoms

50

Zero One Two Three Four Five

Sum of Hyperarousal Symptoms

Figure 5. Distribution of the percentage of youths who have a total of zero, one, two,

three, four, or five symptoms in the Hyperarousal cluster (N=41).

Nearly one-third of the youths presented with no symptoms of hyperarousal (N=13,

31.7%); whereas almost half presented with one symptom (N=18, 43.9%). The remaining

distribution was two symptoms (N=7, 17.1%), three symptoms (N=2, 4.9%), four

symptoms (N=l, 2.4%), and five symptoms (N=0, 0.0%).

73
 Distribution of Sum of Alteration in Affect
Regulation Symptoms

30

25

20

15

10

5 H

Zero One Two Three Four Five Six

Sum of Alteration in Affect Regulation Symptoms

Figure 6. Distribution of the percentage of youths who have a total of zero, one, two,

three, four, five, or six symptoms in the Alterations in Affect Regulation cluster

(N=41).

Approximately twenty percent of the youths had no symptoms within the Affect

Regulation cluster (N=8, 19.5%). The distribution of positive symptom sums was one

symptom (N=7, 17.1%), two symptoms (N=10, 24.4%), three symptoms (N=9, 22.0%),

four symptoms (N=3, 7.3%), five symptoms (N=2, 4.9%), and six symptoms (N=2,

4.9%).

74
 Distribution of Sum of Alteration
in Consciousness Symptoms

100

90

80

70

60
50

40

30

20
10

0
Zero One Two
Sum of Alteration in Consciousness Symptoms

Figure 7. Distribution of the percentage of youths who have a total of zero, one, or

two, symptoms in the Alteration in Consciousness cluster (N=41).

Most of the youths presented with no symptoms of attention or alteration of

consciousness. Only a few presented with one symptom (N=3, 7.3%) and two symptoms

(N=l,2.4%).

Distribution of Sum of Alteration in Self-

Perception Symptoms

45

40

35

30

25

20

15

10

0
Zero One Two Three Four Five Six
Sum of Alteration in Self-Perception Symptoms

75
 Figure 8. Distribution of the percentage of youths who have a total of zero, one, two,

three, four, five, or six symptoms in the Alteration in Self-Perception cluster (N=41).

Approximately forty percent of the youths presented with no symptoms of self-perception

(N=17, 41.5%). Nearly one-third had one symptom (N=13, 31.7%). Just over ten percent

had two symptoms (N=5, 12.2%) or three symptoms (N=6, 14.6%). None of the youths

had four or more symptoms.

Distribution of Sum of Alteration in

Relationships with Others

70 -i

I
60 -j

40 -j ^ H

J •
0 -I ^ ^ m , ^ ^ m 1 ^ ^ m 1 ^ ^ m •
Zero One Two Three
Sum of Alteration in Relationships w i t h Others
Symptoms

Figure 9. Distribution of the percentage of youths who have a total of zero, one, two,

or three symptoms in the Alteration in Relationships with Others cluster (N=41).

Over half of the youths presented with no symptoms in the Alteration in Relationships

cluster (N=24, 58.5%). The remainder of the youths had one symptom (N=9, 22.0%), two

symptoms (N=6, 14.6%), or three symptoms (N=2, 4.9%).

76
 Distribution of Sum of Somatization Cluster Symptoms

100
90
80
70
60
50
40
30
20
10

Zero One Two Three Four Five

Sum of Somatization Cluster Symptoms

Figure 10. Distribution of the percentage of youths who have a total of zero, one,

two, three, four, or five symptoms in the Somatization cluster (N=41).

Somatization symptoms were not observed for most of the youth (N=37, 90.2%). A small

number of youths presented with one symptom (N=l, 2.4%), two symptoms (N=2,

4.9%), or three symptoms (N=l, 2.4%).

77
 Distribution of S u m of A l t e r a t i o n in S y s t e m s
of M e a n i n g Cluster S y m p t o m s

90 -i

80

70 -

60 -

50 -

40 -

30 -

20 -

10 -

0 -
Zero One Two
Sum of Alteration in Systems of Meaning
Cluster Symptoms

Figure 11. Distribution of the percentage of youths who have a total of zero, one or

two symptoms in the Alterations in Systems of Meaning cluster (N=41).

The majority of youths presented with no symptoms in the systems of meaning cluster

(N=32, 78.0%). Approximately fifteen percent presented with one symptom (N=6,

14.6%), and only a few were observed to have two symptoms (N=3, 7.3%).

Clinically positive clusters

A variable was created to calculate the number of positive clusters for each youth

based on the criteria outlined in the DSM-IV and for DESNOS. For example, three or

more symptoms in the Avoidance cluster of PTSD are needed to meet the criteria for

clinical impairment. A youth who was observed to have three symptoms in this area

would have their score recoded into a positive score in the Avoidance cluster. The

clinical cutoff scores were used for all the clusters as outlined in the PTSD and CPTSD

diagnoses. The following graphs illustrate the results.

78
 Percentage of Youths w i t h Negative or
Positive PTSD Clusters

100
90

80

70

60 -
• Negative
50
• Positive
40

30 -

20

10

0
Reexperiencing Avoidance
PTSD Clusters
I
Hyperarousal

Figure 12. This graph depicts the percentage of youths who either met criteria

(positive) or did not meet criteria (negative) for each PTSD cluster (N=41).

Although the vast majority of youths did not meet criteria for the Reexperiencing cluster

(N=37, 90.2), one out often did meet criteria (N=4, 9.8%). Approximately the same

results were found in the Avoidance cluster (negative, N=38, 92.7%; positive, N=3,

7.3%). One-quarter of youths were positive for Hyperarousal cluster (N=10, 24.4%)

versus negative (N=31, 75.6%).

79
 Percentage of Youths w i t h Negative or
Positive Complex PTSD Clusters

• Negative

Jl 1
• Positive

P* .**
II
.^ ^ J> ^
y .</
<^
J j" *f .<> • ^

r Complex PTSD Clusters

Figure 13. This graph depicts the percentage of youths who either met criteria

(positive) or did not meet criteria (negative) for each Complex PTSD cluster (N=41).

More youths were positive in the Affect Regulation cluster (N=21, 51.2%) than negative

(N=20, 48.8). Approximately one-tenth of the youths were positive for the Attention

cluster (N=4, 9.8%) as compared to negative (N=37, 90.2%). One in four youths were

positive in the Self-Perception cluster (N=l 1, 26.8%) versus negative (N=30, 73.2). The

Alterations in Relationship with Others cluster was nearly half positive (N=17, 41.5%)

and half negative (N=24, 58.5%). The majority of youths did not meet criteria for the

Somatization cluster (N=38, 92.7%), but a few met criteria (N=3, 7.3%). Nearly one-

quarter of youths met criteria for a positive score on the Systems of Meaning cluster

(N=9, 22.0%) as compared to not meeting criteria (N=32, 78.0%).

80
Sum of Positive Clusters

The positive cluster scores were added to examine the sum of clusters for each youth

(e.g., positive score on reexperiencing cluster + positive score on hyperarousal cluster).

The results are illustrated below.

Distribution of t h e S u m of Positive
PTSD Clusters

80 -i

70 -

60 -

50 -

40 -

30 -

I
20

10 -

0 -
Zero One Two Three
Sum of Positive PTSD Clusters

Figure 14. The above graph illustrates the distribution of the sum of positive PTSD

clusters (the total number of clinically positive clusters in the PTSD diagnosis for

each youth) for the data sample (N=41).

The majority of the youths did not meet criteria for a positive score on any of the three

clusters in the PTSD diagnosis (N=29, 70.7%). Nearly one-fifth of the youths were

positive for one of the PTSD clusters (N=8, 19.5%). A few youths were positive on two

PTSD clusters (N=3, 7.3), and one youth was positive for all three clusters (N=l, 2.4%).

81
 Distribution of t h e S u m of Complex
PTSD Clusters

40 -

35 -
•
30 -
1
25
1 |
20 -

1 l a
15 -

10 •
1
1 • 1I I1
5 •

0 -
1
• •1 •1•1• • i
Zero One Two Three Four Five Six
Sum of Complex PTSD Clusters

Figure 15. The above graph illustrates the distribution of the sum of positive

Complex PTSD clusters (the total number of clinically positive clusters in the

Complex PTSD diagnosis for each youth) for the data sample (N=41).

Just over one-third of youths did not meet criteria for a positive score on any of the

Complex PTSD clusters (N=15, 36.6%), leaving two-thirds of the youths with at least

one positive cluster. Approximately one-tenth of the youths were had one positive cluster

(N=4, 9.8%). Over one-quarter of the youths were positive on two clusters (N=l 1,

26.8%), and one-fifth of the youths were positive on three clusters (N=8, 19.5%). Only

one youth was positive on four clusters (N=l, 2.4%), five clusters (N=l, 2.4%), and six

clusters (N= 1,2.4%).

82
Positive PTSD and Complex PTSD diagnosis

Based on the above sums, one youth in the study met clinical criteria for the PTSD

diagnosis (N=l, 2.4%), and one youth met clinical criteria for the Complex PTSD

diagnosis (N=l, 2.4%).

Testing

Testing and assessment tools were used in approximately twenty percent of the cases

(N=8, 19.5%o). The following is a list of the various tools that were used.

• Behavior Assessment System for Children (BASC; adolescent and parent

versions)

• Child Depression Inventory (CDI; parent and adolescent versions)

• Trauma Symptom Checklist for Children (TSCC)

• Minnesota Multiphasic Personality Inventory - Adolescent Version (MMPI-A)

• Substance Abuse Subtle Screening Inventory (SASSI)

• Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV)

• Rorschach Inkblot Technique

• Massachusetts Youth Screening Instrument - 2nd Edition (MAYSI-2)

• Beck Depression Inventory (BDI)

Other Diagnoses

Information was collected about the diagnoses given to youths in the report. Court

clinicians are trained to provide functional information to the court but defer awarding

diagnoses unless diagnosis is specifically called for, therefore this may be an artifact

83
yielding fewer reported diagnoses in this study. The following graphs breakdown the

distribution for trauma-related diagnoses and other diagnoses.

Distribution of Trauma-Related Diagnoses in the

Reports

12 i

10

PTSD Complex PTSD Acute Stress Adjustment Other Trauma

Disorder Disorder Disorder
Trauma-Related Diagnoses

Figure 16. The above graph illustrates the distribution of trauma-related diagnoses

that were described in the court clinic evaluations.

Four youths were diagnosed with PTSD accounting for ten percent of the cases (N=4,

9.8%). No youths were diagnoses with Complex PTSD or Acute Stress Disorder.

Adjustment Disorder and Other Trauma Disorder each were diagnosed in one youth

(N=l,2.4%).

84
 Distribution of other Mental Health Diagnoses in Reports

25
1
20

15

Ll
10

0
/ # ^ /• <&* J> »<5> J-
O* o* <f <? <f J? <? O*
<^ o°6 eSA ** v ^ ^ #

Mental Health Diagnoses

Figure 17. The above graph illustrates the distribution of other mental health

diagnoses that were described in the court clinic evaluations (N=41).

The most common diagnosis was Mood Disorder (N=9, 22.0%), followed by Substance

Abuse Disorder (N=8, 19.5%), ADHD/ADD (N=7, 17.1%), Learning Disorder (N=5,

12.2%), and ODD/CD (N=l. 2.4%). No youths were diagnosed with Anxiety Disorders,

Developmental Disorders, or Dissociative Disorders.

Some youths were diagnosed with multiple disorders. For a more accurate

understanding of the prevalence of disorders among the youth, the sum of disorders

(trauma-related and other diagnoses) was calculated for each youth.

85
 Distribution of the Numer of Diagnoses in the
Reports for Each Youth

Zero One Two Three

Number of Diagnoses in the Report

Figure 18. The above graph illustrates the distribution of the total number of

diagnoses documented in the report for each youth (N=41).

Half of the youths were not diagnosed with a disorder (N=21, 51.2%). Among the other

half, approximately one-third were diagnosed with one disorder (N=14, 34.1%), one-

tenth with two disorders (N=4, 9.8%), and two youths were diagnosed with three

disorders (N=2, 4.9%).

Data Analysis

Analysis was primarily designed to explore whether and how exposure to trauma

was related to symptom presentation. Research has shown that multiple and chronic

exposure to trauma during childhood is related to more post-traumatic symptoms in a

broader set of areas than the PTSD diagnosis. The analysis below will provide

information specifically related to youth who are court-involved.

86
 The interaction between demographics, trauma exposure, and trauma symptoms is

first explored in this section. The relationship between trauma exposure and symptoms is

then explored. For the purposes of the analysis and charts below, "any type of trauma"

means that the youth has been exposed to at least one form of trauma, and "sum of

trauma" is the sum of the modes of trauma to which the youth has been exposed (e.g.,

physical abuse + emotional abuse + sexual abuse).

Demographics and Trauma

Gender and the presence/absence of trauma

Chi-square tests were conducted to explore the relationship between gender and the

presence or absence the difference types of trauma. The table below summarizes the chi-

square calculations and significance levels for each type of trauma as a function of

gender.

87
 Table 8

Results of Chi-Square Analysis for Gender and Absence/Presence of

Trauma

Gender
Chi Sig
Absence/Presence of Physical Abuse .158 .691
Absence/Presence Emotional Abuse 1.985 .159
Absence/Presence Neglect .208 .648
Absence/Presence Sexual Abuse 13.555 .000**
Absence/Presence Comm Violence .114 .735
Absence/Presence IPV .370 .543
Absence/Presence Other 6.366 .012**
Absence/Presence Any type of trauma .117 .733
Sum of Trauma (ANOVA) F = .054 .817
* indicates marginal significance levels <.07; **indicates statistically
significance levels <.Q5

No significant differences were found between gender and physical abuse, emotional

abuse, neglect, exposure to community violence, exposure to intimate partner violence,

overall exposure to trauma (i.e., any type of trauma), or the sum of trauma. For gender

and sexual abuse, the breakdown between boys and girls was as follows:

Table 9

Chi-Square Analysis: Gender and Absence/Presence of Sexual Abuse

Sexual Abuse
Absent Present
Female 8(57.1%) 6 (42.9%)
Gender
Male 27(100.0%) 0 (0.0%)

88
 Sexual abuse was significantly more prevalent among girls then boys. Nearly half of

the females had been sexually abused, whereas none of the boys reported having been

sexually abused. Two of the cells in the table had expected values less than 5. A Fisher's

exact test yielded a significance level of .001, which supports the significant relationship

between gender and reported sexual abuse.

Table 10

Chi-Square Analysis: Gender and Absence/Presence of Other Trauma

Other Trauma
Absent Present
Female 11(78.6%) 3(21.4%)
Gender
Male 10(37.0%) 17(63.0%)

Significantly more boys reported experiencing other types of trauma as compared to

girls. Nearly two-thirds of boys reported other trauma versus one-fifth of girls.

Age and the absence/presence of trauma

The relationships between age and the presence/absence of trauma was explored

using one-way Analysis of Variance (ANOVA) tests. The table below summarizes the

findings.

89
 Table 11

Analysis of Variance Results: Age and Absence/Presence of Trauma

Age
F Sig
Absence/Presence of Physical Abuse 1.629 .162
Absence/Presence Emotional Abuse 1.922 .097
Absence/Presence Neglect .464 .853
Absence/Presence Sexual Abuse .465 .852
Absence/Presence Community Violence .521 .812
Absence/Presence IPV 1.398 .239
Absence/Presence Other .715 .660
Absence/Presence Any type of trauma .881 .532
Sum of Trauma .586 .762
* indicates marginal significance levels <.07; **indicates statistically
significance levels <.Q5

No significant relationships existed between age and presence or absence of trauma.

Race and the presence/absence of trauma

The relationship between race and the presence/absence of trauma was explored

using one-way ANOVA. The table below summarizes the findings.

90
 Table 12

Analysis of Variance Results: Race and Absence/Presence of Trauma

Race
F Sig
Absence/Presence of Physical Abuse .546 .740
Absence/Presence Emotional Abuse .311 .903
Absence/Presence Neglect 1.442 .234
Absence/Presence Sexual Abuse .458 .805
Absence/Presence Community Violence .935 .470
Absence/Presence IPV 1.411 .244
Absence/Presence Other .394 .849
Absence/Presence Any type of trauma 1.391 .251
* indicates marginal significance levels <.07; **indicates statistically
significance levels <.Q5

No significant relationships exited between race and the presence/absence of trauma.

