Racial Differences in Children’s Trauma Symptoms Following Complex Trauma Exposure

Abstract

Complex trauma exposure has been defined as multiple or chronic interpersonal trauma that begins early in life, which leads to widespread dysregulation. Previous studies have reported that minorities may be at greater risk for trauma exposure and symptoms; yet, racial differences have not been investigated in the context of complex trauma. The aim of the present study was to determine if there are racial disparities in children’s trauma exposure and outcomes among 167 child survivors of complex trauma (3-18 years, M = 9.90, SD = 3.92; 61.67% female; 62.2% Black). Black children endorsed a greater number of trauma types and were more likely to have experienced community violence and have been placed in child protective custody than White children. Caregivers of White children endorsed higher levels of select internalizing symptoms and social concerns whereas Black children reported higher levels of sexual concerns than White children. White children who experience complex trauma may be at higher risk for some trauma-related difficulties. Alternatively, caregivers of White children may perceive them to have, or be more willing to acknowledge, higher levels of symptoms than Black children. Future work is needed to further investigate the role of race in disclosure of trauma exposure and related symptoms.

Keywords

complex trauma children racial differences posttraumatic stress disorder

Childhood trauma exposure, in the form of physical abuse (PA), sexual abuse (SA), neglect, domestic violence (DV), or community violence (CV), occurs with alarming regularity. Prevalence rates with representative samples indicate that approximately two thirds of children have experienced a traumatic event (Copeland, Keeler, Angold, & Costello, 2007; Finkelhor, Ormrod, & Turner, 2009). The serious implications of these high rates are underscored by the compelling evidence that pediatric trauma exposure is strongly linked with a plethora of chronic and adverse psychological and physical health outcomes (Brown et al., 2009; Copeland et al., 2007; Finkelhor et al., 2009). Furthermore, for many children, traumatic exposure is not limited to experiencing an acute or single trauma but, rather, is chronic and includes multiple forms. Finkelhor, Ormrod, and Turner (2007) documented that in a single year, 64.5% of trauma-exposed children experienced more than one type of trauma, 22% experienced four or more, and 8% experienced seven or more. As prior studies have demonstrated that there is a dose–response relationship between number of trauma exposures and symptoms (e.g., Copeland et al., 2007; Hodges et al., 2013), the negative effects of trauma may be amplified in the context of multiple traumas. Although this research highlights the importance of prioritizing survivors of chronic and multiple traumas and suggests that they may present differently than those whose trauma exposure is more confined, relatively little research has been conducted with this subgroup compared with studies utilizing survivors of single types of trauma.

Various terms have been used in the literature to describe the experience of multiple, chronic trauma including Type II trauma (Terr, 1991), polyvictimization (Finkelhor et al., 2007), accumulated trauma (Briere, Kallman, & Green, 2008), and complex posttraumatic stress disorder (PTSD)/complex trauma (Cook et al., 2005; Herman, 1992). Although the precise definitions differ, these terms overlap in the focus on survivors of more extensive and chronic trauma. Of these constructs, complex trauma is unique in that two complex trauma-focused disorders (i.e., Disorders of Extreme Stress not Otherwise Specified [DESNOS], van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005; Developmental Trauma Disorder [DTD], van der Kolk, 2005), were proposed, albeit unsuccessfully, for inclusion into the Diagnostic and Statistical Manual of Mental Disorders (DSM). Complex trauma was coined to describe the full impact of severe and repeated trauma such as chronic SA or DV, or being a refugee of exposure that was not captured by PTSD (Herman, 1992). Exposure to complex trauma is thought to result in trauma-related dysregulation that impairs functioning in a variety of domains (Cook et al., 2005; van der Kolk, 2005) and has been associated with higher levels of trauma-related symptoms than more acute forms of trauma (Wamser-Nanney, 2016; Wamser-Nanney & Vandenberg, 2013; Cloitre et al., 2009).

Despite the development of two complex trauma diagnostic constructs, there is a dearth of complex trauma research. One gap in this literature is determining whether minority stress in the United States is a risk factor for higher levels of trauma exposure and trauma-related symptoms among children who experienced complex trauma. Using American samples of racial minorities, minority status is related to increased probability for trauma exposure and symptoms (Asnaani & Hall-Clark, 2017; Brewin, Andrews, & Valentine, 2000; Roberts, Gilman, Breslau, Breslau, & Koenen, 2011; Trickey, Siddaway, Meiser-Stedman, Serpell, & Field, 2012). Minority, in the present study, refers to racial minorities in the United States.

As complex trauma is conceptualized to result in a fundamentally different symptom presentation than exposure to more acute trauma (Cook et al., 2005; van der Kolk, 2005), it is important to specifically examine potential racial differences in the context of complex trauma as findings from the acute literature may not extrapolate to complex trauma. Consequently, the aim of the present study was to investigate trauma-related symptom differences between White and Black child survivors of complex trauma, operationalized as chronic or multiple interpersonal trauma(s) that begins early in life, as previously used (Wamser-Nanney, 2016; Wamser-Nanney & Vandenberg, 2013).

