Childhood maltreatment, PTSD, Attachment Study and Health Outcomes

1. Childhood maltreatment, PTSD,
Attachment Study and Health
Outcomes
Christine Wekerle,Ph.D.
Associate Professor, Education,
Psychology, Psychiatry
The University of Western Ontario
cwekerle@uwo.ca

2. Maltreatment and Adolescent
Pathways (MAP) Feasibility Study
Christine Wekerle, Ph.D., PI (cwekerle@uwo.ca)
Anne-Marie Wall, Ph.D.,Co-PI
Harriet MacMillan, MD., Co-I
Nico Trocme, Ph.D., Co-I
Michael Boyle, Ph.D., Co-I
Funded by: CIHR/CAHR, Public Health Agency of Canada
Project Manager: Randy Waechter, M.A.
In Collaboration With:
Children’s Aid Society of Toronto (Deb Goodman)
Advisory Board: Dan Cadman, Rob Ferguson, Heidi Kiang, Nancy
MacLaren, Franz Noritz, Ron Smith, Rhona Delisle
Catholic Children’s Aid Society (Bruce Leslie)
Advisory Board: Jim Langstaff, Sean Wyers, Coreen Van Es,
Mario Giancola, Tara Nassar

3. Maltreatment and Adolescent
Pathways (MAP) Longitudinal Project
• Population-based study of child-welfare involved youth
(Toronto, Montreal, London)
• Nearly $1M Funding CIHR; CHEO CofE
• 5 assessment points, @ 6months, to 2 years
• Research Questions:
• What is the prevalence of mental health in maltreated youth?
• How does the severity, duration, and types of maltreatment
impact on the developmental trajectory of mental ill-health in
adolescence?
• Is there a gender-specific trajectory?
• What protective factors may buffer the negative outcomes
associated with maltreatment?
• What mechanism(s) contributes to negative outcomes in
maltreated youths?

4. Maltreatment and Adolescent
Pathways (MAP) Project
• Prevalence of Mental Health
– Indexes of mental ill-health: Substance abuse,
risky sexual behavior, dating violence, and
externalizing & internalizing symptomatology
– Measures are synchronized with large-scale
population studies (e.g. OSDUS, NLSCY),
making comparison between community and
child-welfare samples possible

5. Maltreatment and Adolescent
Pathways (MAP) Project
• Pathway(s) across adolescence
– Adolescence is a critical developmental period
that is characterized by instability and change
– In tracking the trajectories of different indicators
simultaneously, the pathway approach provides
us with the opportunity to examine the chain of
causal mechanism that is responsible for the
maltreatment-negative outcome relation

6. Maltreatment and Adolescent
Pathways (MAP) Project
• Moderator/mediator of the maltreatment-
negative outcome relation
– Gender
– Protective factor (interpersonal competence,
positive role model, sports involvement, etc.)
– Mechanism (PTSD vs. Information processing
biases)
 Critical to intervention building

7. What is Special about MAP
Research Procss
• Random sampling of 14 to 17 year-old youth from
active caseload in child-welfare population
• Youth report on childhood maltreatment, mental
health, substance use, risky sexual practices,
violence (dating, bullying, delinquency)
• Youth anonymity protected with self-generated ID
methodology
• Multiple data points over 2 years
• Participatory Action Research Model - Partnership
• Funding by CIHR, Public Health Agency of Canada

8. What is Special about MAP
Research Process
List of all active caseloads between
14 - 17 years of age forwarded to
MAP researchers.
20 youth randomly selected from
each branch of CAS
Lists forwarded to MAP liaison
member at each branch of CAS
Liaison at each branch forwards
names of selected youth to
individual worker affiliated with that
youth (re: on caseload). Workers
determine eligibility
Workers contact youth on their
caseload to explain the study and
obtain permission for MAP
researchers to contact the youth
Worker faxes signed “recruitment
form,” with the youth’s name and
contact no. to researchers if youth
consented, or “inability to recruit
feedback form” if youth refuses or is
ineligible
no. of eligibility/ineligibility or refusal
will be documented by the MAP
research office
MAP researchers update original
randomly selected referral lists. Call
eligible youth to set up initial
appointment
MAP researchers meet with youth to
administer initial MAP questionnaire
package. Clinical follow-up
procedure in place. Mandatory
reporting based only on verbal
disclosure.
MAP researcher returns MAP
questionnaire package, data is
entered, consent forms and data
kept separate (confidentiality). Initial
consent longitudinal, consent @ 16
always obtained.
6-month, 1-year, 1.5 year, or 2-year
follow-up note filed as youth
participate. These notes are
reviewed daily by the Project
Manger. Incident report procedure
in place
Youth are contacted by MAP
researchers for 6-month, 1-year etc.
participation at the proper time as
per follow-up notes