Type of Abuse and Individual Symptoms

The first exploration between trauma exposure and symptoms presentation was

between the mode of trauma and individual symptoms. Chi-square tests were used to test

for significant relationships between the presence/absence of trauma and the

presence/absence of each individual symptom for PTSD and Complex PTSD. The table

below summarizes the findings by displaying Chi-Square significance levels for each

comparison. It is important to note that due to a relatively small sample size, Fisher's

Exact Tests were used in all cases to find the exact significance level when expected cell

counts were too low. Consequently, in some cases when the Chi-Square test was

91
significant, the corrected Fisher's Exact Test revealed marginal or no significance level.

Each relationship that was found to be significant using Chi-Square (in table below) is

explored individually to report the corrected Fisher's significance level.

92
Table 13

Chi-Square Analysis: Type of Abuse and Individual Trauma Symptoms

Exp. to
Exp. To
Physical Emotional Sexual Intimate Other
Neglect Community
Abuse Abuse Abuse Partner Trauma
Violence
Violence
Intrusive Memories .408 .001** .877 .000** .368 .771 .317
Nightmares/Distressing
.490 .026** .591 .014** .276 .618 .323
Dreams
Flashbacks,
Hallucinations, Sensory .137 .646 .591 .014** .347 .618 .323
Experiences
Psychological Distress
due to Internal or External .137 .646 .591 .014** .347 .618 .323
Stimuli
Physiological Distress due
to Internal or External .137 .646 .591 .014** .347 .618 .323
Stimuli
Avoid Thoughts, Feelings,
.137 .646 .591 .014** .347 .618 .323
Talking about it
Avoid Places 1.000 1.000 1.000 1.000 1.000 1.00 1.000
Difficulty Remembering
1.000 1.000 1.000 1.000 1.000 1.00 1.000
Information
Diminished Interest .950 .437 .621 .008 .639 .376 .520
Detachment,
.906 .642 .350 .072 .376 .095 .645
Estrangement, Withdrawal
Restricted Range of
.126 .845 .082 .297 .173 .032** .819
Affect
Sense of foreshortened
1.000 1.000 1.000 1.000 1.000 1.000 1.000
future
Sleep Problems .353 .142 .065* .004** .897 .816 .768
Irritability .176 .112 .906 .003** .511 .650 .074
Difficulty Concentrating .527 .845 .133 .071 .511 .695 .658
Hypervigilance .548 .146 .910 .002** .107 .977 .169
Increased or exaggerated
.323 .204 .326 .147 .119 .475 .157
startle response

93
Affect Regulation .067* .369 .970 .019** .139 .684 .262
Modulation of Anger .154 .534 .692 .034** .364 .129 .606
Self-Destructive .037** .006** .236 .000** .307 .121 .477
Suicidal Preoccupation .046** .977 .735 .000** .489 .192 .413
Difficulty Modulating
.408 .065* .154 .000** .226 .300 .317
sexual involvement
Risk-taking Behavior .511 .301 .897 .115 .017** .817 .867
Amnesia .490 .646 .591 .014** .276 .618 .323
Dissociation or
.050** .339 .264 .000** .368 .300 .317
Depersonalization
Ineffectiveness .695 .507 .816 .041** .817 .152 .477
Permanent Damage .926 .020** .466 .008** .280 .355 .948
Guilt and Responsibility .033** .511 .442 .147 .915 .475 .972
Shame .176 .437 .340 .341 .463 .530 .520
Nobody Can Understand .008** .437 .621 .008** .095 .376 .520
Minimizing .184 .839 .166 .846 .045** .817 .087
Inability to Trust .517 .212 .479 .009** .084 .383 .939
Revictimization .762 .657 .877 .035** .226 .300 .317
Victimizing Others .930 .486 .353 .297 .007** .650 .265
Digestive System
.033** .511 .442 .147 .178 .265 .972
Problems
Chronic Pain .569 .511 .442 .147 .915 .265 .972
Cardiopulmonary
.569 .511 .442 .147 .119 .475 .157
Problems
Conversion Symptoms .569 .511 .442 .147 .119 .475 .157
Sexual Symptoms 1.000 1.000 1.000 1.00 1.000 1.000 1.000
Despair and Hopelessness .215 .087 .816 .041** .817 .662 .939
Loss of Previously
.050** .657 .877 .000** .877 .300 .959
Sustaining Beliefs
indicates marginal significance levels <.07; "indicates statistically significance levels <.05

94
Physical abuse and individual trauma symptoms

Physical abuse was significantly related to seven individual symptoms, and

marginally significant with one individual symptom. Below are the contingency tables for

each significant relationship.

Table 14

Chi-Square Analysis: Physical Abuse and Self-Destructive Behavior

Self-Destructive Behavior
Absent Present
Absent 25(89.3%) 3(10.7%)
Physical Abuse
Present 8(61.5%) 5(38.5%)

Chi-square analysis found that physical abuse was significantly related to self-

destructive behavior (^2 = 4.352, p<.05). One cell in the contingency table had an

expected count less than 5. Fisher's exact test was used and produced a corrected level of

.051, which is just above the statistically significant cutoff. Therefore, physical abuse and

self-destructive behavior are marginally related, with more self-destructive behaviors

present among youth who have'been physically abused.

Table 15

Chi-Square Analysis: Physical Abuse and Suicidal Preoccupation

Suicidal Preoccupation
Absent Present
Absent 26(92.9%) 2(7.1%)
Physical Abuse
Present 9 (69.2%) 4 (30.8%)

95
 Chi-square tests indicated that physical abuse is significantly related to suicidal

preoccupation (^2 = 3.967, p<.05). Two cells had an expected value less than 5, and a

Fisher's Exact Test yielded a significance level of .069. Physical abuse was marginally

related to suicidal preoccupation, with a tendency toward greater suicidal preoccupation

among youths who have been physically abused.

Table 16

Chi-Square Analysis: Physical Abuse and Dissociation/Depersonalization

Dissociation/Depersonalization
Absent Present
Absent 27 (96.4%) 1 (3.6%)
Physical Abuse
Present 10(76.9%) 3(23.1 %)

Chi-square tests indicated that physical abuse was significantly related to

dissociation/ depersonalization (%2 = 3.837, p<.05). Two cells had an expected value less

than 5. A Fisher's Exact Test produced an exact significance level of .086. Therefore,

physical abuse was not significantly related to dissociation or depersonalization.

Table 17

Chi-Square Analysis: Physical Abuse and Guilt/Responsibility

Guilt/Responsibility
Absent Present
Absent 28(100.0%) 0(0.0%)
Physical Abuse
Present 11(84.6%) 2(15.4%)

Chi-square tests indicated that physical abuse was significantly related to feelings of

guilt and responsibility (^2 = 4.529, p<0.05). Two of the cells had and expected value

96
less than 5. A Fisher's Exact Test yielded an exact significance level of .095. Therefore,

physical abuse was not significantly related to feelings of guilt or responsibility.

Table 18

Chi-Square Analysis: Physical Abuse and Nobody Can Understand

Nobody Can Understand

Absent Present
Absent 28(100.0%) 0(0.0%)
Physical Abuse
Present 10(76.9%) 3(23.1%)

Chi-square tests indicated that physical abuse was significantly related to feelings

that no one could understand them ( / 2 = 6.972, p<.05). Two cells had an expected value

less than 5. A Fisher's Exact Test produced a .027 level of significance, which

maintained a statistically significant relationship between physical abuse and feelings that

nobody can understand. Youths who had been physically abused were more likely to

suffer from a sense that no one can understand than youths who were not physically

abused.

Table 19

Chi-Square Analysis: Physical Abuse and Digestive System Problems

Digestive System Problems

Absent Present
Absent 28(100.0%) 0(0.0%)
Physical Abuse
Present 11(85.6%) 2(15.4%)

Chi-square tests indicated that physical abuse was significantly related to digestive

system problems ( j 2 = 4.539, p<.05). Two cells had an expected value less than 5,

97
therefore a Fisher's Exact Test was used and produced a .095 significance level.

Consequently, physical abuse was not significantly related to digestive system problems.

Table 20

Chi-Square Analysis: Physical Abuse and Loss of Previously Sustaining Beliefs

Loss of Previously Sustaining Beliefs

Absent Present
Absent 27 (96.4%) 1 (3.6%)
Physical Abuse
Present 10(76.9%) 3(23.1%)

Chi-square tests indicated that physical abuse was significantly related to loss of

previously sustaining beliefs (^2 = 3.837, p<.05). Two cells had an expected value less

than 5. A Fisher's Exact Test produced an exact significance level of .086. Therefore,

physical abuse was not significantly related to loss of previously sustaining beliefs.

Table 21

Chi-Square Analysis: Physical Abuse and Affect Regulation

Affect Regulation
Absent Present
Absent 15(53.6%) 13(46.4%)
Physical Abuse
Present 3(23.1%) 10(76.9%)

Chi-square analyses revealed a marginally significant relationship between physical

abuse and affect regulation ( j 2 = 3.352, p<.07). Therefore, youths who had been

physically abused tended to have more problems with affect regulation than non-

physically abused youths.

98
Emotional abuse and individual trauma symptoms

Statistical analyses using Chi-square found five significant relationships between

emotional abuse and individual trauma symptoms. The following contingency tables

summarize these relationships.

Table 22

Chi-Square Analysis: Emotional Abuse and Intrusive Memories

Intrusive Memories
Absent Present
Absent 33 (97.1%) 1 (2.9%)
Emotional Abuse
Present 4(57.1%) 3(42.9%)

Chi-square tests indicated a significant relationship between emotional abuse and

intrusive memories ( j 2 = 10.505, p<.05). Two cells had an expected value of less than 5.

A Fisher's Exact Test produced an exact significance level of .012, maintaining a

significant relationship between emotional abuse and intrusive memories. The data

suggests that youths who had been emotionally abused tended to experience more

intrusive memories than youths who were not emotionally abused.

Table 23

Chi-Square Analysis: Emotional Abuse and Nightmares/Distressing Dreams

Nightmares/Distressing Dreams
Absent Present
Absent 34(100.0%) 0(0.0%)
Emotional Abuse
Present 6(85.7%) 1(14.3%)

99
 Chi-square analysis indicated that emotional abuse was significantly related to

nightmares/distressing dreams (/2 = 4.979, p<.05). Two cells had an expected value less

than 5. A Fisher's Exact Test produced an exact significance level of .171. Therefore,

emotional abuse was not significantly related to nightmares and distressing dreams.

Table 24

Chi-Square Analysis: Emotional Abuse and Self-Destructive Behavior

Self-Destructive Behavior
Absent Present
Absent 30 (88.2%) 4(11.8%)
Emotional Abuse
Present 3(42.9%) 4(57.1%)

Chi-square analysis revealed a significant relationship between emotional abuse and

self-destructive behavior (^2 = 7.611, p<.05). One cell had an expected value less than 5.

A Fisher's Exact Test yielded an exact significance level of .018, maintaining the

statistically significant relationship between emotional abuse and self-destructive

behavior. Youths who had been emotionally abused were significantly more likely to

engage in self-destructive behaviors.

Table 25

Chi-Square Analysis: Emotional Abuse and Permanent Damage

Permanent Damage
Absent Present
Absent 31(91.2%) 3(8.8%)
Emotional Abuse
Present 4(57.1%) 3(42.9%)

100
 Chi-square analysis indicated that emotional abuse was significantly related to

feelings of permanent damage ( j 2 = 5.382, p<.05). Two cells had an expected value less

than 5. A Fisher's Exact Test yielded an exact significance level of .051, a value just

above statistical significance. Therefore, emotional abuse was marginally related to

feelings of permanent damage. Youths who had been emotionally abused tended to have

more feelings of permanent damage than youths who were not emotionally abused.

A marginally significant relationship was observed between emotional abuse and

difficulty modulating sexual involvement (%2 = 3.394, p<.07). Two of the cells had an

expected value less than 5. A Fisher's Exact Test yielded an exact significance level of

.128. Therefore, no significant relationship existed between emotional abuse and

difficulty modulating sexual involvement.

Neglect and individual trauma symptoms

No statistically significant relationships were observed between neglect and

individual trauma symptoms. One relationship, neglect and sleep problems, was

marginally significant (%2 = 3.405, p<.07). However, one of the cells had an expected

value less than 5, and a Fisher's Exact Test yielded an exact significance level of .087.

Therefore, no relationship existed between neglect and individual trauma symptoms.

Sexual abuse and individual trauma symptoms

A statistically significant relationship was found between sexual abuse and twenty-

four individual trauma symptoms. The tables below summarize the results for each

symptom.

101
Table 26

Chi-Square Analysis: Sexual Abuse and Intrusive Memories

Intrusive Memories
Absent Present
Absent 34(97.1%) 1(2.9%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis indicated that sexual abuse was significantly related to intrusive

memories ( / 2 = 12.929, p<.001). Two cells had an expected value less than 5. A Fisher's

Exact Test yielded a corrected significance level of .007, maintaining the significant

relationship between sexual abuse and intrusive memories. Youths who had been

sexually abused were significantly more likely to experience intrusive memories than

youths who were not sexually abused.

Table 27

Chi-Square Analysis: Sexual Abuse and Nightmares/Distressing Dreams

Nightmares/Distressing Dreams
Absent Present
Absent 35(100.0%) 0(0.0%)
Sexual Abuse
Present 5(83.3%) 1(16.7%)

Chi-square analysis indicated that sexual abuse was significantly related to

nightmares and distressing dreams (%2 = 5.979, p<.05). Two cells had expected cell

counts less than five. A Fisher's Exact Test yielded a corrected .146 significance level.

Therefore, no significant relationship existed between sexual abuse and nightmares and

intrusive dreams.

102
Table 28

Chi-Square Analysis: Sexual Abuse and Flashbacks/Hallucinations/Sensory Experiences

Flashbacks/Hallucinations/Sensory
Experiences
Absent Present
Absent 35(100.0%) 0(0.0%)
Sexual Abuse
Present 5(83.3%) 1(16.7%)

Chi-square analysis indicated that sexual abuse was significantly related to

flashbacks, hallucinations, and sensory experiences (^2 = 5.979, p<.05). Two cells had

expected cell counts less than five. A Fisher's Exact Test yielded a corrected .146

significance level. Therefore, no significant relationship existed between sexual abuse

and flashbacks, hallucinations, or sensory experiences.

Table 29

Chi-Square Analysis: Sexual Abuse and Psychological Distress due to Internal or

External Stimuli

Psychological Distress due to Internal or

External Stimuli
Absent Present
Absent 35(100.0%) 0(0.0%)
Sexual Abuse
Present 5(83.3%) 1(16.7%)

Chi-square analysis indicated that sexual abuse was significantly related to

psychological distress due to internal or external stimuli ( j 2 = 5.979, p<.05). Two cells

had expected cell counts less than five. A Fisher's Exact Test yielded a corrected .146

103
significance level. Therefore, no significant relationship existed between sexual abuse

and psychological distress due to internal or external stimuli.

Table 30

Chi-Square Analysis: Sexual Abuse and Physiological Distress due to Internal or

External Stimuli

Physiological Distress due to Internal or

External Stimuli
Absent Present
Absent 35(100.0%) 0(0.0%)
Sexual Abuse
Present 5(83.3%) 1(16.7%)

Chi-square analysis indicated that sexual abuse was significantly related to

physiological distress due to internal or external stimuli (^2 = 5.979, p<.05). Two cells

had expected cell counts less than five. A Fisher's Exact Test yielded a corrected .146

significance level. Therefore, no significant relationship existed between sexual abuse

and physiological distress due to internal or external stimuli.

Table 31

Chi-Square Analysis: Sexual Abuse and Avoid Thoughts, Feelings, Talking About the
Trauma

Avoid Thoughts, Feelings, Talking About

the Trauma
Absent Present
Absent 35(100.0%) 0(0.0%)
Sexual Abuse
Present 5(83.3%) 1(16.7%)

Chi-square analysis indicated that sexual abuse was significantly related to

avoidance of thoughts or feelings related to the trauma, or talking about aspects of the

104
trauma. (%2 = 5.979, p<.05). Two cells had expected cell counts less than five. A

Fisher's Exact Test yielded a corrected .146 significance level. Therefore, no significant

relationship existed between sexual abuse and avoidance of thoughts or feelings related to

the trauma, or talking about aspects of the trauma.

Table 32

Chi-Square Analysis: Sexual Abuse and Diminished Interest

Diminished Interest
Absent Present
Absent 34(97.1%) 1(2.9%)
Sexual Abuse
Present 4 (66.7%) 3 (33.3%)

Chi-square analysis indicated that sexual abuse was significantly related to

diminished interest in activities (%2 = 7.015, p<.01). Two cells had an expected value

less than five. A Fisher's Exact Test yielded a corrected significance level of .051, which

is just over the limit for statistical significance. Therefore, a marginally significant

relationship existed between sexual abuse and diminished interest whereby youths who

were sexually abused tended to have less interest in activities.