Racial Differences in Trauma Exposure and Symptoms

No studies to date have examined racial differences in levels of trauma exposure and trauma-related symptoms following complex trauma, and relatively few studies have been devoted to racial equivalence in trauma exposure and symptoms in child trauma samples. Yet, national data suggest that minority children are at higher risk for trauma exposure. National prevalence rates of child maltreatment are higher for Black children (14.5 per 1,000 children) and Native American children (13.8 per 1,000 children) than White children (8.1 per 1,000 children; Child Welfare Information Gateway, 2017). Minority status is often found to be a risk factor for childhood trauma exposure (López et al., 2017; Roberts et al., 2011; Sedlak et al., 2010). For example, Sedlak and colleagues (2010) observed that Black children were twice as likely to experience maltreatment than White children and Black children were more likely to experience more severe forms of maltreatment compared with other racial groups. Reasons for the observed differences in trauma exposure are likely a function of racial disparities in resources and limited socioeconomic mobility, institutional racism, and segregation and social isolation (Shihadeh & Flynn, 1996; Williams & Williams-Morris, 2000).

Nonetheless, some studies using either child protective services (CPS) or treatment-seeking samples have reported lower levels of trauma exposure among minorities (Contractor et al., 2015; Lau et al., 2003; Salazar, Keller, Gowen, & Courtney, 2013). Among adolescents in foster care, White children had higher levels of trauma exposure and reported higher levels of every trauma type except indirect trauma than Black children (Salazar et al., 2013). Nonetheless, Miller, Green, Fettes, and Aarons (2011) found that Black youth in CPS were at higher risk for trauma exposure. In a large sample treatment-seeking youth, White children were more likely to have experienced several forms of trauma than minority children (e.g., PA, DV, war, injury, and accidents; Contractor et al., 2015). Conflicting findings may be attributed to sample type (i.e., national surveys vs. treatment-seeking and foster care samples). Indeed, differences in trauma exposure among children in CPS should be interpreted carefully given the context of racial disparities regarding CPS placement (Knott & Donovan, 2010; Lu et al., 2004).

The picture is less clear regarding minority status as a risk factor for higher levels of trauma-related symptoms among children. Although differences have not consistently emerged (Godinet, Li, & Berg, 2014; Hatcher, Maschi, Morgen, & Toldson, 2009; Koolick et al., 2016), several studies have reported that minority children exhibit higher levels of trauma-related symptoms (Kilpatrick et al., 2003; Lengua, Long, Smith, & Meltzoff, 2005; Ross & Kearney, 2015; Trickey et al., 2012). Minority status does predict PTSD symptoms, although the amount of variance explained is small (Trickey et al., 2012). As the limited research in this area is conflicting, the role of minority status in trauma exposure and symptom expression among children remains unclear.

The pediatric literature parallels studies from the adult trauma literature focused on racial differences in response to trauma more broadly, which generally finds minority status to be a risk factor for both trauma exposure (Breslau et al., 1998; Hatch & Dohrenwend, 2007) and levels of symptomology (Perilla, Norris, & Lavizzo, 2002; Pole, Best, Metzler, & Marmar, 2005). One meta-analysis reported that minority status is associated with a small effect size for PTSD risk (Brewin et al., 2000). Levels of PTSD risk are not equivalent across racial minority groups. For instance, Roberts and colleagues (2011) observed a higher PTSD risk among Black Americans and a lower risk among Asians than White Americans, even after adjusting type and number of traumas. A recent review concluded that Black Americans, Latino Americans, and Native Americans have the highest rates of PTSD (Asnaani & Hall-Clark, 2017). Nonetheless, as in the pediatric literature, findings are also inconsistent (Friedman, Schnurr, Sengupta, Holmes, & Ashcraft, 2004; Widom, Czaja, Wilson, Allwood, & Chauhan, 2012). Still, on balance, the bulk of the literature suggests that minorities may be more vulnerable to experiencing trauma as well as its adverse effects.

Explanations for Racial Disparities in Trauma Exposure and Symptoms

Racial inequities regarding trauma exposure and symptoms should be understood in the context of larger sociopolitical framework. Higher levels of trauma-related distress are consistent with the differential vulnerability hypotheses (Dohrenwend & Dohrenwend, 1969) and minority stress models (Clark, Anderson, Clark, & Williams, 1999) that aim to understand the mental health disparities of minorities and posit that these differences can be understood in large part by stressors present in a prejudiced/racist environment. In addition, different patterns of adverse experiences, such as discrimination, race-related verbal assault, or stigmatization, may render minorities as more vulnerable to exposure or may be part of the traumatic experience itself (Pole, Gone, & Kulkarni, 2008; Roberts et al., 2011).

