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Posttraumatic Stress Disorder
(PTSD) Symptomatology as a
Mediator Between Childhood
Maltreatment & Substance Use
Christine...
Christine Wekerle, Ph.D., PI (cwekerle@uwo.ca)
Anne-Marie Wall, Ph.D.,Co-PI
Harriet MacMillan, MD., Co-Investigator
Nico T...
What is the MAP Research
Project?
• Random sampling of 14 to 17 year-old youth from
active caseload in child-welfare popul...
MAP Feasibility Study: Research Process
• Mean Age of tested youth: 15.5 years (SD=1.23)
• Ineligibility Rate: Overall 31%...
MAP Youth Pre-Post Experience
Not at all So-So A lot
0 1 2 3 4 5 6
How relaxed do you feel?* (3.8)
How happy do you feel? ...
Value of MAP Participation?
Not at all So-So A lot
0 1 2 3 4 5 6
• I gained something from filling out this
questionnaire ...
Descriptives of the MAP
Preliminary Analysis Sample
• N Initial Testing: 122 (52% female)
• CAS status:
– Crown Ward: 46 (...
Youth Differences Between MAP
Participating Vs. Refusing, p<.05
Subset Analyses on 85 Ss (n=59 participants, n=26
refusers...
Childhood Maltreatment
Measurement
Childhood Trauma Questionnaire–Short Form (CTQ)
Reference: Bernstein et al. (2003), com...
Childhood Maltreatment
Measurement
Childhood Experiences of Victimization Questionnaire
(CEVQ; under review measure)
Refer...
PTSD Measurement
Trauma Symptom Checklist for Children (TSCC)
Reference: Briere (1996), commercial measure
Stem: “The item...
Substance Abuse Problems
Measurement
Youth Risk Behavior Surveillance Survey
Reference: Centre for Disease Control, Youth ...
Self-report Measure Validity and
Reliability (initial & 6 mo.)
• CTQ (initial) – CEVQ (initial): r=.69, p<.01
• CTQ (initi...
DSM-IV PTSD Criteria
• Specifier: (1) Acute (< 3 months); (2) Chronic (> 3
months); (3) Delayed Onset (6 months past
traum...
DSM-IV PTSD Symptomatology
DSM- IV Symptom Classes:
(1) Re-experiencing:
• recurrent, intrusive thoughts; bad dreams*; sen...
Developmental Traumatology Tenets
(DeBellis, 2001)
• The biological stress system response varies with
individual’s geneti...
Why Childhood Maltreatment,
PTSD, Substance Use Related?
Cognitive models:
• Perceived current threat supports chronic PTS...
Mediator:
PTSD Symptomatology
Adolescent
Substance Abuse,
Substance Use-related
Problems
Severity of Childhood
Maltreatmen...
Emotional Abuse is Common
• CEVQ
– 70% Witness verbal abuse by parents
• 63% occurred before grade 6
– 43% Witness physica...
Physical Abuse is Common
• CEVQ
– 65% Being pushed, grabbed or shoved as a way to
hurt
• 61% before grade 6, 81% parental ...
Neglect is Difficult to Define
• CTQ (growing up as a child …)
– 40% Not having enough to eat
– 22% Parent too drunk or hi...
Sexual Abuse maybe more
common than we think …
• CEVQ
– 32% Being touched or forced to touch other’s private
part
• 54% be...
Posttraumatic Stress Disorder
Symptomatology
Trauma Symptom Checklist for Children (TSCC)
Most frequently endorsed items:
...
Substance Use is Early & More?
• Alcohol Use
– 36% Drinking Before Age 13 (US 28%)
– 49% Binge Drinking Past Year (US 28%)...
Mediators:
Causal Factors Preceding Target Change
• Sobel = βaβb/Sβaβb
(β=unstandardized regression coefficient, S=standar...
PTSD
Symptoms
no. of days
used Alcohol
no. of days
used Cannabis
Maltreatment
Experience
Female .55** .31* .38*
Male .09 ....
Maltreatment
Experience
no. of days
used Alcohol
no. of days
used Cannabis
PTSD
Symptoms
Female .55** .48** .48**
Male .09...
Maltreatment
Experience
# of Alcohol
Related
Problem
# of Cannabis
Related
Problem
PTSD
Symptoms
Female .56** .31* 34*
Mal...
Why PTSD may be > relevant for
females than males?
• These preliminary analyses indicated that PTSD, as currently measured...
Conclusion
• Child welfare youth readily report on their
maltreatment history and well-being
• Child welfare youth indicat...
