Validity of the Childhood Trauma Questionnaire in an

Adolescent Psychiatric Population

DAVID P. BERNSTEIN, PH.D., TARUNA AHLUVALIA, B.A., DAVID POGGE, PH.D.,
AND LEONARD HANDELSMAN, M.D.

ABSTRACT
Objective: To present initial findings on the validity of a recently developed maltreatment inventory, the Childhood
Trauma Questionnaire (CTQ), in a sample of adolescent psychiatric patients. Method: Three hundred ninety-eight male
and female adolescents (aged 12 to 17 years) admitted to the inpatient service of a private psychiatric hospital were
given the CTQ as part of a larger test battery. Structured interviews were also conducted with the primary therapists
of 190 of the patients to obtain ratings of abuse and neglect based on all available data, including clinical interviews
with patients and their relatives and information from referring clinicians and agencies. Results: Principal-components
analysis of the CTQ items yielded five rotated factors-emotional

abuse, emotional neglect, sexual abuse, physical

abuse, and physical neglect--closely replicating the factor structure in an earlier study of adult patients. The internal
consistency of the CTQ factors was extremely high both in the entire sample and in every subgroup examined. When
CTQ factor scores were compared with therapists ratings in a series of logistic regression analyses, relationships
between the two sets of variables were highly specific, supporting the convergent and discriminant validity of the CTQ.
Finally, when therapists ratings were used as the validity criterion, the CTQ exhibited good sensitivity for all forms of
maltreatment, and satisfactory or better levels of specificity. Conclusions: These initial findings suggest that the CTQ
is a sensitive and valid screening questionnaire for childhood trauma in an adolescent psychiatric inpatient setting. J. Am.
Acad. Child Adolesc. Psychiatry, 1997,36(3):340-348. Key Words: abuse, neglect, adolescence, assessment, validity.

Recent studies suggest that childhood trauma and

deprivation are common but frequently underreported
problems among adolescents seen in mental health,
social service, and juvenile justice settings (Cavaiola
and Schiff, 1988; Dembo et al., 1988; Edwall et al.,
1989; Sansonnet-Hayden et al., 1987). Adolescents

Accepted August 15, 1996

Dr. Bernstein is Assistant Profissor of Psychiaty, Mount Sinai School of
Medicine, New York, and Director of Clinical Research, Bronx VeteransAffairs
Medical Center? Drug Dependency Treatment Program. Ms. Ahluvalia is a
Doctoral Candidate at Fairleigb Dirkinson University, RutheTford, NJ. Dr.
Poae is Director of Psychology at Four Winds Hospital, Ketonah, NY,
and Assistant Profissor in the Psychology Department, Fairleigh Dirkinson
University. Dr. Handelsman is Associate Profissor of Psycbiaty, Mount Sinai
School of Medicine and Director, Bronx Veterans Affairs Medical Center:
Drug Dependency Treatment Program.
A version of this paper was presented at the Fourth International Research
Confirenre on Family Violence, Durham, NH, July I995
Reprint requests to Dr. Bernstein, Brow VA Medical Center, Psychiatry
Service 116A, 130 W Kingsbridge Road, Bronx, N Y 10468.
0890-8567/97/3603-0340$03.00/001997 by the American Academy
of Child and Adolescent Psychiatry.

340

referred for reasons such as substance abuse, delinquency, suicide attempts, sexual acting-out, and running away from home often have histories of
maltreatment (Cavaiola and Schiff, 1988; Dembo et
al., 1988; Edwall et al., 1989; Sansonnet-Hayden et
al., 1987), but these may not be disclosed during the
course of routine evaluation. The early identification
of such cases is essential, so that interventions can be
made before the consequences of childhood trauma
become chronic. However, until recently, few systematic methods for assessing maltreatment in adolescence
have been available and the validation of these measures
has been limited (Dembo et al., 1988; Sanders and
Giolas, 1991). In this report, we present initial findings
on the validity of a recently developed measure for
assessing maltreatment, the Childhood Trauma Questionnaire (CTQ), in a large, demographically diverse
sample of adolescent psychiatric inpatients.
The CTQ is a 70-item self-report inventory that
provides brief and relatively noninvasive screening of
maltreatment experiences before the age of 18 years.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 3 6 ~ 3 MARCH

