A Short Form of the Trauma Symptom Checklist for Children

Abstract

The purpose of the current study was to develop a short form (SF) of the Trauma Symptom Checklist for Children (TSCC). The TSCC-SF) maintained 29 items, from the original 54 items, in a sample (N = 215) of sexually abused children who were seeking treatment at a child advocacy center. Exploratory factor analysis refined the original measure, and confirmatory factor analysis provided evidence for best fit for a six-factor, 29-item model. The TSCC-SF evidenced good internal reliability and showed convergent validity with child ratings of post-traumatic stress disorder (PTSD) symptoms obtained from the University of California at Los Angeles PTSD Reaction Index. The TSCC-SF has promise as a shorter assessment measure with sexually abused children in numerous settings, including child advocacy centers and pediatric clinics, where efficient screening and assessment are essential for providing the best standard of care.

Keywords

assessment abuse-related symptoms trauma screening sexual abuse

Childhood sexual abuse (CSA) is a devastating global problem associated with numerous adverse outcomes. Current estimates indicate that approximately one in four girls and one in six boys are sexually abused before age 18 (American Psychological Association, 2014; Centers for Disease Control and Prevention, 2005). Consequences of CSA in youth may include changes to biological stress response systems (e.g., alterations in hypothalamic-pituitary-adrenal (HPA)-axis functioning; Keeshin, Strawn, Out, Granger, & Putnam, 2014; Muller, Errington, Szabo, Pitts, & Jacklin, 2014); cognitive functioning and learning ability (Jones, Trudinger, & Crawford, 2004); behavior problems, including aggression (Child Welfare Information Gateway, 2008; Hornor, 2010); and sexual behavior problems (Allen, Thorn, & Gully, 2015). Additionally, psychiatric disorders, such as post-traumatic stress disorder (PTSD), dissociative disorders, major depressive disorder, and anxiety disorders (Ruggiero, McLeer, & Dixon, 2000), along with interpersonal problems and revictimization (Finkelhor, Ormrod, & Turner, 2007) are commonly reported. Importantly, a number of sexually abused children are reportedly asymptomatic or successfully functioning in some or all realms (Cicchetti, 2013; Cohen et al., 2010). This may be due to incomplete or insensitive assessments, the manifestation of symptoms long after disclosure or in a later developmental period (e.g., adolescence or adulthood) or resiliency on the part of the child (Cohen et al., 2010; Cohen & Mannarino, 2000). The literature on the determinants of resilience in maltreated children shows that the presence of protective factors, such as support from caregivers, mitigates symptomatology (Bolen & Lamb, 2007). In sum, the symptoms that children display following sexual abuse may vary based on a number of factors and therefore must be assessed.

Assessment of Sexually Abused Children

Sexually abused children display a wide variety of outcomes, making it imperative for care providers to carefully assess the effects of the abuse in order to determine the best course of treatment (Kisiel & Lyons, 2001; Maniglio, 2009; Ullman, 2007). Symptoms resulting from CSA often are mistaken for more common childhood disorders. For instance, children with PTSD often present with concentration problems or hyperactivity and are frequently misdiagnosed with attention-deficit hyperactivity disorder (Weinstein, Staffelbach, & Biaggio, 2000). Subsequent treatment using a stimulant medication (e.g., Ritalin) may result in a worsening of intrusion symptoms (Rossman & Ho, 2000). An additional potential misdiagnosis occurs when reexperiencing symptoms of PTSD are confused with the hallucinations usually associated with schizophrenia (Jessop, Scott, & Nurcombe, 2008). Conversely, some clinicians may assume that “sexual abuse” is in itself a diagnosis with a set of predictable symptoms (Babiker & Herbert, 1996), and the label of PTSD may be assigned to a child who has no such disorder. Incorrect assumptions such as these illustrate the need for rigorous assessment of sexually abused children.

