1. Childhood maltreatment, PTSD, and Teen Dating Violence Christine Wekerle,Ph.D. Associate Professor, Education, Psychology, Psychiatry The University of Western Ontario cwekerle@uwo.ca

2. Violence in intimate relationships can be one…in which great intensity of positive longing, anger, and fear may be combined with a lack of felt security, lapses in attention, dysfluent communication, and unregulated arousal. (Lyons-Ruth & Jacobvitz, 1999)

3. Developmental Traumatology Tenets (DeBellis, 2001) The biological stress system response varies with individuals 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

4. Childhood Maltreatment Mediator: Post-traumatic stress symptomatology Poor Mental Health Dating violence Risky sexual behavior Substance abuse Mediators: Causal Factors Preceding Target Change The identification of mediator provides target for cost- effective intervention and ground for evidence-based policy decision.

5. Predictive Distal Factor: Childhood Maltreatment Child maltreatment may be the single most preventable and intervenable contributor to child and adult mental illness (DeBellis, 2003) Effective parenting is the most powerful way to reduce youth problem behaviours (Kumpfer & Alvarado, 2003) Adverse life events are not random – Child maltreatment associated with more problematic family environments, other high impact negative life events (including overlapping types of maltreatment), poverty etc. (Costello et al., 2002)

7. CIS Study: Caregiver Substance Abuse and Environmental Risk Factors –Poverty (income < $15,000, OR=1.6) –Multiple moves in the past 6 months (3+, OR=5.2) –Unsafe housing (OR=1.9) –Minority racial status (Aboriginal OR=3.4; Other Minority OR=1.4) –Low caregiver education (OR=1.9) –Criminal activity (OR=4.8) –Involvement in a violent relationship (OR=3.8) –History of childhood maltreatment (OR=3.2) –Mental (OR=2.8) and physical (OR=2.6) health issues –Lack of social supports (OR=2.6 )

8. DSM-IV PTSD Criteria Specifier: (1) Acute ( 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

9. 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)

10. Mediators: Causal Factors Preceding Target Change PTSD symptomatology as mediator Teens > frequently endorse intrusive memories, numbness, reminders are distressing, dissociative response, efforts to forget about event, hypervigilance, reliving the event (Fletcher, 2003) a significant proportion of adults diagnosed with alcohol dependence experience clinically significant levels of PTSD symptomatology individuals who suffer resultant PTSD as a result of childhood maltreatment may use alcohol as a means of coping (Stewart & Israeli, 2002) PTSD interfere with relationship functioning

11. Cross-lagged Structural Model Of Trauma Symptoms As A Predictor Of Child Maltreatment And Dating Violence For Boys, Adjusted To Include Independent Mediator Paths For Emotional Abuse

12. Cross-lagged Structural Model Of Trauma Symptoms As A Predictor Of Child Maltreatment And Dating Violence For Girls, Adjusted To Include Independent Mediator Paths For Anger

13. Dating Violence Prevention: The Youth Relationships Project Rationale: Youth with a child maltreatment history at greater risk for relationship violence Target Age: Mid-adolescence (age 14-17) [By age 14, 55% had romantic relationship; by 17, 80% had romantic relationship, Carver et al., 2003] Targets: (1) concept of relationships (2) relationships skills (3) social action (mastery via advocacy) Program: 18 sessions (2-hr) coeducational group format, coeducational facilitation – semi-structured manual Results: Reduced dating violence involvement, Reduced PTSD symptomatology within a RCT design with child welfare youth (Wolfe, Wekerle et al., 2003)

14. MAP Feasibility Study: Research Process Mean Age of tested youth: 15.5 years 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% 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 Home ($70.21) + $28.00 = $98.21 (>80% youth selected testing at residence) CAMH ($1.90) + $28.00 = $29.90 (+$5.00 food/refreshment cost)