9. MAP Feasibility Study: Research Process
• Mean Age of tested youth: 15.5 years
• Ineligibility Rate: Overall 31% (Case closed, AWOL, Discharged, mental
health issues, developmental delay, In custody, Not identified client)
• Refusal Rate: Overall 30% (Community: 55%, In-care: 17%; Males: 39%;
Females: 19%)
• Reasons given for Refusal: “Just not interested”/ no reason: 65%
(Parental Refusal: 14%; “Too busy”: 8%;“Not comfortable sharing”:
5%;Other: 8%)
• Recruitment Rate: Overall 70% (Community: 45%; In-care: 83%;Males:
61%; Females: 81%)
• Reasons given for participation: Money: 59%;“No reason given”: 32%;
Other: 9%
• Retention Rate: Overall 90%
• Average testing time: 2.8 hrs (Range = 2.0 to 4.5 hrs)
• Avg. Cost/Ss/Testing: $133.11 – Youth paid ON minimum wage/4hrs
Home ($70.21) + $28.00 = $98.21 (>80% youth selected testing at residence)
CAMH ($1.90) + $28.00 = $29.90
(+$5.00 food/refreshment cost)

10. MAP Feasibility Study: Agency Advisory
Committee Feedback
• Toronto CAS and Toronto CCAS nominated MAP
Advisory Board, monthly meetings, resource liaison
• The MAP Participatory Action Questionnaire (0-7)
– 0: Not at all; 7: Highly
– Relevancy to their work: 5.7
– Collaborative quality: 5.8
– Worker felt that their institution were supportive: 5.7
– Believe in the potential impact of the project: 6.2
• 90% of the Liaison staffers said the workload was not
too heavy – the average workload on the MAP was
1.3 hrs/week

11. MAP Youth Pre-Post Research
Experience Testing
Not at all So-So A lot
0 1 2 3 4 5 6
How relaxed do you feel?* (3.8)
How happy do you feel? * (3.5)
How clear is this study to you(5.0)
How distressed do you feel? (2.4)
How interested..in this study?(4.7)
How important..this study is? (4.9)
How high..your energy level? (3.7)
How easy..to express yourself?(4.1)

12. Value of MAP Participation?
Response Options
Not at all So-So A lot
0 1 2 3 4 5 6
• I gained something from filling out this
questionnaire (3.6)
• Had I known in advance what
completing this questionnaire would
be like for me, I still would have
agreed (4.8)

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

14. Developmental Traumatology
Tenets (DeBellis, 2001)
• The biological stress system response varies with
individual’s genetics, nature of the stressor, and
whether the system can maintain homeostasis or
whether it permanently changes due to stressor
• PTSD symptoms are normal responses, but when
chronic can lead to adverse brain development
• PTSD symptoms represents pathway to more
impairment; intergenerational maltreatment follows
PTSD mediation
• Chronic mobilization of the fight/flight response, is
the key cause of persistent negative neurological
effects and neurobiological changes
• PTSD key causal factor underlying broad range of
academic and mental health impairments

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

16. DSM-IV PTSD Criteria
• Specifier: (1) Acute (< 3 months); (2) Chronic (> 3
months); (3) Delayed Onset (6 months past
traumatic stressor)
• Issues: Intensity, proximity, chronicity of stressor,
age of child, relationship to perpetrator, presence of
supportive and protective caretaker
• Criterion A: Both must be present
(1) traumatic event w/ actual/threatened death or
serious injury to threat to physical integrity to
self/others
(2) response involved intense fear, helplessness,
horror, disorganized or agitated behaviour