Quantitative measures may serve this purpose. Such instruments can be standardized and repeatable, two valuable qualities in the routine assessment of child sexual abuse. Standardized measures are useful to balance mental health care providers’ inherent biases in clinical assessment (Osterberg, Jensen-Doss, Cusack, & de Arellano, 2009). For example, mental health care providers often fail to assess a sufficiently broad range of disorders (Rettew, Lynch, Achenbach, Dumenci, & Ivanova, 2009), attend to diagnostic criteria (Hunsley & Meyer, 2003), and/or collect information once they have selected a diagnosis (Garb, 2005). Standardized instruments are often less intrusive and leading than traditional interview techniques, which may be especially important for abused children (Adams et al., 2007). The use of standardized measures in the assessment of psychiatric disorders is standard practice for adults and older children, but the use of such measures in the diagnosis and treatment of young children is still uncommon (Stover & Berkowitz, 2005).

Current Approaches

Very few assessment measures exist which address both general and trauma-specific symptoms in children, and even fewer are self-report measures. One of the few self-report instruments for abuse- and trauma-related symptomatology in children is the Trauma Symptom Checklist for Children (TSCC; Briere, 1996), which is a 54-item self-report instrument that evaluates abuse- and trauma-related symptomatology in children aged 8–16. The TSCC consists of six scales: Anxiety, Depression, Post-traumatic Stress, Dissociation, Sexual Concerns, and Anger; there also are subscales for Dissociation and Sexual Concerns. Normative data on the TSCC were derived from large samples (total N > 3,000) of nonclinical urban, inner city, and suburban children across the United States. The TSCC appears to be internally consistent (in the mid to high 80s) and shows convergent and predictive validity in samples of traumatized and nontraumatized children (Elliott & Briere, 1994; Friedrich, Jaworski, Huxsahl, & Bengtson, 1997; Lanktree & Briere, 1995). The TSCC has displayed excellent reliability and validity in numerous studies (Sadowski & Friedrich, 2000; Strand, Sarmiento, & Pasquale, 2005), including samples outside of the United States (Bal & Uvin, 2009; Li et al., 2009; Nilsson, Gustafsson, & Svedin, 2012), and appears to be accurate in detecting PTSD (Fricker & Smith, 2001; Mertin & Mohr, 2002).

This measure differs from other instruments in a variety of ways. For instance, the Child Behavior Checklist (CBCL; Achenbach, 1991), a widely used parent-completed, broadband rating scale often employed in clinical work and research with children who have been abused, has excellent psychometric properties but does not specifically assess trauma-specific symptoms (e.g., PTSD and dissociation). Most of the measures that do examine trauma-specific symptoms have not been normed on large, representative samples of the general population (Briere & Elliot, 1997). Briere and Elliott (1997) point out that assessments which are not normed may only be useful in terms of interpreting individual symptom items. Such measures include the Children’s Impact of Traumatic Events Scale–Revised (CITES-R; Wolfe, Gentile, Michienzi, Sas, & Wolfe, 1991), Children’s Attributions and Perceptions Scale (CAPS; Mannarino, Cohen, & Berman, 1994), Child Dissociative Checklist (CDC; Putnam, Helmers, & Trickett, 1993), Children’s PTSD Inventory (Saigh, 2004), and the University of California at Los Angeles (UCLA) PTSD Reaction Index (PTSD-RI; Steinberg, Brymer, Decker, & Pynoos, 2004). Some of these measures are completed by the child (e.g., CITES-R, CAPS, PTSD-RI, and Children’s PTSD Inventory) and some are caregiver ratings (e.g., CDC and PTSD-RI). The CAPS, CDC, PTSD-RI, and Children’s PTSD Inventory measure only a single dimension or construct (e.g., dissociation or PTSD). The Child Sexual Behavior Inventory (CSBI; Friedrich, 1998) is a caregiver rating scale that examines sexual behavior in children and is one of the few measures that assesses symptoms relevant to CSA and has standardized norms. However, it does not measure other symptoms of sexual abuse beyond the one dimension of sexual behavior. A notable exception to the aforementioned measures is the Trauma Symptom Checklist for Young Children (TSCYC; Briere, 2005), which asks a parent or caretaker to rate trauma-related symptoms in children. This measure assesses symptoms relevant to child sexual abuse, and it is reliable, valid, and has been normed. As a parent report, the TSCYC is extremely helpful, but it assesses symptoms based on the caregiver’s perspective. Asking children about their experience of symptoms is important as children tend to report different symptoms at different levels than their parents (Briere, 2005). Parents are also likely to underreport PTSD symptoms in their children (Charuvastra, Goldfarb, Petkova, & Cloitre, 2010; Stover & Berkowitz, 2005).

