The Moderating Effect of Caregiver Support………………

TABLE OF CONTENTS

LIST OF TABLES AND FIGURES……………………………………… v

Chapter 1. Introduction…………………………………………………… 1

Chapter 2. Sexual Abuse………………………………………………….. 4

Chapter 3. Dissociation…………………………………………………… 6

What is Dissociation?...... 6

Why Does Dissociation Develop?...... 7

Dissociation During the Trauma…………………………… 7

Persistent Trauma-Specific Dissociation…………………... 11

Assessment of Dissociation……………………………………. 13

Chapter 4. Dissociation and PTSD ………………………………………... 17

Chapter 5. The Moderating Effect of Caregiver Support………………...... 25

Assessment of Caregiver Support…………………………….. 28

Chapter 6. Current Study…………………………………………………... 31

Chapter 7. Hypotheses…………………………………………………...... 34

Chapter 8. Methods………………………………………………………… 35

Procedures……………………………………………………… 37

Measures …...………………………………………………….. 38

Chapter 9. Results………………………………………………………….. 42

Data Screening…………………………………………………..42

Primary Analyses…. ……...…………………………………… 45

Exploratory Analyses………………………………………...... 46

Chapter 10. Discussion…………………………………………………….. 48

Limitations……………………………………………………... 53

Future Directions………………………………………………. 56

Conclusions……………………………………………………. 58

TABLES…………………………………………………………………… 60

APPENDICES……………………………………………………………… 71

REFERENCES……………………………………………………………... 78

iii

LIST OF TABLES AND FIGURES

Title Page Table 1 Item Comparison of UCLA PTSD Reaction Index for 60 DSM-IV TR versus DSM-5 Table 2 Descriptive Statistics of the Study Sample 63

Table 3 Abuse Characteristics 65

Table 4 Ranges, Means, Standard Deviations and Rates of Clinical 66 Significance Table 5 Zero-Order Correlations between Study Variables 67

Table 6 Hierarchical Regression Analysis Predicting Posttraumatic 68 Stress Symptoms from Dissociation and Caregiver Support Table 7 Zero-Order Correlations between PTSS and Exploratory 69 Study Variables Table 8 Hierarchical Regression Analysis Predicting Posttraumatic 70 Stress Symptoms from Dissociation by Caregiver Blame and Dissociation by Caregiver Support Appendix A Conceptual Model 71

Appendix B CARE Center Protocol 72

Appendix C CAC Protocol 73

Appendix D Dissociation Subscale of TSCC 74

Appendix E UCLA PTSD Reaction Index for DSM-IV 75

Appendix F Parent Support Questionnaire 76

Table 1 Item Comparison of UCLA PTSD Reaction Index for 60 DSM-IV TR versus DSM-5 Table 2 Descriptive Statistics of the Study Sample 63

Table 3 Abuse Characteristics 65

iv 1

Chapter 1. INTRODUCTION

From October 1, 2009 through September 30, 2010, the Department of Health and

Human Services estimated 695,000 children experienced substantiated maltreatment. Of those cases, 17.6% involved physical abuse, and 9.2% involved sexual abuse (U.S.

Department of Health and Human Services, 2011). The effects of maltreatment are quite significant, including internalizing, externalizing, and adjustment-related problems persisting into adulthood (Lansford, Dodge, Pettit, Bates, Crozier, & Kaplow, 2002;

Springer, Sheridan, Kuo, & Carnes, 2007; Yancey & Hansen, 2010). Maltreated youth also demonstrate increased rates of dissociation, which can contribute to the development and maintenance of trauma-related psychopathology, particularly Posttraumatic Stress

Disorder (PTSD; Briere, Scott, & Weathers, 2005; Silberg, 2000).

Dissociation is defined as “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotions, perceptions, body representation, motor control, and behavior.” (APA, 2013, p. 291). Dissociation serves to reduce arousal and feelings of helplessness and to increase perceptions of safety in the midst of overwhelming traumatic exposure (Engelhard, van den Hout, Kindt, Artnz, &

Schouten, 2003; Ginzburg, Butler, Saltzman, & Koopman, 2009; Hopper, Frewen, van der Kolk, & Lanius, 2007). In the context of trauma, persistent dissociation after the traumatic event may reflect an unintentional form of cognitive avoidance in an attempt to manage or distance oneself from the overwhelming emotions triggered by reminders of the event (Briere et al., 2005; Carlson & Dalenberg, 2000; Waelde, Silvern, Carlson,

Fairbank, & Kletter, 2009). Although dissociation may be an adaptive response within the traumatic experience, persistent dissociation during childhood in particular, can trigger a cascade of devastating effects, including impaired development of affect regulation and cognitive skills, placing the child at risk for trauma-related psychopathology, and PTSD in particular (Macfie, Cicchetti, & Toth, 2001; Waelde et al., 2009). Further, the disruption in cognitive processing and affect regulation can interfere with resolution of traumatic stress symptoms by preventing the formation of a cohesive trauma narrative and the effective management of intense emotions triggered by reminders of the maltreatment (Waelde et al., 2009). Given the increased risk for dissociation among maltreated youth (e.g. Collin-Vezina & Hebert, 2005; Kisiel &

Lyons, 2001; van IJzendoorn & Schuengel, 1996), as well as negative effects of dissociation, researchers examining trauma-specific dissociation have called for investigations into potential ways to protect maltreated youth from its negative effects

(Waelde et al, 2009).

Meta-analyses and literature reviews of protective factors suggest that caregiver support of the maltreated child may be the single strongest predictor of mental health outcomes (Bolen, 2002; Elliott & Carnes, 2001; Malloy & Lyons, 2006; Yancey &

Hansen, 2010). Further, caregiver support, as opposed to abuse-related factors, is of particular interest because it is one of the factors amenable to change after maltreatment has occurred (Bolen, 2002; Elliott & Carnes, 2001). Although maltreatment-related caregiver support has been defined in a variety of ways, supportive caregiver behaviors include believing the allegation and blaming the perpetrator for the abuse, pursuing prosecution of the perpetrator, and displaying increased affection towards the child.

Another important aspect of caregiver support is encouraging the child to discuss upsetting thoughts and emotions associated with the abuse. This type of support can help the child integrate memories of the trauma, which may prevent fragmented memories that lead to PTSD (Nelson, 1993; Cohen, Deblinger, Mannarino, & Steer, 2004). When parents discourage the child from discussing emotional and cognitive reactions to abuse, either due to avoidance of upsetting topics, or ambivalence towards the child, they may inadvertently create an environment of cognitive avoidance (Goodman, Quas, Batterman-

Faunce, Riddlesberger, & Kuhn, 1994; Oppenheim, 2006) that strengthens the relationship between dissociation and PTSD. However, firm conclusions regarding the role of abuse-related caregiver support are difficult to draw given the variability in operationalization and method of measurement of this construct (Elliott & Carnes, 2001).

The current study examined the relationship between trauma-specific dissociation and posttraumatic stress symptoms (PTSS) in a sample of children undergoing investigation due to a sexual abuse allegation. Abuse-related caregiver support was examined as a moderator of the relationship between dissociation and PTSS to determine whether low support amplifies the relationship between these variables or alternatively, high support reduces the relationship between dissociation and PTSS.

Chapter 2. SEXUAL ABUSE

According to data collected during a 12-month period in 2009 and 2010 by the

Department of Health and Human Services as part of the National Child Abuse and

Neglect Data System (NCANDS; USDHHS, 2011), 9.2% of maltreatment victims

(neglect, physical abuse, and sexual abuse) were sexually abused. Females appear to be victimized at higher rates than males (Sedlak, et al., 2010; Snyder, 2000); however, boys are more likely to be injured or killed as a result of sexual abuse (Sedlak & Broadhurst,

1996). Although there may be biases in reporting based on socioeconomic status and minority status (Hines, Lemon, Wyatt, & Merdinger, 2004), epidemiological data suggest younger children and African American children were at the highest risk for sexual abuse

(Sedlak, et al., 2010; USDHHS, 2011). Further, sexual abuse may often be experienced as repeated incidents. For example, Finkelhor, Ormrod, and Turner (2007) conducted a longitudinal study with a national sample of 1,467 children and found that those who experienced sexual abuse were 6.9 times more likely to experience sexual abuse the following year. The National Comorbidity Survey, conducted with a national sample of

5,866 participants aged 15-54 years old, found that 16% of the sample reported experiencing sexual abuse prior to 18 years of age (Molnar, Buka, & Kessler, 2001).

Approximately 8.2% of the general sample reported experiencing repeated incidents of sexual abuse; whereas 9.4% reported a single incident of sexual abuse. Notably, those who experienced sexual abuse perpetrated by a family member were more likely to report repeated incidents. In a comprehensive review of the sexual abuse literature, Andrews

and colleagues found that as many as 20% of sexual abuse cases involve more than one incident lasting at least one year (see Andrews, Corry, Slade, Issakidis, & Swanston,

2004). These findings suggest that those who experience sexual abuse are at risk for repeated exposure and/or repeated incident trauma. This potentially chronic exposure to abuse, as well as the interpersonal nature of abuse, place sexually abused children at increased risk for negative mental health outcomes (Finkelhor et al., 2007; Molnar et al.,

2001; Wechsler-Zimring & Kearney, 2011). In fact, sexual abuse has been associated with a wide range of negative mental health outcomes, including PTSD, depression, anxiety, self-harm behaviors, low self-esteem, conduct problems, aggressive behaviors, sexual behaviors, cognitive deficits, and attention problems (e.g., Kaplow, Dodge,

Amaya-Jackson, & Saxe, 2005; Kaplow, Hall, Koenen, & Amaya-Jackson, 2008;

Wechsler-Zimring & Kearney, 2011; Yancey & Hansen, 2010). Sexual abuse has also consistently been demonstrated to increase the risk of dissociation in samples of children and adults, which can have a devastating impact on development and maintenance of

PTSD (Macfie et al., 2001; Wechsler-Zimring & Kearney, 2011).

Chapter 3. DISSOCIATION

What is Dissociation?

Although the term dissociation is relatively recent, discussions of dissociative psychological phenomena in psychological literature are present as early as the 18th century. From that time until the early 20th century, psychologists described a division of personality or consciousness (van der Hart & Dorahy, 2009) that explained hysterical symptoms and neuroses. It was believed that dissociation developed due to somnambulism, later referred to as hypnosis. In the late 19th century and early 20th century, Pierre Janet was the first to emphasize exposure to traumatic stress as the primary cause of dissociation (as cited in van der Hart & Dorahy, 2009). He argued that trauma exposure is related to dissociation in a linear fashion, with increasing exposure resulting in increasing dissociative symptoms. He also noted that duration and repetition of traumatic experiences affect occurrence and duration of dissociative phenomena (as cited in van der Hart & Dorahy, 2009). Interest in dissociation waned through the mid-

20th century. However, in the mid-1980’s, there was a resurgence of interest in dissociative experiences, which focused on the phenomenology, or observable or reportable indicators (van der Hart & Dorahy, 2009; van der Kolk, van der Hart, &

Marmar, 1996). Phenomena no longer needed to stem from a division of consciousness or the personality, but only represent alterations of consciousness to be considered dissociative. Further, interest in dissociation as a normative phenomenon (e.g., hypnotic trance, daydreaming) broadened the definition and conceptualization of the construct.

The Diagnostic and Statistical Manual (DSM) followed this approach by describing dissociation in phenomenological terms, with a focus on observable or reportable symptoms rather than on the underlying structure of personality. Currently, the DSM-V describes dissociation as “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.” (APA, 2013, p. 291).