,
1997

V A L I D I T Y OF T H E C T Q I N A D O L E S C E N T S

In studies of adult substance abusers, the CTQ demonstrated excellent test-retest reliability over a 2- to
6-month interval as well as convergence with a structured trauma interview (Bernstein et al., 1994; Fink
et al., 1995). Principal-components analysis (PCA) of
the scale yielded four rotated factors which were labeled
physical and emotional abuse, emotional neglect, sexual
abuse, and physical neglect (Bernstein et al., 1994).
In the present study, our goal was to validate the
CTQ in a psychiatric population of adolescents aged
12 to 17 years. Specifically, we sought to replicate
and extend our original factor-analytic findings in an
adolescent sample and compare patients reports on
the CTQ to ratings of maltreatment made by their
primary therapists after discharge, based on all available
data at that time. In the absence of a true gold
standard, we selected therapists ratings as our validity
criterion because the therapists had extensive contact
with the patients and their families, other members
of the multidisciplinary treatment team, and other
informants such referring clinicians and agencies; moreover, therapists were often able to support their judgments with independent evidence such as knowledge
of child welfare investigations, appearances in family
or criminal court, or removal of the child from the
parental home.
METHOD
Subjects
Three hundred ninety-eight adolescents admitted to the inpatient
service of a private psychiatric hospital were given the CTQ as
part of a larger test battery. Therapists ratings of maltreatment
were also obtained for 190 of the adolescent patients. Patients
were heterogeneous with regard to age (range = 12 to 17 years,
mean 2 SD = 14.9 2 1.4 years), gender (males = 43%, n = 171;
females = 57%, n = 227), and ethnic composition (white = 67.9%,
Hispanic = 13.3%, African-American = 11.2%). Patients also
represented a broad range of family income, from middle- and
upper-income families with private health insurance to families in
poverty (patients with Medicaid coverage = 51%). The most
frequent presenting psychiatric problems among the patients were
suicide risk, 48.9% (male = 42.9%, female = 53.3%,
= 4.19,
df = 1, p < .05); substance abuse, 37.8% (male = 41.%, female =
34.8%, = 1.98, df= 1 , p > .I); mood disorders, 35.2% (male =
33.5%, female = 36.4%,
= 0.36, df = 1, p > .I); suicide
attempts, 33.4% (male = 23.5%, female = 40.9%,
= 13.12,
df= 1, p < .001); self-mutilation, 22.8% (male = l8.8%, female =
25.9%,
= 2.74, df = 1, p < .l); homicide risk, 21.3% (male =
28.2%, female = 16.1%,
= 8.53,
1, p < .01); assault,
20.3% (male = 31.2%, female = 12.1?40, = 21.84, df= 1, p <
.001); criminal behavior, 18.3% (male = 27.1%, female = 11.6%,
= 15.45, df= 1.p < .001); learning disabilities, 15.5% (male =

x2

x2

x2

x2

x2

xz

df=
x2

x2

J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 6 : 3 , M A R C H 1997

x2

18.8%, female = 12.9%, = 2.55, df= 1, p > . l ) ; and attention

deficit disorder, 14.2% (male = 21.8%, female = 8.5%, = 13.98,
df = 1, p < .001). Patients were excluded from the study if
low intelligence (Wechsler Full Scale I Q <80) or poor reading
competence (Wide Range Achievement Test-Version I11 [WRAT1111 Reading Level below sixth grade) precluded completion of the
CTQ (see Procedures). Patients mean (SD) length of hospital
stay was 6.9 t 5.6 weeks (range = 1 to 37 weeks).

x2

Measures
The CTQ is a 70-item screening inventory that assesses selfreported experiences of abuse and neglect in childhood and adolescence. Most items are phrased in objective, behavioral terms (When
I was growing up, someone tried to touch me in a sexual way or
tried to make me touch them.), while others call for more
subjective evaluations (e.g., When I was growing up, I believe
that I was sexually abused.) (Additional sample items are given
in a previous report [Bernstein et al., 19941, and the entire scale
can be obtained from the authors.) Items are rated on a 5-point
Likert-type scale, with response options ranging from Never true
to Very often true. Instructions for the CTQ ask respondents
about their experiences growing up and, therefore, in the case
of adolescents, do not distinguish between current and past maltreatment. The CTQ requires about 10 to 15 minutes to complete.
A structured trauma interview we developed for this study was
also administered to the therapists of 190 of the adolescent patients
(some of the interview items were taken from a maltreatment
interview for therapists, the Traumatic Events Questionnaire-Therapist Version [D.S. Lipschia, G. Pawl, R.K. Winegar, M.A. Wolfson,
G.L. Faedda, unpublished], and were modified by us with the
permission of Dr. Lipschitz). In this interview, each therapist was
presented with a written definition of the terms, sexual abuse,
physical abuse, emotional abuse, and neglect, developed by
us to reflect standard definitions in the maltreatment literature,
and illustrated by several examples. Sexual abuse was defined as
sexual contact or conduct between a minor child (younger than
17 years of age) and an adult or older person (at least 5 years
older than the child). Examples ranged from rubbing or fondling
to oral, anal, or vaginal penetration to sadistic or ritualistic sexual
abuse (noncontact experiences, such as exposure to pornography
by an adult, were also included). Physical abuse was defined as
bodily assaults on a minor child by an adult or older person that
posed a risk of or resulted in injury. Examples included hitting
with an object or in vulnerable areas; shaking, pushing, or knocking
a child down; and attacks resulting in marks, bruises, or broken
bones. Emotional abuse was defined as verbal assaults on a childs
sense of worth or well-being or any humiliating or demeaning
behavior directed toward a child by an adult or older person.
Examples included insulting or critical remarks or behavior; scapegoating, blaming, taunting, or rejecting; threatening or frightening
comments or behavior; and excessive control over autonomy.
Physical neglect was defined as the failure of caretakers to provide
for a childs basic physical needs, including food, clothing, shelter,
safety, and health care (poor parental supervision was also included
if it placed childrens safety in jeopardy). Examples included having
to go without shoes or a winter coat, wearing dirty clothes more
than occasionally, not visiting the doctor when sick or injured,
frequently missing meals, being left home alone for several hours
or overnight, and being unsupervised away from home for more
than a few hours (or at all, for younger children).

34 1

B E R N S T E I N E T AL.