Table 33

Chi-Square Analysis: Sexual Abuse and Sleep Problems

Sleep Problems
Absent Present
Absent 30(85.7%) 5(14.3%)
Sexual Abuse
Present 2 (33.3%) 4 (66.7%)

105
 Chi-square analysis produced a statistically significant relationship between sexual

abuse and sleep problems ( j 2 = 8.203, p<.01). Two cells had an expected value less than

five. A Fisher's Exact Test yielded a corrected significance level of .015, maintaining the

significant relationship between sexual abuse and sleep problems. Youth who had been

sexually abused were significantly more likely to experience sleep problems than youths

who were not sexually abused.

Table 34

Chi-Square Analysis: Sexual Abuse and Irritability

Irritability
Absent Present
Absent 27(77.1%) 8(22.9%)
Sexual Abuse
Present 1(16.7%) 5(83.3%)

Chi-square analysis indicated a statistically significant relationship between sexual

abuse and irritability ( j 2 = 8.651, p<.01). Two cells had an expected cell count less than

five. A Fisher's Exact Test yielded a corrected .008 significance level, confirming the

significant relationship between sexual abuse and irritability. Therefore, youths who were

sexually abused were significantly more likely to have symptoms of irritability than

youths who were not sexually abused.

106
Table 35

Chi-Square Analysis: Sexual Abuse and Hypervigilance

Hypervigilance
Absent Present
Absent 33 (94.3%) 2 (5.7%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis found a statistically significant relationship between sexual

abuse and hypervigilance (^2 = 9.381, p<.01). Two of the cells had an expected count

less than five. A Fisher's Exact Test produced a corrected significance level of .017,

maintaining the statistically significant relationship. Sexually abused youth were more

likely to be hypervigilant than their counterparts who were not sexually abused.

Table 36

Chi-Square Analysis: Sexual Abuse and Affect Regulation

Affect Regulation
Absent Present
Absent 18 (51.4%) 17 (48.6%)
Sexual Abuse
Present 0 (0.0%) 6 (100.0%)

Chi-square analysis indicated a statistically significant relationship between sexual

abuse and affect regulation problems (%2 - 5.501, p<.05). Two cells had an expected cell

count less than five. A Fisher's Exact Test yielded a corrected .022 significance level,

confirming the statistically significant relationship. Youths with sexual abuse were

107
significantly more likely to suffer from affect regulation problems than youths who were

not sexually abused.

Table 37

Chi-Square Analysis: Sexual Abuse and Modulation of Anger

Modulation of Anger
Absent Present
Absent 16(45.7%) 19(54.3%)
Sexual Abuse
Present 0(0.0%) 6(100.0%)

Chi-square analysis found a statistically significant relationship between sexual

abuse and problems modulating anger (%2 = 4.498, p<.05). Two cells had an expected

cell count less than five. The corrected significance level using Fisher's Exact Test was

.039, confirming the statistically significant relationship. Youths who had suffered sexual

abuse were significantly more likely to have problems modulating their anger than youths

who were not sexually abused.

Table 38

Chi-Square Analysis: Sexual Abuse and Self-Destructive Behavior

Self-Destructive Behavior
Absent Present
Absent 33 (94.3%) 2 (5.7%)
Sexual Abuse
Present 0(0.0%) 6(100.0%)

Chi-square analysis found a statistically significant relationship between sexual

abuse and self-destructive behavior (%2 = 28.993, p<.001). Two cells had an expected

cell count less than five. Fisher's Exact Test produced a corrected significance level of

108
less than .001, confirming the statistically significant relationship. Youths with sexual

abuse histories were significantly more likely to engage in self-destructive behavior than

their counterparts who were not sexually abused.

Table 39

Chi-Square Analysis: Sexual Abuse and Suicidal Preoccupation

Suicidal Preoccupation
Absent Present
Absent 33 (94.3%) 2 (5.7%)
Sexual Abuse
Present 2 (33/3%) 4 (66.7%)

Chi-Square analysis indicated a statistically significant relationship between sexual

abuse and suicidal preoccupation ( j 2 = 15.232, p<.001). One cell had an expected cell

count less than five. Fisher's Exact Test yielded a corrected significance level of .002,

maintaining the significant relationship. Youths who were sexually abused were

significantly more likely to have suicidal preoccupation than youths who were not

sexually abused.

Table 40

Chi-Square Analysis: Sexual Abuse and Difficulty Modulating Sexual Involvement

Difficulty Modulating Sexual Involvement

Absent Present
Absent 34(97.1%) 1(2.9%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis found a statistically significant relationship between sexual

abuse and difficulty modulating sexual involvement (%2 = 12.929, p<.001). Two cells

had an expected cell count less than five. A Fisher's Exact Test produced a corrected .007

109
level of significance, which confirmed the statistically significant relationship. Youths

with a history of sexual abuse had significantly more problems in the area of modulating

sexual involvement than youths with no sexual abuse history.

Table 41

Chi-Square Analysis: Sexual Abuse and Amnesia

Amnesia
Absent Present
Absent 35(100.0%) 0(0.0%)
Sexual Abuse
Present 5(83.3%) 1(16.7%)

Chi-square analysis found a statistically significant relationship between sexual

abuse and amnesia (^2 = 5.979, p<.05). Two cells had an expected cell count less than

five. A Fisher's Exact Test produced a corrected significance level of .146. Therefore, no

significant relationship existed between sexual abuse and amnesia.

Table 42

Chi-Square Analysis: Sexual Abuse and Dissociation or Depersonalization

Dissociation or Depersonalization
Absent Present
Absent 34(97.1%) 1(2.9%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis indicated a significant relationship between sexual abuse and

dissociation or depersonalization (^2 = 12.929, p<.001). Two cells had an expected cell

count less than five. A Fisher's Exact Test yielded a corrected significance level of .007,

confirming the significant relationship. Youths who were sexually abused were

110
significantly more likely to have dissociative or depersonalization symptoms than youths

who were not sexually abused.

Table 43

Chi-Square Analysis: Sexual Abuse and Ineffectiveness

Ineffectiveness
Absent Present
Absent 30(85.7%) 5(14.3%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis found a statistically significant relationship between sexual

abuse and feelings of ineffectiveness ( j 2 = 4.160, p<.05). Two cells had an expected cell

count less than five. A Fisher's Exact Test produced a corrected .077 significance level.

Therefore, no significant relationship existed between sexual abuse and feelings of

ineffectiveness.

Table 44

Chi-Square Analysis: Sexual Abuse and Permanent Damage

Permanent Damage
Absent Present
Absent 32(91.4%) 2(8.6%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis indicated a statistically significant relationship between sexual

abuse and feelings of permanent damage (^2 = 7.037, p<.01). One cell had an expected

cell value less than five. Fisher's Exact Test produced a corrected significance value of

.031, which confirmed the significant relationship. Sexually abused youths were

111
significantly more likely to have feelings of permanent damage than their counterparts

who were not sexually abused.

Table 45

Chi-Square Analysis: Sexual Abuse and Nobody Can Understand

Nobody Can Understand

Absent Present
Absent 34(97.1%) 1(2.9%)
Sexual Abuse
Present 4 (66.7%) 2 (33.3%)

Chi-square analysis found a statistically significant relationship between sexual

abuse and feelings that nobody can understand (%2 = 7.015, p<.01). Two cells had an

expected value less than five. Fisher's Exact Test yielded a corrected significance level of

.051, just over the statistically significant cutoff. Therefore, a marginally significant

relationship existed between sexual abuse and feelings that nobody can understand.

Youths with sexual abuse histories tended to feel that nobody could understand them as

compared to their non-abused counterparts.

Table 46

Chi-Square Analysis: Sexual Abuse and Inability to Trust

Inability to Trust
Absent Present
Absent 29(82.9%) 6(17.1%)
Sexual Abuse
Present 2 (33.3%) 4 (66.7%)

Chi-square analysis indicated a statistically significant relationship between sexual

abuse and inability to trust others (%2 = 6.812, p<.01). Two cells had an expected cell

112
count less than five. A Fishers Exact Test produced a corrected significance level of

.024, confirming the significant relationship. Youths who had been sexually abused were

significantly more likely to have problems trusting others than youths without sexual

abuse.

Table 47

Chi-Square Analysis: Sexual Abuse and Revictimization

Revictimization
Absent Present
Absent 35(100.0%) 0(0.0%)
Sexual Abuse
Present 5(83.3%) 1(16.7%)

Chi-square analysis found a statistically significant relationship between sexual abuse

and revictimization ( j 2 = 4.438, p<.05). Two cells had an expected cell count less than

five. A Fisher's Exact Test yielded a corrected .095 level of significance. Therefore, no

significant relationship existed between sexual abuse and revictimization.

Table 48

Chi-Square Analysis: Sexual Abuse and Despair and Hopelessness

Despair and Hopelessness

Absent Present
Absent 30(85.7%) 5(14.3%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis indicated a statistically significant relationship between sexual

abuse and despair and hopelessness (^2 = 4.160, p<.05). Two cells had an expected cell

count less than five. A Fisher's Exact Test produced a corrected .077 level of

113
significance. Therefore, no significant relationship existed between sexual abuse and

despair and hopelessness.

Table 49

Chi-Square Analysis: Sexual Abuse and Loss of Previously Sustaining Beliefs

Loss of Previously Sustaining Beliefs

Absent Present
Absent 34(97.1%) 1(2.9%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis found a statistically significant relationship between sexual

abuse and loss of previously sustaining beliefs (%2 = 12.929, p<.001). Two cells had an

expected cell count less than five. A Fisher's Exact Test yielded and corrected

significance value of .007, confirming the significant relationship. Youths who suffered

sexual abuse were significantly more likely to experience a loss of previously sustaining

beliefs than their counterparts who were not sexually abused.

Exposure to community violence and individual trauma symptoms

Chi-square statistical analyses were conducted to explore the relationship between

exposure to community violence and individual trauma symptoms. Three significant

relationships were observed. The following tables summarize the results.

114
Table 50

Chi-Square Analysis: Exposure to Community Violence and Risk-Taking Behavior

Risk-Taking Behavior
Absent Present
Exposure to Absent 14(63.6%) 8(36.4%)
Community
Violence Present 5(26.3%) 14(73.7%)

Chi-square analysis found a statistically significant relationship between exposure to

community violence and risk-taking behavior ( j 2 = 5.711, p<.05). Youths exposed to

community violence were significantly more likely to engage in risk-taking behavior than

youths not exposed to community violence.

Table 51

Chi-Square Analysis: Exposure to Community Violence and Minimizing

Minimizing
Absent Present
Exposure to Absent 15(68.2%) 7(31.8%)
Community
Violence Present 7(36.8%) 12(63.2%)

Chi-square analysis indicated a statistically significant relationship between exposure

to community violence and minimizing ( / 2 = 4.027, p<.05). Youths exposed to

community violence were more likely to engage in minimizing than non-exposed youths.

115
Table 52

Chi-Square Analysis: Exposure to Community Violence and Victimizing Others

Minimizing
Absent Present
Exposure to Absent 19(86.4%) 3(13.6%)
Community
Violence Present 9(47.4%) 10(52.6%)

Chi-square analysis found a statistically significant relationship between exposure to

community violence and victimizing others (%2 = 7.159, p<.01). Youths exposed to

community violence were significantly more likely to victimize others than non-exposed

youths.

Exposure to intimate partner violence and individual trauma symptoms

Data analysis was conducted to explore the relationship between exposure to

intimate partner violence and individual trauma symptoms. Only one significant

relationship was observed.

Table 53

Chi-Square Analysis: Exposure to Intimate Partner Violence and Restricted Range of

Affect

Restricted Range of Affect

Absent Present
Exposure to Absent 20(60.6%) 13(39.4%)
Community
Violence Present 8(100.0%) 0(0.0%)

116
 Chi-square analysis found a statistically significant relationship between exposure to

intimate partner violence and restricted range of affect {%2 = 4.615, p<.05). One cell had

an expected cell count less than five. A Fisher's Exact Test produced a corrected

significance level of .033, confirming the significant relationship. Interestingly, youths

not exposed to intimate partner violence were observed to have significantly more

restricted range of affect than youths exposed to intimate partner violence.

Other trauma and individual trauma symptoms

No significant relationships were observed between other trauma and individual

trauma symptoms.

Sum of trauma and individual trauma symptoms

Statistical analysis was conducted between the sum of trauma variable and individual

trauma symptoms to explore whether significant relationships existed between exposure

to multiple modes of trauma and symptom presentation. One-way ANOVAs were

conducted to explore these relationships. The following table summarizes the results.

117
Table 54

Analysis of Variance Results: Sum of Trauma Exposure and Individual Trauma Symptoms

Sum of Trauma
F value Sis
Intrusive Memories 1.330 .274
Nightmares/Distressing Dreams 1.537 .204
Flashbacks, Hallucinations, Sensory Experiences .317 .899
Psychological Distress due to Internal or External
.317 .899
Stimuli
Physiological Distress due to Internal or External
.317 .899
Stimuli
Avoid Thoughts, Feelings, Talking about it .317 .899
Avoid Places — 1.000
Difficulty Remembering Information — 1.000
Diminished Interest 1.498 .216
Detachment, Estrangement, Withdrawal 2.082 .091
Restricted Range of Affect 1.765 .146
Sense of foreshortened future — 1.000
Sleep Problems 1.111 .372
Irritability 1.447 .232
Difficulty Concentrating .483 .786
Hypervigilance .683 .639
Increased or exaggerated startle response .683 .639
Affect Regulation 1.630 .178
Modulation of Anger 1.456 .229
Self-Destructive 3.244 .016**
Suicidal Preoccupation .868 .513
Difficulty Modulating Sexual Involvement 1.330 .274
Risk-taking Behavior 1.040 .410

118
Amnesia .317 .899
Dissociation or Depersonalization 1.614 .182
Ineffectiveness .752 .590
Permanent Damage 3.575 .010**
Guilt and Responsibility .683 .639
Shame .683 .639
Nobody Can Understand 1.715 .157
Minimizing 1.377 .257
Inability to Trust .866 .514
Revictimization 1.829 .133
Victimizing Others 1.297 .288
Digestive System Problems .683 .639
Chronic Pain .683 .639
Cardiopulmonary Problems .683 .639
Conversion Symptoms .683 .639
Sexual Symptoms — 1.000
Despair and Hopelessness 1.930 .114
Loss of Previously Sustaining Beliefs 1.330 .274
* indicates marginal significance levels <.07; **indicates statistically significance levels
<.05

Two significant relationships were found between the sum of trauma variable and

individual trauma symptoms: self-destructive behavior and permanent damage. For self-

destructive behavior, as youths were exposed to more forms of trauma, their likelihood of

engaging in self-destructive behavior increased. Similarly, youths exposed to more forms

of trauma were significantly more likely to experience feelings of permanent damage.

119
 Trauma and the Sum of Cluster Symptoms

The next level of analysis examined the relationship between trauma exposure and

the total number of symptoms per cluster with which a youth presented. This will reveal

any potential relationships between modes of trauma and the tendency to have symptoms

within a certain cluster of PTSD or Complex PTSD. One-way ANOVAs were performed

to examine these relationships. Significance levels are summarized in the table below.

Statistically significant findings will be explored individually below. For reference,

"Trauma Clin" refers to the presence or absence of any kind of trauma (i.e., if the youth

had at least one mode of trauma present they received a positive score and if they had no

trauma exposure they received a score of zero), and "Trauma Agg" is the sum of the

different modes of trauma to which the youth has been exposed.