Although there are varying definitions, there is a general consensus that dissociation is a lack of integration of thought, feelings, and experiences that impacts the development of cohesive memories incorporated into consciousness (ISSD, 2004). Based on this definition, researchers and clinicians include the following as indicators of trauma-specific dissociative processes: amnesia or gaps in awareness, depersonalization, derealization, identity confusion, and identity alteration (Ginzburg et al., 2009; Putnam,

1997; Waelde et al., 2009). Dissociative amnesia or gaps in awareness are described as the inability to recall familiar information, details of events, or lack of memory for entire events or periods of time (ISSD, 2004; Putnam, 1997). As compared to normal forgetfulness, dissociative amnesia tends to pertain to traumatic or stressful events, as well as episodes of extreme dysregulation, including self-harm or violent outbursts (APA,

2013; ISSD, 2004; Putnam, 1997). Youth experiencing trauma-specific dissociation may also present with trance-like states, often reported as “spacing out” or daydreaming, that represent a loss of connection with the external environment (ISSD, 2004).

Depersonalization is described as a loss of sense of self or an out-of-body experience. Similarly, derealization may present as a disconnection from the environment or distorted perceptions such as feeling like watching life like a movie or

seeing the world through a fog, lightheadedness, or dizziness (ISSD, 2004; APA, 2013).

Dissociation may also manifest in disturbances of self-identity including identify confusion and in more severe cases, identity alteration. Identity confusion refers to difficulty understanding the self as a cohesive, consistent personality. Extremely conflicting emotions, thoughts, and behaviors create difficulty identifying consistent patterns that translate to a cohesive sense of self (ISSD, 2004; Putnam, 1997).

Sexually abused youth, in particular, appear to be at increased risk for dissociation

(e.g. Collin-Vezina & Hebert, 2005; Kisiel & Lyons, 2001; van IJzendoorn & Schuengel,

1996). A meta-analysis of studies conducted with adults demonstrated a strong relationship between sexual abuse and dissociative symptoms presenting into adulthood

(van IJzendoorn & Schuengel, 1996). Although much of the research demonstrating this relationship was conducted retrospectively with adults, studies with child and adolescent samples also support the increased risk for dissociation among sexually abused youth.

For example, when comparing a sample of 67 sexually abused girls, ages 7-12 years old, to 67 non-abused controls, sexually abused participants were at an eightfold increased risk of clinical levels of dissociation (Collin-Vezina & Hebert, 2005). In fact, 30% of sexually abused girls demonstrated clinical levels of dissociation compared to 4.5% of non-abused matched controls. Further, findings from another study assessing 118 youth, ages 10-18 years old, in residential treatment, found that victims of sexual abuse had higher rates of self-reported dissociation than victims of physical abuse and non-abused peers (Kisiel & Lyons, 2001).

Although it appears that sexually abused youth are at risk for dissociation, inconsistency of assessment methods, as well as variability of the composition of

samples, make it difficult to decipher how common dissociative processes are among abused youth. Studies examining dissociative experiences or behaviors have found rates ranging from 19% to 73% among maltreated youth (see Silberg, 2000). However,

Silberg speculates that samples demonstrating the highest levels of dissociation consisted of the most severely abused youth, who may present with elevated levels of dissociation when compared to all abused youth.

Why does Dissociation Develop?

Dissociation during the Trauma

Although there is variation in theories regarding the etiology and cognitive mechanisms of dissociation (Cromer, Stevens, DePrince, & Pears, 2006), there is general agreement that trauma predicts dissociative phenomena. Empirical evidence demonstrates that dissociation occurs at higher rates in traumatized versus non- traumatized samples of children and adults alike, the severity of trauma predicts dissociation, and dissociation significantly predicts trauma-related symptoms (e.g.

Bernier, Hebert, & Collin-Vezina, 2013; Macfie et al., 2001; Twaite & Rodriguez-

Srednicki, 2004; Wechsler-Zimring & Kearney, 2011). The following section will discuss the current conceptualization of the etiology and mechanisms of dissociative cognitive processes activated in response to trauma, and abuse, in particular.

Dissociation appears to serve as a defense mechanism in response to trauma with three purposes: 1) reduction of cognitive awareness; 2) emotion regulation; and 3) reduction of physiological arousal (Waelde et al., 2009). When exposed to traumatic events that are perceived as cognitively, emotionally, and physiologically overwhelming, dissociative processes allow the individual to reduce awareness of the event, thereby

reducing overwhelming thoughts and feelings (Silberg & Dallam, 2009). Peritraumatic dissociation, which occurs during or immediately following the traumatic event, prevents adequate encoding of the experience into a contextual and autobiographically based memory (Engelhard et al., 2003; Halligan, Michael, Clark, & Ehlers, 2003; van der Kolk et al., 1996). Instead, perceptions are experienced as fragmented and discrete sensory and emotional elements that are stored away from conscious experience. This allows the individual to compartmentalize the information and affect related to the traumatic experience, thereby reducing overwhelming cognitions and emotions (Putnam, 1997; van der Kolk et al., 1996). In essence, dissociation allows for cognitive and emotional detachment from the environment that is perceived as physically unavoidable or inescapable (van der Kolk, et. al, 1996).

In addition to the cognitive functions of dissociation, biological models of trauma also suggest that dissociation serves as a defense mechanism to reduce physiological arousal (Lanius, et al., 2010). In the face of danger, the sympathetic nervous system activates the “fight-or-flight” response, often accompanied by arousal or anxiety.

However, in some cases, the parasympathetic system is activated, inducing a “freeze” or

“immobilization” response that results in overmodulation of emotions, dampening of pain sensitivity, and distortions in perceptions and consciousness consistent with dissociative phenomena (i.e. depersonalization, derealization). This “freeze” response essentially reduces awareness of overwhelming experiences and hyperarousal. The fact that individuals are more likely to activate the parasympathetic or “freeze” response in the face of inescapable danger, is consistent with evidence that dissociation is also more likely to occur in response to traumas perceived as inescapable such as sexual abuse,

which can be more chronic or ongoing than other forms of trauma (Carlson & Dalenberg,

2000; Lanius et al., 2010).

There is empirical evidence that dissociation does, in fact, reduce cognitive awareness. Engelhard and colleagues (2003) demonstrated the relationship between dissociation and reduced cognitive awareness in a sample of 118 women who experienced pregnancy loss. One month after pregnancy loss, the sample of women completed self-report measures assessing peritraumatic dissociation at the time of pregnancy loss, and memory of the pregnancy loss, including fragmentation, sensory impressions, and emotional intensity. Thought suppression of pregnancy-related memories was also measured. Results indicated that women who endorsed higher rates of dissociation also reported more fragmented memory, more sensory-based memories (i.e. visual images, bodily sensations, smells etc.), more emotionally intense memories, and higher levels of thought suppression. The authors suggest peritraumatic dissociation allows the individual to reduce cognitive awareness in the moment of the trauma, resulting in memories that are predominately sensory and emotion based. The individual may attempt to suppress these emotionally intense memories of the trauma. Although these findings present compelling evidence that peritraumatic dissociation reduces cognitive awareness, the retrospective reporting of peritraumatic dissociation and cross- sectional nature of the study present limitations. As will be discussed below, retrospective reporting may be unreliable regarding reports of dissociative phenomena during a trauma. Further, cross-sectional data such as this prevent conclusions about the causal nature of this relationship.

Persistent Trauma-Specific Dissociation

In addition to peritraumatic dissociation, some individuals may demonstrate persistent trauma-specific dissociation, a pervasive coping mechanism automatically activated in response to traumatic reminders (Macfie et al., 2001; Waelde et al., 2009).

Persistent trauma-specific dissociation, similar to peritraumatic dissociation, serves to reduce arousal and awareness of trauma-related thoughts and reminders. Hopper and colleagues (2007) demonstrated the way in which persistent trauma-specific dissociation serves as a mechanism to regulate arousal. Twenty-seven adults with PTSD listened to three neutral and traumatic script imageries. The participants’ neurobiological activity was simultaneously measured using fMRI technology. Immediately following script and fMRI administration, participants reported symptoms of state dissociation provoked by the script. Dissociation during the script imagery was positively related to frontal cortex activity and negatively related to amygdala activity, which is consistent with dampening of the sympathetic response and reduced emotional responses (Lanius et al., 2010). The authors posit that these findings suggest dissociation during script imagery serves to mentally and emotionally disengage from processing overwhelming traumatic experiences through neurobiological processes. However, no studies have examined whether these findings generalize to children.

Becker-Blease, Freyd, and Pears (2004) demonstrated the relationship between persistent dissociation and reduced cognitive awareness in a sample of preschoolers.

Parents of 80 preschoolers reported previous traumatic experiences that their children experienced (i.e. natural disaster, witnessing violence, physical abuse, sexual abuse, emotional abuse), as well as their child’s current level of dissociation using the dissociation subscale of the Trauma Symptom Checklist for Young Children (TSCYC;

Briere et al., 2001). Interestingly, abused children with high parent-reported dissociation remembered less negatively charged information presented in attention tasks than non- abused children with low dissociation. The authors argue that children who experience abuse develop dissociation as a strategy to reduce awareness of threatening information or traumatic reminders. However, the researchers did not explicitly examine whether preschoolers used dissociation in response to traumatic reminders. Further, parent reports of dissociation were necessary due to the young age of the children in the study, but present limitations regarding the ability of parents to adequately detect internal dissociative processes. These limitations, which are present in much of dissociation research, will be discussed further below.

Assessment of Dissociation

Although increased focus on studying trauma-related dissociative phenomena has contributed to a better understanding of the etiology and presentation of dissociative symptoms, inconsistencies in assessment methods, particularly among youth samples, present challenges to further delineating these processes. Specifically, use of retrospective reporting, as well as observational reports provided by parents or clinicians, present limitations to much of the current body of dissociation literature. The following section will discuss these limitations and potential solutions to address them and advance the current understanding of dissociative processes.

As previously noted, most dissociation research has focused on adults, using retrospective questionnaires and checklists (Bryant, 2007), which present unique challenges. Specifically, limitations to retrospective report include normative forgetting, incorrect recall, and confounding subsequent traumatic experiences that may have

contributed to the development or maintenance of dissociation (Bryant, 2007). These limitations of retrospective reporting are difficult to correct because the alternative of assessing dissociation immediately following trauma, particularly abuse, is difficult, given that youth often delay disclosure of abuse and access to populations acutely traumatized is limited.

Increased interest in persistent trauma-specific dissociation has led to new techniques of assessing dissociation that remediate some of the concerns about retrospective reporting. For example, many studies assessing dissociation inquire about current levels of dissociation (Briere et al., 2005; Wang, Cosden, & Bernal, 2011) without cueing the report to a specific trauma, which may detect normative dissociation or dissociation in response to stressors or traumas other than those of interest in a particular study. The most promising method of assessment involves cuing the participant to traumatic or stressful material, including traumatic memories, and then assessing use of dissociative processes during exposure (Hopper et al., 2007; Kaplow et al., 2005). However, finding opportunities to apply this method are difficult, given ethical concerns about triggering traumatic responses in abused youth for the sole purpose of research.

Even once the limitations of retrospective reporting have been addressed, there remains considerable variability in and limitations to the methods of assessing dissociation. Specifically, research with youth has focused on clinician observation, parent report, and to a lesser extent, child report (Silberg, 2000). One of the most widely used measures of dissociative symptoms in children is the Child Dissociation Checklist

(CDC; Putnam 1997), a 20-item checklist that relies on parent or observer reports of

behavior. Although this measure, as well as other parent or observer measures, has established good reliability and validity, significant limitations to observer ratings exist.