In summary, many of the instruments used with children who have been sexually abused do not specifically assess trauma-related symptoms (e.g., the CBCL), assess only one trauma-related symptom (e.g., sexual behavior using the CSBI), are not normed (e.g., CITES-R, PTSD-RI, CDC, CAPS, and Children’s PTSD Inventory), or are too lengthy. Additionally, many of these measures are parent/caregiver rating scales, which are certainly useful but do not provide a complete picture of trauma symptomatology (e.g., the TSCYC). Only one self-report measure, the TSCC (Briere, 1996), currently addresses all of the issues, except for length.

Study Rationale and Purpose

The psychometric properties of the TSCC are good, but the length of the measure might be discouraging in settings such as child advocacy centers, pediatric primary care clinics, hospitals, and foster care facilities—where staff and children often are pressed for time (Lang & Stein, 2005; Peters, Sunderland, Andrews, Rapee, & Mattick, 2012).

Children also may have trouble completing the lengthy instruments routinely given during an intake or appointment (Boyden & Ennew, 1997; Ruff & Lawson, 1990). Moreover, authors have noted that the length of available screening instruments appears to be a major barrier to the employment of such measures in various settings (Lamb, Orbach, Hershkowitz, Esplin, & Horowitz, 2007; Lang & Stein, 2005). This is unfortunate as screening (a) increases the recognition of a variety of symptoms, (b) improves treatment planning, and (c) provides care providers with a mechanism to measure children’s progress throughout treatment (Sadowski & Friedrich, 2000). Friedrich (2002) discusses the need for screening, noting that a majority of maltreated children entering therapy are never assessed, and suggests there are other instances when brief screening is useful.

The development of an assessment with excellent psychometric properties that provides clinically meaningful information and is quick to administer, simple for children to complete, and easy for providers to score and interpret would likely increase the use of assessment in child sexual abuse cases and contribute to more effective clinical practices.

The purpose of the current study was to develop a short form (SF) of the TSCC, the TSCC-SF), from the original 54 items, in a sample of sexually abused children. An exploratory factor analysis (EFA), using principal components extraction and orthogonal factor rotation (i.e., Varimax), was used to identify the factors with the highest eigenvalue (greater than 1.00) and the items from each of the factors with the highest factor loadings (greater than .40). Parallel analysis was used to confirm these factors. EFA was needed to validate the face-valid factors of the TSCC, which were not derived empirically (Sadowski & Friedrich, 2000). This step was particularly important as Sadowski and Friedrich (2000) found a one-factor solution that explained 36.8% of the total variance, rather than the hypothesized six-factor solution. Confirmatory factor analysis (CFA) then provided information about how well the proposed factor model fit the data. A reliability analysis, using Cronbach’s α, was performed to examine the internal consistency of each factor derived from the CFA. Convergent validity of the TSCC-SF was determined using both self-report measures (i.e., UCLA PTSD-RI—child version) and parent-report measures (i.e., TSCYC, CSBI, CBCL, and UCLA PTSD-RI—parent version).

Method

Procedures

Children initially were referred for outpatient treatment by Child Protective Services (CPS), physicians, and parents. Consent to participate in this study was obtained from a nonoffending parent or guardian, and assent was obtained from child participants. Children who participated had a substantiated history of child sexual abuse, as determined by CPS. The children were accompanied by nonoffending caregivers who completed the parent-report measures. The study was approved by the university institutional review board.