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Posttraumatic Stress Disorder (PTSD) Symptomatology as a Mediator Between Childhood Maltreatment & Substance Use

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Posttraumatic Stress Disorder (PTSD) Symptomatology as a Mediator Between Childhood Maltreatment & Substance Use

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Posttraumatic Stress Disorder (PTSD) Symptomatology as a Mediator Between Childhood Maltreatment & Substance Use

  1. 1. Posttraumatic Stress Disorder (PTSD) Symptomatology as a Mediator Between Childhood Maltreatment & Substance Use Christine Wekerle, Ph.D. Associate Professor, Education, Psychology, Psychiatry The University of Western Ontario cwekerle@uwo.ca
  2. 2. Christine Wekerle, Ph.D., PI (cwekerle@uwo.ca) Anne-Marie Wall, Ph.D.,Co-PI Harriet MacMillan, MD., Co-Investigator Nico Trocme, Ph.D., Co-Investigator Michael Boyle, Ph.D., Co-Investigator Eman Leung, M.A., Co-Investigator Funded by: CIHR/CAHR, Public Health Agency of Canada Project Manager: Randy Waechter, M.A. In Collaboration With: Children’s Aid Society of Toronto (Deb Goodman) Advisory Board: Dan Cadman, Rob Ferguson, Phil Howe,Heidi Kiang/David Firang, Nancy MacLaren/Joanne Filippilli Franz Noritz/Lori Bell, Rhona Delisle/Barry McKendry Catholic Children’s Aid Society (Bruce Leslie) Advisory Board: Jim Langstaff, Sean Wyers, Coreen Van Es, Mario Giancola, Tara Nassar Maltreatment and Adolescent Pathways (MAP) Longitudinal Project
  3. 3. What is the MAP Research Project? • Random sampling of 14 to 17 year-old youth from active caseload in child-welfare population • Youth report on childhood maltreatment, mental health, substance use, risky sexual practices, violence (dating, bullying, delinquency) • Youth anonymity protected with self-generated ID methodology • Multiple data points every 6 months over 2 years • Participatory Action Research Model - Partnership • Funding by CIHR, CHEO Centre of Excellence in Child & Youth Mental Health, Public Health Agency of Canada
  4. 4. MAP Feasibility Study: Research Process • Mean Age of tested youth: 15.5 years (SD=1.23) • Ineligibility Rate: Overall 31% (Case closed, AWOL, Discharged, mental health issues, developmental delay, In custody, Not identified client) • Refusal Rate: Overall 30% (Community: 55%, In-care: 17%; Males: 39%; Females: 19%) • Reasons given for Refusal: “Just not interested”/ no reason: 65% (Parental Refusal: 14%; “Too busy”: 8%;“Not comfortable sharing”: 5%;Other: 8%) • Recruitment Rate: Overall 70% (Community: 45%; In-care: 83%;Males: 61%; Females: 81%) • Reasons given for participation: Money: 59%;“No reason given”: 32%; Other: 9% • Retention Rate: Overall 90% • Average testing time: 2.8 hrs (Range = 2.0 to 4.5 hrs) • Avg. Cost/Ss/Testing: $133.11 – Youth paid ON minimum wage/4hrs (>80% youth selected testing at residence)
  5. 5. MAP Youth Pre-Post Experience Not at all So-So A lot 0 1 2 3 4 5 6 How relaxed do you feel?* (3.8) How happy do you feel? * (3.5) How clear is this study to you(5.0) How distressed do you feel? (2.4) How interested..in this study?(4.7) How important..this study is? (4.9) How high..your energy level? (3.7) How easy..to express yourself?(4.1)
  6. 6. Value of MAP Participation? Not at all So-So A lot 0 1 2 3 4 5 6 • I gained something from filling out this questionnaire (3.6) • Had I known in advance what completing this questionnaire would be like for me, I still would have agreed (4.8)
  7. 7. Descriptives of the MAP Preliminary Analysis Sample • N Initial Testing: 122 (52% female) • CAS status: – Crown Ward: 46 (40%) – Society Ward: 27 (23%) – Community Family/Temporary Care: 10(8.6%) – Voluntary Care: 2 (1.7%)
  8. 8. Youth Differences Between MAP Participating Vs. Refusing, p<.05 Subset Analyses on 85 Ss (n=59 participants, n=26 refusers) • Males > refuse (OR=3.06) • Society Wards > participate (OR=3.33) while community youth < likely to participate (OR=2.96) No significant differences on caseworker rated: • Risk, Experience, Severity Physical, Sexual, Emotional Abuse & Neglect • School Status (in/out; past year average grades obtained; special needs class status; learning disability) • Substance abuse; mental health problems; psychiatric diagnoses; risky sexual behavior; dating violence • Overall level of impairment (youth’s psychological, social, and occupational functioning; DSM-IV: 0-24 serious impairment, 25-49 moderate, 50-74 mild, 75-99 absent of symptom, 100 superior)