These terms were reviewed until it was clear that the therapist
and interviewer were operating from a common definition; discussions with the therapists were limited to clarifying definitional
issues and did not include discussion of specific case material. Each
case from the CTQ respondent pool treated by that therapist
was then individually reviewed and rated. Identifying information
(name, age, dates of hospitalization) was presented to the therapist
along with a copy of the therapists own admission note, discharge
summary, and psychosocial history taken from the patients hospital
chart. Having been thus refamiliarized with the case, the therapist
was asked to rate whether the patient had been sexually, physically,
or emotionally abuse, or neglected, according to the standardized
definitions. For each of the four categories, the therapist was asked
to rate the patient as definitely or definitely not maltreated,
or as uncertain. Therapists were instructed to base their ratings
on all information available to them, including statements of
patients and their relatives, information provided by referring
clinicians and agencies, and other records. Therapists were also
allowed to draw freely on information obtained by other members
of the multidisciplinary treatment team and were encouraged to
exercise their clinical judgment. However, therapists were also
strongly encouraged to assign to the uncertain category any case
for which they felt less than entirely certain about the patients
abuse or neglect status. Thus, while some cases assigned to the
uncertain group may in fact have been victims of abuse or neglect,
those assigned to the definitely or definitely not abused or neglected
groups were considered unambiguous cases.
To determine whether therapists were able to apply the maltreatment definitions in a uniform manner, two therapists, a clinical
psychologist and a clinical social worker, were presented with 10
case vignettes. All vignettes were based on real cases that had been
abstracted from patients clinical charts and incorporated as many
relevant details as possible, including some that were ambiguous
or contradictory (e.g., abuse allegations that were later recanted).
Some vignettes combined material from different cases in order
to provide a sufficient pool of maltreatment experiences of different
types. The therapists were asked to review the standardized definitions and rate each vignette in terms of the presence or absence
of four types of maltreatment: physical, sexual, and emotional
abuse and physical neglect. Their ratings were compared with those
of a senior clinician with expertise in the maltreatment area (D.P.B.).
Mean K values for agreement between the raters and the expert
were extremely high: physical abuse, K = .9; sexual abuse, K = 1.0;
emotional abuse, K = .9; and physical neglect, K = .9.
Once cases were assigned to the definitely abused or neglected
category, specific detailed information was gathered concerning
duration, age of occurrence, nature and severity of abuse or neglect,
identity of the perpetrators, and medical and legal consequences
of the maltreatment. Again, therapists were encouraged to respond
by using the uncertain category if the information sought was
in any way incomplete or ambiguous.
Table 1 indicates that the therapists were often able to cite
independent corroborative data to support their judgments about
patients maltreatment status, such as knowledge of Child Protective
Service investigations, criminal or family court chargeslappearances,
prior psychiatric or medical care for trauma-related problems, or
removal of the child from the parental home.

Procedures
The CTQ was given approximately 1 week after admission as
part of a clinical psychological test battery that included a variety

342

TABLE 1
Percentage of Maltreatment Cases in Which
Therapists Cited Independent Evidence to Support Their
Ratings of Abuse and Neglect
Percent ( n ) of Cases Supported
by Independent Data

CPS report
Criminal court
Family court
Psychiatric care
Medical care
Removal from home
Any of the above

Sexual
Abuse
( n = 43)

Physical
Abuse
(YZ= 61)

Physical
Neglect
( n = 41)

39.5
20.9
16.3
32.6
NA
14.0
62.8

50.8
3.3
18.0
31.1
14.8
31.1
67.7

51.2
0.0
22.0
48.8
NA
43.9
75.6

(17)

(9)
(7)
(14)
(6)
(27)

(31)
(2)
(11)
(19)
(9)
(19)
(42)

(21)
(0)
(9)
(20)
(18)
(31)

Child Protective Service (CPS) investigation; criminal or family

court appearance; patient received prior psychiatric or medical care
for consequences of abuse o r neglect; patient removed from home.
NA = information not available.
of self-administered questionnaires, as well as the WISC-I11 (Psychological Corporation, 1991) and the WRAT-111 (Wilkinson, 1993).
Approximately 25% of patients admitted to the hospital were not
given the CTQ, either because low intelligence (Wechsler Full
Scale I Q <80), poor reading competence (WRAT-111 Reading
Level below sixth grade), or early discharge precluded completion
of the questionnaire portion of the test battery or because they
had been recently tested before admission and did not require
retesting. Data on CTQ responses were extracted from the testing
files of the patients. Thus, specific informed consent for the C T Q
was not solicited, because it was subsumed under the more general
consent for clinical services obtained from patients and their parents
or legal guardians. Instructions for the CTQ were read silently by
the subject, although an examiner was present to answer questions.
Patients were allowed to refuse to complete the instrument for
any reason; however, none of the patients who received the test
battery specifically refused to complete the CTQ. Information
from the CTQ was incorporated into a psychological testing report
that was made available to each patients primary therapist for
clinical purposes. To the best of our knowledge, however, no
referrals to child welfare agencies were made solely on the basis
of testing with the CTQ.
After patients were discharged, their primary therapists (psychologists, psychiatrists, and clinical social workers) were given the
structured interview described above eliciting detailed information
about patients histories of childhood trauma. Fifteen therapists
were interviewed about an average (mean 2 SD) of 12.7 2 6.9
patients (range = 3 to 27 patients) from their caseloads, for a total
of 190 therapist interviews. Therapists were interviewed an average
of 36.4 2 15.4 weeks after their patients discharge. The reasons
for this interval included the fact that some patients were given
the CTQ before the development and pilot testing of the therapist
interview were completed and difficulties in scheduling some of
the therapists. All of the interviews were administered by one of
us (T.A.) with both the interviewer and the therapists kept blind
to the results of the CTQ. Although therapists were refamiliarized
with the case by reviewing their own reports from the hospital
charts, any materials that might have contained references to the