120
Table 55

Analysis of Variance Results: Sum of Cluster Symptoms and Trauma Exposure

Exposure to
Physical Emotional Sexual
Neglect Community
Abuse Abuse Abuse
Violence
Sum of Reexperiencing
.252 .128 .695 .000** .461
Symptoms
Sum of Avoidance
.663 .808 .191 .013** .182
Symptoms
Sum of Hyperarousal
.356 .035** .764 .001** .141
Symptoms
Sum of Alteration in
Affect Regulation .064* .079 .547 .000** .080
Symptoms
Sum of Alteration in
Attention/Consciousness .240 .382 .306 .000** .807
Symptoms
Sum of Alteration in
Self-Perception .027** .251 .489 .003** .248
Symptoms
Sum of Alteration in
.874 .282 .398 .012** .008**
Relationships Symptoms
Sum of Somatization
.201 .383 .307 .050** .535
Symptoms
Sum of Alteration in
.074 .182 .822 .001** .823
Systems of Meaning
Exposure to Presence/
Sum of
Intimate Other Absence of
Modes of
Partner Trauma anv kind of
Trauma
Violence Trauma
Sum of Reexperiencing
.761 .209 .435 .762
Symptoms
Sum of Avoidance
.032** .918 .288 .057*
Symptoms
Sum of Hyperarousal
.937 .870 .071 .148
Symptoms

121
Sum of Alteration in
Affect Regulation .222 .989 .211 .013**
Symptoms
Sum of Alteration in
Attention/Consciousness .342 .266 .382 .253
Symptoms
Sum of Alteration in
Self-Perception .469 .389 .052* .065*
Symptoms
Sum of Alteration in
.333 .780 .034** .343
Relationships Symptoms
Sum of Somatization
.791 .360 .383 .574
Symptoms
Sum of Alteration in
Systems of Meaning .826 .941 .476 .089

indicates marginal significance levels <.07; **indicates statistically significance levels <.05

Physical abuse and sum of cluster symptoms

The relationship between physical abuse and the sums of symptoms in each cluster

was explored. The following graph illustrates mean differences in the two significant

relationships observed.

122
 M e a n s of Significant Relationships B e t w e e n Physical
Abuse and Complex PTSD Clusters

D PA Absent
• PA Present

Alt in Self-Perception Alt in Affect Regulation

Complex PTSD Cluster

Figure 19. The above graph illustrates the mean differences for the significant

relationships observed between physical abuse and the Alterations in Self-Perception

and Alteration in Affect Regulation clusters of the Complex PTSD Diagnosis.

A statistically significant relationship was observed between exposure to physical abuse

and the sums of symptoms in the Alterations in Self-Perception cluster (F=5.317, p<.05).

The average number of symptoms in the self-perception cluster with no physical abuse

was .075, versus 1.54 among those who had been physically abused. Therefore, youths

with histories of physical abuse are significantly more likely to have more problems with

self-perception than their non-abused counterparts.

A marginally significant relationship was observed between physical abuse and the

sum of symptoms in the Alteration in Affect Regulation cluster (F=3.643, p<.07). The

average number of symptoms in this cluster among non-physically abused youth was

1.82, whereas physically abused youth averaged 2.85 symptoms. Physically abused

123
youths tended to have more problems in the affect regulation cluster than youths with no

physical abuse histories.

Emotional abuse and sum of cluster symptoms

Statistical analysis revealed only one significant relationship between emotional

abuse and the sum of symptoms in the hyperarousal clusters (F=4.754, p<.05). The table

below depicts the mean differences.

Mean Difference in Hyperarousal Symptoms for Non-

Emotionally Abused versus Emotionally Abused
Youths

• EA Absent
• EA Present

Hyperarousal Symptoms

Figure 20. The above graph illustrates the significant mean difference in

Hyperarousal symptoms for non-emotionally abused versus emotionally abused

youths.

The average number of Hyperarousal symptoms among non-emotionally abused youth

was .88 versus 1.71 among those exposed to emotional abuse. Emotionally-abused youth

were significantly more likely to have more Hyperarousal symptoms than non-

emotionally abused youth.

124
Neglect and sums of cluster symptoms

No significant relationships were observed between neglect and the sum of

symptoms in each clusters.

Sexual abuse and sum of cluster symptoms

A significant relationship was found between sexual abuse and sum of symptoms in

each cluster. Below is a distribution of the means for youths with and without sexual

abuse histories.

Mean Differences for All Symptom Clusters Between

Sexually Abused and Non-Sexually Abused Youths

D S A Absent
• SA Present

c$> .& ,& oO

0^ ^ J> <>° <? *° # <>° o<
<f ^ «T </ if <P J> j? X
9? V v

Symptom Clusters

Figure 21. The above graph illustrates the significant mean differences in the

number of symptoms (sum of symptoms) across all PTSD and Complex PTSD

clusters between non-sexually abused and sexually abused youths.

125
Significant differences were found between abused versus non-abused youths in the

Reexperiencing (F=l 8.743, p<.00]), Avoidance (F=6J95, p<.05), Hyperarousal

(F=l2.863, p<.001), Affect Regulation (F=43.022, p<.001), Attention/Consciousness

(F=18.894, p<.001), Self-perception (F=10.241, p<.01), Relationships (F=6.872, p<.05),

Somatization (F=4.097, p<.05), and Systems of Meaning clusters (F=12.500, p<.01).

Across all clusters, the youths with sexual abuse histories had at least twice as many

symptoms, with the following breakdown of means: Reexperiencing (non-abused .03,

abused 1.17), Avoidance (non-abused .49, abused 1.50), Hyperarousal (non-abused .83,

abused 2.17), Affect Regulation (non-abused 1.66, abused 5.00), Attention/

Consciousness (non-abused .03, abused .67), Self-perception (non-abused .80, abused

2.17), Relationships (non-abused .51, abused 1.50), Somatization (.11, abused .67),

Systems of Meaning (non-abused .17, abused 1.00). Youths who had been victims of

sexual abuse were significantly more likely to have more symptoms in a cluster than their

non-abused counterparts.

Exposure to community violence and sum of cluster symptoms

One significant relationship was observed between exposure to community violence

and the sum of symptoms in the Alterations in Relationships with Others cluster

(F=7.737, p<.01). The following figure illustrates the mean differences between the two

groups.

126
 Mean Difference in Alteration in Relationship
Symptoms for Youths Not Exposed vs. Exposed to
Community Violence

1.2

o
a
E 0.8
>•
D ECV Absent
<- 0.6
tu • ECV Present
x>
E
Z 0.4

0)
S 0.2

Alteration in Relationship

Figure 22. The above graph depicts the significant mean difference in Alteration in

Relationships with Others symptoms for youths exposed versus not exposed to

community violence.

Youths exposed to community violence had significantly more problems with

relationships and trust (1.05 symptoms) than youths who were not exposed to community

violence (.32 symptoms).

Exposure to intimate partner violence and sum of cluster symptoms

A significant relationship was found between exposure to intimate partner violence

and the sum of symptoms in the Avoidance cluster (F=4.946, p<.05). The following

figure illustrates the mean differences between exposed and non-exposed youth.

127
 Mean Difference in Alteration in Relationship Symptoms for
Youths Not Exposed vs. Exposed to Intimate Partner
Violence

0.9

0.8
ui

o 0.7
a
E 0.6
>•
V)
• IPV Absent
2 0.4 H • IPV Present
E
| 0.3
c
3 0.2
s
0.1

0
Alteration in Relationship

Figure 23. The above graph depicts the significant mean difference in Alteration in

Relationships with Others symptoms for youths exposed versus not exposed to

community violence.

Interestingly, youths who were not exposed to intimate partner violence had significantly

more symptoms in the avoidance cluster than those youths who were exposed.

Other trauma and sum of cluster symptoms

No significant relationships were observed between other trauma exposure and the

sum of symptoms in each cluster.

Absence or presence of any trauma and sum of cluster symptoms

Statistical analyses were performed to explore any significant relationships between

the presence or absence of any trauma and the amount of trauma symptoms in each

cluster. A significant relationship was observed between the presence/absence of trauma

128
and symptoms in the Alterations in Relationships cluster (F=4.830, p<.05), and a

marginally significant relationships with Alterations in Self-Perception symptoms

(F=4.029, p<.07). The following table illustrates the mean differences.

Mean Differences of Significant Relationships Between

Absence/Presence of any Trauma and Sum of Symptoms

1.4 i

• Trauma Absent
• Trauma Present

Alterations in Relationships Alterations in Self-Perception

Figure 24. The above graph depicts the mean difference for the two significant

relationships that were observed between the presence or absence of trauma and the

sum of symptoms in the Alterations in Relationships and Alterations in Self-

Perception clusters.

Youths who had experienced some kind of trauma had significantly more problems with

relationships than their non-abused counterparts. Moreover, abused youths tended to have

more problems with self-perception, although this did not reach the level of statistical

significance.

129
Sum of modes of trauma and sum of cluster symptoms

Statistical analyses were conducted to explore the relationship between the sum of the

modes of trauma to which a youth had been exposed, and the number of symptoms in

each cluster with which they present. One statistically significant relationship was found

with Affect Regulation symptoms (F=3.411, p<.05), and two marginally significant

relationships with Avoidance symptoms (F=2.401, p<-07) and Self-Perception symptoms

(F=2.313, p<.07). The details of each relationship are explored below.

Mean Number of Affect Regulation Symptoms by the

Total Modes of Trauma Experienced

..III
Zero One Two Three
Sum of Modes of T r a u m a
Four Five

Figure 25. The above graph depicts the mean number of Affect Regulation

symptoms as a function of the total modes of trauma to which a youth was exposed.

Overall, the more types of trauma to which youth were exposed, the greater the number

of symptoms in the Alterations of Affect Regulation cluster. Post-hoc tests revealed that

exposure to five modes of trauma yielded significantly more symptoms than four or less

trauma types. Having two or four modes of trauma resulted in significantly more

symptoms than exposure to one form of trauma.

130
 Mean Number of Avoidance Symptoms by the Total
Modes of Trauma Experienced

1.6 -]

0.8

0.6

0.4

0.2

Zero One Two Three Four Five

Sum of Modes of T r a u m a

Figure 26. The above graph depicts the mean number of Avoidance symptoms as a

function of the total modes of trauma to which a youth was exposed.

A marginally significant relationship was observed between the sum of trauma and the

number of symptoms in the Avoidance cluster. Post-hoc tests revealed that the mean

number of symptoms for youths exposed to one form of trauma was significantly higher

than those exposed to zero, two, three, or four modes of trauma. In addition, exposure to

five modes of trauma resulted in significantly more symptoms than exposure to three

modes of trauma.

131
 Mean Number of Self-Perception Symptoms by the
Total Modes of Trauma Experienced

3 -j

2.5 -

2-

1.5 -

Jj
1 -

0.5 -

0 --
Zero
I
One Two Three Four Five
S u m of Modes of T r a u m a

Figure 27. The above graph depicts the mean number of self-perception symptoms

as a function of the total modes of trauma to which a youth was exposed.

A marginally significant relationship was found between the variety of trauma exposure

and the number of symptoms in the Self-Perception cluster. Post-hoc tests revealed that

youths with exposure to five modes of trauma had significantly more symptoms than

youth exposed to zero or one mode of trauma. Similarly, youths exposed to four types of

trauma had significantly more symptoms than youths exposed to zero forms of trauma.

Overall, there was an upward trend in the number of symptoms as the youths were

exposed to more forms of trauma.

Trauma and Positive Clusters

The relationship between exposure to trauma and meeting the criteria for each

symptom cluster was examined. Chi-square analyses compared each mode of trauma to

whether or not the youth met the formal cutoff criteria for each cluster. The table below

132
summarizes the significance levels for each form of trauma, and whether or not the

symptoms cluster was positive or negative.

133
Table 56

Analysis of Variance Results: Trauma Exposure and Positive Clusters

Physical Emotional Sexual Exp. to Com.

Neglect
Abuse Abuse Abuse Violence
Reexperiencing Cluster .408 .001** .877 .000** .368
Avoidance Cluster .950 .437 .621 .008** .639
Hyperarousal Cluster .153 .027** .113 .009** .084
Alteration in Affect
.025** .240 .768 .010** .041**
Regulation Cluster
Alteration in Attention/
.050** .339 .264 .000** .368
Consciousness Cluster
Alteration in Self-
.057* .293 .618 .001** .524
Perception Cluster
Alteration in
.678 .934 .837 .175 .009**
Relationships Cluster
Somatization Cluster .176 .414 .340 .341 .463
Alteration in Systems of
.353 .142 .982 .004** .530
Meaning Cluster
Exp. to Int. Other Pres/Absence Sum of
Partner Vio. Trauma of Trauma Trauma
Reexperiencing Cluster .771 .317 .339 .274
Avoidance Cluster .376 .520 .414 .216
Hyperarousal Cluster .383 .414 .099 .092
Alteration in Affect
.477 .272 .032 * * .018**
Regulation Cluster
Alteration in Attention/
.300 .317 .339 .182
Consciousness Cluster
Alteration in Self-
.448 .335 .411 .223
Perception Cluster
Alteration in
.800 .279 .014** .269
Relationships Cluster
Somatization Cluster .530 .578 .414 .639
Alteration in Systems of
.816 .768 .591 .184
Meaning Cluster
* indicates marginal significance levels <.07; **indicates statistically significance levels <.05

134
Physical abuse and positive clusters

Statistical analysis revealed two significant relationships between physical abuse and

meeting criteria for Alterations in Affect Regulation {%l = 5.034, p<.05), and clinical

criteria for Alterations in Attention and Consciousness ( j 2 = 3.837, p<.05). A marginally

significant relationship was observed between physical abuse and meeting clinical criteria

for Alterations in Self-Perception ( j 2 = 3.621, p<.07). Each relationship is described in

detail below.

Table 57

Chi-Square Analysis: Physical Abuse and Alterations in Affect Regulation Cluster

Positive

Alterations in Affect Regulation Cluster

Absent Present
Absent 17(60.7%) 11(39.3%)
Physical Abuse
Present 3(23.1%) 10(76.9%)

Youths who had been exposed to physical abuse were significantly more likely to

meet clinical criteria for the Alterations in Affect Regulation cluster than youths who had

not been physically abused. Nearly three out of four of the youths who had been

physically abused met clinical criteria for problems in affect regulation, as compared to

approximately one-third of non-abused youths.

135
Table 58

Chi-Square Analysis: Physical Abuse and Alterations in Attention/Consciousness Cluster

Positive

Alterations in Attention/Consciousness
Cluster
Absent Present
Absent 27 (96.4%) 1 (3.6%)
Physical Abuse
Present 10(76.9%) 3(23.1%)

Chi-square analysis revealed a statistically significant relationship between physical

abuse and meeting clinical criteria for the Alterations in Attention and Consciousness

cluster. However, one cell had an expected cell count of less than five. Fisher's Exact

Test revealed a corrected significance level of .086, therefore no significant relationship

existed between physical abuse and meeting criteria for this cluster.

Table 59

Chi-Square Analysis: Physical Abuse and Alterations in Self-Perception Cluster Positive

Alterations in Self-Perception Cluster

Absent Present
Absent 23(82.1%) 5(17.9%)
Physical Abuse
Present 7 (53.8%) 6 (46.2%)

Chi-square analysis revealed a marginally significant relationship between physical

abuse and meeting clinical criteria for the Self-Perception cluster. One cell had an

expected count less than five. Fisher's Exact Test yielded an exact .066 significance

level, confirming the marginally significant relationship. Therefore, youths who had been

136
exposed to physical abuse tended to meet criteria for the Self-Perception cluster more

often than those youth with no physical abuse histories.

Emotional abuse and positive clusters

Statistical analyses revealed two significant relationships between emotional abuse

and meeting clinical criteria for the Reexperiencing cluster (^2 = 10.505, p<.01) and the

Hyperarousal cluster (%2 = 4.910, p<.05). The following tables summarize these specific

findings.

Table 60

Chi-Square Analysis: Emotional Abuse and Reexperiencing Cluster Positive

Reexperiencing Cluster
Absent Present
Absent 33(97.1%) 1(2.9%)
Emotional Abuse
Present 4(57.1%) 3(42.9%)

Chi-square analysis found a significant relationship between emotional abuse and a

positive score on the Reexperiencing cluster. Two cells had an expected cell count less

than five. A Fisher's Exact Test produced an exact significance level of .012, confirming

the significant relationship. Youths who had been exposed to emotional abuse were

significantly more likely to meet clinical criteria for the Reexperiencing cluster than their

non-abused counterparts.

137
Table 61

Chi-Square Analysis: Emotional Abuse and Hyperarousal Cluster Positive

Hyperarousal Cluster
Absent Present
Absent 28(82.4%) 6(17.6%)
Emotional Abuse
Present 3(42.9%) 4(57.1%)

A statistically significant relationship was observed between emotional abuse and a

positive clinical score on the Hyperarousal Cluster using Chi-square analysis. One cell

had an expected cell count less than five. A Fisher's Exact Test yielded an exact .047

significance level, confirming the significant relationship. Therefore, emotionally-abused

youths were significantly more likely to meet clinical criteria for the Hyperarousal cluster

than youths who were not emotionally abused.

Neglect and positive clusters

No significant relationships were found between neglect and meeting clinical criteria

for a cluster.

Sexual abuse and positive clusters

Sexual abuse was significantly related to meeting clinical criteria on almost all of the

symptoms clusters using Chi-square analysis. The following tables describe the nature of

each relationship in detail.