The assessment measures used in this study were part of a larger battery of instruments administered during an intake process at the child advocacy center. The intake process consisted of approximately three sessions in which an intake clinician gathered data. The first session of the intake did not include the intake clinician, but rather allowed the individual therapist to meet with the participant and their family in order to build rapport and gather demographic information on the client. During the first session, the therapist obtained the consent and assent to participate in the research and scheduled a second appointment. The second session with the family began the administration of the intake measures; the parents of the participant were usually scheduled for this first meeting while the child attended a therapy session. The third session involved administration of measures to the child. The number of sessions required to complete the data collection differed based on the availability of the participants and the number of sessions necessary for the participants to complete the instruments. All measures, however, were completed within 1 month of the initial appointment. On the self-report measures, children were occasionally assisted with reading (though not interpretation) of items if their reading recognition for specific words made comprehension difficult.

Sample Characteristics

Participants consisted of 215 children, aged 8–16, who received outpatient treatment services at a child advocacy center on the campus of a state university. From the original 250 children who completed the TSCC, 35 children were dropped (i.e., listwise deletion) from the analysis due to missing TSCC items, resulting in 215 participants for the analysis. Of the 215 children who completed the TSCC, the mean age was 10.90 years (SD = 3.14); 72% were female and 28% were male. In this sample, 51% were Caucasian, 42% were African American, and 7% were Other ethnicities. There were no differences in demographic variables based on missing data. Those children with missing data scored significantly lower on the TSCC-SF Dissociation Scale with a mean of 4.35 (SD = 3.41) as compared to those with no missing data M = 5.98 (SD = 4.09), t(242) = 2.107, p = .036.

Measures

Demographics

A demographic questionnaire collected information about the respondents, including age, gender, and race. Information pertaining to the type, duration, and frequency of abuse and the child’s relationship to the perpetrator also was collected from adults.

TSCC

The TSCC (Briere, 1996) is a standardized, 54-item self-report measure for assessing trauma-related symptoms in children aged 8–16. Each symptom item is rated according to its frequency of occurrence using a 4-point scale ranging from 0 (never) to 3 (almost all of the time). The TSCC yields raw scores and t-scores for validity scales and clinical scales. The clinical scales include Anxiety, Depression, Anger, Post-traumatic Stress, Dissociation, and Sexual Concerns. Two of these scales have subscales (Sexual Concerns contains sexual preoccupation and sexual distress and Dissociation contains fantasy and overt dissociation). The TSCC has two validity scales: Underresponse, measuring unusually low endorsement of commonly endorsed symptoms and Hyperresponse, measuring disproportionate endorsement of rarely endorsed symptoms. The α coefficients for clinical scales range from .77 to .89 in the standardization sample (Briere, 1996). Adequate convergent, discriminant, and predictive validity have been demonstrated in normative and clinical samples (Briere, 1996; Friedrich et al., 1997; Lanktree et al., 2008). Items from the TSCC were used to develop the TSCC-SF.

TSCYC

The TSCYC (Briere, 2005) is a 90-item parent-report measure for the assessment of trauma-related symptoms in children aged 3–12. The clinical scales include Post-traumatic Stress–Intrusion, Post-traumatic Stress–Avoidance, Post-traumatic Stress–Arousal, Sexual Concerns, Anxiety, Depression, Dissociation, and Anger/Aggression. In Briere’s (2001) initial study, the clinical scales had good reliability with αs ranging from .81 to .93. This measure was administered to establish validity since it is a parent report of constructs similar to those assessed by the TSCC. Since the age range for the TSCC (ages 8–16) and the TSCYC (ages 3–12) are not identical, the available subsample of participants for which there were both TSCC and TSCYCs was 116.