J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 6 : 3 , M A R C H 1997

VALIDITY OF T H E C T Q I N ADOLESCENTS

CTQ (e.g., test report summaries) were excluded from this review.
Interviews could not be conducted with the therapists of the
remaining patients because the therapists were no longer available.
No differences were found between adolescents with and without
therapist ratings on age, gender, or ethniciry or on any of the
CTQ factors, except for a small but significant difference in physical
abuse scores (patients with therapist ratings = 14.5 ? 8.0, patients
without therapist ratings = 12.5 ? 6.1; t =2.84, df= 296,p < .01).

Statistics
The factorial structure of the CTQ was investigated by PCA
with varimax rotation. Separate PCAs in males and females produced nearly identical results, so subsequent analyses were performed using the combined sample. Seven items were excluded
from the PCA: a three-item validity scale and four items with very
low communalities (multiple R < .2) with the other CTQ items.
The validity scale, which was designed to detect maltreatment
underreporting, is described elsewhere (D. Bernstein, H. Jelley, L.
Handelsman, unpublished). Four-, five-, and six-factor solutions
were attempted and the five-factor solution was chosen because of
its evident content validiry (in the four-factor solution, items
reflecting physical and emotional abuse loaded highly on a single
large factor, while in the six-cluster solution, the physical neglect
items were dispersed among two small factors). Items were assigned
to the single factor on which they loaded most highly (all items
had factor loadings equal to or greater than .4 on at least one
factor). Internal consistency reliability of the CTQ factors was
determined by Cronbachs a.
Scoring algorithms for the CTQ were based on analyses of five
separate normative samples, including the adolescents described
here, representing a broad range of age, gender, income, ethnicity,
and diagnosis (total N = 979) (D. Bernstein, unpublished study).
Although an extensive discussion of algorithm development is
beyond the scope of this report, a brief summary is as follows.
Items were first assigned to factors based on their loadings in two
independent factor-analytic studies. Although an initial study of
adult substance abusers resulted in a four-factor solution (Bernstein
et al., 1994), the five-factor solution reported here in which physical
and emotional abuse items loaded on separate factors was preferred
for its face validity. An effort was then made to reduce the total
number of items with the goal of producing a shorter version of
the scale. Item-factor correlations and Cronbachs a values (i.e.,
internal consistency reliabilities) were examined across the five
validation samples and items were either dropped or retained
depending on their performance. This resulted in a final set of
algorithms consisting of 50 total items, in addition to the threeitem validity scale: emotional abuse, 12 items; physical abuse, 7
items; sexual abuse, 7 items; emotional neglect, 16 items; and
physical neglect, 8 items. Scores on the five factors are obtained
by taking the sum of the unweighted item raw scores.
T o examine the convergence between CTQ scores and therapists
ratings of maltreatment, a series of logistic regression analyses was
performed in which the five CTQ factors were entered simultaneously and therapists ratings of the presence or absence of maltreatment were used as the (dichotomous) dependent variables. An
additional series of logistic regressions was performed in which
variables were entered hierarchically in sets, with gender entered
first, the CTQ factors second, and the interactions between gender
and the CTQ factors third. Cases that were rated as uncertain
were excluded from all of these analyses (12 cases of sexual abuse,
9 cases of physical abuse, 9 cases of emotional abuse, and 5 cases
of neglect).

J. A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 6 : 3 , M A R C H 1997

The sensitivity and specificity of the CTQ factors for therapists

ratings of abuse and neglect were determined using statistical
sofnvare for nonparametric receiver operating characteristic (ROC)
analysis (Vida, 1993). ROC analysis calculates the sensitivity and
specificity of a scale for every possible cutoff score, allowing the
investigator to select the test threshold that yields the best balance
of false-negative and false-positive errors for his or her purposes
(Hsiao et al., 1989; Mossman and Somoza, 1991). As the CTQ
is intended as a screening measure, we were more concerned with
minimizing false-negative errors (i.e., the nondetection of true
cases) than false-positive errors. Furthermore, noncases of childhood
maltreatment are almost impossible to verify definitively (Briere,
1992), suggesting that criterion variables like therapists ratings are
likely to produce false-negative errors of their own, leading to
underestimates of the true specificity of trauma questionnaires. For
these reasons, our cutoff scores for the CTQ were set to emphasize
test sensitivity over specificity.