138
Table 62

Chi-Square Analysis: Sexual Abuse and Reexperiencing Cluster Positive

Reexperiencing Cluster
Absent Present
Absent 34(97.1%) 1(2.9%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis revealed a significant relationship between sexual abuse and a

clinically positive score on the Reexperiencing cluster (^2 = 12.929, p<.001). However,

two cells had an expected cell count less than five. Fisher's Exact Test produced an exact

significance level of .007, confirming the relationship. Youths who had been sexually

abused were significantly more likely to meet criteria for the Reexperiencing cluster than

their non-sexually abused counterparts.

Table 63

Chi-Square Analysis: Sexual Abuse and Avoidance Cluster Positive

Avoidance Cluster
Absent Present
Absent 34(97.1%) ' 1(2.9%)
Sexual Abuse
Present 4 (66.7%) 2 (33.3%)

Chi-square analysis found a significant relationship between sexual abuse and

meeting clinical criteria for the Avoidance cluster (%2 = 7.015, p<.01).Two cells had an

expected cell count less than five. Fisher's Exact Test produced an exact .051 level of

significance, just nearly missing the threshold for statistical significance. Therefore, a

139
marginally significant relationship existed between emotional abuse and meeting clinical

criteria for the Avoidance cluster, whereby youths with sexual abuse histories tended to

meet criteria more often than their non-abused peers.

Table 64

Chi-Square Analysis: Sexual Abuse and Hyperarousal Cluster Positive

Hyperarousal Cluster
Absent Present
Absent 29(82.9%) 6(17.1%)
Sexual Abuse
Present 2 (33.3%) 4 (66.7%)

Chi-square analysis revealed a significant relationship between sexual abuse and

meeting clinical criteria for the Hyperarousal cluster ( j 2 = 6.812, p<.01). Two cells had

an expected cell count less than five. A Fisher's Exact Test yielded and exact significance

level of .024, confirming the significance of the relationship. Youths who had been

sexually abused were significantly more likely to meet criteria for the Hyperarousal

cluster than their counterparts who were not sexually abused.

Table 65

Chi-Square Analysis: Sexual Abuse and Alterations in Affect Regulation Cluster Positive

Alterations in Affect Regulation Cluster

Absent Present
Absent 20(57.1%) 15(42.9%)
Sexual Abuse
Present 0(0.0%) 6(100.0%)

Chi-square analysis found a significant relationship between sexual abuse and

meeting clinical criteria for the Alterations in Affect Regulation cluster (^2 = 6.694,

140
p<0.05). Two cells had an expected cell count less than five, therefore a Fisher's Exact

Test was used and yielded a corrected .012 significance score, confirming the

relationship. Sexually-abused youths were significantly more likely to meet clinical

criteria for problems with affect regulation than non-sexually abused youths.

Table 66

Chi-Square Analysis: Sexual Abuse and Alterations in Attention/Consciousness Cluster

Positive

Alterations in Attention/Consciousness
Cluster
Absent Present
Absent 34(97.1%) 1(2.9%)
Sexual Abuse
Present 3 (50.0%) 3 (50.0%)

Chi-square analysis revealed a significant relationship between sexual abuse and

meeting clinical criteria for the Alterations in Attention/Consciousness cluster

(%2 = 12.929, p<.001). Two cells had an expected cell count less than five. Fisher's

Exact Test produced an exact significance level of .007, maintaining the significant

relationship. Therefore, youths who had been sexually abused were significantly more

likely to meet clinical criteria for problems with attention and consciousness than their

non-sexually abused peers.

Table 67

Chi-Square Analysis: Sexual Abuse and Alterations in Self-Perception Cluster Positive

Alterations in Self-Perception Cluster

Absent Present
Absent 29(82.9%) 6(17.1%)
Sexual Abuse
Present 1 (16.7%) 5 (83.3%)

141
 Chi-square analysis found a statistically significant relationship between sexual

abuse and meeting clinical criteria for the Alterations in Self-Perception cluster

( j 2 = 11.431, p<.01). Two cells had an expected cell count less than five. Fisher's Exact

Test yielded an exact significance level of .003, confirming the significant relationship.

Youths with sexual abuse histories were significantly more likely to meet clinical criteria

for problems with self-perception than non-sexually abused youths.

Table 68

Chi-Square Analysis: Sexual Abuse and Alterations in Systems of Meaning Cluster

Positive

Alterations in Systems of MeaninR Cluster

Absent Present
Absent 30(85.7%) 5(14.3%)
Sexual Abuse
Present 2 (33.3%) 4 (66.7%)

Chi-square analysis revealed a significant relationship between sexual abuse and

meeting clinical criteria for the Alteration in Systems of Meaning cluster (%2 = 8.203,

p<.01). Two cells had an expected cell value less than five. A Fisher's Exact Test

produced an exact significance level of .015, confirming the significant relationship.

Therefore, sexually-abused youths were significantly more likely to meet clinical criteria

for problems in systems of meaning than non-sexually abused youths.

142
Exposure to community violence and positive clusters

Significant relationships were observed between exposure to community violence

and meeting clinical criteria for the Alterations in Affect Regulation cluster and the

Alterations in Relationships cluster. The tables below describe details of the findings.

Table 69

Chi-Square Analysis: Exposure to Community Violence and Alterations in Affect

Regulation Cluster Positive

Alterations in Affect Regulation Positive

Absent Present
Exposure to Absent 14(63.3%) 8(36.4%)
Community
Violence Present 6(31.6%) 13(68.4%)

Chi-square analysis revealed a statistically significant relationship between exposure

to community violence and meeting the clinical criteria for the Alterations in Affective

Regulation cluster ( j 2 = 4.193, p<.05). Youths who had been exposed to community

violence were significantly more likely to have clinically significant problems with affect

regulation than youths who did not report exposure to community violence.

Table 70

Chi-Square Analysis: Exposure to Community Violence and Alterations in Relationships

Cluster Positive

Alterations in Relationships Positive

Absent Present
Exposure to Absent 17(77.3%) 5(22.7%)
Community
Violence Present 7(36.8%) 12(63.2%)

143
 Chi-square analysis found a statistically significant relationship between exposure to

community violence and meeting clinical criteria for a positive score in the Alterations in

Relationships cluster (%2 = 6.866, p<.01). Youths exposed to community violence were

significantly more likely to meet criteria for problems in relationships than youth who

were not exposed to community violence.

Exposure to intimate partner violence and positive clusters

No significant relationships were observed between exposure to intimate partner

violence and meeting clinical criteria for a PTSD or Complex PTSD cluster.

Other trauma and positive clusters

No significant relationships were observed between exposure to other trauma and

meeting clinical criteria for a PTSD or Complex PTSD cluster.

Absence or presence of any kind of trauma and positive clusters

Two statistically significant relationships were found between the presence/absence

of any trauma and meeting the clinical criteria for Alterations in Affective Regulation and

Alterations in Relationships cluster. The following tables summarize the findings.

144
Table 71

Chi-Square Analysis: Absence/Presence of Trauma and Alterations in Affect Regulation

Cluster Positive

Alterations in Affect Regulation Positive

Absent Present

Absence/Presence Absent 6 (85.7%) 1 (14.3%)

of Trauma Present 14(41.2%) 20 (58.8%)

Chi-square analysis revealed a statistically significant relationship between the

presence/absence of any kind of trauma and meeting the clinical criteria for the Alteration

in Affective Regulation cluster (^2 = 4.609, p<.05). Two cells had an expected cell count

less than five. Fisher's Exact Test produced an exact significance level of .04, confirming

the statistical significance of the relationship. Therefore, youths who had been exposed to

at least one form of trauma were significantly more likely to meet clinical criteria for

problems with affect regulation than youth who had not been exposed to trauma.

Table 72

Chi-Square Analysis: Absence/Presence of Trauma and Alterations in Relationships

Cluster Positive

Alterations in Relationships Positive

Absent Present

Absence/Presence Absent 7(100.0%) 0 (0.0%)

of Trauma Present 17(50.0%) 17(50.0%)

Chi-square analysis found a significant relationship between the presence/absence of

at least one kind of trauma and Alterations in Relationships (%2 = 5.979, p<.05). Two

145
cells had an expected cell count less than five. Fisher's Exact Test yielded an exact

significance level of .015, confirming the significant relationship. Youths who had been

exposed to at least one kind of trauma were significantly more likely to meet clinical

criteria for problems in relationships than youths who were not exposed to trauma.

Sum of modes of trauma and positive clusters

Statistical analysis was conducted to explore relationships between the sum of the

different types of trauma to which youth had been exposed and meeting the criteria for

each cluster. One significant relationship was observed in the Alterations of Affect

Regulation cluster (F=3.175, p<.05). The following graph illustrates the mean

differences.

Sum of Modes of Trauma Experienced and Mean

Score for the Affect Regulation Cluster

1.2

0.8

0.6

0.4

0.2

0
Zero One Two Three Four Five
Sum of Modes of T r a u m a

Figure 28. The above graph illustrates the average positive score for the affect

regulation cluster as a function of the total modes of trauma experienced by each

youth.

146
Least significant difference post-hoc testing was used to determine which means were

significantly different. Youths with exposure to five modes of trauma were significantly

more likely to meet criteria in the affect regulation cluster as compared youths exposed to

zero or one mode of trauma. Similarly, youths exposed to four modes of trauma were

significantly more likely to meet criteria than youths exposed to zero or one mode of

trauma. In addition, youths exposed to two modes of trauma were significantly more

likely to meet criteria than youths exposed to one mode of trauma.

Trauma and the Sum of Positive Clusters

Statistical analysis was performed to explore the relationship between each mode of

trauma and the sum of clusters for PTSD and Complex PTSD whose clinical criteria were

met. For example, if a youth had been exposed to physical abuse and met the criteria for

the avoidance and hyperarousal clusters, statistics were used to explore whether physical

abuse was related to the youth meeting criteria for both clusters. The table below

described the significance levels for each comparison.

147
Table 73

Analysis of Variance Results: Trauma Exposure and Sum of PTSD and Complex PTSD Clusters

Sum of PTSD Clusters Sum of Complex PTSD Clusters

Physical Abuse .242 .021**
Emotional Abuse .003** .439
Neglect .253 .948
Sexual Abuse .000** .000**
Exposure to Community
.641 .069*
Violence
Exposure to Intimate Partner
.490 .740
Violence
Other Trauma .770 .953
Presence/absence of any trauma .105 .026**
Sum of modes of trauma .141 .049**
* indicates marginal significance levels <.07; * indicates statistically significance levels <.05

Physical abuse and sum of clusters

A statistically significant relationship was found between physical abuse and the sum

of positive clusters for the Complex PTSD diagnosis (F=5.798, p<.05). The graph below

illustrates the mean differences.

148
 Physical Abuse and Mean Number of Positive
Complex PTSD Clusters

2.5 i

PA Absent PA Present

Figure 29. The above graph illustrates the average number of clinically positive

Complex PTSD clusters for non-physically abused versus physically abused youths.

Youths exposed to physical abuse were positive on a significantly higher number of

clusters in the Complex PTSD diagnosis. On average, youths with physical abuse met

criteria for two symptom clusters versus only one symptoms cluster for youths with no

physical abuse.

Emotional abuse and sum of positive clusters

Emotional abuse was significantly related to the sum of positive clusters in the PTSD

diagnosis (F=9.990, p<.01). The graph below illustrates the mean differences.

149
 Emotional Abuse and Mean Number of Positive PTSD
Clusters

1.2 i

EA Absent EA Present

Figure 30. The above graph illustrates the average number of clinically positive

PTSD clusters for non-emotionally abused versus emotionally abused youths.

Youths exposed to emotional abuse were significantly more likely to have more positive

PTSD clusters that non-emotionally abused youth. Emotionally-abused youth averaged

over one positive cluster, versus nearly no positive clusters among youths with no

emotional abuse histories.

Neglect and sum of positive clusters

No significant relationships were observed between neglect and the sum of positive

clusters for the PTSD or Complex PTSD diagnosis.

150
Sexual abuse and sum ofpositive clusters

Significant relationships were observed between sexual abuse and the sum of both

PTSD (F=23.619, p<.001) and Complex PTSD clusters (F=23.706, p<.001). The graph

below illustrates the mean differences for both relationships.

Sexual Abuse and Mean Number of Positive

PTSD and Complex PTSD Clusters

4.5 !

• SA Absent
• SA Present

PTSD Complex PTSD

Figure 31. The above graph illustrates the average number of clinically positive

PTSD and Complex PTSD clusters for non-sexually abused versus sexually abused

youths.

Youths who were sexually abused met criteria for significantly more clusters for both the

PTSD and Complex PTSD diagnoses. Sexually-abused youths had over three times as

many positive PTSD clusters and had nearly twice as many positive clusters in the

Complex PTSD diagnosis than their non-sexually abused counterparts.

151
Exposure to community violence and sum ofpositive clusters

Exposure to community violence was marginally related to the sum of positive

clusters for the Complex PTSD diagnosis (F=3.497, p<.07). The graph below illustrates

the mean differences.

Exposure to Community Violence and Mean

Number of Positive Complex PTSD Clusters

2.5 -,

ECV Absent ECV Present

Figure 32. The above graph illustrates the average number of positive Complex

PTSD clusters for youths not exposed to community violence versus youths exposed

to community violence.

Youths who were exposed to community violence tended to have at least two positive

Complex PTSD clusters, versus their non-exposed youth who averaged one positive

cluster.

Exposure to intimate partner violence and sum of clusters

No significant relationships were found between exposure to intimate partner

violence and the sum of positive clusters.

152
Other trauma and sum ofpositive clusters

No significant relationships were found between other trauma and the sum of

positive clusters.

Absence/presnece of any trauma and sum of positive clusters

The presence/absence of at least one form of trauma was significantly related to the

sum of positive clusters in the Complex PTSD diagnosis (F=5.330, p<.05). The graph

below illustrates the mean differences.

Other Trauma and Mean Number of Positive Complex

PTSD Clusters

ifl * • -
3
U 1.6
Q
Pl.4
Q.
<v 1 . 2
a.
§ *
U
v 0.8

Other Trauma Absent Other Trauma Present

Figure 33. The above graph illustrates the average number of positive Complex

PTSD clusters for youths without other trauma versus youths with other trauma.

Youths who had been exposed to at least one form of trauma were significantly more

likely to meet criteria for clusters in the Complex PTSD cluster than their non-abused

153
counterparts. Specifically, traumatized youth met criteria for nearly two clusters, whereas

non-abused youths averaged less than one positive cluster.

Sum of modes of trauma and sum of positive clusters

The relationship between the total types of trauma to which a youth were exposed

and the sum of their positive clusters was observed. A significant relationship was found

between the sum of the forms of trauma experienced and the sum of positive clusters

(F=2.503, p<.05). The graph below illustrates the findings.

Mean Number of Positive Complex PTSD Clusters by Total

Modes of Trauma Experienced

4 -i

3.5

2.5

1.5

1 -

0.5

0
Zero One Two Three Four Five
S u m of M o d e s of T r a u m a

Figure 34. The above graph illustrates the mean differences of positive Complex

PTSD clusters as a function of the total modes of trauma to which a youth was

exposed.

Post-hoc tests of Least Significant Difference were conducted to identify which means

were statistically different. Youths exposed to five modes of trauma had significantly

more positive clusters than youths exposed to zero or one mode of trauma. In addition,

154
youths exposed to two modes of trauma had significantly more positive clusters than

youths exposed to zero forms of trauma. In general, there was an upward trend that as

youths experienced more modes of trauma, they met clinical criteria for more Complex

PTSD symptoms clusters.

Trauma and PTSD or Complex PTSD Diagnosis

Based on the symptoms provided in the report, youths were determined to meet or

not meet criteria for the PTSD and the Complex PTSD diagnosis. The presence and type

of trauma was then compared to whether or not they had met requirement for the

diagnosis. The following table summarizes the findings, by level of significance, of the

relationship between each mode of trauma and whether or not the criteria were met for

each diagnosis based on the information provided in the report.

155
 Table 74

Significance Levels for Chi-Square Analysis of Trauma Exposure and PTSD and
Complex PTSD Diagnosis Positive

PTSD Diagnosis Complex PTSD Diagnosis

Physical Abuse .378 .490
Emotional Abuse .007** .646
Neglect .257 .591
Sexual Abuse .029** .014**
Exposure to Community
.322 .276
Violence
Exposure to Intimate Partner
.767 .618
Violence
Other Trauma .431 .323
Presence/absence of any
.062* .646
trauma
Sum of modes of trauma .256 .899
* indicates marginal significance levels <.07; **indicates statistically significance
levels <.05

Physical abuse and trauma diagnosis

No significant relationships were observed between physical abuse and meeting

clinical criteria for a PTSD or Complex PTSD diagnosis based on information in the

report.