UCLA PTSD-RI—Parent version and child version

The UCLA PTSD-RI (Steinberg et al., 2004) is a 47-item parent-report and child-report measure that screens children and adolescents, aged 7–17, for trauma exposure and PTSD symptoms. The measure provides preliminary Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV; American Psychiatric Association, 2000) diagnostic information and a PTSD symptom frequency score. The UCLA PTSD-RI has evidenced good reliability, convergent validity, and discriminant validity (Steinberg et al., 2004). The internal consistency of the measure was good, with an α of .92 (Steinberg et al., 2004). Furthermore, recent studies evaluating the psychometric properties of the UCLA PTSD-RI have also noted the instrument’s strength and accuracy (Elhai et al., 2013; Steinberg et al., 2013). This measure was utilized to establish convergent validity for the PTSD factor of the TSCC-SF. In this clinical sample, the UCLA PTSD-RI was implemented after much of the original data collection occurred. Thus, there were fewer UCLA PTSD scores available for the validity analysis (n = 55).

CSBI

The CSBI is a 38-item measure completed by a parent or caregiver to determine the presence and frequency of a range of sexual behaviors in children, aged 2–12 years (Friedrich, 1998). The items yield three standardized scores: the CSBI Total Score, the Developmentally Related Sexual Behavior Scale, and the Sexual Abuse Specific Items Scale. The CSBI has demonstrated good internal consistency (r = .72 for the normative sample) and test–retest reliability (r = .85 after 4 weeks; Friedrich et al., 1998). This measure was used to establish convergent validity of the TSCC-SF factor of Sexual Concerns. Since the age range for the TSCC (ages 8–16) and the CSBI (ages 2–12) are not identical, the available subsample of participants for which there were both TSCC and CSBIs was 141.

CBCL

The CBCL (Achenbach, 1991) is a 113-item parent report that provides a rating of the child’s symptomatology. Raw scores are converted into t-scores; factors include Withdrawn, Somatic Complaints, Anxious/Depressed, Social Problems, Thought Problems, Attention Problems, Delinquent Behavior, Aggressive Behavior, and the Other Symptoms Scale. The test–retest reliability of the CBCL was supported by a mean test–retest coefficient of .89 for the problem scales over a 7-day period (Achenbach, 1991). Adequate content, construct, and criterion-related validity have been demonstrated in normative and clinical samples. This measure was administered to establish validity since it is a parent report of some of the constructs (e.g., depression, anxiety, and anger) assessed by the TSCC. Since the age range for the TSCC (ages 8–16) and the CBCL (ages 6–18) are not identical, the available subsample of participants for which there were both TSCC and CBCLs was 130.

Results

EFA

An EFA was conducted using IBM SPSS Statistics 20. Principal component extraction and the orthogonal rotation method (i.e., Varimax) with Kaiser normalization were used in each step of the analysis. Missing data were excluded listwise. At Step 1, the 54 items loaded on 13 factors with eigenvalues exceeding 1.00 Kaiser-Meyer-Olkin (KMO) = .91; Bartlett’s χ² = 6,194.70, p ≤ .001). The 13 factors explained 66% of the variance. The researchers examined each factor and the corresponding items to identify items that loaded on a theoretically inconsistent factor, items that did not load on a factor, and items that cross-loaded on another factor. An iterative process of item removal resulted in 40 items loading on six factors with eigenvalues exceeding 1.00. The results of this analysis seemed to produce the most theoretically consistent measure (KMO = .91, Bartlett’s χ² = 3,006.55, p ≤ .001). The six factors accounted for 58% of the variance. Recent research has argued that the use of the “eigenvalues greater than 1” rule has led to the retention of more factors than is warranted. Thus, the current study employed parallel analysis using a web-based engine to compare eigenvalues extracted from the current data set with eigenvalues extracted from a randomly generated correlation matrix having the same sample size and number of variables (Patil, Singh, Mishra, & Donavan, 2007). Using this method, six factors were still retained. The items corresponded with six theoretical categories: Anger, PTSD, Dissociation, Sexual Concerns, Suicidal Depression, and Anxiety. Items that cross-loaded on multiple factors or were theoretically inconsistent were dropped (5 items total). From the remaining 35 items, the items from each factor with the highest factor loading (>.40) or theoretically appropriate were selected (see Table 1). The Suicidal Depression Scale only retained 4 items, and 1 item was dropped due to cross-loading on another factor and an eigenvalue less than 0.40. CFA was used to validate the resulting 29-item, six-factor model.

