Trauma-informed care as a rights-based "standard of care": A critical review.

BACKGROUND: A growing body of literature on the concept of trauma-informed care (TIC) has emerged in response to greater recognition of the prevalence of childhood trauma. Currently, no review has examined the conceptualization of TIC in various child-serving systems, specifically TIC as a standard of care, the outcomes examined relevant to care, and whether child rights are part of the TIC discourse. METHOD: A systematic search of 12 health and non-health databases, reviewed for relevance to children and youth specifically, was conducted to form a critical review of the literature. RESULTS: Forty-nine documents were selected, which included articles from child welfare (n = 16), education (n = 15), juvenile justice (n = 8), health (n = 7), and multiple sectors (n = 3). A common theme across all sectors was a lack of clear understanding regarding what is TIC and how to implement it. While trauma symptoms are seemingly a good-fit outcome and reflective of a right to rehabilitative health, validated assessment tools were not commonly used. Few studies explicitly included a child rights perspective within TIC. CONCLUSION: Emerging evidence encourages systematic inquiry into the operationalization of TIC to better assess whether it is an established model with consistent measurement. Empirical studies need to embrace established intervention methodology (e.g., improvement from baseline, control groups). From this expanded rigor, the issue as to whether TIC can evolve to a rights-based standard of care can be addressed.

Exploring child maltreatment and its relationship to alcohol and cannabis use in selected Latin American and Caribbean countries.

OBJECTIVES: Research from developed countries shows that child maltreatment increases the risk for substance use and problems. However, little evidence on this relationship is available from developing countries, and recognition of this relationship may have important implications for substance demand reduction strategies, including efforts to prevent and treat substance use and related problems. Latin America and the Caribbean is a rich and diverse region of the world with a large range of social and cultural influences. A working group constituted by the Inter-American Drug Abuse Control Commission and the Center for Addiction and Mental Health in June, 2010 identified research on this relationship as a priority area for a multinational research partnership. METHODS: This paper examines the association between self-reported child maltreatment and use in the past 12 months of alcohol and cannabis in 2294 university students in seven participating universities in six participating countries: Colombia, El Salvador, Jamaica, Nicaragua, Panama and Uruguay. The research also considers the possible impact of religiosity and minimal psychological distress as factors contributing to resiliency in these samples. RESULTS: The results showed that experience of maltreatment was associated with increased use of alcohol and cannabis. However, the effects differed depending on the type of maltreatment experienced. Higher levels of religiosity were consistently associated with lower levels of alcohol and cannabis use, but we found no evidence of an impact of minimal psychological distress on these measures. CONCLUSIONS: This preliminary study shows that the experience of maltreatment may increase the risk of alcohol and cannabis use among university students in Latin American and Caribbean countries, but that higher levels of religiosity may reduce that risk. More work to determine the nature and significance of these relationships is needed.

The Self-Injury Questionnaire: evaluation of the psychometric properties in a clinical population.

This paper presents the findings, from a clinical study, on the reliability and validity of a new measure for intentions in self-harm behaviour, the Self-Injury Questionnaire (SIQ). Eighty-three patients, who had presented to an emergency department with an episode of self-harm/suicidal behaviour, were given the SIQ as part of a battery of measures to evaluate differentiation in self-harm intentions based upon a history of childhood physical and/or sexual abuse. The internal consistency for the total scale was strong (alpha = 0.83). Construct validity demonstrated significant correlations with standardized measures. A principle component analysis of responses yielded a five-factor solution with 'affect regulation' items loading on the first factor. Cronbach's alphas were adequate for each subscale (alpha = 0.72-0.77). These preliminary findings indicate that the SIQ is a valid and reliable measure for research in an acute self-harming population.

Development and validation of the Conflict in Adolescent Dating Relationships Inventory.