Despite the observed racial disparities in trauma exposure and subsequent symptoms, it is unknown whether this is due to key contextual factors such as socioeconomic status (SES), which may partially drive this increased risk. Indeed, SES is a small but significant predictor of PTSD (Brewin et al., 2000) and may act as a risk or protective factor for both trauma exposure and PTSD development (Roberts et al., 2011). However, SES does not fully account for symptom differences (Perilla et al., 2002; Pole et al., 2005). Symptom differences may also be explained by disparities in type of trauma exposure. Black adults may be more likely to experience traumas that carry a higher conditional risk of PTSD (e.g., violent victimization, active combat) than White adults (Breslau et al., 1998; Roberts et al., 2011). Further research is necessary to elucidate the potential for race as a risk factor for trauma-related symptoms.

Racial Differences Following Complex Trauma

Although no prior research—in either the adult or child literature—has examined racial differences among survivors of complex trauma, one study investigated racial disparities among treatment-seeking children who experienced multiple types of trauma and reported that White children were more likely to have a history of multiple forms of trauma and at least one clinical diagnosis than Black or Latino children (Greeson et al., 2011). Nonetheless, relevant factors such as SES or CPS placement were not examined. Conversely, in a national sample of adolescents, Black and Hispanic youth reported higher levels of polyvictimization and symptoms of PTSD and depression than White youth (Andrews et al., 2015). While informative, these studies were not specific to complex trauma and this research is still needed as complex trauma is thought to be a distinct form of trauma exposure (Cook et al., 2005; van der Kolk et al., 2005) that is related to a more complicated and severe symptom profile (Wamser-Nanney, 2016; Wamser-Nanney & Vandenberg, 2013). Evidence of racial differences in symptoms following complex trauma may indicate increased vulnerability to the impact of complex trauma exposure, which has important implications for the conceptualization of complex trauma, and complex trauma research and clinical work.

The Current Study

The primary aims of the present study were to investigate racial differences in types of trauma(s) experienced, aspects of the traumatic event, and trauma-related symptoms among child survivors of complex trauma. Complex trauma was operationalized as chronic interpersonal trauma that began early during children’s development (Wamser-Nanney, 2016; Wamser-Nanney & Vandenberg, 2013). A caregiver identified the child’s race/ethnicity on a categorical form, and the two largest groups in the sample were White children and Black children. To better interpret any observed racial disparities, racial differences in trauma ecologies were examined, including age, type and number of trauma(s), whether the perpetrator was a caregiver, and whether the child was placed into CPS custody. Consistent with prior studies of trauma-exposed children (e.g., Kilpatrick et al., 2003; Lengua et al., 2005), it was hypothesized that Black children and their caregivers would be more likely to report experiencing various types of traumatic events than their White counterparts. Black children were also expected to be placed into CPS custody more frequently than White children (Knott & Donovan, 2010; Lu et al., 2004). Following exposure to complex trauma, both Black children and their caregivers were anticipated to report higher levels of PTSD and other trauma-related symptoms than White children and their caregivers.

Method

Participants

One hundred forty-eight children and adolescents between the ages of 3 and 18 years (M = 10.31, SD = 3.79) who sought treatment with their non-offending legal guardian from a Child Advocacy Center (CAC) participated in the study. There were no exclusionary criteria. The large sample was predominately composed of Black and Caucasian children (63.7% Black, 30.7% Caucasian, 1.4% Hispanic, and 4.2% Biracials/Multiracials). Due to small ns of other minority groups, only Black and Caucasian children were included. Of this subsample, 62.2% were Black, 37.8% were Caucasian, and 62.8% were female, 37.8% male. Household income was rated categorically, with a mean household income of 2.28 (SD = 1.30), which corresponds to US$20,000 to US$40,000. The majority of the children experienced SA (76.6%; see Table 1).

Table 1.

Children’s Exposure to Traumatic Events.

	Percentage Endorsed
Sexual abuse	76.6
Domestic violence	48.5
Physical abuse	46.1
Emotional abuse	42.5
Neglect	41.9
Death of a loved one	16.2
Community violence	13.8
Serious illness	6.6
Serious injury/accident	2.4
Natural disaster	1.8
School violence	1.8
Kidnapping	1.8
War/terrorism	0.6

Measures

Child Behavior Checklist (CBCL/6-18)

The CBCL is a frequently used 113-item measure of children’s symptomatology completed by caregivers of children ages 6 to 18 (Achenbach & Rescorla, 2001). The CBCL yields eight subscales: Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior, and Aggressive Behavior, as well as three total subscales: Internalizing, Externalizing, and Total Problems. Items are rated on a 3-point Likert-type scale from 0 = not true to 2 = very/often true. The CBCL’s content, construct, and criterion-related validity have been well-documented. The Cronbach’s α has ranged from .78 to 1.0 (Achenbach & Rescorla, 2001), and was .95 for this study.