Table 1.

Factor Loadings for Varimax Orthogonal Six-Factor Solution for the TSCC-SF.

	Factors and Eigenvalue
Item No.	Anger	PTSD	Dissociation	Sexual Concerns	Suicidal Depression	Anxiety
	2.83	3.86	2.82	2.30	2.51	2.31
16	.71
13	.68
19	.70
21	.73
46	.64
43		.76
51		.53
35		.68
10		.71
32		.47
12		.71
5			.76
29			.40
30			.64
38			.56
45			.46
17				.79
22				.74
23				.75
44				.69
47				.80
20					.71
52					.70
9					.56
27					.54
2						.49
15						.53
41						.65
33						.64

Note. N = 215 and α = .92 for entire measure. TSCC-SF = Trauma Symptom Checklist for Children–Short Form; PTSD = post-traumatic stress disorder.

CFA

A CFA of the TSCC-SF was conducted using structural equation modeling with Amos 22. There was no missing data in this analysis. The latent variables represent the scales of the TSCC-SF: Anger, PTSD, Dissociation, Sexual Concerns, Suicidal Depression, and Anxiety. The indicators for each latent variable are the specific items from the CFA that make up each scale. The model, with standardized estimates, is presented in Figure 1. The unstandardized estimate for 1 item in each latent factor was set to 1.0, a standard practice for CFA models. Correlated paths among latent paths were freed to vary. Thus, correlated paths among error items were freed to vary within a latent factor. However, the error items that cross-loaded with another factor were restricted. The modification indices were examined to assess for items with the potential to be negatively associated with the overall model fit.

Figure 1.

Hypothesized model of the Trauma Symptom Checklist for Children–Short Form presented with significant standardized estimates.

Overall, the CFA model of the TSCC-SF supported the six-factor model for measuring trauma symptoms in sexually abused children. The χ² for the hypothesized model was significant, χ²(89, 346) = 519.018, p < .001. Although the high χ² may indicate a poor model fit, the ratio of the χ² to the degrees of freedom for the hypothesized model was 1.50, which reflects a good fit and represents a better fit index (Carmines & McIver, 1981; Wheaton, Muthén, Alwin, & Summers, 1977). All of the estimates and covariances were significant (p < .001). The baseline comparison fit indices indicate a good fit for the hypothetical model: normed fit index = .84, incremental fit index = .94, Tucker–Lewis index = .93, and comparative fit index = .94 (Bentler, 1990). The root mean square error of approximation (RMSEA) for the hypothesized model was .048, which indicates an excellent model fit (Browne & Cudeck, 1993). In light of the fit indices pointing to an acceptable model fit, the relatively high χ² suggests a need for additional model fit measures. The use of confidence intervals and tests of p of Close Fit (PCLOSE) significance helps identify the impact of sampling errors or specification errors in the RMSEA (Kenny, Kaniskan, & McCoach, 2014; MacCallum, Browne, & Sugawara, 1996). The hypothesized model yielded a 90% confidence interval for this model with bounds of [0.040, 0.057]. MacCallum, Browne, and Sugawara (1996) note that the width of the confidence interval is very informative regarding the precision in the estimate of the RMSEA.

The one-sided hypothesis PCLOSE test considers a p > .05 (not significant) to be supportive of a close-fitting model (Kenny et al., 2014). The PCLOSE value for this model is .618. Therefore, both the confidence intervals and the PCLOSE significance test further support the overall model fit of the hypothesized model.

Reliability

A reliability analysis, using Cronbach’s α, was conducted to determine the internal consistency of each scale, using the items in the CFA. The scales demonstrated acceptable to good reliability: Anger (α = .83), PTSD (α = .81), Dissociation (α = .73), Sexual Concerns (α = .84), Suicidal Depression (α = .79), and Anxiety (α = .76). The measure as a whole demonstrated excellent reliability (α = .92).