Four studies examined the Conflict in Adolescent Dating Relationships Inventory (CADRI), a measure of abusive behavior among adolescent dating partners. Exploratory factor analysis was used to refine items based on high school participants with dating experience (N = 393; 49% female). Confirmatory factor analysis was used to derive and cross-validate the factor structure with participants from 10 high schools (N = 1,019, 55% female; ages 14-16). The model structure fit for all grades and both sexes, with physical abuse, verbal abuse, and threatening behavior most representative of the underlying "abuse" factor. In Studies 3 and 4, the second-order abuse factor showed acceptable test-retest reliability, partner agreement, and correlation (significant for males only) between observer ratings of dating partners' interactions and youths' CADRI scores. Results support the CADRI as a measure of abusive behavior in adolescent dating relationships.

Child maltreatment: risk of adjustment problems and dating violence in adolescence.

OBJECTIVE: To examine the relationship between child maltreatment, clinically relevant adjustment problems, and dating violence in a community sample of adolescents. METHOD: Adolescents from 10 high schools (N= 1,419; response rate = 62%) in southwestern Ontario completed questionnaires that assessed past maltreatment, current adjustment, and dating violence. Logistic regression was used to compare maltreated and nonmaltreated youths across outcome domains. RESULTS: One third (n = 462) of the school sample reported levels of maltreatment above the cutoff score on the Childhood Trauma Questionnaire. Girls with a history of maltreatment had a higher risk of emotional distress compared with girls without such histories (e.g., odds ratios [OR] for anger, depression, anxiety, and posttraumatic stress-related problems were 7.1, 7.2, 9.3, and 9.8, respectively). They were also at greater risk of violent and nonviolent delinquency (OR = 2.7) and carrying concealed weapons (OR = 7.1). Boys with histories of maltreatment were 2.5 to 3.5 times as likely to report clinical levels of depression, posttraumatic stress, and overt dissociation as were boys without a maltreatment history. They also had a significantly greater risk of using threatening behaviors (OR = 2.8) or physical abuse (OR = 3.4) against their dating partners. CONCLUSIONS: Maltreatment is a significant risk factor for adolescent maladjustment and shows a differential pattern for male and female adolescents.

Childhood maltreatment, posttraumatic stress symptomatology, and adolescent dating violence: considering the value of adolescent perceptions of abuse and a trauma mediational model.

The present study, utilizing both a child protective services and high school sample of midadolescents, examined the issue of self-report of maltreatment as it relates to issues of external validity (i.e., concordance with social worker ratings). reliability (i.e.. overlap with an alternate child maltreatment self-report inventory; association of a self-labeling item as "abused" with their subscale item counterparts), and construct validity (i.e., the association of maltreatment with posttraumatic stress symptomatology and dating violence). Relevant theoretical work in attachment, trauma, and relationship violence points to a mediational model, whereby the relationship between childhood maltreatment and adolescent dating violence would be expected to be accounted for by posttraumatic stress symptomatology. In the high school sample, 1329 adolescents and, in the CPS sample, 224 youth on the active caseloads completed comparable questionnaires in the three domains of interest. For females only, results supported a mediational model in the prediction of dating violence in both samples. For males, child maltreatment and trauma symptomatology added unique contributions to predicting dating violence. with no consistent pattern emerging across samples. When considering the issue of self-labeling as abused. CPS females who self-labeled had higher posttraumatic stress symptomatology and dating violence victimization scores than did their nonlabeling, maltreated counterparts for emotional maltreatment. These results point to the need for ongoing work in understanding the process of disclosure and how maltreatment experiences are consciously conceptualized.

Dating violence in mid-adolescence: theory, significance, and emerging prevention initiatives.

Adolescent dating violence is an important juncture in the developmental pathway to adult partnership violence. As a window of opportunity for positive change, the present review considers the theoretical and empirical work on adolescent dating and dating violence. A consideration of the scope of the problem, developmental processes, and theoretical formulations precede a review of six relationship violence prevention programs designed for and delivered to youth. Five programs are school-based and one operates in the community. Prevention is targeted toward both universal (e.g., all high school students) and selected adolescent populations (e.g., youths with histories of maltreatment, or problems with peer aggression). Programs addressed specific skills and knowledge that oppose the use of violent and abusive behavior toward intimate partners; one program addressed interpersonal violence more generally, and was also included in this review because of its implications for dating violence initiatives. Positive changes were found across studies in violence-related attitudes and knowledge, also, positive gains were noted in self-reported perpetration of dating violence, with less consistent evidence in self-reported victimization. However, these findings should be considered preliminary due to limited follow-up and generalizability. Conceptual and methodological issues are discussed with a view toward improving assessment methods and research design.