Specifically, parents or other observers may underestimate dissociation due to the internal nature of symptoms (Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997). For example, items attempting to measure internal processes such as “living in a fantasy world,” which represents derealization, may be difficult to answer based on the child’s outward behavior. In fact, DePrince and colleagues (2008) found that parent and child reports of dissociation were related; however, parents were not consistently reliable reporters. Specifically, parent reports of dissociation were not sensitive enough to detect a relationship between dissociation and attention problems that emerged when children reported their own dissociation. Ogawa and colleagues (1997) found that observers were particularly inaccurate when reporting depersonalization and derealization. Dissociation has also been assessed through clinician observation of the child (Becker-Blease et al.,

2004; Kaplow et al., 2005). However, this method is subject to the same weaknesses as parent report.

Although self-report seems to be the most reliable way to assess internal dissociative processes, few studies have directly asked youth to report dissociation.

Briere and colleagues (2005) developed a dissociative subscale included on the Trauma

Symptom Checklist for Children (TSCC; Briere, 1996) to measure internal dissociative processes. An adolescent version of the Dissociative Experiences Scale has also been used to investigate dissociative symptoms (A-DES; Armstrong, Putnam, & Carlson,

1997). However, on each of these measures, youth are not cued to report dissociation in relation to a specific trauma. Therefore, this self-report method does not attempt to

differentiate normative dissociation or general dissociation from dissociative behaviors used to cope with traumatic stress or reminders, making it difficult to understand the role of dissociation in response to trauma, specifically.

The current study addressed many of these weaknesses observed in the assessment of dissociation. Specifically, the current study assessed abuse-specific dissociation through youth self-report immediately following forensic disclosure of sexual abuse. This method allowed for a more thorough assessment of dissociation, including the internal experiences that observer reports may not detect. Further, participants were cued to report dissociation experienced while discussing the abuse with the forensic interviewers in order to measure abuse-specific dissociation when exposed to traumatic reminders.

Chapter 4. DISSOCIATION AND PTSD

Although dissociation may be effective at reducing overwhelming cognitions, emotions, and physiological arousal during trauma exposure or exposure to traumatic reminders, dissociation can also have detrimental effects on mental health. The following section will discuss the role of peritraumatic and persistent trauma-specific dissociation in the development and maintenance of the most common trauma-related disorder,

Posttraumatic Stress Disorder (PTSD).

PTSD occurs in response to exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. Symptoms of PTSD are divided into four symptom clusters: 1) re-experiencing symptoms including intrusive distressing memories, flashbacks, nightmares, psychological and physiological distress experienced in the context of reminders of the trauma, and repetitive play; 2) avoidance symptoms including efforts to avoid thoughts, feelings, or external stimuli that remind one of the trauma; 3) negative alterations in cognitions and mood symptoms including inability to remember important aspects of the traumatic event, persistent and negative beliefs about one’s self, others, or the world, distorted cognitions about the cause or consequences of the traumatic event leading to blame, negative emotional state, diminished interest in activities, detachment from others, and inability to experience positive emotions; 4) hyperarousal symptoms such as sleep problems, irritability, hypervigilance, difficulty concentrating, and an exaggerated startle response (APA, 2013). These symptoms must be present at least one month after the trauma (APA, 2013).

Historically, dissociation research focused on the role of peritraumatic dissociation in the development of PTSD after trauma exposure. As previously

discussed, trauma exposure perceived as cognitively, emotionally, or physiologically overwhelming may induce dissociative strategies that reduce awareness of the external environment and internal states of distress. However, as a result, dissociation leads to fragmented and disorganized memories devoid of context or autobiographical reference

(Halligan et al., 2003; McKinnon, Nixon, & Brewer, 2008), making them difficult to intentionally retrieve but easy to unintentionally trigger (Halligan et al., 2003).

Individuals may attempt to avoid triggering these intrusive memories by avoiding thoughts, environments, people, or experiences that remind them of the trauma. Thus, peritraumatic dissociation increases risk for re-experiencing, thought suppression, cognitive distortion, and avoidance behaviors, all of which are core features of PTSD

(Engelhard et al., 2003; Halligan et al., 2003).

There is ample evidence to suggest peritraumatic dissociation is associated with

PTSD. In fact, Ozer, Best, Lipsey, and Weiss (2008) conducted a meta-analysis of adult studies to determine predictors of PTSD. Results indicated that peritraumatic dissociation was the strongest predictor of PTSD, even more so than prior trauma exposure, perceived trauma-related threat, and socioeconomic status variables. Halligan and colleagues (2003) demonstrated the mechanism through which peritraumatic dissociation leads to the development of PTSD in two separate studies examining victims of assault. Researchers assessed the relationship between cognitive processing during the trauma and PTSD among 81 assault victims one year after the assault in the first study and 73 victims three months after assault in the second study. Participants retrospectively recalled cognitive processing during the trauma, including peritraumatic dissociation, data-driven processing (i.e. sensory or perceptually based), self-referent processing (i.e.

acontextual), and trauma memory disorganization. PTSS was reported at four time points: one month after assault (retrospectively), at the time of the interview, and three and six months after the initial data collection. Results indicated that dissociation correlated with both data-driven processing and self-referent processing, and did not uniquely predict PTSD when data-driven and self-referent processing were included in the model. The authors posit that dissociation during the trauma may lead to disorganized trauma memories due to data-driven processing and lack of self-referent processing, which then places the individual at risk for PTSS. However, in spite of the prospective design, participants in both studies were asked to retrospectively report peritraumatic cognitive processing, including peritraumatic dissociation. Further, cognitive processing was related to PTSD at all time points, including the same assessment point in which cognitive processing was assessed. Therefore, interpretations of causal mechanisms must be made with caution.

Emerging evidence suggests this link between peritraumatic dissociation and

PTSD extends to children, as well. For example, Saxe and colleagues (2005) examined peritraumatic responses and symptoms of PTSD in a prospective study of 72 youth, ages

7-17, hospitalized for a burn. Within three days of hospitalization, burn victims reported levels of separation anxiety and burn pain. Nurses reported the child’s level of peritraumatic dissociation. Three months later, children were interviewed using the Child

PTSD Reaction Index to assess symptoms of PTSD. The findings indicated two distinct pathways to PTSD. The first pathway demonstrated that separation anxiety mediated the pathway from the severity of the burn to PTSD symptoms three months later. The second pathway from severity of the burn to PTSD was mediated by peritraumatic dissociation

as reported by the nurse. Notably, age did not influence this pathway. This study provides a strong argument that peritraumatic dissociation mediates the relationship between trauma and PTSD. The assessment of peritraumatic dissociation soon after the traumatic experience mitigated potential problems related to retrospective reporting observed in other dissociation studies. However, the study did not assess the circumstances or cause of the burn, which may have influenced the type of pathway to

PTSD.

Researchers have also examined other forms of dissociation that may influence the development or maintenance of trauma-related psychopathology. Specifically, recent attention has focused on the relationship between trauma-specific dissociation evident weeks, months, or even years after trauma exposure and subsequent PTSD. Persistent trauma-specific dissociation serves to suppress overwhelming and intrusive memories and emotions in the face of traumatic reminders, resulting in continuation of fragmented, unprocessed memories and emotional numbing (Ehlers, Mayou, & Bryant, 2003;

Halligan et al, 2003; Lanius et al., 2010; Murray, Ehlers, & Mayou, 2002; Waelde et al.,

2009). Therefore dissociative coping strategies interfere with long-term recovery after trauma exposure and can maintain symptoms of PTSD (Briere et al, 2005; Halligan et al,

2003; Putnam, 1997). Empirical evidence discussed below supports this theory.

Briere and colleagues (2005) conducted two studies assessing how types of dissociation were differentially related to PTSD. In the first study, 52 trauma-exposed adults completed self-report measures assessing traumatic life events, peritraumatic distress, peritraumatic dissociation, persistent trauma-specific dissociation, and general dissociation not specifically cued to a traumatic experience. Peritraumatic dissociation

was measured through retrospective recall using the Peritraumatic Dissociative

Experiences Scale. Persistent trauma-specific dissociation represented dissociation that occurred immediately after the trauma and persisted up to the time of assessment.

General dissociation was measured using the Dissociative Experiences Scale which measures general dissociative tendencies unrelated to traumatic events. Participants were also administered the Clinician-Administered PTSD Scale in interview form to assess for

PTSD. When peritraumatic, persistent, and general dissociation, as well as peritraumatic distress were analyzed individually, all were related to PTSD. However, when all variables were entered into the analysis together, only persistent trauma-specific dissociation and general dissociation predicted PTSD. Peritraumatic dissociation was no longer a significant predictor of PTSD.

The second study examined 366 trauma-exposed adults with at least one trauma that qualified under criteria for PTSD. Similar to the first study, participants completed measures assessing peritraumatic dissociation, persistent trauma-specific dissociation, generalized dissociation, peritraumatic distress, and PTSD. Univariate analyses indicated that physical and sexual violence, peritraumatic distress, peritraumatic dissociation, trauma-specific dissociation, and generalized dissociation were significantly related to

PTSD. It was noted, however, that persistent trauma-specific dissociation accounted for

34.8% of the variance in PTSD diagnosis. When all variables were added to the model, only persistent trauma-specific dissociation, and two subtypes of general dissociation

(disengagement and emotional constriction) continued to be significant predictors of

PTSD.

Although the cross-sectional and retrospective nature of these two studies do not allow conclusions regarding causal mechanisms, the findings provide convincing evidence for the importance of persistent trauma-specific dissociation in predicting

PTSD. In fact, participants experiencing subclinical levels of persistent trauma-specific dissociation had a 2.9% likelihood of PTSD, whereas those with clinical levels of persistent trauma-specific dissociation had a 56.5% likelihood of PTSD. Although the researchers distinguish between persistent trauma-specific dissociation and general dissociation, this distinction may be arbitrary. There did not appear to be information regarding the trauma to which persistent trauma-specific dissociation was keyed. In fact, the authors acknowledge that in cases of exposure to multiple traumas, what is considered general dissociation may represent persistent trauma-specific dissociation stemming from other trauma exposure. Correlations among predictors were unavailable to examine whether general and persistent trauma-specific dissociation were related.

In addition to Briere’s findings in adult samples, the effects of trauma-specific dissociation on symptoms of PTSD have also been observed in children. Kaplow and colleagues (2005) used a more empirically rigorous prospective study design to assess factors that may mediate the relationship between sexual abuse and PTSD among 156 sexually abused youth ages 8-13 years. Youth participated in a forensic interview and then immediately reported trauma-specific dissociation and anxiety using the TSCC

Dissociation and Anxiety subscales. The authors hoped to measure dissociation used in response to traumatic reminders in the form of the forensic interview. Avoidant behaviors during the interview were also coded and scored. During a follow-up visit conducted 7-36 months after the initial visit, parents provided information regarding any

previous life stress, age at onset of the child sexual abuse, as well as symptoms of posttraumatic stress using the PTSD subscale of the Child Behavior Checklist. Path analysis detected three pathways to PTSD: anxiety/arousal, avoidance, and dissociation.

Notably, dissociation predicted PTSD better than life stress, gender, age, anxiety/arousal, or avoidance.

This study replicated findings observed in adult studies by demonstrating that the relationship between abuse and PTSD in youth is mediated by persistent dissociation.

Additionally, the method of assessing dissociation was more accurate than previous methods. Specifically, trauma-specific dissociation was examined through child report, which may be more sensitive to internal dissociative processes than observer ratings.