Trauma Symptom Checklist for Young Children (TSCYC)

The TSCYC is a 90-item assessment tool to measure children’s PTSD and other trauma-related symptoms for caregivers of children ages 3 to 12 (Briere, 2005). The TSCYC yields eight subscales: PTS-Intrusion, PTS-Avoidance, PTS-Arousal, Sexual Concerns, Anxiety, Depression, Dissociation, and Anger. Items are rated on a 4-point Likert-type scale, 0 = never to 3 = almost all of the time/very often. The TSCYC has demonstrated good reliability, with α coefficients from .81 to .93, as well as predictive validity for childhood trauma (Briere et al., 2001). Cronbach’s α for this study was .94.

Trauma Symptom Checklist for Children (TSCC)

The TSCC is a 54-item self-report instrument that measures children’s trauma-related symptoms for children ages 8 to 16 (Briere, 1996). The TSCC provides validity subscales and clinical subscales for anxiety, depression, anger, PTS, dissociation, and sexual concerns. Symptoms are rated on a 4-point Likert-type scale, 0 = never to 3 = almost all of the time. Alpha coefficients for clinical scales ranged from .77 to .89 in the standardization sample, and adequate convergent, divergent, and predictive validity have been demonstrated in normative and clinical samples. Here, the Cronbach’s α was .93.

UCLA PTSD Index for Diagnostic and Statistical Manual of Mental Disorders (4th ed.;

DSM-IV) Child Version (UPID). The UPID is a 48-item child self-report measure for school-aged children (7-18 years old). It measures both exposure to a variety of traumatic events and DSM-IV (American Psychiatric Association, 1994) PTSD symptoms (Pynoos, Rodriguez, Steinberg, Stuber, & Frederick, 1998). Children rate their level of PTSD symptoms in the previous month in regard to the traumatic event that distresses them most on 5-point Likert-type scale, 0 = never to 4 = most of the time. Satisfactory psychometric properties have been previously documented (Pynoos et al., 1998). In the present study, Cronbach’s α = .77.

Procedure

Study participants were children and their legal guardians who were seeking trauma-focused treatment from a CAC in the Midwest. This subsample was selected from a larger study that examined the empirical support for the complex trauma definition in children (Wamser-Nanney, 2016; Wamser-Nanney & Vandenberg, 2013). CACs are child trauma specialty clinics, and this particular CAC includes forensic interviewing and trauma-focused treatment services. Archival data from patients who received services between 2004 and 2011 were obtained from an existing database collected initially created for program evaluation. Children were eligible for inclusion in the study if they had completed an intake evaluation and had experienced complex trauma. The child’s legal guardian reported on the child’s demographic information, including the child’s race and ethnicity. Participants self-selected their child’s racial and ethnic categories (e.g., White, Black, and Hispanic) on the demographic questionnaire. Both the child and their legal guardian reported on the child’s trauma exposure. As part of routine clinical practice, measures were completed at the beginning of treatment (i.e., first three sessions). The study was approved by the Institutional Review Board of the University of Missouri- St. Louis.

Traumatic exposure

Two independent raters, who were blind to the child’s level of symptoms, rated both the nature (i.e., interpersonal or noninterpersonal) and the chronicity (i.e., chronic or acute) of the child’s trauma exposure (Wamser-Nanney, 2016; Wamser-Nanney & Vandenberg, 2013). Raters were trained research assistants from the CAC who had received training by the first author to code the trauma definitions. Interpersonal traumas were SA, PA, emotional abuse (EA), neglect, DV, homicide, kidnapping, war/terrorism, CV, and school violence. Noninterpersonal traumas were serious illness, serious injury/accident, suicide, natural disaster, and death of a loved one. A trauma was chronic if it occurred for 6 months or longer. If the child was reported to have experienced either multiple episodes of trauma, single instances of trauma perpetrated by different individuals, or different types of traumas that occurred for 6 months or more, it was coded as chronic. In the event of a rater disagreement, the first author made the final decision. Interrater reliability was adequate for the nature of the trauma (Kappa = .69) and the chronicity of the trauma (Kappa = .74).