Emotional abuse and trauma diagnosis.

A significant relationship was observed between emotional abuse and meeting

criteria for the PTSD diagnosis (%2 = 7.248,p<.01). The table below summarizes the

findings.

156
Table 75

Chi-Square Analysis: Emotional Abuse and PTSD Diagnosis Positive

PTSD Diagnosis Positive

Absent Present
Absent 27 (79.4%) 7 (20.6%)
Emotional Abuse
Present 2(28.6%) 5(71.4%)

Two cells had an expected cell count less that five. Fisher's Exact Test produced and

exact significance level of .016, confirming the significant relationship. Youths who were

emotionally abused were significantly more likely to meet clinical criteria for the PTSD

diagnosis than non-emotionally abused youths.

Neglect and trauma diagnosis

No significant relationships were observed between neglect and meeting clinical

criteria for a PTSD or Complex PTSD diagnosis based on information in the report.

Sexual abuse and trauma diagnosis

Significant relationships were observed between sexual abuse and meeting criteria

for both PTSD (^2 = 4.749, p<.05) and Complex PTSD (^2 = 5.979, p<.05). The details

of each relationship are described below.

157
Table 76

Chi-Square Analysis: Sexual Abuse and PTSD Diagnosis Positive

PTSD Diagnosis Positive

Absent Present
Absent 27(77.1%) 8(22.9%)
Sexual Abuse
Present 2(33.3%) 4(66.7%)

Chi-square analysis revealed a significant relationship between sexual abuse and

meeting clinical criteria for PTSD. Two cells had an expected cell count less than five.

Fisher's Exact Test yielded and exact significance level of .05, confirming the

relationship. Youths exposed to sexual abuse were significantly more likely to meet

clinical criteria for PTSD than their non-sexually abused counterparts.

Table 77

Chi-Square Analysis: Sexual Abuse and Complex PTSD Diagnosis Positive

Complex PTSD Diagnosis Positive

Absent Present
Absent 35(100.0%) 0(0.0%)
Sexual Abuse
Present 5(83.3%) 1(16.7%)

Chi-square analysis found a significant relationship between sexual abuse and

meeting the clinical criteria for the Complex PTSD diagnosis. Two cells had an expected

cell count less than five. Fisher's Exact Test produced an exact .146 level of significance.

Therefore, no significant relationship can be confirmed between these variables.

158
Exposure to community violence and trauma diagnosis

No significant relationships were observed between exposure to community violence

and meeting clinical criteria for a PTSD or Complex PTSD diagnosis based on

information in the report.

Exposure to intimate partner violence and trauma diagnosis

No significant relationships were observed between exposure to intimate partner

violence and meeting clinical criteria for a PTSD or Complex PTSD diagnosis based on

information in the report.

Other trauma and trauma diagnosis

No significant relationships were observed between other trauma and meeting

clinical criteria for a PTSD or Complex PTSD diagnosis based on information in the

report.

Absence/presence of any trauma and trauma diagnosis

A marginally significant relationship was observed between the presence/absence of

at least one kind of the trauma and meeting clinical criteria for PTSD (%2 = 3.493,

p<.062). The table below described the findings.

159
Table 78

Chi-Square Analysis: Absence/Presence of Trauma and PTSD Diagnosis Positive

PTSD Diagnosis Positive

Absent Present

Absence/Presence Absent 7(100.0%) 0(0.0%)

of Trauma Present 22(64.7%) 12(35.3%)

Chi-square analysis revealed a significant relationship between the presence of at

least one kind of trauma and the PTSD diagnosis. Two cells had an expected cell count of

less than five. A Fisher's Exact Test yielded a corrected .069 level of significance,

confirming the marginally significant relationship. Therefore, youths who had been

exposed to at least one form of trauma were more likely to meet criteria for the PTSD

diagnosis than non-traumatized youths.

Sum of trauma modes and trauma diagnosis

No significant relationships were observed between the sum of the modes of trauma

to which a youth was exposed and meeting clinical criteria for a PTSD or Complex PTSD

diagnosis based on information in the report.

Trauma Exposure and Diagnoses Identified in the Report

The final statistical analysis was designed to explore potential relationships between

trauma exposure and diagnoses that were made by the clinician in the report. The first

section will explore relationships between trauma exposure and trauma-related diagnoses,

160
and the second section will report relationships between trauma exposure and other

diagnoses.

Trauma exposure and trauma-related diagnoses in the report

The following table summarizes the significance levels between each form of trauma

and the trauma-related diagnosis.

Table 79

Significance Levels of Chi-Square Analysis for Trauma Exposure and Trauma-Related

Diagnoses in Evaluation

p T s n Complex Dissociative ^ f Adjustment — ^

r 1 &LJ _, _. , oucaa „. , 1 rdUIIla
PTSD Disorder ~ r Disorder — —
Disorder Disorder
Physical Abuse .408 .490 .490
Emotional Abuse .065* .646 .646
Neglect .877 .591 .056*
Sexual Abuse .000** .675 .675
Exposure to
Community .877 — — — .347 .276
Violence
Exposure to
Intimate Partner .300 — — — .618 .618
Violence
Other Trauma .317 .323 .323
Presence/absence Q
026** .646
of any trauma
Sum of modes of __,
.451 .899
trauma
* indicates marginal significance levels <.07; **indicates statistically significance levels
<.Q5

Two significant relationships were found: sexual abuse and PTSD diagnosis, and the

presence/absence of any trauma and adjustment disorder. Marginally significant

161
relationships were also observed between emotional abuse and PTSD diagnosis, and

neglect and other trauma disorder. Each relationship is explored in detail below.

Table 80

Chi-Square Analysis: Sexual Abuse arid PTSD D:iagnosis in Evaluation

PTSD Diagnosis in Evaluation

Absent Present
Absent 35(100.0%) 0(0.0%)
Sexual Abuse
Present 2 (33.3%) 4 (66.7%)

Chi-square analysis found a significant relationship between sexual abuse and a

PTSD diagnosis by the clinician in the report (/2 = 25.856, p<.001). Two cells had an

expected cell count less than five. A Fisher's Exact Test produced a corrected .000 level

of significance, confirming the significant relationship. Youths exposed to sexual abuse

were diagnosed with PTSD by the clinician significantly more often that youths who

were not exposed to sexual abuse.

Table 81

Chi-Square Analysis: Emotional Abuse and PTSD Diagnosis in Report

PTSD Diagnosis in Report

Absent Present
Absent 32(94.1%) 2(5.9%)
Emotional Abuse
Present 5(71.4%) 2(28.6%)

Chi-square analysis revealed a marginally significant relationship between emotional

abuse and a PTSD diagnosis by the clinician (%2 = 3.394 ,p<.07). Two cells had an

expected cell count less than five. Fisher's Exact Test yielded a corrected .128

162
significance level. Therefore, no significant relationship existed between emotional abuse

and a PTSD clinician diagnosis by the clinician.

Table 82

Chi-Square Analysis: Absence/Presence of Trauma and Adjustment Disorder

Adjustment Disorder
Absent Present

Absence/Presence Absent 7(100.0%) 0(0.0%)

of Trauma Present 33(97.1%) 1(2.9%)

Chi-square analysis revealed a significant relationship between the presence of any

kind of trauma and a diagnosis of adjustment disorder by the clinician (%2 = 4.979,

p<.05). Two cells had an expected cell count less that five. Fisher's Exact Test produced

a corrected significance level of .171. Therefore, no significant relationship existed

between the presence/absence of any trauma and adjustment disorder diagnosis.

Table 83

Chi-Square Analysis: Neglect and Other Trauma Diagnosis in Report

Other Trauma Diagnosis

Absent Present
Absent 32(100.0%) 0(0.0%)
Neglect
Present 8(88.9%) 1(11.1%)

Chi-square analysis revealed a marginally significant relationship between neglect

and other trauma disorder diagnosis (^2 = 3.644, p<.07). Two cells had an expected cell

count less than five. A Fisher's Exact Test produced a corrected .220 significance level.

Therefore, no relationship existed between neglect and other trauma disorder diagnosis.

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 Trauma exposure and other diagnoses

Statistics were conducted to explore potential relationships between trauma exposure

and other mental health disorders diagnosed by the clinician. The table below

summarizes the findings.

Table 84

Significance Level:s for Chi-Square Analysis of Trauma Exposure and Other Diagnosis in Evaluation

Learning Mood Anxiety Developmental ADHD ODD/CD

Substance
Disorder Disorder Disorder Disorder Abuse
Physical Abuse .671 .906 .845 .137 .193
Emotional Abuse .146 .642 .830 .646 .702
Neglect .206 .982 .591 .591 .472
Sexual Abuse .087 .072 .229 .675 .355
Exposure to
Community .513 .032** .529 .347 .070*
Violence
Exposure to
Intimate Partner .977 .472 .702 .618 .662
Violence
Other Trauma .169 .224 .627 .300 .387
Presence/absence
.279 .123 .375 .646 .702
of any trauma
Sum of modes of
.315 .546 .785 .899 .568
trauma
* indicates marginal significance levels <.07; * indicates statistically significance levels < .05

One statistically significant relationship was observed between exposure to

community violence and mood disorder diagnosis (%2 = 4.583, p<.05). The findings

were as follows:

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Table 85

Chi-Square Analysis: Exposure to Community Violence and Mood Disorder Diagnosis

Mood Disorder Diagnosis

Absent Present
Exposure to Absent 20(90.9%) 2(9.1%)
Community
Violence Present 12(63.2%) 7(36.8%)

Two cells had an expected cell count less than five. Fisher's Exact Test produced and

exact significance level of .038, confirming the relationship. Youths exposed to

community violence were significantly more likely to be diagnosed with a mood disorder

by the clinician than youths not exposed to community violence.

A marginally significant relationship was observed between exposure to community

violence and substance abuse disorder ( j 2 = 3.283, p<.07). The findings were as follows:

Table 86

Chi-Square Analysis: Exposure to Community Violence and Substance Abuse Disorder

Substance Abuse Disorder

Absent Present
Exposure to Absent 20(90.9%) 2(9.1%)
Community
Violence Present 13(68.4%) 6(31.6%)

Two cells had an expected cell count less than five. A Fisher's Exact Test yielded a

corrected .078 level of significance. Therefore, no relationship existed between exposure

to community violence and substance abuse problems.

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 CHAPTER 5

DISCUSSION

The purpose of this study was to explore the prevalence of trauma exposure and

subsequent symptom presentation among court-involved youth. A total of sixty Boston

Juvenile Court Clinic reports were reviewed, and forty-one were used in the data analysis

after youths with previous court involvement were screened out due to limited

background information in their reports. Given the introduction of the new Complex

PTSD or Developmental Trauma Disorder, the study was designed to examine symptom

presentation using the PTSD and Complex PTSD criteria. The goal of the data analysis

was to explore the prevalence and frequency of trauma exposure among these youth,

identify the types of symptoms with which they presented, and to explore possible

relationships between exposure and symptoms. The following is a discussion of the

findings.

Demographics

There were no significant differences between the entire sample (i.e. sixty reports)

and the sample used in the data analysis (i.e., forty-one reports). There were more boys

than girls in both samples. The breakdown of reports was 23.3% Delinquency and 76.7%

CHINS evaluations.

When compared to the general population of Suffolk County, minorities were

slightly overrepresented in the sample. However, it is important to bear in mind that race

or ethnicity was not documented (unknown) in 25% of the cases reviewed for this study,

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therefore an accurate distribution of race and ethnicity for the study sample is not known.

Because no information was available about the racial distribution within the Boston

Juvenile Court, it is unknown how this study's subset compares to the sample of youths

in the Boston Juvenile Court.

In 2007, minorities made up only 24% of the overall juvenile justice population of

Massachusetts, but presented with higher rates at the detention, lockup, probation, and

DYS commitment stages of the juvenile justice system (Citizens for Juvenile Justice,

2007). Based on the information provided in the reports, over 60% of the youths were

minorities. This is consistent with previous findings that minorities are overrepresented in

the juvenile justice process including detention, lockup, probation, and DYS commitment

(Citizens for Juvenile Justice, 2007). This is a significant ongoing problem across all

states for both juvenile and adult populations. Non-profit agencies such as the Citizens

for Juvenile Justice program and researchers are examining the reasons for this

discrepancy. Racial disparity in the juvenile justice population demands that all court

clinicians and staff maintain a culturally-informed and culturally-sensitive approach

when conducting evaluations with these youth.

The majority of the youths were court-involved for the first time, but approximately

one-third had prior court clinic evaluations. The most common case type involved in

court clinic evaluation was CHINS Stubborn, indicating that many of the youths who

were referred by the court had problems at home with parents or other caregivers.

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 Prevalence and Qualitative Analysis of Trauma Exposure

The overall sample had the following breakdown of reported trauma exposure based

on clinician report: 33% were known to be physically abused, 20% were emotionally

abused, 28% were neglected, 6% were sexually abused, 45% were exposed to community

violence, 25% were exposed to intimate partner violence, and 41% were exposed to other

forms of trauma. That these rates add up to over 100% indicates that youth experienced

two or more forms of trauma exposure among those reports where trauma was reported

by the court clinician. These percentages are slightly elevated compared to national

studies (van der Kolk, 2005; Streeck-Fischer & van der Kolk, 2000). Across all forms of

trauma, the range of "no information available" in the court clinic reports was 45-70%.

Among the first court-referred evaluations, the range was 39-69%. One possible

explanation for this is that clinicians may have asked about trauma and chosen to not

document the absence of trauma in the report. Another possibility is that youth were

asked about trauma but declined to acknowledge or disclose maltreatment or other trauma

exposures. Yet another possibility is that clinicians are not specifically asking about

trauma history with each youth, and document the presence of trauma only if the youth

raises the issue. Similarly, it is possible that clinicians do not consistently inquire about

all potential modalities of trauma across each of their cases or that there is significant

variability among clinicians in doing so.

For the reports used in the analysis (i.e., first court reports), the prevalence of trauma

exposure was relatively the same: 30% were physically abused, 17% were emotionally

abused, 22% were neglected, 15% were sexually abused, 46% were exposed to

community violence, 20% were exposed to intimate partner violence, and 48% exposed

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to other forms of trauma. Most of the youths were exposed to multiple forms of these

traumas. Excluding the "other trauma" category, only four cases of trauma exposure were

single incidents, the other sixty-five documented incidents of trauma exposure were

multiple incidents. Single events were more common in the "other trauma" category such

as death of a family member or friend. Only 17% of the youths had no exposure to

trauma based on the information in the court report. Two-thirds were exposed to two or

more forms of trauma. Taken together, on average the large majority of these youths

experienced chronic and repeated exposure to multiple forms of trauma. Given the

research on Complex PTSD, these youth are at high risk for developing symptoms or

meeting criteria for a complex trauma disorder.

There were no significant gender differences in terms of trauma exposure except for

sexual abuse. All of the sexual abuse reports were among girls. This is consistent with

other studies that girls are more likely to be sexually abused then boys (Finkelhor,

Hotaling, Lewis, & Smith, 1990; www.nctsnet.org, National Child Traumatic Stress

Network). It would be interesting to explore whether this difference reflects true gender

differences in terms of experiencing sexual abuse among the general juvenile justice

population (i.e., females are sexually abused more often than males), or whether this

difference reflects issues in gathering, documenting or evaluating this information. For

example, are clinicians less inclined to ask boys about sexual abuse? Do girls

spontaneously report sexual abuse more often than do boys? Do boys tend to deny

experiencing sexual abuse more than do girls? These are questions that can be explored in

future studies.

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 Prevalence and Qualitative Analysis of Symptom Presentation

Individual Symptoms

Only four individual symptoms of PTSD and Complex PTSD were not endorsed, and

over half of the symptoms in both diagnoses had a prevalence of at least ten percent. The

most problematic areas seemed to be in the Hyperarousal cluster of PTSD and the Affect

Regulation and Alterations in Relationships clusters of Complex PTSD.

Within the PTSD diagnosis, few youths presented with problems in the

Reexperiencing cluster. The most common symptom in this cluster was intrusive

memories with ten percent prevalence. One-third of youths had some kind of problem in

the Avoidance cluster. Most of the individual symptoms of avoidance were not endorsed,

or endorsed once, but 22% had problems with feelings of detachment or estrangement

from others, and over 30% exhibited a restricted range of affect. The higher prevalence

rates among these latter symptoms are perhaps because these are more outwardly

observable by clinicians, versus the former symptoms that generally are only determined

by asking the youth. Hyperarousal symptoms were the most endorsed of the PTSD

clusters for youths. The least common symptoms were an exaggerated startle response

with 5% prevalence and hypervigilance with 12% prevalence. One-third of the youths

had problems with irritability, outbursts of anger, and difficult concentrating, and one-

fifth suffered from sleep problems. Although no studies were found to compare these

individual symptom prevalence rates, a high number of youths presented with PTSD

symptoms.