Further, trauma-specific dissociation was assessed immediately following discussion of traumatic memories, which may be more sensitive and accurate than retrospective reporting. However, the researchers did not cue the child to report on dissociation occurring during the forensic interview; instead, questions asked about dissociative responses (i.e. daydreaming) immediately following the interview without referencing dissociation during the interview. Nonetheless, the assessment of dissociation immediately following disclosure represents a vast improvement upon previous methods of retrospective reporting or reporting in the absence of traumatic reminders or stress.

Although the assessment of dissociation was improved, assessment of PTSD presented limitations. Specifically, studies conducted with preschool age and school age children consistently find that the PTSD subscale of the CBCL does not demonstrate sufficient sensitivity to distinguish between PTSD and other psychiatric or behavior problems

(Loeb, Stettler, Gavila, Stein, & Chinitz, 2011; Ruggerio & McLeer, 2000; Sim et al.,

2005). Therefore, Kaplow’s findings may have represented a relationship between abuse, dissociation, and general distress, not PTSD in particular.

The current study will examine the relationship between dissociation and PTSS and correct for weakness noted above. First, the current study measured the relationship between dissociation and PTSD by keying dissociation to the trauma narrative discussed during the forensic interview. Second, the current study utilized an established measure of PTSD. The only previous study to demonstrate the relationship between dissociation and PTSD among abused youth (Kaplow et al., 2005) utilized a measure of PTSD with poor specificity (Loeb et al., 2011; Ruggerio & McLeer, 2000; Sim et al., 2005). The current study improved upon Kaplow’s (2005) methods by utilizing the UCLA PTSD

Reaction Index, a measure of PTSD with good psychometric properties and sufficient sensitivity to distinguish PTSD from other forms of psychopathology. Third, the current study assessed and controlled for, when indicated, the influence of age, gender, and cumulative trauma exposure, which are known to influence the development of PTSD

(Carlson & Dalenberg, 2000; Kearney, Wechsler, Kaur, Lemos-Miller, 2010). By examining and including control variables, the current study was able to examine the unique influence of dissociation on the variation in PTSS among abused youth. The following section will explore the potential ways in which caregiver support following sexual abuse may influence the relationship between dissociation and PTSD in youth.

Chapter 5. THE MODERATING EFFECT OF CAREGIVER SUPPORT

Research regarding the relationship between trauma-specific dissociation and

PTSD has drawn attention to factors that may moderate the impact of dissociation after maltreatment has occurred (Malloy & Lyons, 2006; Waelde et al., 2009; Yancey &

Hansen, 2010). Elliott and Carnes (2001) conducted a comprehensive literature review and suggested that parental support may be the most important factor impacting behavior and emotional adjustment after sexual abuse. In spite of inconsistencies in operationalization and measurement across studies, lack of parental support following sexual abuse disclosure has been related to mental health outcomes, including posttraumatic stress, in child victims (i.e. Cohen & Mannarino, 2000; Elliott & Carnes,

2001; Everill & Waller, 1995; Leifer & Shapiro, 1995; Mannarino & Cohen, 1996;

Roesler & Wind, 1994; Spaccarelli & Fuchs, 1997; Ullman, 2007). Further, in contrast to social support literature that suggests peer support becomes more important than parental support in adolescence, Elliott and Carnes’ (2001) review of the literature revealed parental support is more important than any other source, including peers, in determining adjustment after abuse regardless of the victim’s age.

Caregiver support has the potential to buffer the effects of dissociation in a number of ways, including reducing feelings of guilt, fostering coping with negative emotions, and correcting cognitive distortions. Most relevant to the sexual abuse- dissociation-PTSD pathway is the role of caregiver support on the child’s memory formation. As children develop, they learn to create narratives of specific events and

integrate them into autobiographical memory through meaningful communication with adults, who are more adept at this integrative process (Nelson, 1993). Although children develop the ability to create autobiographical memories around eight years of age

(Nelson, 1993), traumatic experiences can overwhelm the child’s ability to form a cohesive narrative of the trauma and integrate it into autobiographical memory, subsequently increasing risk for posttraumatic symptoms (Halligan et al., 2007). When this integrative process is disrupted, children may once again depend on caregiver support as a vital environmental resource needed to integrate a cohesive narrative into autobiographic memory and reduce risk for posttraumatic stress. Therefore, parents who do not offer opportunities to discuss thoughts and feelings related to the traumatic event and provide emotional support to the child may inadvertently increase risk for PTSD.

Alternatively, those who provide emotional support and communication can buffer against the development and maintenance of PTSD. Caregiver support after trauma exposure may be particularly relevant for children who experience persistent trauma- specific dissociation, which further interrupts this integrative process.

Goodman and colleagues (1994) showed the impact of maternal support on memory for traumatic events in 46 children aged 3-10 years who underwent a painful medical procedure (Voiding Cystourethrogram Fluroscopy) involving genital contact.

An objective narrative of the procedure and the child’s emotional and behavioral responses were collected on the day of the procedure by the researcher, who was present for the procedure. At a later date, on average 11 days after the procedure, the mother reported on her actions and the child’s reactions to the procedure, including the child’s traumatic stress reactions. Maternal actions included the following: discussed the exam

with the child, explained the exam to the child, did not have time to attend to the child’s reaction to the exam, sympathetically talked about the exam with the child, physically comforted the child because of the child’s reaction to the exam, and asked the child questions about the exam. The child also completed a memory questionnaire regarding the procedure during the follow up interview. The memory questionnaire consisted of free recall, doll demonstration, and directive questions. Children whose mothers reported lower levels of sympathy, physical comfort, and time to attend to the child’s needs, as well as failure to discuss and explain the procedure to the child demonstrated greater memory inaccuracies than children whose mothers reported higher levels of these behaviors. Further, children with more inaccurate memories were also more likely to react with traumatic stress reactions (i.e. nightmares, reenactment in play, trauma specific fears). The results of this study suggest that low maternal support after a trauma is related to children’s distorted memories for the traumatic event and those impaired memories place children at risk for posttraumatic stress. However, as will be discussed below, no standardized instrument of maternal support was used in this study, a common issue in trauma-specific caregiver support research.

The findings presented thus far suggest that both dissociation and caregiver support have direct effects on PTSD through a similar mechanism—memory distortion.

Therefore, it is possible that dissociation and caregiver support may have a synergistic effect on PTSD (see Appendix A for model). Specifically, abused youth experiencing trauma-specific dissociation are particularly vulnerable to disorganized and fragmented memories that place them at higher risk for PTSD. Low caregiver support may also reduce the child’s most vital environmental resource needed to integrate a cohesive

narrative into autobiographic memory, compounding the effects of dissociation on symptoms of posttraumatic stress. Conversely, high caregiver support may assist the child in creating a cohesive narrative and correcting cognitive distortions, thereby compensating for the negative effects of dissociation on memory and ultimately reducing symptoms of posttraumatic stress. Although theorists have encouraged empirical investigation of the interaction between the child’s internal processes, such as dissociation, and environmental factors, such as caregiver support, that may affect psychopathology (Spaccarelli, 1994; Williams & Nelson-Gardell, 2012), no study has examined this relationship among youth reporting sexual abuse allegations.

Assessment of Caregiver Support

As alluded to above, assessment of caregiver support has created challenges in understanding its role in preventing negative outcomes. First, there is no clear consensus on the definition of caregiver support after abuse. Studies have defined it as protection from the perpetrator, emotional support, belief of the allegation, and blaming the perpetrator (Elliott & Carnes, 2001; Yancey & Hansen, 2010). Caregivers’ strong emotional reactions may also be perceived as more stressful for the victim, and therefore less supportive (Elliott & Carnes, 2001). Second, studies assessing caregiver support in response to allegations of abuse often use unvalidated questions or measures to assess the construct. In fact, Bolen (2002), who conducted a comprehensive review of the literature regarding guardian support after disclosure of abuse, noted that of the 20 studies reviewed, 18 used four or fewer items to measure caregiver support. She noted that a majority of the studies assessed belief in the allegation as indicative of support, but the questions or methods used to assess belief, emotional support, or protection were widely

variable. Notably, a majority of studies that measured caregiver support after abuse did not ask specifically about ways in which the parent responded to abuse-related emotions or cognitions. These limitations contribute to difficulty establishing a specific theory and body of empirical support for the moderating role of abuse-specific caregiver support on the relationship between dissociation and PTSS. Given that parents may influence the effects of dissociation on symptoms of posttraumatic stress, it is vital to systematically and thoroughly examine the impact of parental responses to sexual abuse.

The Parent Support Questionnaire (PSQ; Mannarino & Cohen, 1996) is a parent- report measure that has demonstrated good internal consistency and reliability based on analysis from a pilot study. However, the authors noted a limitation of the measure in the pilot study that may have contributed to the lack of a relationship observed between caregiver support and mental health outcomes in the pilot sample. Specifically, the mean

PSQ score was 4.5 on a 5-point scale, suggesting that mothers may have inflated their reports of support in order to be perceived positively. Despite this limitation, another study conducted by Cohen and Mannarino (2000) demonstrated the usefulness of the

PSQ in a sample of 49 sexually abused children aged 7-14 years old. The PSQ was used to assess caregiver support as a predictor of treatment outcomes. Findings revealed caregiver blame, as measured by the PSQ-Blame scale, predicted child depressive symptoms as measured by the Childhood Depression Inventory (CDI). Further, overall caregiver support, as measured by the PSQ-Total, predicted transient child anxiety symptoms as measured by the STAIC State. Unfortunately, the mean levels of reported support were not available. Therefore, it was not possible to evaluate Mannarino and

Cohen’s (1996) hypothesis that inflated levels of support in the pilot study or perhaps,

ceiling effects of the measure, precluded detection of the relationship between caregiver support and mental health outcomes. Nonetheless, there is some evidence from the study conducted by Cohen and Mannarino (2000) above, that the PSQ is a useful tool for assessing caregiver support after childhood sexual abuse. The PSQ remains one of the few validated measures of caregiver support related to sexual abuse; therefore, it was used in the current study.

Chapter 6. CURRENT STUDY

In spite of the transient utility of trauma-specific dissociation to reduce awareness and arousal in the face of trauma reminders, dissociative cognitive processes appear to place youth at risk for developing and maintaining PTSS. The goal of current study was to examine the relationship between persistent trauma-specific dissociation and PTSS among sexually abused youth and to determine whether abuse-related caregiver support moderated this relationship (Appendix A). This study built on existing research in a number of ways.

First, the current study assessed dissociation immediately following forensic disclosure by asking youth to report their own levels of dissociation experienced during the disclosure. This method allowed for a more thorough and precise assessment of persistent trauma-specific dissociation, including the internal experiences that observer reports may not detect. Further, specifically asking youth to report on dissociation that occurred during the forensic interview about the sexual abuse allegation provided a real- time assessment of persistent trauma-specific dissociation.

Second, the study utilized the UCLA PTSD Reaction Index, a measure of PTSS with good psychometric properties and sufficient sensitivity to distinguish PTSS from other forms of psychopathology. It should be noted that the measure utilized in the current study aligned with PTSD diagnostic criteria according to DSM-IV TR. A newly released and updated version of UCLA PTSD Index aligns with DSM-V by including seven new items to measure the Negative Cognitions and Mood cluster, as well as four

items intended to assess dissociative symptoms and identify those with the dissociative subtype of PTSD (Steinberg & Beyerlein, 2013; see Table 1 for a comparison). The current study utilized the DSM-IV TR version of the scale due to the unavailability of the updated version during data collection, as well as the lack of established validity and reliability of the new scale. In addition to enhancing the literature by utilizing a psychometrically sound and sensitive measure of PTSS, the current study assessed for control variables that are known to influence dissociation and PTSS. Specifically, the influence of age, gender, and cumulative trauma exposure on levels of PTSS in the current sample were assessed and controlled for in the main analyses when significant.