Results

Preliminary Analyses

Age was examined in relation to the measure subscales, and no differences emerged on either the CBCL, TSCYC, or UPID, although a small inverse correlation was observed for the TSCC hyper-response validity scale, r = −.20, p = .04. Age was not used as a covariate in the analyses. Gender was not investigated within this article as a separate article using this sample is being devoted to gender differences among children who have experienced complex trauma (Wamser-Nanney & Cherry, 2018). Family income was missing in approximately half of the cases (51.5%). The proportion of missing income data was thought to be partially due to half (50.9%) of the sample being accompanied to treatment by an adult who was not their parent. Analyses were then conducted to assess whether the amount of the missing data differed between children who were brought to treatment by someone other than their parent compared with those who were with their parent. Income data were significantly more likely to be present when the child was brought to treatment by his or her parent, χ²(167) = 25.26, p < .001. Indeed, among children brought to treatment by his or her parent, 68% of the income data were complete versus 29.4%. Among the subsample with complete income data, Black children had lower reported incomes than White children (M = 2.00, SD = 1.17, vs. M = 2.63, SD = 1.36). Income was not related to any of the subscales on CBCL, TSCC, TSCYC, or UPID (ps > .05), and due to the lack of relationships with these outcomes and the fair amount of missing data, income was not used as a covariate in the main analyses. Nonetheless, given the importance of contextual variables such as SES when examining racial differences, secondary analyses with the subsample of children who had complete income data were conducted.

Racial Differences for Traumatic Exposure

Chi-square analyses were conducted to see if groups differed on exposure to specific trauma types and particular aspects of the trauma, specifically whether the perpetrator was a caregiver, whether the child was placed into CPS custody, and caregiver-reported number of traumas. Few differences emerged between groups regarding exposure to specific trauma types. As expected, White children were significantly less likely to have experienced CV, χ²(147) = 9.83, p = .002. Black children were marginally less likely to have experienced EA than White children, χ²(147) = 5.49, p = .06. Rates of exposure to all other traumatic events were comparable between groups (ps > .05). Black children were more likely to have been placed into CPS custody, χ²(147) = 17.42, p < .001, as well as be accompanied to treatment by a non-parent than White children (64.1% vs. 33.9%); χ²(167) = 12.83, p < .001. No racial differences emerged for whether the child was abused by a caregiver or for the number of caregiver-reported trauma types (ps > .05).

Caregiver-Reported Racial Differences

In contrast to expectations that caregivers of minority children would report higher levels of symptoms on the CBCL, caregivers of Black children reported lower levels of anxiety/depression, t(115) = 2.09, p = .03, d = .40; social concerns, t(115) = 2.19, p = .03, d = .41; and internalizing symptoms, t(115) = 2.06, p = .04, d = .40; each consistent with a small effect size (see Table 2). The other CBCL subscales were equivalent between groups. On the TSCYC, anxiety concerns were slightly lower among Black children than White children, t(96) = 1.82, p = .07, consistent with a small effect size of d = .38. No other subscales significantly differed; however, small effect sizes were observed for both the PTSD-avoidance symptoms (d = .24) and Sexual Concerns subscales (d = .22), with caregivers of White children reporting higher levels of symptoms compared with caregivers of Black children.

Table 2.

Caregiver-Reported Symptom Levels by Race.

	Black		White		t	d
	M	SD	M	SD	t	d
CBCL
Anxious/depressed	61.61	10.524	65.91	10.965	2.09*	.40
Withdrawn/depressed	63.89	10.31	63.56	10.1	−0.17	.03
Social problems	60.3	8.802	64.28	10.493	2.19*	.41
Somatic complaints	63.92	9.58	65.12	11.46	.61	.12
Thought problems	63.49	9.711	63.35	9.781	−0.07	.01
Attention problems	66.18	12.57	67.77	12.51	0.66	.13
Rule-breaking behavior	65.05	9.4	62.28	8.69	−1.58	.30
Aggressive behavior	64.32	11.26	64.51	11.67	0.09	.02
Internalizing problems	61.66	12.16	66.21	10.25	2.06*	.40
Externalizing problems	63.62	12.55	63.23	10.03	−0.17	.03
Total problems	65.08	11.24	66.6	9.63	0.74	.14
TSCYC
Response level	46.21	9.45	46.05	6.12	−0.09	.02
Atypical response	55.23	13.08	53.83	11.99	−0.54	.11
Anxiety	60.63	18.64	67.12	15.47	1.87^†	.38
Anger	62.28	16.75	60.59	18.79	1.82	.05
Depression	64.23	17.75	65.17	18.05	0.26	.09
PTSD-Total	69.7	18.77	72.78	17.92	0.82	.17
PTSD-Intrusion	68.09	20.06	71.51	20.34	0.83	.17
PTSD-Avoidance	68.74	19.42	73.44	19.47	1.18	.24
PTSD-Arousal	63.16	18.12	66.27	17.56	0.85	.17
Sexual concerns	69.6	21.32	74.59	24.06	1.08	.22
Dissociation	61.56	17.06	64.41	21.53	0.73	.15

Note. CBCL = Child Behavior Checklist; TSCYC = Trauma Symptom Checklist for Young Children; PTSD = posttraumatic stress disorder.

†

p < .10. *p < .05. ***p < .001.

