Validity of CBCL-Derived PTSD and Dissociation Scales

Abstract

There is growing evidence that child neglect is an important risk factor for posttraumatic stress disorder (PTSD) and dissociation. Considering that the Child Behavior Checklist (CBCL) is a widely used measure, the possibility of using validated CBCL-derived trauma symptoms scales could be particularly useful to better understand how trauma symptoms develop among neglected children and adolescents. This study examined the factor structure of three CBCL-derived measures of PTSD and dissociation (namely, PTSD scale, Dissociation scale, and PTSD/Dissociation scale) in a sample of 239 neglected children and adolescents aged 6 to 18 years using the latest version of CBCL (CBCL 6-18). Evidence of convergent validity of these scales was also examined for participants aged 12 and under using two well-validated measures of PTSD and Dissociation: the Trauma Symptoms Checklist for Young Children and the Child Dissociation Checklist. Findings suggest that CBCL-derived measures of trauma symptoms, especially PTSD and Dissociations scales, may be of heuristic value in the study of trauma symptomatology in neglected samples. Factor structure and evidence of convergent validity were supported for these two scales. Results also provide further support to the well-established assumption that PTSD and dissociation are two related but different constructs.

Keywords

neglect child trauma methodology posttraumatic stress disorder confirmatory factor analysis exploratory factor analysis

Introduction

Over the last two decades, several posttraumatic stress disorder (PTSD) scales have been derived from items included in the widely used Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2007; Hulette, Fisher, Kim, Ganger, & Landsverk, 2008; Sim et al., 2005; Wolfe, Gentile, & Wolfe, 1989). In addition to PTSD, some authors have proposed scales assessing dissociation (Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997; Sim et al., 2005), a related feature of trauma symptomatology. The existence of such scales is of heuristic value, since it facilitates the evaluation of trauma symptoms without having to use lengthy and specialized scales. Moreover, these CBCL-derived scales allow the study of trauma symptomatology in the innumerable studies that have already used the CBCL, as was the case for many conducted within the field of child neglect. However, it is of critical importance to examine the factor structure of these scales in samples of children exposed to various types of trauma (e.g., child neglect and sexual abuse), since patterns of item endorsement may vary as a function of the type of trauma to which one is exposed (Kelley, Weathers, McDevitt-Murphy, Eakin, & Flood, 2009; Shevlin & Elklit, 2012).

Among the CBCL-derived measures of PTSD and dissociation symptoms, the three scales proposed by Sim and colleagues (namely, the PTSD scale, the Dissociation scale, and the PTSD/Dissociation scale; Sim et al., 2005) are those for which most facets of validity have been supported. Among the five facets of validity recognized by the American Educational Research Association, the American Psychological Association and the National Council on Measurement in Education (1999), Sim et al. (2005) have shown evidence of validity based on content (with each CBCL item rated by 16 experts in clinical child psychology), on factor structure (within a mixed sample composed of normative, psychiatric and sexually abused participants), and evidence of validity based on relations with other variables (group differences between sexually abused and psychiatric samples vs. normative samples on PTSD and PTSD/Dissociation scales).

Unfortunately, Sim et al.’s study did not include any neglected children or adolescents. Yet, there is growing evidence that child neglect is an important risk factor for the development of both PTSD and dissociation symptomatology in childhood (Hulette et al., 2008; Macfie, Cicchetti, & Toth, 2001; Milot, St-Laurent, Ethier, & Provost, 2010) and adolescence (Collin-Vezina, Coleman, Milne, Sell, & Daigneault, 2011; Ethier & Milot, 2009; Sullivan et al., 2006). However, these findings have to be replicated further, and more research is also needed to better understand mediating and moderating factors associated with the development of trauma symptoms in this population. Considering the fact that the CBCL is a widely used measure of child psychosocial adaptation in developmental research in general, and in maltreatment research in particular, the possibility of using CBCL-derived trauma symptoms scales—such as Sim et al.’s scales—in neglected samples would be particularly useful to achieve this goal.