RESULTS

A PCA of the CTQ items was performed to examine

the factor structure of the questionnaire. PCA yielded
five rotated factors, accounting together for 55% of
the variance between items (Table 2). The five factors
were interpreted as emotional abuse, emotional neglect,
sexual abuse, physical abuse, and physical neglect,
closely replicating the findings of a previous study in
adult substance abusers (Bernstein et al., 1994). The
factors were highly internally consistent, both in the
sample as a whole and in separate subsamples of males
and females and younger and older adolescents (Table
2). Intercorrelations among the five factors ranged from
r = .34 to r = .75 with a median of r = .51 (Table 2).
When therapists were asked to rate the presence or
absence of maltreatment in a subsample of 190 adolescent patients, 23% of patients ( n = 43) were classified
as definitely sexually abused, 33% ( n = 62) as physically
abused, 33% ( n = 62) as emotionally abused, and 22%
( n = 41) as physically neglected. Fifty-six percent of
the subsample ( n = 107) were judged to have at least
one form of childhood trauma, while 39% ( n = 7 3 )
received ratings of two or more forms of trauma.
Point-biserial correlations between CTQ factor
scores and therapist interview ratings showed that despite substantial overlap between different forms of
maltreatment, convergent correlations (e.g., correlations between CTQ factor
and
therapist ratings) were in general larger than discriminant
correlations (i.e., correlations between CTQ factor
3)*
Ores
and nonanalogous therapist
T o examine further the specificity of the relationship

343

B E R N S T E I N ET AL

TABLE 2
Factor Structure and Internal Consistency of Childhood Trauma Questionnaire (CTQ in 398
Male and Female Adolescent Psychiatric Patients

CTQ Factor"

Itemsb Mean (SD)'

17
22

I.
11.
111.
IV.

Emotional abuse
Emotional neglect
Sexual abuse
Physical abuse
V. Physical neglect
Total scale

7
7
10

42.1 (17.2)
52.8 (19.5)
11.3 (7.3)
13.4 (7.1)
16.8 (6.9)

63

136.5 (47.0)

Percent

value

Variance

Male

Female

12-14 yr

15-17 yr

Total

21.9
4.8
3.7
2.4
1.9

34.8

.94
.95
.87

.95
.94
.90
30
.80

.95

.89
.80

.95
.94
.92
.91
.82

.95
.92
.9 1
.82

.95
.94
.9 1
.90
.8 1

55.1

.96

.97

.96

.97

.97

7.6
5.8
3.9
3.0

Reliability (Cronbach's

a)d

Eigen-

" Intercorrelations among factors: emotional abuse with emotional neglect, r = .62, sexual abuse, r = .43, physical abuse, r = .77, physical
neglect, r = .56, emotional neglect with sexual abuse, r = .33, physical abuse, r = .49, physical neglect, r = .50, sexual abuse with physical
abuse, r = .43, physical neglect, r = .43, physical abuse with physial neglect, r = .55, all correlations, p < .001.
Items loading greater than .4 based on principal-components analysis; items assigned to single factor with highest loading.
'Sum of unweighted raw item scores.
dSample sizes for reliability analyses: males, n = 171; females, n = 227; 12- to 14-year-olds, n = 148; 15- to 17-year-olds, n = 247;
entire sample, n = 398.

'

between CTQ scores and therapists' maltreatment ratings, a series of logistic regression analyses was performed with the five CTQ factors entered
simultaneously and each form of maltreatment rated
by the therapists serving in turn as a separate dependent
variable. These analyses indicated that the relationship
between CTQ factors and analogous therapists' ratings
was highly specific (Table 3). When therapists' ratings
of the presence or absence of sexual abuse were used
as the dependent measure, only the CTQ sexual abuse
factor made a unique positive contribution to the
logistic regression model, as indicated by a significant

odds ratio; moreover, CTQ physical neglect was inversely related to therapists' ratings of sexual abuse.
Similarly, therapists' ratings of physical abuse were
uniquely predicted by the CTQ's physical abuse factor.
Therapists' ratings of emotional abuse were positively
associated with the CTQ's physical abuse and emotional abuse factors (the latter at a trend level of
significance), while showing a negative association with
the physical neglect factor. Finally, therapists' ratings
of physical neglect were associated only with the CTQ's
physical and emotional neglect factors. Thus, when
the CTQ factors were allowed to compete with one

TABLE 3
Relationship Between Childhood Trauma Questionnaire (CTQ) Factors and Therapists' Maltreatment Ratings in Adolescent Psychiatric
Patients: Correlational and Logistic Regression Analyses
Therapists' Maltreatment Ratings
Sexual Abuse

CTQ Factors
Sexual abuse
Physical abuse
Emotional abuse
Physical neglect
Emotional neglect

r"

Odds'

.72***
.27***
.32***
.20***
.16**

1.37"'
1.03
1.oo
0.84"'
1.01

Physical Abuse
r"
.22***
.59"**
.49***
.42***
.37***

Emotional Abuse

Oddsb

r"

Oddsb

0.98
1.21***
1.oo
1.01
1.01

.24***

1.02
1.11"'
1.04'
0.92**
1.01

.46***
.46***
.24***
.30***

Physical Neglect
r"
.27***
.30***
.28***
.42***

.36"'*

Oddsb
1.04
1.04
0.96
1.13***
1.03**

Point-biserial correlations between CTQ factors and therapists' maltreatment ratings. Sexual abuse, n = 167; physical abuse, n = 169;
emotional abuse, n = 169; physical neglect, n = 173.
Results of logistic regression analyses. Odds greater than one indicate positive association between CTQ factors and therapists' ratings;
odds less than one indicate negative (i.e., inverse) association. Sexual abuse, n = 167; physical abuse, n = 169; emotional abuse, n = 169;
physical neglect, n = 173.
* p < . l ; * * p < .05; * * * p < .01.