17. DSM-IV PTSD Symptomatology
DSM- IV Symptom Classes:
(1) Re-experiencing: recurrent, intrusive thoughts;
bad dreams*; sense of re-living*; physiological
reactivity and psychological distress* at cue
exposure
(2) Avoidance/Numbing*: avoid thoughts, feelings,
places, people, activities related to trauma*; gaps
in recall; feeling detached; feeling problems;
pessimism about future
(3) Arousal: sleeping, anger, irritability, startle*,
hypervigilance, concentration difficulty
* Higher among chronic, abused youth (Fletcher,
2003)

18. Descriptives of the MAP
Preliminary Analysis Sample
• N size: 116 (53% female)
• CAS status:
– Crown Ward: 46 (40%)
– Society Ward: 27 (23%)
– Community Family/Temporary Care:
10(8.6%)
– Voluntary Care: 2 (1.7%)

19. Emotional Abuse is Common
• CEVQ
– 70% Witness verbal abuse by parents
• 63% occurred before grade 6
– 43% Witness physical abuse by parents
• 55% occurred before grade 6
– 74% Victim of verbal abuse by parents
• 59% occurred before grade 6
• CTQ (While growing up as a child … )
– 72% Family said hurtful or insulting things
– 72% Being called “stupid,” “lazy,” or “ugly” by
family
– 61% Believed were emotionally abused

20. Physical Abuse is Common
• CEVQ
– 65% Being pushed, grabbed or shoved as a way to
hurt
• 61% before grade 6, 81% parental perpetration
– 43% Being kicked, bit or punched as a way to hurt
• 56% before grade 6, 78% parental perpetration
• CTQ (While growing up as a child …)
– 62% Being hit so hard it left marks:
– 57% Being punished with belt, cord, hard objects
• 80% of male endorsed 1 or > physical abuse item
• 54% Youth believed were physically abused

21. Neglect is Difficult to Define
• CTQ (growing up as a child …)
– 40% Not having enough to eat
– 22% Parent too drunk or high to take
care of the family
– 25% Had to wear dirty cloth
– 54% believed were neglected

22. Sexual Abuse maybe more
common than we think …
• CEVQ
– 32% Being touched or forced to touch other’s private
part
• 54% before grade 6
– 26% Being coerced into having sex
• 43% before grade 6 & 30% high school
• CTQ (growing up as a child … )
– 20% Being forced to do or watch sexual things
– 20% Being molested
• 90% female endorsed 1 or > sexual abuse items
• 21% Youth believed were sexually abused

23. Posttraumatic Stress Disorder
Symptomatology
• Trauma Symptom Checklist for
Children (TSCC)
– 75% Feeling afraid something bad might
happen
– 74% Remembering things that happened
that I didn’t like
– 63% Bad dreams or nightmare

24. Internalizing Symptoms (Past Week)
• The Brief Symptom Inventory
– 29% of female and 34% of male thought of
ending life (US. 21% female, 13% male)
– 40% Spells of terror or panic
– 56% Feeling blue
– 56% Feeling no interest in things
– 66% Feeling people cannot be trusted
– 76% Feeling easily annoyed or irritated

25. Externalizing Symptoms
• Trait Anger
– 64% Get physically aggressive when angry
– 83% Get verbally aggressive when angry
– 85% Get “furious” easily
• Past Week Anger
– 50% temper outburst that could not be controlled
– 37% having urge to beat, injury or harm someone
– 30% having urge to break or smash something

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

27. Substance Use is Early & More?
• Alcohol Use
– 36% Drinking Before Age 13 (US 28%)
– 49% Binge Drinking Past Year (US 28%)
– 47 % Past Month Drinking (US 45%)
– 23% Past Month Binge Drinking (US 28%)
• Cannabis Use
– 36% Use Before Age 13 (US 10%)
– 84% Past Year
– 62% Past Month (US 22%)
• Talk to School Counselor
– 3% alcohol related problem
– 3% drug related problem
• Arrested by Police
– 6% alcohol related problem
– 6% drug related problem