In this study, we first sought to examine the factor structure of Sim et al.’s (2005) PTSD, Dissociation, and PTSD/Dissociation scales using maternal CBCL reports (CBCL 6-18; Achenbach & Rescorla, 2001) in a sample of physically neglected children and adolescents. This was done using the latest version of the school-age CBCL. As the CBCL is designed to provide measurement as a function of sex and age, we also tested for configural invariance in sex and age groups. In addition, for participating children aged 12 and under, we examined evidence of convergent validity with two measures of PTSD and Dissociation validated for this age group: the Trauma Symptoms Checklist for Young Children (Briere, 2001) and the Child Dissociation Checklist (Putnam, Helmers, & Trickett, 1993).

Method

Participants

The sample is composed of 239 children and adolescents aged 6 to 18 (mean age = 10 years and 10 months, SD = 36 months). The sample includes 135 boys and 104 girls, nested in 111 families. Children and their mothers were taking part in a larger study focusing on the psychosocial adaptation of children and adolescents victims of physical neglect. This study was conducted with the collaboration of Child Protective Services who were asked to refer children and their mothers for which a history of physical neglect had been substantiated. Physical neglect was defined as failure to provide, lack of supervision and moral–legal–educational maltreatment (Barnett, Manly, & Cicchetti, 1993). The information on whether some children and adolescents may also have experienced other forms of abuse was not available to the research team. Prior to participating, written informed consent was obtained from all mothers. Adolescents aged 14 and older also provided informed consent to participate.

Participants were all Caucasian and French-speaking and came from an urban and rural region in Quebec (Canada). Most participants were from low socioeconomic background with 85% of the families having an annual income lower than 25,000$ (Canadian dollars). Moreover, at the time of the study, 70% of the mothers were unemployed and 68% did not complete a high school degree.

Measures

CBCL—School-Age Form 6-18 (CBCL 6-18))

The CBCL is a widely used and well-validated questionnaire assessing emotional and behavioral problems (Achenbach & Rescorla, 2001). It contains 118 items rated by the caregiver on a 3-point scale: 0 = not true, 1 = somewhat true, and 2 = often true. Based on experts’ ratings, Sim et al. (2005) retained 16 items reflecting either PTSD or Dissociation symptoms. The first PTSD scale was composed of the 7 items that specifically reflected PTSD symptomatology (based on experts’ rating). A second scale was composed of the 3 items that specifically reflected Dissociation symptomatology. Finally, a third scale was composed of the 16 items that reflected both PTSD and Dissociation constructs. The items are listed in Table 1. For the present study, Cronbach’s α for Sim et al.’s (2005) scales were .67 for the PTSD scale, .70 for the Dissociation scale, and .80 for the PTSD/Dissociation scale.

Table 1.

CBCL 6-18 Items for Sim et al.’s (2005) Scales.

	PTSD	Dissociation	PTSD/ Disso.
9. Can’t get his/her mind off certain thoughts; obsessions	X		X
29. Fears certain animals, situations or places other than school	X		X
45. Nervous, high-strung, or tense	X		X
47. Nightmares	X		X
50. Too fearful or anxious	X		X
76. Sleeps less than most kids	X		X
100. Trouble sleeping	X		X
13. Confused or seems in a fog		X	X
17. Daydreams, or gets lost in his/her thoughts		X	X
80. Stares blankly		X	X
8. Can't concentrate, can’t pay attention for long			X
40. Hears sounds or voices that aren’t there			X
66. Repeats certain acts over and over; compulsions			X
84. Strange behavior			X
87. Sudden changes in mood or feelings			X
92. Talks or walks in sleep			X

Note. Numbers refer to the item number in the CBCL 6-18.

Child Dissociative Checklist (CDC)

The CDC is a 20-item questionnaire that measures the presence of dissociative symptoms in children (Putnam et al., 1993). Mothers responded to each statement on a scale of 0 to 2, where 0 corresponds to never, 1 to sometimes, and 2 to often. The CDC shows good psychometric properties, including test–retest reliability and evidence of validity based on content and on relation with other variables (Putnam et al., 1993). In the current study, internal consistency for the total score was .88.