Many more youths showed symptoms of Complex PTSD than PTSD. The most

problematic area was Affect Regulation where over 80% of the youths suffered from at

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least one symptom. There was a wide distribution of symptom presentation and over half

of the youths had multiple symptoms in this cluster. The majority of youths had problems

modulating their emotions, anger, and engaging in risk-taking behavior. High rates (over

half) of endorsing risk-taking behavior may be related to why they are court involved.

Moreover, this indicates that many of these youth are at risk for future victimization or

harm because of their risk-taking behavior. In addition to risk-taking behavior, 20% of

these youths engaged in self-destructive behavior such as substance abuse and self-injury.

A striking finding was that 15% had some suicidal ideation either currently or in the past.

Although adolescence in general is a period of emotional change and irritability, the

majority of these youths had clinically significant problems of emotion regulation.

A handful of youths had problems with attention and concentration or Alteration of

Consciousness with ten percent having at least one symptom in this cluster. Many youths

demonstrated problems with self-perception. Over half had at least one symptom in the

Self-Perception cluster, the most common being minimizing behavior. One possibility for

this behavior is an attempt on their part to portray themselves in a positive light for the

court by minimizing their problems. Another possibility is that this has become a learned

behavior either through family or community living to present a positive appearance,

and/or to keep problems private. Fifteen to twenty percent of the youths also experienced

feelings of ineffectiveness and permanent damage.

More than one-third of youths had problems with relationships. About one-quarter

had problems trusting others and about ten percent had been revictimized by someone.

This is consistent with previous findings that trauma damages a person's ability to trust,

and prior traumatization increases the chances of revictimization. Interestingly, almost

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one-third of the youths had victimized others. One possible explanation for this is

externalizing behavior related to their own experience. Perhaps some of these youths are

exhibiting learned behaviors and some of them may need to engage in victimizing others

for self-preservation in rough neighborhoods. It is also possible that a cohort of these

youth is predisposed to antisocial and victimizing behavior. Further research is needed to

explore these hypotheses.

A small percentage (10%) had problems with somatization. This may be

representative of the true prevalence of somatization symptoms or may be an

underestimate because court clinicians are not trained to consistently inquire about

medical or physical symptoms. In addition, one-quarter of youths exhibited problems

with systems of meaning such as despair and hopelessness. Combined with negative

changes in self-perception this indicates the emergence of poor self-esteem and low self-

worth among these youth.

PTSD and Complex PTSD clusters and diagnoses

Individual symptoms begin to tell the story of the trauma-related problems among

these youths, but more important is whether these youth are meeting clinical threshold for

impairment in functioning due to trauma. For PTSD, ten percent of the youths met the

clinical criteria for the Reexperiencing cluster, 7% met criteria for the Avoidance cluster,

and 25% percent met criteria for the Hyperarousal cluster. When further consolidated,

20% of youths met criteria for one PTSD cluster, 7% were positive on two clusters, and

2% were positive for all three clusters. Conversely, approximately 70% did not meet

clinical thresholds for positive symptoms, but this does not mean that they did not exhibit

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some symptoms of PTSD. Taken together, this data indicates that approximately 30% of

the youths had clinical-level impairment in functioning arising from at least one symptom

cluster of PTSD, with one youth meeting criteria for a PTSD diagnosis based solely on

the information available in the report.

Looking at Complex PTSD, over 50% met clinical criteria for the Affect Regulation

cluster, 10% met criteria for the Attention/Consciousness cluster, 25% met criteria for the

Self-Perception cluster, 40% met criteria for the Alterations in Relationships cluster, 7%

met criteria for the Somatization cluster, and 22% met criteria for the Systems of

Meaning cluster. Only one-third of youths did not meet clinical threshold on any

symptom cluster, which leaves two-thirds of these youths having clinically significant

impairment in at least one symptom area of Complex PTSD. Furthermore, over 50% of

the youths had multiple positive cluster scores. When thinking about the development or

emergence of Complex PTSD, nearly 25% had three or more positive clusters, which is

just shy of meeting criteria for the diagnosis where all six clusters must be positive. One

youth met the clinical criteria for a Complex PTSD diagnosis based solely on the

information in the report. Perhaps with focused assessment and inquiry among these

youths, we may find a higher incidence of Complex PTSD. Preliminary findings from

this study suggest that many of these highly vulnerable youth are already showing signs

of an emerging Complex PTSD disorder.

Other Disorders

The most common diagnoses among the court reports were substance abuse, mood

disorders, and Attention-Deficit/Hyperactivity Disorder or Attention-Deficit Disorder.

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 Analysis of Statistically Significant Findings

Gender and trauma exposure

Significantly more girls experienced sexual abuse compared to boys, and

significantly more boys compared to girls reported "other trauma." Hypotheses about the

former finding were discussed above. However, the latter finding poses an interesting set

of questions with respect to disclosure of trauma or clinician evaluation. It has been

shown that girls are more likely to report incidents of abuse than boys (Gries, Goh, &

Cavanaugh, 1996; Ullman & Filipas, 2005). Given the current findings, perhaps boys are

more willing to disclose other trauma such as family deaths because they are less

intrusive and/or less likely to be perceived as an admission of being a "victim". Perhaps

clinicians are less likely or less inclined to ask boys about specific areas of trauma. It is

also possible that if boys readily disclose other trauma, clinicians may not inquire further

about specific forms of trauma because they have already captured some trauma

information. Further studies may explore whether boys are more reluctant to disclose

certain forms of trauma, or whether there are gender differences in how clinicians assess

for trauma.

Individual symptoms

The purpose of this study was to explore relationships between trauma exposure and

symptom presentation. The findings below should be further explored with larger sample

sizes and specific assessment of symptoms to confirm or question the results. By far,

sexual abuse was significantly related to the most number of individual symptoms,

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confirming previous research that sexual abuse is highly linked to later mental health

problems.

The following is a list of the statistically significant relationships between the type of

trauma experienced and individual symptoms of PTSD and Complex PTSD.

• Physical Abuse

o Affect Regulation (Complex PTSD)

o Nobody Can Understand (Complex PTSD)

• Emotional Abuse

o Self-destructive behaviors (Complex PTSD)

• Sexual Abuse

o Intrusive Memories (PTSD)

o Sleep Problems (PTSD)

o Irritability (PTSD)

o Hypervigilance (PTSD)

o Affect Regulation (Complex PTSD)

o Modulation of Anger (Complex PTSD)

o Self-destructive Behaviors (Complex PTSD)

o Suicidal Preoccupation (Complex PTSD)

o Modulating Sexual Involvement (Complex PTSD)

o Dissociation/Depersonalization (Complex PTSD)

o Permanent Damage (Complex PTSD)

o Inability to Trust (Complex PTSD)

o Loss of Previously Sustaining Beliefs (Complex PTSD)

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 • Exposure to Community Violence

o Risk-taking Behavior (Complex PTSD)

o Minimizing (Complex PTSD)

o Victimizing Others (Complex PTSD)

• Exposure to Intimate Partner Violence

o Restricted Affect (PTSD)

• Other Trauma

o Self-destructive Behavior (Complex PTSD)

o Permanent Damage (Complex PTSD)

Although the above relationships are only between trauma and individual symptoms,

they may illustrate initially seemingly minor differences in how each mode of trauma can

functionally and significantly affect a person. Among those who were physically abused,

a sense that "nobody can understand" may indicate problems with feelings of

helplessness or isolation. Problems with affect regulation among physically abused youth

may suggest poor internal behavioral controls (that may reflect the neurodevelopmental

impact of trauma) or poor modeling of affect regulation by parents if parents or other

caregivers are the perpetrators. However, problems with affect regulation are relatively

universal among traumatized children (Cook et al., 2003). One possibility for the

relationship between emotional abuse and self-destructive behaviors may be that youths

internalize the criticisms and harsh words they endure and try to regulate their emotions

by turning on themselves through self-harm or substance abuse, a possibility consistent

with research on self-harming behaviors and affective regulation.

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 Sexual abuse was significantly related to many symptoms, indicating that overall it

produces a broad range of symptoms. Previous studies have found similar relationships

between sexual abuse and symptoms of affect regulation, hypervigilance, suicidality,

risk-taking behaviors, and difficulty with relationships (Putnam, 2009).

The relationships between exposure to community violence and risk-taking behavior,

minimizing, and victimizing others also generate interesting hypotheses. One possibility

is that these are learned behaviors from witnessing or experiencing community violence.

Another is that youths exposed to community violence live in neighborhoods where such

behaviors as minimizing their own victimization and victimizing others are seen as

strategies to cope, survive and establish respect and self-protection. Yet another

possibility is that neighborhoods where youths experience community violence may

provide more opportunities for trauma exposures that give rise to such kinds of

symptoms. On a larger social scale, many youths living in violent neighborhoods are part

of a marginalized population where parents or caregivers may be working multiple jobs

and consistent supervision of children and adolescents is less available, providing more

opportunities for youth to engage in risk-taking behaviors. Further studies may be able to

confirm whether the correlations persist and what may be the underlying cause(s).

The relationships between "other trauma" responses and self-destructive behaviors

and permanent damage are difficult to understand because a variety of traumatic

experiences fall within this category. The most common forms of trauma were death of a

parent or family member, exposure to parental drug abuse, and parental divorce or

separation. All of these forms of trauma involve some sort of loss or change of the

parent-child relationship. One explanation might be that negative changes in the parent-

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child attachment produces feelings of permanent damage, and maybe these feelings are

turned inward and the youth engages in self-destructive behaviors to regulate his or her

emotions. Further studies are needed to explore this hypothesis.

Marginally significant correlations between trauma exposure and subsequent

symptoms were observed as well. These relationships may indicate a trend toward certain

forms of trauma producing specific symptoms, but further studies with large sample sizes

may help to clarify these relationships. The following is a list of such correlations:

• Physical Abuse

o Self-destructive Behaviors (Complex PTSD)

o Suicidal Preoccupation (Complex PTSD)

• Emotional Abuse

o Permanent Damage (Complex PTSD)

• Sexual Abuse

o Diminished Interest (PTSD)

o Nobody Can Understand (Complex PTSD)

Some correlations between mode of trauma and individual symptoms were

significant based on chi-square analysis, but were found to be not significant with further

analysis due to low sample size. Although there is little to say about the nature of these

correlations because they were ultimately not significant, future studies with larger

sample sizes may help to confirm whether these relationships truly exist. The following is

a list of those relationships that seemed initially statistically significant, but were found to

be not statistically significant.

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 • Physical Abuse

o Dissociation/Depersonalization (Complex PTSD)

o Feelings of Guilt and Responsibility (Complex PTSD)

o Digestive System Problems (Complex PTSD)

o Loss of Previously Sustaining Beliefs (Complex PTSD)

• Emotional Abuse

o Nightmares/Distressing Dreams (PTSD)

• Sexual Abuse

o Nightmares/Distressing Dreams (PTSD)

o Flashbacks/Sensory Experiences (PTSD)

o Psychological Distress Due to Internal/External Stimuli (PTSD)

o Physiological Distress Due to Internal/External Stimuli (PTSD)

o Avoid Thoughts, Feelings, Talking About the Trauma (PTSD)

o Amnesia (Complex PTSD)

o Ineffectiveness (Complex PTSD)

o Revictimization (Complex PTSD)

o Despair/Hopelessness (Complex PTSD)

PTSD and Complex PTSD clusters and diagnoses

To gain a better understanding of the overall impact of each type of trauma, as well

as chronic and repeated exposure to multiple forms of trauma, analysis was conducted to

explore the relationship between trauma exposure and the number of symptoms in a

cluster, whether clinical criteria were met within each cluster, the sum of positive

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clusters, and whether youths met clinical criteria for a PTSD or Complex PTSD

diagnosis.

The first level of analysis explored the relationships between the mode of trauma and

the number of symptoms within each cluster of PTSD and Complex PTSD that a youth

endorsed. Youths who were physically abused were significantly more likely to have

more symptoms in the Self-Perception cluster of Complex PTSD and tended to have

more symptoms in the Affect Regulation cluster of Complex PTSD than those youths

who were not physically abused. One possible explanation for these findings is that

perhaps these youths develop poor self-esteem and low self-worth as a result of their

abuse and have poor ability to regulate their emotions.

Emotionally abused youths were significantly more likely to have more symptoms in

the Hyperarousal cluster than youths who had not been emotionally abused. Sexually

abused youths had significantly more symptoms across all the clusters of PTSD and

Complex PTSD than youths who had not been sexually abused.

Youths exposed to community violence exhibited significantly more symptoms in

the Alterations in Relationships cluster than their counterparts with no exposure. One

possible explanation is that these youths live in unpredictable and violent neighborhoods

where one must be on guard for potential victimization; therefore, it is difficult to form

trusting relationships with others. Finally, youths with "other trauma" had significantly

more problems in the Alterations in Relationships and Self-Perception clusters. Given

that many of these other trauma involved losses of relationships (especially parental

relationships), one explanation might be that that their understanding of relationships

becomes negatively affected by the loss.

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 Analysis also examined the correlation between the number of different forms of

trauma to which youth were exposed and the number of symptoms they exhibited in each

cluster. In other words, if youths are exposed to more kinds of trauma, do they present

with more symptoms and in what domains? This will provide us with information that

could be consistent with previous research findings that chronic and multiple exposure to

traumatic experiences is related to Complex PTSD. Exposure to multiple forms of trauma

was significantly related to more symptoms in the Affect Regulation cluster, suggesting

that the most common problems associated with multiple exposure to traumatic

experiences is difficulty modulating emotions, engaging in self-destructive behaviors,

and suicidal preoccupation. Marginally significant statistical relationships were observed

whereby youths exposed to more forms of trauma tended to have more symptoms in the

Avoidance and Self-Perception clusters. Across all symptom clusters, there was a trend

toward having more symptoms as youths were exposed to more modes of trauma.

A second level of analysis examined the statistical relationship between trauma

exposure and whether the youth meet clinical criteria for a particular cluster. Physically

abused youths were significantly more likely to meet criteria for the Affect Regulation

cluster of Complex PTSD and tended to meet criteria for the Self-Perception cluster of

Complex PTSD than were youths who were not physically abused. Emotionally abused

youths met criteria for the Reexperiencing and Hyperarousal clusters of PTSD

significantly more often than youths who were not emotionally abused. Youths who

experienced sexual abuse were significantly more likely to meet criteria for the

Reexperiencing and Hyperarousal clusters of PTSD, and the Affect Regulation,

Attention/Consciousness, Self-Perception, and Systems of Meaning clusters of Complex

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PTSD than youths who were not sexually abused. Youths exposed to community

violence were significantly more likely to meet criteria for the Affect Regulation and

Alterations in Relationships cluster of Complex PTSD when compared to youths who

were not exposed to community violence. Exposure to any kind of trauma, regardless of

type, was significantly related to meeting criteria for symptoms within the Affect

Regulation cluster. Finally, the more modes of trauma to which youth were exposed, the

more likely they were to meet criteria for the Affect Regulation cluster of PTSD.

A third level of analysis examined the statistical relationships between trauma

exposure and the total number of clusters for which a youth met clinical criteria. Physical

abuse was significantly related to meeting criteria for more Complex PTSD clusters.

Physically abused youth on average were positive for two clusters versus one cluster for

non-physically abused youths. Emotional abuse was significantly related to more positive

PTSD clusters. Emotionally-abused youth presented with an average of one positive

cluster versus nearly no positive clusters among youths with no emotional abuse.

Sexually-abused youths had significantly more positive clusters for both diagnoses with

an average of 1.5 PTSD clusters (abused youth) versus .23 PTSD clusters (non-abused

youth) and 3.83 positive Complex PTSD clusters (abused youth) versus 1.2 positive

clusters (non-abused youths). Youth exposed to community violence had significantly

more positive Complex PTSD clusters with 2.05 versus 1.18 positive clusters among non-

exposed youths.

Exposure to at least one form of trauma was significantly related to meeting criteria

for more Complex PTSD clusters with an average of 1.83 positive clusters as compared

to an average of .43 positive clusters among youths who were not exposed to trauma. In

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addition, youths exposed to more than one form of trauma met criteria for more clusters

significantly more often than those exposed to one form of trauma or no trauma.