'

344

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, A R C H 1997

V A L I D I T Y OF T H E CTQ I N A D O L E S C E N T S

of patients without physical abuse. The emotional

abuse factor correctly classified nearly four fifths of
emotionally abused patients and over seven out of ten
patients without emotional abuse. Finally, the physical
neglect factor correctly identified nearly four fifths of
physically neglected patients and more than 6 out of
10 patients without physical neglect. The area under
the ROC curve was significant for all forms of maltreatment we examined, indicating that the CTQ improved the likelihood of detecting true cases of abuse
and neglect over that which would be expected by
chance, given the base rates of these forms of trauma
in the sample (Table 4).
When the CTQ factors were used to estimate the
prevalence of maltreatment in the sample as a whole,
39.0% of patients ( n = 153) met the cutoff score for
sexual abuse, 44.7% ( n = 178) for physical abuse,
45.5% ( n = 180) for emotional abuse, and 48.9% ( n =
194) for physical neglect; 71.9% ( n = 286) of patients
met the cutoff score for at least one form of maltreatment, and 5 1.3% ( a = 204) for two or more forms
of maltreatment. A significantly greater proportion of
female patients met CTQ cutoff scores for sexual abuse
(female = 47.8%, male = 27.4%,
= 16.77, df = I,
p < .001) and emotional abuse (female = 51.8%,
male = 37.1%,
= 8.47, df = 1 , p < .Ol), but rates

another in the same regression model, their correspondence with equivalent therapists ratings was quite
precise. No significant interactions between gender
and the CTQ factors were found, indicating that
relationships between therapists ratings of maltreatment and the CTQ factors were equivalent in
male and female patients.
ROC analysis was then used to determine the sensitivity and specificity of the CTQ factors at various test
thresholds (i.e., cutoff scores), when therapists ratings
of maltreatment were used as the criterion. These
analyses indicated that the CTQ succeeded in detecting
a high proportion of abused and neglected patients,
based on therapists ratings, while keeping false-positive
errors to acceptable levels (Table 4). In keeping with
the CTQs intended purpose as a screening instrument,
we selected the following cutoff scores to emphasize
test sensitivity over specificity: sexual abuse, 9; physical
abuse, 12; emotional abuse, 30; and physical neglect,
12. When these respective cutoff scores were used, the
CTQs sexual abuse factor correctly classified more
than four out of five sexually abused patients, based
on therapists ratings, and about three out of four
patients without sexual abuse. Similarly, the physical
abuse factor correctly identified more than four fifths
of physically abused patients and nearly three quarters

x2

x2

TABLE 4
Sensitivity and Specificity (With Confidence Intervals) of Childhood Trauma Questionnaire (CTQ
Factors for Therapists Ratings of Maltreatment in Adolescent Psychiatric Patients
~~

Sexual Abuse
(Range = 7-35)
Cut

8
9
10
11
12
13
14
15
16
17
18

Sensitivity

36
.86
34
.84
.79
.79
.77
.74
.70
.70
.67

Specificity

(.71-.94)
(.71-.94)
(.69-.93)
(.69-.93)
(.64-39)
(.64-39)
(.61-38)
(.59-.92)
(.54-32)
(.54-32)
(.51-30)

.68 (.59-.76)
.76 (.67-33)
.79 (.71-36)
.82 (.73-38)
.86 (.79-32)
.90 (.82-.94)
.92 (.85-.96)
.92 (.85-.96)
.94 (37-.97)
.94 ( 3 8 - 3 8 )
.96 (.90-.99)

Physical Abuseb
(Range = 7-35)
Sensitivity

.97
.94
.94
37
.82
.79
.77
.74
.71
.68
.61

(37-.99)
(34-.98)
(34-.98)
(.76-.94)
(.70-.90)
(.66-38)
(.65-37)
(.61-34)
(.58-.81)
(.54-.79)
(.48-.73)

Physical Neglect
(Range = 8 4 0 )

Specificity

.35
.48
.59
.64
.73
.77
.82
.84
.85
.89
.89

(.26-.44)
(.39-.58)
(.49-.68)
(.54-.72)
(.63-.81)
(.68-34)
(.73-38)
(.75-.90)
(.77-.91)
(3-.94)
(3-.94)

Sensitivity

1.0 (.91-1.0)
.95 (.82-.99)
.93 (.79-.98)
.80 (.65-.91)
.78 (.62-29)
.68 (.52-31)
.61 (.44-.75)
.59 (.42-.73)
.54 (.38-.69)
.54 (.38-.69)
.51 (.35-.67)

Specificity

0.0 (0.0-.03)

.20
.36
.50
.61
.73
.78
.83
.87
.90
.91

(.14-.29)
(.28-.44)
(.41-.58)
(.53-.70)
(.64-30)
(.70-34)
(.75-39)
(.80-.92)
(.83-.94)
(.85-.95)