  9. 9. Childhood Maltreatment Measurement Childhood Trauma Questionnaire–Short Form (CTQ) Reference: Bernstein et al. (2003), commercial measure Stem: “When I was growing up” No. of Items: 28 (5-point Likert scale “never true to very often true”) Sample Item: “People in my family hit me so hard that it left me with bruises or marks” 5 subscales: Emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect Berstein’s adolescent sample: Chronbach’s Alpha: EA:.89, PA:.86, SA:.95, EN:.89, PN:.78 • With increasing N, all MAP sample Chronbach Alpha computed for all measures
  10. 10. Childhood Maltreatment Measurement Childhood Experiences of Victimization Questionnaire (CEVQ; under review measure) Reference: Walsh et al. (2002) Stem: “Things that may have happened to you…” No. of Items: 18 major questions, with follow-up queries (Frequency categories: Never; 1-2 times; 3-5 times; 6-10 times; >10 times) Sample Item: “How many times has an adult thrown something at you to hurt you?” 5 subscales: physical, sexual, emotional abuse; bullying; witnessing domestic violence Author-reported Intraclass correlation: severe physical and sexual abuse were .85 and .92 respectively • MAP collecting agency record of # investigations, investigation outcomes, primary substantiated type to compare CEVQ & CTQ
  11. 11. PTSD Measurement Trauma Symptom Checklist for Children (TSCC) Reference: Briere (1996), commercial measure Stem: “The items that follow describe things that youth sometimes think, feel, or do” No. of Items: 54 (Likert Scale “never to “almost all of the time”) Sample Item: “Feeling like I’m not in my body” 5 subscales: Anxiety, depression, posttraumatic stress, sexual concerns, dissociation, and anger Briere child/teen sample: Chronbach’s Alpha: sexual concerns: .65 –.75, other subscales: mid to high .80
  12. 12. Substance Abuse Problems Measurement Youth Risk Behavior Surveillance Survey Reference: Centre for Disease Control, Youth Risk Behavior Surveillance System (2003) Stem/Timeframe: last 30 days, days of use No. of Items: 2 (Frequency categories: Don’t use; 0; 1-2; 3- 7;8-12; 13+; >Once a day) Sample Item: “In the last 30 days, how many days did you consume alcoholic drinks?” “…use cannabis?” No. of Problem Items: 10 2 subscales: alcohol-related problems, drug-related problems Sample Item: “Have you every had any medical problems as a result of your alcohol/drug use?” • MAP have OSDUS questions @ 1 and 2 year data points to compare to Ontario youth population
  13. 13. Self-report Measure Validity and Reliability (initial & 6 mo.) • CTQ (initial) – CEVQ (initial): r=.69, p<.01 • CTQ (initial –6-month): r=.77, p<.01 • CEVQ (initial –6-month): r=.64, p<.01 • Reasonable correspondence between total maltreatment scores at two MAP timepoints • TSCC (initial) – TSCC (6-month): r=.65, p<.01 • Alcohol use past month (initial – 6-month): r=.71, p<.01 • Cannabis use past month (initial – 6-month): r=.73, p<.01 • Alcohol-related problems (initial – 6-month): r=.42, p<.01 • Drug-related problems (initial – 6-month): r=.52, p<.01 • Reasonable correspondence between health outcomes at two MAP testing timepoints
  14. 14. DSM-IV PTSD Criteria • Specifier: (1) Acute (< 3 months); (2) Chronic (> 3 months); (3) Delayed Onset (6 months past traumatic stressor) • Issues: Intensity, proximity, chronicity of stressor, age of child, relationship to perpetrator, presence of supportive and protective caretaker • Criterion A: Both must be present (1) traumatic event w/ actual/threatened death or serious injury to threat to physical integrity to self/others (2) response involved intense fear, helplessness, horror, disorganized or agitated behaviour
  15. 15. DSM-IV PTSD Symptomatology DSM- IV Symptom Classes: (1) Re-experiencing: • recurrent, intrusive thoughts; bad dreams*; sense of re- living*; physiological reactivity and psychological distress* at cue exposure (2) Avoidance/Numbing* • avoid thoughts, feelings, places, people, activities related to trauma*; gaps in recall; feeling detached; feeling problems; pessimism about future (3) Arousal • sleeping, anger, irritability, startle*, hypervigilance, concentration difficulty * Higher among chronic, abused youth (Fletcher, 2003)