Child-Reported Racial Differences

Although no differences emerged on the UPID regarding the symptom subscales, Black children reported experiencing a slightly greater number of types of Criterion A events, t(89) = −1.82, p = .07 (see Table 3). On the TSCC, a significant difference between groups was only observed for the Sexual Concerns Distress subscale, Black children reported higher levels of sexual concerns compared with their White counterparts, t(101) = −2.04, p = .04, d = .40. All other subscales were consistent across groups.

Table 3.

Child-Reported Symptom Levels by Race.

	Black		White		t	d
	M	SD	M	SD	t	d
TSCC
Underresponse	52.73	10.89	50.64	12.44	−0.88	.18
Hyperresponse	58.94	18.58	60.81	20.01	−0.85	.10
Anxiety	54.58	13.65	56.56	14.5	0.47	.14
Depression	53.08	14.09	51.9	12.57	0.46	.09
Anger	50.28	11.88	52.06	12.39	0.71	.15
PTSD-Total	53.99	12.65	53.69	11.7	−0.11	.02
Dissociation	53.15	11.55	53.11	16.69	−0.01	.003
Dissociation-overt	52.85	11.44	53.19	16.59	0.12	.02
Dissociation-fantasy	53.22	12.16	52.03	16.99	0.12	.08
Sexual concerns	61.97	19.56	58.14	21.43	0.11	.18
Sexual concerns-preoccupation	54.64	16.71	53.08	20.43	−0.41	.08
Sexual concerns-distress	67.51	22.6	57.56	25.19	−0.37*	.41
UPID
Criterion B severity	9.19	5.85	9.12	5.96	−0.06	.01
Criterion C severity	10.82	7.09	9.82	6.53	−0.69	.15
Criterion D severity	10.16	4.71	9.88	5.65	−0.27	.05
Total severity score	30.15	15.5	28.68	16.01	−0.45	.09

Note. TSCC = Trauma Symptom Checklist for Children; PTSD = posttraumatic stress disorder; UPID = UCLA PTSD Index for DSM-IV Child Version; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994).

†

p < .10. *p < .05. ***p < .001.

Secondary Analyses Examining Income

Due to the fair amount of missing income data, the main analyses regarding symptoms were conducted again using the subsample of children with complete income data (n = 81). The results were largely the same. As before on the CBCL, caregivers of White children reported lower levels of anxiety/depression, t(555) = 2.20, p = .03; social concerns, t(55) = 1.95, p = .05; and internalizing symptoms, t(55) = 2.45, p = .01. On the TSCYC, the Anxiety subscale no longer differed between groups. For the child-reported measures, the Sexual Concerns Distress TSCC subscale no longer differed between groups and the number of Criterion A events no longer differed by group on the UPID.

Discussion

The primary aim of the present study was to examine racial differences in types of trauma exposure and trauma-related symptoms among children who experienced complex trauma. Little research has previously examined such differences by race among trauma-exposed children in general and no research has investigated racial disparities following complex trauma exposure. Specifically considering the context of complex trauma is important as this form of trauma exposure is thought to result in symptoms that are distinct from more acute forms of trauma, such that two diagnostic constructs have been developed for adults and children (van der Kolk, 2005; van der Kolk et al., 2005).

Consistent with prior studies that have utilized more general trauma-exposed samples, Black children were expected to have been more likely to experience various trauma types than White children; however, there was limited evidence for this hypothesis. Black children were more likely to have experienced CV but were marginally less likely to endorse EA exposure than White children. The observed racial disparity in exposure to CV is consistent with previous literature that Black children have higher rates of CV than other racial groups (Zimmerman & Messner, 2013), and unfortunately this disparity may not decrease with increases in SES (Crouch, Hanson, Saunders, Kilpatrick, & Resnick, 2000). The statistical trend toward White children being more likely to have experienced EA is consistent with a prior study with treatment-seeking trauma-exposed children (e.g., Contractor et al., 2015). As research has not documented higher rates of EA among non-treatment-seeking White children, these findings seem specific to treatment-seeking samples and may not be generalizable to the general population. There are a few speculative reasons for why EA may be more frequently endorsed among White children. EA is a more difficult trauma type to define than other forms of trauma and various cultural groups may conceptualize EA differently (Esteban, 2006; Slep, Heyman, & Snarr, 2011), which may result in differing thresholds for perceiving EA has occurred. Given lower rates of mental health service utilization among minorities (Watson & Hunter, 2015) and racial disparities in the child protective service sector (Knott & Donovan, 2010; Lu et al., 2004), it is also possible that caregivers of White children may be more likely to endorse that EA has occurred due to higher levels of therapeutic rapport and/or perceived psychological safety in acknowledging this type of trauma, a traumatic exposure analog to “White privilege.” Research is still needed to better understand how culture may influence how individuals perceive whether a traumatic event has occurred as well as whether there are differing levels of comfort in disclosing trauma exposure across racial and ethnic groups. Future studies should investigate perceptions of traumatic events, and willingness to disclose experiencing these events, using specific, behavioral examples across racial and ethnic groups to better understand whether racial disparities regarding trauma exposure are the result of differing conceptualizations, reporting rates, exposure, or a mixture of all three.