15. Descriptives of the MAP Preliminary Analysis Sample Gender: 47 (56%) female, 37 male CAS status: –Crown Ward: 32 (42.1%) –Society Ward: 24 (31.6%) –Community Family/Temporary Care: 7(9.2%) –Voluntary Care: 1 (1.3%)

16. Bullying Childhood Experiences of Victimization Questionnaire (CEVQ) –Was Verbally bullied 60% endorsed, 50% before grade 6 –Was Physically bullied 40% endorsed, 34% between 6-8 th grade Ontario Student Drug Use Survey (OSDUS) –Frequency of being bullied at school (grades 7- 12) since September (past 6 months) 31% endorsed –Frequency of bullying at school (grades 7-12) since September (past 6 months) 34% endorsed

17. Emotional Maltreatment CEVQ –Witness verbal abuse to another adult 70% endorsed, 63% occurred before grade 6 –Witness physical abuse to another adult 43% endorsed, 55% occurred before grade 6 –Victim of verbal abuse by parents 74% endorsed, 59% occurred before grade 6 CTQ (growing up as a child … ) –Family said hurtful or insulting things 72% endorsed –Being called stupid, lazy, or ugly by family 72% endorsed

18. Physical Maltreatment CEVQ –Being pushed, grabbed, or shoved as a way to hurt 65% endorsed, 61% before grade 6, 81% parental perpetration – Being kicked, bit or punched as a way to hurt 43% endorsed, 56% before grade 6, 78% parental perpetration Childhood Trauma Questionnaire (CTQ; While growing up as a child …) –Being hit so hard it left marks: 62% endorsed –Being punished with belt, cord, hard objects: 57% endorsed

19. Sexual Maltreatment CEVQ –Being touched or forced to touch others private part 32% endorsed, 54% before grade 6 –Being coerced into having sex 26% endorsed, 43% before grade 6 & 30% high school CTQ (growing up as a child … ) –Being forced to do or watch sexual things 20% endorsed –Being molested 20% endorsed

20. Neglect CTQ (growing up as a child …) –Not having enough to eat 40% endorsed –Parent too drunk or high to take care of the family 22% endorsed –Had to wear dirty cloth 25% endorsed

21. Posttraumatic Stress Disorder Symptomatology Trauma Symptom Checklist for Children (TSCC) –Feeling afraid something bad might happen 75% endorsed –Remembering things that happened that I didnt like 74% endorsed –Bad dreams or nightmare 63%

22. Maltreatment and Trauma

23. MAP Feasibility Study : Preliminary Result 90% of female adolescents had experienced either one or more forms of sexual abuse, and almost 80% of male had experience either one or more forms of physical abuse. The severity and duration of maltreatment experience is associated with the number and acuteness of PTSD symptomatology While in general PTSD symptomatology is associated with the four indicators of poor developmental health in maltreated adolescents, there are stark gender differences: –PTSD symptomatology in maltreated female adolescents is associated with: 1) internalizing symptoms, 2) victimization in dating violence, 3) risky sexual behavior – illicit drug-use as part of their sexual activity, 4) experienced difficulty in stopping drug and alcohol even if they wanted to –PTSD symptomatology in maltreated male adolescents is associated with: 1) externalizing behaviors, 2) perpetration and victimization in dating violence, 3) risky sexual behavior – un-protected sexual activities, 4) more illicit drug use Childhood Maltreatment PTSD Symptomatology Poor Mental Health Dating violence Risky sexual behavior Substance abuse

24. Childhood Maltreatment PTSD Symptomatology Poor Mental Health Dating violence Risky sexual behavior Substance abuse MAP Feasibility Study: Preliminary Result Testing the full mediation model: –Feasibility has small sample size, not enough statistical power – awaits MAP Longitudinal Study –Only partial mediation of PTSD symptomatology in the relationship between childhood maltreatment and internalizing symptom in female, and between maltreatment and victimization in dating violence in the combined sample. –Encourages continued research on PTSD symptomatology as a key mediator of diverse teen outcomes –No current maltreatment-specific PTSD intervention for teens exists; may need gender-specific intervention