Trauma Symptom Checklist for Young Children (TSCYC)

The TSCYC is a 90-item questionnaire measuring trauma symptoms in children from 3 to 12 years old (Briere, 2001). In this study, a global score of PTSD symptoms was obtained by summing up the 27 items that make up the scales associated with the three main symptoms of PTSD (reexperiencing, avoidance, and hyperarousal; American Psychiatric Association, 1994). The TSCYC was completed by the mother who was asked to answer to each statement on a scale of 1 (never) to 4 (always). The TSCYC possesses excellent psychometric qualities (Briere et al., 2001; Gilbert, 2004). For the present study, Cronbach’s αs were .81 for reexperiencing, .83 for avoidance, .86 for hyperarousal, and .93 for the total score. Due to the presence of moderate to high correlations between each subscale (from r = .51 to r = .72), and of high correlations between subscales and the total score (from r = .83 to r = .87), only the total score was retained.

Existing evidence supports the use of these three questionnaires (CBCL 6-18, CDC, and TSCYC) with French-speaking populations. Studies using the CBCL with French-speaking samples have shown evidence of validity based on factor structure (Ivanova et al., 2007) and on the relation with other variables (e.g., Bordeleau, Bernier, & Carrier, 2012; Éthier & Milot, 2009; Hébert, Collin-Vézina, Daignault, Parent, & Tremblay, 2006; Milot, Éthier, St-Laurent, & Provost, 2010). Also, both the CDC and the TSCYC have been used in studies conducted with French-speaking participants, including sexually abused, physically abused and neglected children, and have been associated with other variables in expected directions (Collin-Vézina & Hébert, 2005; Éthier et al., 2010; Hébert et al., 2006; Milot, Éthier et al., 2010; Milot, St-Laurent, et al., 2010).

Procedure

Questionnaires were completed by mothers of the participants during a home visit. The CBCL was completed for all 239 children, while the TSCYC and the CDC were completed only for children aged 12 and under (n = 144). Mothers completed the questionnaires in the presence of a research assistant who was trained to answer their questions if needed.

Data Analyses

Factor Structure Examination

All analyses were conducted using Mplus 6.12 (Muthén & Muthén, 1998–2012). The factor structure of the three Sim et al.’s (2005) scales was examined using factor analysis procedures. First, in order to test whether the PTSD and the Dissociation scales assessed distinct constructs, a single confirmatory factor analysis (CFA) was performed using the 10 items (7 PTSD + 3 Dissociation) included in these two scales. For this purpose, we fit a model in which PTSD and Dissociation symptoms loaded on two distinct but correlated factors. As the PTSD/Dissociation scale (16 items) includes all 10 items comprised in the shorter unidimensional PTSD and Dissociation scales, analyses conducted with this scale were done separately. In order to do so, we modeled a single PTSD/Dissociation scale.

Because of the categorical nature of the items, CFAs were performed using the Weighted Least Square—Means and Variance adjusted estimator, which has been shown to have acceptable performance in small samples (Beauducel & Herzbeg, 2006). Standard errors were corrected using the Huber-White estimator because ignoring the nestedness of children in families might have led to biased standard errors (Rebollo, de Moor, Dolan, & Boomsma, 2006). Model fit was assessed using the chi-square statistic, the normed chi-square statistic (which is the ratio of the chi-square divided by the degrees of freedom), the Comparative Fit Index (CFI), the Tucker–Lewis Index (TLI), and the Root Mean Square Error of Approximation (RMSEA). The model was considered good-fitting when the normed chi-square was less than 2 (Ullman, 2007). As suggested by Marsh, Hau, and Wen (2004), we considered CFI and TLI, respectively, greater than .90 and .95 to reflect acceptable and excellent fit to the data and RMSEA values, respectively, less than .05 and .08 to reflect close and reasonable fit. Also, local fit was assessed using the modification indices command in Mplus. Finally, configural invariance of factorial structure was tested separately in sex and age groups using multiple groups CFA. The age group variable was computed according to the categorization used by Achenbach and Rescorla (2001): 6 to 12 years versus 13 to 18 years. Evidence of convergent validity was investigated by correlating all three Sim et al.’s (2005) scales with both TSCYC and CDC total scores. For this purpose, we allowed the latent factors obtained in the CFA to covary with the TSCYC and CDC total scores.