Emotional Abused
(Range = 12-60)
Cutf

Sensitivity

Specificity

26
27
28
29
30
31
32
33
34
35
36

.87 (.76-.94)
.84 (.72-.92)
.79 (.66.88)
.79 (.66-38)
.79 (.66.88)
.76 (.63-35)
.74 (.61-.84)
.73 (.60-.83)
.69 (.56.80)
.65 (.51-.76)
.61 (.48-.73)

.59 (.49-.68)
.61 (.52-.70)
.63 (.53-.72)
.67 (.57-.76)
.72 (.62-20)
.72 (.63-.80)
.73 (.64.81)
.75 (.66-33)
.75 (.66.83)
.78 (.68-34)
.78 (.69-235)
~

True positives

<

43, true negatives = 124, area under the receiver operating characteristic (ROC) curve

0.88 (SE

0.04), z

~~~

8.10,

.0001.

True positives = 62, true negatives = 110, area under the (ROC) curve = 0.85 (SE = 0.03), z = 7.72, p < .0001.
True positives = 41, true negatives = 135, area under the (ROC) curve = 0.78 (SE = 0.04), z = 5.37, p < .0001.
dTrue positives = 62, true negatives = 109, area under the (ROC) curve = 0.78 (SE = 0.04), z = 6.17, p < .0001.
Cutoff scores for CTQ sexual abuse, physical abuse, and physical neglect factors.
fCutoff scores for CTQ emotional abuse factor.

J. A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 6 : 3 , M A R C H 1 9 9 7

345

BERNSTEIN E T AL

of physical abuse and physical neglect did not differ

between the two genders (physical abuse: female =
48.0%, male = 40.4%,
= 2.32, df = 1, p > .1;
physical neglect: female = 50.4%, male = 46.8%,
=
0.52, df= 1, p > .1).

x2

x2

DISCUSSION

These findings replicate our previous factor-analytic

results and provide initial support for the validity of
the CTQ in an adolescent psychiatric population. PCA
of the CTQ resulted in a five-factor solution nearly
identical with that obtained in a sample of substanceabusing adults (Bernstein et al., 1994). The only exception was that in the adolescents, physical and emotional
abuse items loaded on separate factors, while in the
adults, they loaded on a single factor. The internal
consistency reliability of the CTQ factors was extremely
high, both in the adolescent sample as a whole and
in every subgroup we examined. Furthermore, when
CTQ factor scores were compared with therapists
maltreatment ratings based on all available data, relationships between the two sets of variables were highly
specific, supporting the convergent and discriminant
validity of the CTQ. Finally, when therapists ratings
were used as the validating criterion, the CTQ exhibited
good sensitivity for all forms of maltreatment we examined, along with satisfactory or better levels of specificity, suggesting that the CTQ is an effective screening
measure for childhood trauma in an adolescent psychiatric setting.
These findings also add to a growing literature
indicating a high prevalence of abuse and neglect in
clinically referred adolescents. More than 50% of the
sample were rated as abused or neglected by their
therapists, and more than 70% reported maltreatment
on the questionnaire. These prevalence rates were comparable with or greater than those reported in previous
studies of similar populations (Cavaiola and Schiff,
1988; Dembo et al., 1988; Edwall et al., 1989; Sansonnet-Hayden et al., 1987). Consistent with previous
studies, we found that reports of sexual abuse were more
frequent among adolescent girls than boys (Finkelhor,
1994). Adolescent girls were also more likely to report
histories of emotional abuse; however, given the rarity
with which emotional abuse has been assessed, further
studies will be needed to replicate this gender difference
in other adolescent samples.

346

In this study, we used an all data validation

strategy that capitalized on the fact that patients primary therapists were privy to information from multiple
sources, including in many cases independent corroborative data that could be used to support their judgments, such as knowledge of Child Protective Service
investigations, court appearances, and removal of the
child from the parental home. Furthermore, the rather
lengthy period of hospitalization (an average stay of 1
to 2 months) gave therapists the chance to make
extended observations of patients and their relatives
and to develop a degree of rapport with patients in a
sheltered setting that often fosters the disclosure of
maltreatment. That therapists rarely made use of the
uncertain rating category, even though they were
repeatedly encouraged to do so, attests to their confidence in their judgments.
Although our findings suggest that adolescents selfreports of childhood trauma are usually credible, in
that they are consistent with therapists best estimate
ratings, it will also be important to investigate the
sources of both false-negative and false-positive reporting errors. There is some evidence that response
biases such as the need for social desirability and
defense mechanisms such as repression may lead to
the underreporting of maltreatment (Guenther and
Frey, 1990; Joubert, 1991); on the other hand, deliberately false allegations of abuse by adolescents, although
apparently rare (Everson and Boat, 1989), may produce
false-positive trauma reports in some instances. T o
address these issues, we are reviewing the records of our
adolescent patients in cases in which their questionnaire
responses and therapists ratings differed, as well as
comparing patients CTQ responses to their profiles
on the validity scales of the Minnesota Multiphasic
Personality Inventory-2 (Hathaway and McKinley,
1989). These and similar studies should increase our
understanding of the exceptional circumstances in
which adolescents trauma reports may not be validly interpreted.
These findings need to be considered in light of
certain limitations. First, therapists maltreatment ratings do not constitute a gold standard in the true
sense. Although therapists were kept blind to patients
CTQ responses, their ratings were not entirely independent, in that they were based in part on information
provided by the patient. Furthermore, therapists ratings themselves are subject to possible errors, because

J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 6 : 3 , M A R C H 1997

VALIDITY OF T H E C T Q I N ADOLESCENTS

corroborating suspected maltreatment cases can be difficult, and definitively verifying noncases, nearly impossible (Briere, 1992). Previous research suggests that the