  16. 16. Developmental Traumatology Tenets (DeBellis, 2001) • The biological stress system response varies with individual’s genetics, nature of the stressor, and whether the system can maintain homeostasis or whether it permanently changes due to stressor • PTSD symptoms are normal responses, but when chronic can lead to adverse brain development • PTSD symptoms represents pathway to more impairment; intergenerational maltreatment follows PTSD mediation • Chronic mobilization of the fight/flight response, is the key cause of persistent negative neurological effects and neurobiological changes • PTSD key causal factor underlying broad range of academic and mental health impairments
  17. 17. Why Childhood Maltreatment, PTSD, Substance Use Related? Cognitive models: • Perceived current threat supports chronic PTSD • Greater (negative) emotional reactivity to stimuli • Greater secondary traumatization potential • Preferential processing of maltreatment-related and danger cues (e.g., unresolved anger) • Self-medication via substance use to decrease negative affect (e.g., tension reduction) • Substance use as maladaptive coping • Altered self-schema may support self-destructive behaviors • Substance use as self-harming behavior • Future MAP direction: experimental task will be administered to study alternative mechanisms: biases perceptual/interpretational errors or selective attention?
  18. 18. Mediator: PTSD Symptomatology Adolescent Substance Abuse, Substance Use-related Problems Severity of Childhood Maltreatment Mediators: Causal Factors Preceding Target Change • Mediator = a variable the accounts for the effect of maltreatment on substance abuse • The identification of mediator provides target for cost- effective intervention and ground for evidence-based policy decision.
  19. 19. Emotional Abuse is Common • CEVQ – 70% Witness verbal abuse by parents • 63% occurred before grade 6 – 43% Witness physical abuse by parents • 55% occurred before grade 6 – 74% Victim of verbal abuse by parents • 59% occurred before grade 6 • CTQ (While growing up as a child … ) – 72% Family said hurtful or insulting things – 72% Being called “stupid,” “lazy,” or “ugly” by family – 61% “I believe that I was emotionally abused” – 88.9% Females; 85.4% Males endorsed 1 or > items
  20. 20. Physical Abuse is Common • CEVQ – 65% Being pushed, grabbed or shoved as a way to hurt • 61% before grade 6, 81% parental perpetration – 43% Being kicked, bit or punched as a way to hurt • 56% before grade 6, 78% parental perpetration • CTQ (While growing up as a child …) – 62% Being hit so hard it left marks: – 57% Being punished with belt, cord, hard objects – 54% “I believe that I was physically abused” • 83.9% of Females; 91.3% of Males endorsed 1 or > severe physical abuse items
  21. 21. Neglect is Difficult to Define • CTQ (growing up as a child …) – 40% Not having enough to eat – 22% Parent too drunk or high to take care of the family – 25% Had to wear dirty cloth – 54% “ I believe that I was neglected” – 98.2% Females; 97.7% Males 1> items
  22. 22. Sexual Abuse maybe more common than we think … • CEVQ – 32% Being touched or forced to touch other’s private part • 54% before grade 6; – 26% Being coerced into having sex • 43% before grade 6 & 30% high school – 33% perpetration by a male Other Adult (non-relative) • CTQ (growing up as a child … ) – 20% Being forced to do or watch sexual things – 20% Being molested – 21% “I believe I was sexually abused” • 62.7% female and 16% males endorsed 1 or > contact sexual abuse items
  23. 23. Posttraumatic Stress Disorder Symptomatology Trauma Symptom Checklist for Children (TSCC) Most frequently endorsed items: – 75% Feeling afraid something bad might happen – 74% Remembering things that happened that didn’t like – 63% Bad dreams or nightmare MEAN TSCC Male T Score= 37.34 (SD=29.06) Female T Score= 36.96 (SD=33.16) % in Clinical Range (T=or>70)=19.0% Female,19.6% Male Future MAP work examine factor structure of PTSD symptoms for males and females; child welfare vs. non- child welfare youth with other datasets