Results

PTSD and Dissociation Scales

Factor Structure

Although the chi-square statistic was significant, all the other fit indices (including the normed chi-square) showed that the model adequately fit the data, χ²(34) = 60.54, p < .01, χ²/df = 1.78, CFI = .944, TLI = .93, RMSEA = .06, confidence interval (CI) 90% [.03, .08]; see Table 2 for item standardized loadings. No significant modification indices were found at p < .05 (using a chi-square cutoff of 3.84 with 1 degree of freedom), which lead us to conclude there was no problem with local fit. This suggests that (1) all 10 items load on their hypothesized latent dimension and (2) PTSD and Dissociation scales represent correlated but distinct constructs. The correlation between the PTSD and Dissociation factors was r = .56, p < .05. Also, all fit indices (except for the chi-square statistic) indicated that the factor structure holds across sex, χ²(76) = 124.07, p < .001, χ²/df = 1.63, CFI = .93, TLI = .91, RMSEA = .07, 90% CI [.05, .10], and age groups, χ²(76) = 130.86, p < .001, χ²/df = 1.72, CFI = .92, TLI = .91, RMSEA = .08, 90% CI [.06, .10]. For the latent PTSD factor, correlations with the TSCYC and the CDC were strong (r = .63, p < .05 and r = .51, p < .05, respectively), with the strongest correlation between the PTSD latent factor and the TSCYC measure. For the latent Dissociation factor, correlations with TSCYC and CDC were medium to strong (r = .39, p < .05 and r = .55, p < .05, respectively), with the strongest correlation between the Dissociation latent factor and the CDC measure.

Table 2.

Standardized Coefficients, Standard Errors, and 95% Confidence Intervals From the Confirmatory Factor Analysis (CFA) for the PTSD and the Dissociation Scales.

	PTSD			Dissociation
	Std. C.	S.E.	95% CI	Std. C.	S.E.	95% CI
9. Can’t get his/her mind off certain thoughts; obsessions	.27	.10	[.07, .46]
29. Fears certain animals, situations or places other than school	.61	.09	[.43, .79]
45. Nervous, high-strung, or tense	.63	.08	[.48, .78]
47. Nightmares	.64	.08	[.49, .79]
50. Too fearful or anxious	.89	.05	[.80, .99]
76. Sleeps less than most kids	.54	.11	[.33, .74]
100. Trouble sleeping	.80	.07	[.67, .93]
13. Confused or seems in a fog				.80	.07	[.66, .95]
17. Daydreams, or gets lost in his/her thoughts				.79	.06	[.68, .90]
80. Stares blankly				.77	.08	[.61, .93]

Note. Std, Standardized coefficients; SE, Standard errors; CI, Confidence intervals. Numbers refer to the item number in the CBCL 6-18.

Factor loadings in bold significant at p < .05.

PTSD/Dissociation Scale

Factor Structure

All fit indices (except for the RMSEA and the normed chi-square) indicated that the fit of the one-factor model was not good, χ²(104) = 194.96, p < .001, χ²/df = 1.87, CFI = .85, TLI = .83, RMSEA = .06, 90% CI [.05, .07]. Modification indices suggested the addition of many residual covariances between items composing the original Dissociation scale in order to improve model fit. These results are consistent with the first CFA which indicated that PTSD and Dissociation factors could be differentiated. Therefore, we tested the hypothesis that a two-factor model was a better fit to the data. However, as 6 of the 16 items included in the original Sim et al.’s (2005) PTSD/Dissociation scale (rated by experts as reflecting both constructs) could not be assigned to either the PTSD or Dissociation scales, this hypothesis was tested using an exploratory factor analysis (with geomin oblique rotation). The two-factor solution showed excellent fit, χ²(89) = 113.21, p = .04, χ²/df = 1.27, CFI = .96, TLI = .95, RMSEA = .03, 90% CI [.01, .05] (see Table 3 for item loadings), and explained 52% of the variance. The two factors were correlated at .41, p < .05.

Table 3.

Pattern Coefficients, Standard Errors, Confidence Intervals, and Structure Coefficients From the Exploratory Factor Analysis (EFA) for the PTSD/Dissociation Scale.