28. Violence in Close Relationship
• Physical violence (e.g. kicked, hit, or
punched): 60% perpetrated; 50%
victimized
• Sexual violence (e.g. threatened with rape):
20% perpetrated; 26% victimized
• Emotional violence (e.g. insult with put-
downs): > 90% perpetrated; 97% victimized

29. Sexual Health Better Outcome?
• First intercourse w/ boyfriend, girlfriend
– 50% age 13-year or younger (7.4% US teens)
– Only 20% of their partners are 13 and younger
– 44% Unsure; 8% Didn’t want it
– 17% was unprotected (64% unprotected US teens)
– 17% involved drug and/or alcohol
• Sexual activity in the past 12 months
– 4 or > sexual partners 16% (14.4% US teens)
– Last intercourse: 23% alcohol, 30% other drug
– (US teen: 25.4% used alcohol or other drugs)
– Only 54% have protected sex every time
– 13% never had any protection

30. Attachment Styles
in Maltreated Adolescent

31. Attachment Styles as Cognitive Strategy
for Regulating Emotion in Relationships
• Maltreatment is an exploitive event within
a relational context where
victim/victimizer roles are learned
• Most studies on maltreatment history place primary category as
insecure
• Main (1990) proposed that with insensitive caregiver, child may
develop conditional or secondary attachment strategies to permit
continued maintenance of proximity and self-organization
• Such situations may create vulnerabilities to fragmentation of
incoherence, producing multiple inconsistent models
• Crittenden (1988) found avoidant-ambivalents in maltreated infants
• Defensively biased multple models form the initial stages of
defensive structures that can ultimatley lead to disortion in
personality and psychopathology (Rozenstein & Horowitz, 1996)
• Issue of continuity of attachment across generations; caregiver
psychopathology increases likelihood of child psychopathology
• Dismissing AAI: CD Preoccupied: Affective Disorders hospitalized
psychiatric teens (Mean Age = 16 years)

32. Attachment Styles: Self-reported, dating
partner referenced
• Hazan & Shaver (1987)
– Secure (a scale from 1 [Not at all like me] to 7 [very like me])
“I find it relatively easy to get close to others
and am comfortable depending on them
and having the depend on me. I don’t often
worry about being abandoned or about
someone getting close to me.”

33. Attachment Styles: Self-reported, dating
partner referenced
• Hazan & Shaver (1987)
– Avoidant (a scale from 1 [Not at all like me] to 7 [very like me])
• “I am somewhat uncomfortable being close to
others. I find it difficult to trust them, difficult to allow
museld to depend on them. I am nervous when
anyone gets too close, and often love partner want
me to be more intimate than I feel comfortable
being.”
• Manifestations: minimizing relationships, denial of
distress, controlling/coercive – vulnerable to
aggression, self-medication

34. Attachment Styles: Self-reported, dating
partner referenced
• Hazan & Shaver (1987)
– Ambivalent (from 1 [Not at all like me] to 7 [very like me])
• “I find that others are reluctant to get as close as I
would like. I often worry that my partner doesn’t
really love me or won’t want to stay with me. I want
to merge completely with another person, and this
desire scares people away.”
• Manifestations: “Over-focus” on other; compulsive
caregiving, expressed distress; vulnerable to
internalzing problems

35. Care Arrangement & Attachment Styles
• Society Ward male adolescents scored lowest
on the Security dimension (Chi-sq.=10.18, p=.02)
• Female adolescents who had been placed in
many different homes in the past five years
scored high on the Avoidant dimension
(rho=.33, p=.02).
*Age, ethnicity and SES were controlled for

36. Emotional Maltreatment
& Attachment Styles
Secure Avoidant Ambivalent
Female -.45**
(CEVQ)
-.33*
(CTQ)
.30*
(CEVQ)
.44**
(CTQ)
ns.
Male
ns.
ns.
.30*
(CTQ)
ns.
Correlations in rhos; *p<.05; **p<.01; age, ethnicity and SES were controlled for