Although rates of abuse by a caregiver were equivalent, Black children were more likely to be placed in CPS custody than White children, a finding that is in line with previous studies that have documented racial disparities regarding CPS involvement and placement (Knott & Donovan, 2010; Lu et al., 2004). Proposed explanations for this racial disparity have included racial prejudice and differences in SES and available resources (Pelton, 2015; Putnam-Hornstein, Needell, King, & Johnson-Motoyama, 2013). Black children reported a marginally higher number of types of Criterion A events than White children; however, their caregivers did not. The lack of concordance between child and caregiver reports may be a function of differences in instrumentation or may reflect differences in comfort acknowledging traumatic experiences. As approximately half of the children in the current sample were in CPS custody, some caregivers may have been less willing to disclose trauma due to concerns regarding reporting. The role of CPS placement in disclosure of trauma exposure and symptoms should be examined in future studies investigating racial differences.

Caregivers of Black children were expected to endorse higher levels of trauma-related symptoms, yet relatively few racial differences emerged on caregiver’s reports of children’s symptoms. Caregivers of Black children reported lower levels of anxiety/depression, social concerns, and internalizing symptoms than caregivers of White children on the CBCL, consistent with small effect sizes. Similarly, on the TSCYC, caregivers of Black children reported marginally less anxiety for Black children than White children and small effect sizes were also observed for PTSD-avoidance and sexual concerns. Although these findings are in contrast with much of the prior literature that minority status is a risk factor for trauma-related symptoms (Andrews et al., 2015; Brewin et al., 2000), the results parallel two prior studies with child treatment–seeking samples that reported that White children were at greater risk for trauma symptoms than Black children (Contractor et al., 2015; Greeson et al., 2011). This is an intriguing finding considering, as noted above, minority children may be at a higher risk for trauma exposure (Child Welfare Information Gateway, 2017), and furthermore, Black children were more likely to experience CV than White children. The Greeson and colleagues study is notable as the sample was of a group of children who experienced multiple forms of trauma. Thus, based on the findings from this study and the Greeson study, complex trauma exposure may result in a similar symptom presentation across racial groups. As the acute literature has sometimes found minority status to be a vulnerability factor, it is also possible that minority status is a protective factor following complex trauma exposure via racial socialization serving as a “suit of armor” against a hostile environment and/or a positive racial identity that includes group membership and support (Burt, Lei, & Simons, 2017; Miller, 1999). In addition, spirituality and religiosity are thought to relate to resilience through the process of racial socialization, and by providing a system of meaning, interconnectedness, and coping mechanisms (Burt, Lei, & Simons, 2017). Nonetheless, further research is necessary to examine why there is an observed discrepancy between exposure and symptom levels between racial groups. Although studies have been conducted to examine the resilience of Black children, there has been little progress in this area (Alim et al., 2008; Greeson et al., 2011).

Yet, this conclusion seems unlikely given minority stress models (Clark et al., 1999). The findings in the present study and others (Contractor et al., 2015; Greeson et al., 2011) may be due to several unexamined cultural factors as well as the sample type (i.e., treatment-seeking). Here, much of the group differences were specific to internalizing symptoms, and there may be cultural differences surrounding conceptualization and expression of internalizing behaviors (Watson & Hunter, 2015). Caregivers of White children may be more likely to perceive White children as internalizing compared with Black children. As with trauma exposure, caregivers of White children may be more willing to report higher levels of symptoms than caregivers of minorities, consistent with research documenting cultural mistrust of mental health services (Thompson, Bazile, & Akbar, 2004; Whaley, 2001) and evidence that minorities underutilize mental health services (Watson & Hunter, 2015). Indeed, Black children have been found to underreport symptoms on trauma measures (Sawyer, Bradshaw, & O’Brennan, 2008). Thus, it is likely that the treatment-seeking nature of the sample may have affected the results. At this time, it is crucial to interpret the findings from the current study with this caveat in mind. In the absence of clinician-administered measures, it is unclear whether Black children or their caregivers underreported their symptoms in the current sample. Studies that use of clinician-administered measures may shed light on this issue as these instruments may be helpful in detecting underreporting. Moreover, future research should also prioritize better sampling methods given racial disparities in treatment-seeking.