	Factor 1				Factor 2
	PC	SE	95% CI	SC	PC	SE	95% CI	SC
9. Can’t get his/her mind off certain thoughts^a	.08	.12	[−.16, .32]	.15	.19	.12	[−.05, .43]	.22
29. Fears certain animals, situations or places^a	.05	.17	[−.28, .38]	.27	.53	.12	[.29, .77]	.55
45. Nervous, high-strung, or tense^a	.44	.13	[.19, .69]	.59	.37	.13	[.12, .62]	.55
47. Nightmares^a	−.14	.18	[−.49, .21]	.18	.78	.09	[.60, .96]	.72
50. Too fearful or anxious^a	.22	.19	[−.15, .59]	.50	.71	.11	[.49, .93]	.80
76. Sleeps less than most kids^a	.10	.19	[−.27, .47]	.32	.52	.15	[.23, .81]	.57
100. Trouble sleeping^a	−.08	.19	[−.45, .29]	.29	.90	.08	[.74, 1.06]	.87
13. Confused or seems in a fog^b	.84	.05	[.74, .94]	.84	.00	.01	[−.02, .02]	.35
17. Daydreams, or gets lost in his/her thoughts^b	.79	.07	[.65, .93]	.78	−.03	.10	[−.23, .17]	.30
80. Stares blankly^b	.62	.11	[.40, .84]	.69	.18	.13	[−.07, .43]	.43
8. Can't concentrate, can’t pay attention for long	.39	.10	[.19, .59]	.50	.29	.10	[.09, .49]	.45
40. Hears sounds or voices that aren't there	.47	.19	[.10, .84]	.68	.51	.17	[.18, .84]	.70
66. Repeats certain acts over and over; compulsions	.15	.17	[−.18, .48]	.36	.50	.15	[.21, .79]	.56
84. Strange behavior	.03	.16	[−.28, .34]	.30	.67	.14	[.40, .94]	.68
87. Sudden changes in mood or feelings	.06	.15	[−.23, .35]	.29	.57	.10	[.37, .77]	.60
92. Talks or walks in sleep	−.29	.18	[−.64, .06]	.02	.77	.09	[.59, .95]	.65

Note. PC = pattern coefficients; SE = standard errors; CI = confidence intervals. SC = structure coefficients.

^aItem included in Sim et al.’s PTSD unidimensional scale. ^bItems included in Sim et al.’s Dissociation unidimensional scale.

Factor loadings in boldface are significant at p < .05. Numbers refer to the item number in the CBCL 6-18.

The first factor, composed of 6 items, seemed to capture dissociative symptomatology (see Table 3 for both structure and pattern coefficients). Interestingly, the 3 items with the highest loadings on this first factor (item numbers 13, 17, and 80) correspond to the 3 items included by Sim et al. (2005) in their Dissociation scale, thus further supporting the dimensionality of the original short dissociative symptoms scale. The other 3 items (item numbers 8, 40, and 45), which have loadings lower than .50, also load on the second factor. The second factor, composed of 12 items, seemed to more closely capture PTSD symptomatology. Among these are 6 of the 7 items composing the Sim et al.’s PTSD scale (item numbers 29, 45, 47, 50, 76, and 100). However, the presence of 6 additional items (item numbers 8, 40, 66, 84, 87, and 92) loading on this second factor suggests that Factor 2 includes but expands the unidimensional PTSD scale. Finally, on the 6 items that have been rated by the experts as reflecting both PTSD and Dissociation construct, only two loaded on both factors (item numbers 8 and 40), whereas the remaining four loaded on the second factor only. The first factor, which seemed to more closely capture dissociative symptoms, was moderately associated with the TSCYC (r = .37, p < .05) and more strongly with the CDC (r = .55, p < .05). The second, which seemed to more closely capture PTSD symptomatology, was strongly associated with both the TSCYC, r = .65, p < .05, and the CDC, r = .58, p < .05.