Third, the current study responded to calls in the sexual abuse literature to study factors that may protect abused youth against the negative effects of dissociation on

PTSS by examining caregiver support, the most promising factor that is amenable to change after abuse disclosure. Although the direct effects of caregiver support and dissociation on PTSS have been demonstrated, no study has examined the synergistic effect of caregiver support and dissociation on PTSS. The current study added to the abuse literature by examining the moderating role of abuse-related caregiver support on the relationship between dissociation and PTSS. Notably, the few studies that examined caregiver support among sexually abused youth focused on general support, not support specifically related to abuse. Although general support is important for mental health, trauma-specific support may be particularly important regarding PTSS. Further, studies utilized unvalidated measures or questions to assess widely ranging operationalizations of caregiver support after abuse. Therefore, this study utilized the PSQ, one of the few

existing comprehensive measures of abuse-specific caregiver support with known psychometric properties.

Chapter 7. HYPOTHESES

It was hypothesized that persistent trauma-specific dissociation during the forensic interview would be associated with PTSS and that this relationship would be moderated by abuse-related caregiver support. More specifically, low levels of caregiver support would strengthen the magnitude of the association between dissociation and PTSS compared to high levels of caregiver support.

Chapter 8. METHODS

The current study is part of a larger investigation examining children’s reactions to forensic disclosure in child abuse investigations. Participants were recruited at the

Audrey Hepburn Children at Risk (CARE) Center/Children’s Advocacy Center during scheduled visits for the forensic interview and/or medical exam investigating allegations of physical or sexual abuse. Four Tulane University doctoral students from the

Psychology Department Stress and Trauma Lab recruited all participants from October

2010 through March 2013. All four recruiters were female. Two recruiters were

Caucasian, one was Filipino, and one was Palestinian. Inclusionary criteria included: 1) the child must be between the ages of 8 and 16 years old; 2) the child must be an identified victim of abuse; 3) the child and caregiver must speak English; and 4) the child must not receive special education services in school to be recruited into the study. Non- offending legal guardians were required to be present and consent to participate. Child assent was also required for participation in the current study.

Participation rate was available from September 2012 through March 2013 and indicated 61.3% (N=19) of eligible youth consented to participate in the current study. A total of 73 children were recruited into the study. Of the 73 recruited children, 6 children were excluded because: 3 children were witnesses, not victims, of abuse; 2 children had no record of abuse disclosure; and 1 child left most measures blank despite assent to participate. Of the remaining 67 participants, 57 participants reported sexual abuse alone or sexual and physical abuse. The sample was further reduced due to missing data; the

caregivers of 4 participants did not complete the Parent Support Questionnaire and 1 child participant did not complete the TSCC Dissociation measure.

The final study sample consisted of 52 youth ages 8-16 years (M = 12.94, SD =

2.18). Table 2 presents demographic information for the sample. Approximately 85% of the sample was female (n = 44). Approximately 60% of participants were African

American, 31% Caucasian, 4% Multiracial, and 2% Latino American/Hispanic. Ethnicity was not reported for two participants. The non-offending caregiver reported socioeconomic status by indicating which $10,000 range represented the total household income (e.g. $0-$10,000, $11,000-$19, 000, etc.). Table 2 provides the percentage of participants falling in each range. Approximately 65% of the sample reported a total household income below $29,000. Participants reported an average of 4 people living in the home (SD = 1.75). Ninety-six percent of the sample attended public school (n = 50).

Eighty-five percent (n = 44) of participants presented as alleged victims of sexual abuse and 15% (n = 8) reported both sexual and physical abuse. Table 3 provides information regarding abuse characteristics, including the child’s relationship to the offender, age and gender of offenders, and whether the youth in the current sample reported single or multiple incidents of abuse. The majority (85%) of non-offending caregivers in the study were biological parents (93% mothers); other caregivers included a stepmother (2%), an aunt (2%), a grandfather (2%), and five female caregivers with unspecified relation to the child (10%).

The study sample demonstrated some differences when compared to the population served at the CAC/CARE Center in 2013. Specifically, the current sample consisted of a higher proportion of females (84.6%) compared to the proportion of

females served by the CAC/CARE Center (61.9%). The current sample was also older than the Center’s population. In fact, 46% of the Center’s sample falls in the 0-6 years age range, a group that was excluded from the current sample of 8-16 year old youth.

The majority of both the typical population of CAC/CARE Center clients, as well as the current sample, identified as African American. In 2013, 70.9% of clients identified as

African American, compared to 60% of the current sample.

Procedures

Recruitment took place at the CARE Center/CAC. The Center provides a child- friendly environment for pediatricians and trained forensic interviewers to conduct forensic interviews and medical exams after allegations of abuse. The CAC conducts forensic interviews only, often used in the initial stage of the investigation. The CARE

Center provides both forensic interviews and medical evaluations conducted by trained medical professionals during one two-hour visit to the Center. Eighty-three percent of participants (n = 43) were recruited from the CARE Center and 17% (n = 9) were recruited from the CAC. Participants recruited at the CARE Center were not significantly different from those recruited from the CAC when examining all study variables.

Informed consent and assent were obtained from the guardian and child, respectively. Participants were recruited after orientation to their visit by the

CARE/CAC staff (see Appendices B and C). While the child participated in the forensic interview, the researcher orally administered measures to the caregiver assessing child trauma history and symptoms of posttraumatic stress. The caregiver independently completed a measure assessing caregiver support related to the abuse. Youth visiting the

CARE Center completed the dissociation measure immediately following the forensic interview, with prompting to report dissociation during the interview. Following the medical exam, youth completed the measure assessing PTSS. For those presenting to the

CAC, measures assessing dissociation and PTSS were administered immediately following the interview. No medical exam was conducted as part of the CAC protocol.

Measures

Incident characteristics, including frequency of abuse, type of abuse, and the relationship of the child to the perpetrator was obtained through record review for descriptive purposes. Trained undergraduate research assistants reviewed the file to code whether the abuse was single incident or multiple incident abuse, the type/s of abuse, and the nature of the relationship between the perpetrator and the child (parent, parent paramour, family friend, acquaintance, stranger). The coding was verified by a graduate student at the conclusion of data collection.

Cumulative trauma exposure was assessed with child report on Part I of the

UCLA PTSD Reaction Index for DSM-IV. Part I assesses the child’s exposure to potentially traumatic events. The total number of events endorsed, including the current sexual abuse allegation, was summed to represent cumulative trauma exposure. The summed value was used to describe the overall trauma exposure of the sample and to test whether cumulative trauma should be included as a control variable in the analyses.

Dissociation was assessed using the dissociation subscale of the Trauma

Symptom Checklist for Children (TSCC; Briere, 1996; See Appendix D). The TSCC evaluates posttraumatic stress symptoms in children ages 8-16 years old. The 10-item

Dissociation scale of the TSCC has demonstrated good reliability (α = .80 to .89; Briere,

1996; Crouch, Smith, Ezzell, & Saunders, 1999), as well as convergent and predictive validity in samples of traumatized and non-traumatized children and adolescents (Briere,

1996). Children were asked to report the frequency of dissociative behaviors during the forensic interview on a scale ranging from “0” (Never) to “3” (Almost all the time).

Internal consistency for the current sample was modest (α = .61).

Due to overlap with PTSS, three items were removed from the dissociation scale prior to data analysis. Specifically, item 9 (“Trying not to have feelings”) and item 2

(“Going away in my mind, trying not to think”) overlapped with the item assessing an avoidance cluster symptom of PTSD (“I try not to talk about, think about, or have feelings about what happened.”). Item 5 (“Forgetting, can’t remember things”) overlapped with another avoidance cluster symptom of PTSD (“I have trouble remembering important parts of what happened”). Although these exclusions increased the independence of the dissociation and PTSS scales, removal of items resulted in slightly decreased internal consistency of the abbreviated scale for the current sample (α

= .53). However, the broad range of the 95% confidence interval of Cronenbach’s Alpha

(CI = .30 - .70) suggests that the relatively low number of questions on the scale and low variance of responses among participants may have contributed to measurement error of the internal consistency statistic (Ponterotto & Ruckdeschel, 2007). Given that the upper- bound of the confidence interval falls within the satisfactory range for internal consistency (α < .65) among research measures with less than ten items and sample size less than 100, the current measure was considered satisfactory (Ponterotto &

Ruckdeschel, 2007). Nonetheless, results will be interpreted in light of this potential limitation.

Posttraumatic Stress Symptoms (PTSS) were assessed using the UCLA PTSD

Reaction Index for DSM-IV. The UCLA PTSD Reaction Index (Appendix E) is a 20- item measure assessing symptoms of PTSS based on DSM-IV criteria (APA, 2000).

Youth were asked to rate the severity of each symptom in the past month on a scale ranging from “0” (None of the time) to “3” (Most of the time). The UCLA PTSD

Reaction Index has demonstrated good test-retest reliability (α = .84), as well as excellent internal consistency (α = 0.90; Rousos et al., 2005). This measure demonstrated good internal consistency (α = 0.89) in the current sample.

The sum of the 17 items that map onto the DSM-IV PTSD criteria were used as a measure of symptom severity (e.g., Berger, Pat-Horenczyk, & Gelkopf, 2007; Salloum,

Carter, Burch, Garfinkel, & Overstreet, 2011; Salloum & Overstreet, 2012). These items demonstrated good internal consistency (α = 0.89) in the current sample. For descriptive purposes, youth with a score of 38 or higher were classified as exhibiting clinically significant symptoms of PTSS. This cutoff score has demonstrated good sensitivity

(0.93) and specificity (0.87) when identifying youth with PTSD and therefore is commonly used when assessing PTSS (the work of Rodriguez, Steinberg, Saltzman and

Pynoos as cited in Steinberg, Brymer, Decker, & Pynoos, 2004).

Caregiver support was assessed using the Parent Support Questionnaire (PSQ;

Mannarino & Cohen, 1996; Appendix F). The PSQ is a 19-item measure assessing parents' thoughts and perceptions in the two weeks prior to the study about the degree and kind of support they have provided related to their child’s abuse. Test-retest reliability of the total scale after two weeks was reported as .82 (Mannarino & Cohen, 1996). Internal consistency was not available. In addition to a Total Support scale, items can be divided

into two subscales. The eight-item “Support” subscale indicates more caregiver support as scores increase. Internal consistency for the subscale has been reported as .73 and test- retest reliability after two weeks as .70 (Mannarino & Cohen, 1996). The 11-items that make up the “Blame” subscale are reverse coded so higher scores represented less blame of the child and/or more blame of the perpetrator. Internal consistency for the subscale has been reported as .70 and test-retest reliability after two weeks as .83 (Mannarino &

Cohen, 1996).

Item scores were averaged for the Total Parent Support composite used in the analyses. The internal consistency of the full scale was acceptable (α = .73). The items corresponding to each subscale were averaged to represent the Support and Blame subscales. The Blame subscale demonstrated acceptable internal consistency (α = .81).

The Support subscale demonstrated internal consistency (α = .50) that was significantly below that demonstrated in previous studies. As discussed above, the confidence interval of this statistic (CI = .26, .68) suggests the small number of scale items and extremely low variance contributed to measurement error. The upper-bound of the confidence interval falls within the satisfactory range for internal consistency (α < .65) among research measures with less than ten items and sample size less than 10. Therefore, the current measure was considered satisfactory (Ponterotto & Ruckdeschel, 2007); however results were interpreted with caution.