The role of child maltreatment and attachment style in adolescent relationship violence.

Utilizing attachment theory as a basis for conceptualizing close relationships among adolescents, this study investigated two important relationship risk factors (child maltreatment, and adolescent self-perceived insecure attachment style) as predictors of "offender" and "victim" experiences in youth relationships. In addition to considering the influence of these risk factors, we further considered their interaction in predicting conflict in close relationships. Of interest was the extent to which attachment styles may function as a moderator of the relationship between childhood abuse and current abuse in teen close relationships. High school students (N = 321) in grades 9 and 10 completed questionnaires tapping their histories of maltreatment, currently viewed styles of attachment, and conflict in close relationships over the past 6 months. Maltreatment alone emerged as the most consistent predictor, accounting for 13-18% of the variance in male's physically, sexually, and verbally abusive behaviors; in contrast, it was not highly predictive of female's abusive behaviors. Maltreatment was predictive of victimization experiences for both males and females. Attachment style did not substantially add to the prediction of relationship conflict beyond maltreatment; however, avoidant attachment style emerged repeatedly as a significant predictor of female abusiveness and victimization. Attachment self-ratings were found to function as a moderator of child maltreatment in predicting primarily male coercive behavior towards a relationship partner as well as predicting male's experience of coercion from a partner. Thus, the presence of childhood maltreatment and adolescent self-perceived insecure attachment style applies predominantly to male youth. The implication of these gender differences for understanding relationship violence is discussed.

Factors associated with abusive relationships among maltreated and nonmaltreated youth.

This study sought to understand how experiences of maltreatment occurring prior to 12 years of age affect adolescent peer and dating relationships. A school-based sample of 15-year-olds was divided into maltreated (n = 132) and nonmaltreated (n = 227) subgroups based on self-reported maltreatment. These two groups were then compared on two theoretically determined dimensions of adjustment (i.e., interpersonal sensitivity/hostility; personal resourceS) and self- and teacher-report measures of peer and dating relationships. Findings supported the hypothesis that maltreated youths significantly differed from nonmaltreated youths in terms of adjustment problems as well as conflict with dating partners and close friends. Maltreated youths reported significantly more verbal and physical abuse both toward and by their dating partners, and were seen by teachers as engaging in more acts of aggression and harassment toward others. In regression analyses, the significant association between maltreatment and dating conflict for males was strengthened by including adjustment dimensions in the equation; for females, adjustment variables mediated the association between maltreatment and dating conflict. Results are discussed in relation to a maladaptive interpersonal trajectory for maltreated children, wherein a violent interactional dynamic in adolescent close relationships may be setting the stage for violence in intimate partnerships.

Factors associated with the development of posttraumatic stress disorder among child victims of sexual abuse.

This study examined the relationship between the development of PTSD and selected victim and event characteristics. The sample consisted of 69 girls and 21 boys (mean age = 12.4 years) who had been referred to a child witness preparation program following documentation of sexual abuse. Comparisons of PTSD positive (N = 44) and PTSD negative (N = 46) subgroups found significant differences on variables of age, sex, duration of the abuse, and the use of violence or coercion by the offender. Comparisons on psychological test data indicated that the PTSD subgroup significantly differed from the non-PTSD subgroup on the basis of children's abuse-related fears, anxiety, depression, and feelings of guilt related to the abuse. Hierarchical multiple regression analysis indicated that factors related to the nature and severity of the abuse and the child's self-report of guilt feelings each contributed significantly to explaining 37% of the variance in PTSD symptoms, even after the variables of receptive language ability, age, and sex were controlled. Discriminant function analysis correctly classified 78.4% of the respondents. The importance of considering PTSD in relation to child sexual abuse is discussed, along with limitations of the current study.