Validity

Overall, scale scores on the TSCC-SF were compared with raw scale scores on self-report measures and parent-report measures of symptoms in children in an effort to examine the convergent validity of the TSCC-SF. The UCLA PTSD-RI for DSM IV–child version was the only self-report measure besides the TSCC-SF examined in the study. The total PTSD score of the TSCC-SF was significantly correlated with the total PTSD score on the UCLA PTSD-RI–child version (r =.760, p = .000). There was no significant correlation between the UCLA PTSD-RI–parent version and the TSCC-SF. Similarly, the PTSD score of the TSCC-SF was positively though modestly correlated with only the TSCYC PTSD Intrusion Scale (r = .163, p = .033).

The Anger Scale of the TSCC-SF was significantly correlated with the TSCYC Anger/Aggression T score (r = .168, p = .03). Additionally, there were several correlations between the TSCC-SF Anger Scale and subscales on the CBCL. These include Rule Breaking (r = .290, p = .000), Aggressive Behavior (r = .193, p = .03), Oppositional Defiant Problems (r = .239, p = .003), and the Conduct Problems Scale (r = .279, p = .001).

The Suicidal Depression Scale of the TSCC-SF was significantly correlated with the Depression Scale of the TSCYC (r = .159, p = .04) and the corresponding scale of the CBCL—Withdrawn/Depressed (r = .245, p = .003). Furthermore, the TSCC-SF Anxiety Scale correlated with the total score of the CBCL Anxiety Scale (r = .180, p = .02) as well as the TSCYC Anxiety Scale (r = .179, p = .02). Findings indicated the Dissociation Scale on the TSCC-SF was correlated with the UCLA PTSD Parent RI (r = .253, p = .03) and the UCLA PTSD Child RI (r = .574, p = .000); however, it was not significantly correlated with corresponding scales on the TSCYC. The Sexual Concerns Scale of the TSCC-SF was not significantly correlated with the CSBI, the Sex Scale on the CBCL, or the Sexual Concerns Scale of the TSCYC.

Discussion

The purpose of this study was to develop a short version of the TSCC to be used with sexually abused children. An EFA produced a 29-item measure with six scales. CFA provided reasonable support for the six-factor model, and the retained items were judged to be theoretically consistent. Each of the factors, as well as the measure as a whole, demonstrated good reliability.

Convergent validity was found between the PTSD subscale of the TSCC-SF and another self-report measure of PTSD (i.e., PTSD-RI). However, the TSCC-SF PTSD Scale was only modestly related to the parent-report measure of PTSD (i.e., PTSD-RI). This points to an important discrepancy in reporting and underscores the importance of also asking children, and not merely parents, about trauma symptoms. Briere (2001) expressed that it is not unusual for children to endorse different symptoms at different levels than are reported by their parents. Another study found that agreement between parents and children on the child’s PTSD symptoms was poor except for reports on nightmares, physical reactivity to reminders of the trauma, and sleep problems (Charuvastra et al., 2010), all of which are fairly visible indicators of PTSD.

Internalizing symptoms may be especially difficult to recognize in young children due to the child’s undeveloped verbal abilities and their inability to communicate about complex emotions (Stover & Berkowitz, 2005). In contrast, Lanktree et al. (2008) found moderate convergent validity between the child-report TSCC and parent-report TSCYC. However, the small association between the measures’ relevant scales indicates the importance of obtaining multiple perspectives on child symptomatology.

The results of the CFA and reliability analysis, as well as the convergent validity between the TSCC and the UCLA PTSD-RI, point to the use of the TSCC-SF in order to quickly assess abused children for trauma symptoms, particularly if time and resources are limited. This is often the case in settings that provide abused children with medical care, evaluations, or therapy. Wherry, Huey, and Medford (2015) surveyed 264 child advocacy center directors to determine their top reasons for referring children for treatment and found that severity of abuse and emotionality (e.g., becoming upset, angry, and crying) of the child during the forensic interview were the top-ranked reasons. Thus, actual symptomatology of the child is often neglected. A shorter tool would likely improve referral practices in child advocacy centers (Wherry, Huey, & Medford, 2015).

