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

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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