The final level of analysis examined the relationship between trauma exposure and

meeting clinical criteria for the PTSD and Complex PTSD diagnoses. Youths who were

emotionally abused were significantly more likely to meet full criteria for PTSD than

youth without histories of emotional abuse. Sexually abused youths were significantly

more likely to meet criteria for PTSD than youths without sexual abuse histories.

Preliminary results found that sexual abuse was significantly related statistically to

meeting clinical criteria for a Complex PTSD diagnosis but a small sample size does not

allow confirmation of this correlation.

Implications for Court-Involved Youth

Overall, the study generally supported findings that chronic, repeated, and multiple

exposure to trauma is related to more post-traumatic symptoms, particularly for the

Complex PTSD diagnosis. The findings are also consistent with previous research that

youths involved in the juvenile justice system are more likely to have histories of

exposure to traumatic experiences and subsequent symptoms (Famularo et al., 1990).

While the purpose of this study was primarily exploratory and qualitative, these

results have several implications for court-involved youth. First and foremost, over ten

percent of the youths in the study presented with past or present suicidal ideation. This is

consistent with previous findings that youths involved with the legal system are a

significant risk for suicide, and even more risk if they have histories of abuse, neglect,

substance abuse, and/or running away (Hendren & Blumenthal, 1989). Clinicians should

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conduct a thorough assessment of suicidal ideation during the first interview session and

take appropriate steps for the safety of youths who are at identifiable risk for suicide.

Many of these youths also presented with substance abuse problems. At a young age,

substance use can negatively impact development of youths whose trauma histories may

already have contributed to developmental problems. It has been shown in previous

studies that incarcerated and court-involved youth suffer from disproportionate

prevalence of emotional and substance abuse problems (Granello & Hanna, 2003).

Ongoing family problems can also have a particularly negative impact on court-

involved youth. Many of the youths in this study already live in distressed or even chaotic

and dysfunctional family systems. One study identified several risk factors that led to the

re-involvement or re-incarceration of court-involved youth. These factors in order from

highest to lowest predictors are: number of prior offenses, carrying a weapon, neglect or

abuse by parents, being with peers at the time of the offense, gang involvement, being

male, being female, having a mother who abuses substances, poor parental relationships,

not living with two parents, either biological or stepparents, or being a person of color

(Granello & Hanna, 2003). Almost all of these factors were present among the youth

reviewed in this study. The current findings support previous research that these youth

are at risk for re-involvement in court given their trauma histories if they do not receive

appropriate intervention and treatment.

Implications for Practice

The mental health and safety of any youth should always be regarded with the

utmost importance warranting appropriate responses to assure safety and care. Given the

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high prevalence of trauma among this court-involved cohort, clinicians evaluating court-

involved youth should always use a trauma-informed approach for their evaluations.

There is disproportionate representation of minority youth in juvenile justice systems and

clinicians should similarly maintain a culturally-sensitive approach. These approaches

will hopefully foster a sufficiently good working alliance that the child will feel

comfortable sharing the type of sensitive information that is most useful in understanding

their histories of traumatic experiences, their mental health symptoms, and their safety

and treatment needs.

Regarding the assessment of trauma exposure and trauma symptoms, clinicians are

recommended to specifically and consistently ask about all forms of trauma. Use of

established assessment tools such as the Trauma Symptom Checklist for Children, the

Minnesota Multiphasic Personality Inventory - Adolescent version, the Structured

Interview for Disorder of Extreme Stress, and the Beck Depression Inventory is

encouraged to gather trauma-related information, particularly if the youth presents as

guarded or unwilling to share such sensitive information through direct interview. High

prevalence rates of trauma exposure among these youth suggest that clinicians should

assume that the youth they interview has been exposed to some form of trauma (a

principle consistent with provisions of trauma-informed assessment and care).

Treatment recommendations in the reports should aim to specifically address trauma

symptoms. Court clinicians are urged to maintain an awareness of the best treatment

practices for traumatized youth. Recent studies have found that cognitive-behavioral

therapy, sensorimotor therapy, family systems therapy, group therapy, and

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pharmacotherapy are useful methods for treating complex trauma disorders (Courtois &

Ford, 2009).

Limitations of the Study

Record review

The primary source of data for this study was record review. Therefore, information

provided is only as useful and comprehensive as the information provided in the court

clinic reports. Variability in court clinician assessment styles and absence of consistent

assessment methods regarding documentation of the impact of trauma yields inevitable

confounds because clinicians have different approaches to their work. Given that many of

the court reports had no information available on the presence or absence of trauma, it

may be helpful to encourage clinicians to document information about trauma in a more

comprehensive or systematic fashion so that judges, probation officers, and mental health

providers who may access the reports can benefit from the information for treatment

purposes. At the very least, it would be helpful if reports indicated whether or not inquiry

regarding traumatic exposures had been conducted so that the reader would know

whether the youth had denied traumatic exposure or whether the clinician had not

inquired about these kinds of experiences.

Subject pool

Reports were taken from the Boston Juvenile Court Clinic in Suffolk County, MA. It

is possible that clinical, forensic and judicial practices vary across counties and states in

186
the country. To this extent, the findings in this research may not generalize beyond the

Boston area.

Sample size

The sample size for this study is relatively small. Several statistical analyses were

affected by the small sample size in that significant relationships could not be confirmed

when too few cases were noted. A larger sample size may have helped to clarify

statistical relationships between variables.

Data collection tool

The information in this study is only as thorough and useful as the data collected

from the data collection tool, based upon the court clinic reports reviewed for this

research. This study may be used as a beginning for future studies and more

comprehensive data collection methods to examine this subject.

Inter-rater reliability

Only one person (the author) coded the court clinic evaluations using the data

collection tool. Therefore, there may be an inherent confound based on the author's

perception of symptoms descriptions in the reports. Future studies should include

multiple coders with measures of inter-rater reliability to increase validity and assess the

inter-rater reliability of results.

187
 Implications for Future Research

Many of the findings in this study are preliminary and exploratory findings. There

are many directions in which future research can go in terms of exploring the prevalence

of trauma symptoms, and the nature of the relationships between trauma exposure and

subsequent symptoms among court-involved youth.

Most importantly, future research should attempt to obtain primary source data

through interviews with court-involved youth that includes use of tools with established

reliability in identifying traumatic exposures and the impact these exposures may have

had. These youths hold the information that is most vital to truly understanding the types

of trauma they experience and the mental health problems they suffer as a result.

Established assessment tools can also be used to help those youths who have trouble

expressing or reporting their symptoms. Future research in this area can help to better

understand and potentially elaborate on this study's findings.

The statistical relationships observed in this study between the type of trauma

exposure and the symptom presentation should be interpreted with caution. This study is

preliminary and exploratory in nature. Future studies should focus on the exploration and

understanding of possible differential effects of various forms of trauma and subsequent

symptom presentation. This can significantly improve assessment and treatment

recommendations based on the type(s) of trauma to which youth were exposed.

With the addition of the Complex PTSD/Developmental Trauma Disorder to the next

revision of the DSM, future studies should conduct more thorough and accurate

prevalence studies among court-involved youth, and youth in general. This information

can help court clinicians in their assessment and treatment of court-involved youths.

188
 In conducting this study, some patterns and anecdotal information were noted as

possible areas for future research. It was observed that parents of these court-involved

youths had experienced their own trauma and came from families who already had

problems with parent-child relationships that seemed to be intergenerationally replicating

among the youths in this study. Future studies may explore the impact of

transgenerational trauma exposure and family dynamics on the mental health problems of

these youth.

Anecdotally, some of the conflict between the youths and the parents stemmed from

differences between how the child wants to live his or her life and how the parents want

the child to live that life. While this is a common developmental problem between

parents and adolescents, it is possible that those families who meet the threshold of

requiring court assistance (i.e., CHINS) to manage these problems may have certain

commonalities that may help clinicians with their assessment and treatment

recommendations (e.g., trauma-informed parenting classes).

Some of the court reports provided detailed information about the youth's

temperament as an infant or child. Future studies may want to explore the relationship

between temperament and later mental health symptoms.

Other questions that can be explored are:

• What is leading these youths to become involved in the court? Why are they

involved more than once?

• How/does the court process amplify some of these trauma symptoms?

189
 • How can clinicians help kids who have been traumatized to not feel re-

traumatized by the court process, or provide some understanding and opportunity

to share their story?

• What can probation officers, judges, and court staff do to engage traumatized

children in a safe and trauma-informed manner?

• What is the role and nature of the attachment between the child and the caregiver

in mitigating the presence of symptoms?

• Does attachment between the child and the caregiver play a role in court

involvement (i.e., what types of attachment do court-involved youths and their

families exhibit)?

• Is the parent's own trauma history related to the child's mental health problems?

Conclusions

Court-involved youth are among the most vulnerable and marginalized youths in our

society. Trauma only amplifies the intensity of their negative experiences and increases

their vulnerability. Untreated trauma symptoms can severely impact a person's

functioning across the lifespan. Court clinicians encounter these youths at an incredibly

vulnerable and pivotal point in their lives where significant and positive changes can

occur to improve the future of these youths. The importance of proper assessment and

treatment of these youth cannot be understated. It is hoped that this study will be used as

a springboard for many more studies that will ultimately benefit the current and future

lives of these children.

190
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 APPENDIX A

DATA COLLECTION FORM

PACKET #:

DEMOGRAPHICS
1. Sex:
• Male
• Female
• Transgender
• Other

2. Age:

3. Race:

4. Ethnicity:

5. Grade Level:

6. First Court Report:

• Yes
• No
Age at First Court Involvement:

Type of Case:

7. Type of Evaluation:
• CHINS Runaway
• CHINS Stubborn
• CHINS Habitual Offender
• CHINS Truancy
• Delinquency
o Type of Evaluation:
• 68A
• CST
• CR
• Other:
o Charges:

199
TRAUMA HISTORY
8. Physical Abuse
• Yes
o Single Event
o Multiple Events
• No
o Client Denied
. o No information available

9. Emotional Abuse
• Yes
o Single Event
o Multiple Events
• No
o Client Denied
o No information available

10. Neglect
• Yes
o Single Event
o Multiple Events
• No
o Client Denied
o No information available

11. Sexual Abuse and Rape

• Yes
o Single Event
o Multiple Events
• No
o Client Denied
o No information available

12. Exposure to Community Violence

• Yes
o Single Event
o Multiple Events
• No
o Client Denied
o No information available

13. Exposure to Intimate Partner Violence

• Yes
o Single Event
 o Multiple Events
• No
o Client Denied
o No information available

14. Other
• Yes
o Single Event
• Description:

o Multiple Events
• Description:

• No
o Client Denied
o No information available

SYMPTOMS AND ASSESSMENT

15. PTSD
• Reexperiencing of Event
o Intrusive Memories
o Nightmares/distressing dreams
o Flashback, hallucination, sensory reexperiencing of event
o Psychological distress in response to external or internal cues
o Physiological distress in response to external or internal cues
• Avoidance
o Avoid thoughts, feelings, conversation associated with trauma
o Avoid places associated with trauma
o Difficulty/inability to remember aspects of the trauma
o Diminished interest activities
o Detachment or estrangement from others, withdrawal
o Restricted range of affect or emotion
o Sense of foreshortened future
• Hyperarousal
o Sleep problems
o Irritability
o Difficulty concentrating
o Hypervigilance
o Increased/exaggerated startle response

16. Complex PTSD

• Alteration in Regulation of Affect and impulses
o Affect Regulation

201
 o Modulation of Anger
o Self-Destructive
o Suicidal Preoccupation
o Difficulty Modulating Sexual Involvement
o Excessive Risk-taking
• Alterations in Attention or Consciousness
o Amnesia
o Transient Dissociative Episodes and Depersonalization
• Alterations in Self-Perception
o Ineffectiveness
o Permanent Damage
o Guilt and Responsibility
o Shame
o Nobody can understand
o Minimizing
• Alterations in Relations with Others
o Inability to Trust
o Revictimization
o Victimizing others
• Somatization
o Digestive System problems
o Chronic Pain
o Cardiopulmonary Symptoms
o Conversion Symptoms
o Sexual Symptoms
• Alterations in Systems of Meaning
o Despair and hopelessness
o Loss of Previously Sustaining Beliefs

17. Trauma Assessment/Testing:

• YES
Types of Assessment Tools Used:

• NO

DIAGNOSIS AND FORMULATION

18. Trauma Diagnosis in report
• YES
o Post-traumatic Stress Disorder
o Complex PTSD/Developmental Trauma Disorder
o Acute Stress Disorder
o Adjustment Disorder
o Other:

202
 • NO

19. Other Diagnoses in report

• Learning Disorder
o If yes, explain:

• Mood Disorder
o If yes, explain:

• Anxiety Disorder
o If yes, explain.

• Developmental Disorder
o If yes, explain.

• Dissociative Disorder
o If yes, explain.

• Attention-Deficit Disorder
o If yes, explain.

• Substance Abuse Disorder

o If yes, explain.

20. Meets Criteria for a Trauma Diagnosis based on symptoms reported in

evaluation
• YES
o Post-traumatic Stress Disorder
o Complex PTSD/Developmental Trauma Disorder
o Acute Stress Disorder
o Adjustment Disorder
o Other:

• NO

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 APPENDIX B
Letter for Approval from Chief Justice Martha P. Grace

Chief Justice Martha P. Grace

Administrative Office of the Trial Court
P.O. Box 9664
E. W. Brooke Court House
Boston, MA 02114
December 11, 2008

Dear Honorable Chief Justice Grace,

I have taken the liberty to write to you following the suggestion of Robert Kinscherff,
Ph.D., Esq., and Patricia Cone, Ph.D., J.D. I am working towards my doctorate in
Clinical Psychology and I am currently in my final year of graduate study at the
Massachusetts School of Professional Psychology. I am in the process of designing my
dissertation, which aims to investigate the presence and assessment of trauma and trauma
symptoms among court-involved youth.

I am writing to you to request your support and permission to access the juvenile court
files of Massachusetts, for the means of conducting research for my dissertation. I plan to
specifically examine the types of trauma and symptoms that are present among court-
involved youth using a data collection form that I have created, as well as how trauma
was assessed by clinicians. I am also requesting permission to photocopy evaluations for
ease of data gathering and cursory review of the reports. The reports will only be
reviewed on-site at the Boston Juvenile Court Clinic, and will be destroyed at the BJCC
via shredding. A log of the court clinic reports that are reviewed and then destroyed will
be maintained and given to Tom Riffin, Psy.D., for the court's records. I also plan to
interview some of the clinicians at the BJCC to gather additional information related to
my project. Confidentiality and ethical considerations have been outlined in my attached
proposal. The process of collecting and maintaining all data will follow the Ethical
Standards outlined by the American Psychological Association as approved by the
Massachusetts School of Professional Psychology Internal Review Board for research
(see attached approval).

My dissertation committee, Robert Kinscherff, Ph.D., J.D., Linda Daniels, Psy.D. D., and
Penny Haney, Ph.D., will supervise my research.

I appreciate your consideration regarding my request for access to the juvenile court files.
Please let me know if any further information will be helpful. I look forward to hearing
from you.

Respectfully,
Mathilde Pelaprat

204
 APPENDIX C

NAME DOCKET # DATE COPIED DATE

DESTROYED

205
 APPENDIX D

Suffolk County Juvenile Court Clinic

Edward W. Brooke Courthouse
24 New Chardon Street
Room 2-700
Boston, MA 02114
617-788-6460

December 15, 2008

Patricia Cone, PhD, JD

Director of Court Clinic Services
Administrative Office of the Juvenile Court
Three Center Plaza
Boston, MA 02108

Dear Dr. Cone:

After reviewing the guidelines you have set out for Mathilde Pelaprat's doctoral project proposal
I am in support of her conducting her research project at the Boston Juvenile Court Clinic using
data from the Suffolk County Juvenile Court Clinic evaluation reports.

Specifically, the Juvenile Court Clinic Administrative Assistant will assist Ms. Pelaprat in
systematically identifying cases for her review (that meets her procedural and case selection
protocol) and assist her in accessing those records. She will be provided space at the Court Clinic
to review reports and she will need to implement a procedure, involving a coded system, to
maintain confidentiality of the information. As you have indicated, no reports will be taken from
the premises as she will complete and score her instruments on-site. Staff will be available to be
interviewed by Ms. Pelaprat as part of her project, but she will need to accommodate to their
schedules.

Please let me know if there are any further issues that arise for which we can assist Ms. Pelaprat
regarding her research project.

Sincerely,

Thomas K. Riffin, PsyD

Director, Suffolk County Juvenile Court Clinic

206