Chapter 9. RESULTS

Data screening

Data screening techniques were conducted prior to running statistical analyses

(Tabachnick & Fidell, 2007). The accuracy of the dataset was verified by examining randomly selected entries and examining observed ranges of each variable. Examination of missing data indicated four participants omitted one item on the PSQ, one participant omitted two items on the PSQ and one item on the UCLA PTSD Reaction Index, and one participant omitted two items on the UCLA PTSD Reaction Index. Another participant omitted two items on the UCLA PTSD Reaction Index. Each of these items was replaced with the corresponding subscale average for that participant. This resulted in a sample size of 52 participants with composite scores for all relevant measures.

One univariate outlier was identified with a z score greater than 3.00 standard deviations from the mean on the Parent Support Questionnaire, as well as the Blame subscale. Each univariate outlier score was converted to the value of the next most extreme score within three standard deviations of the mean, according to the winsorizing procedure (Kline, 2011). Assumptions of univariate normality were tested by examining skew and kurtosis in each of the study variables. The Blame subscale demonstrated significant negative skew. Therefore, log 10 transformations were performed

(Tabachnick & Fidell, 2007) prior to conducting exploratory regression analyses.

Examination of multivariate outliers using Mahalanobis distance yielded none.

Descriptive Information of Study Variables

Descriptive statistics, including, ranges, observed means, standard deviations, and the percent of children reporting clinically significant levels of PTSS, are presented in

Table 4.

Incident Characteristics

For approximately half of the sample, the alleged perpetrator was a non-relative acquaintance of the child (51.9%). The child identified a parent paramour as the alleged perpetrator in 17.3% of cases and a biological parent in 9.6% of cases. Approximately

17% of the time the alleged perpetrator was another relative and only one child reported abuse by a stranger. Sixty-seven percent of the alleged perpetrators were adults and all alleged perpetrators were male. Regarding chronicity of the abuse, 53.3% reported a single incident of abuse and 46.7% reported multiple incidents.

Descriptive Information for and Correlations among Study Variables

The current sample reported low levels of dissociation such that participants’ mean summed score was 3.46 (SD = 3.08) out of a possible score ranging from 0-21. In fact, only two participants (3.8%) reported clinically significant levels of dissociation.

Although this was unexpected given higher rates of dissociation reported among sexually abused youth, Silberg (2000) suggests that these higher rates are obtained from those who experienced the most severe forms of sexual abuse and the highest levels of mental illness. Therefore, the levels of dissociation observed in the current study may be representative of the broader population of sexually abused youth.

Observed PTSS in the current sample (M = 30.80, SD = 15.51) were slightly higher than that reported in a national sample of youth with at least one trauma (M =

26.60, SD = 14.90) who presented to diverse settings (Steinberg et al., 2013). Thirty-six

percent of participants reported clinically significant levels of PTSS (n = 19). Zero-order correlations among study variables, as presented in Table 4, revealed dissociative symptoms related only to PTSS (r = .38, p < .01) such that participants who reported more symptoms of dissociation were also more likely to report more PTSS.

Non-offending caregivers reported high levels of overall support (M =4.66; SD =

.31) similar to levels observed in other study samples (M = 4.5; Mannarino & Cohen,

1996). Further, there was little variance in caregiver responses. No significant correlations were observed between Total Support and other study variables.

Examination of potential control variables indicated only age demonstrated a significant trend level relationship with PTSS (r = .27, p = .05) such that older children reported higher levels of PTSS. There was no association between child sex and PTSS symptoms. Although there is evidence that females are more likely than males to experience PTSS in response to trauma (see Tolin & Foa, 2006 for a review), there is some disagreement in the sexual abuse literature. In fact, in a large study utilizing a national sample of sexually abused adolescents ages 11-16, no sex differences in trauma symptoms were observed. The authors suggest that small sample sizes and restricted age ranges may partially account for sex differences found in some studies (Maikovich-Fong

& Jaffee, 2010). It is also possible that the males presenting with sexual abuse allegations in the current study may represent a subset of the male youth population demonstrating higher levels of distress. In fact, males in the current study reported higher rates of cumulative trauma exposure than females (r = -.32, p < .05).

Participants reported an average of 3.48 previous traumas (SD = 1.50). As such, the cumulative trauma exposure of the current sample was commiserate with that of a

national sample of youth ages 7-18 years old who reported an average exposure to 3.0-4.4 previous traumas, with mean exposure increasing with age (Steinberg, et al., 2013).

Contrary to findings in previous studies, the relationship between cumulative trauma exposure and PTSS was not observed in the current sample. Because age was the sole control variable related to PTSS, only age was included as a control variable in regression analyses.

Primary Analyses

It was hypothesized that dissociation during the forensic interview would be positively associated with PTSS after controlling for other factors known to increase risk for PTSS. Further, it was hypothesized that overall caregiver support would moderate the relationship between dissociation and PTSS such that low caregiver support would strengthen the relationship between dissociation and PTSS. These hypotheses were tested using a hierarchical regression analysis. First, the caregiver support and dissociation variables were centered around the mean to control for multicollinearity (Fairchild &

McQuillin, 2010). The centered variables were multiplied together to form the two-way interaction variable (caregiver support x dissociation). Age was entered on the first step.

Caregiver support and dissociation were entered on the second step, and the two-way interaction term on the third step. The percentage of variance at each step, the amount of change in R2 and the corresponding F value for that change was examined to test significance of the caregiver x dissociation interaction.

The hierarchical regression analysis predicting PTSS produced a main effect of dissociation only (see Table 6). The second step of the model, composed of dissociation and caregiver support accounted for 27% of the variance; however, only dissociation

significantly predicted PTSS. The two-way interaction term entered on Step 3 accounted for 0.1% of the variance and was not a significant predictor of PTSS. The final model was significant (F(4, 47) = 4.29, p <.01). As expected, higher levels of dissociation during the forensic interview was related to more symptoms of posttraumatic stress when controlling for the age of the child. However, contrary to the study hypothesis, there was no significant interaction between dissociation and caregiver support.

Exploratory Analyses

The Blame and Support subscales were examined to assess whether either subscale moderated the relationship between dissociation and PTSS. Non-offending caregivers reported high levels of support (M =4.69; SD = .35) and blame (M =4.64; SD =

.42). As previously noted, the Blame subscale was skewed and transformed accordingly prior to conducting analyses. Zero-order correlations of study variables for this exploratory analysis are presented in Table 7.

A hierarchical regression analysis was used to examine the unique moderating effect of the blame and support. First, the Blame subscale, Support subscale, and dissociation variables were centered around the mean to control for multicollinearity

(Fairchild & McQuillin, 2010). The centered Blame and Support subscale variables were each multiplied by the centered dissociation variable to form two two-way interaction variables (caregiver blame x dissociation; caregiver support x dissociation). Age was entered on the first step. Blame subscale, Support subscale, and dissociation were entered on the second step, and the two-way interaction terms were entered on the third step. The percentage of variance at each step, the amount of change in R2 and the

corresponding F value for that change was examined to test significance of each step interaction.

Hierarchical regression analyses predicting PTSS indicated that dissociation, blame, and support, entered on the second step of the model, accounted for 30% of the variance, which was significant. Examination of beta weights indicated that dissociation and blame were significant predictors of PTSS symptoms. Specifically, as caregivers reported more blame of the child/less blame of the perpetrator, children reported more

PTSS. The analysis did not produce significant interactions between dissociation and caregiver blame or dissociation and caregiver support (see Table 8). The final model was significant (F(6,45) = 3.24, p <.05).

Chapter 10. DISCUSSION

The current study examined whether the use of dissociation during a forensic interview was related to symptoms of posttraumatic stress among sexually abused youth.

The role of abuse-specific caregiver support in this relationship was also examined in an effort to identify factors that may be intervened upon post-disclosure to enhance resilience and reduce risk for PTSS among abused youth. Youth in the current study reported cumulative trauma exposure similar to national samples; however, they reported higher than average levels of PTSS, reflecting the powerful impact of sexual abuse on mental health.

Emerging evidence suggests that persistent trauma-specific dissociation influences the development and maintenance of PTSS. However, most studies providing support for this relationship were conducted retrospectively with adult samples, used measures of PTSS with poor specificity, used observer ratings of dissociation, and/or did not cue dissociative symptoms to the trauma. The forensic setting of the current study allowed the unique opportunity to collect self-reported dissociation in response to the narrative retelling of the abuse, which improved the ability to detect dissociative tendencies, particularly depersonalization and derealization. Further, PTSS was assessed with a measure demonstrating good sensitivity and specificity, an improvement from previous research examining the relationship between dissociation and PTSS among traumatized youth. Abuse-specific caregiver responses to the child were examined with a comprehensive measure of support.

The first component of the hypothesis was confirmed such that trauma-specific persistent dissociation was associated with higher levels of PTSS. These results are consistent with previous studies demonstrating that trauma-specific dissociation influences the development and maintenance of PTSS (e.g. Briere et al., 2005; Kaplow et al., 2005). In accordance with trauma theory, abused youth may use dissociation to manage overwhelming emotions related to the abuse (Becker-Blease et al., 2004; Hopper et al., 2007, Waelde, 2009). However, these dissociative tendencies may prevent them from resolving symptoms of posttraumatic stress and subsequently contribute to and maintain their PTSS (Briere et al., 2005; Engelhard et al., 2003; Halligan et al., 2003).

The updated diagnostic description of PTSD in the DSM-5 recognizes the important role of dissociation in PTSD nosology by delineating a dissociative subtype of

PTSD (APA, 2013). Specifically, those reporting symptoms of depersonalization and derealization, in addition to re-experiencing, arousal, negative alterations in cognition and mood, and hyperarousal symptoms, meet criteria for the PTSD-Dissociative subtype.

Although assessment of clinically significant rates of this subtype was beyond the scope of the current study, results confirm the strong relationship between dissociation and

PTSS in a sample of youth reporting sexual abuse. However, the cross-sectional nature of the current study prohibits conclusions about the cause and effect relationship between these symptoms.

The second hypothesis component that abuse-specific caregiver support would moderate the relationship between dissociation and PTSS was not confirmed. Although ample evidence suggests caregiver support after sexual abuse significantly influences mental health outcomes, including PTSS, the construct has been poorly defined and few

studies utilized standardized measures of support. The current study improved upon this by using the Parent Support Questionnaire, one of few standardized measures, that includes multiple dimensions of support. Contrary to expectations, total abuse-specific caregiver support did not moderate the relationship between dissociation and PTSS or relate to PTSS independently. These findings were surprising, given evidence in abuse literature that caregiver support is an important determinant of child mental health outcomes. Notably, as in other studies using the PSQ, the average level of total support reported by caregivers was observed to be quite high, with relatively little variability.

One potential explanation for this observation is that the current sample represents a subsample of children with supportive parents. In fact, evidence suggests that children with unsupportive parents are less likely to disclose abuse and more likely to recant during the forensic interview (Elliott & Briere, 1994; Hershkowitz, Lanes, & Lamb,

2007).

However, there is some evidence that overall support is a multidimensional construct such that emotional support and blame are only modestly correlated (Smith et al., 2010). Given this evidence and the fact that previous studies demonstrating this relationship have focused on specific aspects of support (emotional support, belief, blame, etc.), exploratory analyses examined the Support and Blame subscales separately to determine whether these more specific types of support moderated the relationship between dissociation and PTSS. Results indicated the Support subscale did not demonstrate a relationship with PTSS or moderate the relationship between dissociation and PTSS.