37. Physical Maltreatment
and Attachment Styles
Secure Avoidant Ambivalent
Female
ns.
.45**
(CEVQ)
.49**
(CTQ)
ns.
Male
ns. ns. ns.
Correlations in rhos; *p<.05; **p<.01; age, ethnicity and SES were controlled for

38. Sexual Maltreatment
and Attachment Styles
Secure Avoidant Ambivalent
Female
ns.
.30*
(CEVQ)
ns.
ns.
Male
ns. ns. ns.
Correlations in rhos; *p<.05; **p<.01; age, ethnicity and SES were controlled for

39. Neglect and Attachment Styles
Secure Avoidant Ambivalent
Female NA
(CEVQ)
-.37*
(CTQ)
NA
(CEVQ)
.46**
(CTQ)
ns.
Male
ns. ns. ns.
Correlations in rhos; *p<.05; **p<.01; age, ethnicity and SES were controlled for

40. Cumulative Maltreatment Experience
and Attachment Styles
Secure Avoidant Ambivalent
Female -40**
(CEVQ)
-.44**
(CTQ)
.40**
(CEVQ)
.50**
(CTQ)
ns.
Male
ns. ns. ns.
Correlations in rhos; *p<.05; **p<.01; age, ethnicity and SES were controlled for

41. Attachment Styles
and Trauma Symptomatology
Secure Avoidant Ambivalent
Female
ns. .39 .39
Male
ns. .32* ns.
Correlations in rhos; *p<.05; **p<.01; age, ethnicity and SES were controlled for

42. Attachment Styles
and Health Outcomes
Relationship Violence
Sexual Health
Substance use
Externalizing & Internalizing Symptomatology

43. Attachment Styles
and Relationship Violence
• Females who scored high on the
Ambivalent dimension also reported
perpetrate more relationship violence
(rho=.35, p=.05).
• However, male who scored high on the
Ambivalent dimension reported
marginally more victimization by their
partner in a relationship (rho=.40, p=.07).

44. Attachment Styles & Sexual Health
• The higher a female scored on the Avoidant
dimension, the older was her first sexual
partner (rho=.37, p=.04). The higher a female
scored on the Ambivalent dimension, the
younger was her 1st
partner (rho=-.38, p=.03).
• High scores on the Avoidant dimension among
females were marginally associated with less
protected sex (rho=-.31, p=.07). High score on
the Ambivalent dimension among males were
associated with less protected sex (rho=-.42,
p=.05).

45. Attachment Style & Substance Use
• For female, the higher the score on the Avoidant
dimension, the more cigarettes were smoked in the
past 12-month (rho=.41, p=.02). On the other hand,
the more secure the female is the less drug she uses
each time (rho=-.43, p=.03).
• Also among females, the higher the Avoidant score,
the more cigarettes were smoked (rho=.42, p=.02),
and more cannabis (rho=.53, p=.01) was used in the
last 30 days on school property.
• For male who scored high on the Avoidant
dimension, they smoked larger amount of cigarettes
(rho=.40, p=.05).
• Also, the more secure the male scored, the less likely
he will to be arrested (rho=-.31, p=.05).

46. Attachment Style
and Internalizing Symptom
• For female, but not male, high Avoidant
(rho=.48, p<.01) and Ambivalent
(rho=.39, p<.01) scores are associated
with the number of internalizing
symptoms. Security in female, on the
other hand, is negative correlated with
the number of internalizing symptom
she suffered (rho=-.33, p=.03)

47. Attachment Style
and Externalizing Symptom
• High Avoidant score in female was
associated with high trait anger (rho=.30,
p=.04), and so was high Ambivalent
score (rho=.32, p=.03). Attachment styles
does not, however, relate to expression of
anger.
• The relationship between high Avoidant score
and high trait anger can also be found among
males (rho=.36; p=.02).

48. Conclusion
• Child welfare youth readily report on their
history and well-being
• Child welfare youth indicate low distress from
answering sensitive questions
• Child welfare youth show vulnerabilities
across major mental health areas of
internalizing and externalizing symptoms
• Child welfare youth report substantial amount
and types of victimization
• Sexual protection may be one are of strength
• Child welfare youth are one sub-population
where mental health, substance abuse, and
delinquency coincide