  24. 24. Substance Use is Early & More? • Alcohol Use – 36% Drinking Before Age 13 (US 28%) – 49% Binge Drinking Past Year (US 28%) – 47 % Past Month Drinking (US 45%) – 23% Past Month Binge Drinking (US 28%) – Mean Days Past Month Use=3-7 days (15.9% Female and 32.3% male drank >= 3 days in the past month) • Cannabis Use – 36% Use Before Age 13 (US 10%) – 84% Past Year – 62% Past Month (US 22%) – Mean Days Cannabis Use Past Days =1-2 days (54.5% Female and 90.6% male ever used Cannabis in the past month) • Talk to School Counselor – 3% alcohol related problem – 3% drug related problem • Arrested by Police – 6% alcohol related problem – 6% drug related problem
  25. 25. Mediators: Causal Factors Preceding Target Change • Sobel = βaβb/Sβaβb (β=unstandardized regression coefficient, S=standard error) Where Sβaβb = (βa 2 Sb 2 + βb 2 Sa 2 - Sa 2 Sb 2 )0.5 Mediator: PTSD Symptomatology Adolescent Substance Abuse, Substance Use-related Problems Severity of Childhood Maltreatment Direct effect of maltreatment on substance abuse Direct effect of maltreatment on substance use-related problem βa (Sa) βb (Sb)
  26. 26. PTSD Symptoms no. of days used Alcohol no. of days used Cannabis Maltreatment Experience Female .55** .31* .38* Male .09 .13 -.13 Initial Testing: Direct Effect Maltreatment, Past Month Number of days using Alcohol/Drug, number of Alcohol/Drug Use-related Problem PTSD Symptoms # of Alcohol Related Problem # of Cannabis Related Problem Maltreatment Experience Female .56** .41** 33* Male .09 .03 .06 * p<.05, ** p<.01 * p<.05, ** p<.01 N.B. Recent publication (Preacher & Hayes, 2004) suggested that significant direct effect is not a necessary precondition for mediation, as per Baron and Kenny (1986)
  27. 27. Maltreatment Experience no. of days used Alcohol no. of days used Cannabis PTSD Symptoms Female .55** .48** .48** Male .09 .18 .16 * p<.05, ** p<.01 Childhood Maltreatment *p<.05; **p<.01 Childhood Maltreatment *p<.05; **p<.01 PTSD Symptomatology no. of days used Alcohol last month 6.47 (1.67)** .01 (.003)* PTSD Symptomatology no. of days used Cannabis last month 6.47 (1.67)** .03 (.008)* Sobel=2.68** (Female only) Sobel=2.87** (Female only) Initial Testing: Maltreatment, PTSD, and the Past Month Number of days using Alcohol/Drug
  28. 28. Maltreatment Experience # of Alcohol Related Problem # of Cannabis Related Problem PTSD Symptoms Female .56** .31* 34* Male .09 .04 -.03 * p<.05, ** P<.01 PTSD Symptomatology Childhood Maltreatment no. of Alcohol Related Problems 6.47 (1.67)** 0.02 (0.01)* *p<.05; **p<.01 PTSD Symptomatology Childhood Maltreatment no. of Cannabis # Related Problems 6.47 (1.67)** 0.03 (0.01)* *p<.05; **p<.01 Sobel=2.07* (Female only) Sobel=1.94* (Female only) Initial Testing: Maltreatment, PTSD, and the number of Alcohol/Drug Related Problem
  29. 29. Why PTSD may be > relevant for females than males? • These preliminary analyses indicated that PTSD, as currently measured, may be a more relevant process for females than males • MAP initial analyses based on simultaneously obtained measurement • However, gender-based hypotheses is suggested as over-emphasized: • Meta-analyses review support gender similarities hypothesis in normative samples (Hyde, 2005) – Moderate, stable effect (d=.4-.6) across studies, males > physical, verbal aggression – Small/moderate effects (d=.2 to .4) for female > males in spelling, language, affiliative communication – Small effect for females > males in depressive symptoms in midadolescence (13-16 yrs.) (d=.16) – Small/moderate effects for males > females in self-esteem increasing over 7 yr to 18 yr period (d=.16-.33) But in clinical samples, females > males in PTSD, MD diagnoses Question: Presence of gender-specific clinical pathways or gender-specific pathways?  Future work subgroup analyses
  30. 30. Conclusion • Child welfare youth readily report on their maltreatment history and well-being • Child welfare youth indicate low distress from answering sensitive questions • Child welfare youth report substantial amount and types of victimization • Sexual protection may be one are of strength • Child welfare youth are one sub-population where mental health, substance abuse coincide • PTSD mediational model supported for females only • PTSD mediational model points to targeting PTSD symptomatology to reduce/prevent substance use and problems associated with substance use as potentially promising

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