In spite of expectations, support did not relate to PTSS or moderate the relationship between dissociation and PTSS among sexually abused youth in the current study. However, the PSQ Support subscale demonstrated some notable unique characteristics that may have prevented detection of the relationship between support and

PTSS. Specifically, caregivers reported exceptionally high levels of support with little variability across questions. These skewed responses and low variance contributed to questionable internal consistency of the subscale and potentially impacted the ability to detect any possible relationships with support. In fact, researchers using the PSQ noted similarly high levels of reported support that may have influenced findings (Mannarino &

Cohen, 1996). These high levels of support and low variability of responses in general and when compared to blame, may be explained in a number of ways.

Caregivers may, in fact, be highly supportive, with a relatively better emphasis and understanding of the importance of support, as compared to blame attributions.

Alternatively, social desirability factors may inflate support more so than blame, providing an explanation for the differential findings among the Support and Blame subscales (Mannarino & Cohen, 1996; Smith, et al., 2010). Caregivers, particularly those presenting in a forensic setting, may be more sensitive to judgment about their interactions and support of their child, as opposed to their perceptions of blame for the abuse. Although it was impossible to evaluate this claim specifically with the PSQ, there is some evidence that parent reports of support, in particular, may be skewed by social desirability factors. Smith and colleagues (2010) examined maternal reports of support and blame collected from caregivers of youth visiting Child Advocacy Centers. Mothers also completed the Marlow-Crowne Desirability Scale to assess for mothers’ general

tendency to endorse socially acceptable responses. Caregivers who endorsed socially desirable answers were more likely to report higher levels of emotional support. Notably, social desirability did not significantly relate to reported blame or doubt. Regarding the current study, it is possible social desirability factors influenced caregiver reports on the

Support subscale and reduced the ability to detect an effect. Further research is imperative to develop effective methods of assessing abuse-specific caregiver support in order to evaluate its true role in child mental health outcomes after abuse.

Exploratory findings also indicated blame was not a significant moderator of the relationship between dissociation and PTSS; however, the blame subscale was significantly associated with PTSS. Although blame does not appear to have a synergistic relationship with PTSS when combined with dissociation, an additive relationship was present. Although, causal attributions cannot be assumed, these findings are consistent with the theory that attributions caregivers make regarding blame for the abuse have a powerful effect on PTSS among sexually abused youth. Specifically, caregiver-reported blame may impact PTSS by influencing the child’s perceptions of blame. Ehlers and Clark (2000) theorize that negative cognitive appraisals, such as self- blame, may bias recall of the event and contribute to the development and maintenance of a cognitively distorted trauma narrative. Further, these negative appraisals serve as internal triggers of intrusive or re-experiencing symptoms and maintain PTSS. No study has examined child self-blame as a mediator between caregiver-reported blame and

PTSS. However, there is evidence that caregiver-reported blame of the child is associated with child-reported self-blame (Hazzard, Celano, Gould, Lawry, & Webb,

1995) and self-blame is associated with PTSS (i.e. Canton-Cortes, Canton, & Cortes,

2012; Feiring & Cleland, 2007). In fact, child self-blame is now considered a core feature of the cognitive alterations cluster of DSM-5 PTSD diagnostic criteria. Given the relationship between caregiver-reported blame of the child and child self-blame and the inclusion of child self-blame as a symptom of PTSD, it is expected that the inclusion of self-blame in PTSD criteria will only serve to strengthen observed relationships between caregiver-reported blame of the child and PTSS in future studies.

Limitations

Despite significant improvements from previous studies, there were a number of limitations to note. The setting of data collection in the current study presented both advantages and unforeseen disadvantages. Specifically, the CAC/Care Center setting provided a unique opportunity to assess persistent trauma-specific dissociation immediately following a traumatic reminder in the form of the forensic interview, allowing for a more specific assessment of dissociation used in response to traumatic triggers. However, recruitment in the CAC/Care Center was more difficult than expected, in part, due to high no-show rates and children presenting with an adult other than the legal guardian. These factors led to a smaller sample size than expected and subsequently, lower than desirable reliability of the scales measuring dissociation and caregiver support. Accordingly, the study sample and scale reliability may not have been of sufficient size to detect the moderating effects of overall caregiver support or the support or blame subscales (Whisman & McClelland, 2005). Further, the study design utilizing two continuous variables is particularly vulnerable to Type II errors (McClelland

& Judd, 1993). Therefore, the lack of significant moderation present in this study should be interpreted with caution.

Additionally, characteristics of the current sample may represent a limitation.

Recruitment was limited to children ages 8 to 16 years, who were not in state custody, and who presented with a legal guardian. Further, children who received special education services at school were not recruited due to concerns about ability to assent and answer study questions. Therefore, the current sample may be biased such that those who experienced more severe abuse, younger children, and those placed in state custody were not included in the current sample, limiting the generalizability of findings. Future studies should aim to recruit a larger and more diverse sample of sexually abused youth.

Although the current study improved upon previous research by assessing dissociation in response to the sexual abuse narrative, and by using a sensitive and specific measure of PTSS, limitations regarding the dissociation and PTSS assessment are noted. First, the use of DSM-IV TR criteria for PTSD may limit the generalizability of the current findings, although it is reasonably expected these diagnostic changes will serve to strengthen the relationship between blame and PTSS. Second, 53.9% of participants reported a trauma other than the sexual abuse as their most bothersome trauma. Unfortunately, study design did not allow flexibility to assess dissociation and

PTSS in response to the most bothersome trauma when it was not reported as the sexual abuse. Therefore, it is possible that participants may be experiencing dissociation and/or

PTSS that is not triggered by the abuse narrative or captured in the screening process.

Alternatively, there is some evidence to suggest children are not always accurate when choosing the trauma most correlated with their PTSS. For example, Aisenberg, Ayon, and Orozco-Figueroa (2008) found that among middle schoolers reporting exposure to various forms of community violence and symptoms of PTSS, the most severe type of

exposure had the greater impact on PTSS when compared to the reported most bothersome type of exposure. Future research may correct this limitation by limiting samples to those reporting sexual abuse as their most bothersome trauma.

Unique findings related to control variables suggest that these findings may not readily generalize to the sexually abused population. Specifically, commonly observed relationships between pre-existing child characteristics, such as gender and cumulative trauma were not observed. As noted above, girls were not at a higher risk of PTSS in the current study, which may reflect the unique setting of the current study and a biased sampling of more severely abused boys. Additionally, cumulative trauma did not predict

PTSS among participants. While unexpected when considering the trauma literature as a whole, there is some evidence that sexual abuse may operate in a different manner from other forms of trauma when using an additive model to predict PTSS. In fact, Finkelhor and colleagues (2009) found that sexual abuse had a super additive effect on PTSS that was quantitatively different from that of other forms of trauma. Nonetheless, these findings should be generalized with caution. Further research should aim to better understand the way in which cumulative trauma influences mental health outcomes among sexually abused youth.

Finally, the cross-sectional design of the current study presents another limitation, such that the causal pathway from dissociation and caregiver blame to PTSS cannot be determined. Further, caregiver reactions are likely to be fluid over time due to a variety of factors, including the relationship with the perpetrator, caregiver distress, and caregiver mental health (Alaggia, 2002; Elliott & Carnes, 2001). Therefore, the model examined in the current study should be replicated with a longitudinal design to

determine the temporal occurrence of dissociation and PTSS, as well as the role of caregiver support.

Future directions

There are a number of ways in which future research can build upon the current findings. First, the inconsistent operationalization of caregiver support and dearth of measures continues to be a barrier to assessing the potential impact on PTSS after sexual abuse and comparing findings across heterogeneous samples of sexually abused youth.

Although there is a general consensus that support after sexual abuse is an important predictor of child mental health, there is vast inconsistencies in operationalization and measurement of this construct that make it difficult to compare across studies. For example, many studies demonstrating a relationship between “support” and PTSS defined support as one more of the following: general support without reference to the abuse, belief in the abuse allegation, legal/protective actions taken by the caregiver, actions taken against the perpetrator, emotional support, blame, or even generically asked how

“supportive” the caregiver has been. The current study added to the literature by using a validated measure of support that examined both emotional support and blame. Future research can build upon these findings by creating and validating one comprehensive measure of support that includes all aspects of support that have demonstrated an impact on PTSS in previous research. This multidimensional measure will allow for more detailed examination of the differential effect of types of support among sexually abused youth.

Second, samples of sexually abused youth vary according to exclusionary criteria such child characteristics (i.e. age, gender), characteristics of the abuse (chronicity, types

of sexual acts), characteristics of the perpetrator, and child’s current placement. As

Silberg (2000) suggested, these differences among studies make it difficult to compare findings across studies. Therefore, future research should attempt to concurrently examine various types of support with an inclusive sample of sexually abused youth in order to examine the role of caregiver support in predicting PTSS. While it is important to study the relationships between support and mental health outcomes independently, perhaps the relationship between support and PTSS is more clearly elucidated in a complex model that includes the many factors influencing resilience among sexually abused youth (i.e. Bal, Crombez, De Bourdeaudhuij, & Van Oost, 2009; Spacarelli,

1994). Further, a longitudinal design may help determine the causal pathways present in the relationships between dissociation, caregiver blame of the child, and PTSS. Of course, difficulty recruiting large samples of abused youth who can self-report immediately following a traumatic reminder remains a significant barrier to this goal.

Finally, further research is necessary to develop effective methods of assessing dissociation during the forensic interview and caregiver’s attributions of blame for the sexual abuse within settings that have initial contact after disclosure with sexually-abused youth and their caregivers. Given the inclusion of dissociative symptoms in the diagnostic criteria for PTSS in DSM-5, newly developed tools are now available to assess for both dissociation and PTSS (Steinberg & Beyerlein, 2014). In the current study, the

PSQ blame subscale proved to be a valid tool in screening for the caregivers’ attributes of blame; therefore, it may be considered for inclusion as part of the initial screening process during the CAC/Care Center visit. Additionally, future studies should examine methods of intervening to help caregivers appropriately assign blame for the sexual

abuse. Although there is evidence that intervention that include caregiver sessions impact emotional support provided by the caregiver and child PTSS (Berkowitz, Stover,

& Marans, 2011; Cohen et al., 2004), these studies did not specifically assess impact of the intervention on blame. Therefore, future studies should aim to identify effective interventions that can be employed immediately following disclosure to prevent or correct caregiver’s attributions of blame.

Conclusion

There is increasing awareness of the negative impact of sexual abuse on a child’s mental health and the important role caregivers play in encouraging resilience. As this awareness builds, centers conducting forensic interviews, such as CACs, and medical exams, such as the Care Center, are highly encouraged to routinely screen for posttraumatic stress symptoms, as well as the ability of the caregiver to support the child.

Centers play an important role in providing referrals for treatment and psychoeducation for caregivers that can disrupt the development of trauma symptoms among victims and their families (Jenny, Crawford, & Committee on Child Abuse and Neglect, 2013;

National Children’s Alliance, 2011). Given the changes in diagnostic criteria for PTSD, this screening should now routinely include screening for dissociative symptoms included in the dissociative subtype of PTSD. Further, guidelines for forensic interviewers and medical professionals regarding caregivers encourages screening for the caregiver’s belief in the investigation, distress, and ability to support the child. The present study supports further screening of caregivers’ attributions of blame, as well as providing psychoeducation and referrals for intervention as needed. Continued examination of the role of caregiver responses to sexual abuse will serve to more fully address the goals of

forensic interviewers and medical examiners to enhance resilience among victims of sexual abuse and to promote a more ecologically valid model of understanding its effects.

