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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 ii 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, 2 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. 3 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. 4 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 5 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
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