nondetection of true maltreatment cases (i.e., false
negatives) is more common than the false detection
of noncases (i.e., false positives) (Briere, 1992). Some
true cases of abuse or neglect might therefore be
detected by a questionnaire but be unknown to therapists, a misclassification that would underestimate the
specificity of the test by misclassifying true-positive
cases on the questionnaire as false positives. This might
occur, for example, if some adolescents felt more comfortable disclosing their maltreatment histories on a
questionnaire than in a clinical interview or therapy
session. In support of this view, many of the adolescents
rated as uncertain by their therapists were classified
as positive maltreatment cases by the CTQ 5 of 11
uncertain cases of sexual abuse, 7 of 9 uncertain cases
of physical abuse, 6 of 9 uncertain cases of emotional
abuse, and 4 of 5 uncertain cases of neglect. Estimates
of the specificity of the CTQ given in this report are
therefore best regarded as representing the lower limit
of the true specificity of the questionnaire.
Second, we could have used other approaches to
validate the trauma histories obtained with the CTQ.
For example, child welfare records could have been
used as the validating criterion, rather than therapists
ratings. However, this strategy also has its limitations.
For example, many cases of abuse and neglect never
come to the attention of child welfare agencies (Finkelhor, 1994) and a variety of factors can affect the
accuracy of Child Protective Service reports (Eckenrode
et al., 1988). In fact, the corroboration of childhood
trauma faces inherent difficulties, such as the passage
of time and the secrecy often surrounding these experiences (Briere, 1992). An absolute means of verification
(i.e., a true gold standard) is therefore rarely available.
For this reason, we used an all data validation
strategy, in which therapists were asked to pool information from multiple sources rather than relying on a
single source of corroboration. However, studies using
a variety of methodological approaches will be needed
to fully address this complex issue.
Third, the elapsed time between patients completion
of the CTQ and administration of the therapist interviews might have influenced our findings, although
the direction of any possible effect is difficult to determine. O n the one hand, certain cases may have appeared

J. AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 3 6 : 3 , MARCH 1997

less ambiguous in hindsight than they did in vivo; on

the other hand, the deterioration of memory over
time may have produced greater ambiguity in case
determination. Although we attempted to mitigate
against such factors by providing therapists with copies
of their own reports from the hospital charts, it is still
conceivable that a shorter interval might have produced
different results. Finally, our findings regarding sensitivities, specificities, cutoff scores, and other results of
the ROC analyses are most conservatively generalized
to adolescent inpatient settings until they can be replicated in other groups of adolescent patients (e.g.,
outpatients).
Our findings support the use of the CTQ for both
research and clinical purposes. Research on the causes
and consequences of child abuse and neglect has often
been hampered by unvalidated instruments (Briere,
1992). Our validation of the CTQ using an operationally defined external criterion-therapists ratings that
capitalized on all available data about the patientshould help provide a more solid methodological basis
for maltreatment assessment in future research.
As a clinical instrument, the CTQ provides rapid
screening for history of child abuse and neglect. When
used in conjunction with other available data, it may
help to identify adolescents who, by virtue of their
trauma histories, are at risk for developing a broad
range of psychiatric symptoms and behavior problems,
including posttraumatic stress disorder, addictions, depression, delinquency, and self-injurious behavior
(Kendall-Tackett et al., 1993). Moreover, the scale
gives clinicians a means of initiating a dialog with
adolescents about sensitive topics that might otherwise
go undisclosed. Querying adolescents about their questionnaire responses during follow-up interviews or therapy sessions can lead to the disclosure of further details,
such as the identity of perpetrators, victimization of
other family members, and whether the reported maltreatment was in the past or is still ongoing. Although
clinicians should exercise caution regarding the potentially distressing nature of this material, allowing patients to explore these issues at their own pace (Brooks,
1985)) a discussion of adolescents questionnaire responses may reveal important additional information
about childhood events and open up a therapeutic
dialog in which maltreatment experiences can begin
to be explored.

347

B E R N S T E I N E T AL.

As is the case for any psychological test, however,

the CTQ is not a substitute for a clinicians own
judgment. The CTQs proper clinical use is as a
screening instrument; it is not itself a gold standard
for assessing childhood trauma. Clinical judgment must
therefore be used in interpreting responses to the
questionnaire, taking into account all available information about the patient. When used as part of an
integrated evaluation procedure, the CTQ can provide
informarion that may help clinicians make informed
treatment decisions.
In conclusion, research suggests that childhood maltreatment is often underreported in clinical settings
but that systematic assessments may increase rates of
disclosure (Briere and Zaidi, 1989). Adolescents may
be reluctant to reveal such experiences in interviews
or therapy sessions, not only because of feelings of
shame and guilt, but also because of their need for
autonomy and frequent ambivalence about authority
(Erikson, 1969). The CTQ offers adolescents the opportunity to disclose traumatic experiences in a selfreport format that may be congruent with their own
needs for privacy. Our findings suggest that it is a
sensitive and valid means of screening adolescents for
a history of childhood maltreatment.

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