There is also a need for quick and accurate assessment of symptoms, particularly traumatic stress symptoms, in other settings. Cohen, Kelleher, and Mannarino (2008) documented that over 90% of youth seen in a pediatric primary care clinic reported exposure to a potentially traumatic event, and of these individuals, 25% met full or partial criteria for PTSD. Despite such high incidences of children coming in with either potentially traumatic experiences or PTSD symptoms, pediatricians rarely assess for trauma due to the length of available instruments (Cohen, Kelleher, & Mannarino, 2008).

Further, a brief measure that still contains clinically relevant scales as opposed to a single, total score, is essential for determining specific symptom clusters. Although it might be possible for this measure to be reduced to an even shorter version, the distinct scales would not be retained, and valuable clinical information would be lost. Thus, this version represents the best balance between brevity and clinical utility.

The current study has several limitations. First, the participants consisted of children and parents who sought treatment, thus excluding families who decided not to come to therapy. Additionally, there were no nonabused children included in this study nor were there children who had experienced another form of abuse or trauma. Thus, there is a need for additional work to help establish norms and whether the SF could be useful with populations of children exposed to other types of trauma or multiple traumas, and how their symptom profiles might differ from those obtained with this population of children referred for sexual abuse. In future studies, the TSCC-SF should be compared to other child self-report measures that include trauma symptoms or assess domains that overlap with the TSCC-SF, for further evidence of convergent validity. Further, the relatively small sample size did not allow for splitting the sample into EFA and CFA analysis. Thus, future studies examining the TSCC-SF should conduct a CFA of the factor structure. The validity scales (Hyperresponse and Underresponse) were not retained in the TSCC-SF. However, the TSCC-SF is meant to be a brief screening and assessment measure, and a mental health care provider may choose to administer additional instruments if they are concerned about a child’s response. Additionally, not all children and parents completed all measures, so there were not as many completed TSCCs as there were TSCYCs. This was due to either nonoverlapping age criteria for administration of both instruments or the clinician’s decision to pursue an immediate therapeutic intervention rather than engage in extensive assessment. Albeit a limitation, the clinicians’ decisions support the necessity of a brief, single measure like the TSCC-SF that can be used even when there is evidence that an intervention is needed immediately. Reducing the number of items may prove beneficial to children in clinical situations, but the cost of a copyrighted measure to clinicians likely would remain the same. One alternative would be to alter wording of items while assessing the same constructs. This would require a complete reanalysis of items and structure, but if made available through the public domain could be beneficial to both clinicians and the children they serve.

Future studies might examine the instrument’s sensitivity to treatment changes, as the TSCC-SF should be a valuable tool for clinicians to determine the impact of treatment on trauma symptom resolution and for researchers conducting longitudinal research on dimensions of change in trauma symptoms. A strength of this study was the representation of African American children in the sample. Nonetheless, future research should examine the properties of the TSCC-SF using a sample with more representation of Hispanics. Additionally, a future study on the reliability and validity of the TSCC-SF using additional self-report measures would be necessary before confidently implementing this measure in clinical settings. Next, the raw scores need to be standardized in a normative process.

The TSCC-SF holds promise as a brief screening measure in identifying symptomatology and treatment needs in children who are sexually abused. Since so few child self-report measures exist, the TSCC-SF might be particularly helpful as part of a multiinformant package, wherein parents also complete a screening measure, such as the TSCYC-SF (Wherry, Corson, & Hunsaker, 2013). Obtaining multiple viewpoints on trauma symptoms would give care providers the type of input they need to ensure speedy, individualized, and effective treatment for 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) received no financial support for the research, authorship, and/or publication of this article.

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