Discussion

This study provides further support to the usefulness of CBCL-derived PTSD and dissociation scales in maltreatment samples, in particular with physically neglected children and adolescents. Results provided evidence of validity of Sim et al.’s (2005) trauma symptoms scales, at least for the two unidimensional PTSD and Dissociation scales. First, factor structure was supported for these two scales, with the 7 PTSD and the 3 Dissociation items loading on their respective factors. The test of the configural invariance also showed that factor structure of both the PTSD and the Dissociation scales holds as a function of sex and age group. Moreover, patterns of correlations showed that the PTSD latent factor was more strongly related to the TSCYC total score than to the CDC total score, whereas the opposite pattern was found for the Dissociation latent factor. Interestingly, these results corroborate expert ratings of the 10 CBCL items included in these two scales (7 items for the PTSD scale and 3 items for the Dissociation scale) as well as Sim et al.’s (2005) findings on these two scales. The use of both the PTSD and the Dissociation Sim et al.’s (2005) scales within a neglected sample is thus well supported considering that there is evidence of validity based on content, factor structure, and relation with other variables.

On the other hand, analyses conducted with the long PTSD/Dissociation scale did not support the one-factor structure, with results of both CFA and EFA showing that the 16 items included in the PTSD/Dissociation scale were best represented by two distinct factors. This finding may not be so surprising, since it might be quite difficult to find empirical support for a single-factor scale reflecting two distinct but related concepts, as it is the case for the PTSD/Dissociation scale. Results showed that among the 6 items rated by the experts as reflecting both PTSD and Dissociation constructs, only 2 loaded on both EFA factors. Moreover, of the 16 items included in the bidimensional PTSD/Dissociation scale, only 3 loaded on both EFA factors. As supported by the factor structure, some items such as “Repeats certain acts over and over” (Item 66) or “Talks or walks in sleep” (Item 92) may be more reflective of PTSD symptomatology, whereas other items such as “Confused or seems in a fog” (Item 13) and “Stares blankly” (Item 80) are clear indicators of dissociation. However, these results may also be specific to physically neglected children or an artifact of the sample used in this study. Further investigation is necessary to clarify this issue.

Taken together, these results suggest that CBCL-derived measures of trauma symptoms, especially the PTSD and the Dissociation scales, may be of heuristic value in the study in trauma symptomatology in neglected children and adolescents. Results also provide further empirical support to the well-established assumption that PTSD and dissociation symptoms are two related but different constructs (as reflected by the existence of distinct diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, American Psychiatric Association, 1994).

Nevertheless, one must keep in mind that the CBCL was not developed to assess trauma symptomatology. Although Sim et al.’s (2005) CBCL-derived PTSD and Dissociation scales may be useful in research, there is no available evidence to suggest that the use of these scales should be extended to clinical settings. For instance, according to the American Psychiatric Association (1994), both PTSD and dissociative symptomatology are multidimensional (e.g., PTSD includes the three following clusters of symptoms: reexperiencing, avoidance, and hypervigilance), which cannot be fully accounted by the CBCL-PTSD and Dissociation scales.

Limitations of the Study

A few limitations should be noted. First, analyses were conducted based on mother reports. These results need to be replicated with other informants, such as fathers or other caretakers. Also, in this study, evidence of convergent validity was shown for participants aged 12 and under. Future research should examine if these relations hold true in adolescence. Additionally, all participants were Caucasian and French speaking, and it might be necessary to replicate results with a larger, more ethnically diverse sample. Finally, other limitations include the small sample size and the use of a convenience sample.

Future Directions

Although very few studies have assessed trauma-related symptoms in neglected children and adolescents, many have used the CBCL as a measure of maladaptative functioning in neglected samples. Interestingly, the current study provides empirical support to the use of the CBCL as a measure of both PTSD and dissociation in neglected samples. Consequently, questions such as “How do PTSD and dissociative symptoms develop and evolve in neglected children?” and “What are the correlates of trauma-related symptoms in neglected children?” may thus be addressed through already existing studies that have used CBCL measures, allowing for a better understanding of the traumatic nature of child neglect. Future research should focus on the study of the moderating and mediating mechanisms associated with the development and persistence of trauma symptomatology in neglected children as well as on the various facets of child functioning (e.g., cognitive, social, and academic) that might be negatively impacted by the presence of trauma-related symptoms. In addition, considering that our findings support the existence of two distinct factors representing respectively PTSD and dissociation symptoms, another goal for future research should be to study the similarities and differences in the developmental processes associated with these two classes of symptoms among neglected children.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by grants from the Fonds de recherche Société et culture du Québec.

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