As other research has found minority status to be a risk factor (Breslau et al., 1998; Perilla et al., 2002), it seems premature to conclude that minority status is not a risk factor due to the treatment-seeking nature of the sample, as discussed above. Furthermore, perhaps the nature of the treatment-seeking setting elicits these cultural factors more so than other settings, as the measures were collected in the context of treatment, as compared with anonymous data collection methods. Caregivers of children of different racial groups may also have different symptoms threshold for initiating trauma-focused treatment, which could skew the results. The level of therapeutic rapport at the time of the assessment was not captured in this study, which is likely important. Studies that re-administer assessment measures after therapeutic rapport has been firmly established may be fruitful. This may be of particular relevance following complex trauma exposure, as survivors of complex trauma understandably may present with difficulties trusting others, as captured by DESNOS and DTD (van der Kolk, 2005; van der Kolk et al., 2005). Future studies should contrast treatment-seeking samples with community samples to better understand the influence of this setting on the results. Until work has been conducted with non-treatment-seeking samples and therapeutic rapport has been equally established across groups, it seems premature to conclude that White children are at greater risk for trauma symptoms following complex trauma exposure.

The hypothesis that Black children would report higher levels of symptoms was largely unsupported. On the TSCC, Black children reported higher levels of distress related to sexual concerns than White children; however, no other group differences were observed. It is unclear why racial differences would be specific to the Sexual Concerns Distress subscale, especially given that Black children did not experience higher rates of SA than White children. Higher levels of sexual concern distress as reported by Black children may be a function of chance or differences in socialization and perceptions of Black children. If this finding is replicated in other samples, this issue should be further examined. The findings from the children’s self-report measures converge with the caregiver reports in that minority status was not found to be a strong risk factor for higher levels of PTSD and most of the trauma-related symptom outcomes as reported by either children or their caregivers.

Results of secondary analyses using the subsample of children with income data were largely consistent with primary findings, except a few results failed to reach significance, likely due to a smaller sample size. It is possible that many of the previous findings regarding minority status as a risk factor might be partially explained by differences in rates of trauma exposure and other contextual variables such as SES. For instance, one study reported that trauma-related symptom differences between Black, White, and Hispanic adolescents were accounted for by rates of trauma exposure and that income moderated the relationship between trauma exposure and levels of symptoms, such that the relationship between exposure and symptoms was stronger for low SES households (Andrews et al., 2015). However, when SES has been controlled for, symptom differences have remained in other studies (Perilla et al., 2002; Pole et al., 2005). It is noteworthy that the present study found that Black children consistently demonstrated higher levels of anxiety/depression, internalizing, and social concerns, even after accounting for SES. Nonetheless, other findings (i.e., number of Criterion A exposures, differing levels of sexual concern, and anxiety) were no longer discrepant between racial groups in the secondary analyses, which may indicate that income level and related variables (e.g., neighborhood factors, family resources) were driving these results versus race. Alternatively, differences in findings may be due to small sample size and reduced power. Future studies should consistently measure income, and other relevant family- and community-level factors, to further elucidate these racial and SES-related differences following complex trauma.

Limitations and Conclusions

It is important to place the findings of the study into the context of the study’s limitations. Foremost, this study utilized a treatment-seeking sample, which may include children with more numerous or severe symptoms than other trauma-exposed samples and restricts the sample to only those children with a legal guardian who is willing to initiate trauma-focused treatment. Minorities may be less likely to seek trauma-focused services (Koenen, Goodwin, Struening, Hellman, & Guardino, 2003). Racial differences that would then be present in a non-treatment-seeking study may be masked by this selection bias. In addition, this study only compared two racial groups, and the examination of additional groups is important to better elucidate similarities and differences in both exposure to trauma and symptom expression. Traumas were also reported by children and their caregivers, and without the use of a clinician-administered instrument, it is not clear if the child experienced the event or if the caregiver suspected it occurred. As parent–child agreement for trauma measures has been found to be relatively moderate, although may be higher for more chronic traumas (Meiser-Stedman, Smith, Glucksman, Yule, & Dalgleish, 2007), the use of both caregiver- and child-reported measures is a strength of the study. Prior research has observed that utilizing more than one informant provides a more complete summary through multiple perspectives (Lanktree et al., 2008).

Despite the study limitations, the results from the current study add to our understanding of racial differences in trauma exposure and complex trauma. Although minority status was not a risk factor for poorer outcomes following complex trauma in this treatment-seeking sample, research with general samples is required before conclusions can be drawn regarding the influence of race on trauma-related outcomes following complex trauma exposure as cultural factors may have impacted the generalizability of the sample and endorsement of trauma exposure and trauma-related symptoms. It is important to determine if complex trauma has a differential impact by race, as racial disparities may indicate differing treatment needs. Furthermore, if racial differences are replicated in other studies, it will then be critical to understand the processes by which these disparities exist to identify targets for prevention and intervention.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Rachel Wamser-Nanney is an assistant professor in the Department of Psychological Sciences at the University of Missouri–St. Louis.

Kathryn E. Cherry is a clinical psychology doctoral student in the Department of Psychological Sciences at the University of Missouri–St. Louis.

Claudia Campbell is an undergraduate student at the University of Missouri–St. Louis.

Elise Trombetta is an undergraduate student at the University of Missouri–St. Louis.

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