60 Table 1

Item Comparison of UCLA PTSD Reaction Index for DSM-IV TR versus DSM-5

UCLA RI for DSM-IV TR UCLA RI for DSM-5 Cluster B: Re-experiencing Symptoms Cluster B: Re-experiencing Symptoms I have upsetting thoughts, pictures, or sounds Same item of what happened come into my mind when I do not want them to.

I have dreams about what happened or other I have bad dreams about what happened or bad dreams. other bad dreams.

I feel like I am back at the time when the bad I feel like I am back at the time when the bad thing happened, living through it again. thing happened, like it’s happening all over again.

When something reminds me of what Same item happened, I get very upset, afraid, or sad.

When something reminds me of what Same item happened, I have strong feelings in my body, like my heart beats fast, my head aches, or my stomach aches. Cluster C: Avoidance Cluster C: Avoidance I try not to talk about, think about, or have I try not to think about or have feelings about feelings about what happened. what happened.

I try to stay away from people, places, or I try to stay away from people, places, or things that make me remember what things that remind me about what happened. happened.

I have trouble remembering important parts of Same item Cluster D what happened.

I feel like staying by myself and not being Similar item in Cluster D with my friends.

I feel alone inside and not close to other Similar item in Cluster D people.

I have trouble feeling happiness or love. Same item in Cluster D

I have trouble feeling sadness or anger. Omitted from DSM-5 version

I think that I will not live a long life. Omitted from DSM-5 version

Cluster D: Negative Alterations in Cognitions and Mood Same item in Cluster C I have trouble remembering important parts of what happened.

I have thoughts like “I am bad.”

I have thoughts like “The world is really dangerous.”

I have thoughts like “I will never be able to trust people.”

I am mad at someone for making the bad thing happen, not doing more to stop it, or to help after.

Similar item not included as core symptom I feel that part of what happened was my fault.

I feel like what happened was sickening or gross.

I feel ashamed or embarrassed over what happened.

I feel afraid or scared.

I want to get back at someone for what happened.

I don’t feel like doing things with my family and friends or other things that I liked to do.

Similar item in Cluster C I feel alone, even when I’m around other people.

Same item in Cluster C I have trouble feeling happiness or love. Cluster D: Hyperarousal Cluster E: Alterations in Arousal and Reactivity I have trouble going to sleep or I wake up I have trouble going to sleep, wake up often, often during the night. or have trouble getting back to sleep.

I feel grouchy, angry, or mad. I get upset easily or get into arguments or physical fights.

I have trouble concentrating or paying Same item attention.

I watch out for danger or things that I am I am on the lookout for danger or things that afraid of. I am afraid of (like looking over my shoulder even when nothing is there).

I feel jumpy or startle easily, like when I hear I feel jumpy or startle easily, like when I hear a loud noise or when something surprises me. a loud noise or when something surprises me.

I hurt myself on purpose

I do risky or unsafe things that could really hurt me or someone else. Dissociative Symptoms I feel like I am seeing myself or what I am doing from outside my body (like watching myself in a movie).

I feel not connected to my body, like I’m not really there inside.

I feel like things around me look strange, different, or like I am in a fog.

I feel like things around me are not real, like I am in a dream.

Table 2 Descriptive Statistics of the Study Sample

Total Sample (n = 52) Gender Male 15.4% Female 84.6%

Ethnicity Caucasian 30.8% African American 59.6% Latino American 1.9% Multiracial 3.8% Missing 2.0%

Age (in years) 12.95 SD=2.18 Range = 8.34 - 16.59

Previous Trauma 3.48 SD = 1.50 Range = 1-7

Socioeconomic Status Less than $10,000 23.1% $11,000 - $19,000 23.1% $20,000 - $29,000 17.6% $30,000 – $39,000 7.8% $40,000 – $49,000 7.8% $50,000 – $59,000 7.8% Greater than $59,000 11.8% Missing 1.9%

School Type Public School 96.2% Private School 3.8%

Non-offending Caregiver Relationship to Child Mother 78.8% Father 5.8% Stepmother 1.9% Aunt 1.9%

Grandfather 1.9% Female (unknown relation) 10%

Table 3

Abuse Characteristics

Total Sample (n = 52)

Type of Abuse

Sexual 84.6%

Sexual and Physical 15.4%

Child’s relationship to Perpetrator

Parent 9.6%

Parent Paramour 17.3%

Other Relative 17.3%

Acquaintance 51.9%

Stranger 1.9%

Unknown 1.9%

Age of Perpetrator

Adult 67.3%

Juvenile 26.9%

Unknown 5.7%

Gender of Perpetrator

Male 98.1%

Unknown 1.9%

Number of Incidents

Once 53.3%

More than once 46.7%

Table 4

Ranges, Means, Standard Deviations and Rates of Clinical Significance

Observed Possible Mean % Clinically Rangea Range (SD)a Significantb

Dissociation 0 - 10 0 - 21 3.46 (3.08) 3.8%

Parent Support 3.84-5 0 - 5 4.66 (.31) -- Questionnairea

Posttraumatic Stress 3-61 0 - 68 30.80 36.5% Symptomsb (15.51) a responses averaged; b Summed score ≥ 38

Table 5

Zero-Order Correlations between Study Variables

1 2 3 4 5 6

1. Age 1 .19 -.06 -.04 .08 .27+

2. Gender 1 -.32* -.02 .07 .17

3. Previous Trauma 1 .12 .01 .14

4. Dissociation 1 -.02 .39**

5. PSQ (Total Support) 1 .18

6. PTSS 1

N = 52; *p < .05, **p < .01; p < .10+ Gender coded as Male = 1 and Female = 2

Table 6

Hierarchical Regression Analysis Predicting Posttraumatic Stress Symptoms from Dissociation and Caregiver Support

Posttraumatic Stress Symptoms

∆R2 ∆F B SE

Step 1 .073 3.921+

Age 1.918+ .969

Step 2 .193 6.323*

Dissociation 2.023* .623

Caregiver Support 9.255 6.116

Step 3 .001 .088

Dissociation x Support -.783 2.631

+ 2 *p < .01; p=.053; Final Model is significant; F (4,47) = 4.290, p<.01, R = .267

Table 7

Zero-Order Correlations between PTSS and Exploratory Study Variables

1 2 3 4 5 6 7

1. Age 1 .19 -.06 -.04 .08 .21 .27+

2. Gender 1 -.32* -.02 -.19 -.10 .16

3. Previous Trauma 1 .12 .03 -.04 .14

4. Dissociation 1 -.07 -.14 .38*

5. Caregiver Blame subscale 1 -.13 -.25+

6. Caregiver Support subscale 1 -.01

7. PTSS 1

N = 52; *p < .05; **p < .01; +p < .10

Table 8

Hierarchical Regression Analysis Predicting Posttraumatic Stress Symptoms from Dissociation by Caregiver Blame and Dissociation by Caregiver Support

Posttraumatic Stress Symptoms

∆R2 ∆F B SE

Step 1 .073 3.921

Age 1.918+ .969

Step 2 .225 5.016**

Dissociation 1.871** .625

Caregiver Blame -33.372* 15.829

Caregiver Support -2.455 5.561

Step 3 .004 .142

Dissociation x Blame 3.962 7.523

Dissociation x Support .423 1.906

+ 2 *p < .05; **p < .01; p=.053; Final Model is significant; F (2,47) = 3.245, p<.05, R = 0.302

Appendix A

Conceptual Model

Caregiver Support Caregiver Support

Trauma Dissociation PTSD

*shaded model represents model examined in the current study

Appendix B

CARE Center Protocol

Appendix C

CAC Protocol

Appendix D

Dissociation Subscale of TSCC

Appendix E

UCLA PTSD Reaction Index for DSM-IV

Here is a list of problems people sometimes have after very bad things happen. Please THINK about the bad thing that happened to you that you wrote about in Question #14 on the page 2. Then, READ each problem on the list carefully. CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how often the problem has happened to you in the past month. Use the Rating Sheet on Page 5 to help you decide how often the problem has happened in the past month. PLEASE BE SURE TO ANSWER ALL QUESTIONS HOW MUCH OF THE TIME DURING None Little Some Much Most THE PAST MONTH 1 I watch out for danger or things that I am afraid of. 0 1 2 3 4 D4 2 When something reminds me of what happened, I get very upset, 0 1 2 3 4 B4 afraid or sad. 3 I have upsetting thoughts, pictures, or sounds of what happened 0 1 2 3 4 B1 come into my mind when I do not want them to. 4 I feel grouchy, angry or mad. 0 1 2 3 4 D2 5 I have dreams about what happened or other bad dreams. 0 1 2 3 4 B2 6 I feel like I am back at the time when the bad thing happened, 0 1 2 3 4 B3 living 7 I feel like staying by myself and not being with my friends. 0 1 2 3 4 C4 8 I feel alone inside and not close to other people. 0 1 2 3 4 C5 9 I try not to talk about, think about, or have feelings about what 0 1 2 3 4 C1 happened. 10 I have trouble feeling happiness or love. 0 1 2 3 4 C6 11 I have trouble feeling sadness or anger. 0 1 2 3 4 C6 12 I feel jumpy or startle easily, like when I hear a loud noise or 0 1 2 3 4 D5 when something surprises me. 13 I have trouble going to sleep or I wake up often during the night. 0 1 2 3 4 D1 14 I think that some part of what happened is my fault. 0 1 2 3 4 AF 15 I have trouble remembering important parts of what happened. 0 1 2 3 4 C3 16 I have trouble concentrating or paying attention. 0 1 2 3 4 D3 17 I try to stay away from people, places, or things that make me 0 1 2 3 4 C2 remember what happened. 18 When something reminds me of what happened, I have strong 0 1 2 3 4 B5 feelings in my body, like my heart beats fast, my head aches, or my stomach aches. 19 I think that I will not live a long life. 0 1 2 3 4 C7 20 I am afraid that the bad thing will happen again. 0 1 2 3 4 AF

Appendix F

Parent Support Questionnaire

ID #: ______TIME: T1 T2 T3 DATE:______

PSQ

Instructions: For each statement, please select your child’s point on the scale (1-5) that best describes your reactions to your child’s sexual abuse in the last two weeks. Please record the appropriate number next to each item.

1 2 3 4 5 / / / / / Never Rarely Sometimes Frequently Always

___ 1. Have you been supportive of your child since they reported the sexual abuse? ___ 2. Have you encouraged your child to tell you how they feel about the abuse? ___ 3. Since your child reported the sexual abuse, have you reassured him/her that you would stand by him/her? ___ 4. Since your child reported the sexual abuse, have you told your child that things would work out okay? ___ 5. Have you tried to offer suggestions to your child about how they can cope with the sexual abuse? ___ 6. Have you tried to make your child feel safe and secure since they reported the sexual abuse? ___ 7. Have you tried to be understanding about your child's feelings regarding the sexual abuse? ___ 8. Since your child reported the sexual abuse, have you told him/her that you love him/her? ___ 9. Do you ever feel the sexual abuse was your child's fault? ___ 10. Do you ever think your child could have stopped the sexual abuse if they wanted to? ___ 11. Do you ever think your child did something to cause the sexual abuse? ___ 12. Have you criticized or punished your child for anything they did (or didn't do) regarding the abuse? ___ 13. Do you blame the perpetrator for the sexual abuse? ___ 14. Do you think it was the perpetrator's fault the sexual abuse occurred? ___ 15. Do you think the perpetrator was wrong to sexually abuse your child?

___ 16. Have you told your child the sexual abuse was not his/her fault? ___ 17. Have you told your child you are not angry at him/her for the sexual abuse? ___ 18. Do you feel the perpetrator should be punished for sexually abusing your child? ___ 19. Have you told your child that you want the perpetrator punished?

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